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Allogeneic Hematopoictic Cell Transplant for Hematological Cancers and Myclodysplastic Syndromes in HIV-Infected Individuals
(Posted to clinicaltrials.gov.as.NCT01410.344)
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bmt ctn protocol 0903 (amc-080)

Study Chairpersons Joseph Alvarnas, M.D.' and Richard Ambinder, M.D.'
Protocol Team Gorgun Alpek, M.D., M.H.S.'
Robert Harocchi, M.D., PhD.*
Enc Balsley Shelly Cance, Sc De Sierr Devine, M D *
Chostine Durand, M.D.'
Charlos Flexner, M.D.,
Seve Forman, M.D.  
Mary Horowitz, M.D. M.S.*
Rick Jones, M.D.  
Lawrence Kaplan, M.D.  
Amnta Knshnan, M.D. 1 Jennifer Le-Rademacher, Ph.D.*
Richard Little, M D.  
Brent Logan, Ph.D. Richard Mazıarı, M.D."
John Mellon, M.D.'° Willis Navarro, M D '' Anella Noy, M.D."
Uday Popat, M D ''
R yan Shickls, PharmD. 19 Aruna Subramanian, M. D. i Jason Thompson John Zaia, M.D.'
Sponsored by the National Institutes of Health National Heart, Lung, and Blood Institute National Cancer Institute
'City of Hupe National Medical Center i lohns Hopkins Medical Institutions
'University of Maryland Medical Center *The Olluo State Liniversity Medical Center
'National Cancer Institute
'Oregon Health and Science University
''
'National Dome Manuw Program
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core study participants affiliate study

University of California Los Angeles University of Utah City of Hope National Medical Center H. Lee Moffitt Cancer Center Johns Hopkins Medical Institutions Memorial Sloan-Kettering Cancer Center Ohio State Consortium University of California San Francisco University of Florida University of Texas MD Anderson Cancer Center Texas Transplant Institute Weill Cornell Medical College University of Maryland Medical Systems Mayo Clinic - Phoenix Hackensack University Medical Center i
protocol synopsis - bmt ctn
core study participants affiliate study

Allogeneic Hematopoietic Cell Transplant for Hematological Cancers and Myelodysplastic Syndromes in HIV-Infected Individuals Study Chairpersons: Joseph Alvarnas, M.D. and Richard Ambinder, M.D.  
| Primary Objective:   | The primary objective is to assess the feasibility and safety of allogeneic hematopoietic cell transplantation (HCT) in HIVinfected patients. The primary endpoint is 100-Day Non-Relapse  Mortality (NRM).   |
|----------------------|---|  
Secondary Objectives: Patients will be assessed for the following endpoints:  
| 1.                                                                              | Disease status at Day 100 post-HCT                                                                                                                                                     |           |         |    |          |     |           |
|---------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------|---------|----|----------|-----|-----------|
| 2.                                                                              | Time to hematopoietic recovery                                                                                                                                                         |           |         |    |          |     |           |
| 3.                                                                              | Chimerism at 4 weeks, 100 days, and 6 months                                                                                                                                           |           |         |    |          |     |           |
| 4.                                                                              | Hematologic function at 100 days and 6 months                                                                                                                                          |           |         |    |          |     |           |
| 5.                                                                              | Infections                                                                                                                                                                             |           |         |    |          |     |           |
| 6.                                                                              | Six-month overall survival                                                                                                                                                             |           |         |    |          |     |           |
| 7.                                                                              | Acute graft-vs-host disease                                                                                                                                                            |           |         |    |          |     |           |
| 8.                                                                              | Chronic graft-vs-host disease                                                                                                                                                          |           |         |    |          |     |           |
| 9.                                                                              | Immunologic reconstitution at 8 weeks, 6, 12 and 24 months                                                                                                                             |           |         |    |          |     |           |
| 10.                                                                             | To                                                                                                                                                                                     | determine | whether | a  | strategy | for | optimized |
| antiretroviral therapy can be maintained throughout the  peritransplant period. |                                                                                                                                                                                        |           |         |    |          |     |           |
| 11.                                                                             | Impact of HCT on the HIV reservoir at Day 100, 6, 12 and  24 months post-HCT for all patients and for those who  have been maintained on optimized antiretroviral therapy  throughout. |           |         |    |          |     |           |  
| Study Design:         | This study is designed as a Phase II multi-center trial.                                                                                                                                                                                                                                                                                                                               |
|-----------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Accrual Objective:    | The trial will accrue 15 patients.                                                                                                                                                                                                                                                                                                                                                     |
| Accrual Period:       | The estimated accrual period is 2 years.                                                                                                                                                                                                                                                                                                                                               |
| Eligibility Criteria: | Patients ≥ 15 years old, HIV-infected and diagnosed with acute  myeloid leukemia (AML) or acute lymphocytic leukemia (ALL) in  first or second complete remission (CR); Int-2 or high-risk  myelodysplastic syndrome (MDS) with < 10% marrow blasts and  no circulating myeloblasts after their most recent therapy; or  Hodgkin or non-Hodgkin lymphoma beyond first CR with at least |  
a partial response to last treatment. Patients must have either an 8/8 matched related donor at HLA-A, -B, -C, (serologic typing or higher resolution) and –DRB1 (at high resolution using DNA based typing), or at least a 7/8 matched unrelated donor at HLA-A, -B, -C and DRB1 (at high resolution using DNA based typing). A 7/8 matched related donor match is permitted only if an 8/8 unrelated donor cannot be identified. A secondary matching criterion is the presence of homozygosity for the CCR5delta32 mutation. Allogeneic transplantation using cord blood, T-cell depletion or prior allogeneic HCT are not allowed for this study.  
Patients must have adequate organ function defined as 1) left  
ventricular ejection fraction at rest ≥40%; 2) DLCO, FEV1, FVC ≥  
45% predicted; 3) total bilirubin ≤ 2.0 mg/dL, and ALT and AST ≤ 5 x upper limit of normal (ULN); 4) creatinine clearance > 40mL/min (measured or calculated). Karnofsky/Lansky performance status ≥ 70%.  
Treatment Description: Patients with HIV infection and hematological malignancies or myelodysplastic syndromes (MDS) will be treated with either reduced-intensity or fully ablative allogeneic hematopoietic cell transplantation (HCT). Where feasible, an attempt will be made to identify hematopoietic cell donors who are homozygotes for the CCR5delta32 mutation. Patients will receive standard immunosuppressive therapy post-transplant that will be tapered as per the institutional standard of care. Graft-versus-host disease will be treated per the institutional standard of care.  
Study Duration: Patients will be followed for two years following allogeneic HCT.
protocol synopsis - bmt ctn
table of contents

| 1.                             | BACKGROUND AND RATIONALE .                                                              |
|--------------------------------|-----------------------------------------------------------------------------------------|
| 1.1.                           | Background .                                                                            |
| 1.2.                           | Autologous Hematopoietic Cell Transplantation for Patients with HIV Infection .1-2      |
| 1.3.                           | Allogeneic HCT for Patients with HIV Infection .                                        |
| 2.                             | STUDY DESIGN                                                                            |
| 2.1.                           | Study Overview .                                                                        |
| Study Objectives and Rationale |                                                                                         |
| 2.2.                           |                                                                                         |
| 2.2.1.                         | Primary Objective                                                                       |
| 2.2.2.                         | Secondary Objectives                                                                    |
| 2.3.                           | Patient Eligibility                                                                     |
| 2.3.1.                         | Patient Inclusion Criteria                                                              |
| 2.3.2.                         | Patient Exclusion Criteria .                                                            |
| 2.4.                           | Donor Selection Criteria                                                                |
| 2.4.1.                         | Donor Exclusion Criteria .                                                              |
| 2.5.                           | Study Treatments                                                                        |
| 2.5.1.                         | Reduced Intensity Conditioning Regimens                                                 |
| 2.5.2.                         | Myeloablative Conditioning Regimens                                                     |
| 2.5.3.                         | GVHD Prophylaxis Regimen                                                                |
| 2.5.4.                         | Antiretroviral Therapy Overview                                                         |
| 2.5.5.                         | Initiation of Antifungal Prophylaxis in Ritonavir-Based Antiretroviral Therapy.....2-18 |
| 2.6.                           | Supportive Care                                                                         |
| 2.6.1.                         | Post-HCT .                                                                              |
| 2.7.                           | Participant Risks                                                                       |
| 2.8.                           | Therapy Toxicities .                                                                    |
| 2.8.1.                         | BUSULFAN .                                                                              |
| 2.8.2.                         | Melphalan                                                                               |
| 2.8.3.                         | Fludarabine                                                                             |
| 2.8.4.                         | Cyclophosphamide                                                                        |
| 2.8.5.                         | Total Body Irradiation                                                                  |
| Tacrolimus                     |                                                                                         |
| 2.8.6.                         |                                                                                         |
| 2.8.7.                         | Sirolimus                                                                               |
| 2.8.8.                         | Methotrexate .                                                                          |
| 2.8.9.                         | Mycophenolate Mofetil (MMF)                                                             |
| 3.                             | STUDY ENDPOINTS                                                                         |
| Primary Endpoints              |                                                                                         |
| 3.1.                           |                                                                                         |
| 3.2.                           | Secondary Endpoints                                                                     |
| 3.2.1.                         | 100-day Disease Status Following Transplant                                             |
| 3.2.2.                         | Time to Hematopoietic Recovery .                                                        |
| 3.2.3.                         | C Chimerism                                                                             |
| 3.2.4.                         | Hematologic Function                                                                    |  
| 3.2.5.   | Occurrence of Infections 3-1                                  |
|----------|---------------------------------------------------------------|
| 3.2.6.   | Six Month Overall Survival 3-1                                |
| 3.2.7.   | Acute Graft-versus-Host Disease (GVHD) 3-2                    |
| 3.2.8.   | Chronic Graft-versus-Host Disease (GVHD) 3-2                  |
| 3.2.9.   | Immunologic Reconstitution 3-2                                |
| 3.2.10.  | Impact of Therapy on the HIV Reservoir 3-2                    |
| 3.3.     | Disease Status Assessment 3-2                                 |
| 3.3.1.   | Lymphoma 3-2                                                  |
| 3.3.2.   | Acute Leukemia and Myelodysplastic Syndromes 3-7              |
| 4.       | PATIENT ENROLLMENT AND EVALUATION 4-1                         |
| 4.1.     | Enrollment Procedures 4-1                                     |
| 4.1.1.   | Screening and Eligibility Procedures 4-1                      |
| 4.2.     | Study Monitoring 4-2                                          |
| 4.2.1.   | Follow-up Schedule 4-2                                        |
| 4.2.2.   | Adverse Event Reporting 4-3                                   |
| 4.2.3.   | Patient Evaluations prior to the HCT conditioning therapy 4-3 |
| 4.2.4.   | Patient Post-HCT Evaluations 4-5                              |
| 5.       | STATISTICAL CONSIDERATIONS 5-1                                |
| 5.1.     | Study Overview 5-1                                            |
| 5.1.1.   | Accrual 5-1                                                   |
| 5.1.2.   | Primary Endpoint 5-1                                          |
| 5.2.     | Sample Size Calculations and Stopping Guidelines 5-1          |
| 5.3.     | Demographic and Baseline Characteristics 5-3                  |
| 5.4.     | Analysis Plan 5-4                                             |
| 5.4.1.   | Analysis of the Primary Endpoint 5-4                          |
| 5.4.2.   | Analysis of Secondary Endpoints 5-4                           |
protocol synopsis - bmt ctn
list of appendices

| APPENDIX A:   | HUMAN SUBJECTS                                                          |
|---------------|-------------------------------------------------------------------------|
| APPENDIX B:   | INFORMED CONSENT                                                        |
| APPENDIX C:   | LABORATORY PROCEDURES                                                   |
| APPENDIX D:   | TREATMENT REVIEW COMMITTEE                                              |
| APPENDIX E:   | SUGGESTED PROPHYLAXIS                                                   |
| APPENDIX F:   | PHARMACOKINETIC DRUG-DRUG INTERACTIONS WITH  ANTIRETROVIRAL MEDICATIONS |
| APPENDIX G:   | KARNOFSKY AND LANSKY PERFORMANCE STATUS SCALES                          |
| APPENDIX H:   | SEQUENTIAL PROBABILITY RATIO TEST USING FUTILITY  BOUNDARY              |  
| APPENDIX I:   | IDENTIFICATION OF CCR5DELTA32 MUTATION  HOMOZYGOUS DONORS   |
|---------------|-------------------------------------------------------------|
| APPENDIX J:   | REFERENCES                                                  |  
vi
chapter 1
1. background and rationale 1.1.

Survival in patients with Human Immunodeficiency Virus (HIV) has improved dramatically with the advent of Highly-Active Antiretroviral Therapy (HAART). Despite improvements in HIVinfection-related survival, the risk of malignancies remains significant in patients with HIV
infection. While Non-Hodgkin lymphoma (NHL) is an AIDS-defining diagnosis, a comparison of a large cohort of HIV-infected patients to the Surveillance, Epidemiology and End Results (SEER) data demonstrates a significantly higher incidence of several cancers that are treated with allogeneic HCT, including Hodgkin lymphoma and leukemias in patients with HIV infection (Patel). Prior to the advent of HAART, the treatment of patients with malignancy in the setting of HIV infection was hamstrung by limited chemotherapy tolerance and complications due to opportunistic infection. Since the widespread availability of HAART, there have been significant improvements in the capacity to treat this patient population in a fashion comparable to that of patients without HIV infection. This has, in turn, lead to marked improvements in the outcomes of patients with malignancies in the setting of HIV infection. The prognosis for patients with AIDS-related lymphoma is dramatically different in the era of HAART therapy. In a comparison of treatment outcomes for patients treated before and after the advent of HAART, there is a statistically significant improvement in the overall survival of patients treated with HAART (p = 0.002). While the International Prognostic Index (IPI) remains a useful tool for estimating the prognosis of patients with AIDS-related NHL, the CD4 count of less than 100 per microliter has independent prognostic value for this group of patients. The impact of HAART therapy upon the immunological and functional status of patients with HIV infection has permitted the extension of aggressive therapeutic regimens to this patient population. HAART allows a significant portion of patients to often reduce their viral load to undetectable levels and therefore tolerate far more aggressive therapeutic interventions than would have been possible previously. Although HIV disease progression can be reversed with combination antiretroviral (ARV) therapy, antiretrovirals don't cure HIV-infected individuals. This is because HIV establishes latent infection in long-lived resting memory CD4+ T cells. This cellular reservoir of latent virus is the major barrier to HIV cure. Antiretrovirals only have activity against actively replicating virus and therefore "intensified" combinations of 4 and 5 drugs do not affect latent infection. Antiretrovirals are effective at preventing establishment of chronic HIV infection. For example, administration of antiretrovirals are very effective in blocking maternal to child transmission and in blocking health care worker infection following needlestick exposure.
chapter 1
1.2. autologous hematopoietic cell transplantation

Based upon the opportunity afforded by this degree of viral suppression, high-dose therapy with autologous hematopoietic cell transplantation (HCT) has been extended to patients with AIDSrelated NHL and Hodgkin lymphoma with results that appear to be comparable to those achieved in patients without HIV infection. Treatment-related complications appear to be comparable to those seen in the non-HIV-infected patient population. Across multiple trials, the probability of survival after high-dose conditioning followed by autologous HCT for patients with AIDSrelated NHL ranges between 39% to 85% as seen in Table 1.2.  
| Patients  Surviving  (%)                                                                                  |     |                             |      |     |       |
|-----------------------------------------------------------------------------------------------------------|-----|-----------------------------|------|-----|-------|
| Krishnan                                                                                                  | 0   | 20                          | 5%   | 32  | 85    |
| Spitzer                                                                                                   | 2   | 20                          | 5%   | 5.8 | 50+?? |
| Re                                                                                                        | 4   | 10                          | 0%   | 18  | 39    |
| Gabarre                                                                                                   | ?   | 14                          | ?    | 1   | 71    |
| Serrano                                                                                                   | 0   | 11                          | 0%   | 32  | 73    |
| EBMT                                                                                                      | NA  | 68                          | 7.5% | 32  | 61    |
| * Abstracts of references are provided in Appendix I Failed to  Mobilize  (n) Patients  Transplanted  (n) | TRM | Median  follow-up  (months) |      |     |       |
| Reference                                                                                                 |     |                             |      |     |       |
chapter 1
1.3. allogeneic hct for patients

The experience with allogeneic HCT transplantation for patients with HIV infection has been quite limited. Prior to the advent of HAART therapy, the key limiting factors in the use of allogeneic HCT in this patient population was control of the HIV infection and management of opportunistic infections. In a paper published in 1987, 3 patients who were diagnosed with HIV infection following transplantation were managed through the use of donor lymphocyte infusions and cytokine therapy (Vilmer). Two of the patients had undergone prior HCT for aplastic anemia and the third had been treated for acute leukemia. All of the patients demonstrated evidence of marrow failure. Patients were treated with 6 donor lymphocyte infusions, a 3-month course of alpha interferon and subsequently received gamma interferon. While all 3 patients had improvements in their blood counts following treatment, all had detectable HIV infection and suppressed CD4 levels. In a case report published by the Johns Hopkins group, a 41-year-old man with AIDS-related lymphoma was treated with fully ablative allogeneic HCT using total body irradiation combined with cyclophosphamide (Holland). The patient received 2 weeks of pre-treatment with zidovudine prior to transplant and received the drug post-transplant. He achieved engraftment on Day + 17 but unfortunately died of complications related to progressive disease on Day + 47. Polymerase chain reaction (PCR) studies of peripheral blood were negative for HIV at Day + 32 and analysis of multiple autopsy tissues did not demonstrate detectable virus at the time of the patient's death.  
Additional case reports from the pre-HAART era demonstrated the feasibility of performing allogeneic transplantation for patients with HIV infection who were treated with multiple antiretroviral agents prior to and following allogeneic HCT, but in 2 of 3 cases, the patients remained PCR-positive for evidence of residual HIV infection (Torlontano, Giri). The 1 patient who did not demonstrate evidence of post-transplant HIV infection had poor count recovery following transplant and died of ARDS (Contu). The availability of HAART therapy seems to have had an impact upon the feasibility of HCT in this patient population. In a review of the CIBMTR registry data, 23 patients with HIV infection were identified as having undergone allogeneic transplant (Gupta). Nine of the 23 (39%)
underwent allogeneic HCT HIV after 1996, in the HAART era. At a median follow-up of 59 months, six of the 23 patients were alive. Four of the nine post-1996 patients were alive whereas only 2 of 14 pre-1996 patients were alive. The data suggest that allogeneic HCT is feasible for selected HIV-positive patients. Despite the capacity of HAART therapy to suppress HIV viral loads to low or undetectable levels, the experience with allogeneic HCT remains quite limited. In a 2002 case report, a 33year-old woman with acute myelogenous leukemia (AML) in first complete remission, HIV and hepatitis C infection underwent fully ablative CD34-selected allogeneic graft from a sibling donor (Sora). She was treated with HAART prior to transplant and achieved an undetectable viral load. The transplant course was complicated by grade II graft-versus-host disease (GVHD) that responded to treatment. At the time of the report, the patient remained in a complete remission with an undetectable HIV viral load at 39 months post-HCT. One of the challenges in managing patients with HAART through the transplant course may be the risk of HIV-reactivation/graft infection during periods of antiretroviral therapy interruption. In a 2001 report of 2 patients treated with reduced-intensity allogeneic transplant, 1 of the patients developed a febrile illness consistent with acute HIV reactivation (Kang). The viral load rose to 1,000,000 copies/mL during this time. This patient eventually died of relapsed Hodgkin lymphoma 12 months post-HCT. The other patient who underwent transplant for AML received a gene-modified graft that was engineered to inhibit wild type Rev. This patient demonstrated an undetectable HIV viral load post-transplant and remains free of disease. In another case report from 2007, a 34-year-old man with HIV infection and severe aplastic anemia (SAA) underwent allogeneic HCT (Wolf). During interruption of HAART therapy, the patient demonstrated a rapid rise in his HIV viral load. Despite this, the patient engrafted at Day + 18. He achieved viral suppression following retreatment with his antiretroviral regimen. Conversely there are some data that show that the donor graft may be capable of mounting and anti-HIV response mediated by CD8+ cells (Woolfrey). Two patients with AML underwent allogeneic HCT (1 matched sibling, 1 unrelated donor) following a non-myeloablative regimen
(fludarabine 90 mg/m2and TBI 2 Gray) and were monitored with HIV RNA levels, proviral DNA levels and peripheral blood mononuclear cell quantitative HIV cultures post-transplant. Antiretroviral therapy was chosen to avoid significant drug interactions and hepatotoxicity potentially related to nevirapine. GVHD prophylaxis consisted of cyclosporine and mycophenolate. HAART was administered throughout the transplant course. One patient suffered a relapse of his disease at Day + 44. Immunosuppression was withdrawn. This patient died as a result of complications related to GVHD and obliterative bronchiolitis. Both donors had wild type CCR5 coreceptor. Both patients had undetectable viral loads from prior to transplant through Day + 180. HIV proviral DNA was detected in 1 patient at Days + 56 and +180. Through an analysis of donor T-cell responses to multiple HIV epitopes, cells recovered from patient 2 demonstrated anti-HIV-specific T-cell responses to 8 of the 26 selected epitopes. The experience with reduced-intensity allogeneic HCT for patients with HIV has expanded with the recent publication of the Ohio State University experience (Hamadani). Three patients with HIV underwent allogeneic HCT following conditioning with fludarabine and busulfan with or without antithymocyte globulin (1 patient without). GVHD prophylaxis consisted of tacrolimus and mini-dose methotrexate. The patients underwent transplant for AML in 2nd complete remission, Burkitt lymphoma and plasmablastic lymphoma, respectively. Patients continued HAART throughout the transplant course without interruption. One patient developed acute GVHD. At the time of the study publication, all patients were alive, free of disease and off of immunosuppressive therapy (range 368-802 days). One patient had a detectable viral load beyond 1 year following HCT. The "Holy Grail" for allogeneic transplantation for patients with HIV-infection would be a cure of the underlying disorder for which transplant was performed and the concomitant eradication of the HIV infection. The recent case report of a patient who underwent allogeneic HCT for AML and received a graft from a donor with the CCR5delta32/delta32 mutation may herald this possibility (Hütter). One of the key mechanisms for HIV-1 entry into CD4 lymphocytes is chemokine receptor 5 (CCR5). The delta32 mutation represents a 32 base pair deletion in the allele that may confer significant resistance to HIV infection in homozygotes for the mutation. In this case report, a 40-year-old man with AML and concomitant HIV infection underwent allogeneic transplant from an unrelated donor. At the time of diagnosis with acute leukemia, the viral load was undetectable and the CD4 count was 415/mcl. The patient achieved a complete response following standard therapy, but relapsed 7 months following treatment. At the time of relapse, the patient underwent an unrelated donor transplant using a donor who was a homozygote for the delta32 allele. The patient received a CD34-selected graft. GVHD prophylaxis consisted of cyclosporine A and rabbit antithymocyte globulin. The patient engrafted on Day + 13. He experienced grade I GVHD of the skin that responded to therapy. The patient relapsed at Day +391 and was treated with a second transplant from the same donor following preparation with 2 Gray TBI. The patient's HIV viral load remains undetectable at 20 months following transplant despite discontinuation of HAART. While a graft from a donor with the CCR5delta32/delta32 mutation may result in cure, evidence has been emerging that transplant using such donors may not be necessary for cure. Maintenance of antiretroviral therapy throughout the transplant period may prevent infection of donor cells and thus prevent the establishment of a retroviral reservoir in donor cells. Achievement of full chimerism with replacement of host-derived CD4 T cells with donor cells may abolish the host reservoir. The failure to detect residual infectious virus in the Berlin patient suggests that no cellular reservoir of infectious virus survived transplantation (including donor lymphocyte infusion). Recent data from Boston suggests that two patients who underwent allotransplantation from donors who were not selected to be resistant to HIV, also cleared the long term reservoir and have had antiretroviral therapy stopped. As of this writing (October 2013), they appear to be retrovirus-free off therapy. Thus in the context of the present study we may be able to learn whether antiretrovirals can prevent the infection of HIV-susceptible donor cells and if infection is prevented, whether the patient will be cured of HIV as host infected cells are replaced by donor cells. Subcutaneous enfuvirtide. The HIV-1 fusion inhibitor enfuvirtide (T20, Fuzeon), will be administered during high-risk periods for nausea and vomiting, specifically during the administration of high dose ARV during alloHSCT when oral medications cannot be tolerated as for example during high dose cyclophosphamide or during periods of severe mucositis.  
Enfuvirtide or T20, is the only available non-oral antiretroviral approved for treatment of HIV-1 infection, besides the intravenous form of zidovudine (AZT) which is contraindicated during alloHSCT due to bone marrow suppression. In most cases, enfuvirtide monotherapy is not sufficiently potent to suppress active viral replication in most patients; however we believe that the temporary use of enfuvirtide monotherapy in patients undergoing alloHSCT population is justified for several reasons. First, it has been demonstrated ARV simplification to less potent regimens, such as protease inhibitor monotherapy, is effective; this suggests that less antiretroviral activity is required to maintain viral suppression compared to the amount of antiretroviral activity required to induce viral suppression. Second, patients undergoing alloHSCT are likely to be profoundly lymphopenic due to conditioning chemotherapy; viral dynamic theory states that the amount of viral replication is directly related to the number of lymphocytes. Therefore in cytopenic patients with already suppressed plasma HIV-1 RNA levels, there should be less viral replication to inhibit. During any periods of enfuvirtide monotherapy, weekly viral loads will be measured using real-time PCR with a sensitivity of 20 copies HIV-1 RNA per milliliter of plasma. If there is virologic failure/breakthrough, defined as 2 consecutive measures of > 200 copies HIV-1 RNA/mL, enfuvirtide will be discontinued. The patient would then be off all antiretroviral medications and this would be considered a failure to maintain ARV. Enfuvirtide monotherapy does present the risk of development of enfuvirtide resistance. In clinical trials of enfuvirtide monotherapy, it took 14 days for resistance to develop. In this clinical trial, we anticipate the use of enfuvirtide monotherapy on the order of days. If virologic failure is observed with this strategy, resistance testing for enfuvirtide will be performed. If resistance does develop it is highly unlikely to compromise future management of the patient's HIV infection as enfuvirtide is rarely used in clinical practice due to the availability of many other oral antiretrovirals and no cross-resistance exists between enfuvirtide and other antiretroviral agents.
chapter 1
chapter 2 2. study design

The study is designed to evaluate the feasibility and safety of reduced-intensity and fully-ablative allogeneic hematopoietic cell transplantation (HCT) for patients with hematological malignancies or myelodysplastic syndromes (MDS) who have HIV infection. The goal of the study is to assess the 100 day Non-relapse Mortality as well as immunological reconstitution in this patient population. Where feasible, an attempt will be made to identify HLA-compatible hematopoietic stem cell donors who are homozygotes for the delta32 mutation of the chemokine receptor 5 (CCR5delta32). Patients will undergo a treatment plan review prior to registration on the trial. All patients will undergo allogeneic HCT from a matched sibling or unrelated donor. In addition, the subcutaneous antiretroviral, enfuvirtide, will be added during any periods when oral medications are unlikely to be tolerated due to nausea (e.g. during administration of high dose cyclophosphamide) or cannot be tolerated for other reasons (e.g. mucositis).
chapter 1
2.2. study objectives and rationale

The rationale for this trial is to demonstrate the feasibility and safety of allogeneic HCT for patients with chemotherapy-sensitive hematological malignancies and coincident HIV-infection. In particular the trial will focus upon the 100-day non-relapse mortality as an indicator of the safety of transplant in this patient population. Correlative assays will focus upon the incidence of infectious complications in this patient population, the evolution of HIV infection and immunological reconstitution. Where feasible (and when this can be accomplished without compromise of either the donor quality or the timeliness of transplantation), an attempt will be made to identify donors who are homozygotes for the delta32 mutation for CCR5. In light of emerging evidence that it may be possible to prevent infection of transplanted cells with HIV, we are also seeking to optimize the antiretroviral strategy so as to minimize or eliminate interruptions and to capture detailed compliance information. If it emerges that some patients are cured of retroviral infection while others are not, it will be important to determine whether the failures were associated with treatment interruptions in antiretroviral therapy or other explanations.
chapter 1
2.2.1. primary objective

The primary objective of this multicenter study is to assess the feasibility and safety of allogeneic hematopoietic cell transplantation (HCT) in HIV-infected patients. The primary endpoint is 100-Day Non-Relapse Mortality (NRM). 2.2.2. Secondary Objectives
- Disease status at Day 100 post-HCT
- Time to hematopoietic recovery
- Chimerism at 4 weeks, 100 days and 6 months post-HCT
- Hematologic function at 100 days and 6 months post-HCT
- Infections
- Six-month overall survival - Acute graft-vs.-host disease
- Chronic graft-vs.-host disease
- Immunologic reconstitution at 8 weeks and 6, 12, and 24 months post-HCT
- To determine whether a strategy for optimized antiretroviral therapy can be maintained throughout the peritransplant period.  
- Impact of HCT on the HIV reservoir at Day 100, 6, 12 and 24 months post-HCT for all patients and for those who have been maintained on optimized antiretroviral therapy throughout.
chapter 1
2.3. patient eligibility

Patients must meet specified eligibility criteria for entry into the study. 2.3.1. Patient Inclusion Criteria Patients fulfilling the following criteria will be eligible for entry into this study:
1. HIV-1 infection, as documented by a rapid HIV test or any FDA-Approved HIV-1 Enzyme or Chemiluminescence Immunoassay (E/CIA) test kit and confirmed by Western Blot at any time prior to study entry. HIV antigen, plasma HIV-1 RNA, or a secondary antibody test by a method other than rapid HIV and E/CIA is acceptable as an alternative test. Alternatively, if a rapid HIV test or any FDA-Approved HIV-1 Enzyme or Chemiluminescence Immunoassay (E/CIA) test is not available, two HIV-1 RNA values ≥ 2000 copies/mL at least 24 hours apart performed by any laboratory that has CLIA certification, or its equivalent, may be used to document infection.  
2. Patients must be willing to comply with effective Antiretroviral Therapy.  
3. Patients must be ≥ 15 years of age.  
4. Hematological malignancy associated with a poor prognosis with medical therapy alone.  
Diagnoses to be included:
a) Patients with the diagnosis of Acute Myeloid or Lymphocytic Leukemia (AML or ALL) in first or second complete remission.  
b) Patients with advanced myelodysplastic syndromes (MDS), including those with International Prognostic Scoring System (IPSS) Int-2 and high-risk disease with less than 10% marrow blasts and no circulating myeloblasts after most recent therapy. Patients with acute leukemia that develops from a pre-existing MDS must meet the inclusion criteria for patients with AML detailed above.  
c) Hodgkin Lymphoma beyond first remission achieving at least a partial response to most recent therapy with no evidence of progression prior to transplant.  
d) Non-Hodgkin Lymphoma beyond first remission achieving at least a partial response to most recent therapy with no evidence of progression prior to transplant.  
5. Donor/Recipient HLA Matching:
a) Related donor: must be an 8/8 match at HLA-A, -B, -C, (serologic typing or higher resolution) and –DRB1 (at high resolution using DNA based typing). A 7/8 related donor match is permitted only if an 8/8 unrelated donor cannot be identified.  
b) Unrelated donor: must be a 7/8 or 8/8 match at HLA-A, -B, -C, and -DRB1 (at high resolution using DNA based typing).
6. Patients with adequate organ function as measured by:
a) Cardiac: Left ventricular ejection fraction at rest ≥ 40% demonstrated by MUGA
or echocardiogram. Patients with known heart disease must have a functional status no worse than American Heart Association Class I defined as patients with cardiac disease but without resulting limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain.
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b) hepatic

i. Total Bilirubin < 2.0 mg/dL (except for isolated hyperbilirubinemia attributed to Gilbert syndrome or antiretroviral therapy as specified in Appendix E) and ALT and AST < 5x the upper limit of normal.  
ii. Concomitant Hepatitis: Patients with chronic hepatitis B or C may be enrolled on the trial providing the above bilirubin and transaminase criteria are met. In addition, there must be no clinical or pathologic evidence of irreversible chronic liver disease, and there must be no active viral replication as evidenced by an undetectable hepatitis viral load by a PCRbased assay.  
c) Renal: Creatinine clearance (calculated creatinine clearance is permitted) >
40 mL/min.
d) Pulmonary: DLCO, FEV1, FVC ≥ 45% of predicted (corrected for hemoglobin).  
7. Signed Informed Consent 2.3.2. Patient Exclusion Criteria Patients with the following will be ineligible for registration onto this study:
1. Karnofsky/Lansky performance score < 70%. 2. Active CNS malignancy; however, patients with a history of positive CSF cytology that has become negative with intrathecal chemotherapy are eligible.  
3. Uncontrolled bacterial, viral or fungal infection (currently taking medication and with progression or no clinical improvement).  
4. Active CMV retinitis or other CMV-related organ dysfunction. 5. AIDS related syndromes or symptoms that pose a perceived excessive risk for transplantation-related morbidity as determined by the principal investigator.  
6. Untreatable HIV infection due to multidrug antiretroviral resistance. Patients with a detectable viral load > 750 copies/ml should be evaluated with an HIV drug resistance test (HIV-1 genotype). The results should be included as part of the Antiretroviral Review (described in Appendix D). This Review Committee will make the final determination as to whether HIV viremia could potentially be suppressed with alternate antiretroviral therapy. .  
7. Pregnant (positive β-HCG) or breastfeeding.
8. Fertile men or women unwilling to use contraceptive techniques from the time of initiation of mobilization until six-months post-transplant.  
9. Prior allogeneic HCT.  
10. Patients with psychosocial conditions that would prevent study compliance and followup, as determined by the principal investigator.  
11. T-cell depletion (including ATG or alemtuzumab) is not allowed.
12. Use of cord blood as the source of hematopoietic cells is not allowed.
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2.4. donor selection criteria

Patients are eligible for transplantation using either compatible related donors or an appropriately compatible unrelated donor as identified through the National Marrow Donor Program (NMDP) that meets institutional criteria. Allogeneic transplantation using cord blood unit(s) as a hematopoietic stem cell source is prohibited under this protocol.
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donor inclusion criteria

1. Unrelated donors will be identified through the National Marrow Donor Program
(NMDP).  
2. No contraindications to donation of hematopoietic stem cells. 3. CCR5delta32 mutation: An additional matching criterion for this study will be the presence of homozygosity for the CCR5delta32 mutation. When feasible based on donor likelihood of CCR5delta32 homozygosity and timeliness, potential donors will be assessed for CCR5delta32 homozygosity. Among equivalently desirable donors as determined by transplant center donor selection criteria, a donor who is found to be a homozygote for CCR5delta32 will be favored as long as such a selection does not compromise the optimal timing of HCT. HLA matching as a selection criterion will always take precedence over CCR5delta32 homozygosity (see Appendix E for details).  
2.4.1. Donor Exclusion Criteria 1. Monozygotic twin donors. 2. Females who are pregnant (positive serum β HCG) or breastfeeding. 3. HIV seropositive.
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2.5. study treatments

In general reduced-intensity conditioning (RIC) is reserved for patients with co-morbidities or older patients in whom regimen-related mortality weighs against myeloablative conditioning (MAC). However, the selection of a RIC or MAC regimen in any particular patient is left to the discretion of investigators at the participating center in accordance with institutional standards. Table 2.5A outlines the diseases, conditioning regimens and GVHD prophylaxis regimens allowed for this study.  
| Diagnosis                                                                                                                                      | RIC    | MAC                                                    | GVHD   |
|------------------------------------------------------------------------------------------------------------------------------------------------|--------|--------------------------------------------------------|--------|
| AML in morphologic CR1/2 MDS: IPSS int-2/high with  <10% marrow blasts HL beyond CR1 in PR/CR ALL in morphologic CR1/2 NHL beyond CR1 in PR/CR | Flu/Bu | Tac/MTX or  Tac/Sirolimus or  Post-Tx Cy with  Tac/MMF |        |
| Bu/Flu                                                                                                                                         | Tac/MTX or PostTx CY with  Tac/MMF  (Tac/MMF not  required with posttx CY for 8/8  matches)        |                                                        |        |
| Flu/Mel                                                                                                                                        | Cy/TBI | Tac/MTX or  Tac/Sirolimus                              |        |  
2.5.1. Reduced Intensity Conditioning Regimens Reduced intensity conditioning regimens permitted in this protocol are detailed below. 2.5.1.1. Fludarabine and busulfan (Flu/Bu)
Fludarabine will be given in a total dose of 120-180 mg/m2 and busulfan will be given in a total dose of ≤ 8 mg/kg PO or 6.4 mg/kg IV with the recommended Flu/Bu regimen as follows:
- Days -6 to -2: Flu (30 mg/m2/day, total dose of 150 mg/m2)  
- Days -5 to -4: Busulfan (4mg/kg/day PO or 3.2 mg/kg/day IV, 130 mg/m2/day IV, total dose of 8 mg/kg PO or 6.4 mg/kg IV, or 260 mg/m2IV, respectively)
The sequence of fludarabine and busulfan administration in RIC regimens will be done according to institutional standards. Intravenous busulfan may be administered in divided doses or once daily. Oral busulfan must be administered in divided doses. Busulfan dose adjustments for obesity are listed in Section 2.5.2.4. Fludarabine dose adjustments for renal impairment are listed in Section 2.5.2.3. See Section 2.5.4 and Table 2.5.4 for critical information about antiretroviral management in the setting of a busulfan-containing reduced intensity conditioning regimen when the antiretroviral regimen includes ritonavir. 2.5.1.2. Fludarabine and melphalan (Flu/Mel)
Fludarabine will be given in a total dose of 120-180 mg/m2and melphalan in a total dose of ≤ 150 mg/m2 with the recommended Flu/Mel regimen as follows:
- Days -5 to -2: Flu (30mg/m2/day, total dose of 120 mg/m2)  
- Day -1: Mel (140mg/m2)
The sequence of fludarabine and melphalan administration in RIC regimens will be done according to institutional standards as long as the prescribed doses are the same as the regimen above. Dividing the dose of melphalan over two days is permitted. Fludarabine dose adjustments for renal impairment are listed in Section 2.5.2.3.
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2.5.2. myeloablative conditioning regimens

Myeloablative regimens permitted in this protocol are detailed below. See Section 2.5.4 and Table 2.5.4 for critical information about antiretroviral management in the setting of a myeloablative regimen when the antiretroviral regimen includes ritonavir.
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2.5.2.1. busulfan and fludarabine (bu/flu)

Fludarabine will be given in a total dose of 120-180mg/m2 and busulfan will be given in a total dose of ≤16mg/kg PO or 12.8 mg/kg IV with the Bu/Flu regimen as follows:  
- Days -5 to -2: Busulfan (4 mg/kg/day PO with Bu Css 900±100 ng/mL (or per institutional standard), 3.2 mg/kg/day IV or 130 mg/m2/day IV; total dose of 16 mg/kg, 12.8 mg/kg or 520 mg/m2, respectively)
- Days -5 to -2: Flu (30 mg/m2/day, total dose of 120 mg/m2)
- The sequence of busulfan and fludarabine administration in MAC regimens will be done according to institutional standards. Busulfan may be administered intravenously in divided doses or once daily. Appropriate busulfan dosing adjustments per institutional standard should be made when levels are available to achieve the target Css. Busulfan dose adjustments for obesity are listed in Section 2.5.2.4. Fludarabine dose adjustments for renal impairment are listed in Section 2.5.2.3.
2.5.2.2.Cyclophosphamide and total body irradiation (Cy/TBI) Cyclophosphamide will be given in a total dose of 120 mg/kg and fractionated total body irradiation will be given in a total dose of 1200-1420 cGy with the recommended Cy/TBI
regimen as follows:
- Days -7 to -4: TBI (total dose of 1200-1420 cGy)  
- Days -3 to -2: Cy (60 mg/kg/day, total dose of 120 mg/kg)
- The sequence of cyclophosphamide, TBI and TBI administration practices in MAC
regimens will be done accordingly to institutional standards. Cyclophosphamide dose adjustments for obesity are listed in Section 2.5.2.4.
(See Appendix F for detailed information on pharmacokinetic interactions.) MESNA will be given to reduce the risk of cyclophosphamide-associated hemorrhagic cystitis. MESNA will be dosed based on cyclophosphamide dose and may be administered per institutional guidelines. 2.5.2.3.Conditioning agent dose adjustments for renal impairment Fludarabine: Patients with a creatinine clearance of 40-70 ml/min (measured or calculated) should have a 20% dose reduction. 2.5.2.4.Conditioning agent dose adjustments for obesity Busulfan: Busulfan will be dosed according to the recipient's ideal body weight (IBW), unless the patient weighs more than 125% of IBW, in which case the drug will be dosed according to the adjusted IBW (AIBW; see below for formulas). Fludarabine: Fludarabine will not be dose adjusted for obesity. Cyclophosphamide: Cyclophosphamide will be dosed according to the recipient's ideal body weight (IBW), unless the patient weighs less than IBW, in which case the drug will be dosed according to the actual body weight.
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ideal body weight (ibw) formulas

Males IBW = 50 kg + 2.3 kg/inch over 5 feet Females IBW = 45.5 kg + 2.3 kg/inch over 5 feet
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2.5.3. gvhd prophylaxis regimen

Transplant centers must use the GVHD prophylaxis regimens that are listed below in Table 2.5B.  
Guidelines for continuing ARV therapy with various prophylaxis regimens are detailed below in Table 2.5C.  
| Conditioning Regimen / Match                           | GVHD Prophylaxis                                                                                                                                                                              |                                |
|--------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------|
| Fludarabine/Busulfan (Flu/Bu) - RIC /                  | Tacrolimus                                                                                                                                                                                    |                                |
| 7/8 or 8/8 Match                                       | -                                                                                                                                                                                             | Blood trough levels 5-15 ng/mL |
| -                                                      | Tacrolimus initiation tapering and  discontinuation is per institutional guidelines                                                                                                           |                                |
| Methotrexate - 15 mg/m2 Day 1 - 5-10 mg/m2 Days 3, 6 and 11 Tacrolimus - Blood trough levels 5-10 ng/mL - Tacrolimus initiation tapering and  discontinuation is per institutional guidelines Sirolimus - 12 mg loading dose on Day -3 - 4 mg daily starting on Day -2 adjusted to  maintain a trough level between 3-12 ng/ml - Sirolimus tapering and discontinuation is per  institutional guidelines Post-transplant Cyclophosphamide - 50 mg/kg Days 3 and 4 (with MESNA) Tacrolimus - Beginning on Day 5, administer tacrolimus to  achieve trough levels 5-15 ng/mL for 6 months - 1 mg Day 5 and dose adjusted weekly after Day  7 and continued for 6 months posttransplantation - Tacrolimus tapering and discontinuation is per  institutional guidelines MMF - 15 mg/kg po TID (max dose 1 gm po TID) Day  5 to Day 35                                                        |                                                                                                                                                                                               |                                |
| Busulfan/Fludarabine (Bu/Flu) - MAC / 7/8 or 8/8 Match | Tacrolimus - Blood trough levels 5-15 ng/mL - Tacrolimus initiation tapering and  discontinuation is per institutional guidelines Methotrexate - 15 mg/m2 Day 1 - 5-10 mg/m2 Days 3, 6 and 11 |                                |
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table 2.5b gvhd prophylaxis regimens

| Conditioning Regimen / Match                                                                                                                  | GVHD Prophylaxis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           |
|-----------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Post-transplant Cyclophosphamide (8/8 match) - 50 mg/kg Days 3 and 4 (with MESNA) - Note that tacrolimus/MMF is not required in this  setting |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            |
| Busulfan/Fludarabine (Bu/Flu) - MAC 7/8 Match Busulfan/Fludarabine (Bu/Flu) - MAC 8/8 Match                                                   | Post-transplant Cyclophosphamide - 50 mg/kg Days 3 and 4 (with MESNA) Tacrolimus - Beginning on Day 5, administer tacrolimus to  achieve trough levels 5-15 ng/mL for 6 months - 1 mg Day 5 and dose adjusted weekly after Day  7 and continued for 6 months posttransplantation - Tacrolimus tapering, and discontinuation is per  institutional guidelines MMF 15 mg/kg po TID (max dose 1 gm po TID) Day 5 to  Day 35                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            |
| Fludarabine/Melphalan (Flu/Mel) - RIC Cyclophosphamide/Total Body Irradiation  (Cy/TBI) - MAC/ 7/8 or 8/8 Match                               | Tacrolimus - Blood trough levels 5-15 ng/mL - Tacrolimus initiation tapering and  discontinuation is per institutional guidelines Methotrexate - 15 mg/m2 Day 1 - 5-10 mg/m2 Days 3, 6 and 11 Tacrolimus - Blood trough levels 5-10 ng/mL - Tacrolimus initiation tapering and  discontinuation is per institutional guidelines Sirolimus - 12 mg loading dose on Day -3 - 4 mg daily starting on Day -2 adjusted to  maintain a trough level between 3-12 ng/ml - Sirolimus tapering and discontinuation is per  institutional guidelines |  
| Raltegravir or  Dolutegravir Based Regimen                                                    | NNRTI2                                                                                                     | Boosted PI3, 4 Based Regimen   |
|-----------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------|--------------------------------|
| GVHD Prophylaxis                                                                              | Other                                                                                                      |                                |
| Based Regimen                                                                                 |                                                                                                            |                                |
| Agent                                                                                         | Continue                                                                                                   |                                |
| antiretroviral  therapy.                                                                      |                                                                                                            |                                |
| Tacrolimus dose  adjustments will  be required  (Appendix F)                                  | Continue                                                                                                   |                                |
| antiretroviral  therapy.                                                                      |                                                                                                            |                                |
| Tacrolimus dose  adjustments will  be required  (Appendix F)                                  |                                                                                                            |                                |
| Continue                                                                                      |                                                                                                            |                                |
| antiretroviral  therapy as  tolerated                                                         | Consultation  recommended,                                                                                 |                                |
| reviewed on a case  by case basis                                                             |                                                                                                            |                                |
| Tacrolimus                                                                                    | Continue                                                                                                   |                                |
| antiretroviral  therapy.  Sirolimus dose  adjustments will  be required  (Appendix F)         | Continue                                                                                                   |                                |
| antiretroviral                                                                                |                                                                                                            |                                |
| therapy. Sirolimus  dose adjustments  will be required  (Appendix F)                          |                                                                                                            |                                |
| Continue                                                                                      |                                                                                                            |                                |
| antiretroviral  therapy as  tolerated                                                         | Consultation  recommended,                                                                                 |                                |
| reviewed on a case  by case basis                                                             |                                                                                                            |                                |
| Sirolimus                                                                                     | Continue                                                                                                   |                                |
| antiretroviral  therapy as  tolerated with  caution and  frequent  monitoring  (Appendix F)   | Hold antiretroviral  therapy during Cy  prophylaxis.  Restart  antiretrovirals at  Day +5 as  tolerated. 4 |                                |
| Continue                                                                                      |                                                                                                            |                                |
| antiretroviral  therapy as  tolerated                                                         | Consultation  recommended,                                                                                 |                                |
| reviewed on a case  by case basis5                                                            |                                                                                                            |                                |
| Cyclophosphamide  (Cy)                                                                        |                                                                                                            |                                |
| 1Patients should be switched to raltegravir or dolutegravir-based regimens whenever possible. |                                                                                                            |                                |
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table 2.5c continuation of antiretroviral

1Patients should be switched to raltegravir or dolutegravir-based regimens whenever possible.  
2NNRTI (Non-nucleoside Reverse Transcriptase Inhibitors).  
3PI (Protease Inhibitors).  
4Ritonavir - containing antiretroviral therapy. 5Restart antiretroviral therapy after cyclophosphamide prophylaxis (Day +5) as soon as patient can tolerate oral medications.
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(see appendix f for detailed

Recommendations on GVHD prophylaxis are included in Sections 2.5.3.1 to 2.5.3.4.
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2.5.3.1. tacrolimus

Tacrolimus doses are adjusted to target whole blood levels between 5 and 15 ng/mL, except when the patient is receiving both tacrolimus and sirolimus, in which case it is recommended that serum trough levels of tacrolimus do not exceed 10 ng/mL. When a patient is switched from intravenous to oral tacrolimus, the dose is increased by 3-4 fold to adjust for the lower bioavailability of oral compared to intravenous tacrolimus. Drugs that may affect tacrolimus levels are:  
1. Caspofungin, phenobarbital, phenytoin, rifampin, carbamazepine, rifabutin, St. John's Wort (**lowers levels**);
2. Glucocorticoids, fluconazole, voriconazole, posaconazole, ketoconazole, itraconazole, grapefruit juice, amprenavir, bromocriptine, chloramphenicol, cimetidine, cisapride, clarithromycin, clotrimazole, danazol, diltiazem, erythromycin, ethinyl estradiol, metoclopramide, metronidazole, mibefradil, nefazodone, nelfinavir, nifedipine, omeprazole, quinupristin/dalfopristin, ritonavir, saquinavir, theophylline, troleandomycin, verapamil (**increases levels**).
Per the tacrolimus package insert, when initiating therapy with posaconazole or voriconazole in patients already receiving tacrolimus, it is recommended that the tacrolimus dose be reduced to one-third of the original dose and followed with frequent monitoring of the tacrolimus blood levels. Increased tacrolimus levels have been associated with nephrotoxicity. When posaconazole or voriconazole are discontinued, tacrolimus levels should be carefully monitored and the dose increased as necessary (see Appendix F). Cyclosporine may be substituted for tacrolimus if the patient is intolerant of tacrolimus.
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2.5.3.2. methotrexate

The regimen of methotrexate for GVHD prophylaxis will employ intravenous doses of 15 mg per m2on Day 1 post-transplant, and 10 or 5 mg/m2on Days 3, 6, and 11 post-transplant according to institutional standards. Third space syndromes with large accumulation of ascites or pleural effusions are a contraindication to the use of methotrexate. Dose reductions per institutional guidelines should be made for renal, hepatic and mucosal toxicity. Determinations of blood levels are indicated 24-72 hours after administration in patients with impaired renal function. Leucovorin rescue should be considered in patients with decreased clearance, severe toxicity or fluid accumulation/effusions. Drugs that may increase methotrexate levels are:  
1. Non-steroidal anti inflammatory drugs 2. Penicillins 3. Diuretics 2.5.3.3. Sirolimus
Sirolimus is recommended to be given to adult patients in a loading dose of 12 mg on Day –3 followed by a daily oral dose of 4 mg per day. Doses may be repeated if the subject vomits within 15 minutes of an oral dose. Levels of sirolimus need to be monitored frequently during initiation of treatment until target level is reached. Monitoring should be done weekly or monthly once the level reaches steady state. Frequent monitoring is required if a new medication is initiated or if the patient develops renal insufficiency. The target serum level for sirolimus is 3-12 ng/mL.  
Dose adjustments are based on clinical judgment of the treating physician after considering clinical toxicity, serum levels, GVHD, concomitant drug use and the rate of rise or decline of the serum level. For levels < 3 ng/mL, it is suggested, but not required, that the dose of sirolimus be increased by approximately 25% increments no more frequently than every 2 days, rounded to the nearest full milligram until the target range is achieved. Conversely, for levels > 12 ng/mL, it is suggested, but not required, that the dose be decreased by approximately 25% no more frequently than every 2 days until the target level is achieved. Alternatively, sirolimus can be held entirely as long as serum levels are monitored and the drug is restarted when the level returns to the therapeutic range and the treating physician feels it is appropriate to restart the agent.  
Drugs that may **increase** sirolimus blood concentrations include:
- Calcium channel blockers: diltiazem, nicardipine, verapamil.  
- Calcineurin inhibitors: cyclosporine. - Antifungal agents: ketoconazole, clotrimazole, fluconazole, itraconazole, voriconazole, posaconazole.  
- Macrolide antibiotics: clarithromycin, erythromycin, troleandomycin. - Gastrointestinal prokinetic agents: cisapride, metoclopramide. - Other drugs: rifampin, bromocriptine, cimetidine, danazol, HIV-protease inhibitors (e.g.,
ritonavir, indinavir).
Drugs that may **decrease** sirolimus concentrations include:  
- Anticonvulsants: carbamazepine, phenobarbital, phenytoin. - Antibiotics: rifabutin, rifapentine. - Herbal preparations: St. John's Wort (*Hypericum perforatum*) could result in reduced sirolimus concentrations.
Due to extreme interactions with sirolimus, voriconazole is contraindicated during sirolimus therapy. In the event of suspected or documented fungal infection, alternative antifungal therapy should be used wherever possible (see Appendix F for further details). The uses of sirolimus and myeloablative doses of busulfan are associated with hepatic veno-occlusive disease (sinusoidal obstructive syndrome) and thus should be avoided. 2.5.3.4.Post-transplantation Cyclophosphamide with MESNA Post-transplantation cyclophosphamide with MESNA may only be used with fludarabine/busulfan for non-myeloablative and busulfan/fludarabine for myeloablative conditioning regimens. MESNA will be given to reduce the risk of cyclophosphamide-associated hemorrhagic cystitis. MESNA will be dosed based on cyclophosphamide dose and may be administered per institutional guidelines.
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it is crucial that no

Tacrolimus and MMF should not be used with post-transplant cyclophosphamide if the patient received a myeloablative conditioning regimen and the donor/recipient match is 8/8. Additional immunosuppression for patients receiving post-transplant cyclophosphamide:  
- Full myeloablative regimen and donor/recipient match is 8/8: no additional prophylaxis is given
- Full myeloablative regimen with a 7/8 match and for Flu/Bu non-myeloablative regimen:
− On Day 5, patients will begin prophylaxis with Tacrolimus and Mycophenolic Acid Mofetil (MMF). Tacrolimus will be given at a dose of 1 mg IV daily then will be changed to a PO dosing schedule once a therapeutic level is achieved or as per institutional standards.  
− MMF will be given at a dose of 15 mg/kg PO TID (based upon actual body weight)
with the maximum total daily dose not to exceed 3 grams (1 g PO TID).  
− MMF prophylaxis will be discontinued after the last dose on Day 35 and Tacrolimus prophylaxis will be discontinued per institutional standards typically around Day 180.  
2.5.4. Antiretroviral Therapy Overview
Based on preliminary results from the Dana-Farber group showing that continuous antiretroviral (ARV) treatment may help prevent HIV infection in transplanted cells (ref), ARV treatment should be continued throughout the transplant process whenever possible. Antiretroviral (ARV) therapy is optimally effective when administered in combination and with consistency. However, almost all ARV medications are orally administered. It should be noted that the integrase strand transfer inhibitors (INSTIs, raltegravir and dolutegravir) are associated with low levels of GI toxicity and may be better tolerated in patients experiencing nausea than ritonavir-boosted protease inhibitor based-regimens. Elvitegravir, also an INSTI, is co-formulated (Stribild) with tenofovir, emtricitabine, and cobicistat. Co-administration of Stribild is contraindicated with drugs that are highly depending on CYP3A for clearance due to the cobicistat component. It should be used with caution in this study. Use of Enfuvirtide as a Bridging Agent When Oral ARVs Cannot Be Tolerated When oral medications cannot be tolerated due to nausea and vomiting, mucositis, or other reasons, the patient should receive the subcutaneously administered antiretroviral enfuvirtide at standard doses in order to maintain HIV suppression. Enfuvirtide monotherapy may lead to HIV resistance if used as monotherapy for prolonged periods of time, but in the short-term, the risk of acquired resistance is modest. In addition to subcutaneous administration, the benefits of enfuvirtide include that it has few drug interactions and that it is in a unique drug class without cross-resistance with other ARVs should resistance to enfuvirtide develop. **Intravenous** zidovudine is not allowed because of the possible marrow suppressive effects which could impact engraftment.  
ARVs and High Dose Chemotherapy The ARV guidelines (Appendices D **and E)** are designed to minimize the possibility of drug interactions with high dose chemotherapy. Patients on Myeloablative Conditioning Regimens *Receiving Ritonavir-Containing ARV* Therapy: Ritonavir-containing ARV therapy will restart not sooner than 12 hours after the last chemotherapy infusion, including post-transplant cyclophosphamide, as tolerated. Enfuvirtide monotherapy at standard doses should be administered as a bridging ARV therapy irrespective of the conditioning regimen when oral ARV cannot be tolerated until multi-agent ARV therapy can be resumed. Patients on Reduced Intensity Conditioning Regimens: Patients will continue on oral ARV therapy. Enfuvirtide monotherapy should be administered as above if for any reason, the patient is unable to tolerate oral ARV therapy. Table 2.5.4 outlines continuation guidelines for ARV regimens based on the conditioning regimen used.  
| Raltegravir or  Dolutegravir Based Regimen                                                                                | NNRTI Based                                                                                    | Boosted PI Based  Regimen**   |
|---------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------|-------------------------------|
| Reduced Intensity                                                                                                         | Other                                                                                          |                               |
| Regimen                                                                                                                   |                                                                                                |                               |
| Conditioning Fludarabine  Busulfan                                                                                        | Continue  throughout                                                                           |                               |
| conditioning as  tolerated                                                                                                | Discontinue ARV  96 hours prior to  conditioning and  resume after  conditioning as  tolerated |                               |
| Continue  throughout                                                                                                      |                                                                                                |                               |
| conditioning as  tolerated†                                                                                               | Consultation  recommended,                                                                     |                               |
| reviewed on a case  by case basis Consultation  recommended,  reviewed on a case  by case basis                           |                                                                                                |                               |
| Myeloablative Conditioning Fludarabine Busulfan*                                                                          | Continue  throughout                                                                           |                               |
| conditioning as  tolerated                                                                                                |                                                                                                |                               |
| Fludarabine Melphalan                                                                                                     | Continue  throughout                                                                           |                               |
| conditioning as  tolerated                                                                                                | Continue  throughout                                                                           |                               |
| conditioning as  tolerated                                                                                                | Continue  throughout                                                                           |                               |
| conditioning as  tolerated Discontinue ARV  96 hours prior to  conditioning and  resume after  conditioning as  tolerated |                                                                                                |                               |
| Continue  throughout                                                                                                      |                                                                                                |                               |
| conditioning as  tolerated†                                                                                               | Consultation  recommended,                                                                     |                               |
| reviewed on a case  by case basis                                                                                         |                                                                                                |                               |
| Cyclophosphamide Total  Body Irradiation (1200 -                                                                          | Continue                                                                                       |                               |
| 1420 cGy)                                                                                                                 | throughout                                                                                     |                               |
| conditioning as  tolerated                                                                                                | Discontinue ARV  96 hours prior to  conditioning and  resume after  conditioning as  tolerated |                               |
| Continue  throughout                                                                                                      |                                                                                                |                               |
| conditioning as  tolerated†                                                                                               | Consultation  recommended,                                                                     |                               |
| reviewed on a case  by case basis                                                                                         |                                                                                                |                               |
| *PO doses adjusted to maintain BU Css at 900 ± 100 ng/mL or per institutional standard                                    |                                                                                                |                               |
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table 2.5.4 continuation of antiretroviral

*PO doses adjusted to maintain BU Css at 900 ± 100 ng/mL or per institutional standard ** Patients receiving cyclophosphamide for GVHD prophylaxis should not resume boosted PI based regimens until Day +5 as tolerated
†Busulfan levels may be decreased when co-administered with NNRTIs See Appendix F [Table F-1] for detailed information on each interaction. Ritonavir-Based ARV Therapy and Immunosuppressive Medications Serious and prolonged toxicity is possible for patients concurrently receiving ritonavir-based (boosted-PI) therapy and the immunosuppressive agents tacrolimus or sirolimus. The introduction of immunosuppressive therapy must be systematic, carefully monitored and consistent throughout the peri-transplantation period. At the inception of immunosuppression, patients may or may not be receiving antiretroviral therapy based on the conditioning regimen selected. Patients receiving ritonavir throughout conditioning are to be managed differently than those who are not. This is due to the potent inhibition of CYP3A4 and P-glycoprotein by ritonavir, resulting in the delayed metabolism and consequently higher serum levels of tacrolimus, and sirolimus. Daily monitoring of serum trough levels of cyclosporine, tacrolimus and sirolimus is the most accurate way to provide effective immunosuppression while minimizing toxicity. In the setting of less frequent monitoring, dose adjustments can be predicted based on the metabolic pathways for each agent; however, the drug-drug interactions with ritonavir have not been studied extensively and must be supported by routine therapeutic drug monitoring as soon as possible.  
Only the doses of tacrolimus and sirolimus should be adjusted; antiretroviral therapy must be continued at the dose prescribed. For all patients, the following is recommended:  
1) Intravenous tacrolimus is preferred to avoid gastrointestinal cytochrome P450 co-enzyme inhibition during the peri-transplantation period, however oral therapy with tacrolimus, or sirolimus is permitted 2) Serum trough levels should be obtained no later than Day 5 of concurrent immunosuppressive and antiretroviral therapy 3) If clinical signs or symptoms of severe toxicity (neurotoxicity) are present OR if serum trough levels of tacrolimus/sirolimus exceed the upper limits of acceptable (*tacrolimus* >25 ng/mL, sirolimus >25 ng/mL), then BOTH antiretroviral therapy and tacrolimus/sirolimus should be held, a level repeated in 24 hours and therapy resumed once the level is within the target range 4) No dose adjustments are required for mycophenolate mofetil or methotrexate 5) Dosing recommendations based on serum levels are provided below and in Appendix F
6) Recommended standard dosing **(or per institutional standard)**:
a. Tacrolimus i. IV: 0.03 mg/kg every 24 hours (based on Ideal Body Weight)
ii. PO: 0.12 mg/kg/day divided into 2 doses b. Sirolimus i. PO: 12 mg once, then 4 mg daily as a single dose Dosing recommendations are provided for each of the following:  
  
*Day 1 represents the first day of concurrent therapy with cyclosporine, tacrolimus, or sirolimus and ritonavir-based antiretroviral therapy.
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2) patients discontinuing ritonavir-based therapy

a. Antiretroviral therapy should be discontinued 4-7 days prior to any myeloablative conditioning regimen and busulfan-containing reducedintensity conditioning b. Antiretroviral therapy should be restarted no sooner than Day -1 as tolerated c. For patients receiving post-transplant cyclophosphamide for GVHD
prophylaxis, antiretroviral therapy will be restarted on Day +5 as tolerated  
  
*Day 1 represents the first day of concurrent therapy with tacrolimus, or sirolimus and ritonavir-based antiretroviral therapy. For patients restarting antiretroviral therapy, **this should be Day -1**, unless they are unable to tolerate oral medications or receive cyclophosphamide for GVHD prophylaxis.  
3) Dosing based on a serum trough level of tacrolimus, or sirolimus while receiving ritonavir-based therapy  
| Immunosuppressive  Agent                                                                                                                       | Target Trough   | Recommendation1                                                                                                                                                                                          |
|------------------------------------------------------------------------------------------------------------------------------------------------|-----------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Tacrolimus                                                                                                                                     | 5 - 15 ng/mL    | < 5 ng/mL: Administer 1 mg (PO) or 0.25 mg (IV)2 >5 - 15 ng/mL: Administer 0.5 mg (PO) or 0.125 mg (IV) 2 >15 - 25 ng/mL: HOLD tacrolimus & repeat level in 24h > 25 ng/mL: HOLD both tacrolimus and ARV |
| Sirolimus                                                                                                                                      | 3 - 12 ng/mL    | < 3 ng/mL: Administer 0.4 mg (PO) 2 >3 - 12 ng/mL: Administer 0.3 mg (PO) 2 >12-25ng/mL: HOLD sirolimus & repeat level in 24h >25ng/mL: HOLD both sirolimus and ARV                                      |
| ARV= Antiretroviral Therapy 1See Appendix F (Table F-3) for detailed information 2Administer a one-time dose in response to the observed level |                 |                                                                                                                                                                                                          |  
2.5.5. Initiation of Antifungal Prophylaxis in Ritonavir-Based Antiretroviral Therapy Detailed information is available in Appendix F Table F-6 for patients receiving ritonavir-based antiretroviral therapy. Initiating antifungal prophylaxis in patients concomitantly receiving ritonavir may result in serious toxicity. Moreover, many antifungal agents affect the metabolism of the immunosuppressive agents, tacrolimus, sirolimus and cyclophosphamide, also resulting in the increased risk of serious adverse events. *Careful selection of the most appropriate antifungal* agent and routine therapeutic drug monitoring are strategies to minimize the risk of severe toxicity. Fluconazole is effective against yeasts other than *Candida krusei* and some *C. glabrata*, but is not effective against moulds. For patients at high risk for mould infections (such as those with cell-mediated immunodeficiency from GVHD) or those with a prior history of invasive aspergillosis, prophylaxis with an anti-mould agent is recommended. Given the three-way interaction between selected immunosuppressive drugs, HIV medications (especially protease inhibitors) and triazole agents (especially voriconazole, itraconazole, and to a lesser extent posaconazole), the echinocandins (anidulafungin, caspofungin, micafungin) and amphotericin B (either the aerosolized or intravenous formulations) are preferred for prophylaxis. The echinocandins are effective against *Aspergillus* mould only, whereas amphotericin B has a broader spectrum of mould activity. Aerosolized liposomal amphotericin B has been shown to be effective in reducing invasive pulmonary aspergillosis in leukemic and HCT patients.
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2.5.5.1.voriconazole

Voriconazole is metabolized by, and inhibits the activities of, human cytochrome P450 enzymes CYP2C19, CYP3A4 and CYP2C9. The affinity of voriconazole is the highest for CYP2C19, followed by CYP2C9 and CYP3A4; however there is a large degree of inter-individual variability in voriconazole pharmacokinetics. The interactions between voriconazole and the antiretroviral agents, specifically ritonavir, are complex. *Concurrent use of high-dose ritonavir* (400-600 *mg twice daily) is contraindicated* due to significant reduction in plasma concentration of voriconazole. Low-dose ritonavir (100mg twice daily) has been shown to decrease the voriconazole AUC by 39% in healthy subjects after 9 days; however, upon initiation of voriconazole, the AUC may be increased by 4.5 fold. This is due to a time- and dose-dependent interaction where ritonavir initially inhibits voriconazole metabolism, followed by delayed induction. Moreover, voriconazole may further inhibit the metabolism of immunosuppressive agents, such as tacrolimus, sirolimus and cyclophosphamide. The following is recommended for initiating voriconazole prophylaxis in patients receiving protease inhibitor-based antiretroviral therapy:  
1) No high-dose ritonavir (contra-indicated due to significant reduction of plasma voriconazole concentrations)
2) Avoid loading doses (due to significant voriconazole effect on calcineurin inhibitors and sirolimus levels); initiate prophylaxis with voriconazole 4 mg/kg IV or 200mg PO every 12 hours 3) Therapeutic drug monitoring of voriconazole is required within 7 days of concomitant therapy (due to significant effect of protease inhibitors on voriconazole) a. Serum trough levels ≥ 1 mcg/ml are desired for optimal efficacy b. Serum trough levels > 6 mcg/ml are associated with greater toxicity 4) Close monitoring (daily if possible) of serum levels for cyclosporine, tacrolimus or sirolimus is strongly recommended (due to significant effect of voriconazole on these agents) a. In the absence of an appropriate level, administer 10% of the standard dose of cyclosporine, tacrolimus or sirolimus (see Section 2.5.4)
5) Monitor closely for signs or symptoms of voriconazole toxicity (hepatotoxicity, CNS
toxicity)
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2.5.5.2.posaconazole

Posaconazole also inhibits the activity of human cytochrome P450 enzymes especially the isoform CYP3A4, which can increase the plasma concentration and exposure of drugs metabolized by this enzyme. However, posaconazole does not inhibit the CYP450 isoforms CYP1A2, 2C8/9, 2D6, or 2E1, and thus potentially has a lower drug interaction potential than voriconazole. Unlike voriconazole, posaconazole metabolism is mediated primarily by uridine diphosphate glucuronosyltransferase. In general, the metabolic pathways of posaconazole and ritonavir suggest that posaconazole may increase the plasma concentrations of ritonavir, and ritonavir may decrease the plasma concentration of posaconazole. Posaconazole may further inhibit the metabolism of immunosuppressive agents, such as tacrolimus, sirolimus and cyclophosphamide. The following is recommended for initiating posaconazole prophylaxis in patients receiving protease inhibitor-based antiretroviral therapy:  
1) No high-dose ritonavir (contra-indicated due to significant reduction of plasma posaconazole concentrations)
2) Therapeutic drug monitoring of posaconazole is required within 7 days of concomitant therapy (due to significant effect of protease inhibitors on posaconazole). Therapeutic levels of posaconazole have not been established, but low levels have been encountered in the setting of impaired absorption with poor food intake, acute GVHD, or diarrhea.  
3) Close monitoring (daily if possible) of serum levels for cyclosporine, tacrolimus or sirolimus is strongly recommended (due to significant effect of posaconazole on these agents) a. In the absence of an appropriate level, administer 10% of the standard dose of tacrolimus or sirolimus (see Section 2.5.4)
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2.6. supportive care 2.6.1. post-hct

All supportive care will be given in keeping with BMT CTN MOP and local institutional guidelines. 2.6.1.1. Prophylaxis against infections All patients will receive prophylaxis against bacterial, fungal and viral infections during the postHCT period according to the BMT CTN MOP. Additional guidelines for HIV patients in this study are summarized in Appendix E.
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2.6.1.2. cryopreservation

Donor's stem cells may be cryopreserved prior to transplantation at the discretion of treating institution and in keeping with NMDP policy if an unrelated donor. 2.6.1.3. Post-HCT growth factors Use of Post-HCT growth factors will be according to institutional standards.
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2.7. participant risks

HCT recipients incur risks from high-dose conditioning and post-HCT therapy, which must be weighed against the risk of the disease for which the HCT is prescribed. Major risks following transplantation include: 1) Infection which can be bacterial, viral, parasitic, or fungal. Often, these infections are life-threatening, particularly when caused by viral or fungal agents, and are associated with high mortality in the transplant population. The published experience shows increased risk of CMV viremia, but no increase in mortality related to that virus; 2) Damage of all or any of the major organs may occur as a result of reactions to drugs (e.g., chemotherapy, antibiotics, anti-fungal medications), and as a result of destructive processes (e.g., infection), and may have a fatal outcome; brain damage can result in severe loss of cognitive or neurologic function; 3) Relapse or progression may occur, especially in patients with advanced disease status at time of treatment; 4) Unknown toxicities may occur in any individual patient due to multiple events and cumulative effects which may involve any and all organs, including the brain; and, 5) Death.
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2.8. therapy toxicities

All toxicities will be graded using the Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0. All of the following listed agents are commercially available. Refer to www.fda.gov for full adverse event information regarding the agents listed below. All of the following agents should be administered per institutional standards, and stored per package insert instructions.
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2.8.1. busulfan

Busulfan is a bi-functional alkylating agent. Toxicities include the following: Severe bone marrow hypoplasia, which would be fatal without administration of bone marrow, stem cells; nausea and vomiting, which can be decreased by the use of sedation and anti-emetics; stomatitis and diarrhea, which can be treated symptomatically with fluid replacement and atropine or diphenoxylate HCl; pulmonary fibrosis characterized by delayed onset of cough, shortness of breath and low-grade fever; hepatic damage, which can occur in combination with cyclophosphamide or as a single agent and can result in significant hepatic toxicity, which can be fatal; temporary hyperpigmentation of the skin and nail bed changes; and grand mal seizures, which can be prevented by the prophylactic administration of phenytoin.
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2.8.2. melphalan

Melphalan, an alkylating agent, is a phenylalanine derivative of nitrogen mustard. At high doses, the likely toxicities include myelosuppression, gastrointestinal toxicity and alopecia. The duration of profound myelosuppression decreases with the use of stem cell transplantation and colony stimulating factors. Gastrointestinal toxicity, which includes potentially severe stomatitis, esophagitis and diarrhea, may require intravenous narcotics for mucositis-related pain, intravenous hydration and alimentation, and antibiotics. Less likely is hepatotoxicity. Rare but serious toxicities reported include pulmonary fibrosis and interstitial pneumonitis, venoocclusive disease of the liver, skin hypersensitivity, vasculitis, hemolytic anemia, allergic reactions, and a small risk of developing second cancers.
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2.8.3. fludarabine

a. Neurotoxicity: Agitation or confusion, blurred vision, loss of hearing, peripheral neuropathy or weakness have been reported. Severe neurologic effects, including blindness, coma, and death are seen in 36% of patients treated with doses approximately four times greater than recommended; severe CNS toxicity is rarely seen with doses in the recommended range for non-transplant therapy of hematologic malignancies. Effect of chronic use on the CNS is unknown, although patients have received recommended doses for up to 15 courses. The dose used in this study is approximately 1.5 times the usual one-course dose given in non-transplant settings. Doses and schedules such as those used in this study have been used in adult and pediatric patients and increased neurotoxicity has not been observed.  
b. Anemia: Life-threatening and sometimes fatal autoimmune hemolytic anemia has been reported after one or more cycles of therapy in patients with or without a previous history of autoimmune hemolytic anemia or a positive Coombs' test and who may or may not be in remission; no mechanisms for development of this complication have been identified. Corticosteroids may or may not be effective in controlling these episodes. The majority of patients re-challenged developed a recurrence of the hemolytic process.  
c. Cardiovascular: Deep venous thrombosis, phlebitis, transient ischemic attack, and aneurysm (1%) are reported.
d. Fever: 60% of patients develop fever. e. Skin Rash: 15% of patients develop a skin rash, which may be pruritic.  
f. Digestive: Gastrointestinal side effects include: nausea/vomiting (36%), diarrhea (15%),
stomatitis (9%), anorexia (7%), GI bleeding and esophagitis (3%), mucositis (2%), liver failure, abnormal liver function test, constipation, dysphagia (1%) and mouth sores.  
g. Some other effects are: Chills (11%), peripheral edema (8%), myalgia (4%), osteoporosis
(2%), pancytopenia, arthralgia (1%), dysuria (4%), urinary tract infection and hematuria (2%); renal failure, abnormal renal function test, and proteinuria (1%); and, very rarely, hemorrhagic cystitis and pulmonary toxicity.
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2.8.4. cyclophosphamide

Cyclophosphamide side effects include: nausea/vomiting, cardiomyopathy, skin rash, mucositis, stomatitis, sterility, diarrhea, hemorrhagic cystitis, fluid weight gain/edema, alopecia and hemolytic anemia.
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2.8.5. total body irradiation

TBI can cause: nausea and vomiting, diarrhea, parotitis (rapid onset within 24-48 hours, usually self-limited), generalized mild erythema, hyperpigmentation, fever, mucositis, and alopecia. Late effects include: possible growth retardation, vertebral deformities, cataracts, probable increased risk of secondary malignant neoplasms, sterility, nephropathy, interstitial pneumonitis and veno-occlusive disease.
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2.8.6. tacrolimus

Side effects include: reversible renal insufficiency, hypertension, hypomagnesemia, hypokalemia, and neurologic toxicity. A syndrome of thrombotic microangiopathy, comprised of microangiopathic hemolytic anemia, thrombocytopenia and renal dysfunction has been described in association with sirolimus and tacrolimus use. In common with all other immunosuppressants, it may increase the risk of opportunistic infections and post-transplant lymphoproliferative disorders.
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2.8.7. sirolimus

Despite the similarity between sirolimus and tacrolimus, sirolimus is not associated with neurotoxicity or nephrotoxicity because of its inability to inhibit calcineurin. Phase III clinical trials have indicated that the primary toxicities are hypertriglyceridemia, hypercholesterolemia, mild thrombocytopenia, anemia, leukopenia, hypokalemia, elevated LDH, arthralgia, epistaxis, edema, and infections. Clinically significant elevations in hepatic transaminases without sequelae were noted in the prior Phase II study with this drug.
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2.8.8. methotrexate

The most frequently reported adverse reactions associated with methotrexate use as GVHD prophylaxis include ulcerative stomatitis, leucopenia and suppressed hematopoiesis, nausea, and abdominal distress. Other frequently reported adverse effects are malaise, undue fatigue, chills and fever, dizziness and decreased resistance to infection. Methotrexate may be associated with increased rates of pulmonary complications after transplantation. The risk of infections is due to the suppression of hematopoiesis after transplantation.
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2.8.9. mycophenolate mofetil (mmf)

The most frequent reported adverse reactions associated with MMF include infection, upset stomach and nausea. Less common reported adverse effects are low blood counts, vomiting and diarrhea. Some rare but serious reported adverse reactions include serious injury to the gut including bloody stools and vomit, secondary cancers such as lymphoproliferative disease or lymphoma, serious infections of the brain, risks to a baby in pregnancy and progressive multifocal leukoencephalopathy (PML).
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chapter 3 3. study endpoints

Patients will be assessed for 100-Day Non-Relapse Mortality. The events for non-relapse mortality are death due to any cause other than relapse of the underlying malignancy.
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3.2. secondary endpoints

3.2.1. 100-day Disease Status Following Transplant Patients will be assessed for disease status at Day 100 post-HCT: complete remission, partial remission (HL, NHL), stable disease (HL, NHL), relapse. 3.2.2. Time to Hematopoietic Recovery Time to neutrophil recovery will be the first of three consecutive days of > 500 neutrophils/μL following the expected nadir. Patients who never nadir will be censored for time to neutrophil recovery. Time to platelet engraftment will be the date platelet count is > 20,000/μL for the first of three consecutive labs with no platelet transfusions 7 days prior.
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3.2.3. chimerism

Blood samples will be evaluated for T cell and myeloid chimerism at 4 weeks, Day 100, and 6 months post-transplant. 3.2.4. Hematologic Function Hematologic function will be defined by ANC >1500, Hemoglobin >10g/dL without transfusion support, and platelets >100,000 and measured at Day 100 and6 months. Use of growth factors will be noted. 3.2.5. Occurrence of Infections Microbiologically documented infections will be reported by site of disease, date of onset, severity, and resolution, if any. 3.2.6. Six Month Overall Survival Overall survival is defined as time from transplant to death or last follow-up.
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3.2.7. acute graft-versus-host disease (gvhd)

Acute GVHD will be graded according to the BMT CTN MOP. The time to onset of acute grades II-IV GVHD and grades III-IV GVHD will be recorded, as well as the maximum grade experienced. 3.2.8. Chronic Graft-versus-Host Disease (GVHD) Chronic GVHD will be scored according to the BMT CTN MOP. The time to onset of limited and extensive chronic GVHD will be recorded.
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3.2.9. immunologic reconstitution

This will be measured in all patients at 8 weeks, 6, 12 and 24 months. Tests to be performed on peripheral blood at those time points include CD2, CD3, CD4, CD8, CD19, CD3+/CD25+, CD45 RA/RO, CD56+/CD3-, and quantitative immunoglobulins (IgM, IgG and IgA).
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3.2.10. impact of therapy on

HIV-1 RNA in plasma will be measured by standard real-time RT-PCR (detection limit 40 copies/ml) and by the investigational single copy assay (SCA, detection limit 0.38 copy/ml). HIV-1 DNA in peripheral blood mononuclear cells (PBMCs) and other cells will be quantified using the same primers and probes used for SCA but without a reverse transcription step. HIV-1 DNA levels will be normalized by cell number and amplifiable cellular DNA (GAPDH). Assays will be performed in triplicate on each sample. HIV-1 RNA levels will be measured in plasma prior to the initiation of ablative chemotherapy, and at Day 100, 6, 12 and 24 months posttransplant. The latent HIV reservoir measurement assay at approximately 13 months will only occur in those patients who have no measurable viral load by single copy HIV assay at 12 months (Appendix C). Definition of maintenance of ARV: All attempts should be made to maintain the oral ARV regimen through the first year after transplantation. Subcutaneous enfuvirtide should be added during administration of high-dose cyclophosphamide (due to the risk of nausea and vomiting) and other similarly nauseating regimens and during any other periods when oral ARV is not tolerated (e.g. mucositis). If participants are unable to take oral ARV but are maintained on subcutaneous enfuvirtide alone, this will be considered maintenance of ARV. Failure to maintain ARV will be defined as ≥ 24 hours after the next scheduled dose is expected to be received without any ARV therapy.
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3.3. disease status assessment 3.3.1.

Patients at each data collection period are classified into one of the disease statuses specified below (CR, PR, SD, PD). After HCT and until relapse/progression, all disease status classifications are relative to the patient's pre-HCT disease status. Tests used for evaluation of disease status would be physical examination, laboratory testing, bone marrow biopsy and aspirate, PET scans, and CT scans of neck, chest, abdomen and pelvis as indicated.  
Segments of this section are excerpts from the Bruce Cheson, et al, article "Revised Response Criteria for Malignant Lymphoma."
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complete remission (cr)

The designation of CR requires the following (Table 3.1):
- Complete disappearance of all detectable clinical evidence of disease and disease-related symptoms if present before therapy.  
- Typically FDG-avid lymphoma: in patients with no pretreatment PET scan or when the PET scan was positive before therapy, a post-treatment residual mass of any size is permitted as long as it is PET negative.  
- Variably FDG-avid lymphomas/FDG avidity unknown: in patients without a pretreatment PET scan, or if a pretreatment PET scan was negative, all lymph nodes and nodal masses must have regressed on CT to normal size (≤ 1.5 cm in their greatest transverse diameter for nodes > 1.5 cm before therapy). Previously involved nodes that were 1.1 to 1.5 cm in their long axis and more than 1.0 cm in their short axis before treatment must have decreased to ≤ 1.0cm in their short axis after treatment.  
- The spleen and/or liver, if considered to be enlarged before therapy on the basis of a physical examination or CT scan, should not be palpable on physical exam and should be considered normal size by imaging studies, and nodules related to lymphoma should disappear. However, determination of splenic involvement is not always reliable because a spleen considered normal in size may still contain lymphoma, whereas an enlarged spleen may reflect variations in anatomy, blood volume, the use of hematopoietic growth factors, or causes other than lymphoma.  
- If bone marrow was involved by lymphoma before treatment, the infiltrate must have cleared on repeat bone marrow biopsy. The biopsy sample on which this determination is made must be adequate (with a goal of > 20 mm unilateral core). If the sample is indeterminate by morphology, it should be negative by immunohistochemistry. A sample that is negative by immunohistochemistry but that demonstrates a small population of clonal lymphocytes by flow cytometry will be considered a CR until data become available demonstrating a clear difference in patient outcome.  
| TABLE 3.1: RESPONSE DEFINITIONS - NON-HODGKINS'S LYMPHOMA*                                                                                                      |                                                                                  |                                                                                                                                                                                                             |                                                                                                                                       |                                                                                                                  |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------|
| Response                                                                                                                                                        | Definition                                                                       | Nodal Masses                                                                                                                                                                                                | Spleen, Liver                                                                                                                         | Bone Marrow                                                                                                      |
| CR                                                                                                                                                              | Disappearance  of all evidence  of disease                                       | (a) FDG-avid or PET positive  prior to therapy; mass of any  size permitted if PET negative                                                                                                                 | Not palpable,  nodules  disappeared                                                                                                   | Infiltrate cleared on  repeat biopsy; if  indeterminate by  morphology, immunohistochemistry  should be negative |
| (b) Variably FDG-avid or PET  negative; regression to normal  size on CT                                                                                        |                                                                                  |                                                                                                                                                                                                             |                                                                                                                                       |                                                                                                                  |
| PR                                                                                                                                                              | Regression of  measurable  disease and no  new sites                             | ≥ 50% decrease in SPD of up to  6 largest dominant masses; no  increase in size of other nodes                                                                                                              | ≥ 50% decrease  in SPD of  nodules (for  single nodule  in greatest  transverse  diameter); no  increase in size  of liver or  spleen | Irrelevant if positive  prior to therapy; cell  type should be  specified                                        |
| (a) FDG-avid or PET positive  prior to therapy; one or more  PET positive at previously  involved site (b) Variably FDG-avid or PET  negative; regression on CT |                                                                                  |                                                                                                                                                                                                             |                                                                                                                                       |                                                                                                                  |
| SD                                                                                                                                                              | Failure to  attain CR/PR  or PD                                                  | (a) FDG-avid or PET positive  prior to therapy; PET positive at  prior sites of disease and no  new sites on CT or PET (b) Variably FDG-avid or PET  negative; no change in size of  previous lesions on CT |                                                                                                                                       |                                                                                                                  |
| Relapsed  disease or  PD                                                                                                                                        | Any new  lesion or  increase by ≥ 50% of  previously  involved sites  from nadir | Appearance of a new lesion(s)  > 1.5 cm in any axis, ≥ 50%  increase in SPD of more than  one node, or ≥ 50% increase in  longest diameter of a previously  identified node > 1 cm in short  axis           | > 50% increase  from nadir in  the SPD of any  previous  lesions                                                                      | New or recurrent  involvement                                                                                    |
| Lesions PET positive if FDGavid lymphoma or PET positive prior to therapy                                                                                                                                                                 |                                                                                  |                                                                                                                                                                                                             |                                                                                                                                       |                                                                                                                  |
| Abbreviations: CR, complete remission; FDG, [18F]fluorodeoxyglucose; PET, positron emission tomography; CT, computed                                            |                                                                                  |                                                                                                                                                                                                             |                                                                                                                                       |                                                                                                                  |
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complete remission undetermined (cru)

- The use of the above definition for CR and that below for PR eliminates the category of CRu.
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partial remission (pr)

The designation of PR requires all of the following:
- At least a 50% decrease in sum of the product of the diameters (SPD) of up to six of the largest dominant nodes or nodal masses. These nodes or masses should be selected according to all of the following: they should be clearly measurable in at least 2 perpendicular dimensions; if possible they should be from disparate regions of the body; and they should include mediastinal and retroperitoneal areas of disease whenever these sites are involved.  
- No increase should be observed in the size of other nodes, liver or spleen.
- Splenic and hepatic nodules must regress by  50% in their SPD or, for single nodules in the greatest transverse diameter.  
- With the exception of splenic and hepatic nodules, involvement of other organs is usually assessable and no measurable disease should be present.  
- Bone marrow assessment is irrelevant for determination of a PR if the sample was positive before treatment. However, if positive, the cell type should be specified (eg, large-cell lymphoma or small neoplastic B cells). Patients who achieve a CR by the above criteria, but who have persistent morphologic bone marrow involvement will be considered partial responders. When the bone marrow was involved before therapy and a clinical CR was achieved, but with no bone marrow assessment after treatment, patients should be considered partial responders.  
- No new sites of disease should be observed.  
- Typically FDG-avid lymphoma: for patients with no pretreatment PET scan or if the PET
scan was positive before therapy, the post-treatment PET should be positive in at least one previously involved site.  
- Variably FDG-avid lymphomas/FDG-avidity unknown: for patients without a pretreatment PET scan, or if a pretreatment PET scan was negative, CT criteria should be used. In patients with follicular lymphoma or mantle-cell lymphoma, a PET scan is only indicated with one, or at most two, residual masses that have regressed by more than 50% on CT; those with more than two residual lesions are unlikely to be PET negative and should be considered partial responders.
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stable disease (sd)

Stable disease (SD) is defined as the following:
- A patient is considered to have SD when he or she fails to attain the criteria needed for a CR or PR, but does not fulfill those for progressive disease (see Relapsed Disease [after CR]/Progressive Disease [after PR, SD]).  
- Typically FDG-avid lymphomas: the PET should be positive at prior sites of disease with no new areas of involvement on the post-treatment CT or PET.  
- Variably FDG-avid lymphomas/FDG-avidity unknown: for patients without a pretreatment PET scan or if the pretreatment PET was negative, there must be no change in the size of the previous lesions on the post-treatment CT scan.
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relapsed disease (rd after cr)/

Lymph nodes should be considered abnormal if the long axis is more than 1.5 cm regardless of the short axis. If a lymph node has a long axis of 1.1 to 1.5 cm, it should only be considered abnormal if its short axis is more than 1.0. Lymph nodes ≤ 1.0 x ≤ 1.0cm will not be considered as abnormal for relapse or progressive disease.  
- Appearance of any new lesion more than 1.5 cm in any axis during or at the end of therapy, even if other lesions are decreasing in size. Increased FDG uptake in a previously unaffected site should only be considered relapsed or progressive disease after confirmation with other modalities. In patients with no prior history of pulmonary lymphoma, new lung nodules identified by CT are mostly benign. Thus, a therapeutic decision should not be made solely on the basis of the PET without histologic confirmation.  
- At least a 50% increase from nadir in the SPD of any previously involved nodes or in a single involved node, or the size of other lesions (e.g, splenic or hepatic nodules). To be considered progressive disease, a lymph node with a diameter of the short axis of less than 1.0 cm must increase by  50% and to a size of 1.5 x 1.5 cm or more than 1.5 cm in the long axis.  
- At least a 50% increase in the longest diameter of any single previously identified node more than 1 cm in its short axis.
- Lesions should be PET positive if observed in a typical FDG-avid lymphoma or the lesion was PET positive before therapy unless the lesion is too small to be detected with current PET systems (< 1.5 cm in its long axis by CT). Measurable extranodal disease should be assessed in a manner similar to that for nodal disease. For these recommendations, the spleen is considered nodal disease. Disease that is only assessable (e.g. pleural effusions, bone lesions) will be recorded as present or absent only, unless, while an abnormality is still noted by imaging studies or physical examination, it is found to be histologically negative. In clinical trials where PET is unavailable to the vast majority of participants, or where PET is not deemed necessary or appropriate for use (e.g. a trial in patients with MALT lymphoma), response should be assessed as above, but only using CT scans. However, residual masses should not be assigned CRu status, but should be considered partial responses.  
3.3.2. Acute Leukemia and Myelodysplastic Syndromes Assessment after transplantation response will be assessment as follows: Complete Remission:
- Bone marrow myeloblasts < 5% by morphologic assessment; - No circulating blasts;  
- Neutrophil count ≥ 1,000/µL; - Absence of previous cytogenetic or molecular abnormality identified prior to transplantation in the bone marrow aspirate.
Disease Relapse for Patients with AML:  
- Increase in bone marrow blast to ≥ 5% by morphologic assessment not attributed to other causes (e.g., bone marrow regeneration); or if < 5%, reappearance of blasts with the same leukemia phenotype as present at diagnosis.  
- Reappearance of blasts with aberrant phenotype by flow cytometry. - Reappearance of leukemic blasts in the peripheral blood. - Reappearance of previous cytogenetic or molecular marker of disease present prior to transplantation.  
- The development of extramedullary leukemia or leukemic cells in the cerebral spinal fluid.
Disease Relapse for Patients with MDS:
- Satisfying above criteria for evolution into acute leukemia; or,  
- Reappearance of pre-transplant morphologic abnormalities, detected in two consecutive bone marrow specimens taken at least one month apart; or,
- Reappearance of pre-transplant cytogenetic abnormality in at least one metaphase on each of two separate consecutive examinations at least one month apart, regardless of the number of metaphases analyzed.
chapter 4
4. patient enrollment and evaluation

4.1.1. Screening and Eligibility Procedures Patients will be registered using the BMT CTN Electronic Data Capture System
(AdvantageEDCSM). The following procedures should be followed:  
1. An authorized user at the transplant center completes the Segment 0 Screening Form
(patient demographic data and the date that informed consent was signed). A study number will be generated for the patient with the submission of the Segment 0 Screening Form. - Potential Unrelated Donor Transplant: Patients requiring an unrelated donor should be enrolled in the Segment 0 at least 3 months prior to the proposed start of conditioning. In some cases, patients will not be able to be enrolled at least 3 months prior to the proposed start of conditioning. If this is the case, the patient should be enrolled as early as possible but no less than 2 weeks prior to the proposed start of conditioning.  
- Potential Related Donor Transplant: Patients with an available related donor should be enrolled in Segment 0 approximately 8 to 10 weeks (but no less than 2 weeks) prior to the proposed start of conditioning.
Note: There are two reasons for completing the screening enrollment phase early. First, blood specimens are collected at baseline to address important research questions in this study. Secondly, for patients requiring an unrelated donor, sufficient time is needed for the unrelated donor search.  
2. The transplant coordinator at the transplant center should proceed with their institution's standard procedure to identify a sibling donor, if applicable. If an unrelated donor search is to be pursued, then the coordinator should inform the transplant center's assigned NMDP coordinator through the standard procedure for any unrelated donor.  
3. Due to the complex nature of the patient population and the potential for numerous drugdrug interactions between the antiretroviral regimen and the allogeneic HCT treatment regimen, each patient's treatment regimen must be reviewed with the Treatment Review Committee. Appendix D details the process for getting Treatment Review Committee approval. This review should typically occur at least 4 weeks prior to the planned transplant date in order to allow sufficient time for any necessary adjustments to the patient's medication regimen. In some patients' circumstances, a 4-week lead time may not be possible; this alone will not make the patient ineligible for the study.
4. Prior to initiation of conditioning therapy (typically 1-2 weeks), an authorized user at the transplant center completes Segment A of the Enrollment Form in AdvantageEDC. Segment A includes questions that verify eligibility and captures the proposed start date of conditioning.
chapter 4
4.2. study monitoring 4.2.1. follow-up

The follow-up schedule for scheduled study visits is outlined in Table 4.2.1. A detailed description of each of the forms and the procedures required for forms completion and submission can be found in the Data Management Handbook and User's Guide. The Data Management Handbook, including the Forms Submission Schedule, is available on the homepage of the Internet data entry system. Follow-up Visits: Follow-up visits will begin as soon as patients are enrolled onto the study. The follow-up period is 24months.  
| Target Day                         |          |
|------------------------------------|----------|
| (+ 2 Days to Day 100 Post-HCT)     |          |
| (+ 28 Days After Day 100 Post-HCT) |          |
| Study Visit 1 week                 | 7 days   |
| 2 week                             | 14 days  |
| 3 week                             | 21 days  |
| 4 week                             | 28 days  |
| 5 week                             | 35 days  |
| 6 week                             | 42 days  |
| 8 week                             | 56 days  |
| 100 day                            | 100 days |
| 6 month                            | 180 days |
| 12 month                           | 365 days |
| 13 month                           | 395 days |
| 24 month                           | 730 days |  
Criteria for Forms Submission: Criteria for timeliness of submission for all study forms are detailed in the Data Management Handbook and User's Guide. Forms that are not entered into AdvantageEDC within the specified time will be considered delinquent. A missing form will continue to be requested either until the form is entered into the AdvantageEDC and integrated into the Data and Coordinating Center's (DCC) master database or until an exception is granted and entered into the Missing Form Exception File, as detailed in the Data Management Handbook.  
Reporting Patient Deaths: Recipient Death Information must be entered into AdvantageEDC
within 24 hours of knowledge of the patient's death on the Death Form. If the cause of death is unknown at that time, the cause of death field may be left blank. However, once the cause of death is determined, the form must be updated in AdvantageEDC. In addition, all deaths must be reported via the Unexpected Grade 3-5 Adverse Event Forms in AdvantageEDC for this study. CIBMTR Data Reporting: Centers participating in BMT CTN trials must register pre- and post-transplant outcomes on all consecutive hematopoietic stem transplants done at their institution during their time of participation to the Center for International Blood and Marrow Transplant Research (CIBMTR). Registration is done using procedures and forms of the Stem Cell Transplant Outcomes Database (SCTOD). (Note: Federal legislation requires submission of these forms for all US allotransplant recipients.) Enrollment of BMT CTN \#0903 must be indicated on the SCTOD pre-transplant registration form. Additionally, CIBMTR pre- and posttransplant Report Forms must also be submitted for all patients enrolled on this trial. CIBMTR
forms will be submitted directly to the CIBMTR at the times specified on the Form Submission Schedule. Weekly GVHD Monitoring: GVHD should be monitored in accordance with BMT CTN guidelines as specified in the Manual of Procedures. Patients should be assessed weekly until Day 56 post-transplant for GVHD. After Day 56, patients will be assessed at each follow-up visit (Day 100, and 6, 12, and 24 months) for the presence of GVHD. For scheduling, a target day range has been provided in Table 4.2.1.
chapter 4
4.2.2. adverse event reporting

Unexpected, grade 3-5 adverse events (AE) and all deaths will be reported through an expedited AE reporting system via AdvantageEDC. Unexpected, grade 4-5 AEs must be reported within 24 hours of knowledge of the event. Unexpected, grade 3 AEs must be reported within three business days of knowledge of the event. Expected AEs will be reported using NCI's Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0 at regular intervals as defined on the Form Submission Schedule. Tables 4.2.2.A and 4.2.2.B summarize patient clinical assessments over the course of the study. 4.2.3. Patient Evaluations prior to the HCT conditioning therapy The following observations need to be performed within 3 months of initiation of conditioning:  
1. CMV IgG, hepatitis panel (HAV Ab, HBsAb, HBsAg, HBcAb, HCVAb), HSV 1 and 2 IgG, RPR or VDRL, toxoplasma IgG, VZV IgG, and HTLV1 antibody.  
2. EKG 3. Creatinine clearance (calculated creatinine clearance is permitted).
4. CMV PCR or antigenemia assay.  
5. DLCO, FEV1 and FVC.
6. HIV-1 RNA level (HIV viral load by standard assay).  
7. CD4 count. 8. If hepatitis B core and/or hepatitis C antibodies are positive, hepatitis B DNA PCR and/or hepatitis C RNA PCR must be checked.  
9. Cardiac ejection fraction by MUGA or echocardiography.
10. Signed informed consent form.  
The following observations need to be performed within 8 weeks prior to initiation of conditioning:  
1. History, physical examination, height and weight, body surface area, neurologic examination, measurement of all palpable peripheral lymph nodes and measurement of other sites of disease present on physical.  
a. Lumbar puncture(s) for determination of presence of CNS disease for patients with either non-Hodgkin's lymphoma or acute lymphocytic leukemia is required.  
b. Duration of HIV/AIDS diagnosis, history of prior opportunistic illnesses. c. Presence or absence of "B"-symptoms (unexplained fevers, night sweats, involuntary weight loss greater than 10% normal body weight).  
d. Medication list to include all antiviral, antibiotics and opportunistic infection prophylaxis.
2. β-HCG serum pregnancy test for females of childbearing potential.  
3. Blood samples for evaluation of immune reconstitution by flow cytometry (CD2, CD3, CD4, CD8, CD19, CD3+/CD25+, CD45RA/RO, and CD56+/CD3-) and quantitative immunoglobulins (IgM, IgG, and IgA).  
4. Blood collected for latent virus recovery assay; will be collected for only those patients that have documented undetectable plasma HIV-1 by standard assay at the time of enrollment (see Appendix C).
The following tests and observations will be performed within 4 weeks prior to initiation of conditioning:
1. For lymphoma patients: CT scans of neck, chest, abdomen and pelvis. Neck CT only required if previous site of disease. PET scan should be performed.  
2. Bone marrow aspiration and biopsy, including cytogenetics
The following tests and observations will be performed within 1-3 weeks prior to initiation of conditioning:
1. Blood for HIV single copy measurements (see Appendix C). 2. Optional future research sample collection for consenting patients (see Appendix C).  
The following tests and observations will be performed within 1 week prior to initiation of conditioning:
1. Karnofsky/Lansky performance status.  
2. CBC with differential, platelet count, creatinine, bilirubin, LDH, alkaline phosphatase.  
3. ALT, AST, sodium, magnesium, potassium, chloride, and CO2.  
4. Blood for Microbial Translocation Markers collected within 1 week prior to the initiation of conditioning and on Day -3 of conditioning (see Appendix C).  
5. Blood for HIV single copy measurement (see Appendix C).
4.2.4. Patient Post-HCT Evaluations  
1. Physical examination and weight weekly until 4 weeks then at 8 weeks, 100 days, 6, 12 and 24 months post-HCT.  
2. CBC at least twice a week from Day 0 until ANC > 500/mm3for 2 days after nadir reached. Thereafter CBC twice per week until Day 28 (or 4 weeks), then at 8 weeks, Day 100, 6, 12 and 24 months post-HCT.  
3. Toxicity assessments at 4 weeks, 8 weeks, Day 100, 6, 12, and 24 months post-HCT. 4. Evaluation of immune reconstitution by flow cytometry (CD2, CD3, CD4, CD8, CD19, CD3+/CD25+, CD45 RA/RO, and CD56+/CD3-) and quantitative immunoglobulins (IgM, IgG and IgA) at 8 weeks, 6, 12, and 24 months post-HCT.  
5. CMV PCR or antigenemia assay measured weekly Day 0 through 8 weeks; follow-up at Day 100.
6. HIV-1 RNA level at 100 days, 12 and 24 months (viral load) by standard assay.  
7. Blood for HIV single copy measurement at Day 100, and 6, 12, and 24 months post-HCT
(see Appendix C).  
8. Blood collected for latent virus recovery assay to be scheduled for only those patients where HIV-1 RNA by standard assay and the single copy research assay are negative at 12 months post-transplant to be done at approximately 13 months post-HCT (see Appendix C).  
9. Blood collected for Microbial Translocation Monitoring at Days 7, 14 and 100 (see Appendix C).  
10. Blood collected for Immune Reconstitution Studies (Research) at 8 weeks and 6 and 12 months (see Appendix C).  
11. Acute Graft versus Host Disease assessments weekly Day 0 through 8 weeks; follow-up at Day 100.
12. Chronic Graft versus Host Disease assessments at 100 days, 6, 12, and 24 months. 13. Chimerism (T cell and myeloid) will be assessed at 4 weeks, 100 days and 6 months.  
14. Weekly phone calls from the CIBMTR Survey Research Group inquiring about any missed doses of ARV or immunosuppressive medications after initial hospital discharge from allogeneic marrow transplant until completion of the study, disease relapse, or until discontinuation of ARV.
15. Disease restaging:
a) Lymphoma
- CT scan at 100 days, 6 and 12 months post-transplant  
- PET or PET CT at 100 days post-transplant, with a 6 month PET or PET-CT
performed if the Day 100 scan results are equivocal
- Bone marrow biopsy/aspirate for patients with previously documented marrow involvement at Day 100 and 12 months post-transplant b) Acute Leukemia or Myelodysplastic Syndromes
- Bone marrow biopsy/aspirate for pathology and cytogenetics at 100 days and 12 months post-transplant.  
| Prior to Conditioning                                                                                                                                | Day −3 of  Conditioning       |       |       |      |    |
|------------------------------------------------------------------------------------------------------------------------------------------------------|-------|-------|-------|------|----|
| CMV IgG, Hepatitis Panel (HAV Ab, HBsAg, HBcAb, HBsAb, HCV Ab), HSV  1/2 IgG, Toxoplasma IgG, VZV IgG, Syphilis (RPR or VDRL), HTLV1 antibody        | X     |       |       |      |    |
| EKG                                                                                                                                                  | X     |       |       |      |    |
| DLCO, FEV1, FVC                                                                                                                                      | X     |       |       |      |    |
| Creatinine Clearance                                                                                                                                 | X 1   |       |       |      |    |
| CMV PCR or Antigenemia Assay                                                                                                                         | X     |       |       |      |    |
| HIV-1 RNA Viral Load, CD4 Count                                                                                                                      | X     |       |       |      |    |
| HepB DNA PCR and HepC RNA PCR if HepB and/or HepC Ab are positive,  respectively                                                                     | X     |       |       |      |    |
| Ejection Fraction (MUGA or ECHO)                                                                                                                     | X     |       |       |      |    |
| History, Physical Examination, Height and Weight, Body Surface Area,  Neurologic Examination, careful measurement of all palpable peripheral lymph   | X2    |       |       |      |    |
| nodes and measurement of other sites of disease present on physical.  Required Studies/Testing                                                       | −3    | −8    | −4    | −1-3 | −1 |
| months                                                                                                                                               | weeks | weeks | weeks | week |    |
| For lymphoma patients: CT scans of neck, chest, abdomen and pelvis. Neck CT  only required if previous site of disease. PET scan should be performed | X2    |       |       |      |    |
| Lumbar puncture(s) for determination of presence of CNS disease for patients  with either non-Hodgkin's lymphoma or acute lymphocytic leukemia       | X2    |       |       |      |    |
| Bone Marrow Aspiration and Biopsy, including cytogenetics                                                                                            | X     |       |       |      |    |
| β –HCG Serum Pregnancy Test for Females of Childbearing Potential                                                                                    | X     |       |       |      |    |
| Informed Consent                                                                                                                                     | X     |       |       |      |    |
| Immune Reconstitution Assays (Transplant Center)                                                                                                     | X3    |       |       |      |    |
| Karnofsky/Lansky Performance Score                                                                                                                   | X     |       |       |      |    |
| CBC with Differential, Platelet Count, Creatinine, Bilirubin, Alkaline  Phosphatase, AST, ALT, LDH, Sodium, Magnesium, Potassium, Chloride and       | X     |       |       |      |    |
| CO2 Blood for Microbial Translocation Monitoring (See Appendix C)                                                                                    | X     | X     |       |      |    |
| Blood for HIV Single Copy PCR Assessment (See Appendix C)                                                                                            | X     | X     |       |      |    |
table 4.2.2a pre-hct evaluations
4.2.2. adverse event reporting

| Prior to Conditioning                                        | Day −3 of  Conditioning       |       |       |      |    |
|--------------------------------------------------------------|-------|-------|-------|------|----|
| Blood for Latent HIV Reservoir Measurements (See Appendix C) | X4    |       |       |      |    |
| Optional Future Research Blood Sample                        | X     |       |       |      |    |
| Required Studies/Testing                                     | −3    | −8    | −4    | −1-3 | −1 |
| months                                                       | weeks | weeks | weeks | week |    |  
1 Calculated creatinine clearance is permitted.  
2 To include:
a. Lumbar puncture(s) for determination of presence of CNS disease for non-Hodgkin's lymphoma and Acute Lymphoblastic Leukemia patients only. b. Duration of AIDS diagnosis, history of prior opportunistic illnesses. c. Presence or absence of "B"-symptoms (unexplained fevers, night sweats, involuntary weight loss greater than 10% normal body weight) for lymphoma patients. d. Medication list to include all antiviral, antibiotics and opportunistic prophylaxis.  
3 To include: CD2, CD3, CD4, CD8, CD19, CD3+/CD25+, CD45RA/RO, and CD56+/CD3- and quantitative immunoglobulins (IgM, IgG, and IgA).  
4 Collection of blood for Latent HIV Reservoir testing. Once the patient is consented and enrolled on the trial, a peripheral blood sample will be collected at approximately 8 weeks prior to initiation of conditioning for only those patients that have documented undetectable plasma HIV-1 by standard assay upon enrollment (see Appendix C).  
| Weeks                                                                                                                                                                                                     | Months                                                                                                                            |    |    |    |    |    |    |     |    |    |    |    |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------|----|----|----|----|----|----|-----|----|----|----|----|
| Post-HCT                                                                                                                                                                                                  | Post-HCT                                                                                                                          |    |    |    |    |    |    |     |    |    |    |    |
| Study Assessments/                                                                                                                                                                                        | Day                                                                                                                               |    |    |    |    |    |    |     |    |    |    |    |
| Testing                                                                                                                                                                                                   | 1                                                                                                                                 | 2  | 3  | 4  | 5  | 6  | 8  | 100 | 6  | 12 | 13 | 24 |
| CBC1 , Physical Exam, and Weight1                                                                                                                                                                         | X                                                                                                                                 | X  | X  | X  | X  | X  | X  | X   | X  |    |    |    |
| Immune Reconstitution Assays2 (Transplant Center)                                                                                                                                                         | X                                                                                                                                 | X  | X  | X  |    |    |    |     |    |    |    |    |
| HIV-1 RNA Viral Load3                                                                                                                                                                                     | X                                                                                                                                 | X  | X  |    |    |    |    |     |    |    |    |    |
| PET or PET-CT (lymphoma patients)                                                                                                                                                                         | X4                                                                                                                                | X  |    |    |    |    |    |     |    |    |    |    |
| CT Scan (lymphoma patients)                                                                                                                                                                               | X                                                                                                                                 | X  | X  |    |    |    |    |     |    |    |    |    |
| Bone marrow biopsy/aspirate for pathology (acute leukemia,  MDS patients and lymphoma patients with previously  documented marrow involvement; include cytogenetics for  acute leukemia and MDS patients) | X                                                                                                                                 | X  |    |    |    |    |    |     |    |    |    |    |
| Toxicity Assessment                                                                                                                                                                                       | X                                                                                                                                 | X  | X  | X  | X  | X  |    |     |    |    |    |    |
| Chimerism (T cell and myeloid)                                                                                                                                                                            | X                                                                                                                                 | X  | X  |    |    |    |    |     |    |    |    |    |
| CMV PCR or antigenemia                                                                                                                                                                                    | X                                                                                                                                 | X  | X  | X  | X  | X  | X  | X   |    |    |    |    |
| Acute GVHD Assessment                                                                                                                                                                                     | X                                                                                                                                 | X  | X  | X  | X  | X  | X  | X   |    |    |    |    |
| Chronic GVHD Assessment                                                                                                                                                                                   | X                                                                                                                                 | X  | X  | X  |    |    |    |     |    |    |    |    |
| CIBMTR Survey Research Group Phone Call                                                                                                                                                                   | Weekly after initial hospital discharge from HCT until completion of the study,  disease relapse, or until discontinuation of ARV |    |    |    |    |    |    |     |    |    |    |    |
| Blood for Microbial Translocation Monitoring (See Appendix                                                                                                                                                | X                                                                                                                                 | X  | X  |    |    |    |    |     |    |    |    |    |
| C) Blood for HIV Single Copy PCR Assessment (See Appendix                                                                                                                                                 | X                                                                                                                                 | X  | X  | X  |    |    |    |     |    |    |    |    |
| C) Blood for Latent HIV Reservoir Measurements6 (See                                                                                                                                                      | X                                                                                                                                 |    |    |    |    |    |    |     |    |    |    |    |
| Appendix C)                                                                                                                                                                                               |                                                                                                                                   |    |    |    |    |    |    |     |    |    |    |    |
table 4.2.2b post-hct evaluations
4.2.2. adverse event reporting

| Weeks                                             | Months   |    |    |    |    |    |    |     |    |    |    |    |
|---------------------------------------------------|----------|----|----|----|----|----|----|-----|----|----|----|----|
| Post-HCT                                          | Post-HCT |    |    |    |    |    |    |     |    |    |    |    |
| Study Assessments/                                | Day      |    |    |    |    |    |    |     |    |    |    |    |
| Testing                                           | 1        | 2  | 3  | 4  | 5  | 6  | 8  | 100 | 6  | 12 | 13 | 24 |
| Blood for Immune Reconstitution Assays (Research) | X        | X  | X  |    |    |    |    |     |    |    |    |    |
| Notes for Table 4.2.2B:                           |          |    |    |    |    |    |    |     |    |    |    |    |  
Notes for Table 4.2.2B:
1 To be performed at least twice weekly from Day 0 until ANC > 500/mm3for 2 days after nadir reached. Thereafter, twice weekly until Day 28 (or 4 weeks), then at 8 weeks, Day 100, 6, 12 and 24 months post-HCT.  
2Immune reconstitution assays by flow cytometry (CD2, CD3, CD4, CD8, CD19, CD3+/CD25+, CD45 RA/RO, and CD56+/CD3) and quantitative immunoglobulins (IgM,
IgG and IgA).  
3 HIV-1 viral RNA plasma level (viral load) at 100 days, 12 and 24 months by standard assay.  
4PET or PET-CT performed if the Day 100 Scan results are equivocal at 6 months. 5 For lymphoma patients, CT scans of neck, chest, abdomen and pelvis. Neck CT only required if previous site of disease.  
6 Collection of blood sample to be scheduled for only those patients where HIV-1 RNA by standard assay is undetectable at 12 months post-transplant (see Appendix C).
chapter 5
5. statistical considerations 5.1. study

This study is designed as a Phase II multi-center trial to assess the feasibility and safety of allogeneic hematopoietic cell transplantation (HCT) in HIV-infected patients. The target enrollment is 15 patients.
chapter 5
5.1.1. accrual

Accrual will be across multiple sites and remain open until 15 patients are transplanted. It is estimated that two years of accrual will be necessary to enroll the targeted sample size.
chapter 5
5.1.2. primary endpoint

The primary endpoint for the study is 100-day Non-Relapse Mortality (NRM).
chapter 5
5.2. sample size calculations and

The sample size is 15 patients for this trial. Allogeneic transplant for patients with HIV is considered unacceptable if 100-day non-relapse mortality probability is 45% or higher. The objective of the study is to show that 100-day NRM is lower than 45%. In patients without HIV, non relapse mortality probability 100 days after allogeneic transplant is expected to be lower than 15%. Therefore, we framed this objective as a hypothesis test of the null hypothesis H0:p>=0.45, where p is the 100 day NRM probability, and this study is adequately powered against the alternative hypothesis H1:p=0.15. The stopping rule and study design described in detail below has a 8% chance of concluding that allogeneic transplant for patients with HIV has less than 45% NRM when in fact the 100 day NRM rate is 45% (type I error), and an 83% chance of concluding that the NRM rate is lower than 45% when the 100 day NRM rate is 15% (power). To guard against excessive mortality, non-relapse mortality will be monitored up to 100 days post transplant and if rates significantly exceed pre-set thresholds, the NHLBI will be notified in order that the DSMB can be advised. Policies and composition of the DSMB are described in the BMT CTN's Manual of Procedures. The stopping guidelines serve as a trigger for consultation with DSMB for additional review, and are not formal "stopping rules" that would mandate automatic closure of study enrollment. A truncated Sequential Probability Ratio Test (SPRT) based on a binomial test of proportions for non-relapse mortality will be used as described below. This sequential testing procedure conserves type I error across all of the monitoring looks for NRM. The SPRT can be represented graphically. At each interim analysis, the number of patients enrolled is plotted against the total number of patients who have experienced NRM. The continuation region of the SPRT is defined by two parallel lines. For a hypothesis test H0:  = 0 versus H1:  = 1 where 0 > 1, if the graph falls above the upper boundary, accept H0 and if the graph falls below the lower boundary reject H0 and conclude H1. Only the upper boundary will be used to protect against excessive NRM which would make it unlikely that we could conclude that the NRM is less than 45% by the end of the study.  
The usual measures of performance of an SPRT are the error probabilities  and  of rejecting H0 when  = 0 and of accepting H0 when  = 1, respectively, and the expected sample size E(N|i). Note that since the test uses only the upper boundary, and is truncated by a finite sample size, the size of the test will be slightly lower than the nominal level. The test to be used in this protocol was developed from the following SPRT:
- An SPRT testing H0: p = 45% versus H1: p = 15% NRM, with nominal type I and II
errors of 7% and 30%, respectively.  
- The slope of the parallel lines for monitoring NRM is 0.283 and the intercepts are –1.53 and 0.74.  
- Note that the stopping rule shown in Table 5.1 *was constructed using the futility* boundary *of this SPRT test. The futility boundary was used to ensure that the DSMB* will be notified if it is no longer likely that we will be able to demonstrate that 100-day NRM is lower than 45%, thus protecting against excessive NRM.  
The futility stopping boundary is shown in Figure 5.1 for the SPRT test.  
  
The futility stopping rules are summarized in Table 5.1 for the SPRT test.  
| Number of patients enrolled   | SPRT stopping boundary   |
|-------------------------------|--------------------------|
| (n)                           | (x)                      |
| 2-4                           | 2                        |
| 5-7                           | 3                        |
| 8-11                          | 4                        |
| 12-15                         | 5                        |  
* Stopping guideline is triggered if ≥ x patients out of n patients enrolled experience NRM.  
The actual operating characteristics of the truncated test (shown in Table 5.2) were determined in a simulation study. The simulation assumed uniform accrual of 15 patients over a two-year time period.
chapter 5
table 5.2 operating characteristics of

| Non-relapse Mortality                               |      |      |      |      |
|-----------------------------------------------------|------|------|------|------|
| True 100-day rate                                   | 45%  | 35%  | 25%  | 15%  |
| Probability stop and accept the null hypothesis     | .92  | .75  | .47  | .17  |
| Probability continue to full recruitment and reject | 0.08 | 0.25 | 0.53 | 0.83 |
| the null hypothesis Mean month stopped              | 11.8 | 15.6 | 20.2 | 24.5 |
| Mean # endpoints                                    | 2.7  | 2.9  | 2.8  | 2.0  |
| Mean patients with 100 days follow up               | 6.0  | 8.2  | 10.8 | 13.4 |  
The SPRT stops and accepts the null hypothesis 92% of the time when the true 100-day NRM is 45% and 17% of the time when the true 100-day NRM is 15%. This corresponds to a type I error of 8% and type II error of 17%. When the true 100-day NRM rate is 45%, on average the DSMB will be consulted 11.8 months after opening, when 2.7 events have been observed in 6 patients.
chapter 5
5.3. demographic and baseline characteristics

Demographics and baseline characteristics will be summarized for all patients. Characteristics to be examined are: age, gender, race/ethnicity, performance status, disease stage, genotype, donor type, donor gender, donor-recipient CMV, HLA matching, graft type, HIV load, CD4 counts, and number of prior chemotherapy regimens as treatment of primary malignancy and number of prior HIV regimens.
chapter 5
5.4. analysis plan 5.4.1. analysis

The primary analysis will consist of estimating the 100-day NRM probability along with a 95% confidence interval using the cumulative incidence function. In a secondary analysis, a Cochran-Mantel-Haenszel test will be used to compare 100-day NRM probabilities between patients enrolled in this study to matched non-HIV-infected patients from the CIBMTR database. Closely matched controls will be identified at ratio 1:4 using the following criteria: age, gender, year of transplant, performance status, interval from diagnosis to transplant, diagnosis, disease status, preparative regimen/intensity, GVHD prophylaxis regimen, cytogenetics if available for acute leukemias.  
5.4.2. Analysis of Secondary Endpoints
chapter 5
disease status

The proportion of patients in complete remission, partial remission, stable disease, and relapse at 100 days post-transplant will be described.
chapter 5
time to hematopoietic recovery

Time to neutrophil recovery and platelet engraftment will be described separately in the myeloablative and reduced intensity groups, using cumulative incidence function with death prior to engraftment as the competing risk.
chapter 5
chimerism

Donor T-cell and myeloid chimerism at4 weeks, 100 days, and 6 months will be described separately in the myeloablative and reduced intensity groups, according to proportions with mixed (5-95% donor cells), full (>95%), or graft rejection (<5%).
chapter 5
hematologic function

The proportions of patients with hematologic function at 100 days and 6 months will be described in patients surviving to these time points.
chapter 5
occurrence of infections

Microbiologically documented infections will be reported by site of disease, date of onset, severity, and resolution, if any. This data will be captured via an event-driven case report form and will be collected from Day 0 until two years post-transplant or relapse. The incidence of viral, fungal and bacterial infections will be tabulated for each patient according to Chapter 5 of the BMT CTN Technical Manual of Procedures.
chapter 5
overall survival

The 6-month overall survival probability with 95% confidence interval will be estimated using the Kaplan-Meier product limit estimator. In an additional analysis, a Cochran-Mantel-Haenszel test will be used to compare 6-month overall survival probabilities between patients in the study to matched controls selected for the secondary analysis of 100-day NRM of Section 5.5.1.
chapter 5
acute graft versus host disease

Cumulative incidence of grade II-IV and III-IV acute GVHD will be estimated at 100 days, treating death as a competing risk.
chapter 5
chronic graft versus host disease

Cumulative incidence of chronic GVHD will be estimated at 100 days, 6 and 24 months, treating death as a competing risk.
chapter 5
immunologic reconstitution

Immune reconstitution assays on peripheral blood which include CD2, CD3, CD4, CD8, CD19, CD3+/CD25+, CD45 RA/RO, CD56+/CD3-, and quantitative immunoglobulins (IgM, IgG and IgA) will be measured in all patients prior to the conditioning, at 8 weeks, and 6 and 12 months post-transplant. These will be summarized at each time point using descriptive statistics.
chapter 5
maintenance of antiretroviral therapy

Maintenance of antiretroviral therapy will be monitored in all patients until time or death or two years post HCT whichever occurs first. Number and proportion of patients maintaining ARV will be summarized at 6, 12, and 24 months post-transplant.
chapter 5
impact of therapy on hiv-1

HIV RNA levels will be measured prior to initiation of ablative chemotherapy, and at Day 100, 12 months, 13 months (for some patients) and 24 months post-transplant. Standard assay will measure HIV RNA levels (viral load) and for patients with no detectable viral RNA using the standard assay, a single copy assay will be performed to assess persistent viremia. The proportion of patients with undetectable viral loads at Day 100, and 12 and 24 months will be examined and an exact binomial confidence interval will be calculated. Additionally, change in viral loads status between consecutive time points will be described by the proportion of patients whose viral loads changed from detectable to undetectable between assessment times.
appendix a human subjects
1. subject consent

A conference will be held with the patient and family to discuss this study and alternative treatments available for the treatment of the underlying disease. The Principal Investigator or another designated physician will conduct the conference. Potential risks associated HCT should be discussed as objectively as possible. The consent document should be reviewed with the patient and family prior to proceeding to ablative therapy. Informed consent from the patient will be obtained using a form approved by the Institutional Review Board of the institution enrolling the patient.
appendix a human subjects
2. confidentiality

Confidentiality will be maintained by masking of individual names and assignment of a patient identifier code. The identifier code representing the patient's identity will be kept separately from the research file at the center. The ID code will be transmitted to the BMT CTN Data and Coordinating Center upon enrollment.
appendix a human subjects
3. participation of women and

Women, ethnic minorities, and other populations will be included in this study. Accrual of women and minorities at each center will be monitored to determine whether their rates of enrollment are reflective of the distribution of potentially eligible women and minorities expected from data reported to the CIBMTR and from published data on the incidence of AML, ALL, MDS, and Hodgkin and Non-Hodgkin Lymphoma. Centers will be notified if their rates differ significantly from those expected and asked to develop appropriate recruitment strategies.
appendix b informed consent and
3. participation of women and

| Your Name:                                       | ________________________________                                                                                                                                                                       |
|--------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Study Title:                                     | Allogeneic Hematopoietic Cell Transplant for Hematological Cancers and  Myelodysplastic Syndromes in HIV-Infected Individuals                                                                          |
| Protocol:                                        | BMT CTN #0903 (AMC 080)                                                                                                                                                                                |
| Principal Co-Investigator:                       | Joseph Alvarnas, M.D. City of Hope, Department of Hematology/HCT  MOB 3001  1500 E Duarte Road, Duarte, CA 91010  email: jalvarnas@coh.org phone: 626-359-8111 x 60329 fax: 626-301-8973               |
| Principal Co-Investigator:                       | Richard Ambinder, MD, PhD Johns Hopkins Medical Institutions 389 Cancer Research Building 1, Rm 389, 1650 Orleans,  Baltimore, MD 21287 email: rambind1@jhmi.edu phone: 410-955-8839 fax: 410 -550-960 |
| Transplant Center Investigator:                  | ________________________                                                                                                                                                                               |
| (Insert contact information for PI at your site) |                                                                                                                                                                                                        |  
Sponsor: The National Institutes of Health (NIH) is sponsoring this study by providing financial support through the Blood and Marrow Transplant Clinical Trials Network (BMT CTN).
appendix b informed consent and
1. introduction

We invite you to join this clinical trial, also known as a research study. We are doing this study because we want to find out how well allogeneic marrow transplant (a marrow transplant using cells from someone other than the patient) treats specific blood cancers in people with HIV (human immunodeficiency virus). This study will take at least two (2) years and will include 15 participants. This Consent Form will tell you about the purpose of the study, its possible risks and benefits, other options available to you, and your rights as a participant in the study. Everyone who takes part in research at [insert facility name] should know that:
- Being in any research study is voluntary.  
- You may or may not benefit from being in the study. Knowledge we gain from this study may benefit others.  
- If you join the study, you can quit the study at any time. - If you decide to quit the study, it will not affect your care at [insert name of facility or institution].  
- Please ask the study staff questions about anything that you do not understand, or if you would like to have more information.  
- You can ask questions now or any time during the study. - Please take the time you need to talk about the study with your doctor, study staff, and your family and friends. It is your decision to be in the study. If you decide to join, please sign and date the end of the Consent Form.
You and your doctor will discuss other treatment choices if you do not want to participate in this study.
appendix b informed consent and
2. background

The National Institutes of Health (NIH), through the Blood and Marrow Transplant Clinical Trials Network (BMT CTN), are providing staff support and money for this research study. This study will look at the risks and benefits of allogeneic transplant for people with specific kinds of blood cancers and HIV infection. Blood Cancer and Transplant For people with a blood cancer, the main treatment choices include chemotherapy, radiation therapy, immunotherapy, and a transplant using cells that can make blood. The blood-making cells are most often collected from bone marrow and the bloodstream. These cells are called hematopoietic cells and transplant using these kinds of cells is called hematopoietic cell transplant, or HCT. These treatments may be used alone or used in combination. For some people with a blood cancer, a HCT transplant may offer the best chance to be free of signs of disease for a long time (long-term remission). This clinical trial will study how well allogeneic transplant works as a treatment for people who have a blood cancer and HIV. An allogeneic transplant uses blood-making cells from a family member or an unrelated donor to remove and replace the abnormal blood cells in the patient. An allogeneic transplant is a common treatment for patients with a blood cancer that has either returned (relapsed) or does not respond well to other treatments (refractory), or is known to be likely to return (high risk). The blood cancers we will include in this study are: acute myeloid or lymphocytic leukemia (AML or ALL), myelodysplastic syndrome (MDS), Hodgkin lymphoma and non-Hodgkin lymphoma.
appendix b informed consent and
conditioning regimen

We will use a combination of chemotherapy and in some cases radiation as a treatment to destroy cancer cells and help donor cells start to grow in your bone marrow. Depending on the combination used, each treatment (or "conditioning regimen") can have a different intensity or strength.  
- High intensity treatment uses a combination of chemotherapy that uses strong or higher amounts of drugs and sometimes radiation. This is also called "myeloablative conditioning".  
- Reduced intensity treatment uses a combination of chemotherapy, using less strong or lower amounts of drugs and sometimes radiation. This is also called "reduced intensity conditioning".  
Both kinds of treatments are used by blood and marrow transplant doctors around the world and are not experimental. You and your doctor will decide which conditioning regimen intensity is the best choice for you. This study will help us to better understand how to use these treatments in people with HIV who have an allogeneic transplant to treat their blood cancer. If you volunteer to join this study, the treating physician at the center will assign you to have either a high intensity or a reduced intensity treatment before you receive the blood stem cells or bone marrow from your donor.
appendix b informed consent and
3. purpose

The main purpose of this study is to learn how well allogeneic transplant treats blood cancers in people with HIV. We invite you to participate in this study because you have HIV and a blood cancer.
appendix b informed consent and
4. right to ask questions

You have the right to ask questions about the study at any time. If you have questions about your rights as a participant or you want to leave the study, please contact: [insert contact info]
appendix b informed consent and
5. procedures

Before you join the study, we will evaluate your general health, medical history, and your current medications.
appendix b informed consent and
study participation

Your study participation will last for **2 years** after your transplant. Follow-up tests for your transplant (described below) will last as long as you need care. We would like to keep track of your medical condition for the rest of your life. We would contact you and the doctor who gives your regular medical care by phone or mail once a year. Following up with you every year helps us learn about the long-term effects of the study and transplant. Many transplant centers include this type of long-term follow-up as part of their regular medical care.
appendix b informed consent and
before you start your treatment

You will need to have health evaluations before you start treatment, while you receive your treatment, and for several years after you finish your treatment. These tests are standard care for patients with blood cancer and would happen even if you were not part of this study. It will be up to your study doctor to decide what tests you need and when. If you decide to join, we will ask you to sign this Consent Form, and you will get a copy of the signed form to keep. You will have several tests to find out if you can be in the study. The tests include:
- Medical history  
- Physical examination, including height and weight
- Blood and urine tests - Heart function tests, including a MUGA or an electrocardiogram (ECG)
- Lung (pulmonary) function tests
- Tests to evaluate your blood cancer including a bone marrow biopsy/aspirate
- If you have lymphoma, you will also have PET (positron-emission tomography) and/or CT (computed tomography) scans
- A blood pregnancy test if you are a woman able to have children. If you are pregnant, you will not be able to take part in this study.
appendix b informed consent and
during the study - study

We will evaluate your health at specific points during your participation. These tests and how often they are scheduled are standard care for patients receiving an allogeneic transplant and would be done even if you were not part of this study.
appendix b informed consent and
- research study evaluations

Researchers are trying to learn more about HIV and the effect of HCT on HIV. Much of this research is done using blood samples. As a result, blood samples will be collected from you during the study to help researchers learn more about the effect of HCT on your HIV.  
− In patients that do not have any detectable HIV using standard tests, 30 mL (about 6 teaspoons) of blood will be drawn at two times before your HCT and at 100 days, 6 months, 12 months and 24 months after your HCT. Another 180 mL (about 36 teaspoons) of blood will also be drawn before your HCT and 13 months after your HCT if necessary. This blood will be used to look closer at any HIV that may still be present in your body.  
− In all patients, 10 mL (about 2 teaspoons) of blood will be drawn at two times before your HCT and at 1 week, 2 weeks and 100 days after your HCT. Another 37 mL (about 7 teaspoons) will be drawn at 8 weeks, 6 months and 12 months after your HCT. This blood will be used to look at how your immune system is responding to the treatment.
appendix b informed consent and
- antiretroviral therapy

Your antiretroviral therapy (your HIV therapy) will be reviewed. An outside review committee will look at your therapy and discuss with your doctor the best way to adjust your therapy throughout your HCT. Your doctor may or may not adjust your therapy depending on what is best for you. Taking your anti-HIV and transplant-related medicines is very important and the study team would like to understand how you are doing taking your medications regularly and on schedule. In order to track that, a study representative will contact you weekly, for up to two years, to check in with you and ask if you were able to take your anti-HIV medicines and certain medicines used for your transplant. If you have been unable to take your medicines for any reason, it is very important to let your transplant team know right away. For safety, a study representative may also contact your study team to let them know if you are having trouble taking your anti-HIV or certain transplant medicines.  
In order for study staff to contact you if you have moved or changed your contact information, it might be necessary to use an internet-based search service to find you. By choosing to participate in the BMT CTN 0903 study, you are giving the NMDP, CIBMTR, and/or your transplant center authorization and instruction to use such a service to search public and non-public information solely for the purpose of attempting to locate you. If you change you move or change your contact information, you should let the study staff know.
appendix b informed consent and
- conditioning regimen (chemotherapy)

The conditioning regimen is a combination of chemotherapy and/or radiation given to patients before the donor cells are infused. This treatment allows donor cells to start growing (or "engraft") in your bone marrow. The conditioning regimen also helps to destroy remaining cancer cells that might not be found in tests. Several chemotherapy drugs can be used as part of the conditioning treatment. The choice and amount of drugs or radiation determines the treatment intensity (strength). Common drug combinations used in allogeneic transplant include:
1) Busulfan and fludarabine  
2) Fludarabine and melphalan 3) Radiation and cyclophosphamide (**Cytoxan)**
Allogeneic transplantation kills cancer through the conditioning regimen and through the immune cells from the donor that might recognize cancer cells and destroy them. Conditioning regimens with high intensity are also known as myeloablative conditioning regimens. High intensity treatments work very well to destroy remaining cancer cells because they use very high amounts chemotherapy or radiation. High intensity treatments can also have more side effects during and after transplant. Using a lower or "reduced" intensity treatment before transplant can have fewer serious problems from the chemotherapy drugs. While the cancer killing effects may also be lower, studies show that immune cells given during the transplant can help destroy remaining cancer cells. Allogeneic transplants with reduced intensity conditioning (RIC) regimens are often used for people who cannot have high doses of chemotherapy drugs or radiation because of their age or other medical problems. Your doctor will decide which type of conditioning treatment is the best choice for you, depending on the kind of blood cancer you have and your overall health. The table below lists the 4 conditioning regimens that will be used in this study.  
| Reduced Intensity Treatments   | High Intensity Treatments         |    |                                                     |
|--------------------------------|-----------------------------------|----|-----------------------------------------------------|
| A                              | Fludarabine + Busulfan (Flu/Bu)   | C  | Busulfan + Fludarabine (Bu/Flu)                     |
| B                              | Fludarabine + Melphalan (Flu/Mel) | D  | Cyclophosphamide + Total Body  Irradiation (Cy/TBI) |
appendix b informed consent and
table b-1 conditioning regimens -

We will use your intravenous catheter or central line to give you the blood or bone marrow stem cells that were collected before your transplant. The cells will travel to your bone marrow where they will start to make healthy, new blood cells after several weeks.
appendix b informed consent and
6. alternative treatments

Participation in this study is optional. If you choose not to participate you may still receive an allogeneic transplant for treatment of your disease. It is possible that the treatment and the evaluations you would receive could be very similar to what would be if you were enrolled in this clinical trial. Your study doctor will talk with you about your options. If you decide not to participate in this research study, your medical care will not be affected in any way. Your other choices may include:
- Treatment with other drugs, radiation, or a combination of drugs and radiation without a transplant.  
- An allogeneic hematopoietic cell transplant that is not part of the study, or another type of transplant.  
- Participation in another clinical trial (if available, check with your doctor).  
- No treatment for your blood cancer at this time.
Every treatment option has benefits and risks. Talk with your doctor about your treatment choices before you decide if you will take part in this study.
appendix b informed consent and
7. risks and discomforts

You will have side effects while on the study. Side effects can range from mild to very serious. The risks and discomforts in participating in this study will be similar to what you may have with a blood or bone marrow cell transplant if you do not participate in this trial. There are differences in side effects from medications based on the strength of your conditioning regimen. Myeloablative regimens often cause more side effects early after transplant compared to reduced intensity regimens. Other complications from transplants, such as graft-versus-host disease (GVHD) and infections happen equally in patients who have either type of regimen. Your health care team will give you medicines to help lower side effects such as feeling sick to your stomach (nausea). In some cases, side effects can be long lasting or may never go away.
appendix b informed consent and
a. side effects of allogeneic

Short term (days to weeks): During the transplant, you will have a higher risk of infection and bleeding from low blood counts. There is also the risk that your blood counts will not recover even though we gave you donated blood stem cells. This risk is rare, but it can happen. After your transplant, you have a higher risk of infections. This is because the new immune system needs time to learn again how to best fight some infections and because you will need to take medicines that lower immunity to reduce the risk of graftversus-host disease (GVHD). See below for more information about GVHD.  
Long term (years): If you have an allogeneic transplant, you will have a higher risk of developing cancers that are caused by the chemotherapy given as part of the transplant or to treat the blood cancer before your transplant. These secondary cancers can be of any type, including blood cancers such as leukemia. Your HIV infection also gives you a higher risk for some cancers, so the true risk for allogeneic transplant for HIV-associated cancers is not yet known.
appendix b informed consent and
b. risks related to medications

All chemotherapy and radiation treatments used as conditioning regimens in this study are commonly used in allogeneic hematopoietic cell transplantation. The side effects may vary, based on the dose that is given. This applies to busulfan, which is used in different amounts for myeloablative and reduced intensity regimens.  
| Likely Side Effects                        |                                                                                                                                                                                             |                                                                                                                                                                                       |                         |
|--------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------|
| (May happen in 20% of  patients or more)   | Less Likely                                                                                                                                                                                 |                                                                                                                                                                                       |                         |
| (May happen in less than  20% of patients) | Rare                                                                                                                                                                                        |                                                                                                                                                                                       |                         |
| (May happen in less  than 2% of patients)  |                                                                                                                                                                                             |                                                                                                                                                                                       |                         |
| Busulfan (Bu)                              | Abdominal discomfort Constipation Diarrhea Dizziness Fluid retention Headache Heartburn Insomnia Lack of appetite Mouth sores  Nausea and vomiting Running nose Skin rashes Irregular or no | Cough Hepatic Veno-occlusive  disease High blood pressure High magnesium and  phosphorus levels in the  blood High sugar levels in the  blood Infertility Low blood pressure Seizures | Cataracts Lung fibrosis |  
| Likely Side Effects                                                                                                                                   |                                                                                               |                                                     |
|-------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------|-----------------------------------------------------|
| (May happen in 20% of  patients or more)                                                                                                              | Less Likely                                                                                   |                                                     |
| (May happen in less than  20% of patients)                                                                                                            | Rare                                                                                          |                                                     |
| (May happen in less  than 2% of patients)                                                                                                             |                                                                                               |                                                     |
| menstrual cycles                                                                                                                                      |                                                                                               |                                                     |
| Tachycardia                                                                                                                                           |                                                                                               |                                                     |
| Cyclophosphamide                                                                                                                                      | Damage to male (testes)                                                                       |                                                     |
| (Cy)                                                                                                                                                  | and female (ovaries)  sex glands                                                              |                                                     |
| Diarrhea Fluid retention Hair loss Infertility Irregular or no  menstrual cycles Loss of appetite  Nausea, Vomiting Suppression of the  immune system | Bleeding in the bladder Inflammation of the heart  muscle (heart failure) Shortness of breath | Allergic reaction Lung fibrosis Serious skin rashes |  
| Likely Side Effects                        |                                                                             |                                                                                              |                                                                       |
|--------------------------------------------|-----------------------------------------------------------------------------|----------------------------------------------------------------------------------------------|-----------------------------------------------------------------------|
| (May happen in 20% of  patients or more)   | Less Likely                                                                 |                                                                                              |                                                                       |
| (May happen in less than  20% of patients) | Rare                                                                        |                                                                                              |                                                                       |
| (May happen in less  than 2% of patients)  |                                                                             |                                                                                              |                                                                       |
| Fludarabine (Flu)                          | Diarrhea Mouth sores  Nausea and vomiting Suppression of the  immune system | Fever Numbness in the  extremities Sleepiness Visual changes Weakness                        | Coma Cough Inflammation of the  lung Interstitial Pneumonia Skin rash |
| Melphalan (Mel)                            | Constipation Diarrhea Hair loss Mucositis Nausea and vomiting               | Heart rhythm  abnormalities Hepatitis Kidney failure                                         | Allergic reaction Interstitial Pneumonia Seizure Lung fibrosis        |
| Total Body                                 | Fatigue                                                                     |                                                                                              |                                                                       |
| Irradiation (TBI)                          | Hair loss Infertility Loss of appetite Mouth sores Nausea and vomiting      | Cataracts Inflammation of the  parotid glands Skin pigmentation  (reversible) Stunted Growth | Lung fibrosis Second cancers                                          |
appendix b informed consent and
c. risks related to the

Graft-versus-Host Disease (GVHD) is a medical condition that can become very serious and may cause death. GVHD is a common development after allogeneic stem cell transplant. It happens when the donor cells attack and damage your organ tissues after transplant. GVHD can cause:
- **Skin problems** including rashes, sores or blisters
- **Feeling sick** to your stomach (nausea)  
- **Throwing up** (vomiting) - **Abdominal pain** - **Diarrhea**
- Liver damage **or jaundice** (yellowing of the skin or eyes) - **There are other side effects that may be seen**
appendix b informed consent and
- gvhd may be bad

The most common forms of GVHD are relatively mild. Other forms of GVHD can be chronic and last well past your transplant date. GVHD can be very hard to predict. You will be monitored closely for this condition. We will give you medications to try and prevent GVHD. These medications are usually started around the time you receive the donor cells and can continue many months after the transplant. These medications do not completely prevent GVHD and more medications might be needed if you do develop GVHD.  
Your doctor will decide which GVHD prevention treatment you will receive. This choice is not part of this research study and your doctor will decide on the medications based on what is routinely used in this institution as part of allogeneic transplants. Below is a list of commonly used medications to prevent GVHD. Your doctor may choose to use other medications than what is listed here.  
- **Tacrolimus:** This medication is used to try to prevent GVHD. The immediate side effects you may experience include nausea (feeling sick to your stomach) or vomiting (throwing up) when the medications are given orally. Other side effects you may experience include high blood pressure (hypertension), shaking of the hands (tremor), increased hair growth and possibly an effect on mental function. If you have these effects, they generally go away if your doctor lowers the amount of medication you take. A few patients have had a seizure while on this medication. Your liver or kidneys might not work as well as they did before. If this happens, your doctor may lower the amount of drug you take or stop giving the drug completely. The effect on kidneys seems to increase when other medications, which might cause kidney problems, are given at the same time, especially antibiotics. Occasionally, the kidney damage caused may require the use of an artificial kidney machine (hemodialysis). Some patients given tacrolimus develop diabetes and must take insulin while taking tacrolimus. Rarely, patients receiving tacrolimus may develop low platelets and kidney problems that require stopping the tacrolimus, which can increase the risk of GVHD. This condition, called TTP/HUS Syndrome, can also be life-threatening. It is very important that you do not eat grapefruit or drink grapefruit juice. Grapefruit has an ingredient called bergamottin, which can affect some of the treatment drugs, including tacrolimus, used in this study. Common soft drinks that have bergamottin are Fresca, Squirt and Sunny Delight.  
- **Sirolimus:** This medication is used to try to prevent GVHD. The immediate side effects you may experience include fast heart rate, pain during breathing, shortness of breath, chest pain, nausea or vomiting. Other side effects you may experience include pale skin, easy bruising, fever, chills, body aches, night sweats, swelling in your face, stomach, hands or feet, pain or burning when you urinate, headache or skin rash. If you experience these effects, they generally go away when the dose of the medication is decreased. Sirolimus may increase your risk of developing lymphoma or other forms of cancer. Talk with your doctor about your specific cancer risk. Rarely, patients receiving sirolimus may develop low platelets and kidney problems that require stopping the sirolimus, which can increase the risk of GVHD. This condition, called TTP/HUS Syndrome, can also be life-threatening. It is very important that you do not eat grapefruit or drink grapefruit juice. Grapefruit has an ingredient called bergamottin, which can affect some of the treatment drugs, including tacrolimus, used in this study. Common soft drinks that have bergamottin are Fresca, Squirt and Sunny Delight.  
- **Mycophenolate Mofetil:** MMF is a potent immunosuppressive drug that blocks the growth of the immune cells that can cause GVHD. Side-effects you might experience include nausea and vomiting, diarrhea, infection, low blood counts, serious injury to your gut (digestive tract) including bloody stools and vomit, secondary cancers, such as lymphoproliferative disease or lymphoma, serious infections of the brain, risk to an unborn child, or Progressive Multifocal Leukoencephalopathy (PML).  
- **Cyclophosphamide:** This is a chemotherapy drug that works by slowing or stopping cell growth. Side-effects you might experience include nausea and vomiting, bone marrow suppression, stomach ache, diarrhea, darkening of the skin or nails, hair loss (alopecia) or thinning of hair, changes in color and texture of the hair, and feeling tired. Blood in your urine (hemorrhagic cystitis) is a common complication. Although it is used to treat cancer, it may increase your risk of developing another kind of cancer, sometimes months to years after treatment.  
- **Methotrexate:** This is also a medication used to try to prevent GVHD.  
Methotrexate causes damage to cells, and therefore can affect many different tissues of your body. It may cause or can worsen the mouth sores or inflammation of the mouth which you may have already developed from the procedures and medications used to prepare you for the transplant. Methotrexate may slow down the recovery of blood cells after transplantation. Methotrexate can cause kidney damage. If your kidneys are already damaged for other reasons, it can worsen kidney function. If kidney damage does occur, the methotrexate dose may be reduced or the medication may not be given at all.  
- **Tacrolimus and Methotrexate:** These medications interfere with the body's defense system (the immune system). This may cause you to have more infections (especially viral infections and pneumonia) for several months after transplant.