A Cohort Observational Study Evaluating The Incidence And
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A Cohort Observational Study Evaluating Predictors, Incidence And Immunopathogenesis Of Immune Reconstitution Syndrome (IRIS) In HIV-1 Infected Patients With CD4 Count <100 Cells/µL Who Are Initiating Antiretroviral Therapy NIH Principal Investigator/Protocol Chair: Irini Sereti, M.D., M.H.S. KEMRI/WRP Principal Investigator/ Protocol Co-Chair: Frederick Sawe, MBChB, MMED USAMRU-K Principal Investigator/ Protocol Co-Chair: Douglas Shaffer, M.D., M.H.S. South East Asia Research Collaboration with Hawaii (SEARCH) Thai Red Cross AIDS Research Centre Principal Investigator/ Protocol Co-Chair: Jintanat Ananworanich, MD, PhD Accountable Investigator: Lead Associate Investigator: Irini Sereti, M.D., M.H.S. Virginia Sheikh, M.D. Associate Investigators: JoAnn Mican, M.D. Alice Pau, Pharm. D. Stephen Migueles, M.D. Margo Smith, M.D. Eunice Obiero, MBChB, MMED Samoel Khamadi, PhD Kibet Shikuku, MBChB, MMED Nittaya Phanuphak, MD Wisit Prasithsirikul, MD Somsit Tansuphaswadikul, MD Alex Schuetz, PhD Nipat Teeratakulpisarm, MD Thep Chalermchai Study Statistician Dean Follmann, Ph.D. Study Coordinators Gregg Roby, R.N. Alexander Ober, R.N. Hellen Ngeno, B.S.N. Z#AI001121-01 Version 5.2 Initial IRB submission 11/7/2005 IRIS Version 5.2, June 2, 2011 1 RESEARCH FACILITIES WHERE THE CLINICAL INVESTIGATION WILL BE CONDUCTED National Institutes of Health, Clinical Center National Institute of Allergy and Infectious Diseases- HIV Clinic Building 10, 8th floor clinic (OP-8) and CRC-5SE North NIAID Ward 10 Center Drive Bethesda, MD 20892 (FWA00005897) Kenya Medical Research Institute/Walter Reed Project Clinical Research Center Hospital Road PO Box 1357-20200 Kericho, Kenya (FWA00002066) South East Asia Research Collaboration with Hawaii (SEARCH) The Thai Red Cross AIDS Research Centre (TRCARC) 104 Rajdumri Road Pathumwan, Bangkok 10330, Thailand (FWA00008378) Bamrasnaradura Infectious Disease Institute 126 Tiwanon Road, Muang Nonthaburi 11000, Thailand (FWA00008374) CLINICAL LABORATORY FACILITIES TO BE USED IN THE CLINICAL INVESTIGATION 1) Department of Laboratory Medicine Dr. Thomas Fleisher, Chief Building 10- Room 2C306 National Institutes of Health Bethesda, MD 20892 2) NCI- Frederick Cancer Research & Development Center Fort Detrick Dr. Michael Baseler- Head Clinical Services Program Boyles Street, Building 1050 Frederick, MD 21702-1201 3) Kenya Medical Research Institute/Walter Reed Project Clinical Research Center Laboratory Dr. Kibet Shikuku, Deputy Director IRIS Version 5.2, June 2, 2011 2 Hospital Road PO Box 1357-20200 Kericho, Kenya 4) Kericho District Hospital Laboratory Lilly Kirui, H. Dip., Director Hospital Road P.O. Box 1357 Kericho, 20200 Kenya 5) Kenya Medical Research Institute/Walter Reed Project Basic Sciences Laboratory John Waitumbi, PhD, Director PO Box 54-40100 Kisumu-Kakamega Road Kisumu, Kenya 6) Central Reference Tuberculosis Laboratory National Leprosy and Tuberculosis Program Joseph Sitenei, MBChB, Director P.O. Box 20781 Nairobi, Kenya 7) The Thai Red Cross AIDS Research Centre (TRC-ARC) 104 Rajdumri Road Pathumwan, Bangkok 10330, Thailand 8) Bamrasnaradura Infectious Disease Institute (BIDI) Bamrasnaradura Infectious Disease Institute 126 Tiwanon Road, Muang Nonthaburi 11000, Thailand 9) Armed Forces Research Institute of Medical Sciences (AFRIMS) U.S. Army Medical Component Department of Retrovirology 315/6 Rajvithi Road, Bangkok 10400, Thailand IRIS Version 5.2, June 2, 2011 3 TABLE OF CONTENTS ABBREVIATIONS ........................................................................................................... 6 1. SCHEMA/PRECIS........................................................................................................ 9 2. HYPOTHESIS AND STUDY OBJECTIVES .......................................................... 10 2.1 Primary Hypothesis ...................................................................................................................... 10 2.2 Primary Objective ........................................................................................................................ 10 2.3 Secondary Objectives ................................................................................................................... 10 3. INTRODUCTION ....................................................................................................... 10 3.1 Background and Study Rationale ................................................................................................. 10 3.2 What is Immune Reconstitution Syndrome (IRIS)? ...................................................................... 11 3.3 Immunopathogenesis of IRIS ........................................................................................................ 12 3.4 Importance of IRIS Studies ........................................................................................................... 14 4. STUDY DESIGN ......................................................................................................... 14 5. SELECTION AND ENROLLMENT OF PATIENTS ............................................ 14 5.1 Inclusion Criteria ......................................................................................................................... 14 5.2 Exclusion Criteria ........................................................................................................................ 16 5.3 Study Enrollment Procedures ....................................................................................................... 16 5.4 Co-enrollment Guidelines ............................................................................................................ 16 6. STUDY TREATMENT............................................................................................... 16 6.1 Anti-retroviral Therapy ................................................................................................................ 16 6.2 Prophylaxis for Opportunistic Infections ..................................................................................... 16 6.3 Treatment of Opportunistic Infections or AIDS-associated Illnesses........................................... 16 6.4 Clinical Manifestations of IRIS Episodes ..................................................................................... 17 7. CLINICAL AND LABORATORY EVALUATIONS ............................................. 18 7.1 Schedule of Events (US) ............................................................................................................... 18 7.2 Definitions for Schedule of Events- timing of Evaluations ........................................................... 20 7.3 Special Instructions and Definitions of Evaluations .................................................................... 24 8. CRITERIA FOR IRIS END POINTS ....................................................................... 28 9. CRITERIA FOR STUDY DISCONTINUATION ................................................... 29 10. STATISTICAL CONSIDERATIONS..................................................................... 29 10.1 General Design-Statistical Considerations ................................................................................ 29 10.2 Secondary Analyses .................................................................................................................... 31 10.3 Interim Analyses ........................................................................................................................ 31 11. DATA COLLECTION AND MONITORING AND ADVERSE EVENT EXPERIENCE REPORTING ................................................................................................................... 31 11.1 Definitions .................................................................................................................................. 32 11.2 Serious Adverse Event (SAE) Reporting..................................................................................... 33 12. HUMAN SUBJECTS ................................................................................................ 34 12.1 Institutional Review Board (IRB) Review and Informed Consent .............................................. 35 IRIS Version 5.2, June 2, 2011 4 12.2 Subject Confidentiality ............................................................................................................... 35 12.3 Minority Recruitment (US) ......................................................................................................... 35 12.4 Inclusion of Children and Pregnant Women .............................................................................. 36 12.5 Risks and Benefits Associated with Study Participation ............................................................ 36 12.6 Study Discontinuation ................................................................................................................ 37 12.7 Remuneration ............................................................................................................................. 37 12.8 Illiterate and Foreign-speaking Subjects (US site) .................................................................... 37 13. DATA MANAGEMENT AND RECORD RETENTION ..................................... 37 13.1 Data Management Plan.............................................................................................................. 37 13.2 Record Retention ........................................................................................................................ 38 14. PUBLICATION OF RESEARCH FINDINGS ...................................................... 38 15. BIOHAZARD CONTAINMENT ............................................................................ 38 15. REFERENCES .......................................................................................................... 40 16. APPENDIX A: IRIS CRITERIA* ........................................................................... 43 17. APPENDIX B- DAIDS TOXICITY TABLE .......................................................... 44 18. APPENDIX C- PROTOCOL RELATED RESEARCH USE OF STORED HUMAN SAMPLES, SPECIMENS AND DATA.............................................................................................. 62 19. APPENDIX D-KERICHO SITE SPECIFIC APPENDIX .................................... 63 20. APPENDIX E-THAILAND SITE SPECIFIC APPENDIX………………………….87 IRIS Version 5.2, June 2, 2011 5 ABBREVIATIONS Abbreviation Text AB AE Ag ACTG AFB AIDS ALT (SGPT) ANC ART ARV AST (SGOT) AZT BMI BP BU BWs CAP CBC CDC CLADE CLIA CMV CNS CRAg CRC CRIMSON CRP CSF CSWs CT CXR DAIDS DIR DOD DTH EBV ELISA ESR FDA GALT GCP GI Abstinence/Be Faithful adverse event antigen AIDS Clinical Trial Group Acid Fast Bacilli acquired immunodeficiency syndrome alanine transaminase absolute neutrophil count antiretroviral therapy antiretroviral aspartate transaminase zidovudine body mass index blood pressure Boston University barworkers College of American Pathologists complete blood count Centers for Disease Control and Prevention Clinic-based ART & Diagnostic Evaluation Clinical Laboratory Improvement Amendments cytomegalovirus central nervous system Cryptococcus antigen Clinical Research Center Clinical Research Information Management System C-reactive protein cerebrospinal fluid commercial sex workers computed tomography chest x-ray Division of AIDS Division of Intramural Research Department of Defence delayed-type hypersensitivity Epstein-Barr Virus enzyme-linked immunosorbent assay erythrocyte sedimentation rate Food and Drug Administration gut-associated lymphocyte tissue Guidelines for Good Clinical Practices gastrointestinal IRIS Version 5.2, June 2, 2011 6 Abbreviation Text HAART HepBcAb HepBsAb HBsAg HCV HeAb HeAg β-hCG HDL HEENT Hg HIV HVTN IAVI ICH IDCRP IFN IRB IRD IRIS KDH KEMRI LDH LDL LLN LN MAC MAI MCV MDR MOH MVA NIAID NIH NRTI NNRTI NSAID O-GAC OI OVC PAVE PBMC PCP highly active anti-retroviral therapy antibody to hepatitis B core antigen antibody to hepatitis B surface antigen hepatitis B surface antigen hepatitis C virus antibody to hepatitis E antigen hepatitis E antigen beta-human chorionic gonadotropin high density lipoprotein head, eyes, ears, nose, and throat hemoglobin human immunodeficiency virus HIV Vaccine Trials Network International AIDS Vaccine Initiative International Conference on Harmonization Infectious Diseases Clinical Research Program interferons institutional review board immune restoration disease immune reconstitution inflammatory syndrome Kericho District Hospital Kenya Medical Research Institute lactate dehydrogenase low density lipoprotein lower limit of normal Lymph node Mycobacterium avium complex Mycobacterium avium intracellulare mean corpuscular volume multi-drug resistant Ministry of Health Modified Vaccinia Ankara National Institute of Allergy and Infectious Diseases National Institutes of Health nucleoside reverse transcriptase inhibitor non-nucleoside reverse transcriptase inhibitor nonsteroidal anti-inflammatory drug Office of the Global Aids Coordinator opportunistic infection Orphans and Vulnerable Children Partnership for AIDS Vaccine Evaluation peripheral mononuclear cells Pneumocystis jirovecii pneumonia IRIS Version 5.2, June 2, 2011 7 Abbreviation Text PCR PD-1 PDCs PEPFAR PHE PI PLT PMD PML PMTCT PPD PT PTT RBC RCHSPB RNA RPR RSC SAE STIAs T4 TB (MTB) TCR TDs TG Th Treg TSH ULN USAMRU-K USMHRP USUHS WBC WHO Wk WRAIR WRP VCT VZV ZN polymerase chain reaction programmed death-1 plasmacytoid dendritic cells President’s Emergency Plan For AIDS Relief Public Health Evaluation protease inhibitor platelet count Primary medical doctor progressive multifocal leukoencephalopathy Prevention of Mother To Child Transmission purified protein derivative prothrombin time partial thromboplastin time red blood cells Regulatory Compliance and Human Subjects Protection Branch ribonucleic acid rapid plasma reagin Radiation Safety Committee Serious Adverse Event sexually transmitted infection clinic attendees thyroxine tuberculosis (mycobacterial tuberculosis) T-cell receptor truck drivers triglycerides Helper T cells regulatory T cells Thyrotropin, thyroid-stimulating hormone Upper limit of normal United States Army Medical Research Unit-Kenya United States Military HIV Research Program Uniformed Services University of the Health Sciences white blood cell count World Health Organization week Walter Reed Army Institute of Research Walter Reed Project Voluntary Counseling and Testing Varicella zoster virus Ziehl-Neelsen IRIS Version 5.2, June 2, 2011 8 1. SCHEMA/PRECIS A cohort observational study evaluating the predictors, incidence, clinical presentation and immunopathogenesis of Immune ReconstItution Syndrome (IRIS) in human immunodeficiency virus (HIV-1) infected patients with CD4 Count <100 cells/µL who are initiating antiretroviral therapy. Immune reconstitution syndrome (IRIS) is a clinical syndrome that has been described in HIV-infected patients after initiation of highly active anti-retroviral therapy (HAART), and is characterized by paradoxical acute worsening of an underlying opportunistic infection or AIDS-defining illness. There is no widely accepted syndromic definition, the pathogenesis of the syndrome is unclear and there is no specific therapy. The syndrome is more common in patients with low CD4+ T cell counts (<50 cells/µl) and in those with certain underlying infections (e.g. mycobacterial or cryptococcal infection) and is typically observed when there is evidence of response to HAART and while patients are still at risk for other opportunistic infections (OIs) or AIDS defining illnesses (e.g. pneumocystis jirovecii pneumonia or cytomegalovirus [CMV] retinitis). The incidence of IRIS varies depending on the studied population and is very frequent in developing countries creating significant diagnostic and therapeutic challenges as well as utilization of limited health resources. DESIGN International observational cohort study. Participants will be evaluated at baseline and followed according to the protocol follow up schedule after initiation of antiretroviral therapy for a total of two years. Acute symptoms that may be representing manifestations of IRIS will also be evaluated at additional acute care visits if necessary. DURATION Enrollment is expected to take 2 years. Each volunteer will be followed for two years with an optional 2-year extension for US participants only. Total duration of the study will be approximately 8 years (including the optional extension phase in US). SAMPLE SIZE Approximately 500 patients will be enrolled over a 2- year period 200 in Kenya, 100 in Thailand and approximately 200 in US.(enrollment in US will continue approximately until the other sites are full). Based on the incidence of IRIS in patients with low CD4 counts (approximately 20-40%), we anticipate strong power (~90%) to identify baseline factors predictive of IRIS. POPULATION HIV-1-infected men and women, age >18 years, antiretroviral therapy (ART)-naïve with CD4+ T cell counts <100 cells/mm3. Participants will be recruited and followed at three sites: the broader Washington DC, Kericho, Kenya and Bangkok, Thailand areas. REGIMEN Participants will be initiated on ART according to the clinical standard of care. If an OI or other AIDS defining illness is identified prior to or during screening or at any point during the study, they will also be treated according to standard of care. IRIS Version 5.2, June 2, 2011 9 2. HYPOTHESIS AND STUDY OBJECTIVES 2.1 PRIMARY HYPOTHESIS Baseline predictors exist [e.g. CD4 count, presence of OIs, hemoglobin level, body mass index (BMI), and immunologic parameters] in persons with advanced HIV infection (CD4 <100 cells/mm3) starting highly active anti-retroviral therapy (HAART) that significantly increase the risk of developing immune reconstitution syndrome (IRIS). 2.2 PRIMARY OBJECTIVE To identify baseline predictors of IRIS within 6 months of HAART initiation prospectively in a group of HIV-1 infected patients with advanced disease who are starting antiretroviral therapy. To evaluate the immunopathogenesis of IRIS with the goal to identify more appropriate targets for future therapeutic interventions. 2.3 SECONDARY OBJECTIVES 1. To evaluate the impact of IRIS on the risk of subsequent death (attributable mortality). 2. To study the incidence and clinical manifestations of IRIS prospectively in a group of HIV-1 infected patients with advanced disease who are initiating antiretroviral therapy. 3. Evaluate the baseline clinical and immunological characteristics of individuals who develop IRIS and compare them with those who do not. 4. Evaluate the incidence of pre-existing asymptomatic diseases (e.g. cryptococcus) that may lead to unmasking IRIS. 5. Evaluate the possibility that risk factors for IRIS differ by geographical site (US versus Africa versus Thailand) evaluating statistically risk factors by site interaction. 6. Evaluate IRIS immunopathogenesis with prospective follow up of lymphocyte subsets including regulatory T cells (Treg), evaluation of pathogen specific responses (depending on the infectious agent that gets diagnosed), measurement of markers of inflammation and T-cell turnover and evaluation of T-cell repertoire and innate immune responses. 7. To help establish an improved definition of IRIS by describing systematically its clinical presentations, identifying risk factors and understanding its immunopathogenesis. 8. Compare IRIS incidence in participants with CD4+ T cell counts <50 cells/µL versus those with CD4+ T cell counts between 50-100 cells/µL at baseline (pre-HAART). 9. Evaluate prospectively the immune reconstitution of patients who eventually develop IRIS versus those who do not. 10. Evaluate prospectively the role of gut-associated lymphoid tissue (GALT) depletion and reconstitution and its potential association with health and disease in a subset of participants (US and Thailand sites only). 11. Evaluate the impact of HAART on cytomegalovirus (CMV) and Epstein-Barr virus (EBV) viremia in patients with advanced HIV infection (US site only). 3. INTRODUCTION 3.1 BACKGROUND AND STUDY RATIONALE Immune reconstitution syndrome (IRIS) is a term used to encompass clinical presentations of paradoxical worsening of infectious or non-infectious diseases in patients with HIV infection after IRIS Version 5.2, June 2, 2011 10 initiation of potent antiretroviral therapy (ART). The exact etiology of IRIS is unclear but the pathogenesis seems to include an excessive inflammatory response rather than increased susceptibility to opportunistic pathogens. The lack of understanding of the immunopathogenesis of IRIS significantly impairs rational design of preventive or therapeutic strategies. IRIS’s clinical presentations and possible pathogenesis have been reviewed extensively but have not been studied prospectively in an extensive or systematic way [1-6]. Preliminary evidence suggests that the impact of IRIS, regarding morbidity and even mortality, will be much higher on HIV-infected patients in developing countries, as anti-retroviral therapy is becoming more widely available and is typically initiated at a very low CD4+ T cell count with more frequent coexistence of clinically evident or subclinical opportunistic infections such as tuberculosis (TB) [7-11]. 3.2 WHAT IS IMMUNE RECONSTITUTION SYNDROME (IRIS)? Immune reconstitution syndrome or immune reconstitution inflammatory syndrome (IRIS) or immune restoration disease (IRD) was initially described after the introduction of zidovudine (AZT) monotherapy when some treated patients presented with intense inflammatory lymphadenopathy secondary to Mycobacterium avium complex (MAC) [12-14]. The phenomenon became more prevalent after the introduction of combination ART and has now been described in association with several opportunistic infections, tumors, and auto-immune phenomena [15-24]. Most cases are seen in association with mycobacterial disease (both tuberculosis and atypical mycobacterial infections) [9, 25], cryptococcal disease [26], CMV infection, Pneumocystis jirovecii pneumonia (PCP), chronic hepatitis B or C but also progressive multifocal leukoencephalopathy (PML), Kaposi’s sarcoma, and less commonly encountered conditions such as Leishmaniasis, Bartonellosis, sarcoidosis, or Grave’s disease [1]. Similar inflammatory or paradoxical worsening of clinical condition has been described in a smaller proportion of HIV-seronegative patients treated for tuberculosis [27, 28], in patients with recovering neutrophils, or in patients that are in steroid-tapering phase of therapy for other diseases. Most of the evidence regarding IRIS comes from observational retrospective studies and case series, and as of to date there is no specific definition, but certain characteristics are consistent and generally accepted as specific for IRIS such as: 1) An intense inflammatory response (clinically and histologically) despite the absence or scant presence of live organisms in histologic specimens, and the lack of pathogen isolation from the bloodstream (in the setting of IRIS associated with an OI). 2) A paradoxical response, i.e., worsening of clinical or radiologic parameters despite successful antimicrobial therapy. This phenomenon is not exclusive to HIV infection and is described in 23% of HIV-seronegative patients who are being treated for tuberculosis. 3) A higher frequency in patients with HIV infection and low CD4+ T cell counts (<50 cells/µL), which could be related to higher microbial antigen load or more significant immune dysregulation. 4) An association with virologic response to ART. 5) Typical occurrence within the first few months of initiation of ART with some notable IRIS Version 5.2, June 2, 2011 11 exceptions (i.e. Grave’s disease which typically occurs 1-2 years later). 6) Clinical and microbiologic presentation of infectious diseases that is distinct from the new presentation of an opportunistic infection (for example negative blood cultures in patients with MAC despite fever and lymphadenopathy; negative cryptococcal blood culture despite presence of cryptococcal antigenemia; uveitis instead of retinitis with CMV infection). 7) Despite significant morbidity, there is overall low mortality associated with IRIS, and response is usually observed with either no specific therapy or a combination of medical (nonsteroidal anti-inflammatory drugs [NSAIDS] or steroids) with or without mechanical (drainage of lymph node [LN]) measures, typically without discontinuation of ART. 8) The term “unmasking” is frequently used to designate unusual or exuberant presentations of OI or infections or tumors that were not present pre-HAART but occurred soon after antiretroviral therapy (ARV) introduction. These are thought to represent either pre-existing occult infections that were asymptomatic due to the immune suppression of HIV and are being unmasked by an awakened immune system or true new infections that are generating a dysregulated immune response. Although some attempts have been made for a more detailed specific definition, as in [1, 2] and Appendix A, recognition of IRIS remains a clinical judgment decision. 3.3 IMMUNOPATHOGENESIS OF IRIS The etiology and pathogenesis of IRIS are unclear, but the syndrome is thought to be a manifestation of the emergence of pathogen-specific immune responses, as suggested by some studies, possibly in the absence of adequate recovery of regulatory mechanisms and overall imbalance of immune responses after suppression of HIV viral load and decrease in generalized immune activation. In some patients, delayed-type hypersensitivity (DTH) responses may convert from non-reactive to reactive at the same time as IRIS presentations, and in others a pathogen-specific immune response (as measured by cytokine production) may be observed that was not detected prior to ART [13, 29-32]. Although these findings have not been consistent, it is possible that each disease, that can be associated with IRIS, may have certain unique immunopathogenesis features. Serum markers of inflammation such as IL-6 and TNF-α have been described to be elevated in patients with IRIS and mycobacterial disease, despite overall decreases in other markers of immune activation [3335]. Finally, certain genetic markers may be related and predispose to the development of IRIS [36, 37]. Although the pathogenesis of IRIS remains elusive, certain parameters, specifically presence of a foreign antigen (Ag) and low CD4 counts and possible genetic factors, have been suggested based on existing data from retrospective studies [1]. It is thought that IRIS is an exuberant Th1 response in the absence of appropriate or adequate regulatory mechanisms. There is evidence of increased Th1 responses from one study in TB-IRIS [38], but the role of inadequate Th2 response, inadequate Treg control, or the possible contribution of Th17 responses or dendritic cells have not been investigated. Investigating further the hypothesis of an exuberant Th1 response, the immunologic work up of this study will focus on describing the course of T cell activation as measured by Ki67, programmed death-1 (PD-1), and HLAD-DR with CD38 co-expression, memory and naïve subset recovery post-HAART, and presence of Tregs before, during and after an IRIS episode. We IRIS Version 5.2, June 2, 2011 12 will compare this course of T cell activation with that observed in control patients who do not develop IRIS and have or do not have similar baseline characteristics including type of OI, baseline CD4 count, and virologic response to therapy. The role of recovering plasmacytoid dendritic cells (PDCs) with production of type I interferons (IFNs) will also be investigated. Ag-specific responses will focus on examination of the multi-functional aspect of responding T cells with respect to production of cytokines, perforin and granzyme B. We will compare HIV-specific responses to the responses against the underlying pathogen in patients with infections based upon Ag availability. Our hypothesis is that IRIS is associated with intense Th1 (and/or Th17) responses in the absence of appropriate regulatory control (i.e. lack of IL-10, lack of functional Treg, perhaps with a recovery of DC function in the right genetic host background). An expansion of effector CD4 T cells (as opposed to central memory or naïve) may be associated with IRIS and T-cell receptor (TCR) repertoire analyses will attempt to also look at possible skewing. The possibility that abrupt reversion of PD-1+ status of either CD4 or CD8 T cells leading to reversal of functional exhaustion (and thus exuberant Ag-specific responses) will also be investigated. It is hypothesized that the cytokine environment during IRIS (which has not been reported to date) will be that of inflammatory cytokines. Finally, the study of markers like Creactive protein (CRP) will also be conducted particularly with respect to their potential predictive value of impending IRIS either pre-HAART or soon after virologic suppression but before the IRIS events become fully symptomatic. Since the manifestations of IRIS suggest an intense inflammatory response in the presence of significant antigenic burden, most cases have been treated with continuation of the pathogen-specific therapy, with or without the addition of anti-inflammatory medications (non-steroid or steroid) [27, 39], and occasionally (mostly in the presence of severe neurologic complications), with temporary discontinuation of ART. The higher incidence of IRIS observed in retrospective studies of patients who started ARV and OI therapy almost simultaneously [40] suggests that a decrease of the microbial burden for 4-8 weeks prior to the initiation of HAART may decrease the incidence of IRIS but at the possible risk of emergence of a new OI in those patients with CD4+ T cell count <100 cells/µL [41, 42]. There are no randomized, controlled studies to date addressing the timing of OI therapy in relation to ART. IRIS Version 5.2, June 2, 2011 13 3.4 IMPORTANCE OF IRIS STUDIES Despite the early description, the high incidence, and the occasional dramatic clinical presentation of IRIS, few prospective studies have been done to date and there is still lack of a concrete definition and understanding of its pathogenesis in an era of significant advances in immunologic research and study of Ag-specific immune responses. IRIS is becoming prevalent in the developing world, where ARV therapy is becoming available for patients with advanced disease (<200 cells/µL with the median usually ~100 cells/µL). The high frequency of IRIS is thus related to the more advanced stage of disease and also probably to the much higher prevalence of TB co-infection which is frequently associated with IRIS. The IRIS presentation can pose significant diagnostic and therapeutic problems in a population with high incidence of other opportunistic infections, multi-drug resistant (MDR) TB, and limited health care resources. Identification of predictors of high risk patients are important for clinical purposes but attempts to develop a predictive model based on retrospective data have failed and are flawed because they’re based on small number of IRIS episodes from a single center or clinic generating data that are not generalizable [43, 44].A better definition of IRIS is needed, and the pathogenesis needs to be studied, so that better targets for therapy can be identified and prevention in high-risk populations can be planned. 4. STUDY DESIGN This is an international, observational cohort study of ART-naïve patients with CD4+ T cell counts <100 cells/µL. Participants will be followed at protocol-specified intervals that approximate local standards of care and treatment for a duration of up to 2 years, with additional unscheduled visits when acute symptoms develop that could be representing manifestations of IRIS, a new OI or AIDS-defining or associated illness. By having US, Kenyan and Thailand-based enrollment, the resulting cohort will have more generalizable data. 5. SELECTION AND ENROLLMENT OF PATIENTS 5.1 INCLUSION CRITERIA 1. For the National Institutes of Health (NIH)/US site: HIV-1 infection, as documented by OraQuick rapid test using venipuncture whole blood, or fingerstick whole blood done at screening; or by reactive enzyme-linked immunosorbent assay (ELISA) and Western Blot as determined by NIH Clinical Pathology Laboratory or SAIC-Frederick Inc Monitoring Laboratory. HIV infection as determined by an outside Clinical Laboratory Improvement Amendments (CLIA)-approved laboratory facility will be accepted for enrollment and verified by a standard HIV-1 ELISA with Western Blot at NIH For the Kenya Medical Research Institute/Walter Reed Project Clinical Research Center (KEMRI/WRP CRC)/Kenya site: HIV-1 infection will initially be diagnosed based upon two, serial rapid HIV tests according to Kenya Ministry of Health (MOH) guidelines. Volunteers entering this study will have HIV infection reconfirmed by two serial rapid HIV test in accordance with Kenya MOH guidelines and testing algorithm IRIS Version 5.2, June 2, 2011 14 2. 3. 4. 5. 6. 7. 8. 9. followed by a confirmation with a Western Blot using FDA approved kits. Samples from participants with discrepant results (between the results from other institution and KEMRI/WRP-CRC laboratory) and/or indeterminate/negative Western Blot will be subjected to a nucleic acid assay i.e. DNA or RNA PCR. For Thailand, HIV-1 screening and confirmatory testing will be based on 3, serial rapid HIV tests according to the Thai Ministry of Public Health guidelines. The subjects will initially be tested with an ELISA method that detects both HIV antigen and antibody. Confirmatory testing of HIV reactive samples by two different antibody detection methods will follow. Positive results by all three methods confirm HIV diagnosis. Discrepancy between the tests will require a nucleic acid detection method to confirm HIV diagnosis. No previous treatment with potent combination anti-retroviral therapy (ART), defined as any protease inhibitor (PI)-based or non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen, or even triple nucleoside reverse transcriptase inhibitors (NRTI)-based regimen, consisting of at least three antiretroviral drugs (including a boosted PI with NNRTI combination). Patients with limited use of ART (less than 12 weeks duration) more than 24 weeks before screening will be eligible for study participation. Screening CD4+ cell count ≤100 cells/mm3 *. Residence within the wider Washington D.C. area (approximately within a 120-mile radius from the NIH Bethesda campus) for the National Institutes of Health/US site and residents of the Kericho District Hospital catchment area, an approximate 93-mile (150 kilometers) radius, for the KEMRI/WRP CRC/Kenya site. Residence within the Bangkok Metropolitan area and nearby provinces are allowed to participate (approximately 120-mile radius from each of the clinical site) Men and women age 18 years. Ability and willingness of subject or legal guardian/representative to understand study requirements and give informed consent. Be willing to allow storage of blood or tissue samples for future research (For Thailand: storage of blood or tissue samples is an optional procedure and therefore not an inclusion criteria) Be willing to have HLA testing (For Thailand: HLA testing is an optional procedure and therefore not an inclusion criteria) For the NIH/US site: Participants must have primary care physician or will need to agree to find one during the first 24 weeks on study. For the KEMRI/WRP/Kenya site: Participants must be enrolled in the Kericho District Hospital HIV Clinic. For the two Thailand clinical sites: participants must be enrolled in the HIV clinic at either of the sites. *CD4 <100 cells/µL from an outside or the site’s laboratory within 8 weeks prior to screening can be accepted as the screening value IRIS Version 5.2, June 2, 2011 15 5.2 EXCLUSION CRITERIA 1. 2. Active drug or alcohol use or dependence that, in the opinion of the investigator, would interfere with adherence to study requirements. Pregnancy will be an exclusion criterion for study entry given the intense nature of the protocol regarding blood draws, diagnostic testing, and follow- up 5.3 STUDY ENROLLMENT PROCEDURES Prior to implementation of this protocol, the protocol and consent form will need to be approved by the NIAID institutional review board (IRB) and the IRB of potentially collaborating institutions. In addition, the protocol and consent form will be approved by the Kenya Medical Research Institute (KEMRI) and the Uniformed Services University IRB. In Thailand, the protocol and consent forms will be approved by the Department of Disease Control (DDC) at the Ministry of Public Health and the Chulalongkorn University IRBs. Once an eligible candidate for study entry has been identified, details will be carefully discussed with the subject. The subject will be asked to read and sign the consent form that was approved by the IRB. 5.4 CO-ENROLLMENT GUIDELINES Co-enrollment to the biopsy protocol (US NIH Site only) for rectal and/or LN biopsies will also be encouraged if patients elect to have research biopsies. 6. STUDY TREATMENT 6.1 ANTI-RETROVIRAL THERAPY Potent antiretroviral therapy will follow the published treatment guidelines overall and reflect current standard of care with Food and Drug Administration (FDA)-approved drugs or drugs available through expanded access [45] for the NIH/US site and based upon Kenya Ministry of Health (MOH) and World Health Organization (WHO) guidelines [43, 44] for the KEMRI/ Walter Reed Project (WRP)/Kenya site. The Thailand sites will follow the HIV treatment guidelines published by the Thai Ministry of Public Health. The choice of ART will be individualized to some degree, based on specific clinical or laboratory parameters and personal preferences or adherence issues. The ART regimens will be chosen in consultation with the participant’s primary care physician. ART will be continued throughout episodes of IRIS, but may need to be discontinued temporarily in situations where severe inflammatory responses present with lifethreatening or serious neurologic complications (i.e., enlargement of lymph nodes compressing the airways and/or progression of central nervous system [CNS] lesions with edema). 6.2 PROPHYLAXIS FOR OPPORTUNISTIC INFECTIONS Opportunistic infection prophylaxis will be administered according to standard of care and established local practice guidelines and may be discontinued once immune reconstitution has been achieved according to published treatment guidelines. 6.3 TREATMENT OF OPPORTUNISTIC INFECTIONS OR AIDS-ASSOCIATED ILLNESSES Participants with an opportunistic infection or with AIDS-associated illness or malignancy will be treated according to local standard of care and published treatment guidelines where available, in consultation with the primary care provider. IRIS Version 5.2, June 2, 2011 16 Observational data have shown that the incidence of IRIS can be higher in the presence of high antigenic load of opportunistic pathogens. A suggestion has been made to treat certain opportunistic infections such as tuberculosis, MAC, or cryptococcosis for 4-8 weeks prior to HAART initiation. Randomized studies are currently trying to address the question of immediate versus deferred ART initiation in HIV-infected patients with CD4+ T cell counts <200 cells/µL. In more advanced disease (CD4+ <100 cells/µL), which reflects the study population selected for this study, observational studies have found increased incidence of new AIDS-defining illness or OIs in patients whose ART initiation was delayed. Since there is no consensus on the best timing of ART initiation, but there is evidence that new diagnoses can emerge if ART is delayed in patients with CD4+ T cell count <100 cells/µL, ART in all participants will be initiated within 4 weeks from screening regardless of the presence of an OI or another underlying AIDS-defining illness. 6.4 CLINICAL MANIFESTATIONS OF IRIS EPISODES There is no standard of care or specific treatment for IRIS. Participants presenting with a clinical picture compatible with IRIS will undergo an appropriate work-up for exclusion of other diagnoses. Treatment may require any one, or any possible combination, of the following procedures: a. Mechanical intervention: examples include drainage of enlarged lymph nodes, thoracentesis, paracentesis, or lumbar puncture. b. Non-steroid anti-inflammatory drugs that may decrease fever or other inflammatory manifestations. c. Pain or antipyretic medications for symptomatic relief. d. Corticosteroids for more serious manifestations such as severe lymph node enlargement, impending respiratory decompensation, and/or neurologic symptoms. e. Rarely, ART discontinuation for life-threatening situations such as progressive neurologic complications. IRIS Version 5.2, June 2, 2011 17 7. CLINICAL AND LABORATORY EVALUATIONS 7.1 SCHEDULE OF EVENTS (US) Evaluation Screening (-28 days) Documentation of HIV X Medical & Medication History X Body mass index (BMI)4 Pre-ART (-27 to 0 days) X ART1 (Wk 0) Wk 23 Wk 43 Wk 83 Wk 123 Wk 243 X X X X X Nadir CD4+ Count X Clinical Assessment X X X X X Wk 363 Wk 483 Wk 64 and 803 Wk 96 (EOS)6 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X Amylase, Lipase X5 (X)5 Lipid Profile (fasting) X Exam2 Physical Hematology (CBC and differential and ESR) Chemistries, CRP X As clinically indicated X PT/PTT, D-Dimer X X Urinalysis X X Pregnancy Testing X X X X X X X X X (X) X X X X X X Flow Cytometry (routine and research) HIV-RNA (optional) HIV Genotype X TSH and Free T4 X Hepatitis A, B, C Screen X Cryptococcal Serum Ag X Toxoplasma Serology (IgG) X X X X X X X X X X X X X X As clinically indicated and before research procedures (apheresis, biopsies) X X X X X X X X X X As clinically indicated X6 1: An elective hospital admission may be scheduled between screening and ART initiation to facilitate testing and for participant convenience. Testing of pre-ART visit may be completed in more than one day 2: Weeks 48-80: visits will occur every 16 weeks, research flow cytometry will be optional 3: All visits will require a medical doctor (MD) visit. 4: BMI= weight (kg) divided by [height x height (cm)] 5: Amylase and lipase can be done on either pre-entry or entry visits 6: Optional extended follow up every 16 weeks up to week 192 IRIS Version 5.2, June 2, 2011 18 Schedule of Events (Cont’d) Evaluation PPD Screening Pre-ART ART1 (-28 days) (-27 to 0 days) (Wk 0) X RPR X Urine GC, Chlamydia PCR X Cervical Pap Smear X5 CMV Blood PCR X CMV serology (IgG) X EBV PCR (cell) X Eye Clinic Evaluation X6 EKG X Chest X-Ray X HLA-typing X Stored PBMC/plasma Stored Serum 2-pass Apheresis7 GI Biopsy8 LN Biopsy9 (>2 cm) Photography 10 Wk 2 Wk 4 X2 Wk 8 (X) Wk 12 Wk 24 Wk 36 X Wk 48 X3 Wk 64 and 80 Wk 96 (EOS)4 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X (X) optional X X X X X X X X X X (X) optional X X (X) (X) X (X) (X) (X) (X) X X As indicated based on changes of observed lesions 1: An elective hospital admission may be scheduled between screening and ART initiation to facilitate testing and for participant convenience. 2, 3: PPD will be repeated at week 4 or 8 only if non-reactive at baseline. If PPD non-reactive at baseline and week 4, it will be repeated yearly (at weeks 48 and 96) 4: Optional extended follow up every 16 weeks up to week 192. 5: Pap smear can be delayed up until week 4 of study and will be repeated as clinically indicated or according to local practices. Results from PMD will be accepted. 6: And every 24 weeks thereafter until CD4 >100 cells/µL for >12 weeks or as clinically indicated. 7: NIH/US and Bangkok (optional) sites only. If adequate venous access and Hg >9g/dl, PLT >50,000 and not pregnant for female participants. It will be repeated every 48 weeks after week 48. 8, 9: Optional under a different protocol, time points shown are approximate. q 10: Skin or mucosal lesions that require close follow up (i.e. Kaposi’s sarcoma [KS] lesions, skin, or genital warts). IRIS Version 5.2, June 2, 2011 19 7.2 DEFINITIONS FOR SCHEDULE OF EVENTS- TIMING OF EVALUATIONS 7.2.1 Screening Screening evaluations to determine eligibility must be completed within 28 days prior to day of ART initiation. These will include laboratory documentation of HIV status, CD4+ T cell count, complete blood count (CBC) and HIV RNA, if needed to expedite genotype results (US site) as well as clinical and medication history. Study participants will sign informed consent before screening or research labs are collected. CD4 T cell counts from an outside or the site’s laboratory within 8 weeks prior to screening can be accepted as the screening value. For US site only: standard consent may be signed on the day of screening if outside CD4 count as above is available or as soon as the CD4 count determining eligibility becomes available. Pre-ART and ART visits will be combined for the Kenya and Thailand site but tests may be performed in more than one day (see Appendix D and E). For the Kenya site, a CXR done during routine care in the HIV clinic will be accepted if done within one month prior to screening. In addition, chemistries may be done as part of screening and repeated if necessary and clinically indicated prior to ART initiation (see Appendix D). 7.2.2 Pre-ART Pre-ART evaluations must be completed within 27 days prior to ART evaluations and may require more than one visits (days). Pre-ART and ART (week 0) visits may be combined, if it is feasible to schedule all the required testing and obtain standard informed consent. 1. 2. History and physical exam (including BMI) CBC with differential and erythrocyte sedimentation rate (ESR) Chemistry with CRP (CRP in US only) and for KEMRI/WRP/KENYA and Thailand Chemistries will routinely include electrolytes, Renal and liver function tests. 3. Amylase and lipase 4. A fasting lipid profile 5. Prothrombin time (PT)/ partial thromboplastin time (PTT) and D-dimer (US only) 6. Flow cytometry: routine (CD4 and CD8 T cell counts) and research as outlined in immunologic studies) 7. 8. HIV Viral load HIV genotype (may be done at baseline/screening visit if it facilitates clinical care) 9. Urinalysis (as clinically indicated for the Kenya and Thailand sites) 10. Thyroid stimulating hormone (TSH) and free thyroxine (T4) (US) 11. Hepatitis A, B, C screening (Hepatitis A in US only) 12. Cryptococcal serum antigen IRIS Version 5.2, June 2, 2011 20 13. 14. Urine Histoplasma antigen if clinically indicated or according to standard of care (Thai site) Toxoplasma serology (IgG) (US and Thailand) 15. Purified protein derivative PPD testing 16. Rapid plasma reagin (RPR; Syphilis diagnostic) 17. Urine Neisseria gonorrhoeae (GC) and Chlamydia polymerase chain reaction (PCR) (US only) 18. Cervical Pap smear (anal Pap smear in Thailand according to local clinical practices) 19. Ophthalmological evaluation (Eye Clinic) 20. CMV PCR (blood) (US only) 21. CMV serology (IgG) (US only) 22. EBV PCR (peripheral mononuclear cells [PBMC]) (US only) 23. Chest x-ray (CXR) 24. ECG (US and Thai sites only) 25. Photography of any skin or other lesions that require follow up over time 26. Pregnancy test (urine or serum) for women of childbearing potential 27. Cell/serum and plasma storage 28. HLA typing Additional pre-ART research tests in US and Thailand will include: 29. Apheresis (optional and if venous access is adequate and if Hg is ≥9 gm/dL and PLT> 50,000 with negative pregnancy test in women) 30. Rectal biopsy (optional under different protocol at the US NIH site and optional at the Thailand site). 31. Genital secretion collection (procedure performed in Thailand only and is optional) 32. LN biopsy (optional in US under a separate protocol) if a node is found to be larger than 2 cm in diameter - the LN will be processed for microbiology, pathology and research (flow cytometry). LN biopsy may also be required at any point for clinical diagnostic reasons. The following tests will be accepted if done at NIH within 8 weeks of screening under a different NIH protocol or in Kenya at the Kericho District Hospital or another treatment facility: EKG, CXR, CMV and Toxoplasma serology, hepatitis A, B, C screening, TSH and free T4, RPR, and PPD. At NIH, eye clinic evaluation will be accepted if done at NIH within the past 3 months. For the Kericho IRIS Version 5.2, June 2, 2011 21 and Thai sites, eye clinic evaluation will be accepted if done by a qualified ophthalmologist, ophthalmology technician, or qualified Medical or Clinical Officer in the past 3 months. Additionally, HLA typing and HIV testing performed at NIH at any point prior to screening will not be repeated. An elective hospital admission may be scheduled between screening and ART initiation to facilitate testing and for participant convenience. 7.2.3 ART (day of ART initiation) ART evaluations must occur within 27 days after pre-ART evaluations or the pre-ART and ART visits can be combined. These will include: 1. Targeted review of history including medication history and targeted physical exam. 2. Pregnancy test (urine, but serum will be acceptable if urine was not obtained) 3. Flow Cytometry 4. HIV RNA 5. Safety laboratory testing will be repeated only if clinically indicated and if they were performed more than 2 weeks prior to entry. Lipase and amylase will be done once either at pre-ART or ART visits and as clinically indicated thereafter. 6. CMV and EBV PCR will also be done at ART visit if pre-ART visit was more than 14 days before (US only). 7. ESR/ CRP and D-dimer/PT, PTT (US only) will be done at ART visit unless they were done less than 7 days before (at pre-ART visit). 8. Storage of cells, plasma and serum 7.2.4 Week 2 to Week 80 Visits Week 2 to week 80 visits will include a medical and medication history as well as clinical assessment with targeted physical exam (BMI at weeks 12, 24 and 48, full physical exam recommended yearly). A study medical doctor (MD) visit will be required until week 48, and then yearly and as clinically indicated. For the Kenya site, study participants will be seen by a Clinical Officer or Medical Doctor consistent with the standard of care in Kenya. For the Thailand site, study participants will be seen by a Medical Doctor. Additional testing may include: 1. Flow cytometry (except weeks 64 and 80 for the Thailand site) 2. HIV-RNA 3. CBC (with differential and ESR), D-dimer with PT/PTT (US only), UA (as clinically indicated for the Kenya and Thailand sites) and chemistries (with CRP in US only). For KEMRI/WRP/KENYA chemistries will routinely include electrolytes, renal and liver function tests. For the Thailand site, electrolytes and BUN/Cr will be performed at weeks 12, 24, 48 and 80, fasting lipid profile will be performed at weeks 24 and 48, liver function test will be performed at every visit except for week 8. 4. CMV blood PCR (US only) 5. EBV PCR (US only) 6. Storage of cells, plasma and serum (no storage at week 80 for the Thailand site) IRIS Version 5.2, June 2, 2011 22 Additionally: PPD will be repeated at week 4 or 8 if non-reactive at baseline. Eye evaluation will be repeated approximately every 24 weeks until CD4 counts are >100 cells/µl for >12 weeks. At weeks 24 and 48: fasting lipid profile, Pap smear (US and Thailand only, not protocol mandated but recommended in the US, to be performed at weeks 24 and 48 in Thailand according to local practices). Apheresis (US and optional in Thailand) will occur at approximately weeks 12 and 48 and then yearly provided conditions are met: adequate venous access, Hg >9gr/dL, PLT >50,000 and negative pregnancy test). Yearly testing (approximately at weeks 48 and 96) will also include: 1. PPD if non-reactive at baseline and week 4 2. RPR 3. Fasting lipid profile 4. Urinalysis (as clinically indicated for the Kenya and Thailand sites) 5. Pap smear will be strongly recommended but is not required by protocol (report will be acceptable from outside medical doctor) Study visits may occur within a +/-10-day window period in the first 24 weeks of the study and within a +/-21-day window period for the rest of the study. Unscheduled visits occurring within the above accepted windows of a scheduled visit may replace the scheduled per protocol visit. During the optional extension period at the NIH (week 96 to end of study), the window period for visits may be up to 2 months. 7.2.5 Premature Study Discontinuation Evaluations If a participant elects to discontinue study participation for whatever reason, evaluations will be done at the end of study visit which would correspond to those listed below as final evaluations of the end of study visit. 7.2.6 Final Study Evaluations Final evaluations are required at the subject’s final visit, Week 96 or at premature study discontinuation. These will include: 1. Complete history and physical exam (with BMI calculation) 2. Clinical assessment of signs and symptoms 3. HIV viral load and flow cytometry 4. CBC with differential, ESR 5. PT/PTT, D-dimer (for US only) 6. Chemistry panel, CRP (US) and for KEMRI/WRP/KENYA, Chemistries will routinely include electrolytes, Renal and liver function tests. 7. Urinalysis (as clinically indicated for the Kenya and Thailand sites) 8. Stored PBMC, plasma and serum 7.2.7 Unscheduled Visits Unscheduled visits due to acute events that necessitate outpatient or inpatient evaluations and that, according to the medical team, may be representing presentations of IRIS will entail evaluations that IRIS Version 5.2, June 2, 2011 23 are clinically indicated including flow cytometry and HIV-RNA. In addition, and if the team suspects IRIS, cell, serum and plasma storage may be done if blood volume restrictions allow and apheresis (US only) may be scheduled at the closest possible time point that the subject’s clinical condition and scheduling limitations would permit. Unscheduled visits occurring within a 14-day window of a scheduled visit may replace the scheduled per protocol visit. 7.2.8 Optional Study Extension Up to Week 192 (US site only) US participants may choose to continue their study participation an additional two years up to week 192. Visits will occur approximately every 16 weeks and data collection and evaluations will be the same as between weeks 48 to 96. If patients have ongoing clinical issues a few additional visits may be allowed as indicated until care is appropriately transitioned. Selected research labs may also be done (as in protocol visits betweek week 96 and 192) if the clinical issues are related to IRIS or other HIV complications. 7.3 SPECIAL INSTRUCTIONS AND DEFINITIONS OF EVALUATIONS 7.3.1 Documentation of HIV For the NIH site: HIV-1 infection, can be documented by OraQuick test at screening to assure timely scheduling of the protocol evaluations prior to ART initiation. HIV testing by ELISA, with Western blot confirmation will also be done at screening if not done previously at NIH. For the Kenya Medical Institute/Walter Reed Project Clinical Research Center (KEMRI/WRP CRC)/Kenya site: HIV-1 infection will initially be diagnosed based upon two, serial rapid HIV tests according to Kenya MOH guidelines. Volunteers entering this study will have HIV infection reconfirmed by two serial rapid HIV test in accordance with the Kenya MOH guidelines and testing algorithm followed by a confirmation with a Western Blot. For Thailand, HIV-1 screening and confirmatory testing will be based on 3, serial rapid HIV tests according to the Thai Ministry of Public Health guidelines. The subjects will initially be tested with an ELISA method that detects both HIV antigen and antibody. Confirmatory testing of HIV reactive samples by two different antibody detection methods will follow. Positive results by all three methods confirm HIV diagnosis. Discrepancy between the tests will require a nucleic acid detection method to confirm HIV diagnosis. 7.3.2 Medical History A medical history must be present in source documents. All diagnoses, related and unrelated to HIV infection, should be recorded regardless of when they occurred. Any allergies to any medications and/or their formulations must be present in the Clinical Research Information Management System (CRIMSON) documents or study source documents/case report forms. 7.3.3 Medication History A medication history must be present in source documents, including: Complete HIV treatment history, including start and stop dates of any antiretroviral medication. IRIS Version 5.2, June 2, 2011 24 Complete treatment history of any prescription or non-prescription medications taken for the treatment or prophylaxis of opportunistic infections, including actual or estimated start and stop dates. All prescription medications (in addition to those noted above) taken within 90 days prior to screening, including actual or estimated start and stop dates. Medications for prophylaxis or treatment of HIV-associated diseases such as TB should be recorded regardless of when they were taken. Nonprescription medications, to include analgesics, antipyretics, anti-histamines, and antacids, taken within 30 days prior to screening. Include actual or estimated start and stop dates. Alternative therapies to include acupuncture, homeopathic medicine, herbal medications, and vitamins, taken within 90 days prior to screening. Include actual or estimated start and stop dates. All antiretrovirals, prescription and non-prescription medications, dietary supplements, and herbal treatments will be recorded. 7.3.4 Nadir CD4+ T Cell Count The subject’s nadir CD4+ cell count (absolute value and date) will be considered the lowest CD4 T cell count documented prior to ART initiation (on either screening or pre-ART or ART visits) and should be documented. Results will be recorded in CRIMSON or study source documents/case report form. 7.3.5 Clinical Assessments Signs and Symptoms All signs and symptoms that meet documentation requirements (grade 3 and 4, specific diagnoses) within 30 days prior to screening must be documented. In addition, after enrollment all signs and symptoms meeting documentation requirements (grade 3 and 4, suspected IRIS, specific diagnoses) must be recorded in CRIMSON at the NIH/US Site and on study source documents/case report forms for the KEMRI/WRP/Kenya and TRCARC Bangkok sites throughout the course of the study. Toxicity analysis will be based on the criteria outlined in the Division of AIDS (DAIDS) Table for Grading Severity of Adult Adverse Experiences, December 2004, and is shown in Appendix B. Diagnoses All confirmed and probable diagnoses made since the last visit will be recorded in CRIMSON at the NIH/US Site and on study source documents/case report forms for the KEMRI/WRP/Kenya and TRCARC Bangkok sites, including current status at the time of study visit. Vital Signs IRIS Version 5.2, June 2, 2011 25 Temperature, pulse, blood pressure (BP), respiratory rate and pulse oximetry (US only) will be collected at all visits and recorded in CRIMSON at the NIH/US Site and on study source documents/case report forms for the KEMRI/WRP/Kenya and TRCARC Bangkok sites. Physical Exam The physical examination includes the following: Height, weight, vital signs as above General appearance Skin Head, eyes, ears, nose, and throat (HEENT) Neck Respiratory Chest/breasts Cardiovascular Abdominal Genital/urinary/peri-rectal Extremities CNS: Cranial nerves, motor, and sensory Note: Evaluation of subject’s height is required at entry only. Full exam performed at baseline and yearly, targeted exam (guided by symptoms) in all other visits . 7.3.6 Laboratory Evaluations (see Appendix D (Kericho Site Schedule of Events) for Kenya specific laboratory evaluations and appendix E for Thailand sites) Please refer to Appendix B for toxicity grading which is based on the DAIDS Table for Grading Severity of Adult Adverse Experiences, dated December 2004. Hematology: Hemoglobin, hematocrit, red blood cells (RBC), mean corpuscular volume (MCV), white blood cell count (WBC), differential WBC, absolute neutrophil count (ANC), and platelets. Erythrocyte sedimentation rate (ESR) will also be performed. Blood Chemistries: Glucose, creatinine, creatine kinase, electrolytes (sodium, potassium, chloride, phosphate, and bicarbonate), calcium, magnesium, lactate dehydrogenase (LDH), total protein, CRP (US only) and albumin. At the KEMRI/WRP/Kenya and Thai sites, according to local clinical standards phosphate, magnesium, calcium, lactate dehydrogenase, and total protein will be performed only if clinically indicated. Thyroid Function Tests (US and Thailand only): T4 and TSH. PT/PTT and D-dimer (US only). Hepatitis A (US only), B, and C: hepatitis A serology (IgG, IgM), hepatitis B serology (hepatitis B surface antigen [HBsAg], antibody to hepatitis B surface antigen [anti-HepBsAb], antibody to hepatitis B core antigen [anti-HepBcAb] and hepatitis E antigen [HeAg]/ antibody to hepatitis E antigen [antiHeAb]), and hepatitis C antibody (ELISA) and hepatitis C virus ( HCV) RNA. At the KEMRI/WRP IRIS Version 5.2, June 2, 2011 26 Kenya site, only Hepatitis B and C serology (IgG) will be checked. For Thailand, only Hepatitis B and C serology will be performed. Liver Function Tests: Total bilirubin, AST (SGOT), ALT (SGPT), alkaline phosphatase (or GGT), and direct bilirubin. Urinalysis: Microscopic analysis Fasting lipid profile: Total cholesterol, HDL, LDL and triglycerides Pregnancy Test: For women of childbearing potential: β-hCG test with a sensitivity of 25-50 mIU/mL using urine. If entry is less than 72 hours after pre-entry, a pregnancy test is not required to be repeated at entry. If urine is not available, serum will be an acceptable alternative. 7.3.7 ECG (US and Thailand only) A baseline 12-lead ECG is required at study entry and as clinically indicated after that. 7.3.8 Chest X-ray A baseline chest x-ray is required at entry. It may be repeated at later time points if clinically indicated. 7.3.9 Virologic Studies (HIV Viral Load) For NIH: Plasma HIV-1 RNA (Real Time) The screening test for HIV-1 RNA will be performed at SAIC Frederick, using the bDNA assay. For Kericho: The screening test for HIV-1 RNA will be performed at the Kenya Medical Institute/Walter Reed Project Clinical Research Center laboratory, using the Roche Amplicor 1.5. For Thailand: The HIV-1 RNA will be performed at AFRIMS using the Roche Amplicor 1.5. 7.3.10 Stored plasma/PBMC/serum (Appendix C) Plasma, serum and PBMCs will be stored for HIV-related research at all visits, including unscheduled visits, for possible IRIS assessments, whenever possible, depending on the subject’s blood volume restrictions. 7.3.11 Immunologic Studies For NIH: Flow cytometry Enumeration and phenotyping of lymphocytes will be performed on samples from all visits at SAIC Frederick laboratory. For Kericho: Enumeration and phenotyping of lymphocytes will be performed on samples from all visits at the Kenya Medical Institute/Walter Reed Project Clinical Research Center laboratory. For Thailand: Enumeration and phenotyping of lymphocytes will be performed on samples from all visits at the AFRIMS laboratory. Real time flow cytometry will also follow: 1. Proportion and enumeration of CD4 and CD8 T cells with naïve versus memory phenotype 2. Proportion and enumeration of activated CD4 and CD8 T cells as measured by HLA-DR and CD38 expression 3. Proportion and enumeration of proliferating CD4 and CD8 T cells as measured by intracellular Ki67 IRIS Version 5.2, June 2, 2011 27 4. 5. 6. 7. Proportion and enumeration of CD4 and CD8 T cells expressing IL-7Ra (CD127) Proportion and enumeration of CD4 and CD8 T cells expressing PD-1 Proportion and enumeration of Treg cells (CD4+/FoxP3+/CD25+or-) Proportion of myeloid (CD11c) and plasmacytoid (CD123+) dendritic cells Stored serum and plasma (~2 mL per visit) will be used to measure the following (by multiplex assays): 1. Levels of pro-inflammatory cytokines 2. Th1/Th2 and Th17 cytokines 3. CRP, D-dimer and chemokines Stored PBMC (~20 x 106 cells/visit) will be used to test: 1. Ag-specific responses by ICCS and CFSE dilution assays. Stimulation assays will include negative and positive controls, HIV-gag and CMV peptides (in CMV+ recipients) and Ag relevant to the underlying pathogen if these are available (i.e. PPD, ESAT-6 or CFP-10 for TB, MAC, Cryptosporidium, Varicella zoster virus VZV). 2. If sufficient cells are available, the tetramer+ cells for specific peptides will be followed. 3. If sufficient cells are available (probably only in certain patients with apheresis) the TCR repertoire of sorted CD4 and CD8 T cells will be studied at study time points of interest. 4. If sufficient cells are available (probably only in certain patients with apheresis) the function (i.e. suppression) of sorted phenotypically Treg cells (CD4+/CD25high/CD127low) will be studied at study time points of interest. 7.3.12 Discarded Clinical Specimens Discarded specimens collected for clinical reasons (blood, tissue, lung fluid) may also be used for research. 8. CRITERIA FOR IRIS END POINTS The study team will meet regularly to evaluate study progression and presentations of participants during acute or scheduled visits that may be representing IRIS episodes. Based upon the modified AIDS Clinical Trials Group (ACTG) criteria for IRIS (Appendix A) and according to clinical presentation, laboratory, radiologic findings and study team discussion, the episodes will be categorized as: a) Consistent with IRIS (meeting all five criteria outlined in Appendix A) b) Suspicious for IRIS (meeting four of the criteria listed in Appendix A) c) Consistent with alternate diagnosis (new OI, recurrence of previous OI, AIDS-defining illness, other disease or drug toxicity) Additional work up and evaluation of the participant or stored specimens may be decided during these meetings. An endpoint committee chaired by an internationally recognized IRIS expert (Dr Martyn French) and two other infectious disease experts as well as representation from the study team will review and adjudicate all cases considered for IRIS (1 of 3 endpoints as assigned above). The committee will make final recommendations to the protocol chairs with regard to endpoint assignment and will comment on IRIS Version 5.2, June 2, 2011 28 the issue of “unmasking”. The endpoint committee will meet after the first 10 cases are evaluated for IRIS and at regular intervals thereafter. The endpoint committee may ask for additional clinical or laboratory data from the study teams. Data independent of any patient identifiers, including additional laboratory tests on stored specimens, will be provided to the endpoint committee. For the Kenya site, overall review of subjects having any clinical event that may be consistent with IRIS (as defined in Appendix A), review of source documents and/or case report forms for substantiation of IRIS criteria, and end point review/IRIS case adjudication will all be covered in a standard operating procedure document specific for the Kericho site. Telephone conferences will be held between the NIH team (lead by the Chair or her designee) and the Kericho team and/or the Thai team according to the needs as defined by the study Chair and Co-chairs. The following are intended to be the primary topics for discussion during these team calls: all subjects newly enrolled to the study; any case suspicious of IRIS; any subject experiencing a protocol defined Serious Adverse Event (SAE) or any other clinical or adverse event (AE) a team member feels should be discussed; and other study related topics. A case report form for IRIS definition and end point determination will be completed for all subjects having clinical events suspicious of IRIS. This case report form will serve as the basis for discussion during the weekly telephone conferences. 9. CRITERIA FOR STUDY DISCONTINUATION Reasons for withdrawal from study are: 1. Request by the subject to withdraw. 2. Request for withdrawal by the primary care provider, if she/he thinks the study is no longer in the best interest of the subject. 3. Subject judged by the investigator to be at significant risk of failing to comply with the provisions of the protocol and to cause harm to self or seriously interfere with the validity of the study results (for instance, in case of frequently missed visits). 4. Termination of the study at the discretion of the IRBs, NIAID, KEMRI, WRAIR, Infectious Diseases Clinical Research Program (IDCRP), Chulalongkorn University IRB, the Department of Disease Control, Ministry of Public Health IRB, or principal investigator. Pregnancy during study participation will not mandate study withdrawal provided that the participant is receiving adequate obstetric care and continued study participation will be permitted if the subject wishes to remain on study. For NIH and Thailand, all aphereses, research biopsies and blood draws will be suspended during the gestation and 12 month post-delivery period. For all sites, blood draws will follow local standard of care in a pregnant woman with HIV infection on ART. 10. STATISTICAL CONSIDERATIONS 10.1 GENERAL DESIGN-STATISTICAL CONSIDERATIONS This protocol aims to evaluate the role of different baseline factors on the risk of developing IRIS (Immune Reconstitution Syndrome) within 6 months of ART initiation. The study will be conducted in IRIS Version 5.2, June 2, 2011 29 3 sites: US, Kenya and Thailand with a total enrollment of approximately 500. The site in Kenya will enroll 200 participants, the site in Thailand will enroll 100 and the site in US will enroll approximately 200 as it will remain open to enrollment up until the other sites have completed enrollment so that the maximum anticipated enrollment will be 500 so that a sample size of 400 will be evaluable for the main study objectives. Each volunteer will be followed for a minimum of 2 years. Important secondary objectives are to estimate the incidence of IRIS both overall and stratified by different risk factors, to assess the risk of death associated with IRIS, and to describe the role of immune markers in the context of IRIS. To describe power for this study consider a binary baseline characteristic or covariate (e.g baseline CD4 count above/below the median, or infection at baseline). The probability of identifying this binary covariate as a significant risk factor depends on the rate of the binary characteristic and the assumed IRIS rates for the two values of the binary characteristic. The table below identifies specific scenarios for which a 400-sample study provides around 90% power. From the 5th row of the table we see that if the overall IRIS rate is 0.30, 1/3 of the sample have the binary characteristic (e.g. CD4 <median), and the IRIS rate for those with high CD4 counts is 0.40 then we will have 86% power to detect CD4 count as a predictor of IRIS. The study is extremely well powered to detect a risk factor that doubles the risk of IRIS. Statistical power to detect an important binary covariate on the risk of IRIS under different scenarios. N=400 OVERALL IRIS RATE Rate of Binary IRIS rate with characteristic binary characteristic .20 1/2 1/3 1/5 1/2 1/3 1/5 .30 0.26 0.30 0.33 0.37 0.40 0.44 IRIS rate without binary characteristic 0.14 0.15 0.17 0.23 0.25 0.27 Rate ratio Power 1.86 2.00 1.97 1.61 1.60 1.66 0.85 0.93 0.87 0.87 0.86 0.85 The risk factors of primary interest are CD4 count at baseline (above/below the median) and the presence of an infection (either active or occult) at baseline. The primary analysis will be conducted using a Cox regression model stratified by site using time to IRIS as the outcome. In these analyses, death will be treated as a censoring variable. Separate models will be used for each of the above binary risk factors. Additional Cox regression models will be used to evaluate other risk factors such as BMI, hemoglobin, infection type e.g. mycobacterial versus other, or active versus occult. Multivariate Cox regression will also be performed. Although the primary analysis will be done with all sites combined, statistical tests of risk factor by site interaction will be conducted to examine the possibility that the risk factor(s) is site-specific. IRIS Version 5.2, June 2, 2011 30 10.2 SECONDARY ANALYSES Each patient will be classified into one of four possible categories 6 months after ART initiation: A=Alive and experienced IRIS, B=Dead after experiencing IRIS, C=Dead without experiencing IRIS, D=Alive without IRIS. Incidence will be calculated as (A+B)/(A+B+C+D). IRIS-attributable mortality during the first 6 months will be calculated as B/A+B+C+D. If censoring is an issue, i.e. drop-out before the 6 month ART anniversary, cumulative incidence curves will be used to estimate the proportion of patients in the above 4 states over the first 6 months of follow-up [46]. These analyses will be conducted both separately and pooled over the three sites. Additionally, cumulative incidence curves of IRIS will be estimate to describe the time course of IRIS over the entire course of follow up. To evaluate the impact of IRIS on the risk of subsequent death, a Cox regression model using death as the outcome will be estimated where IRIS is treated as a time varying covariate which is 0 until IRIS occurs and 1 thereafter. Similar models e.g. a time varying covariate which is 0 except for the 3 months after IRIS, will be used to assess if IRIS is associated with a transient increase in the risk of death. Multivariate Cox regression will also be used to account for baseline variables in some of these analyses. To evaluate the impact of IRIS on subsequent CD4 counts, multiple linear regression will be used to predict CD4 counts at 1 year post ART initiation using whether IRIS occurred within the first 6 months and baseline variables e.g. baseline CD4. Random effects longitudinal models will also be used to assess how the trajectory of CD4 counts is impacted by IRIS. Statistical analyses of immunophenotypic, cytokine/chemokines, and immune response parameters will adopt the approach taken for other baseline variables. Thus these parameters will be used as predictors of time to IRIS in univariate and multivariate Cox regression models. 10.3 INTERIM ANALYSES Interim analyses will be completed approximately after 200 study participants have completed a minimum of 24-week follow-up and all data are available. 10.4 REPLACEMENT OF SUBJECTS There will be no replacement of subjects, since the sample size is adequate to allow 5-10% losses to follow-up. 11. DATA COLLECTION AND MONITORING AND ADVERSE EVENT EXPERIENCE REPORTING The trial will be conducted in compliance with this protocol, International Conference on Harmonization (ICH) Guidelines for Good Clinical Practice (GCP), and any applicable national and international regulatory requirements. The principal and associate investigators will be monitoring all aspects of the study in accordance with the appropriate regulations and will have regular meetings with periodic quality control of data documentation and collection. The objectives of the monitoring meetings will be: 1) To verify the prompt reporting of all data points, including reporting SAEs and IRIS Version 5.2, June 2, 2011 31 checking availability of signed informed consent, 2) To compare individual subject records, CRIMSON data pulls and/or the study source documents/case report forms (supporting data, laboratory specimen records and medical records to include physician progress notes, nurses’ notes, subjects’ hospital charts), 3) To ensure protection of study subjects, compliance with the protocol, and accuracy and completeness of records. The principal investigator (and/or designee) will make study documents (e.g., consent forms, CRIMSON data pulls) and pertinent hospital or clinical records readily available for inspection by the local IRB and the NIAID staff for confirmation of the study data. 11.1 DEFINITIONS Adverse Event: An adverse event (AE) is any undesirable experience/unwanted effect that occurs in a patient or to a study participant during the course of a clinical trial (or a reasonable time after trial termination) whether or not that experience is considered related to the drug/ investigational product. An AE can therefore be any unfavorable and unintended physical or psychological sign (including an abnormal laboratory finding), symptom, or disease temporally associated with the use of a medicinal/investigational product, whether or not considered related to the medicinal/investigational product. This includes exacerbation of pre-existing conditions and intercurrent illnesses. Stable chronic conditions which are present prior to clinical trial entry and do not worsen are not considered AEs and will be accounted for in the subject’s medical history. Serious Adverse Event: An AE is determined to be "serious" based on study participant/event outcome or action criteria usually associated with experiences that pose a threat to a patient/participant's life or functioning. An SAE is any undesirable experience that at any dose results in one of the following outcomes: Death Life-threatening event (the study subject was at risk of death at the time of the event; it does not refer to an event which hypothetically might have caused death if it were more severe) Inpatient hospitalization or prolongation of existing hospitalization Persistent or significant disability/incapacity (A substantial disruption of a person's ability to conduct normal life functions). Congenital anomaly/birth defect Important medical event that may not be immediately life-threatening or result in death or hospitalization but may jeopardize the patient/study participant or may require intervention to prevent one of the other outcomes listed above Each AE will be classified by the investigator as “serious” or “non-serious.” An AE needs to meet only one of the above criteria to be considered serious. A change in vital signs, diagnostic tests (e.g., an electrocardiogram), or laboratory test results may be determined to be an SAE if the change is of sufficient magnitude to meet one of the above criteria. IRIS Version 5.2, June 2, 2011 32 Unanticipated problem that is not an Adverse Event (UPnonAE): An unanticipated problem that does not fit the definition of an adverse event, but which may, in the opinion of the investigator, involves risk to the subject, affect others in the research study, or significantly impact the integrity of research data. For example, report occurrences of breaches of confidentiality, accidental destruction of study records, or unaccounted-for study drug. Protocol Violation: Any change, divergence, or departure from the study procedures in an IRBapproved research protocol that has a major impact on the subject’s rights, safety, or well-being and/or the completeness, accuracy or reliability of the study data. Protocol Deviation: Any change, divergence, or departure from the IRB approved study procedures in a research protocol that does not have a major impact on the subject's rights, safety or well-being, or the completeness, accuracy and reliability of the study data. Unanticipated Problem: Any incident, experience, or outcome that is 1. unexpected in terms of nature, severity, or frequency in relation to a. the research risks that are described in the IRB-approved research protocol and informed consent document; Investigator’s Brochure or other study documents; and b. the characteristics of the subject population being studied; and 2. related or possibly related to participation in the research; and 3. places subjects or others at a greater risk of harm (including physical, psychological, economic, or social harm) than was previously known or recognized. 11.2 DOCUMENTATION AND SERIOUS ADVERSE EVENT (SAE) REPORTING This is an observational cohort study with care of participants that will follow clinical standards and/or published guidelines. Documentation will focus mostly on diagnoses and medications as well as unscheduled visits or hospitalizations for acute problems that may be representing IRIS. Laboratory abnormalities reaching grades 3 and 4 will also be documented. All patients in this protocol will have diagnoses and medications listed by the clinic staff and entered into a computerized database or case report forms and source documents in Kenya and Thailand. Reporting will occur from enrollment until the last study visit. If an event suspicious for IRIS is still ongoing at study completion, additional clinical follow up until resolution of the event may be arranged by the study team. The AEs will be graded as per the DAIDS toxicity table, if they fall into a graded category; otherwise they will be categorized by severity as follows: Mild (Grade 1): Transient or mild symptoms; no limitation in activity; no intervention required. Symptoms causing no or minimal interference with usual social and functional activities IRIS Version 5.2, June 2, 2011 33 Moderate (Grade 2): Symptoms causing greater than minimal interference with usual social and functional activities. No or minimal intervention required. It is uncomfortable or an embarrassment. Severe (Grade 3): Symptoms causing inability to perform usual social and functional activities. Medical intervention often required. Life-threatening (Grade 4): Symptoms causing inability to perform basic self-care functions OR Medical or operative intervention indicated to prevent permanent impairment, persistent disability, or death. Analysis will be performed by queries to the NIH, and Kericho, and TRCARC Bangkok databases. The data will be reviewed (monitored) on an ongoing basis by the study coordinators and the principal investigator. Hospitalizations will be documented in the subsequent clinic notes and events during hospitalization will be summarized. Reporting and grading of clinical events and laboratory abnormalities will be based upon the primary diagnosis(es) felt responsible for the hospitalization and supporting data For prolonged hospitalizations, notes will be needed while the participant is an inpatient to replace and follow the timeline of missed clinic visits. Unscheduled visits or hospitalizations that are considered suspicious for IRIS will generate separate clinic notes. SAE reporting to IRBs (USUHS IRB, KEMRI, Chulalongkorn University, Thai Department of Disease Control, BIDI, NIAID and WRAIR) will be as follows: IRB reporting within 7 days of investigator awareness: All unanticipated problems that are either AEs or non-AEs, (as defined by Section 11.1 above) and all protocol violations IRB reporting at the time of Continuing Review (CR): All unanticipated problems All protocol deviations which in the opinion of the investigator should be reported. It will be the responsibility of the investigator to report any occurrence that in his/her clinical judgment is serious and unexpected during study follow-up. Additional reporting for the KEMRI/WRP/Kenya Site is outlined in Appendix D, Section 9. 12. HUMAN SUBJECTS IRIS Version 5.2, June 2, 2011 34 12.1 INSTITUTIONAL REVIEW BOARD (IRB) REVIEW AND INFORMED CONSENT This protocol, the informed consent document and any subsequent modifications will be reviewed and approved by the IRB or ethics committees in both the US, Kenya and Thailand responsible for oversight of the study. A signed consent form will be obtained from the subject (legal guardian, or person with power of attorney for subjects who cannot consent for themselves). The consent form will describe the purpose of the study, the procedures to be followed, and the risks and benefits of participation. A copy of the consent form will be given to the subject, parent, or legal guardian and this fact will be documented in the subject’s record. Advertisements may be used to assist in enrollment of study subjects and will be submitted for IRB review when available. Four IRBs have oversight of this protocol. 1. Uniformed Services University of Health Sciences Infectious Diseases IRB (USUHS ID IRB). The USUHS ID IRB is the IRB of record for the Infectious Diseases Clinical Research Program (IDCRP). IDCRP is the sponsor of the Kericho and Thailand sites in this study being executed at NIH, in Kericho and in Thailand. The USUHS ID IRB will review the protocol in its entirety and will oversee aspects of the Kericho and Thai study. 2. National Institute of Allergy and Infectious Diseases (NIAID) IRB. The NIAID IRB is the IRB of record for the NIAID. NIAID is the sponsor of the NIH portion of this protocol and has oversight given the study initially was opened in the NIH clinical center and continues to be active there. The NIAID IRB will review the protocol in its entirety and will oversee aspects of the NIH study. 3. Kenya Medical Research Institute (KEMRI) IRB. The KEMRI IRB is the Kenya IRB of record for all Unites States Army Medical Research Unit-Kenya (USAMRU-K) studies conducted in Kenya and will be the IRB of record for study execution in Kenya. The KEMRI will review the protocol in its entirety and will oversee aspects of the Kericho study. 4. Thai IRB The Chulalongkorn University IRB is the responsible IRB for the TRC-ARC site. The Department of Disease Control, Ministry of Public Health IRB and the BIDI Ethical Committee are the responsible IRBs for the BIDI site. 12.2 SUBJECT CONFIDENTIALITY Stored laboratory specimens will be identified by coded number only, in order to maintain subject confidentiality. All records will be kept locked. All computer entry and networking programs will be done with coded numbers only. Clinical information will not be released without written permission of the subject, except as necessary for monitoring by the IRB, FDA, and NIAID. 12.3 MINORITY RECRUITMENT (US) Patients will be recruited for participation in this study without bias to gender, racial, economic, or social status. Patients new to the NIH will be recruited from outside physician referrals. Subjects will IRIS Version 5.2, June 2, 2011 35 be recruited from NIH clinics and local public, academic, and private clinics. The study will be advertised and posted on the NIH web site. The Division of Intramural Research (DIR) maintains an active outreach program to recruit women and persons from racial or ethnic minorities to participate in clinical trials. Whenever possible, this study will take advantage of the DIR program. 12.4 INCLUSION OF CHILDREN AND PREGNANT WOMEN This study will be confined to HIV-infected adults greater than or equal to 18 years of age. Since there will be no direct benefit associated with study participation, children will be excluded. Pregnant women will also be excluded at the time of screening since there is no benefit from participation and the study (particularly at entry) is intense with frequent blood draws, apheresis and some optional invasive procedures. Pregnant women will only be allowed to continue participation if pregnancy occurs during study participation, provided that they have adequate obstetric care and with the provision that they will not undergo protocol-mandated apheresis (US and Thai sites only) or research blood draws during the gestation and 12 month post-delivery period. 12.5 RISKS AND BENEFITS ASSOCIATED WITH STUDY PARTICIPATION Ionizing radiation In this study a chest x-ray (CXR) will be done at baseline in all participants for research purposes (or one will be available from the routine care and treatment). The calculated effective dose for the combination of these tests is 0.029 rem. The study has been reviewed and approved by the Radiation Safety Committee (RSC) of NIH. The amount of radiation exposure in this study is below the dose guideline established by the NIH RSC for research subjects. This guideline is an effective dose of 5 rem (or 5,000 mrem) received per year. Blood draw and apheresis The potential risks of the needle stick for blood drawing and the venous catheter placement include pain, bruising, hematoma, fainting, and, very rarely, infection. Other uncommon side effects of the apheresis procedure include anxiety, chills, pain, and lightheadedness. There may also be a slightly increased bleeding tendency for a few hours after the procedure due to the temporary presence of the anticoagulant. Adverse reactions to leukapheresis procedures are rare. No more then 550 cc of blood will be drawn for research during a 8-week period in accordance with NIH guidelines. Discarded specimens collected for clinical reasons (blood, tissue, lung fluid) may also be used for research. Potential benefits associated with study participation include a potentially more intense than standard of care follow up with laboratory and clinical evaluation. At NIH, anti-retroviral medications and therapy for opportunistic infections will be provided by the NIAID clinic so that adherence and medication changes can be followed closely. At the end of the IRIS Version 5.2, June 2, 2011 36 study (2-4 years), the participants may be provided with a 3-4 month supply until an alternate source of therapy is identified. The social worker will assist with this transition prior to the end of study. In Kenya, anti-retroviral medications and therapy for opportunistic infections will be provided free of charge by the Kericho District Hospital at either the Kericho District Hospital HIV clinic or KEMRI/WRP CRC satellite. Adherence and medication changes will be followed closely with counseling by necessary medical staff including medical doctors, clinical officers, nurses, and pharmacists. A social worker who is part of the research team will offer necessary services. Regardless of study participation, patients will continue to receive antiretroviral therapy provided by the Kericho District Hospital both during and after the study under the President’s Emergency Plan for AIDS Relief. In Thailand, antiretroviral and opportunistic infections therapy will be provided at no cost under the Thai government’s universal health care coverage. Adherence counseling at every visit will be performed by the physicians, study nurses and pharmacists. 12.6 Study Discontinuation The study may be discontinued at any time by the NIAID IRB or the NIAID, or other government agencies as part of their duties to ensure that research subjects are protected. 12.7 Remuneration At the NIH/US site, subjects will receive $20 for each protocol mandated scheduled study visit to compensate for inconvenience and extra blood drawn for research purposes. Additionally, $100 will be given for each 2-pass pheresis. Participants may receive partial remuneration (payment) for the immediate costs associated with their study-related expenses (travel costs, lodging, etc). Participation in optional biopsies (gastrointestinal and lymph node) will be compensated according to those protocols. At the KEMRI/WRP/Kenya site, participants will receive 750 KSH (approximately 10 USD) for each study defined visit and 500 KSH (approximately 7 USD) or less (at the discretion of the study team) for each unscheduled visit. In Thailand, participants will receive 1000 Baht (approximately 30 USD) for each study visit to pay for travel and to compensate for loss of work time.Subjects will receive an additional 1500 (approximately 45 USD) for each visit with apheresis and an additional 1500 Baht (approximately 45 USD) for each visit with gut biopsy. These procedures will be done at Chulalongkorn University Hospital and will likely be done on a different day as the main study visit. The reimbursement will cover the costs for travel and food, and for loss of work time. 12.8 Illiterate, Blind or Foreign-speaking Subjects (US site) When a subject is illiterate, blind and/or a non-English speaker, the short form consent process will be carried out according to the NIH CC M-77-2 policy after approval from the NIAID IRB. 13. DATA MANAGEMENT AND RECORD RETENTION 13.1 Data Management Plan At NIH, study data will be collected at the study site and maintained in an electronic data system (CRIMSON) which will be completed on an ongoing basis during the study. Data entered into IRIS Version 5.2, June 2, 2011 37 electronic data systems shall be performed by authorized individuals. Corrections to electronic data systems shall be tracked electronically (password protected) with time, date, individual making the correction, and what was changed. Data from CRIMSON Data System will be collected directly from subjects during study visits and telephone calls, or will be abstracted from subjects’ diaries, and medical records. At NIH and in Kenya and Thailand, the Investigator is responsible for assuring that the data collected is complete, accurate, and recorded in a timely manner. Source documentation (the point of initial recording of information) should support the data collected and must be signed and dated by the person recording and/or reviewing the data. Source documents include all recordings of observations or notations of clinical activities, and all reports and records necessary for the evaluation and reconstruction of the clinical trial. Source documents include, but are not limited to, the subject’s medical records, laboratory reports, ECG tracings, x-rays, radiologist’s reports, subject’s diaries, biopsy reports, ultrasound photographs, progress notes, pharmacy records, and any other similar reports or records of procedures performed during the subject’s participation in the study. The subject’s medical record must record his/her participation in the clinical trial and what medications (with doses and frequency) or other medical interventions or treatments were administered, as well as any adverse reactions experienced during the trial. 13.2 Record Retention Research records for all study subjects including history and physical findings, laboratory data, and results of consultations are to be maintained by the investigators in a secure storage facility for a minimum of 3 years following study completion. These records are to be maintained in compliance with IRB and/or State and Federal requirements, whichever is longest. It is the investigator’s responsibility to retain copies of source documents until notified in writing by NIAID that they can be destroyed. NIAID must be notified in writing and acknowledgment must be received by the site prior to destruction or relocation of research records. In Kenya, research records will be maintained at the KEMRI/WRP Clinical Research Center in a double locked, fire protected record archiving section. Records will be maintained for the period of time following the study that meets necessary NIH, IDCRP, and Kenyan guidelines. In Thailand, research records will be maintained at the SEARCH/TRC-ARC clinical research center in a double locked data archiving section. Records will be maintained for the period of time following the study that meets necessary NIH, IDCRP, Kenyan and Thai guidelines. 14. PUBLICATION OF RESEARCH FINDINGS Publication of the results of this trial will be governed by the study team (chair and co-chairs). Any presentation, abstract, or manuscript will be made available to the entire study team prior to submission and will require approval by the Chair or Co-chairs or their designees. 15. BIOHAZARD CONTAINMENT As the transmission of HIV-1 and other blood-borne pathogens can occur through contact with contaminated needles, blood, and blood products appropriate blood and secretion precautions will be employed by all personnel in the drawing of blood and shipping and handling of all specimens for this IRIS Version 5.2, June 2, 2011 38 study, as currently recommended by the Centers for Disease Control and Prevention (CDC) and the NIH and KEMRI for the Kenya site. All infectious specimens will be transported using packaging mandated in the Code of Federal Regulations, 42 CFR Part 72. Sites should refer to individual carrier guidelines (e.g., Federal Express, Airborne Express) for specific instructions. IRIS Version 5.2, June 2, 2011 39 15. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. French, M.A., P. Price, and S.F. Stone, Immune restoration disease after antiretroviral therapy. Aids, 2004. 18(12): p. 1615-27. Shelburne, S.A., 3rd and R.J. Hamill, The immune reconstitution inflammatory syndrome. AIDS Rev, 2003. 5(2): p. 67-79. Stoll, M. and R.E. Schmidt, Immune Restoration Inflammatory Syndromes: The Dark Side of Successful Antiretroviral Treatment. Curr Infect Dis Rep, 2003. 5(3): p. 266-276. French, M. and P. Price, Immune restoration disease in HIV patients: aberrant immune responses after antiretroviral therapy. J HIV Ther, 2002. 7(2): p. 46-51. French, M.A., Antiretroviral therapy. Immune restoration disease in HIV-infected patients on HAART. AIDS Read, 1999. 9(8): p. 548-9, 554-5, 559-62. Foudraine, N.A., et al., Immunopathology as a result of highly active antiretroviral therapy in HIV-1-infected patients. Aids, 1999. 13(2): p. 177-84. Breen, R.A., et al., Does immune reconstitution syndrome promote active tuberculosis in patients receiving highly active antiretroviral therapy? Aids, 2005. 19(11): p. 1201-6. Kumarasamy, N., et al., Clinical profile of HIV in India. Indian J Med Res, 2005. 121(4): p. 377-94. Lawn, S.D., L.G. Bekker, and R.F. Miller, Immune reconstitution disease associated with mycobacterial infections in HIV-infected individuals receiving antiretrovirals. Lancet Infect Dis, 2005. 5(6): p. 361-73. Lawn, S.D., L.G. Bekker, and R. Wood, How effectively does HAART restore immune responses to Mycobacterium tuberculosis? Implications for tuberculosis control. Aids, 2005. 19(11): p. 1113-24. Michailidis, C., et al., Clinical characteristics of IRIS syndrome in patients with HIV and tuberculosis. Antivir Ther, 2005. 10(3): p. 417-22. Mallal, S.A., I.R. James, and M.A. French, Detection of subclinical Mycobacterium avium intracellulare complex infection in immunodeficient HIV-infected patients treated with zidovudine. Aids, 1994. 8(9): p. 1263-9. French, M.A., et al., Correction of human immunodeficiency virus-associated depression of delayed-type hypersensitivity (DTH) after zidovudine therapy: DTH, CD4+ T-cell numbers, and epidermal Langerhans cell density are independent variables. Clin Immunol Immunopathol, 1990. 55(1): p. 86-96. Barbaro, D.J., V.L. Orcutt, and B.M. Coldiron, Mycobacterium avium-Mycobacterium intracellulare infection limited to the skin and lymph nodes in patients with AIDS. Rev Infect Dis, 1989. 11(4): p. 625-8. Tangsinmankong, N., et al., Varicella zoster as a manifestation of immune restoration disease in HIV-infected children. J Allergy Clin Immunol, 2004. 113(4): p. 742-6. Rouanet, I., et al., Acute clinical hepatitis by immune restoration in a human immunodeficiency virus/hepatitis B virus co-infected patient receiving antiretroviral therapy. Eur J Gastroenterol Hepatol, 2003. 15(1): p. 95-7. Safdar, A., et al., Fatal immune restoration disease in human immunodeficiency virus type 1infected patients with progressive multifocal leukoencephalopathy: impact of antiretroviral therapy-associated immune reconstitution. Clin Infect Dis, 2002. 35(10): p. 1250-7. IRIS Version 5.2, June 2, 2011 40 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. Jubault, V., et al., Sequential occurrence of thyroid autoantibodies and Graves' disease after immune restoration in severely immunocompromised human immunodeficiency virus-1-infected patients. J Clin Endocrinol Metab, 2000. 85(11): p. 4254-7. Rosenfeld, C.R. and L.H. Calabrese, Progression of autoimmune thyroiditis in an HIV-infected woman on HAART. AIDS Read, 1999. 9(6): p. 393-4, 397. Mirmirani, P., et al., Sarcoidosis in a patient with AIDS: a manifestation of immune restoration syndrome. J Am Acad Dermatol, 1999. 41(2 Pt 2): p. 285-6. Bartley, P.B., A.M. Allworth, and D.P. Eisen, Mycobacterium avium complex causing endobronchial disease in AIDS patients after partial immune restoration. Int J Tuberc Lung Dis, 1999. 3(12): p. 1132-6. Nussenblatt, R.B. and H.C. Lane, Human immunodeficiency virus disease: changing patterns of intraocular inflammation. Am J Ophthalmol, 1998. 125(3): p. 374-82. John, M., J. Flexman, and M.A. French, Hepatitis C virus-associated hepatitis following treatment of HIV-infected patients with HIV protease inhibitors: an immune restoration disease? Aids, 1998. 12(17): p. 2289-93. Chien, J.W. and J.L. Johnson, Paradoxical reactions in HIV and pulmonary TB. Chest, 1998. 114(3): p. 933-6. de Boer, M.G., et al., Immune restoration disease in HIV-infected individuals receiving highly active antiretroviral therapy: clinical and immunological characteristics. Neth J Med, 2003. 61(12): p. 408-12. Shelburne, S.A., 3rd, et al., The role of immune reconstitution inflammatory syndrome in AIDSrelated Cryptococcus neoformans disease in the era of highly active antiretroviral therapy. Clin Infect Dis, 2005. 40(7): p. 1049-52. Hawkey, C.R., et al., Characterization and management of paradoxical upgrading reactions in HIV-uninfected patients with lymph node tuberculosis. Clin Infect Dis, 2005. 40(9): p. 1368-71. Breen, R.A., et al., Paradoxical reactions during tuberculosis treatment in patients with and without HIV co-infection. Thorax, 2004. 59(8): p. 704-7. Miller, R.F., et al., Cerebral CD8+ lymphocytosis in HIV-1 infected patients with immune restoration induced by HAART. Acta Neuropathol (Berl), 2004. 108(1): p. 17-23. Stone, S.F., et al., Cytomegalovirus (CMV) retinitis immune restoration disease occurs during highly active antiretroviral therapy-induced restoration of CMV-specific immune responses within a predominant Th2 cytokine environment. J Infect Dis, 2002. 185(12): p. 1813-7. Shen, Y., et al., Antiretroviral agents restore Mycobacterium-specific T-cell immune responses and facilitate controlling a fatal tuberculosis-like disease in Macaques coinfected with simian immunodeficiency virus and Mycobacterium bovis BCG. J Virol, 2001. 75(18): p. 8690-6. Komanduri, K.V., et al., Restoration of cytomegalovirus-specific CD4+ T-lymphocyte responses after ganciclovir and highly active antiretroviral therapy in individuals infected with HIV-1. Nat Med, 1998. 4(8): p. 953-6. Stone, S.F., et al., Levels of IL-6 and soluble IL-6 receptor are increased in HIV patients with a history of immune restoration disease after HAART. HIV Med, 2002. 3(1): p. 21-7. Stone, S.F., et al., Plasma bioavailable interleukin-6 is elevated in human immunodeficiency virus-infected patients who experience herpesvirus-associated immune restoration disease after start of highly active antiretroviral therapy. J Infect Dis, 2001. 184(8): p. 1073-7. IRIS Version 5.2, June 2, 2011 41 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. Keane, N.M., et al., An evaluation of serum soluble CD30 levels and serum CD26 (DPPIV) enzyme activity as markers of type 2 and type 1 cytokines in HIV patients receiving highly active antiretroviral therapy. Clin Exp Immunol, 2001. 126(1): p. 111-6. Price, P., et al., Polymorphisms in cytokine genes define subpopulations of HIV-1 patients who experienced immune restoration diseases. Aids, 2002. 16(15): p. 2043-7. Price, P., et al., MHC haplotypes affect the expression of opportunistic infections in HIV patients. Hum Immunol, 2001. 62(2): p. 157-64. Bourgarit, A., et al., Explosion of tuberculin-specific Th1-responses induces immune restoration syndrome in tuberculosis and HIV co-infected patients. Aids, 2006. 20(2): p. F1-7. Bukharie, H., Paradoxical response to anti-tuberculous drugs: resolution with corticosteroid therapy. Scand J Infect Dis, 2000. 32(1): p. 96-7. Shelburne, S.A., et al., Incidence and risk factors for immune reconstitution inflammatory syndrome during highly active antiretroviral therapy. Aids, 2005. 19(4): p. 399-406. Dean, G.L., et al., Treatment of tuberculosis in HIV-infected persons in the era of highly active antiretroviral therapy. Aids, 2002. 16(1): p. 75-83. Sungkanuparph, S., et al., Opportunistic infections after the initiation of highly active antiretroviral therapy in advanced AIDS patients in an area with a high prevalence of tuberculosis. Aids, 2003. 17(14): p. 2129-31. Manabe, Y.C., et al., Immune Reconstitution Inflammatory Sydnrome. J Acquir Immune Defic Syndr, 2007. 46(4): p. 456-462. Robertson, J., et al., Immune reconstitution syndrome in HIV: validating a case definition and identifying clinical predictors in persons initiating antiretroviral therapy. Clin Infect Dis, 2006. 42(11): p. 1639-46. DHHS. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents http:// AIDSinfo.nih.gov. Gooley, T.A., et al., Estimation of failure probabilities in the presence of competing risks: new representations of old estimators. Stat Med, 1999. 18(6): p. 695-706. IRIS Version 5.2, June 2, 2011 42 16. APPENDIX A: IRIS CRITERIA* 1. Initiation (reintroduction or change) in antiretroviral therapy/regimen. AND 2. Evidence of: a. an increase in CD4+ cell count as defined by ≥50 cells/mm3 or a ≥2- fold rise in CD4+ cell count, and/or b. decrease in the HIV-1 viral load of >0.5 log10 AND 3. Symptoms and/or signs consistent with an infectious/inflammatory condition. AND 4. These symptoms and/or signs cannot be explained by a newly acquired infection, the expected clinical course of a previously recognized infectious agent, or the side effects of antiretroviral therapy itself. AND 5. For purposes of data collection, the infectious/inflammatory condition must be attributable to a specific pathogen or condition. * AIDS Clinical Trials Group (ACTG) criteria May 24th 2005. IRIS Version 5.2, June 2, 2011 43 17. APPENDIX B- DAIDS TOXICITY TABLE Division of AIDS table for grading the severity of ADULT AND PEDIATRIC adverse events Publish Date: December, 2004 Quick Reference The Division of AIDS Table for Grading the Severity of Adult and Pediatric Adverse Events (“DAIDS AE grading table”) is a descriptive terminology which can be utilized for Adverse Event (AE) reporting. A grading (severity) scale is provided for each AE term. General Instructions Estimating Severity Grade If the need arises to grade a clinical AE that is not identified in the DAIDS AE grading table, use the category “Estimating Severity Grade” located at the top of Page 3. For AEs that are not listed in the table but will be collected systematically for a study/trial, protocol teams are highly encouraged to define study-specific severity scales within the protocol or an appendix to the protocol. (Please see “Template Wording for the Expedited Adverse Event Reporting Section of DAIDS-sponsored Protocols”.) This is particularly important for laboratory values because the “Estimating Severity Grade” category only applies to clinical symptoms. Grading Adult and Pediatric AEs The DAIDS AE grading table includes parameters for grading both Adult and Pediatric AEs. When a single set of parameters is not appropriate for grading specific types of AEs for both Adult and Pediatric populations, separate sets of parameters for Adult and/or Pediatric populations (with specified respective age ranges) are given in the table. If there is no distinction in the table between Adult and Pediatric values for a type of AE, then the single set of parameters listed is to be used for grading the severity of both Adult and Pediatric events of that type. Determining Severity Grade If the severity of an AE could fall under either one of two grades (e.g., the severity of an AE could be either Grade 2 or Grade 3), select the higher of the two grades for the AE. Definitions IRIS Version 5.2, June 2, 2011 44 Basic Self-care Functions Adult Activities such as bathing, dressing, toileting, transfer/movement, continence, and feeding. Young Children Activities that are age and culturally appropriate (e.g., feeding self with culturally appropriate eating implement). LLN Lower limit of normal Medical Intervention Use of pharmacologic or biologic agent(s) for treatment of an AE. NA Not Applicable Operative Intervention Surgical OR other invasive mechanical procedures. ULN Upper limit of normal Usual Social & Functional Activities Adult Adaptive tasks and desirable activities, such as going to work, shopping, cooking, use of transportation, pursuing a hobby, etc. Young Children Activities that are age and culturally appropriate (e.g., social interactions, play activities, learning tasks, etc.). IRIS Version 5.2, June 2, 2011 45 CLINICAL PARAMETER GRADE 1 MILD GRADE 2 MODERATE GRADE 3 SEVERE GRADE 4 Symptoms causing no or minimal interference with usual social & functional activities Symptoms causing greater than minimal interference with usual social & functional activities Symptoms causing inability to perform usual social & functional activities Symptoms causing inability to perform basic self-care functions OR Medical or operative intervention indicated to prevent permanent impairment, persistent disability, or death Acute systemic allergic reaction Localized urticaria (wheals) with no medical intervention indicated Localized urticaria with medical intervention indicated OR Mild angioedema with no medical intervention indicated Generalized urticaria OR Angioedema with medical intervention indicated OR Symptomatic mild bronchospasm Acute anaphylaxis OR Life-threatening bronchospasm OR laryngeal edema Chills Symptoms causing no or minimal interference with usual social & functional activities Symptoms causing greater than minimal interference with usual social & functional activities Symptoms causing inability to perform usual social & functional activities NA Fatigue Malaise Symptoms causing no or minimal interference with usual social & functional activities Symptoms causing greater than minimal interference with usual social & functional activities Symptoms causing inability to perform usual social & functional activities Incapacitating fatigue/ malaise symptoms causing inability to perform basic self-care functions Fever (nonaxillary) 37.7 – 38.6C 38.7 – 39.3C 39.4 – 40.5C >40.5C Pain (indicate body site) DO NOT use for pain due to injection (See Injection Site Reactions: Injection site pain) See also Headache, Arthralgia, and Myalgia Pain causing no or minimal interference with usual social & functional activities Pain causing greater than minimal interference with usual social & functional activities Pain causing inability to perform usual social & functional activities Disabling pain causing inability to perform basic self-care functions OR Hospitalization (other than emergency room visit) indicated Unintentional weight loss NA 5 – 9% loss in body weight from baseline 10 – 19% loss in body weight from baseline 20% loss in body weight from baseline OR Aggressive intervention indicated [e.g., tube feeding or total parenteral nutrition (TPN)] POTENTIALLY LIFE-THREATENING ESTIMATING SEVERITY GRADE Clinical adverse event NOT identified elsewhere in this DAIDS AE grading table SYSTEMIC IRIS Version 5.2, June 2, 2011 46 CLINICAL PARAMETER GRADE 1 MILD GRADE 2 MODERATE GRADE 3 SEVERE GRADE 4 Localized, no systemic antimicrobial treatment indicated AND Symptoms causing no or minimal interference with usual social & functional activities Systemic antimicrobial treatment indicated OR Symptoms causing greater than minimal interference with usual social & functional activities Systemic antimicrobial treatment indicated AND Symptoms causing inability to perform usual social & functional activities OR Operative intervention (other than simple incision and drainage) indicated Life-threatening consequences (e.g., septic shock) Pain/tenderness limiting use of limb OR Pain/tenderness causing greater than minimal interference with usual social & functional activities Pain/tenderness causing inability to perform usual social & functional activities Pain/tenderness causing inability to perform basic self-care function OR Hospitalization (other than emergency room visit) indicated for management of pain/tenderness POTENTIALLY LIFE-THREATENING INFECTION Infection (any other than HIV infection) INJECTION SITE REACTIONS Injection site pain (pain without touching) Or Tenderness (pain when area is touched) Pain/tenderness causing no or minimal limitation of use of limb Injection site reaction (localized) Adult >15 years Erythema OR Induration of 5x5 cm – 9x9 cm (or 25 cm2 – 81cm2) Erythema OR Induration OR Edema >9 cm any diameter (or >81 cm2) Ulceration OR Secondary infection OR Phlebitis OR Sterile abscess OR Drainage Necrosis (involving dermis and deeper tissue) Pediatric 15 years Erythema OR Induration OR Edema present but 2.5 cm diameter Erythema OR Induration OR Edema >2.5 cm diameter but <50% surface area of the extremity segment (e.g., upper arm/thigh) Erythema OR Induration OR Edema involving 50% surface area of the extremity segment (e.g., upper arm/thigh) OR Ulceration OR Secondary infection OR Phlebitis OR Sterile abscess OR Drainage Necrosis (involving dermis and deeper tissue) Itching localized to injection site AND Relieved spontaneously or with <48 hours treatment Itching beyond the injection site but not generalized OR Itching localized to injection site requiring 48 hours treatment Generalized itching causing inability to perform usual social & functional activities NA Thinning or patchy hair loss detectable by health care provider Complete hair loss NA Pruritis associated with injection See also Skin: Pruritis (itching - no skin lesions) SKIN – DERMATOLOGICAL Alopecia Thinning detectable by study participant (or by caregiver for young children and disabled adults) IRIS Version 5.2, June 2, 2011 47 CLINICAL PARAMETER GRADE 1 MILD GRADE 2 MODERATE GRADE 3 SEVERE GRADE 4 Cutaneous reaction – rash Localized macular rash Diffuse macular, maculopapular, or morbilliform rash OR Target lesions Diffuse macular, maculopapular, or morbilliform rash with vesicles or limited number of bullae OR Superficial ulcerations of mucous membrane limited to one site Extensive or generalized bullous lesions OR Stevens-Johnson syndrome OR Ulceration of mucous membrane involving two or more distinct mucosal sites OR Toxic epidermal necrolysis (TEN) Hyperpigmentation Slight or localized Marked or generalized NA NA Hypopigmentation Slight or localized Marked or generalized NA NA Pruritis (itching – no skin lesions) (See also Injection Site Reactions: Pruritis associated with injection) Itching causing no or minimal interference with usual social & functional activities Itching causing greater than minimal interference with usual social & functional activities Itching causing inability to perform usual social & functional activities NA POTENTIALLY LIFE-THREATENING CARDIOVASCULAR Cardiac arrhythmia (general) (By ECG or physical exam) Asymptomatic AND No intervention indicated Asymptomatic AND Non-urgent medical intervention indicated Symptomatic, non-lifethreatening AND Nonurgent medical intervention indicated Life-threatening arrhythmia OR Urgent intervention indicated Cardiacischemia/infarction NA NA Symptomatic ischemia (stable angina) OR Testing consistent with ischemia Unstable angina OR Acute myocardial infarction Hemorrhage (significant acute blood loss) NA Symptomatic AND No transfusion indicated Symptomatic AND Transfusion of 2 units packed RBCs (for children 10 cc/kg) indicated Life-threatening hypotension OR Transfusion of >2 units packed RBCs (for children >10 cc/kg) indicated (with repeat testing at same visit) >140 – 159 mmHg systolic OR >90 – 99 mmHg diastolic >160 – 179 mmHg systolic OR >100 – 109 mmHg diastolic >180 mmHg systolic OR >110 mmHg diastolic Life-threatening consequences (e.g., malignant hypertension) OR Hospitalization indicated (other than emergency room visit) Pediatric 17 years NA 91st – 94th percentile adjusted for age, height, and gender (systolic and/or diastolic) ≥95th percentile adjusted for age, height, and gender (systolic and/or diastolic) Life-threatening consequences (e.g., malignant hypertension) OR Hospitalization indicated (other than emergency room visit) Hypertension Adult >17 years (with repeat testing at same visit) IRIS Version 5.2, June 2, 2011 48 CLINICAL PARAMETER GRADE 1 MILD GRADE 2 MODERATE GRADE 3 SEVERE GRADE 4 POTENTIALLY LIFE-THREATENING Hypotension NA Symptomatic, corrected with oral fluid replacement Symptomatic, IV fluids indicated Shock requiring use of vasopressors or mechanical assistance to maintain blood pressure Pericardial effusion Asymptomatic, small effusion requiring no intervention Asymptomatic, moderate or larger effusion requiring no intervention Effusion with non-life threatening physiologic consequences OR Effusion with non-urgent intervention indicated Life-threatening consequences (e.g., tamponade) OR Urgent intervention indicated Adult >16 years PR interval 0.21 – 0.25 sec PR interval >0.25 sec Type II 2nd degree AV block OR Ventricular pause >3.0 sec Complete AV block Pediatric ≤16 years 1st degree AV block (PR > normal for age and rate) Type I 2nd degree AV block Type II 2nd degree AV block Complete AV block Adult >16 years Asymptomatic, QTc interval 0.45 – 0.47 sec OR Increase interval <0.03 sec above baseline Asymptomatic, QTc interval 0.48 – 0.49 sec OR Increase in interval 0.03 – 0.05 sec above baseline Asymptomatic, QTc interval 0.50 sec OR Increase in interval 0.06 sec above baseline Life-threatening consequences, e.g. Torsade de pointes or other associated serious ventricular dysrhythmia Pediatric ≤16 years Asymptomatic, QTc interval 0.450 – 0.464 sec Asymptomatic, QTc interval 0.465 – 0.479 sec Asymptomatic, QTc interval 0.480 sec Life-threatening consequences, e.g. Torsade de pointes or other associated serious ventricular dysrhythmia Thrombosis/embolism NA Deep vein thrombosis AND No intervention indicated (e.g., anticoagulation, lysis filter, invasive procedure) Deep vein thrombosis AND Intervention indicated (e.g., anticoagulation, lysis filter, invasive procedure) Embolic event (e.g., pulmonary embolism, life-threatening thrombus) Vasovagal episode (associated with a procedure of any kind) Present without loss of consciousness Present with transient loss of consciousness NA NA Ventricular dysfunction (congestive heart failure) NA Asymptomatic diagnostic finding AND intervention indicated New onset with symptoms OR Worsening symptomatic congestive heart failure Life-threatening congestive heart failure Prolonged PR interval Prolonged QTc IRIS Version 5.2, June 2, 2011 49 CLINICAL PARAMETER GRADE 1 MILD GRADE 2 MODERATE GRADE 3 SEVERE GRADE 4 POTENTIALLY LIFE-THREATENING GASTROINTESTINAL Anorexia Loss of appetite without decreased oral intake Loss of appetite associated with decreased oral intake without significant weight loss Loss of appetite associated with significant weight loss Life-threatening consequences OR Aggressive intervention indicated [e.g., tube feeding or total parenteral nutrition (TPN)] Ascites Asymptomatic Symptomatic AND Intervention indicated (e.g., diuretics or therapeutic paracentesis) Symptomatic despite intervention Life-threatening consequences Cholecystitis NA Symptomatic AND Medical intervention indicated Radiologic, endoscopic, or operative intervention indicated Life-threatening consequences (e.g., sepsis or perforation) Constipation NA Persistent constipation requiring regular use of dietary modifications, laxatives, or enemas Obstipation with manual evacuation indicated Life-threatening consequences (e.g., obstruction) Adult and Pediatric 1 year Transient or intermittent episodes of unformed stools OR Increase of ≤3 stools over baseline per 24-hour period Persistent episodes of unformed to watery stools OR Increase of 4 – 6 stools over baseline per 24-hour period Bloody diarrhea OR Increase of ≥7 stools per 24-hour period OR IV fluid replacement indicated Life-threatening consequences (e.g., hypotensive shock) Pediatric <1 year Liquid stools (more unformed than usual) but usual number of stools Liquid stools with increased number of stools OR Mild dehydration Liquid stools with moderate dehydration Liquid stools resulting in severe dehydration with aggressive rehydration indicated OR Hypotensive shock DysphagiaOdynophagia Symptomatic but able to eat usual diet Symptoms causing altered dietary intake without medical intervention indicated Symptoms causing severely altered dietary intake with medical intervention indicated Life-threatening reduction in oral intake Mucositis/stomatitis (clinical exam) Indicate site (e.g., larynx, oral) See Genitourinary for Vulvovaginitis See also DysphagiaOdynophagia and Erythema of the mucosa Patchy pseudomembranes or ulcerations Confluent pseudomembranes or ulcerations OR Mucosal bleeding with minor trauma Tissue necrosis OR Diffuse spontaneous mucosal bleeding OR Life-threatening consequences (e.g., aspiration, choking) Diarrhea IRIS Version 5.2, June 2, 2011 50 CLINICAL PARAMETER GRADE 1 MILD GRADE 2 MODERATE GRADE 3 SEVERE GRADE 4 Nausea Transient (<24 hours) or intermittent nausea with no or minimal interference with oral intake Persistent nausea resulting in decreased oral intake for 24 – 48 hours Persistent nausea resulting in minimal oral intake for >48 hours OR Aggressive rehydration indicated (e.g., IV fluids) Life-threatening consequences (e.g., hypotensive shock) Pancreatitis NA Symptomatic AND Hospitalization not indicated (other than emergency room visit) Symptomatic AND Hospitalization indicated (other than emergency room visit) Life-threatening consequences (e.g., circulatory failure, hemorrhage, sepsis) Proctitis (functionalsymptomatic) Also see Mucositis/stomatitis for clinical exam Rectal discomfort AND No intervention indicated Symptoms causing greater than minimal interference with usual social & functional activities OR Medical intervention indicated Symptoms causing inability to perform usual social & functional activities OR Operative intervention indicated Life-threatening consequences (e.g., perforation) Vomiting Transient or intermittent vomiting with no or minimal interference with oral intake Frequent episodes of vomiting with no or mild dehydration Persistent vomiting resulting in orthostatic hypotension OR Aggressive rehydration indicated (e.g., IV fluids) Life-threatening consequences (e.g., hypotensive shock) Alteration in personality-behavior or in mood (e.g., agitation, anxiety, depression, mania, psychosis) Alteration causing no or minimal interference with usual social & functional activities Alteration causing greater than minimal interference with usual social & functional activities Alteration causing inability to perform usual social & functional activities Behavior potentially harmful to self or others (e.g., suicidal and homicidal ideation or attempt, acute psychosis) OR Causing inability to perform basic self-care functions Altered Mental Status For Dementia, see Cognitive and behavioral/attentional disturbance (including dementia and attention deficit disorder) Changes causing no or minimal interference with usual social & functional activities Mild lethargy or somnolence causing greater than minimal interference with usual social & functional activities Confusion, memory impairment, lethargy, or somnolence causing inability to perform usual social & functional activities Delirium OR obtundation, OR coma Ataxia Asymptomatic ataxia detectable on exam OR Minimal ataxia causing no or minimal interference with usual social & functional activities Symptomatic ataxia causing greater than minimal interference with usual social & functional activities Symptomatic ataxia causing inability to perform usual social & functional activities Disabling ataxia causing inability to perform basic self-care functions POTENTIALLY LIFE-THREATENING Proctitis NEUROLOGIC IRIS Version 5.2, June 2, 2011 51 CLINICAL PARAMETER GRADE 1 MILD GRADE 2 MODERATE GRADE 3 SEVERE GRADE 4 POTENTIALLY LIFE-THREATENING Cognitive and behavioral/attentional disturbance (including dementia and attention deficit disorder) Disability causing no or minimal interference with usual social & functional activities OR Specialized resources not indicated Disability causing greater than minimal interference with usual social & functional activities OR Specialized resources on part-time basis indicated Disability causing inability to perform usual social & functional activities OR Specialized resources on a full-time basis indicated Disability causing inability to perform basic self-care functions OR Institutionalization indicated CNS ischemia (acute) NA NA Transient ischemic attack Cerebral vascular accident (CVA, stroke) with neurological deficit Developmental delay – Pediatric 16 years Mild developmental delay, either motor or cognitive, as determined by comparison with a developmental screening tool appropriate for the setting Moderate developmental delay, either motor or cognitive, as determined by comparison with a developmental screening tool appropriate for the setting Severe developmental delay, either motor or cognitive, as determined by comparison with a developmental screening tool appropriate for the setting Developmental regression, either motor or cognitive, as determined by comparison with a developmental screening tool appropriate for the setting Headache Symptoms causing no or minimal interference with usual social & functional activities Symptoms causing greater than minimal interference with usual social & functional activities Symptoms causing inability to perform usual social & functional activities Symptoms causing inability to perform basic self-care functions OR Hospitalization indicated (other than emergency room visit) OR Headache with significant impairment of alertness or other neurologic function Insomnia NA Difficulty sleeping causing greater than minimal interference with usual social & functional activities Difficulty sleeping causing inability to perform usual social & functional activities Disabling insomnia causing inability to perform basic self-care functions Neuromuscular weakness (including myopathy & neuropathy) Asymptomatic with decreased strength on exam OR Minimal muscle weakness causing no or minimal interference with usual social & functional activities Muscle weakness causing greater than minimal interference with usual social & functional activities Muscle weakness causing inability to perform usual social & functional activities Disabling muscle weakness causing inability to perform basic self-care functions OR Respiratory muscle weakness impairing ventilation Neurosensory alteration (including paresthesia and painful neuropathy) Asymptomatic with sensory alteration on exam or minimal paresthesia causing no or minimal interference with Sensory alteration or paresthesia causing greater than minimal interference with usual social & functional activities Sensory alteration or paresthesia causing inability to perform usual social & functional activities Disabling sensory alteration or paresthesia causing inability to perform basic self-care functions IRIS Version 5.2, June 2, 2011 52 CLINICAL PARAMETER GRADE 1 MILD GRADE 2 MODERATE GRADE 3 SEVERE GRADE 4 POTENTIALLY LIFE-THREATENING usual social & functional activities NA 1 seizure 2 – 4 seizures Seizures of any kind which are prolonged, repetitive (e.g., status epilepticus), or difficult to control (e.g., refractory epilepsy) NA Increased frequency of pre-existing seizures (non-repetitive) without change in seizure character OR Infrequent breakthrough seizures while on stable medication in a previously controlled seizure disorder Change in seizure character from baseline either in duration or quality (e.g., severity or focality) Seizures of any kind which are prolonged, repetitive (e.g., status epilepticus), or difficult to control (e.g., refractory epilepsy) Seizure – Pediatric <18 years Seizure, generalized onset with or without secondary generalization, lasting <5 minutes with <24 hours post ictal state Seizure, generalized onset with or without secondary generalization, lasting 5 – 20 minutes with < 24 hours post ictal state Seizure, generalized onset with or without secondary generalization, lasting >20 minutes Seizure, generalized onset with or without secondary generalization, requiring intubation and sedation Syncope (not associated with a procedure) NA Present NA NA Vertigo Vertigo causing no or minimal interference with usual social & functional activities Vertigo causing greater than minimal interference with usual social & functional activities Vertigo causing inability to perform usual social & functional activities Disabling vertigo causing inability to perform basic self-care functions FEV1 or peak flow reduced to 70 – 80% FEV1 or peak flow 50 – 69% FEV1 or peak flow 25 – 49% Cyanosis OR FEV1 or peak flow <25% OR Intubation Seizure: (new onset) – Adult ≥18 years See also Seizure: (known pre-existing seizure disorder) Seizure: (known preexisting seizure disorder) – Adult ≥18 years For worsening of existing epilepsy the grades should be based on an increase from previous level of control to any of these levels. RESPIRATORY Bronchospasm (acute) Dyspnea or respiratory distress Adult ≥14 years Dyspnea on exertion with no or minimal interference with usual social & functional activities Dyspnea on exertion causing greater than minimal interference with usual social & functional activities Dyspnea at rest causing inability to perform usual social & functional activities Respiratory failure with ventilatory support indicated Pediatric <14 years Wheezing OR minimal increase in Nasal flaring OR Intercostal retractions Dyspnea at rest causing inability to perform usual Respiratory failure with ventilatory support IRIS Version 5.2, June 2, 2011 53 CLINICAL PARAMETER GRADE 1 MILD respiratory rate for age GRADE 2 MODERATE GRADE 3 SEVERE GRADE 4 POTENTIALLY LIFE-THREATENING OR Pulse oximetry 90 – 95% social & functional activities OR Pulse oximetry <90% indicated MUSCULOSKELETAL Arthralgia See also Arthritis Joint pain causing no or minimal interference with usual social & functional activities Joint pain causing greater than minimal interference with usual social & functional activities Joint pain causing inability to perform usual social & functional activities Disabling joint pain causing inability to perform basic self-care functions Arthritis See also Arthralgia Stiffness or joint swelling causing no or minimal interference with usual social & functional activities Stiffness or joint swelling causing greater than minimal interference with usual social & functional activities Stiffness or joint swelling causing inability to perform usual social & functional activities Disabling joint stiffness or swelling causing inability to perform basic self-care functions Adult ≥21 years BMD* t-score -2.5 to -1.0 BMD t-score <-2.5 Pathological fracture (including loss of vertebral height) Pathologic fracture causing life-threatening consequences Pediatric <21 years BMD z-score -2.5 to -1.0 BMD z-score <-2.5 Pathological fracture (including loss of vertebral height) Pathologic fracture causing life-threatening consequences Myalgia (non-injection site) Muscle pain causing no or minimal interference with usual social & functional activities Muscle pain causing greater than minimal interference with usual social & functional activities Muscle pain causing inability to perform usual social & functional activities Disabling muscle pain causing inability to perform basic self-care functions Osteonecrosis NA Asymptomatic with radiographic findings AND No operative intervention indicated Symptomatic bone pain with radiographic findings OR Operative intervention indicated Disabling bone pain with radiographic findings causing inability to perform basic self-care functions Cervicitis (symptoms) (For use in studies evaluating topical study agents) For other cervicitis see Infection: Infection (any other than HIV infection) Symptoms causing no or minimal interference with usual social & functional activities Symptoms causing greater than minimal interference with usual social & functional activities Symptoms causing inability to perform usual social & functional activities Symptoms causing inability to perform basic self-care functions Cervicitis (clinical exam) Minimal cervical abnormalities on examination Moderate cervical abnormalities on examination Severe cervical abnormalities on examination (erythema, Epithelial disruption >75% total surface Bone Mineral Loss GENITOURINARY IRIS Version 5.2, June 2, 2011 54 CLINICAL PARAMETER GRADE 1 MILD GRADE 2 MODERATE GRADE 3 SEVERE GRADE 4 (For use in studies evaluating topical study agents) For other cervicitis see Infection: Infection (any other than HIV infection) (erythema, mucopurulent discharge, or friability) OR Epithelial disruption <25% of total surface (erythema, mucopurulent discharge, or friability) OR Epithelial disruption of 25 – 49% total surface mucopurulent discharge, or friability) OR Epithelial disruption 50 – 75% total surface Inter-menstrual bleeding (IMB) Spotting observed by participant OR Minimal blood observed during clinical or colposcopic examination Inter-menstrual bleeding not greater in duration or amount than usual menstrual cycle Inter-menstrual bleeding greater in duration or amount than usual menstrual cycle Hemorrhage with lifethreatening hypotension OR Operative intervention indicated Urinary tract obstruction (e.g., stone) NA Signs or symptoms of urinary tract obstruction without hydronephrosis or renal dysfunction Signs or symptoms of urinary tract obstruction with hydronephrosis or renal dysfunction Obstruction causing lifethreatening consequences Vulvovaginitis (symptoms) (Use in studies evaluating topical study agents) For other vulvovaginitis see Infection: Infection (any other than HIV infection) Symptoms causing no or minimal interference with usual social & functional activities Symptoms causing greater than minimal interference with usual social & functional activities Symptoms causing inability to perform usual social & functional activities Symptoms causing inability to perform basic self-care functions Vulvovaginitis (clinical exam) (Use in studies evaluating topical study agents) For other vulvovaginitis see Infection: Infection (any other than HIV infection) Minimal vaginal abnormalities on examination OR Epithelial disruption <25% of total surface Moderate vaginal abnormalities on examination OR Epithelial disruption of 25 - 49% total surface Severe vaginal abnormalities on examination OR Epithelial disruption 50 - 75% total surface Vaginal perforation OR Epithelial disruption >75% total surface Uveitis Asymptomatic but detectable on exam Symptomatic anterior uveitis OR Medical intervention indicated Posterior or pan-uveitis OR Operative intervention indicated Disabling visual loss in affected eye(s) Visual changes (from baseline) Visual changes causing no or minimal interference with usual social & functional activities Visual changes causing greater than minimal interference with usual social & functional activities Visual changes causing inability to perform usual social & functional activities Disabling visual loss in affected eye(s) POTENTIALLY LIFE-THREATENING OCULAR/VISUAL IRIS Version 5.2, June 2, 2011 55 CLINICAL PARAMETER GRADE 1 MILD GRADE 2 MODERATE GRADE 3 SEVERE GRADE 4 POTENTIALLY LIFE-THREATENING ENDOCRINE/METABOLIC Abnormal fat accumulation (e.g., back of neck, breasts, abdomen) Detectable by study participant (or by caregiver for young children and disabled adults) Detectable on physical exam by health care provider Disfiguring OR Obvious changes on casual visual inspection NA Diabetes mellitus NA New onset without need to initiate medication OR Modification of current medications to regain glucose control New onset with initiation of medication indicated OR Diabetes uncontrolled despite treatment modification Life-threatening consequences (e.g., ketoacidosis, hyperosmolar nonketotic coma) Gynecomastia Detectable by study participant or caregiver (for young children and disabled adults) Detectable on physical exam by health care provider Disfiguring OR Obvious on casual visual inspection NA Hyperthyroidism Asymptomatic Symptomatic causing greater than minimal interference with usual social & functional activities OR Thyroid suppression therapy indicated Symptoms causing inability to perform usual social & functional activities OR Uncontrolled despite treatment modification Life-threatening consequences (e.g., thyroid storm) Hypothyroidism Asymptomatic Symptomatic causing greater than minimal interference with usual social & functional activities OR Thyroid replacement therapy indicated Symptoms causing inability to perform usual social & functional activities OR Uncontrolled despite treatment modification Life-threatening consequences (e.g., myxedema coma) Lipoatrophy (e.g., fat loss from the face, extremities, buttocks) Detectable by study participant (or by caregiver for young children and disabled adults) Detectable on physical exam by health care provider Disfiguring OR Obvious on casual visual inspection NA IRIS Version 5.2, June 2, 2011 56 LABORATORY PARAMETER GRADE 1 MILD HEMATOLOGY GRADE 2 MODERATE GRADE 3 SEVERE GRADE 4 POTENTIALLY LIFE-THREATENING Standard International Units are listed in italics Absolute CD4+ count – Adult and Pediatric >13 years (HIV NEGATIVE ONLY) 300 – 400/mm3 300 – 400/µL 200 – 299/mm3 200 – 299/µL 100 – 199/mm3 100 – 199/µL <100/mm3 <100/µL Absolute lymphocyte count – Adult and Pediatric >13 years (HIV NEGATIVE ONLY) 600 – 650/mm3 0.600 x 109 – 0.650 x 109/L 500 – 599/mm3 0.500 x 109 – 0.599 x 109/L 350 – 499/mm3 0.350 x 109 – 0.499 x 109/L <350/mm3 <0.350 x 109/L Absolute neutrophil count (ANC) Adult and Pediatric, >7 days 1,000 – 1,300/mm3 1.000 x 109 – 1.300 x 109/L 750 – 999/mm3 0.750 x 109 – 0.999 x 109/L 500 – 749/mm3 0.500 x 109 – 0.749 x 109/L <500/mm3 <0.500 x 109/L Infant†, 2 – 7 days 1,250 – 1,500/mm3 1.250 x 109 – 1.500 x 109/L 1,000 – 1,249/mm3 1.000 x 109 – 1.249 x 109/L 750 – 999/mm3 0.750 x 109 – 0.999 x 109/L <750/mm3 <0.750 x 109/L Infant†, 1 day 4,000 – 5,000/mm3 4.000 x 109 – 5.000 x 109/L 3,000 – 3,999/mm3 3.000 x 109 – 3.999 x109/L 1,500 – 2,999/mm3 1.500 x 109 – 2.999 x 109/L <1,500/mm3 <1.500 x 109/L Fibrinogen, decreased 100 – 200 mg/dL 1.00 – 2.00 g/L OR 0.75 – 0.99 x LLN 75 – 99 mg/dL 0.75 – 0.99 g/L OR 0.50 – 0.74 x LLN 50 – 74 mg/dL 0.50 – 0.74 g/L OR 0.25 – 0.49 x LLN <50 mg/dL <0.50 g/L OR <0.25 x LLN OR Associated with gross bleeding Adult and Pediatric 57 days (HIV POSITIVE ONLY) 8.5 – 10.0 g/dL 1.32 – 1.55 mmol/L 7.5 – 8.4 g/dL 1.16 – 1.31 mmol/L 6.50 – 7.4 g/dL 1.01 – 1.15 mmol/L <6.5 g/dL <1.01 mmol/L Adult and Pediatric 57 days (HIV NEGATIVE ONLY) 10.0 – 10.9 g/dL 1.55 – 1.69 mmol/L OR Any decrease 2.5 – 3.4 g/dL 0.39 – 0.53 mmol/L 9.0 – 9.9 g/dL 1.40 – 1.54 mmol/L OR Any decrease 3.5 – 4.4 g/dL 0.54 – 0.68 mmol/L 7.0 – 8.9 g/dL 1.09 – 1.39 mmol/L OR Any decrease 4.5 g/dL 0.69 mmol/L <7.0 g/dL <1.09 mmol/L Infant†, 36 – 56 days (HIV POSITIVE OR NEGATIVE) 8.5 – 9.4 g/dL 1.32 – 1.46 mmol/L 7.0 – 8.4 g/dL 1.09 – 1.31 mmol/L 6.0 – 6.9 g/dL 0.93 – 1.08 mmol/L <6.00 g/dL <0.93 mmol/L Infant†, 22 – 35 days (HIV POSITIVE OR NEGATIVE) 9.5 – 10.5 g/dL 1.47 – 1.63 mmol/L 8.0 – 9.4 g/dL 1.24 – 1.46 mmol/L 7.0 – 7.9 g/dL 1.09 – 1.23 mmol/L <7.00 g/dL <1.09 mmol/L Hemoglobin (Hgb) 57 LABORATORY PARAMETER Infant†, 1 – 21 days (HIV POSITIVE OR NEGATIVE) GRADE 1 MILD GRADE 2 MODERATE GRADE 3 SEVERE GRADE 4 POTENTIALLY LIFE-THREATENING 12.0 – 13.0 g/dL 1.86 – 2.02 mmol/L 10.0 – 11.9 g/dL 1.55 – 1.85 mmol/L 9.0 – 9.9 g/dL 1.40 – 1.54 mmol/L <9.0 g/dL <1.40 mmol/L International Normalized Ratio of prothrombin time (INR) 1.1 – 1.5 x ULN 1.6 – 2.0 x ULN 2.1 – 3.0 x ULN >3.0 x ULN Methemoglobin 5.0 – 10.0% 10.1 – 15.0% 15.1 – 20.0% >20.0% Prothrombin Time (PT) 1.1 – 1.25 x ULN 1.26 – 1.50 x ULN 1.51 – 3.00 x ULN >3.00 x ULN Partial Thromboplastin Time (PTT) 1.1 – 1.66 x ULN 1.67 – 2.33 x ULN 2.34 – 3.00 x ULN >3.00 x ULN Platelets, decreased 100,000 – 124,999/mm3 100.000 x 109 – 124.999 x 109/L 50,000 – 99,999/mm3 50.000 x 109 – 99.999 x 109/L 25,000 – 49,999/mm3 25.000 x 109 – 49.999 x 109/L <25,000/mm3 <25.000 x 109/L WBC, decreased 2,000 – 2,500/mm3 2.000 x 109 – 2.500 x 109/L 1,500 – 1,999/mm3 1.500 x 109 – 1.999 x 109/L 1,000 – 1,499/mm3 1.000 x 109 – 1.499 x 109/L <1,000/mm3 <1.000 x 109/L CHEMISTRIES Standard International Units are listed in italics Acidosis NA pH <normal, but 7.3 pH <7.3 without lifethreatening consequences pH <7.3 with lifethreatening consequences Albumin, serum, low 3.0 g/dL – < LLN 30 g/L – < LLN 2.0 – 2.9 g/dL 20 – 29 g/L < 2.0 g/dL < 20 g/L NA Alkaline Phosphatase 1.25 – 2.5 x ULN† 2.6 – 5.0 x ULN† 5.1 – 10.0 x ULN† > 10.0 x ULN† Alkalosis NA pH > normal, but 7.5 pH >7.5 without lifethreatening consequences pH >7.5 with lifethreatening consequences ALT (SGPT) 1.25 – 2.5 x ULN 2.6 – 5.0 x ULN 5.1 – 10.0 x ULN >10.0 x ULN AST (SGOT) 1.25 – 2.5 x ULN 2.6 – 5.0 x ULN 5.1 – 10.0 x ULN >10.0 x ULN Bicarbonate, serum, low 16.0 mEq/L – < LLN 16.0 mmol/L – < LLN 11.0 – 15.9 mEq/L 11.0 – 15.9 mmol/L 8.0 – 10.9 mEq/L 8.0 – 10.9 mmol/L <8.0 mEq/L <8.0 mmol/L Adult and Pediatric >14 days 1.1 – 1.5 x ULN 1.6 – 2.5 x ULN 2.6 – 5.0 x ULN 5.0 x ULN Infant†, ≤14 days (non-hemolytic) NA 20.0 – 25.0 mg/dL 342 – 428 µmol/L 25.1 – 30.0 mg/dL 429 – 513 µmol/L >30.0 mg/dL >513.0 µmol/L Infant†, ≤14 days (hemolytic) NA NA 20.0 – 25.0 mg/dL 342 – 428 µmol/L >25.0 mg/dL >428 µmol/L Bilirubin (Total) Calcium, serum, high (corrected for albumin) 58 LABORATORY PARAMETER GRADE 1 MILD GRADE 2 MODERATE GRADE 3 SEVERE GRADE 4 POTENTIALLY LIFE-THREATENING Adult and Pediatric ≥7 days 10.6 – 11.5 mg/dL 2.65 – 2.88 mmol/L 11.6 – 12.5 mg/dL 2.89 – 3.13 mmol/L 12.6 – 13.5 mg/dL 3.14 – 3.38 mmol/L >13.5 mg/dL >3.38 mmol/L Infant†, <7 days 11.5 – 12.4 mg/dL 2.88 – 3.10 mmol/L 12.5 – 12.9 mg/dL 3.11 – 3.23 mmol/L 13.0 – 13.5 mg/dL 3.245 – 3.38 mmol/L >13.5 mg/dL >3.38 mmol/L Calcium, serum, low (corrected for albumin) Adult and Pediatric ≥7 days 7.8 – 8.4 mg/dL 1.95 – 2.10 mmol/L 7.0 – 7.7 mg/dL 1.75 – 1.94 mmol/L 6.1 – 6.9 mg/dL 1.53 – 1.74 mmol/L <6.1 mg/dL <1.53 mmol/L Infant†, <7 days 6.5 – 7.5 mg/dL 1.63 – 1.88 mmol/L 6.0 – 6.4 mg/dL 1.50 – 1.62 mmol/L 5.50 – 5.90 mg/dL 1.38 – 1.51 mmol/L <5.50 mg/dL <1.38 mmol/L Cardiac troponin I (cTnI) NA NA NA Levels consistent with myocardial infarction or unstable angina as defined by the manufacturer Cardiac troponin T (cTnT) NA NA NA 0.20 ng/mL OR Levels consistent with myocardial infarction or unstable angina as defined by the manufacturer Adult ≥18 years 200 – 239 mg/dL 5.18 – 6.19 mmol/L 240 – 300 mg/dL 6.20 – 7.77 mmol/L > 300 mg/dL > 7.77 mmol/L NA Pediatric <18 years 170 – 199 mg/dL 4.40 – 5.15 mmol/L 200 – 300 mg/dL 5.16 – 7.77 mmol/L > 300 mg/dL > 7.77 mmol/L NA Creatine Kinase 3.0 – 5.9 x ULN† 6.0 – 9.9 x ULN† 10.0 – 19.9 x ULN† 20.0 x ULN† Creatinine 1.1 – 1.3 x ULN† 1.4 – 1.8 x ULN† 1.9 – 3.4 x ULN† 3.5 x ULN† Nonfasting 116 – 160 mg/dL 6.44 – 8.88 mmol/L 161 – 250 mg/dL 8.89 – 13.88 mmol/L 251 – 500 mg/dL 13.89 – 27.75 mmol/L >500 mg/dL >27.75 mmol/L Fasting 110 – 125 mg/dL 6.11 – 6.94 mmol/L 126 – 250 mg/dL 6.95 – 13.88 mmol/L 251 – 500 mg/dL 13.89 – 27.75 mmol/L >500 mg/dL >27.75 mmol/L Adult and Pediatric ≥1 month 55 – 64 mg/dL 3.05 – 3.55 mmol/L 40 – 54 mg/dL 2.22 – 3.06 mmol/L 30 – 39 mg/dL 1.67 – 2.23 mmol/L <30 mg/dL <1.67 mmol/L Infant†, <1 month 50 – 54 mg/dL 2.78 – 3.00 mmol/L 40 – 49 mg/dL 2.22 – 2.77 mmol/L 30 – 39 mg/dL 1.67 – 2.21 mmol/L <30 mg/dL <1.67 mmol/L <2.0 x ULN without acidosis 2.0 x ULN without acidosis Increased lactate with pH <7.3 without lifethreatening Increased lactate with pH <7.3 with lifethreatening Cholesterol (fasting) Glucose, serum, high Glucose, serum, low Lactate 59 LABORATORY PARAMETER GRADE 1 MILD GRADE 2 MODERATE GRADE 3 SEVERE GRADE 4 POTENTIALLY LIFE-THREATENING consequences consequences LDL cholesterol (fasting) Adult ≥18 years 130 – 159 mg/dL 3.37 – 4.12 mmol/L 160 – 190 mg/dL 4.13 – 4.90 mmol/L 190 mg/dL 4.91 mmol/L NA Pediatric >2 - <18 years 110 – 129 mg/dL 2.85 – 3.34 mmol/L 130 – 189 mg/dL 3.35 – 4.90 mmol/L ≥190 mg/dL ≥4.91 mmol/L NA Lipase 1.1 – 1.5 x ULN 1.6 – 3.0 x ULN 3.1 – 5.0 x ULN >5.0 x ULN Magnesium, serum, low 1.2 – 1.4 mEq/L 0.60 – 0.70 mmol/L 0.9 – 1.1 mEq/L 0.45 – 0.59 mmol/L 0.6 – 0.8 mEq/L 0.30 – 0.44 mmol /L <0.60 mEq/L <0.30 mmol/L Pancreatic amylase 1.1 – 1.5 x ULN 1.6 – 2.0 x ULN 2.1 – 5.0 x ULN >5.0 x ULN Adult and Pediatric >14 years 2.5 mg/dL – <LLN 0.81 mmol/L – <LLN 2.0 – 2.4 mg/dL 0.65 – 0.80 mmol/L 1.0 – 1.9 mg/dL 0.32 – 0.64 mmol/L <1.00 mg/dL <0.32 mmol/L Pediatric 1 year – 14 years 3.0 – 3.5 mg/dL 0.97 – 1.13 mmol/L 2.5 – 2.9 mg/dL 0.81 – 0.96 mmol/L 1.5 – 2.4 mg/dL 0.48 – 0.80 mmol/L <1.50 mg/dL <0.48 mmol/L Pediatric <1 year 3.5 – 4.5 mg/dL 1.13 – 1.45 mmol/L 2.5 – 3.4 mg/dL 0.81 – 1.12 mmol/L 1.5 – 2.4 mg/dL 0.48 – 0.80 mmol/L <1.50 mg/dL <0.48 mmol/L Potassium, serum, high 5.6 – 6.0 mEq/L 5.6 – 6.0 mmol/L 6.1 – 6.5 mEq/L 6.1 – 6.5 mmol/L 6.6 – 7.0 mEq/L 6.6 – 7.0 mmol/L >7.0 mEq/L >7.0 mmol/L Potassium, serum, low 3.0 – 3.4 mEq/L 3.0 – 3.4 mmol/L 2.5 – 2.9 mEq/L 2.5 – 2.9 mmol/L 2.0 – 2.4 mEq/L 2.0 – 2.4 mmol/L <2.0 mEq/L <2.0 mmol/L Sodium, serum, high 146 – 150 mEq/L 146 – 150 mmol/L 151 – 154 mEq/L 151 – 154 mmol/L 155 – 159 mEq/L 155 – 159 mmol/L 160 mEq/L 160 mmol/L Sodium, serum, low 130 – 135 mEq/L 130 – 135 mmol/L 125 – 129 mEq/L 125 – 129 mmol/L 121 – 124 mEq/L 121 – 124 mmol/L 120 mEq/L 120 mmol/L Triglycerides (fasting) NA 500 – 750 mg/dL 5.65 – 8.48 mmol/L 751 – 1,200 mg/dL 8.49 – 13.56 mmol/L >1,200 mg/dL >13.56 mmol/L Uric acid 7.5 – 10.0 mg/dL 0.45 – 0.59 mmol/L 10.1 – 12.0 mg/dL 0.60 – 0.71 mmol/L 12.1 – 15.0 mg/dL 0.72 – 0.89 mmol/L >15.0 mg/dL >0.89 mmol/L Phosphate, serum, low URINALYSIS Standard International Units are listed in italics Hematuria (microscopic) 6 – 10 RBC/HPF > 10 RBC/HPF Gross, with or without clots OR with RBC casts Transfusion indicated Proteinuria, random collection 1+ 2–3+ 4+ NA 1,000 – 1,999 mg/24 h 1.000 – 1.999 g/d 2,000 – 3,500 mg/24 h 2.000 – 3.500 g/d >3,500 mg/24 h >3.500 g/d Proteinuria, 24 hour collection Adult and Pediatric 10 years 200 – 999 mg/24 h 0.200 – 0.999 g/d 60 LABORATORY PARAMETER Pediatric > 3 mo <10 years GRADE 1 MILD GRADE 2 MODERATE 201 – 499 mg/m2/24 h 0.201 – 0.499 g/d 500 – 799 mg/m2/24 h 0.500 – 0.799 g/d GRADE 3 SEVERE 800 – 1,000 mg/m2/24 h 0.800 – 1.000 g/d GRADE 4 POTENTIALLY LIFE-THREATENING >1,000 mg/ m2/24 h >1.000 g/d * bone mineral density (BMD) 61 18. APPENDIX C- PROTOCOL RELATED RESEARCH USE OF STORED HUMAN SAMPLES, SPECIMENS AND DATA 1. INTENDED USE OF THE SAMPLES/SPECIMENS/DATA Samples and data collected under this protocol will be used to study the immunopathogenesis of immune reconstitution in immune deficient patients with HIV infection. HLA genetic testing will be performed. 2. HOW SAMPLES/SPECIMENS/DATA WILL BE STORED Samples will be stored and tracked utilizing the NCI FCRF REPOSITORY operated by SAIC FREDERICK. 3. WHAT WILL HAPPEN TO THE SAMPLES/SPECIMENS/DATA AT THE COMPLETION OF THE PROTOCOL? In the future, other investigators (both at NIH and outside) may wish to study these samples and/or data. In that case, IRB approval must be sought prior to any sharing of samples. Any clinical information shared about the sample with or without patient identifiers would similarly require prior IRB approval. At the completion of the protocol (termination), samples and data will either be destroyed, or after IRB approval, transferred to another existing protocol or a repository. 5. WHAT CIRCUMSTANCES WOULD PROMPT THE PI TO REPORT TO THE IRB LOSS OR DESTRUCTION OF SAMPLES/SPECIMENS/DATA The NIH Intramural Protocol Violation definition related to loss of or destruction of samples (for example, due to freezer malfunction) will be followed in reporting to the IRB: The violation compromises the scientific integrity of the data collected for the study. Any loss or unanticipated destruction of samples (for example, due to freezer malfunction) or data (for example, misplacing a printout of data with identifiers) will be reported to the IRB. 62 19. APPENDIX D-KERICHO SITE SPECIFIC APPENDIX 63 A Cohort Observational Study Evaluating Predictors, Incidence And Immunopathogenesis Of Immune Reconstitution Syndrome (IRIS) In HIV-1 Infected Patients With CD4 Count <100 Cells/µL Who Are Initiating Antiretroviral Therapy Study Conducted By U.S. Military HIV Research Program, Rockville, MD, U.S.A. U.S. Army Medical Research Unit-Kenya / Kenya Medical Research Institute-Walter Reed Project HIV Program Study Sponsored By Infectious Disease Clinical Research Program Version 5.2 June 2, 2011 NIH # 06-I-0086 KEMRI # 1470 IDCRP # 008 64 Kericho Site Addendum Version 5.2 June 2, 2011 APPENDIX D: KERICHO SITE SPECIFIC ADDENDUM TABLE OF CONTENTS 1. KERICHO AND U.S. PRINCIPAL INVESTIGATORS / PROTOCOL CHAIRS & CO-CHAIR ................................................................................................. 66 2. OTHER KERICHO SITE STAFF ........................................................................... 67 3. LOCAL IRB ............................................................................................................... 68 4. KERICHO SITE DESCRIPTION .......................................................................... 69 5. INFORMED CONSENT PROCESS .................................................................................... 74 6. SUBJECT ENROLLMENT AND FOLLOW-UP ............................................................... 74 7. KERICHO SITE SCHEDULE OF EVENTS1,2 ................................................................... 76 8. LABORATORY EVALUATIONS FOR STUDY VOLUNTEERS ................................... 78 9. PROTOCOL MONITORING .............................................................................................. 79 10. DATA MANAGEMENT PLAN .......................................................................................... 80 11. STUDY RISKS AND BENEFITS ........................................................................................ 81 12. REPORTING TO IRBS ........................................................................................... 81 A. B. C. D. ANNUAL REPORTING ............................................................................................................ 81 UNANTICIPATED ADVERSE EVENTS OR SERIOUS ADVERSE EVENTS .................................. 81 MODIFICATIONS OF THE PROTOCOL .................................................................................... 82 PROTOCOL DEVIATIONS ...................................................................................................... 82 13. CONFIDENTIALITY AND STORAGE OF DOCUMENTS............................... 82 14. POLICY REGARDING RESEARCH-RELATED INJURIES ........................... 83 65 Kericho Site Addendum Version 5.2 June 2, 2011 1. KERICHO AND U.S. PRINCIPAL INVESTIGATORS / PROTOCOL CHAIRS & CO-CHAIR A. Site Principal Investigator / Protocol Chair: Fredrick Sawe, MBChB MMED Kenya Medical Research Institute/Walter Reed Project HIV Program Hospital Road P.O. Box 1357 Kericho, 20200; Kenya Mobile phone: 254-724-255-623 E-mail: fsawe@wrp-kch.org Site Principal Investigator / Protocol Co-Chair: Douglas N. Shaffer, MD, MHS Kenya Medical Research Institute/Walter Reed Project HIV Program Hospital Road P.O. Box 1357 Kericho, 20200; Kenya Mobile phone: 254-724-255-620 E-mail: dshaffer@wrp-kch.org B. United States Principal Investigator / Protocol Chair: Irini Sereti, MD, MHS Division of Clinical Research, National Institute of Allergy & Infectious Diseases, National Institutes of Health Bldg 10, Rm 11C103 (MSC 1880) 10 Center Drive Bethesda, MD 20892 Phone: 301-496-5533 66 Kericho Site Addendum Version 5.2 June 2, 2011 2. OTHER KERICHO SITE STAFF A. Associate Investigators Kibet Shikuku, MBChB, MMED Kenya Medical Research Institute/Walter Reed Project HIV Program Hospital Road P.O. Box 1357 Kericho, 20200; Kenya Mobile phone: 254-720-789-843 E-mail: kshikuku@wrp-kch.org Eunice Obiero, MBChB, MMED Kericho District Hospital Hospital Road P.O. Box 1357 Kericho, 20200 Kenya Mobile phone: 254-721-474-804 E-mail: obieroe@africaonline.co.ke Samoel Khamadi, PhD Kenya Medical Research Institute/Walter Reed Project HIV Program Hospital Road P.O. Box 1357 Kericho, 20200; Kenya B. Nurse Coordinator Hellen Ngeno, BSN Kenya Medical Research Institute/Walter Reed Project HIV Program Hospital Road P.O. Box 1357 Kericho, 20200; Kenya Mobile phone: 254-720-250-920 E-mail: hngeno@wrp-kch.org C. Local Medical Monitor Jonah Maswai, MBChB, MPH Kenya Medical Research Institute/Walter Reed Project HIV Program Hospital Road 67 Kericho Site Specific Addendum Version 5.2 June 2, 2011 P.O. Box 1357 Kericho, 20200; Kenya Mobile phone: 254-722-672-548 E-mail: jmaswai@wrp-kch.org 3. LOCAL IRB Kenya Medical Research Institute Ethics Review Committee FWA #00002066 P.O. Box 54840, 00200 Nairobi, 00200, Kenya Telephone: 254-20-2722541 Fax: 254-20-2720030 Version 5.2, June 2, 2011 68 Kericho Site Specific Addendum Version 5.2 June 2, 2011 4. KERICHO SITE DESCRIPTION A. General Overview Site and Population Description The US Army Medical Research Unit-Kenya (USAMRU-K) is a Special Foreign Activity of the Walter Reed Army Institute of Research (WRAIR), Washington, DC. USAMRU-K is affiliated through a Cooperative Agreement with the Kenya Medical Research Institute (KEMRI). The unit was activated on a temporary basis in 1969 at the invitation of the Government of Kenya to study trypanosomiasis. The success of that initial venture led to the establishment of a permanent activity in 1973. Over the past 32 years, research has been conducted on malaria, trypanosomiasis, leishmaniasis, entomology, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) and arboviruses, with more than 250 manuscripts published. The USAMRU-K HIV Program is a component of the US Military HIV Research Program (USMHRP). In Kenya, the HIV Program field site is located at the KEMRI/WRP Clinical Research Center [CRC]) about 260 kilometers northwest of Nairobi along the NairobiKisumu highway in the rural Kenyan town of Kericho (1). Kericho’s district population is approximately 500,000, although the larger catchments area for both HIV research and treatment is approximately 2.5 million covering the southern portion of the Rift Valley Province. Kericho is located among the African Highlands in the Rift Valley and well known for the tea that is grown in this region and the rolling “seas of green” within the tea plantations. The primary tribe represented in Kericho is Kipsigis, a sub-tribe of the Kalenjin tribe. Kisii, Luhya, and Luo tribes are also represented in Kericho, and to a lesser extent Kikuyu. Kiswahili is most often spoken within the town; however and consistent with the predominant tribe, Kipsigis is more often spoken in the rural villages around Kericho. The primary industry in this region is tea with two large, international tea companies being centered in Kericho District: James Finlay, Kenya Ltd. and Unilever Tea Kenya Ltd. Kericho was ranked as the twentieth richest district in Kenya in the 2005/06 national integrated household budget survey. Income in Kericho comes mainly from agricultural activities, with about 40-50% of the population living below the poverty line. The annual national gross domestic product per capita in 2005 averaged KSh 35,045 (equivalent to USD 565 at current exchange rates of 1 USD = KSh 62 (2). In Kenya, the age of majority (i.e. legal age of recognized adulthood or independence) is 18 years. The Kenyan national literacy level according the Kenya Adult Literacy Survey report published in March 2007 by the Kenya National Bureau of Statistics was 64%. In Kericho, the literacy level is 74.3% in men and 68.9% in women (3). The healthcare system in the larger Kericho area (southern Rift Valley) is primarily provided by the government through a network of public hospitals, health centers, and dispensaries run by the Kenya Ministry of Health. The government health facilities do not charge for treatment but levy a small fee for facility maintenance, which can be waived for those not able to pay. In addition to government health care facilities, there are a few faith based and private health care facilities providing services at a small fee. Acess to Version 5.2, June 2, 2011 69 Kericho Site Specific Addendum Version 5.2 June 2, 2011 most health care facilities is good given a fairly reliable public transport system exists in the region. The KEMRI/WRP CRC is the primary HIV research site. Situated on the grounds of the Kericho District Hospital (KDH)/Ministry of Health (MOH), the 7100 square feet CRC supports both HIV vaccine and therapeutics/operational research and care and treatment in the southern Rift Valley Province. The CRC is composed of a clinical area including a central pharmacy that provides both vaccine and study drug products as well as additional non-study medicines for HIV and other non-study related care. The CRC is a designated satellite HIV clinic under the KDH. The CRC also contains a state-of-the-art research laboratory and Information Technology (IT) center that support both HIV research and treatment programs. Both the CRC pharmacy and laboratory are approved by the National Institute of Allergy and Infectious Diseases/Division of AIDS (NIAID/DAIDS) to participate in DAIDS sponsored vaccine (Site # 1502) and therapeutics (Site #12501) studies, the only research site with such approval in Kenya. Ongoing and Future Research The KEMRI/WRP HIV program has a vibrant research portfolio. Completing follow-up in December 2006, the HIV program is currently in the close-out phase of Kenya’s largest prospective, observational HIV cohort study: “HIV and Malaria Cohort Study Among Plantation Workers and Adult Dependents in Kericho, Kenya” (4). A key precursor to conducting HIV vaccine research, the HIV cohort study opened in June, 2003. After a 6month enrollment period, the study followed an initial, closed cohort of 2801 adult plantation workers and dependents bi-annually for 36 months. The primary goals of the study were to describe HIV incidence and prevalence, HIV risk factors and related infections, HIV vaccine study feasibility and acceptability, and to develop local “normal” laboratory values that can be used for HIV research in this area. In addition to description of local HIV genotype (1), key manuscripts have been published regarding HIV prevalence and the relationship between traditional circumcision and incident HIV (5,6). Currently, the next cohort study is under protocol review and anticipated to open in 2008 (7). This “high risk cohort study” aims to ascertain HIV-1 prevalence, incidence, cohort retention, and host genetics and viral diversity in high risk cohorts in East Africa. This study is a non-randomized, closed cohort, prospective, serial three-monthly follow-up, 18-month observational study. In Kenya, the study population will include men and women, aged 1550 years old, who are members of the following high risk groups: Commercial Sex Workers (CSWs), Barworkers (BWs), Sexually Transmitted Infection Clinic Attendees (STIAs), and Truck Drivers (TDs). In April 2006, the first and largest HIV vaccine study to date outside of Nairobi (the third in Kenya’s history and the first US government-sponsored HIV vaccine study in Kenya) opened at the KEMRI/WRP CRC (8). Sponsored by the National Institutes of Health (NIH)’s Vaccine Research Center, this study was a Phase I/II clinical trial evaluating the safety and immunogenicity of a multiclade HIV-1 DNA plasmid vaccine boosted by a multiclade HIV-1 Version 5.2, June 2, 2011 70 Kericho Site Specific Addendum Version 5.2 June 2, 2011 recombinant adenovirus-5 vector in HIV uninfected adult volunteers in East Africa. The Kericho program enrolled 120 subjects in total in both phase I and II components, completed final vaccinations in February 2007, and completed follow-up in August 2007. In follow-up to this Phase I/II DNA/rAd5 vaccine study, the HIV program has been preparing to participate in the follow-on Phase IIb “test of concept” vaccine study. Currently under consideration by NIAID, this study is to be conducted under the “Partnership for AIDS Vaccine Evaluation” (PAVE) consortium including the Centers for Disease Control and Prevention (CDC), HIV Vaccine Trials Network (HVTN), International AIDS Vaccine Initiative (IAVI), and USMHRP in North and South America as well as Africa. The HIV Program is scheduled to enroll 700 volunteers in larger Kericho District. Finally with regard to vaccine research, the HIV program is currently being considered by the Division of Retrovirology to conduct a Phase I DNA-Modified Vaccinia Ankara (MVA) vaccine study, using WRAIR MVA product, possibly in 2009. In addition to conducting HIV vaccine research, the HIV Program also conducts critical operational research related to understanding best treatments for HIV/AIDS in Africa. In May 2006, the program opened its first interventional, therapeutics trial, the “Optimal Combination After Nevirapine Exposure (OCTANE)” study (9). USAMRU-K’s HIV program is 1 of 10 sites in Africa to conduct this study sponsored by the NIH. This study looks at optimal HIV treatments for women who have taken single dose nevirapine in the context of Prevention of Mother to Child Transmission (PMTCT) of HIV. The fact that USAMRU-K HIV PMTCT program has counseled over 140,000 pregnant women and given single dose nevirapine to over 5,200 underscores the critical importance of such operational research. After reaching the site’s initial enrollment quota, the site has been asked to continuing enrolling in effort to facilitate overall study accrual. The HIV Program plans to conduct two other NIH/AIDS Clinical Trials Group (ACTG) studies. The first study (A5190) is titled “Assessment of Safety and Toxicity among Infants Born To HIV-1-Infected Women Enrolled in Antiretroviral Treatment Protocols in Diverse Areas of the World” (10). This is a prospective, observational, cohort study of infants born to HIV-1-infected women while enrolled in NIH-sponsored, international, antiretroviral treatment protocols. Infants enrolled in the study will be followed prospectively to describe the safety, toxicity, and potential side effects of in utero and breast milk exposure to the ARV drugs used in international treatment protocols. Second, the site has been invited by ACTG to participate in A5221, “A Strategy Study of Immediate Versus Deferred Initiation of Antiretroviral Therapy for HIV-Infected Persons Treated for Tuberculosis with CD4 <200 cells/mm3” (11). A5221 is a randomized, open-label study to determine whether the strategy of immediate [within approximately 2 weeks after starting treatment for tuberculosis (TB)] versus deferred (8-12 weeks after start of TB treatment) initiation of antiretroviral therapy (ART) reduces mortality and AIDS-defining events in participants being treated for TB. The HIV program will be conducting qualitative research as well as public health evaluations as complimentary operational research to ongoing and future HIV research and treatment. In collaboration with the University of California at San Diego, the HIV Program will conduct a multi- center, qualitative study to assess the acceptability of amenorrhea secondary to contraception and desired contraceptive features among HIV-infected women in different Version 5.2, June 2, 2011 71 Kericho Site Specific Addendum Version 5.2 June 2, 2011 cultural settings (12). With support from the United States Presidents Emergency Plan for AIDS Relief (PEPFAR), protocol development is underway for a Public Health Evaluation (PHE) titled “Clinic-based ART & Diagnostic Evaluation (CLADE)” (13). CLADE is a clinic-based, randomized (1:1), non-blinded, controlled, study aimed at evaluating the superiority of two Kenya MOH antiretroviral therapy (ART) diagnostic evaluations in treatment naive patients beginning MOH approved first-line ART: “routine care,” the most common approach to ART roll-out where CD4 and clinical World Health Organization (WHO) staging are the primary initial diagnostic and follow-up evaluations; and, “viral load guided care”, where viral loads are incorporated into evaluations consistent with the most recent MOH 2007 guidelines. Finally, the HIV program (KEMRI and WRP) conducts studies in collaboration with the Boston University School of Public Health (BU). The BU-KEMRI-WRP collaboration has already successfully completed a study describing the impact of HIV-morbidity on labor productivity in local tea estates (14). The results of this study were the foundation for the second, ongoing phase of research. Having demonstrated the impact of HIV morbidity on labor productivity, this second phase of research now evaluates the impact of antiretroviral therapy on labor productivity and other quality-of-life determinants. This collaboration is also conducting two other studies 1) “Economic Outcomes of Antiretroviral Therapy in the Southern Rift Valley Province”, which evaluates economic outcomes of persons receiving ART in rural households; and, 2) “Costs and Outcomes of Models for Delivering Antiretroviral Therapy for HIV/AIDS in Kenya”, which is evaluating cost of providing ART District Hospital or Health Canters in Southern Rift Valley Province. B. HIV and Opportunistic Infections As elsewhere in Kenya, HIV disease is a significant health burden in Kericho. HIV prevalence estimates for the larger Kericho area of the south Rift Valley Province range from 6% (based upon Demographic and Health Survey estimates for “rural” Kenya) to 14% (based upon research conducted by the HIV program in Kericho) (5,15). HIV prevalence reaches nearly 20% in females in some areas (15). Systematically collected and published data regarding prevalence of opportunistic infections (OIs) in Kenya is limited. Most recent guidelines published by the MOH broadly note a range of OIs based upon CD4 count and WHO Stage that has often been used in describing OIs in Western settings (16). These OIs include the following in order of progressing WHO stage and decreasing CD4 count: pulmonary tuberculosis, oral thrush and oral hairy leukoplakia, Kaposi’s sarcoma, Pneumocystis jiroveci pneumonia, non-Hodgkin’s lymphoma, esophageal candidiasis, cryptosporidiosis, chronic herpes, cerebral toxoplasmosis, cryptococcus, cytomegalovirus retinitis, and Mycobacterium avium complex. More specific reference to OIs in Kenya focuses upon Mycobacterium tuberculosis, Pneumocystis jiroveci pneumonia, cryptosporidiosis, toxoplasmosis, cytomegalovirus, Mycobacterium avium complex, Salmonella typhi, and Streptococcus pneumoniae (17). In addition to this list more local to Kenya, cryptococcal meningitis and Kaposi’s sarcoma are seen with notable prevalence as well. C. HIV Prevention, Care, and Treatment Version 5.2, June 2, 2011 72 Kericho Site Specific Addendum Version 5.2 June 2, 2011 In addition to primary HIV vaccine and drug research, the USMARU-K HIV Program also supports comprehensive HIV prevention, care, and treatment services as one of the US Government agencies implementing the President’s Emergency Plan for AIDS Relief through the US Embassy in Nairobi. The US Department of Defense (DOD)/USAMRU-K HIV Program recognized the importance of bringing comprehensive HIV/AIDS services to the larger Kericho area of the south Rift Valley Province where research is ongoing. Twenty-four months prior to the first vaccine clinical trail, the HIV Program brought HIV treatment to the Kericho District through the Emergency Plan. In close collaboration with the Kenya MOH and through the US Embassy in Nairobi, the HIV Program has to date opened 25 ART centers in 8 districts of the south Rift Valley Province with a total population of 2.5 million people. In addition, 170 PMTCT of HIV clinics and 40 Voluntary Counseling and Testing (VCT) centers have been opened. One faith based organization in the Kericho District has been developed to provide Abstinence and “Be faithful” (AB) services. Two Orphans and Vulnerable Children (OVC) programs have been opened. The US DOD’s Emergency Plan roll out in Kericho has been recognized for its success as highlighted by the US Embassy in Nairobi for visits by Ambassadors Bellamy and Ranneberger, the Assistant to the President on Policy and Strategic Planning (Mr. M. Gerson), the Ambassador for the Office of the Global Aids Coordinator (O-GAC), the Institute of Medicine during their evaluation of Emergency Plan programs in Kenya, and many others. To date in the southern Rift Valley Province, the US DOD has directly aided the Kenya MOH to enroll almost 20,000 Kenyans in to HIV clinics, start nearly 10,000 Kenyans on life-saving antiretroviral therapy, treat over 1000 persons with HIV/TB coinfection, provide HIV counseling and testing to almost 100,000 Kenyans, offer AB messages/services to nearly 125,000 Kenyans, provide PMTCT services to over 140,000 Kenyan mothers, and provide care to almost 1200 orphans and vulnerable children. Among HIV clinics in the southern Rift Valley Province, the KDH is by far the largest and most successful. It is possibly the largest District Hospital HIV clinic in Kenya (18,19). To date, the KDH HIV Clinic has enrolled approximately 6000 Kenyans, approximately half starting on first line antiretroviral therapy. Most recent analyses of data available suggest a 12-month mortality rate of approximately 8%. D. Roles of Researchers For the Kericho site, the primary role of the researchers will be study execution as outlined in the protocol and relevant standard operating procedures. All participants in this study will be enrolled in the Kericho District Hospital HIV clinic; however, some out-patient HIV care may be provided at the Kericho Clinical Research Center consistent with routine practices for all research conducted at the Kericho Clinical Research Center. As with all HIV studies conducted at the Clinical Research Center, HIV+ participants in IRIS will have the support of the PEPFAR program for dealing with any HIV-related incidental findings and various other medical issues that may occur where appropriate as covered by the Kericho District Hospital. Version 5.2, June 2, 2011 73 Kericho Site Specific Addendum Version 5.2 June 2, 2011 5. INFORMED CONSENT PROCESS For the Kericho site, the informed consent process follows a Standard Operating Procedure and begins with the first contact with a potential study participant and continues throughout the course of study. The initial consent process will be conducted by the designated study personnel in a dedicated room at the Kericho District Hospital and may proceed with or without antecedent group education depending upon the potential participant’s preference. The English informed consent document has been translated into Kiswahili and will be administered in the either language based upon the potential participant’s preference. Patients need to understand either Kiswahili or English to participate in the study. In the event that the subject is illiterate, a witness will be present during the entire consenting process and will sign the consent document according to study Standard Operating Procedure. The informed consent process will be accomplished and documented before any study related procedures begin. The subject will be given a copy of the signed informed consent form as per Standard Operation Procedure. 6. SUBJECT ENROLLMENT AND FOLLOW-UP Two hundred volunteers with advanced HIV (CD4 count <100 cells/mm3) will be recruited over 2 years (100 year-1, and 100 year-2). Volunteers will be recruited primarily from the KDH HIV clinic, combined HIV/TB clinic, and in-patient wards and followed according to Kenya MOH guidelines for routine HIV care and treatment at the KEMRI/WRP CRC satellite clinic (18). Based upon evaluation and at the discretion of the clinician, volunteers may be recruited from other nearby hospitals if follow-up is not deemed to be troublesome as is the practice at KDH. Follow-up for the observational study is consistent with routine HIV care visits as recommended by the Kenya MOH (20). Recruitment will occur at the Kericho District Hospital primarily at (but not limited to) the HIV (Highly Active Antiretroviral Therapy (HAART)) Clinic, combined TB/HIV Clinic, and in-patient wards according to a study recruitment Standard Operating Procedures document. At the discretion of the PI, volunteers may be recruited similarly from nearby hospitals. Briefly, initial recruitment will occur primarily by word of mouth. Interested individuals will be provided a study informed consent document (Kiswahili and/or English versions) to take home and invited to speak further with study staff if interested. Open educational sessions regarding the study as well as individual informed consent sessions will be offered for interested persons. Routine clinical and laboratory information (e.g. medical history, CD4 count) available as part of standard medical care may be used in the decision to invite the clinic patients to learn about the IRIS study. For example, a patient with a CD4 count of 250/mm3 will not be invited to potentially participate in the study. Patients who decide they are not interested in participating in the study or who do not provide consent will continue routine HIV care. Patients who express further interest to participate will proceed to formal consenting process by the study PI or designee. Patients who provide informed consent will be escorted by a study nurse or designee to the KEMRI/WRP Clinical Research Center in order to start the study related procedures. Version 5.2, June 2, 2011 74 Kericho Site Specific Addendum Version 5.2, June 2, 2011 Version 5.2 June 2, 2011 75 Kericho Site Specific Addendum Version 5.2 June 2, 2011 7. KERICHO SITE SCHEDULE OF EVENTS1,2 Evaluation Documentation of HIV (R) Medical & Medication History (C) Nadir CD4 Count (C) Clinical Assessment (C) Physical Exam (C) BMI (C) Hematology (CBC and differential) (C) ESR (R) Chemistries3 (C) Amylase/Lipase (C) Lipid Profile (fasting) (C) Albumin (R) Urinalysis (C) Pregnancy Test (C) Flow Cytometry (C, R) HIV-RNA (C, R) HIV genotype ( R ) Hepatitis B, C (C, R) Cryptococcal Serum Ag (C) PPD6 (R) RPR (C) Cervical Pap Smear (C) Eye Clinic Evaluation (C, R) Chest X-Ray (R) HLA-Typing (R) Stored PBMC/Plasma (R) Stored Serum (R) Photography9 (R) Screening (-28 days) X X X X X X X X4 Pre-ART/ART (-27 to 0 days) Wk0 Wk 2 Wk 4 Wk 8 Wk 12 Wk 24 Wk 36 Wk 48 Wks 64 & 80 Wk 96 (EOS) X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X5 X X X X X X X7 X8 X X X X X X X X X X X X as clinically indicated X X X X X X as clinically indicated and annually as clinically indicated X X X X X X X X X X X X C only X X X X X6 X X as clinically indicated X6 X6 X X as clinically indicated as clinically indicated X X X X X X X X X X X X X X X X as indicated Version 5.2, June 2, 2011 76 Kericho Site Specific Addendum Version 5.2 June 2, 2011 Kericho Site Schedule of Events Key Evaluation codes: C=data obtained secondarily as part of routine clinical care; R=research related procedure; C, R=both clinical care and research related. 1. All visits are consistent with Kenya Ministry of Health follow-up for routine clinical care. Pre-ART and ART visits will be combined but tests may be performed in more than 1 day. Study participants will be seen by a clinical officer or medical officer at each study visit. 2. Phlebotomy volumes are 48mls for each visit except for the screening (8mLs) and entry (58mLs) visits. Phlebotomy will include only clinical laboratory evaluations when the Hg is < 7.0 gm/dl. In cases where only clinical laboratory evaluations are used, any remaining discard samples may be used for research evaluations. 3. Chemistries will routinely include electrolytes (Na, K, Cl), urea, creatinine, non-fasting glucose, ALT/AST. Other tests (e.g. Ca) may be ordered at clinician’s discretion. Chemistries will be completed during screening consistent with the standard of care and may be repeated during pre-ART/ART if clinically indicated. 4. Only CD4 performed at screening. 5. May be repeated once if required by laboratory. 6. PPD will be repeated at week 4 only if non-reactive at baseline. If non-reactive at baseline and week 4, PPD will be repeated at weeks 48 and 96. 7. Pap smears will be conducted at entry (may be delayed up to week 4) and at weeks 48 and 96 but is nnt required per protocol. Results from a local medical doctor will be accepted. 8. And every 24 weeks thereafter until CD4 >100 cells/mm3 for >12 weeks or as clinically indicated. 9. With documented consent from volunteer. Unless otherwise noted in the site-specific appendix, the parent protocol will be followed. Version 5.2, June 2, 2011 77 Kericho Site Specific Addendum Version 5.2 June 2, 2011 8. LABORATORY EVALUATIONS FOR STUDY VOLUNTEERS Laboratory support for patients receiving routine clinical care at the KDH is primarily provided by the KDH laboratory. The KEMRI/WRP CRC laboratory has served as the reference laboratory for HIV care and treatment clinics in the southern Rift Valley Province from the outset of the PEPFAR program in April 2004. Support initially focused upon safety labs (basic chemistries including transaminases, complete blood counts) and CD4s as necessary to promptly and safely open HIV clinics in response to the Emergency Plan. While initially conducting all safety labs and CD4 counts for up to 11 treatment facilities in the southern Rift Valley Province, technology to conduct safety labs has been transferred to 9 of the 11 sites. In addition to serving as a back-up laboratory, the KEMRI/WRP CRC laboratory provides QA/QC support to HIV clinical laboratories in the region and HIV viral load testing for persons suspected of antiretroviral therapy failure under the auspices of the MOH. The KEMRI/WRP CRC laboratory is scheduled to receive funding in 2008 under the Emergency Plan to further develop the capacity to serve as the regional reference laboratory for early infant diagnoses (HIV polymerase chain reaction [PCR]) as well as evaluation for common opportunistic infections (e.g. Mycobacterium tuberculosis including culture capabilities, microscopy for Pneumocystis jiroveci, serology for toxoplasmosis and cytomegalovirus). The KDH laboratory is a MOH laboratory that has been developed with support from KEMRI/WRP under the Emergency Plan to serve not only the KDH but also regional MOH HIV clinical laboratories for safety labs and CD4 counts (technology transfer from the KEMRI/WRP CRC laboratory to KDH). Currently, the KDH laboratory conducts ZiehlNeelsen (ZN) staining for Acid Fast Bacilli (AFB). Specimens are sent to the National Public Health Laboratory in Nairobi for TB cultures. In addition, the KDH laboratory conducts routine gram stain, microscopy, culture and sensitivity for non-blood specimens, potassium hydroxide staining for fungal infections, and examination of stool for ova and parasites. Currently, the KEMRI/WRP CRC laboratory supports HIV diagnostics including enzymelinked immunosorbent assay (ELISA), Western Blot, HIV viral load, and CD4 for both observational cohort and interventional studies. In addition to HIV diagnostics, CD4, and HIV viral loads, the laboratory also conducts routine chemistries and complete blood counts, malaria slides for parasites, urine microscopy, India ink and Cryptococcus antigen testing (CRAg), rapid plasma reagin (RPR)/serodia for syphilis, and hepatitis B serology. The KEMRI/WRP CRC laboratory is approved by the KEMRI, Kenya Medical Technicians Board, and NIAID/DAIDS (for both vaccine [Site #1502] and therapeutics [Site #12501]) studies. The KEMRI/WRP CRC laboratory is currently enrolled in several external quality assurance programs: College of American Pathologists (CAP) – hematology, flow cytometry, HIV serology, chemistry, pregnancy, RPR, and hepatitis B surface antigen; WRAIR – HIV-1 serology, viral load; UKNEQAS – flow cytometry and hematology; CD Chex (Streck) – flow cytometry; Canadian QASI – flow cytometry; VQA (Rash Laboratories USA) – HIV-1 RNA and HIV-1 DNA (Whole Blood); CDC - HIV-1 DNA (DBS); HUQAS (Human Diagnostic) – chemistry; and, IQAP (Beckmann Coulter) – hematology. The laboratory has also enrolled for rapid HIV 1 and 2, HIV DNA (whole blood), and prothrombin time (PT)/partial thromboplastin time (PTT) for 2008. The laboratory anticipates undergoing CAP accreditation Version 5.2, June 2, 2011 78 Kericho Site Specific Addendum Version 5.2 June 2, 2011 in January 2008. The KEMRI/WRP CRC lab will be the only CAP accredited laboratory in Kenya and one of 4 in East Africa. Routine care and treatment under this observational cohort protocol will be supported by the Emergency Plan consistent with support provided in this region. Additional testing to be incorporated in to the KEMRI/WRP CRC laboratory for support of persons in HIV care and treatment programs in this region will include ZN staining for AFB. PCR probes will be used to differentiate M. tuberculosis from M. avium complex (MAC). In addition, silver staining for P. jiroveci pneumonia will be introduced to the KEMRI/WRP CRC lab. Serological testing for cytomegalovirus, toxoplasmosis, herpes simplex virus, and hepatitis C will also be conducted at the KEMRI/WRP CRC laboratory. The USAMRU-K Kisumu sub-location laboratories will perform routine blood and cerebrospinal fluid (CSF) cultures as well as diagnostic testing (PCR) for both Salmonella typhi and brucella. Other tests available at the Kisumu laboratory include PCR for rickettsia, leptospira, and influenza. All such testing would be at the discretion of the clinician as indicated. Finally, the NIH laboratory will be utilized for clinical diagnostic testing for pathogens not tested in Kenya (e.g. Epstein-Barr virus and Cytomegalovirus PCR). 9. PROTOCOL MONITORING Monitoring at the Kericho site will be conducted according to the “NIAID Intramural Clinical Monitoring Guidelines.” Monitors under contract to the NIAID/Regulatory Compliance and Human Subjects Protection Branch (RCHSPB) will visit the clinical research site to monitor all aspects of the study in accordance with the appropriate regulations and the approved protocol. The objectives of a monitoring visit will be: 1) to verify the existence of signed informed consent documents for each monitored subject; 2) to verify the prompt and accurate recording of all monitored data points, and prompt reporting of all SAEs; 3) to compare abstracted information with individual subject’s records and source documents (subjects’ charts, laboratory analyses and test results, physicians’ progress notes, nurses’ notes, and any other relevant original subject information); and 4) to ensure protection of study subjects, investigators’ compliance with the protocol, and completeness and accuracy of study records. The monitors also will inspect the clinical site regulatory files to ensure that regulatory requirements and applicable guidelines (International Conference on Harmonization- Good Clinical Practices [ICH-GCP]) are being followed. During the monitoring visits, the investigator (and/or designee) and other study personnel will be available to discuss the study progress and monitoring visit. The investigator (and/or designee) will make study documents (e.g. consent forms and pertinent hospital or clinical records) readily available for inspection by the local institutional review board (IRB), the site monitors, and the NIAID staff for confirmation of the study data. A specific monitoring plan will be discussed with the Principal Investigator and study staff prior to enrollment. The plan will outline the frequency of monitoring visits based on such factors as study enrollment, data collection status and regulatory obligations. Version 5.2, June 2, 2011 79 Kericho Site Specific Addendum Version 5.2 June 2, 2011 10. DATA MANAGEMENT PLAN In Kenya, study data will be collected at the study site and maintained on paper case report forms (CRFs). These forms are to be completed on an ongoing basis during the study. The CRFs and instructions will be distributed to the site by the monitoring sponsor or printed by the sites themselves after sponsor approval. Data entries on paper CRFs must be completed legibly with black ballpoint pen. Corrections must be made by striking through the incorrect entry with a single line (taking care not to obliterate or render the original entry illegible) and entering the correct information adjacent to the incorrect entry. Corrections to paper CRFs must be initialed and dated by the person making the correction. All CRFs should be reviewed by the Investigator and signed as required. The CRFs will be stored at the Clinical Research Center archive room (see below). CRF data will be entered into the Research Support System (RSS) and Global Registry and Enrollment System (GRES). Both are Oracle® based password, protected data systems developed by the Henry M. Jackson Foundation in Rockville, Maryland, USA and used extensively by USMHRP. Study participant registry and enrollment entry date will be entered into GRES at the Kenya Medical Research Institute/Walter Reed Project Clinical Research Center Information Technology Department. This database will contain identifiers such as Participant Identification Number (PIN), participant names, and the HIV clinic ID number. These are all used in coordinating follow-up. Other study data will be double entered into the RSS by two data clerks. Reconciliation will be performed and any discrepancies will be resolved. Once data entry is complete and reconciled, the CRFs will be filed in a locked, secured room. All study data will be maintained in the RSS, with only the PIN serving as the identifier for each participant. Data will be stored in an Oracle® relational database. Database backups will occur daily. Back-up sets will be stored in a secure fireproof cabinet in Kericho and at an offsite location. A full copy of the cleaned RSS dataset (containing no participant identifiers) will be delivered at least semi-annually and at study completion to the NIH for analysis. The Clinical Research Center Information Technology Department is secured with limited access controlled by an electronic lock. The server room is temperature controlled with “sensor phones” to alert staff of any pre-set temperature deviations. All research servers are backed up daily, and a copy of the backup saved securely in a fireproof safe at an offsite location. The CRC archive room is secured by double locks, the inside lock being an electronic PIN controlled lock. The Clinical Research Center (CRC) Information Technology Department is within the larger Clinical Research Center complex, approved by the US Embassy Regional Security Officer (RSO), guarded 24 hours a day, and protected by a surrounding concrete fence. The offsite location is within the KEMRI/WRP Office complex is across the road, approximately 20 meters away from the KEMRI/WRP CRC. The office complex is approved by the US Embassy Regional Security Officer (RSO), guarded 24 hours a Version 5.2, June 2, 2011 80 Kericho Site Specific Addendum Version 5.2 June 2, 2011 day, and protected by 2 locked doors (the second being accessible only by entry of assigned code for each staff). 11. STUDY RISKS AND BENEFITS Potential study risks are limited in this observational study and include, but are not limited to, primarily radiation and phlebotomy. Such risks are shared by persons receiving routine HIV care and treatment. Steps have been taken to mitigate such risks. The Kenya Radiation Protection Board has inspected and certified the Kericho District Hospital X-ray Department and provides continued oversight. For all X-ray procedures, the principle of ALARA (As Low As Reasonably Achievable) is applied to ensure that the minimum radiation does of diagnostic value is given. As routine, patients are given clear instructions and positioned appropriately for X-ray procedures, and a lead shield will be used to protect the patient against scattered radiation. Data recording media are inspected for any light leakage. Phlebotomy practices at the KEMRI/WRP CRC are covered by a Standard Operating Procedure. Briefly, trained and experienced study staff perform phlebotomy in designated and equipped phlebotomy areas. Subjects with hemoglobin concentrations less than 7 gm/dl will have blood drawn for tests necessary for the clinical management of the subject only. No research related tests will be done for the subjects until the hemoglobin concentration is above 7 gm/dl. In cases where only clinical laboratory evaluations are used, any remaining discarded samples may be used for research evaluations. Quality assurance/quality control procedures are in place to ensure appropriate phlebotomy practices are observed. Specific procedure is outlined in Standard Operating Procedure guiding the care for emergency/urgent phlebotomy procedures (e.g. syncope or near syncope). Discarded specimens collected for clinical reasons may be used for research evaluations. 12. REPORTING TO IRBS A. ANNUAL REPORTING A continuing review report will be submitted to all IRBs having overview of this study including KEMRI, USUHS, and NIAID before the date determined by the IRB of record, but not less than once a year. After all study related activities, including data analysis are completed, a final report may be submitted to the IRBs. B. UNANTICIPATED ADVERSE EVENTS OR SERIOUS ADVERSE EVENTS All volunteers participating in this observational study will have adverse event (AE) information collected by the clinic staff. The AEs will be graded as per the DAIDS Table for Version 5.2, June 2, 2011 81 Kericho Site Specific Addendum Version 5.2 June 2, 2011 Grading Severity of Adult Adverse Experiences, dated December 2004 (Appendix B). General AE reporting is described in the main protocol (Section 11.1 and 11.2). Additional reporting for the Kericho Site Unanticipated problems involving risk to volunteers or others, serious adverse events (SAEs) related to participation in the study and all volunteer deaths should be promptly reported to the local IRB as well as all participating IRBs to include KEMRI, IDCRP, NIAID. Similarly, unanticipated problems involving risk to subjects or others, SAEs related to participation in the study and all subject deaths should be promptly reported By to the local and all participating IRBs to include to KEMRI, USUHS, NIAID. The medical monitor is also required to review all unanticipated problems involving risk to subjects or others, SAEs and all subject deaths associated with the protocol and provide an unbiased written report of the event. At a minimum, the medical monitor should comment on the outcomes of the event or problem, and in the case of an SAE or death, comment on the relationship t o participation in the study. The medical monitor should also indicate whether he/she concurs with the details of the report provided by the study investigator. Reports for events determined by either the investigator or medical monitor to be possibly or definitively related to participation and reports of events resulting in death should be promptly forwarded to all-participating IRBs. C. MODIFICATIONS OF THE PROTOCOL All amendments to this protocol will also be submitted to the IRBs having overview of this study including KEMRI, USUHS, and NIAID. Written approval from all IRBs having overview and implementation from the WRAIR Commander must be received prior to implementation of any protocol amendment. D. PROTOCOL DEVIATIONS All IRBs having overview of this study including KEMRI, USUHS, and NIAID will all be notified of any deviations/ departures from the protocol that may have an effect on the safety of volunteers and integrity of the study. All deviations will be reported to the KEMRI IRB immediately they occur and in the continuing review reports and the final study report to other participating IRBs. 13. CONFIDENTIALITY AND STORAGE OF DOCUMENTS Each study volunteer will be provided an identification number for study purposes. These identification numbers will be used for all laboratory tests or samples stored for testing in future studies. The study participants’ medical records and the list of names, addresses, and identification numbers will be kept locked in file cabinets with access limited to study personnel only. Any publication of this study will not use the study participant’s name or Version 5.2, June 2, 2011 82 Kericho Site Specific Addendum Version 5.2 June 2, 2011 identify him/her personally. Efforts will be made to keep the study participants’ personal information confidential. The personal information may be disclosed if required by law. Study records may be reviewed by any and/or all IRBs or regulatory bodies having overview including KEMRI, USUHS, and NIH. 14. POLICY REGARDING RESEARCH-RELATED INJURIES The study site will provide short-term medical care for any injury resulting from participation in this research. The NIH or the U.S. Federal Government will not provide long-term medical care or financial compensation for research-related injuries. Should a participant be injured as a direct result of taking part in this research study, the volunteer will be provided emergency medical care only, at no cost, for that injury. The U.S. Federal Government will not provide long term care (more than 6 months) for any injuries resulting from study participation. The participant will not receive any compensation for illness or injury. The participant will be given information on where to get further treatment if needed. The volunteer will be informed that this is not a waiver or release of your legal rights. Version 5.2, June 2, 2011 83 Kericho Site Specific Addendum Version 5.2 June 2, 2011 12. SITE-SPECIFIC ADDENDUM REFERENCES 1. Kenya Integrated Household Budget Survey (2005/06). Kenya National Bureau of Statistics, Ministry of Planning and National Development. 2007. (ISBN: 9966-767-08-8). 2. Kenya National Adult Literacy Survey. Kenya National Bureau of Statistics. March 2007. 3. U.S. Military HIV Research Program – Kenya. http://www.hivresearch.org/globalefforts/kenya.html. Accessed November 14, 2007. 4. HIV and Malaria Cohort Study Among Plantation Workers and Adult Dependents in Kericho, Kenya. v29. RV142, WRAIR #855, KEMRI #590. 5. Foglia G, Sateren W, Renzullo P, et al. High Prevalence of HIV Infection Among Rural Tea Plantation Residents in Kericho, Kenya. Epidemiol Infect 2007;Jun 29:1-9. 6. Shaffer D, Bautista C, Sateren W, et al. The Protective Effect of Circumcision on Incident HIV in Rural, Low Risk Men Circumcised Predominately by Traditional Healers in Kenya: Two-Year Follow-up of the Kericho HIV Cohort Study. J Acquir Immune Defic Syndr 2007;45(4):371-379. 7. HIV-1 Prevalence, Incidence, Cohort Retention, and Host Genetics and Viral Diversity in High Risk Cohorts in East Africa. RV217b, WRAIR #1373, KEMRI TBD. 8. A Phase I/II Clinical Trial to Evaluate the Safety and Immunogenicity of a Multiclade HIV-1 DNA Plasmid Vaccine Boosted by a Multiclade HIV-1 Recombinant Adenovirus-5 Vector Vaccine in HIV Uninfected Adult Volunteers in East Africa. http://clinicaltrials.gov/ct/show/NCT00123968?order=1. Accessed November 14, 2007. 9. Optimal Combination Therapy After Nevirapine Exposure (OCTANE). http://clinicaltrials.gov/ct/show/NCT00089505?order=1. Accessed November 14, 2007. 10. Assessment of Safety and Toxicity among Infants Born To HIV-1-Infected Women Enrolled in Antiretroviral Treatment Protocols in Diverse Areas of the World http://clinicaltrials.gov/ct/show/NCT00100867?order=1. Accessed November 14, 2007. 11. A Strategy Study of Immediate Versus Deferred Initiation of Antiretroviral Therapy for HIV-Infected Persons Treated for Tuberculosis with CD4 <200 Cells/mm3. http://clinicaltrials.gov/ct/show/NCT00108862?order=1. Accessed November 14, 2007. 12. Multi- Cultural Qualitative Assessment of Acceptability of amenorrhea Secondary to Contraception and desired Contraceptive Feature Among HIV-Infected Women. RV221, WRAIR #1348, KEMRI #1240. 13. CLADE: Clinic-based ART & Diagnostic Evaluation: A Public Health Evaluation of Routine vs. Viral Load Guided ART in Rural Kenya. In development. 14. Fox M, Rosen S, MacLeod W, et al. The impact of HIV/AIDS on Labour Productivity in Kenya. Trop Med Int Health 2004;9(3):318-24. 15. National AIDS and STI Control Programme, Ministry of Health, Kenya. AIDS in Kenya. 7th ed. Nairobi, Kenya: NASCOP; 2005. 16. National AIDS and STI Control Programme, Ministry of Health, Kenya. HIV Related Opportunistic Infections, Diagnosis and Treatment: A Healthcare Workers Guide. 2 nd Edition. Nairobi, Kenya: NASCOP; 2006. 17. Holmes C, Losina E, Walensky R, et al. Review of Human Immunodeficiency Virus Type 1–Related Opportunistic Infections in Sub-Saharan Africa. Clinical Infectious Diseases 2003; 36:652–62. 18. Muttai H, Obiero E, …, and Shaffer D. Integration of HIV and TB Services Within The District Hospital: Experiences From the Kericho District Hospital in Kenya. Oral Abstract Version 5.2, June 2, 2011 84 Kericho Site Specific Addendum Version 5.2 June 2, 2011 Session. The President’s Emergency Plan for AIDS Relief Implementers Meeting; Kigali, Rwanda. June 16-19, 2007. 19. Obiero E, Langat B, Shaffer D, et al. Scaling Up An HIV/AIDS Clinic In Rural Kenya: Experience From The Kericho District Hospital. Oral Abstract Session. The President’s Emergency Plan for AIDS Relief Second Annual Field Meeting; Addis Ababa, Ethiopia. May 22-27, 2005. 20. National AIDS and STI Control Programme, Ministry of Health, Kenya. Kenya National Clinical Manual For ART Providers: A Concise and Practical Guide to ART Provision. 2nd Edition. Nairobi, Kenya: NASCOP; 2007. Version 5.2, June 2, 2011 85 Kericho Site Specific Addendum Version 5.2 June 2, 2011 12. SIGNATURE OF PRINCIPAL INVESTIGATOR/SITE CHAIR I will perform the foregoing protocol and Kericho specific addendum as written in the abovedescribed Study Protocol. _______________________________________ Frederick K. Sawe Site Principal Investigator/Chair, Kericho __________________ _______________________________________ Douglas N. Shaffer __________________ Date (dd/mm/yyyy) SITE PRINCIP INVESTIGATOR/CO-CHAIR, KERICHO (DD/MM/YYYY) Version 5.2, June 2, 2011 DATE 86 Kericho Site Addendum Version 5.2 June 2, 2011 APPENDIX E: THAILAND SITE ADDENDUM 87 Thailand Site Specific Addendum June 2, 2011 A Cohort Observational Study Evaluating Predictors, Incidence And Immunopathogenesis of Immune Reconstitution Syndrome (IRIS) In HIV-1 Infected Patients with CD4 Count <100 Cells/µL who Are Initiating Antiretroviral Therapy in Thailand Study Conducted By The South East Asia Research Collaboration with Hawaii, Bangkok, Thailand The Thai Red Cross AIDS Research Centre, Bangkok, Thailand The Bamrasnaradura Infectious Disease Institute, Nonthaburi, Thailand The National Institute of Allergy & Infectious Diseases, National Institutes of Health, Maryland, U.S.A. Study Sponsored By Infectious Disease Clinical Research Program 88 Thailand Site Specific Addendum 1. THAILAND AND U.S. PRINCIPAL INVESTIGATORS / PROTOCOL CHAIRS & CO-CHAIR A. Site Principal Investigator / Protocol Chair: Jintanat Ananworanich, MD, PhD South East Asia Research Collaboration with Hawaii (SEARCH) Thai Red Cross AIDS Research Centre (TRCARC) 104 Rajdumri Road, Tower 2, 2nd floor Pathumwan, Bangkok 10330, Thailand Email: jintanat.a@searchthailand.org Office phone: +662 254 2566 to 9 Mobile phone: +6681 341 4644 Site Co-Principal Investigators / SiteProtocol Co-Chairs: Nittaya Phanuphak, MD TRCARC 104 Rajdumri Road, Pathumwan Bangkok 10330, Thailand Email: nittaya.p@trcarc.org Office phone: +662 253 0996 to 7 Mobile phone: +6681 825 3544 Somsit Tansuphaswadikul, MD BIDI 126 Tiwanon Road, Muang Nonthaburi 11000, Thailand Email: somsittan@gmail.com Office phone: +662 590 3631-2 Mobile phone: +6689 478 3003 Wisit Prasithsirikul, MD BIDI 126 Tiwanon Road, Muang Nonthaburi 11000, Thailand Email: drwisit_p@yahoo.com Office phone: +662 590 3631-2 Mobile phone: +6681 811 5610 B. United States Principal Investigator / Protocol Chair: Irini Sereti, MD, MHS Division of Clinical Research, NIAID, NIH Bldg 10, Rm 11C103 (MSC 1880) 10 Center Drive Bethesda, MD 20892 Email: ISereti@niaid.nih.gov Phone: 301-496-5533 June 2, 2011 2. OTHER THAILAND SITE STAFF A. Associate Investigators Nipat Teeratakulpisarn, MD TRCARC 104 Rajdumri Road, Pathumwan Bangkok 10330, Thailand Email: tnipat@trcarc.org Office phone: +662 253 0996 to 7 Mobile phone: +6681 792 6220 Thep Chalermchai, MD SEARCH and TRCARC 104 Rajdumri Road, Tower 2, 2nd floor Pathumwan, Bangkok 10330, Thailand Email: thep.c@searchthailand.org Office phone: +662 254 2566 to 9 Mobile phone: +6681 555 2552 Alex Schuetz, PhD AFRIMS, Retrovirology 315/6 Rajvithi Road, Bangkok 10400, Thailand Office phone: Mobile phone: +6685 980 2464 B. Nurse Coordinator Nitiya Chomchey, RN SEARCH and TRCARC 104 Rajdumri Road, Tower 2, 2nd floor Pathumwan, Bangkok 10330, Thailand Email: nitiya.c@searchthailand.org Office phone: +662 254 2566 to 9 Mobile phone: +6686 322 3522 C. Local Medical Monitor Somchai Sriplienchan, MD, MPH Department of Retrovirology USAMC-AFRIMS 315/6 Rajvithi Road Bangkok, 10400, Thailand Email: SomchaiS@afrims.org Office phone: +662 644 4888 ext. 3415 3. LOCAL INSTITUTIONAL REVIEW BOARDS (IRB) Chulalongkorn University FWA #00008378 Research Section, Faculty of Medicine Chulalongkorn University 1873 Rama IV, Pathumwan, Bangkok 10330, Thailand. Tel +662 256 4455 Ext 14, 15 89 Thailand Site Specific Addendum June 2, 2011 Department of Disease Control (DDC), Ministry of Public Health FWA # 00013622 Tiwanond Road, Nonthaburi 11000, Thailand Tel +662 590 3175 Fax +662 965 9610 90 Thailand Site Specific Addendum June 2, 2011 2. THAILAND SITE DESCRIPTION A. General Overview Site and Population Description (Figure 1) The coordinating unit for this study will be the South East Asia Research Collaboration with Hawaii (SEARCH) in Bangkok, Thailand. SEARCH is a subunit of the Thai Red Cross AIDS Research Centre (TRCARC) and a collaboration between the US Armed Forces Research Institute of Medical Sciences (AFRIMS), the University of Hawaii and the TRCARC. Two clinical sites will be used for this study to recruit and follow subjects. These are 1) the Thai Red Cross Anonymous Clinic (TRC-AC) which is a subunit of the TRCARC situated in the same complex as SEARCH. Radiologic or invasive investigations will be done at Chulalongkorn University Hospital, a sister organization of the TRCARC, which is next door to the TRCARC. 2) Bamrasnaradura Infectious Disease Institute (BIDI) which is the largest HIV and infectious hospital in Thailand. TRCARC and SEARCH have long term relationship and track record in collaborating with BIDI for various HIV-related studies. The laboratories involved in this study will be 1) the HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT) Laboratory. HIV-NAT is a subunit of the TRCARC and is located within the same complex as SEARCH and TRC-AC. HIV-NAT will perform all laboratories for this study and for both clinical sites 2) AFRIMS laboratory which will perform the advanced flow cytometry and store samples. Figure 1: Relationship between coordinating unit, clinical sites and laboratories involved South East Asia Research Collaboration with Hawaii (SEARCH) SEARCH was established in 2005 and has been the coordinating center for USHMRP’s research studies on acute HIV infection, HIV sequencing in high risk populations and HIV vaccine cohort One of the SEARCH studies, RV 254/SEARCH 010 study: “Establish and characterize an acute HIV infection cohort at the TRC-AC”, is described in more detail here. 91 Thailand Site Specific Addendum June 2, 2011 The study will evaluate the clinical, immunological, and virological characteristics of persons with acute HIV infection and describe demographics and behavioral risk factors for HIV. Optional study procedures performed in this study include leukopheresis, gut biopsy, cerebrospinal fluid collection and brain MRI/MRS and anogenital sample collection. As of December 2009, there are 15 acute HIV infection cases identified with 10 cases enrolled. This study shows the capability of SEARCH to coordinate a complicated study with its partners (TRC-AC, HIV-NAT laboratory, AFRIMS laboratory, Chulalongkorn University Hospital). Dr. Jintanat Ananworanich, the principal investigator of this study, is Chief of SEARCH and Deputy Director in Scientific Affairs at HIV-NAT and staff physician at the TRC-AC. Therefore, she is in the position to ensure a smooth collaboration between the 3 subunits within the TRCARC. Thai Red Cross Anonymous Clinic (TRC-AC) The TRC-AC was established in 1991 as the first voluntary counseling and testing (VCT) clinic in Thailand and in the region. Clients with HIV infection can receive services which include latent and active tuberculosis case finding, CD4 count, HIV RNA, genotypic drug resistance testing, ARV treatment and monitoring. In 2007, there were 6,125 new clients (32% women, 54% heterosexual men and 14% men who have sex with men, MSM) and the overall HIV prevalence rate was 15% (women 14.5%, heterosexual men 11.3%, MSM 30.1%). During 2006-2009, 2,647 clients were diagnosed with HIV infection. Percentage of these clients who had CD4 cell count < 200 cells/mm3 was 35.3%, 27.6% and 46.9% in women, men who have sex with men and heterosexual men, respectively. HIV-NAT laboratory The HIV-NAT laboratory facility comprises approximately 1,184 square ft of space. The laboratory has the capacity to perform diagnostic immuno-assays for HIV, HBV, HCV, syphilis, cell immunophenotyping by flow cytometry, HIV RNA quantitation, HIV DNA PCR, p24 antigen, PCR for Chlamydia, gonorrhea, haematology, chemistry, pharmacokinetics, and molecular biology-related techniques. The external quality assurance programs participated include the UKNEQAS (UK national external quality assurance scheme), the College of American Pathologists (CAP), the Virology Quality Assessment Program (VQA) from Rush Presbyterian-St. Lukes Medical Center Chicago, Illinois and the Walter Reed Army Institute of Research. The Cobas IT 5000 Solution laboratory information system is used. The laboratory currently employs 7 full-time medical technologists, one part time medical technologist, three assistant technologists, one scientist and one pharmacologist in addition to a full-time manager. Bamrasnaradura Infectious Disease Institute (BIDI) The BIDI was designated by the Ministry of Public Health in 1987 as country’s premier hospital for HIV/AIDS patients. With the country’s roll-out of antiretroviral (ARV) treatment in 2000, the mortality rate for HIV patients in the BIDI has decreased from 33% in 1999 to around 16% in the recent years. Approximately 50,000 services are currently provided at the HIV out-patient clinic and approximately 1,500 services are provided at the HIV in-patient clinic each year. Approximately 6,000 patients are currently receiving ARV at the BIDI with around 400-500 patients eligible to start ARV each year. For this study, the BIDI will be responsible for recruiting the participants from its out-patient and in-patient units and performing study procedures. B. HIV and Opportunistic Infections in Thailand 92 Thailand Site Specific Addendum June 2, 2011 Currently, the prevalence of HIV infection in Thailand is 1.2% of adults with about 550,000 Thais living with HIV. The majority of Thailand’s HIV infections are reported to be through heterosexual transmission, followed by male homosexual transmission. The five most common opportunistic infections among HIV/AIDS patients in Thailand are Mycobacterium tuberculosis (30.3%), Pneumocystis carinii pneumonia (20.0%), cryptococcosis (14%), candidiasis of esophagus, trachea or bronchi (4.9%) and recurrent bacterial pneumonia (3.4%). C. HIV Prevention, Care, and Treatment Targeted prevention campaigns carried out in Thailand have significantly reduced HIV incidence and prevalence with the number of new HIV infections per year reduced from over 140,000 in the early 1990s to about 14,000 in 2007. In 2000, Thailand started the roll-out of ARV. In 2007, Thailand’s ARV coverage was about 60% with over 100,000 Thais receiving ARV. This has led to substantial reductions in the number of HIV-related deaths. All Thai nationals can access ARV and HIV-related treatments at no cost through the National Health Security Office (NHSO), the Social Security Office (SSO) or the Civil Servant Medical Benefit Scheme (CSMBS). D. Roles of Researchers The study will be coordinated by SEARCH. All participants in this study will be enrolled from the TRC-AC and the BIDI. Both sites will provide out-patient HIV care and in-patient care will be provided mainly at the BIDI. Subjects at the TRC-AC site may also be hospitalized at Chulalongkorn University Hospital. HIV-NAT and AFRIMS laboratories will perform all lab tests for this study. 3. INFORMED CONSENT PROCESS Information sheets for the main protocol and the optional procedures (leukapheresis, gut biopsy, genital secretion collection and genetic (HLA) testing) along with the consent forms will firstly be prepared in English and translated into Thai with IRB approval. Interested subjects will be approached by study staff at the TRC-AC and BIDI sties. No study procedures will occur prior to the subject giving informed consent. 4. SUBJECT ENROLLMENT AND FOLLOW-UP One hundred participants with advanced HIV (CD4 count <100 cells/mm3) will be recruited over 1 year. These patients will form part of a global cohort of 500 patients across three worldwide sites, created to provide degrees of power for primary analysis as described in section 10.1 (main protocol). The patients will be distributed between the US, Kenya and Thailand in a 1:2:1 ratio respectively, determined for reasons of logistical and recruitment practicality. Thai participants will be recruited primarily from the TRC-AC and the out-patient and in-patient wards at the BIDI. Recruitment will occur primarily in the clinics, by poster and flyers and by word of mouth. They will be followed according to the Thailand National Antiretroviral Treatment Guidelines for routine HIV care and treatment at both sites, and anti-retroviral therapy recommended as per those guidelines. The investigators will not be responsible for the cost of anti-HIV treatment, which will be funded by the nationwide government program for Thai citizens. Study participants will be considered as "lost to follow-up" if they are not reviewed as per protocol for a contiguous period of at least six months following their most recent study visit. Study participants who are lost to follow-up will be discontinued from the study. Management of any clinical presentations compatible with IRIS will include a full work-up to 93 Thailand Site Specific Addendum June 2, 2011 exlude other diagnoses and further investigation and treatment as clinically indicated and according to local guidelines and practice. 5. TUBERCULOSIS WHO data estimates the prevalence of all forms of TB in Thailand at 192 per 100,000 in 2007. All Thai study participants, regardless of prior TB status, will undergo a tuberculosis purified protein deriative (PPD) test (Thai Red Cross Tuberculin PPD Preparation) at study entry and at weeks 48 and 96. If PPD is negative at baseline, it will also be repeated at either week 4 or 8. The PPD test will be administered and interpreted by a trained nurse, with a reading of raised induration greater than 10mm in diameter at 48 hours after administration considered as positive. 6. SCHEDULE OF EVENTS The schedule of events is shown in Table 1. Optional procedures which require a separate consent form include 2-pass apheresis, gut biopsy, genital secretion collection and HLA testing. The study will complete in 96 weeks. The study visits will be at weeks 2, 4, 8, and 12 after the baseline visit, every 12 weeks until week 48 and every 16 weeks thereafter until the end of the study. 7. DESCRIPTION OF OPTIONAL PROCEDURES i. Gut Biopsy Gut biopsies will be performed in patients who consent for this procedure at the Chulalongkorn University Hospital, 500 meters from the TRCARC, by a gastroenterologist. Biopsy specimens will be cryo-preserved for transcriptional analysis and immunohistochemistry and collected in RPMI medium 1640 (Invitrogen) for flow cytometric analysis. Phenotyping of colon lymphocytes using fresh lymphocytes and multi-parameter flow cytometry may include the following panels: Activation: CD3/CD4/CD8/HLA-DR/CD38; Memory: CD3/CD4/CD8/CD/27/CD45RO/CCR5 and T reg: CD3/CD4/CD8/CD25/FoxP3/Ki67. HIV RNA in tissue will be determined by real time PCR. Other HIV-specific immune responses may also be evaluated. ii. Leukapheresis Leukapheresis will be performed to collect PBMCs and plasma storage at study entry and weeks 12 and 48 at the Chulalongkorn University Hospital by an experienced apheresis technician using a continuous flow apheresis device. During leukapheresis, whole blood will be withdrawn from a peripheral vein and channeled into a cell separator where the cellular factions are separated by centrifugation. The lymphocyte fraction is directed into a collection bag and the red cells and platelets are returned to the patient. The cell separator kit is anticoagulated with sodium citrate. Some plasma from leukapheresis will be stored. The blood volume loss from red blood cell loss and plasma storage wil be about 50ml. The procedure takes about 2-3 hours and requires one or two needle access sites. Leukapheresis will allow the collection of between 5 x 109 to 10 x 109 PMBCs while minimizing the total blood volume taken from participants. Each leukopac (bag of white cells) will be sent to the TRCARC for PMBC isolation. PBMCs will be divided into aliquots and cryopreserved (-135°C or lower) within 8 hours. Subjects who wish to not have leukapheresis will have phlebotomy of 64ml instead for each of the leukapheresis visits. iii. Genital Secretion Collection In volunteers who consent for this procedure, the following genital secretion(s) will be collected at the TRCARC by the study investigator or study nurse: semen (in men), anal 94 Thailand Site Specific Addendum iv. June 2, 2011 wash and swab (in MSM), cervicovaginal wash and vaginal swab (in women). Collection of genital secretions allows direct study of the cellular and cytokine immune response to HIV infection in the genital compartment and allows assessment of response to treatment in this compartment also. This will permit correlation of genital compartment immunopathogenesis and disease progression with possible newly or increasingly symptomatic underlying sexually transmitted infections compatible with IRIS. HLA testing The goal of HLA testing is to study what types of genetic coding are associated with better or worse HIV disease, response to HIV drugs and the occurrence of IRIS There is no extra blood draw from volunteers who consent for this procedure. The testing will be done at a later time and will be done using stored PBMC, which are already drawn as part of the main study. 8. LABORATORY EVALUATIONS FOR STUDY PARTICIPANTS The HIV-NAT laboratory will perform all laboratory investigations for this study and for both TRC-AC and BIDI clinical sites. The AFRIMS laboratory will perform the advanced flow cytometry and will store samples. Some samples will be sent to NIH for additional testing which may include, but may not be limited to, immunohistochemistry of gut tissue to assess lymphocyte subsets, and full-length, single genome analysis of viral sequences and host factors from peripheral blood and genital compartments and colon. 9. DATA MANAGEMENT PLAN Case report forms (CRF) will be provided for each participant and used in accordance with Good Clinical Practices. Data from CRF will be double-data entered and compiled in an electronic database at SEARCH. Data from this protocol will be retained for at least 5 years after study completion. The data manager will be responsible for data storage. 10. ANALYSIS OF DATA This study is designed to investigate the predictors, incidence, clinical presentation and immunopathogenesis of infective IRIS occuring within the first six months of antiretroviral therapy. Section 10 (main protocol) describes the primary and secondary statistical analyses that wil be used to evaluate the data obtained. The use of multivariate Cox regression analyses will minimize the influence of confounding variables, such as gender, age and risk behaviours (including intravenous drug use). 11. RETENTION OF STUDY SAMPLES Biological samples will be stored for a period not exceeding five years from the date of patient enrollment. If samples are required beyond this date, approval for renewal of sample storage will be sought, Samples will be kept at the TRCARC in Bangkok and/or the National Institutes for Health storage facilities in the United States. 12. STUDY RISKS AND BENEFITS Potential risks associated with the main study procedures include risks from phlebotomy, namely: pain, bruising, (pre)syncope and the small chance of infection. There are risks associated with the optional study procedures. These risks mainly include hypocalcemia related to apheresis; gas pain, slight bleeding and intestinal perforation and infection from gut biopsy, an uncomfortable feeling or irritation related to genital secretion collection, and a very small risk that the information from genetic testing becomes known to others. The screening visit chest x-ray involves exposure to a radiation dose of approximately 0.029rem (or approximately equal to 10 days background radiation exposure). The benefits of this observational study are primarily the accumulation of knowledge about IRIS that may inform 95 Thailand Site Specific Addendum June 2, 2011 future management of this condition. Study participants may also benefit from more frequent contact with and review by healthcare providers, which may result in patient worries being addressed earlier than is usual for non-study participants. 13. PREGNANCY Male study participants will be offered free condoms. Female study participants of child bearing potential will be offered free condoms and hormonal contraception. Females who are pregnant at the time of screening will be excluded from the study; those who become pregnant during the course of the study will not be excluded and the investigators will coordinate with their doctors to ensure that they receive appropriate obstetric and prevention of mother to child transmission care. Pregnant study participants will not be offered the following optional procedures: gut biopsy, leukapheresis and collection of genital secretions, during the gestation and 12 month post-delivery period. 14. STUDY MONITORING The study will be monitored by a designated research nurse to ensure correct completion, compliance and accuracy of informed consents and serious adverse event reports. Monitoring will take place on a regular basis at intervals of not more than three months starting from enrollment of the first two patients. The investigators will assist study monitoring by making available all relevant documentation (including, but not limited to: informed consent forms, clinical records and results of laboratory, radiological or other clinical investigations). The monitor will issue a report following the completion of each monitoring visit. 15. REPORTING TO IRBs A continuing review report, a final report, serious adverse event (SAE) report, any report on protocol modifications and report on protocol deviations will be submitted to the IRBs overseeing this study according to standard requirements and regulations. 16. CONFIDENTIALITY AND STORAGE OF DOCUMENTS Each study participant will be provided a study identification number to be used for all laboratory tests or samples stored for testing in future studies. Personal identification information will be kept locked with access limited to study personnel only. Study records may be reviewed by IRBs or regulatory bodies having overview or as required by law. 17. POLICY REGARDING RESEARCH-RELATED INJURIES In the event of an injury resulting directly from participation within this study, the study site will provide access to immediate treatment. The costs of short-term treatment (of a duration not exceeding six months) for injuries deemed to be directly related to study participation will be borne entirely by the study site. Advice regarding access to any necessary longer-term care will be given to the patient. No compensation is offered for illness or injury. It will be explained to the volunteer that in taking advantage of this policy, he/she does not give up or waive his/her statutory rights. In the event of a presumptive research-related injury, subjects should in the first instance contact the responsible study nurse. 96 Thailand Site Specific Addendum June 2, 2011 Table 1: Schedule of Events Evaluation Screening ART1 (-28 days) (Week 0) Documentation of HIV X Medical & Medication History X Nadir CD4 Count X Clinical Assessment X Exam3 CBC and Differential (2ml) Week 36 Week 48 X X X X X X X X X X Week 80 X X X Week 96 (EOS) X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X Weeks 64 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X TSH and free T4 (3ml) Hepatitis B, C Antibody Screen (3ml) Cryptococcal Serum Ag and Toxoplasma Serology (3ml) Histoplasma Urine Ag PPD4 X X X X X Anal Pap Week 24 X ALT, GGT , T/d Bili (2ml) Glucose, TG, Chol, LDL, HDL (fasting) (2ml) CD4 % and Count (2ml) Advanced flow cytometry (2ml) HIV-RNA (5ml) Smear5 Week 12 X X Cervical Pap Week 8 X Bun/Cr, Electrolytes (2ml) Smear5 Week 4 X Body Mass Index (BMI)2 Physical X Week 2 X X X X X X X X X X X X X X X X X X X X X X 1: An elective hospital admission may be scheduled for the entry visit to facilitate testing and for participant’s convenience. Testing of the entry visit may be completed in more than one day. 2: BMI= weight (kg) divided by [height x height (cm)] 3: All visits will require a medical doctor (MD) visit. 4: PPD will be repeated at week 4 or 8 only if negative at baseline. If PPD negative at baseline and week 4, it will be repeated yearly (at weeks 48 and 96). 5: Cervical Pap smear will be performed in women. Anal Pap smear will be performed in participants with history of receptive anal sex as per standard clinical practice in the clinic. The first Pap smear can be delayed up until week 4 of study and will be repeated as clinically indicated or at weeks 24, 48 and then yearly according to local practices. 97 Thailand Site Specific Addendum June 2, 2011 Schedule of Events (continued) Evaluation Screening (-28 days) Study Entry1 (-27 to 0 days) Week 2 Week 4 Week 8 Mycobacterial Blood Cx (5ml) Week 12 Week 24 Week 36 Week 48 Week 64 As clinically indicated Week 80 RPR, FTA-ABS (2ml) X ECG X Chest X-Ray X HLA-typing (Optional) X Stored PBMC/Plasma6 (52ml) X X X X X X X X X X X X X X X X X X X X Stored Serum6 (12ml) X Week 96 (EOS) (Optional)7 X X GI Biopsy (Optional) Genital Secretion Collection (Optional) Amylase or Lipase (2ml) X X X As clinically indicated Urinalysis X As clinically indicated Pregnancy Test X As clinically indicated Genotyping (6ml) X As clinically indicated Examination8 X As clinically indicated 2-pass Apheresis Eye X X X X X X X For skin or mucosal lesions that require close follow up Photography9 Total Blood Volume X As clinically indicated (ml)10 4 36+64 13+64 13+64 11+64 15+64 17+64 17+64 19+64 11+64 13+0 19+64 6: 64ml of blood will be drawn for storage of PBMCs and serum, except at weeks 0, 12 and 48 where this will be replaced by apheresis for patients who have elected to and are permitted to undergo this procedure. 7: If adequate venous access and Hg >9g/dl, PLT >50,000 and not pregnant for female participants. 8: And every 24 weeks thereafter until CD4 >100 cells/µL for >12 weeks or as clinically indicated. 9: Skin or mucosal lesions that require close follow up (i.e. Kaposi’s sarcoma [KS] lesions, skin, or genital warts). 10: Calculated as the sum total of blood drawn for non-optional procedures at each study visit. Expressed as the volume of blood required from all patients (first figure) plus any extra required from patients who elect not to undergo apheresis (second figure). 98
