CONRAD’s Cellulose Sulfate HIV Prevention Trial Dr. Lut Van Damme On behalf of The CS Phase III Study Team

Preclinical Testing CS was tested in different models with different endpoints and using several strains of HIV and showed in vitro effectiveness Preclinical testing in the rabbit vaginal irritation model, in monkeys, or explants gave no indication for potential of harm; no increase in pro-inflammatory markers

Conclusions from safety studies and contraceptive trial in women Ten safety studies in women and two contraceptive trials No difference in symptoms, colposcopy findings, vaginal infections, systemic labs, or cytokines when compared with KY Jelly Increase in E. coli in the CS group and decrease in Lactobacillus H202+ in both groups: Both changes have been previously reported with the use of other products Effective contraceptive with few adverse events related to gel use Also two male tolerance studies were done.

HIV Prevention Trial

Objectives and Endpoints Primary: Effectiveness in preventing male-to-female transmission of HIV-infection through vaginal intercourse by comparing HIV incidence in both arms (ITT) Secondary: Effectiveness in preventing male-to-female transmission of gonorrhea and chlamydia infection through vaginal intercourse by comparing the incidence in both arms (ITT – time to first event)

Design and Population Design: Randomized (1:1 allocation), placebo-controlled, blinded, two-arm, multicenter Study Population: HIV negative women, 18 years or older, with multiple partners Randomization used permuted blocks, stratified on site.

Organizational Chart and Sites BENIN PI- Michel Alary Co-PI- Fernand Guedou INDIA-CH PI- Suniti Solomon CONRAD FHI ITM INDIA-BA PI- Marissa Becker Co-PI- Reynold Washington UGANDA PI- Florence Mirembe Mention roles of FHI (monitoring; DM/DA; BSS; audits) and ITM; IDMC SOUTH AFRICA PI- Roshini Govinden Co-PI- Gita Ramjee

Placebo & Gel Delivery Placebo: “Universal” placebo specially developed to have “no” effect on pathogens or microflora Gel delivery: Single use opaque applicators, delivering 3.5ml Gels were to be used within one hour before each vaginal intercourse The placebo has been specifically developed for microbicide trials and is used in other trials as well. It has been tested for safety by CONRAD.

Procedures Informed consent with questionnaire Monthly clinic visits HIV tests: screening, enrollment, FU1, 3, 6, 9 and 12 (final) Pelvic exams: quarterly Tracing of participants Behavioral and Social Science work Repeat ICQ every quarter; monthly visits: questions on compliance, AE collection and condom/gel counseling and distribution

Lab Endpoints Testing HIV Gonorrhea and Chlamydia: SDA testing Screening and enrollment: national/local algorithm Follow-up: Rapid tests: Determine, Bioline, Unigold on finger prick blood; second venous sample if first algorithm positive Final sample: PCR (except for Bangalore) Gonorrhea and Chlamydia: SDA testing QC program: all positive and 10% of negative samples; most HIV seroconversions confirmed by ITM Diagnose pas na twee stalen pos; SDA because of inhibition. Voor 4 seroconvertors in Durban geen bevestiging in Antwerpen.

Sample Size and Power Planned sample size = 2,574 HIV negative women Assumptions: 50% effectiveness of CS 2-sided significance level of 0.05 80% power 80% of participants completing 12-month follow up HIV-incidence in control arm: 4% 66 events required

(Interim) Analysis and IDMC One planned interim analysis with Independent Data Monitoring Committee meeting after ~ 33 HIV seroconversions - 26 January 2007 Guidance from the IDMC requested if p<0.10 in the direction of harm (i.e. stop for harm or futility)

Population Tree Screened 2985 Enrolled 1428 CS Placebo Total 3 PCR Positive CS Placebo Total ITT population 717 708 1425 HIV analysis 706 692 1398 Lost to follow-up 10.7% 9.0% 9.9% Discontinued early 2.4% 1.0% 1.7% Completed final visit 86.9% 90.0% 88.4% Screening/enrollment started in July 2005; last visit on 31 March 2007. Staggered start of sites. Women excluded from primary HIV analysis when no HIV FU test (10 LFU and 1 early disc. on CS, 15 LFU and 1 early disc. on placebo).  98.1% contributed data to the effectiveness analysis. Data base is still not 100% final. Some queries have not been answered yet, no effect on HIV # but may slightly change incidence. LTFU: benin: 24%; SA:11%; Ug: 5%; almost zero in India.

Baseline characteristics Placebo Age (years) 30.3 30.9 Education (years) 7.8 Ever pregnant 90.0% 92.5% Married 22.7% 23.2% Vaginal acts in past 7 days 11.6 11.0 Condom use (screening) 60.7% 61.3% Condom use (enrollment) 81.3% 80.8%

Results Events RR (95% CI) Two-sided p value CS Placebo HIV (Interim) 24 11 2.23 (1.05, 5.03) 0.022 HIV (ITT - Final) 25 16 1.61 (0.86, 3.01) 0.135 HIV (per protocol) 23 2.17 (1.06, 4.45) 0.030 Gonorrhea 53 49 1.10 (0.74, 1.62) 0.634 Chlamydia 37 52 0.71 (0.47, 1.08) 0.111 Conditional power < 1% Data on adherence were presented this morning No PCR for BA. Incidence: CS 5.3 – P:3.34 – overall: 4.31

KM Estimates of Incident HIV Infection Probabilities, by Treatment Group Placebo CS

Conclusion CS is not effective against HIV transmission All polyanions are different, two other trials are ongoing and passed several IDMC meetings The field may learn from this experience if further exploration leads to potential markers of no effect/increased risk A range of HIV prevention tools/products needed

Possible biological causes of CS clinical failure Hypothesis I. CS stimulates HIV capture through DC sign interaction Hypothesis II. Repeated and frequent exposure of cervicovaginal mucosa to CS causes a subclinical inflammatory reaction or local immune dysfunction Hypothesis III. Repeated daily administration of CS causes microflora disturbances and/or pathogenic outgrowth Do not mention Balzarini

Plans Explore phase III data base Send panel of blinded products to different laboratories for further testing Analyze self-collected vaginal swabs Evaluate data from ongoing monkey study Initiate safety study in 60 women in the USA (Norfolk and Pittsburgh)

Sponsors and Collaborators Sponsors: USAID and Bill & Melinda Gates Foundation CS PHASE III TEAM South Africa Team Medical Research Council Gita Ramjee Roshini Govinden Vinodh Edward Raju Evasen Rashika Maharaj Uganda Team Makerere University Medical School Florence Mirembe Clemensia Nakabiito Bina Pande Tom Tenywa Benin Team Centre hospitalier Affilié Universitaire de Québec Michel Alary Fernand Guédou Isaac Minani Marguérite Massinga Loembé CONRAD Team Lut Van Damme Suzanne Murphy Louisa Wahala Laria Jones FHI Doug Taylor Jennifer Deese Lisa Saylor Wes Rountree Betsy Tolley And Monitors ITM Tania Crucitti Said Abdellati Katrien Fransen Greet Beelaert Vicky Cuylaerts Chennai Team Y R Gaitonde Medical Education & Research Foundation Suniti Solomon Aylur K. Ganesh A K Srikrishnan Sethulakshmi C. Johnson Murugavel G. Kailapuri Bangalore Team University of Manitoba/St. John’s Medical College Marissa Becker B S Pradeep Reynold Washington Stephen Moses Satya Narayana Kevin Mendonca