1. Protocol Requirements for Product Holds/Discontinuations MTN-025

2. Objectives  Identify the conditions that would require a product hold or discontinuation  Review conditions that require follow up per protocol before product resumed

3. Product Hold vs. Permanent Discontinuation  Some product holds will be temporary, with product use resumed after time has elapsed Pregnancy, for example  Some holds will turn into permanent discontinuations Positive rapid HIV test, confirmed, for example  All are clinical, that is, initiated by study staff

4. Criteria for Permanent Discontinuation of Study Product  A participant will be permanently discontinued from VR product use automatically Acquisition of HIV-1 infection (confirmed) Allergic reaction to the VR

5. Acquisition of HIV-infection  Initiate product hold IMMEDIATELY with first reactive rapid HIV test (on same day as result)  If the participant is determined to be HIV- uninfected, resume product use  Permanently discontinue the study VR if HIV-1 infection is confirmed

6. General Criteria for Automatic Product Hold Initiation  Reactive rapid HIV test  Pregnancy (per positive urine test result)  Breastfeeding (per ppt report)  Ppt report of use of PEP for HIV exposure  Grade 3 related AE  Grade 4 AE, regardless of relationship to study product  Participant is unable or unwilling to comply with required study procedures, or otherwise might be put at undue risk to their safety and well-being by continuing product use, according to the judgment of the IoR/designee*

7. Guidance with Regard to AEs  General guidance  Specific AEs addressed in section 9.5  Sexually Transmitted Infections

8. 8 HOPE Product Use Management: HIV Infection no rapid test(s) positive CONTINUE product. HOLD product pending confirmatory testing. PERMANENTLY DISCONTINUE product. HIV rapid tests one or more rapid tests positive status after confirmatory testing = HIV infected RESUME product. status after confirmatory testing = HIV uninfected START Protocol Reference: Section 9.3 and 9.6 If confirmatory HIV testing is unclear; contact the Network Laboratory for guidance.

9. 9 Protocol Reference: Section 9.3 HOPE Product Use Management: Allergic Reaction to the Vaginal Ring PERMANENTLY DISCONTINUE product.

10. 10 HOLD product until negative pregnancy test AND pelvic exam confirms absence of findings that contraindicate resumption. Protocol Reference: Sections 9.3 and 9.7 * After a pregnancy hold, VR use should not be resumed earlier than 2 weeks after a 1st trimester loss, or earlier than 4 weeks after 2nd trimester (or later) pregnancy loss or delivery. Product restart timelines should begin when the pregnancy is lost (i.e., bleeding, elective termination, etc). This restart timeline should only be based off a negative pregnancy test if the date of pregnancy loss is completely unknown. Only resume if not breastfeeding. HOPE Product Use Management: Pregnant

11. 11 HOPE Product Use Management: Breastfeeding HOLD product until participant reports complete cessation of breastfeeding. Protocol Reference: Section 9.3

12. 12 HOLD product until participant reports completion of PEP AND she is confirmed HIV-negative at the study site per protocol Appendix III. HOPE Product Use Management: PEP Protocol Reference: Section 9.3

13. 13 HOPE Product Use Management: Grade 1 and Grade 2 Adverse Events no CONTINUE product. AE addressed in protocol section 9.5? yes Follow relevant protocol section Protocol Reference: Section 9.4

14. 14 HOLD product. Re-evaluate at least weekly for up to 2 weeks. RESUME product. If same grade 3 AE recurs, HOLD product and CONSULT PSRT. HOPE Product Use Management: Grade 3 Adverse Events AE addressed in protocol section 9.5? yes Follow relevant protocol section Assess AE relationship to product remains grade >2 after 2 weeks of hold grade ≤2 within 2 weeks after initiating hold no CONTINUE product. not related related START Protocol Reference: Section 9.4 Consult PSRT

15. 15 HOPE Product Use Management: Grade 4 Adverse Events no AE addressed in protocol section 9.5? yes Follow relevant protocol section HOLD product. CONSULT PSRT. Protocol Reference: Section 9.4 *Temporary product hold must continue until a recommendation is received from the PSRT.

16. 16 HOPE Product Use Management: Sexually Transmitted Infections and Reproductive Tract Infections CONTINUE product, unless other product hold guidelines apply. Consult the PSRT if a temporary hold is deemed necessary and instituted by the IoR/designee. Protocol Reference: Section 9.5 Observed single dose treatment should be provided whenever possible, per clinician discretion. When clinically appropriate, investigators should use oral or parenteral (in the case of syphilis, for example) medications when at all possible.

17. 17 HOPE Product Use Management: Superficial epithelial disruption (abrasion/ peeling) CONTINUE product Protocol Reference: Section 9.5 If condition worsens, temporarily HOLD product and consult the PSRT Re-evaluate by speculum exam 3- 5 days Has condition worsened? no yes CONTINUE product.

18. 18 no Continue to HOLD product. CONSULT PSRT. Treat per local standard of care. Protocol Reference: Section 9.5 yes RESUME product. HOPE Product Use Management: Deep epithelial disruption (ulceration) Re-evaluate within 2-3 days. Has the AE resolved? Remove vaginal ring and if confirmed deep epithelial disruption by IoR/designee HOLD product. Re-evaluate in 3-5 days. Has the AE resolved? yes no RESUME product. Has the AE recurred? no CONTINUE product. yes HOLD product. CONSULT PSRT.

19. 19 no HOLD product. CONSULT PSRT. Treat per local standard of care. Protocol Reference: Section 9.5 yes Re-evaluate at next scheduled visit HOPE Product Use Management: Localized erythema or edema (area < 50% of vulvar surface or combined vaginal and cervical surface) Re-evaluate by speculum in 3-5 days. Has condition worsened? CONTINUE product Is the participant asymptomatic? yes no CONTINUE product.

20. 20 no Continue to HOLD product. CONSULT PSRT. Treat per local standard of care. Protocol Reference: Section 9.5 yes RESUME product. HOPE Product Use Management: Generalized erythema or severe edema (area > 50% of vulvar surface or combined vaginal and cervical surface affected by erythema) Re-evaluate within 2-3 days. Has the AE resolved? HOLD product and perform naked eye exam. Re-evaluate in 3-5 days. Has the AE resolved? yes no RESUME product.

21. 21 HOPE Product Use Management: Unexpected genital bleeding CONTINUE product and perform naked eye exam Protocol Reference: Section 9.5 *If determined to be due to deep epithelial disruption, refer to those guidelines; otherwise continue study product use

22. 22 HOPE Product Use Management: Cervicitis (including findings on exam such as inflammation and/or friability) HOLD product and evaluate for GC/ CT* Positive for GC/ CT? yes Provide treatment and re-evaluate after 3-5 days. All signs and symptoms resolved? Protocol Reference: Section 9.5 *Consider syndromic management pending results of testing and per clinician discretion. RESUME product. no Re-evaluate 3-5 days after exam. All signs and symptoms resolved? yes no CONSULT PSRT. CONSULT PSRT. no yes

23. 23 HOPE Product Use Management: Genital petechia(e), genital ecchymosis CONTINUE product and perform naked eye exam Protocol Reference: Section 9.5 * Further evaluation or treatment per clinician discretion.

24. 24 HOPE Product Use Management: Study compliance & Safety concerns  HOLD product if a participant: is unable or unwilling to comply with required study procedures, or might be put at undue risk to her safety and well-being by continuing product use, according to the judgment of the IoR/ designee.  CONSULT the PSRT on all product holds instituted for this reason for further guidance on resuming product use, continuing the temporary hold, or progressing to permanent discontinuation.  If the underlying reason for the product hold resolves, CONSULT the PSRT to resume study product at that time. Protocol Reference: Section 9.8

25. 25 HOPE Product Use Management: CO-ENROLLMENT  If co-enrollment in another study is identified, obtain as much information as possible about the other study from the participant and the other study team.  HOLD product upon identification of co-enrollment unless the other study is known to not involve a study product and/or confirmation is available from the other study team that the participant is not using another study product.  CONSULT the PSRT on further management of the participant.  Schedule the participant to return when a response from the PSRT is expected. Protocol Reference: Section 5.6