1. A Phase II, Randomized, Placebo-Controlled Study of Once-Weekly Alendronate in HIV- Infected Subjects with Decreased Bone Mineral Density Receiving Calcium and Vitamin D Grace A McComsey, Michelle A Kendall, Pablo Tebas, Susan Swindells, Evelyn Hogg, Beverly Alston-Smith, Carol Suckow, Geetha Gopalakrishnan, Constance Benson, and David A Wohl on behalf of the ACTG A5163 team

2. Background Decreased bone mineral density (BMD) is prevalent among persons living with HIV infection, as are traditional risk factors for reduced BMD. Decreased bone mineral density (BMD) is prevalent among persons living with HIV infection, as are traditional risk factors for reduced BMD. Alendronate is a bisphosphonate that inhibits osteoclast-mediated bone resorption and is FDA- approved for the treatment of osteoporosis in men and women. Alendronate is a bisphosphonate that inhibits osteoclast-mediated bone resorption and is FDA- approved for the treatment of osteoporosis in men and women. Small open-label studies of alendronate in combination with calcium and vitamin D in HIV+ individuals suggested the drug increases lumbar spine BMD and is well tolerated (Guaraldi 2004; Mondy 2005; Negredo 2005). Small open-label studies of alendronate in combination with calcium and vitamin D in HIV+ individuals suggested the drug increases lumbar spine BMD and is well tolerated (Guaraldi 2004; Mondy 2005; Negredo 2005).

3. Study Design A5163 is a 48-week prospective, randomized, double blinded, placebo-controlled trial to evaluate the effects of alendronate versus placebo, with calcium and vitamin D supplementation, on BMD in patients with HIV. A5163 is a 48-week prospective, randomized, double blinded, placebo-controlled trial to evaluate the effects of alendronate versus placebo, with calcium and vitamin D supplementation, on BMD in patients with HIV.

4. Study Design Alendronate + Calcium/Vitamin D n=42 Placebo+ Calcium/Vitamin D n=40 Study Regimen: 48 weeks -Alendronate or matching placebo 70 mg weekly -Calcium carbonate/Vitamin D (500 mg/200 IU BID) HIV+ Lumbar t- score ≤-1.5 VL <5000 CD4 > 100 Randomization was stratified by CD4+ cell count at screening (100-200 cells/mm 3 or >200 cells/mm 3 )

5. Inclusion/Exclusion Criteria Inclusion Documented HIV Documented HIV ≥ 25 years ≥ 25 years CD4 ≥ 100 cells/mm 3 CD4 ≥ 100 cells/mm 3 HIV-1 RNA ≤ 5,000 cps/mL HIV-1 RNA ≤ 5,000 cps/mL Lumbar spine t-score ≤ -1.5 Lumbar spine t-score ≤ -1.5 Stable ARV for ≥ 12 wks Stable ARV for ≥ 12 wks No plan to alter ARV, exercise habits, or diet No plan to alter ARV, exercise habits, or diet Exclusion Pregnancy or breast-feeding Untreated hypogonadism or hyperthyroidism 25-OH vitamin D <15 ng /mL Hepatitis C PTH > 80 pg/mL Chronic systemic steroids Treatment for osteoporosis Recent bone fracture Esophageal pathology

6. A5163 Main Objectives To examine the efficacy of once-weekly alendronate and daily calcium and vitamin D in the treatment of HIV-associated decreased BMD, as assessed by percent change in lumbar spine BMD from baseline to week 48 in men receiving alendronate versus placebo To examine the efficacy of once-weekly alendronate and daily calcium and vitamin D in the treatment of HIV-associated decreased BMD, as assessed by percent change in lumbar spine BMD from baseline to week 48 in men receiving alendronate versus placebo To assess the safety and tolerability of once- weekly alendronate in HIV-infected subjects To assess the safety and tolerability of once- weekly alendronate in HIV-infected subjects To examine gender interactions in the efficacy of once-weekly alendronate and daily calcium and vitamin D in the treatment of HIV-associated decreased BMD To examine gender interactions in the efficacy of once-weekly alendronate and daily calcium and vitamin D in the treatment of HIV-associated decreased BMD

7. Statistical Considerations Study powered (80% power; 2-sided alpha = 0.05) to detect an absolute difference of 3.5% in the mean percent change between arms in men. An additional 20% enrolled to account for possible drop-out and unevaluable DXA scans for a total of 27-30 men per arm. Study powered (80% power; 2-sided alpha = 0.05) to detect an absolute difference of 3.5% in the mean percent change between arms in men. An additional 20% enrolled to account for possible drop-out and unevaluable DXA scans for a total of 27-30 men per arm. To test for moderate treatment/sex interactions, 10-13 women per arm were also included (total n=80) To test for moderate treatment/sex interactions, 10-13 women per arm were also included (total n=80)

8. Baseline Characteristics Alendronate N=42 Placebo N=40 Age48 (33-63)46 (30-68) Men71%70% % White 69%85% CD4 cell count 482 (105-1387)463 (189-1237) HIV RNA < 400 cps/mL 90%93% Current smoking 36%35% BMI23.9 (20.1-38.6)24.2 (19.1-35.1) PI at study entry Tenofovir at entry Lumbar spine t-score Lumbar spine t-score < -2.5 69% 38% -2.15 (-3.3, -1.5) 24% 63% 38% -1.95 (-3.0, -1.5)* 18% *p=0.05

9. BMD Lumbar Spine ( men and women ) Week 02448 % change from baseline 0 1 2 3 4 5 Vitamin D + Ca + Alendronate Vitamin D + Ca * p=0.0006 * significant within arms † significant between arms * p=0.0003 * p=0.02 † p=0.03

10. * p<0.0001 * significant within arms † significant between arms * p=0.009 * p=0.03 † p=0.004 † p=0.05

11. * p=0.0002 * p=0.002 * significant within arms † significant between arms † p=0.007

12. Results Two traumatic fractures occurred during the study (one per arm) Two traumatic fractures occurred during the study (one per arm)

13. Results Two traumatic fractures occurred during the study (one per arm). Two traumatic fractures occurred during the study (one per arm). No evidence of a treatment/sex interaction when we considered the % change from baseline to week 48 in BMD assessed at the lumbar spine, total hip, or trochanter (p=0.41, 0.82, and 0.19, respectively). No evidence of a treatment/sex interaction when we considered the % change from baseline to week 48 in BMD assessed at the lumbar spine, total hip, or trochanter (p=0.41, 0.82, and 0.19, respectively). Changes from 0  24 weeks strongly predicted changes from 0  48 weeks Changes from 0  24 weeks strongly predicted changes from 0  48 weeks In a multivariable model correcting for treatment, BMI and baseline L-spine BMD, black race was associated with a smaller % change from baseline in lumbar spine BMD with alendronate (p=0.003) In a multivariable model correcting for treatment, BMI and baseline L-spine BMD, black race was associated with a smaller % change from baseline in lumbar spine BMD with alendronate (p=0.003)

14. Results Two traumatic fractures occurred during the study (one per arm). Two traumatic fractures occurred during the study (one per arm). No evidence of a treatment/sex interaction when we considered the % change from baseline to week 48 in BMD assessed at the lumbar spine, total hip, or trochanter (p=0.41, 0.82, and 0.19, respectively). No evidence of a treatment/sex interaction when we considered the % change from baseline to week 48 in BMD assessed at the lumbar spine, total hip, or trochanter (p=0.41, 0.82, and 0.19, respectively). Changes from 0  24 weeks strongly predicted changes from 0  48 weeks Changes from 0  24 weeks strongly predicted changes from 0  48 weeks In a multivariable model correcting for treatment, BMI and baseline L-spine BMD, black race was associated with a smaller % change from baseline in lumbar spine BMD with alendronate (p=0.003) In a multivariable model correcting for treatment, BMI and baseline L-spine BMD, black race was associated with a smaller % change from baseline in lumbar spine BMD with alendronate (p=0.003)

15. Results Two traumatic fractures occurred during the study (one per arm). Two traumatic fractures occurred during the study (one per arm). No evidence of a treatment/sex interaction when we considered the % change from baseline to week 48 in BMD assessed at the lumbar spine, total hip, or trochanter (p=0.41, 0.82, and 0.19, respectively). No evidence of a treatment/sex interaction when we considered the % change from baseline to week 48 in BMD assessed at the lumbar spine, total hip, or trochanter (p=0.41, 0.82, and 0.19, respectively). Changes from 0  24 weeks strongly predicted changes from 0  48 weeks Changes from 0  24 weeks strongly predicted changes from 0  48 weeks In a multivariable model correcting for treatment, BMI and baseline L-spine BMD, black race was associated with a smaller % change from baseline in lumbar spine BMD with alendronate (p=0.003) In a multivariable model correcting for treatment, BMI and baseline L-spine BMD, black race was associated with a smaller % change from baseline in lumbar spine BMD with alendronate (p=0.003)

16. Safety/Tolerability More signs/symptoms of Grade  3 in the placebo arm (15% versus 0% in the alendronate arm; p=0.01) More signs/symptoms of Grade  3 in the placebo arm (15% versus 0% in the alendronate arm; p=0.01) No difference between treatment arms in Grade  3 laboratory toxicities (15% on placebo arm versus 17% on alendronate; p>0.9) No difference between treatment arms in Grade  3 laboratory toxicities (15% on placebo arm versus 17% on alendronate; p>0.9) No discontinuation related to toxicity No discontinuation related to toxicity

17. Study Limitations Osteopenia may not require treatment Osteopenia may not require treatment Duration relatively short Duration relatively short need longer term efficacy and tolerability need longer term efficacy and tolerability 21% changed ARV during study (5 TDF) 21% changed ARV during study (5 TDF) results unchanged when these 5 subjects were excluded results unchanged when these 5 subjects were excluded

18. Conclusions Alendronate given with calcium/vitamin D led to significant increases in lumbar spine, total hip and trochanter BMD Alendronate given with calcium/vitamin D led to significant increases in lumbar spine, total hip and trochanter BMD Calcium/vitamin D alone led to modest increases in BMD Calcium/vitamin D alone led to modest increases in BMD Alendronate was well tolerated, without significant adverse events Alendronate was well tolerated, without significant adverse events There was no evidence of treatment/sex interactions at any of the bone sites examined There was no evidence of treatment/sex interactions at any of the bone sites examined

19. Acknowledgments David Wohl David Wohl Pablo Tebas Pablo Tebas Michelle Kendall Michelle Kendall Janet Andersen Janet Andersen Evelyn Hogg Evelyn Hogg Lynette Purdue Lynette Purdue Susan Swindells Susan Swindells Geetha Gopalakrishnan Geetha Gopalakrishnan Melissa G. Kerkau Melissa G. Kerkau Marjorie Busby Marjorie Busby Carol Suckow Carol Suckow Amy Sbrolla Amy Sbrolla Enid Vazquez Enid Vazquez Jennifer Nowak Jennifer Nowak Murray Abramson Murray Abramson Anne E. de Papp Anne E. de Papp Mary E. Melton Mary E. Melton All Participating ACTU Sites and Study Participants! Merck for alendronate/placebo