Alternative Delivery Strategies for Hiv Prevention & Treatment

ALTERNATIVE DELIVERY STRATEGIES FOR HIV PREVENTION & TREATMENT

by Ethel D. Weld, MD

A dissertation submitted to Johns Hopkins University in conformity with the requirements for the degree of Doctor of Philosophy

Baltimore, Maryland

April 2019

Abstract

The three parts of this thesis are as follows: 1) A comparative pre-phase I study exploring the impact of volume of microbicide gel vehicle on distribution through the distal colon, user experience, and acceptability (Section II); 2) An analysis of the colorectal distribution of lymphocytes and cell-free HIV surrogate in autologous seminal plasma following simulated anal intercourse (Section III); and 3) A survey study exploring the interest of U.S. youth living with

HIV in long-acting injectable antiretrovirals (Section IV).

Section II: Methods: Eight HIV negative men with a history of recent RAI were enrolled into a two- period, sequence randomized, dosing study comparing 3.5 mL and 10 mL of radiolabeled (1 mCi

99mTc-DTPA) universal placebo hydroxyethyl cellulose (HEC) gel. Each participant received two doses in the research unit, one of each volume, separated by a washout period of at least 2 weeks.

Each research unit dose was followed by a self-administered take-home dose. Safety and gastrointestinal distribution were assessed after the research unit doses; safety, perceptibility, and acceptability were assessed after take-home doses. Results: There were no adverse effects of

Grade 2 or higher and all resolved spontaneously. Both volumes were well tolerated and received high acceptability scores. The 3.5 mL and 10 mL gel volumes distributed similarly (p>0.2) within the rectosigmoid. Both volumes covered the typical gastrointestinal distribution of ejaculate following simulated intercourse based on other studies. Conclusion: Either of these gel volumes could reasonably be pursued for the next phase of development of rectal microbicides.

Section III: Objective: The objective of this study was to explore the luminal distribution and clearance of cell-associated (lymphocytes) and cell-free (seminal plasma) HIV surrogates within the distal colon following simulated receptive anal intercourse. Methods: Six healthy, HIV- uninfected men gave semen samples in sterile containers. Samples were centrifuged and the supernatant (seminal plasma) collected and frozen. Peripheral blood lymphocytes were harvested

from subjects via apheresis and labeled with 111Indium (In)-oxine on the dosing day. 111In-labeled autologous lymphocytes and 99Technetium (Tc)-sulfur colloid (HIV surrogate) were reconstituted with 3 mL of autologous seminal plasma. Reconstituted seminal plasma was inserted into the rectum using a phallic device with artificial urethra. Distribution of radiolabels in time and space was assessed with SPECT/CT at 3 timepoints. Analysis of radiolabel distribution was performed using a flexible principal curve algorithm in R. Pharmacokinetic distance parameters were defined.

Results: Median (interquartile range (IQR)) PK distance paarameters for cell-associated (In) and cell-free (Tc) HIV surrogate were described; distribution was similar between cell-free and cell- associated HIV surrogate. Conclusions: Both autologous lymphocytes and HIV surrogate particle in seminal plasma distribute to a maximal distance of around 15 cm from the anorectal junction

(which is ~19 cm from the anal verge), with a maximal signal intensity around 6 cm from the anorectal junction. This represents and maps the ideal target distribution for rectal microbicides.

Section IV: Objectives: This study aimed to characterize attitudes to long-acting antiretrovirals

(LAARV), among youth aged 13 to 24 years living with perinatally- and non-perinatally-acquired

HIV (PHIV and NPHIV, respectively). Methods: A cross-sectional survey of 303 Youth Living with HIV (YHIV) followed at four pediatric/adolescent HIV clinics in the USA was performed.

Findings: Overall, 88% of YHIV reported probable or definite willingness to use LAARV. The enthusiasm level was similar between PHIV and NPHIV youth (p=0.93). Youth with HIV viral load >1000 copies/mL had significantly higher interest than youth with suppressed viral load (PR

1.12 [95% CI: 1.03 - 1.20]; p= 0.005). Proportion of respondents endorsing definite willingness to use was significantly higher with decreased injection frequency compared to increased injection frequency. Conclusions: YHIV at four urban US pediatric/adolescent HIV clinics had high levels of enthusiasm for LAARV. LAARV should be given high priority as a potentially viable treatment option to improve clinical outcomes in YHIV.

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Dissertation Readers

Brian Caffo (committee chair), Craig Hendrix (thesis advisor), Diane Griffin (academic advisor),

Khalil Ghanem, David Levine

Preface

“One of the first duties of the physician is to educate the masses not to take medicine.” --W. Osler

Acknowledgments

All thanks are due to my mentors Craig Hendrix and Allison Agwu for their patient and wise guidance throughout my time in the GTPCI program, and for helping me to develop the work and ideas contained in this thesis. My gratitude also goes to the GTPCI program leadership and administrators for their calm stewardship over the years. The participants in these challenging studies devoted their time, vital resources and energies to the project of expanding scientific understanding, and have thus earned my profound gratitude. Love and thanks to MDEMQF, T, S, and s, who have given me their unflinching fandom and love, have sat companionably with me through many long nights and Grape-Nuts moments, and some of whom even went so far as to attend my thesis defense in a Derby hat.

Table of Contents

Section I: Introduction………………………………………………………..……………….Page 1

Section II: A Comparative Pre-Phase I Study of the Impact of Gel Vehicle Volume on Distal Colon

Distribution, User Experience, and Acceptability…………………………………….………...…4

Section III: Colorectal Distribution of Lymphocytes and Cell-Free HIV Surrogate in Autologous

Seminal Plasma Following Simulated Anal Intercourse…………………………………….……25

Section IV: Interest of Youth Living with HIV in Long-Acting Antiretrovirals…………….…..44

Section V: Overall Thesis Conclusions………………………………………………………...…73

References:

Appendices………………………………………………………………………………………...76

Bibliography……………………………………………………………………………………….94

Curriculum Vitae…………………………………………………………………………………104

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List of Tables

Table IIa. Summary of Adverse Events…………………………………………………….…..…..13

Table IIb. Averaged Perceptibility (User Sensory Perception and Experience (USPE)) Scale Item

Scores, Standard Deviations, Cronbach’s Coefficient Alphas (CCA), Cohen’s Effect Sizes (d), and p-values for Low- and High-volume Gel Comparisons……………………………………....……15

Table IIIa. Pharmacokinetic Distance Parameters for Distribution of 111In-Labeled Lymphocytes and 99Tc-labeled HIV Surrogate Particle Through Colorectal Space…………..…….…..……..….35

Table IIIb. P-values (direction of difference) for comparison of PK Distance Parameters by

Timepoint………………………………………………………………………………………….36

Table IVa. Baseline Characteristics Stratified by Mode of Acquisition of HIV…………………...52

Table IVb. Crude and adjusted Prevalence Ratio (PR) and 95% Confidence Interval of the interest level in Intramuscular LAARV by Poisson Regression with robust variance…………………..…54

Table IVc. Female participants’ willingness to try IM and implantable LAARV based on past experience with contraceptive technologies…………………..…………………………………..59

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List of Figures

Figure IIa: Study Schema………………………………………………………………………..…..9

Figure IIb. Pharmacokinetic distance parameters for two volumes (3.5 mL and 10 mL) of HEC gel delivered through applicator……………………………………………………………….…....…18

Figure IIIa. Distance Parameters Versus Time for Cell-Associated and Cell-Free HIV

Surrogates…………………………………………………………………………………….…….37

Figure IVa. Youth Preference for Intramuscular over Subdermal Implantable LAARV…….……53

Figure IVb. Adjusted Prevalence Ratio of High Interest in LAARV By Participant

Characteristics……………………………………………………………………………………...56

Figure IVc. Comparison of Interest in LAARv by Various Characteristics………………..…..….57

Figure IVd.1: Gradient of Definite or Probable Willingness to Use Increases with Decreased

Injection Frequency………………………………………………………………….……………..60

Figure IVd.2: Proportion of Definite Willingness to Use Is Higher with Decreased Injection

Frequency Compared to Increased Injection Frequency…………………………………………...61

Section I: Introduction

The broad significance of this research to medicine is that it lays the groundwork for new dosing and delivery approaches for the biomedical prevention and treatment of HIV while directly tackling the problem of poor adherence to biomedical interventions—the Achilles heel of even the most dazzling, painstakingly conceived and researched, and life-saving of technologies. (1) In the words of former U.S. Surgeon General C. Everett Koop, “drugs don’t work in patients who don’t take them.” (2) Non-adherence (not taking medications as prescribed, or not taking prescribed medicines at all) has been called “America’s other drug problem”, and is estimated to be responsible for $300 billion in avoidable health care costs and 125,000 preventable deaths yearly.

(3) Non-adherence to HIV biomedical prevention technologies such as pre-exposure prophylaxis

(PrEP) leads to HIV acquisition in certain risk settings, and in the realm of HIV treatment, now that treatment as prevention is a better understood prevention strategy, non-adherence leads not only to potentially disastrous consequences for the untreated infected individual, but also to HIV transmission at the community level.

By carefully understanding and leveraging patients’ routine behaviors, a behaviorally congruent approach to prevention or treatment may avoid the necessity of asking people to change their lifestyles.(4) The operative concept of this type of approach is that if you minimize the amount that patients must deviate from their existing behaviors, patients are more likely to adhere. For example, oral tenofovir disoproxil fumarate-emtricitabine (TDF-FTC) as Pre-Exposure Prophylaxis (PrEP) against HIV is a modality of prevention that requires healthy people to embrace ingesting daily pills (a deviation from the existing behavior of not taking daily pills). In contrast, topical tenofovir, applied via rectal douche as a microbicide, requires minimal deviation from the existing behavior

of pericoital douching, which is reported by 80% of men who have sex with men (MSM), who constitute the majority (70%) of the epidemic in the US.(5)

Prevention technologies that can be used on-demand and begin with an understanding of pre- existing sexual behaviors have a good chance of achieving enhanced adherence. This is particularly so when these technologies are seen as being compatible with or enhancing sexual pleasure, as compared to prevention technologies (such as barrier methods) that are commonly seen as detracting from pleasure.(6) The wisely designed prevention method must incorporate considerations not only of existing sexual behaviors, but also of pleasure.

HIV in long-acting injectable antiretrovirals (Section IV). The major research questions of Sections

II and III focus on where, anatomically, a topical product for HIV prevention must be in order to prevent HIV, and what volume of microbicide gel is preferable from the standpoint not only of anatomic coverage but also from the perspective of acceptability. This lays the groundwork for ongoing studies that will endeavor to deliver clinically relevant, protective concentrations of tenofovir diphosphate to target cells in the colonic epithelium, in order to prevent HIV acquired via unprotected receptive anal intercourse. Section IV is also an exploration of the acceptability of novel delivery and dosing strategies, among a key population, youth with HIV.

Ultimately, it is clear that an effective human-centered HIV prevention technology designed so that people will actually use it has the potential to shrink the epidemic far more substantially than would a prevention technology that ignores the needs and desires of persons for whom the

technology is intended. But for people who are already living with HIV, a human-centered treatment technology is one which acknowledges the reality of the difficulty of adhering to daily pills, and meets the challenge of medication non-adherence by lessening the frequency and burdens of medication adherence (e.g. via less frequent dosing strategies). The hope is that increased acceptability of biomedical prevention and treatment modalities will ultimately translate into increased adherence, and that hypothetical willingness to use will eventually translate into intention to use, early adoption, and actual use. Furthermore, such acceptability data will form a critical foundation from which to advocate for the rollout of long-acting technologies among populations with the lowest rates of virologic suppression and the highest rates of adherence difficulties.

Likewise, understanding the acceptability of topical prevention products in populations at high risk for HIV will enable the targeting of microbicide technologies where they are best received and most needed.

Section II:

A Comparative Pre-Phase I Study of the Impact of Gel Vehicle Volume on Distal Colon

Distribution, User Experience, and Acceptability

Ethel D. Weld1*, Hiwot Hiruy1*, Kate Morrow Guthrie2,3, Joseph L. Fava3, Sara E. Vargas2,3,

Karen Buckheit4, Robert Buckheit4, Hans Spiegel5, Jennifer Breakey1,

Edward J. Fuchs1, Craig W. Hendrix1

Publication citation: Weld ED, Hiruy H, Guthrie KM, Fava J, Vargas S, Buckheit K, Buckheit R, Breakey J, Fuchs E, Hendrix C. "A Comparative Pre-Phase I Study of the Impact of Gel Vehicle Volume on Distal Colon Distribution, User Experience, and Acceptability" AIDS Research and Human Retroviruses. December 2016, ahead of print. doi:10.1089/aid.2016.0167.

Keywords: microbicide pre-exposure prophylaxis human immunodeficiency virus gastrointestinal distribution pharmacokinetics user experience acceptability/ perceptibility

1 Johns Hopkins University School of Medicine, Divisions of Clinical Pharmacology & Infectious Disease; 2Department of Psychiatry & Human Behavior, Alpert Medical School of Brown University, Providence, RI; 3Centers for Behavioral & Preventive Medicine, The Miriam Hospital; 4ImQuest BioSciences, Inc.; 5NIH/Division of AIDS. *These two authors contributed equally.

Abstract

Background: For persons at risk of HIV infection who practice receptive anal intercourse (RAI), topical rectal microbicides represent a promising option for coitally-dependent protection. The study compared colorectal distribution and user sensory experiences of two different volumes of rectal gel for suitability as rectal microbicide.

Methods: Eight HIV negative men with a history of recent RAI were enrolled into a two-period, sequence randomized, dosing study comparing 3.5 mL and 10 mL of radiolabeled (1 mCi 99mTc-

DTPA) universal placebo hydroxyethyl cellulose (HEC) gel. Each participant received two doses in the research unit, one of each volume, separated by a washout period of at least 2 weeks. Each research unit dose was followed by a self-administered take-home dose in the context of preparing for RAI. Safety and gastrointestinal distribution were assessed after the research unit doses; safety, perceptibility, and acceptability were assessed after take-home doses.

Results: There were no adverse effects of Grade 2 or higher and all resolved spontaneously. Both volumes were well tolerated and received high acceptability scores. Perceptibility scores showed meaningful effect size differences ranging from Cohen’s d=.5 to d=1.2. The 3.5 mL and 10 mL gel volumes distributed similarly (p>0.2) within the rectosigmoid ranging from 0.23 cm to 6.5 cm and

0.42 cm to 6.58 cm from the anorectal junction, respectively. Both volumes covered the typical gastrointestinal distribution of ejaculate following simulated intercourse based on other studies.

Conclusion: Either of these gel volumes could reasonably be pursued for the next phase of development of rectal microbicides.

Introduction

The HIV epidemic spreads among persons that may be dis-empowered to negotiate the use of barrier methods of protection, and therefore have high vulnerability to acquiring the virus. (7) Men who have sex with men (MSM) represent a particularly high-risk population, and account for 66% of estimated new HIV infections in the United States. (8) Alarmingly, from 2008 to 2010, there was a 22% increase in new cases of HIV among young gay and bisexual men, and a 12% increase overall among gay and bisexual men, even at this late stage in the three-decade-long epidemic.

Now, in the era of pre-exposure prophylaxis (PrEP), there continue to be 38 739 new HIV infections per year in the United States (2017 estimate), 25 748 of them among MSM.(8, 9)

Accordingly, there is an urgent need for prevention methods that are controlled by receptive partners, do not require the cooperation or consent of the insertive partners, and are highly safe, acceptable, and effective. Topical microbicides are products formulated for rectal or vaginal application to protect against sexually transmitted infections including HIV. Several trials have shown that vaginal antiretroviral-containing gels and rings have modest efficacy in preventing the acquisition of HIV in women when adherence is good. (10-14) Efficacy of rectal microbicides has not been evaluated in clinical trials, but they represent a promising option for the prevention of

HIV acquired through RAI.

FDA Guidance from 2014 on the development of microbicides for the prevention of HIV underlines the importance of testing not only the active pharmaceutical ingredient (API) in microbicides, but also the optimal formulation for its delivery. (15) This is especially important given the finding that hyperosmolar lubricants and enemas may damage the colonic epithelium and potentially increase the risk of HIV acquisition. (16-18) Many formulation factors might influence vehicle distribution within the distal gastrointestinal tract, including rheology, viscosity, osmolality, pH, and excipient content of the gel vehicle. These same factors impact sensations

experienced by users and their sexual partners (i.e., perceptibility) and, as such, may impact acceptability and use. The effect of product volume on distribution has previously been assessed in gel and enema studies using larger volumes of gel with widely varying viscosities. (19-26) One study found no difference in retrograde colonic distribution of 20mL and 80mL of rectally administered, radiolabeled ropivacaine gel (19). Another study that examined a hypoosmolar product (FemGlide, 32 mOsm/kg) in men who practice RAI assessed the acceptability of 4 escalating volumes of a placebo gel from 5mL to 50mL, and established that the maximum acceptable volume for use during RAI was 35mL. (27)

Efficacy is critical, but not sufficient, for real-world use. To effectively prevent disease, rectal microbicides must be acceptable to the user and used consistently in the context of sexual risk.

Previous work has shown that users can discriminate between, and form preferences for, formulations with different physicochemical properties as a function of the sensory experiences elicited by specific formulation properties (e.g., viscosity and rheological performance). (28, 29)

User sensory perceptions and experiences (USPEs) of applying and using products during rectal sex will likely impact willingness to use rectal products among those at risk for HIV.

The intent of the present study was to evaluate the distribution and user experience of smaller volumes, less than or equal to 10mL, because these volumes are more easily portable than larger volumes and consistent in size with commercial sexual lubricants. Further, in our prior experience,

10 mL volumes have been shown to distribute within the rectosigmoid to distances consistent with

HIV surrogate distribution (cell-free and cell-associated HIV surrogates) within autologous semen following simulated intercourse. They also demonstrate near complete overlap in distribution with microbicide gels in clinical mixing studies where a candidate microbicide is dosed prior to simulated rectal sex with ejaculation.(30-34) In contrast, many other rectal HIV microbicide development studies have used a 3.5 mL to 4 mL gel volume commonly used in vaginal HIV

microbicide studies, and often with the same vaginal applicator. (35-37) The 3.5 mL volume approximates that of vaginal dosage forms used in other clinical settings, is also a well-tolerated volume, and is sufficiently smaller than 10mL, so that we anticipated an ability to show a difference in distribution.

Universal placebo (HEC) was chosen as test vehicle, as it is readily available, isoosmolar (298 mOsm/kg), previously demonstrated to be safe and acceptable to both vaginal and rectal mucosa, and allows direct comparison of the effects of volume on distribution of the same product within the same study. The isoosmolar HEC was selected to avoid toxicity to the rectal mucosa as seen for hyperosmolar formulations, as well as possible negative effects on mucus production induced by hypoosmolar products, as seen in some experimental models. (18, 38) Further, relevant to the choice to study an isoosmolar gel is the desire to minimize reduction in intraluminal gel volume anticipated with hypoosmolar formulations or increase in gel volume with a hyperosmolar formulation, either of which might affect the colonic distribution of the product. The study explored the potential differences in rectal distribution due to these relatively small gel volumes to guide subsequent rectal microbicide development studies.

Materials & Methods

Study Design

A two period, randomized, sequential rectal dosing study was performed, comparing two volumes

(3.5 mL vs. 10 mL) of universal placebo gel. Subjects received one dose of each volume mixed with 99mTc-radiolabeled diethylene triamine pentaacetic acid (DTPA) in the research unit and one non-radiolabeled take home dose for dosing at home in the context of RAI. Participants were provided with and told to self-administer an isoosmolar preparatory enema (Normal Saline at a volume of 125 mL) at least 8 hours prior to the start of dosing. (See Study Schema in Figure II.a.)

Figure II.a. Study Schema

For ease of initial insertion of the tip of the applicator, a 0.1-oz. packet of xo lubricant was provided to participants for home use for ease of enema tip insertion, and was also used for the

Research Unit doses. However, for the purpose of ease of RAI, no lubricant was provided to the participants for home use, in order to minimize confounding variables. Participants were instructed to do what they normally would do in preparation for RAI, including using lubricant if that was part of their routine practice. For Research Unit doses, study staff administered the study product to participants using a 10-cm syringe attached via Luer-lock to a rectal applicator (Northern Pharmacy

& Medical Equipment, #001-921-6670); doses at home were self-administered by participants using the same applicator.

The sequence of volumes was randomized in order to minimize bias stemming from participants’ or staff’s anticipation of the sequence of volumes, but could not be blinded. Eight healthy, HIV- uninfected men reporting a history of RAI were enrolled; this population was most likely to have opportunities for product use in the timeframe prescribed by the protocol, and their past experience provided a context for USPE and willingness-to-use assessments. Women were not eligible as the focus of this work was on MSM who are the primary, though not only, target group to use rectal

microbicide products. Limiting the study to MSM over age 18 also enabled comparisons with our previous enema study results which were all in adult men, without the potentially confounding sex and age-related variables (hormonal influence and anatomic differences.) In addition, the very small sample size in this study was felt unlikely to tolerate well the potential for additional variability introduced by anatomic, hormonal, and age-related differences. The Johns Hopkins

Medicine Institutional Review Board approved the study and all participants provided their written informed consent to participate in the study prior to being screened.

Imaging colon distribution of study product

Following each research unit dose of product, one Single Photon Emission Computed

Tomography/ Computed Tomography (SPECT/CT) imaging study was performed 4 hours and 24 hours after dose administration using a dual-head Millenium VH SPECT/CT system (GE Medical

Systems, Waukesha, WI) equipped with a computed tomography (CT) unit (Hawkeye). By predetermined plan, it was agreed to stop performing 24-hour scans if there was inadequate colonic signal at that time point in the first few participants. All assessments of colonic distribution of gel in this study were made based on the 4 hour scans. As previously detailed, a filtered back projection algorithm was used to reconstruct CT images onto a 256 × 256 matrix size. SPECT images were then attenuation-corrected and reconstructed using the ordered subset expectation maximization (OSEM) algorithm and fused with the CT images into a 128 × 128 × 128 matrix size, with each voxel representing 3.45 mm3. This reconstruction was performed using the General

Electric Xeleris workstation, software version 3.0 (GE Medical Systems, Waukesha, WI). (31, 34,

39, 40)

A flexible principal curve algorithm in R version 3.2.0 (The R Foundation for Statistical

Computing, Vienna, Austria) was used to construct a 3-dimensional curve through the colon images, as previously described. (41, 42) First, the origin and end of the centerline through the

signal were established. Next, a centerline was fit to the signal using a principal curve algorithm, after which a concentration-by-distance curve was constructed based on voxel intensity within a 1 cm radius disc orthogonal to the centerline. Finally, concentration-by-distance curves were generated, with counts per minute (CPM) in each one voxel thick orthogonal disc being the concentration equivalent for this analysis. To enable a common frame of reference across studies, the axial distance from the anorectal junction (set as distance equal to zero) to the beginning of the centerline was added to the concentration-distance curve. The z-axis location of the anorectal junction was identified as the slice which contained the puborectal sling distal to the most distal air-filled section of rectum. Pharmacokinetic-distance parameters were calculated using Phoenix

WinNonlin software (Certara, LP) as previously described. (42) Briefly, Dmin is the most distal signal in the body, calculated as the distance between the anorectal junction and the origin of the radiolabeled centerline. Dmax is the distance furthest from the anorectal junction (most proximal) at which signal is detected, DCmax is the distance at which maximal signal intensity is found, and Dave is the mean residence distance (area of first moment divided by area of zero moment, similar to mean residence time, but substituting distance for time). Output of the R algorithm was in units of voxel side—a voxel is a cube with each side measuring 0.3453 cm. Distances here cited are in centimeters, converted from voxel side units to centimeters by dividing distance units by 2.89 to get distance in cm.

Intraluminal Gel Retention

Percent of intraluminal gel retention was estimated as the product of (A) percent of gel removed from the applicator, (B) the percent of that removed gel that was applied to the body, and (C) the fraction of gel applied to the body that remained inside the colon (i.e., was not expelled).

Dosimetry determined radiation on gloves, chux, dosing syringe, and other supplies for calculation

of A and B. C was determined by SPECT/CT region of interest assessment of intraluminal distinct from extracorporeal signal.

Perceptibility and Acceptability

To assess perceptibility, each participant completed a USPE survey – one after RAI with the 3.5 mL volume gel and one after RAI with the 10 mL volume gel. The USPE surveys included questions about sexual behavior (e.g., sexual sequencing, whether the insertive partner used a condom) and items assessing various aspects of the user’s sensory experience (USPEs: see table for descriptions of sensations captures by each USPE scale). Likert-type items were rated to assess the level of agreement with each particular item from (1) do not agree at all to (5) agree completely.

(We conducted both in-depth and cognitive interviews in order to adapt the items from the vaginal to the rectal compartments, and to characterize new concepts (e.g., bloating) that participants noted are relevant to rectal sex.) From these items, we calculated averaged scale item scores using scales previously validated for vaginal sex (28, 29), (43)

To assess acceptability, we asked participants first to rate the likelihood that they would use either product (i.e., the 3.5 mL and 10 mL products) to prevent against HIV on a 5-point Likert scale assessing ‘definitely NOT,’ ‘probably NOT,’ ‘unsure,’ ‘probably,’ or ‘definitely.’ We also asked participants to select which of the two volumes they would choose to use if they had to pick a single product.

Statistical Analysis

Distribution parameters and retention results for the 3.5 mL and 10 mL volume were summarized using descriptive statistics and compared using the Wilcoxon signed ranks test with a p-value less than 0.05 considered statistically significant (Stata Intercooled 13.1 for Windows, StataCorp LP,

College Station, TX). Results were plotted with SigmaPlot 13.0 (Systat Software, Inc., San Jose,

California). Principal components analysis was conducted using IBM SPSS Statistics for Windows,

Release 20.0.0 (©IBM Corp., 2011, Armonk, NY, www.ibm.com) to examine the internal validity of the USPE scales. The internal consistency reliability of the scales was measured using

Cronbach’s Coefficient Alpha (CCA) statistic, and Cohen’s d effect size statistic (a standardized deviation measure used with means) was used to describe the magnitude of found effects, where values of 0.2, 0.5, and 0.8 note small, medium, and large effect sizes, respectively. (44, 45)

Results

Subjects

Nine healthy, HIV-seronegative, male research participants were enrolled in the study. One of these subjects discontinued the study early before receiving both study volumes, due to intercurrent illness deemed by site investigators and the DSMB to be unrelated to the study product. Eight male subjects with a median age of 44 years (interquartile range [IQR] 29.2, 49.8) completed all study visits. Research participants self-identified as white (4) and African-American (4); none indicated that they were Hispanic.

Safety

A total of 13 unique adverse events (AE’s) were reported by a total of 6 subjects (See Table II.a).

Five of these AE’s were deemed to be related to the product and occurred in a total of 2 subjects, and all of them were mild (Grade I) and resolved without intervention. The AE’s included anorectal pain related to RAI in the absence of lubricant, constipation, tenesmus, mild rectal discomfort associated with constipation, and bloating.

Table II.a. Summary of Adverse Events

Name of Relations PT Severity Visit Outcome & Adverse System hip to Action Treatment Comment ID (Grade) at which Date Event Product

reporte d Subject thought the study product gel was also a lubricant, so he did not use 40 Anorectal Visit 5 - Resolved - No additional lubricant for RAI GI 1 - Mild Related None 01 Pain 12/16/14 12/8/14 Change after home dosing and experienced some rectal tenderness that resolved without intervention 40 Visit 8 - Resolved - No Constipation GI 1 - Mild Related None 01 12/23/15 12/20/14 Change Subject c/o rectal discomfort 40 Rectal Pain/ Visit 8 - Resolved - No related to constipation and GI 1 - Mild Related None 01 Discomfort 12/23/15 12/20/14 Change efforts to a force bowel movement 40 Visit 8 - Resolved - Not No Subject experienced burning Dysuria GU 1 - Mild None 01 12/23/15 12/23/14 Related Change sensation during urination 40 Sensation to Visit 5 - Resolved - No GI 1- Mild Related None 06 Defecate 4/21/15 4/9/15 Change 40 Visit 5 - Resolved - No Bloated GI 1 - Mild Related None 06 4/21/15 4/9/15 Change Reported after inquiry by Continuing 40 Visit 8 - Not No study RN regarding delay in Anal Soreness GI 1 - Mild at None 03 5/22/15 related Change completion of 2nd home End of Study dosing Reported after inquiry by Continuing 40 Decreased Reprod Visit 8 - Not No study RN regarding delay in 1 - Mild at None 03 Sex Drive uctive 5/22/15 related Change completion of 2nd home End of Study dosing Perman Between Continuing Removed Subject withdrawn from 40 Stage IV 3 - Not ently GU Visit 4 at from study, reported as an SAE to 05 Melanoma Severe related Discont and 5 End of Study Study DAIDS via DAERS inued Neuro Continuing Subject was in a car accident 40 Pain - Right Visit 8 - Not No muscul 1 - Mild at None on 5/29/15 - he was rear- 06 Shoulder 6/30/15 related Change ar End of Study ended Decreased Neuro Continuing Subject was in a car accident 40 Visit 8 - Not No Right muscul 1 - Mild at None on 5/29/15 - he was rear- 06 6/30/15 related Change Grip Strength ar End of Study ended Subject reports tenderness 40 Perianal Visit 2 - Resolved - Not No GI 1 - Mild None following forceful attempt to 09 Tenderness 8/5/15 8/6/15 Related Change defecate Skin - Between 2 - 40 Dermat Visit 4 Resolved - Not No Rash Moderat None 08 ologica and 5 - 8/9/15 Related Change e l 8/6/15

Perceptibility and Acceptability

Eight participants completed perceptibility (i.e., sensory experiences) and acceptability (i.e., willingness to use) surveys following take-home doses. A final preference survey comparing volumes was completed after the second take home dose. The USPE sexual activity scales performed well when adapted to the receptive intercourse experience, both on an individual item

level and with respect to internal consistency indices for the scales. CCA values for the USPE

scales ranged from 0.62 to 0.98 for the 3.5 mL gel and 0.56 to 0.95 for the 10 mL gel, where values

<0.60 indicate poor reliability, values 0.60 to <0.70 are acceptable, above >0.70 to <0.80 are

considered good, >0.80 to <0.90 very good, and >0.90 excellent. (46, 47) Several scales showed

conceptually consistent findings in volume comparisons. In reviewing the data conservatively

(avoiding high inter-item correlations and missingness) and only reporting here those scales that

have moderate to large preliminary effect sizes (i.e., d’s > 0.40), we found the following scales had

higher averaged scale item scores for the high volume gel: Application (APP): Leakage, SEX:

Spreading Behavior, SEX: Messiness, SEX: Product Awareness, and SEX: Leakage. To the

contrary and equally consistent conceptually, SEX: Naturalness and SEX: Perceived Wetness had

higher averaged scale item scores for the low volume gel. These scores reflect hypothesized

relationships between volume and sensory experiences elicited by those gel volumes, with the high

volume gel being rated as spreading more, being more messy, and leaking more, and the low

volume gel feeling more like typical RAI (where lubricants usually are of lesser volume and are

applied externally). The SEX: Pleasure and SEX: Stimulating scales also exhibited conceptual

consistency, with higher endorsement of pleasure for the participant and his partner with the higher

volume gel, though both averaged scale item scores were below 2.0 (agreeing a little). See Table

II.b for specific details.

Table II.b.: Averaged Perceptibility (User Sensory Perception and Experience (USPE)) Scale Item Scores, Standard Deviations, Cronbach’s Coefficient Alphas (CCA), Cohen’s Effect Sizes (d), and p-values for Low- and High-volume Gel Comparisons

3.5mL 10mL Perceptibility (USPE) Scale¥ mean mean d* p- - description of constructs captured by each scale (sd) (sd) (d, r=0) value [CCA] [CCA] 1.19 1.43 1.51a APP*: Leakage - Leakage immediately upon insertion (N=7) (0.26) (0.50) .09 (.63) [.62] [.70]

2.40 2.87 SEX**: Spreading Behavior - Ease of stroke and product spread as .47 (0.92) (1.68) .51 sex continued (N=5) (.33) [.88] [.82] 1.24 1.45 SEX: Messiness - perceptions of the product feeling watery or .53 (0.32) (0.56) .38 leaking/dripping/messiness as sex continued (N=7) (.49) [.72] [.90] SEX: Perceived Wetness – Sensations of product covering the 3.13 2.63 .77 rectum by the end of sex; sensations of wetness, similar to post-sex (1.31) (0.90) .27 (.45) or post-orgasm (N=6) [.81] [.56] 2.09 2.80 SEX: Product Awareness - Aware of product intra-rectally during 1.43a (0.91) (0.96) .21 sex; feeling product moving in rectum (N=5) (.54) [.88] [.95] SEX: Leakage - Sensations of product leaking out during/after RAS; 1.45 2.00 sensation of the product close to anal sphincter by end of RAS; .60b (0.33) (1.31) .44 sensation of product in pubic hair after RAS; feeling the need to (.67) [.73] [.88] clean up after RAS (N=5) 1.39 1.61 SEX: Stimulating – perceptions of product enhancing sexual 1.90a (0.56) (0.89) .19 pleasure; stimulated (N=6) (.31) [.95] [.90] 3.00 2.21 SEX: Naturalness - Product felt natural, same as natural lubrication, 1.20 (1.02) (1.14) .049c leakage looked like natural fluids/lubes (N=8) (.73) [.98] [.81] 1.43 1.71 SEX: Pleasure - Product made sex better for partner; stimulated .47 (0.66) (0.78) .42 partner; pleasurable for both (N=7) (.40) [.84] [.57] ¥ Rectal USPE scales not included (data not shown): APP: Ease, APP: Discreet-Portable, APP: Product Awareness, SEX: Initial Penetration, SEX: Initial Lubrication, SEX: Lubricity, SEX: Effortful, SEX: Noticeable Columns 2 & 3 contain means with standard deviations in parentheses and Cronbach’s coefficient alpha beneath; column 4 contains the adjusted Cohen’s d effect size using the correlation between measures with the Cohen’s d effect size in parentheses computed with no correlation; column 5 is the p-value for each analysis. Effect sizes of d=.2, d=.5, and d=.8 are considered, respectively, small, medium and large. * APP: application experience scale; ** SEX: sexual activity experience scale a Denotes very high correlation (>.80) that greatly increased analysis effect size, and may not be stable. b Denotes negative correlation between measurements that reduced analysis effect size. c One item removed from scale construction because 7 of 8 participants in high volume condition had missing data on this item. This resulted in a 3-item scale used to compare groups.

When asked to focus on the sensory experience of each product during RAI, four participants

responded that they would “definitely” use either product to reduce their chance of getting HIV.

Two responded that they would “probably” use either product. One participant was “unsure” of his

willingness to use either product. Further, when asked which of the two volumes they would

choose to use for HIV prevention if they had to choose one, five of eight chose the 3.5 mL volume, while three of eight chose the 10 mL volume.

Gel Volume Retention

After the first four subjects were scanned, it was apparent that no radiolabel remained in the colon

24 hours after dosing, and therefore, as pre-specified in the protocol, no further scans were performed at the 24-hour time point; 7 of 16 (43.8%) originally planned 24-hour scans were performed in 4 subjects. The applicator delivered a slightly greater, but statistically significant, percent of the 10 mL dose intra-colonically, median 94.8% (range 93.8-95.6%) when compared to the 3.5 mL dose, 88.6% (range 81.9 – 90.2%) using the Wilcoxon matched-pairs ranked-sum test

(p=0.012)

Luminal distribution

There were no significant differences in the four pharmacokinetic distance parameters between the

10 mL volume and the 3.5 mL volume of gel (Figure 1; all p values > 0.05, paired Wilcoxon rank sum test). Median Dmin was 0.42 cm (range -0.24 to 1.56 cm) for the 10 mL volume and 0.24 cm

(range 0.35 to 0.96 cm) for the 3.5 mL volume; Dave was 3.18 cm (2.81 to 4.38 cm) for the 10 mL volume and 3.32 cm (2.75 to 6.03 cm) for the 3.5 mL volume; DCmax was 3.55 cm (1.96 to 5.98 cm) for the 10 mL volume and 4.02 cm (1.81 to 6.30 cm) for the 3.5 mL volume; and Dmax was

6.58 cm (6.00 to 16.43 cm) for the 10 mL volume and 6.52 cm (5.78 to 12.30 cm) for the 3.5 mL volume. (See Figure II.b.)

Figure II.b. Pharmacokinetic distance parameters for two volumes (3.5 mL and 10 mL) of HEC gel delivered through applicator. Dmin is the most distal location at which signal is detected, Dmax is the most proximal location of signal detection, DCmax is the distance at which maximum signal intensity is found, and Dave is the mean residence distance. All distances are relative to the anorectal junction (of which distance equals zero) with progression proximally defined as a positive direction. Each symbol represents one individual subject. HEC, hydroxyethyl cellulose.

17 cm

10 10 cm

8 7 cm

4 cm

3 0 cm

2333

Discussion

This study evaluated two candidate rectal microbicide gel volumes using luminal distribution of radiolabeled gel at 4 hours, safety assessments, perceptibility assessments, and acceptability assessments, and found that there were no statistically significant differences in any of these measures. The slight difference in the percent of gel dose retained internally between the two volumes is partly explained by the larger percentage of the dose in dead space for the smaller volume syringe. The distributions seen in this study are consistent with our past work which has demonstrated that isoosmolar gels tend to distribute proximally to 20 cm by 2 hours after dosing, and migrate slightly more distally by 4 hours after dosing.(48)

The present study examines luminal distribution as the initial drug distribution step which largely determines secondary distribution of drug into adjacent colonic tissue. Adequacy of luminal distribution has been assessed in two ways: luminal distribution of HIV surrogates alone after simulated anal sex and by in vivo mixing experiments in which microbicide candidate dosing is

followed by simulated ejaculation of viral surrogates and coincident distribution is assessed.

Distribution of both the 3.5 mL and 10 mL HEC gel in this study is consistent with the luminal distribution of the cell-free and cell-associated HIV surrogates in autologous semen after simulated anal sex in prior work, (31) and in prior studies using 10 mL gel volumes, HIV cell-free surrogate was observed to mix nearly to completion (86%) with a rectal microbicide vehicle. (33) It is our suspicion that with 3.5 mL volumes, while distribution may be the same, the mixing with as much as a 2.5 mL ejaculate in the lumen is less effective than with a 10 mL volume.

Among other important study limitations, the product examined vehicle only without API. This also prevented our assessment of tissue API concentrations. In particular, tissue drug concentration and homogeneity in the region of expected HIV distribution would be highly influential in rectal microbicide product development and are influenced by more variables than luminal distribution alone. Past studies have evaluated some of these issues. In the CHARM-02 trial, the 10 mL tenofovir gel was co-located with 86% (standard deviation 19%) of the viral surrogate

(administered in a 2.5mL semen suspension) based on dual-isotope SPECT imaging. (33)

However, even assuming that luminal distribution of a gel has a direct relationship to mucosal distribution, it is unknown whether the excellent mixing of 2.5mL of ejaculate with 10mL of microbicide observed in the CHARM 02 study would be mirrored by similarly excellent mixing of

2.5mL of ejaculate with a smaller, 3.5mL volume. Acting solely on the basis of luminal distribution might ignore the critical piece of microbicide mixing with semen and HIV.

As mentioned, this study was performed only in adult men. While the ultimate goal of developing an effective HIV microbicide would be to develop a product for women and adolescents too, and for dual compartment use, the goal of this study was to describe the rectal distribution of differing volumes of Universal Placebo. There is a crucial need to involve women and adolescents in future

clinical development where inclusion is more statistically sound, with larger sample sizes and where planned comparisons between genders and across the age spectrum can be performed.

This is the first study to use perceptibility (USPE) measures for product evaluation in receptive anal intercourse. Differences of a half a standardized deviation or greater were noted in a subset of user sensory perception and experiences (USPEs) scales between the volumes experienced in this sample, but, given the small sample size, statistical power was low, and comparisons in USPE scale scores should be interpreted as preliminary. In general, effect sizes for behavioral measures are typically in a medium effect size range (i.e., d=.50), and require larger samples to be adequately powered to achieve statistical significance. (49) However, averaged USPE scale item scores show little differences in the sensations participants felt when evaluating the two volumes of gel. These perceptibility responses suggest that both volumes of gel elicit similar sensory experiences. When perceptibility responses are aligned with the acceptability (i.e., willingness to use) responses, and with the imaging data, the overall interpretation of the data suggest that either volume could be tolerated and would likely be used in similar participants. Larger psychometric validation studies would allow for more robust analyses of user sensory experience patterns that could further delineate which product properties, including volume, will most consistently and clearly predict user sensory experiences, and practices. Subsequent studies with larger sample sizes could add great value in using USPEs to better understand the relationship between product properties,

USPEs, drug delivery, acceptability and use.

Overall, our study suggests that both volumes of HEC universal placebo gel administered rectally are safe and well-tolerated by participants, consistent with numerous prior studies of a variety of gels. Furthermore, both of these volumes distribute in the same manner within the distal colon.

Fundamental questions of tissue concentrations of API and their persistence, luminal mixing of microbicide and virus, pharmacodynamic measures such as antiviral effect, and other formulation

factors remain for further study, and are active areas of investigation in several ongoing projects within the larger Integrated Preclinical/ Clinical HIV Topical Microbicide Program. This study addresses an important pharmaceutical variable in optimizing formulation development of a much needed, safe, effective, and highly acceptable rectal microbicide for the prevention of rectally- acquired HIV.

Acknowledgments

The authors gratefully acknowledge the time and contributions of the research participants in this clinical study, the staff of the Drug Development Unit, and the kind assistance of Jeff Leal of the

Image Response Assessment Team (IRAT) Lab at Johns Hopkins University and Jim Turpin of the

Integrated Preclinical/ Clinical HIV Topical Microbicide Program.

Funding

NIH U19AI101961 Development and Evaluation of Dual Compartment Combination

Microbicides; NIH T32 GM066691-11 and GM066691-12, NIGMS.

Author Disclosure Statement

The authors have no disclosures to report.

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Section III.

Colorectal Distribution of Lymphocytes and Cell-Free HIV Surrogate in Autologous Seminal Plasma Following Simulated Anal Intercourse

E.D. Weld 1, 2,, K. Ogasawara3, E.J. Fuchs1, C.W. Hendrix1,2

2Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; 2Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA; 3Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

Abstract Background: Unprotected anal intercourse remains the greatest HIV sexual transmission risk for men who have sex with men (MSM). Rational design of topical rectal antiretroviral microbicides depends critically on understanding the spatiotemporal distribution of HIV infectious elements throughout the colorectal space.

Objective: The objective of this study was to explore the luminal distribution and clearance of cell- associated (lymphocytes) and cell-free (seminal plasma) HIV surrogates within the distal colon following simulated receptive anal intercourse.

Methods: Six healthy, HIV-uninfected men were recruited and gave semen samples in sterile containers. Samples were centrifuged and the supernatant (seminal plasma) collected and frozen.

Peripheral blood lymphocytes were harvested from subjects via apheresis and labeled with 111Indium (In)-oxine on the dosing day. 111In-labeled autologous lymphocytes and 99Technetium (Tc)-sulfur colloid (HIV surrogate) were reconstituted with 3 mL of autologous seminal plasma. Reconstituted seminal plasma was inserted into the rectum using a phallic device with artificial urethra; the device was manipulated to simulate the physical stresses of coitus.

Distribution of radiolabels in time and space was assessed with SPECT/CT at 3 timepoints.

Analysis of radiolabel distribution was performed using a flexible principal curve algorithm in R.

Pharmacokinetic distance parameters were defined as follows: Dmin (most distal signal, closest to the anorectal junction); DCmax (point of most intense signal); Dave (average distance, similar to

MRT); and Dmax (most proximal signal, furthest from the anorectal junction).

Results/ Findings: Median (interquartile range (IQR)) Dmax for cell-associated (In) and cell-free

(Tc) HIV surrogate was 14.59 cm (13.63, 15.78) & 16.46 cm (13.73, 16.92), respectively. Median

(IQR) DCmax for cell-associated (In) and cell-free (Tc) HIV surrogate was 6.15 cm (5.22, 8.51) &

7.08 cm (5.45, 7.57), respectively. Median minimum distance traveled from the anorectal junction

(Dmin) for cell-associated (In) and cell-free (Tc) HIV surrogate was 0.95 cm (-0.08, 3.45) & 1.73 cm (-0.08, 2.92). Median (IQR) Dave was 6.13 (5.15, 8.44) for cell-associated HIV surrogate and

7.12 (5.23, 7.23) for cell-free surrogate. There were no significant differences in any PK distance distribution parameter between cell-free and cell-associated HIV surrogate.

Conclusions: Cell-free and lymphocyte-associated HIV distribution throughout the colorectum can be quantified and characterized with temporal-spatial pharmacokinetic methods. Both autologous lymphocytes and HIV surrogate particle in seminal plasma distribute to a maximal distance of around 15 cm from the anorectal junction (which is ~19 cm from the anal verge), with a maximal signal intensity around 6 cm from the anorectal junction. This represents and maps the ideal target distribution for rectal microbicides.

Introduction

The highest burden of HIV in the U.S. is borne by men who have sex with men (MSM), who have a prevalence estimated at 15% and new diagnosis rate of 0.7 per 100 (1,3)For African-American

MSM in the USA, the lifetime prevalence of HIV is 1 in 2. In other parts of the world, MSM and transgender women (TGW) have a markedly disproportionate burden of HIV compared to

UNAIDS estimates of the prevalence of HIV in adult males.(50-52) Estimated prevalence ratios of

HIV in MSM compared to the general population have ranged from 3:1 to 25:1.(51) Globally, there is a 48-fold higher risk of HIV among TGW than among the population at large.(53) Regardless of gender, receptive partners who practice condomless receptive anal intercourse (cRAI) are at high risk of HIV.

It is now well understood that condomless receptive anal intercourse (cRAI) carries the highest per- act risk of HIV acquisition of all sexual behaviors. The per-act risk of HIV from cRAI has been estimated as high as 1.38%, as compared to 0.08% for receptive vaginal intercourse and 0.01% for insertive anal intercourse.(54, 55) This is likely a dominant factor explaining the disproportionate incidence and prevalence of HIV in people who practice condomless receptive anal intercourse—of which there is a well-established prevalence in both women and men. The estimated proportion of heterosexual women who practice RAI is 1 in 4, and up to 81% the time, women’s most recent anal sex encounters were condomless, often depending on whether with a steady or casual partner); among MSM, rates of cRAI within the past 2 years of up to 42% have been reported.(56-58)

Pre-exposure prophylaxis (PrEP), a strategy of uninfected people taking combination antiretrovirals to prevent HIV infection, has been established as highly effective, with a protective efficacy of

>97% in the setting of fastidious adherence. However, PrEP as a preventive strategy has been hobbled by adherence concerns. Expanding the armamentarium of choices for PrEP demands consideration of topical, user-dependent products that can be used on demand in a sexual context to

prevent HIV, and do not require healthy people to adhere to daily oral medications. In the absence of an effective vaccine, cure, or widespread consistent use of barrier methods such as condoms, topical prevention strategies such as microbicides can and should play a key role in stemming the

HIV epidemic. Microbicides are products applied to the relevant sexual mucosa by receptive partners to prevent the acquisition of sexually transmitted infections including HIV. They are as yet untested in phase 3 trials, but may ultimately be found to be effective to prevent HIV when used in an on-demand manner prior to sex. Also crucially, topical products can be viewed as consistent with (and not detracting from) sexual pleasure, are controlled by the receptive partner, and do not require any action from the insertive partner.

The past five years have seen a modest burst of studies on topical rectal microbicides.(33, 35, 36)

Originally formulated as gels and films for vaginal use by receptive partners, topical microbicides have evolved to be considered and studied for pericoital rectal use by receptive partners. Some advantages of such topical methods are that they result in lower systemic levels of drugs while maintaining adequate levels at the sexual tissue most relevant for exposure, they can be used in an

“on-demand” manner because they rapidly achieve levels of drug in tissue that can be considered adequate for protection, and in some cases, the formulation can be congruent with product use already a part of existing sexual behaviors (e.g., douching or lubricant use). Recent macaque SHIV challenge studies, as a model of human HIV infection, have revealed a high level of protection from a rectal tenofovir-containing douche; 5 out of 6 animals given a single tenofovir douche were protected against repeated weekly rectal challenge with SHIV, in comparison to 3 out of 6 animals given oral Truvada®. (59)

Rational design of topical rectal antiretroviral microbicides depends critically on understanding the spatiotemporal distribution of HIV infectious elements throughout the colorectal space, so that microbicides intended as HIV PrEP can be designed to outdistance and outlast that distribution.

Previous work has found that the distribution of candidate microbicide gels and seminal fluid surrogates throughout the gastrointestinal tract can be described quantitatively with both indirect single photon emission computed tomography (SPECT)/computed tomography (CT) and magnetic resonance imaging (MRI).(34, 42) Others have demonstrated that periluminal HIV target cells

(including CD4+ T cells, antigen-presenting cells, and an HIV-binding molecule gp340 expressed by epithelial cells) are present in simple columnar epithelium within the rectal/ sigmoid region.(60)

Immunological elements that affect the location, activation status, or trafficking of these HIV target cells are likely also to influence mucosal transmission of HIV; regardless, topical drug prevention efficacy will depend critically on co-localization of drug and virus.(61) The precise luminal distance traveled by HIV in seminal fluid is as yet unknown except in descriptive analyses. These indicate that both cell-free and cell-associated surrogates migrate to a largely overlapping distribution within the rectosigmoid colon after simulated receptive anal intercourse. In effort to understand the luminal distribution of HIV within the colorectal space, we quantitatively assessed the distribution of radiolabeled cell-free and cell-associated HIV surrogates administered rectally to male participants.

Methods

University School of Medicine reviewed and approved this study. The primary study has been previously reported.(31) Briefly, the study took place over a total of four visits, consisting of two outpatient screening visits, a single two-day inpatient hospitalization, and a follow-up outpatient visit. Six healthy, HIV-uninfected men were recruited, gave their informed consent for

participation, and enrolled in the study. Cell-free HIV, with a particle diameter of 120 nm, was simulated by a commercially-available radiolabeled sulfur colloid in solution, which was chosen because of its similar average particle size of 100 nm. (62) Cell-associated HIV (such as would be integrated within CD4+ lymphocytes) was simulated by radiolabeling autologous lymphocytes harvested from participants

Lymphocyte Harvesting. Upon inpatient admission, subjects underwent up to 4 hours of apheresis to harvest from whole blood a fraction enriched with lymphocytes.

Seminal Plasma Harvesting. Before admission, participants underwent collection of semen into sterile containers, from which seminal plasma was isolated and frozen at −80°C until dose preparation. Subjects collected their own ejaculate during 2 or 3 collections, to obtain 3 mL of seminal plasma. Seminal plasma was isolated from the ejaculate by centrifugation, and then frozen at -20oC.

To avoid errors in matching autologous samples to their source participant, only one subject entered the autologous sample collection portion of the study at a time, and each product was labeled with two unique identifiers and cross-confirmed with two personnel at each step of dose preparation (harvesting to administration).

Radiolabeling. Peripheral blood lymphocytes (harvested via apheresis) were labeled with 111In- oxine on the dosing day. The cell-free HIV surrogate preparation consisted of 37 MBq (±10%) radiolabeled, inert 99mTc-sulfur colloid particles (Cardinal Health, Timonium, MD) mixed with 0.5 mL of previously collected autologous seminal plasma, also mixed on the morning of dosing. The apheresis product (lymphocytes) was radiolabeled with 9.25 MBq (±10%) 111In-oxine (Cardinal

Health, Arbutus, MD) and re-suspended in 2.5 mL of autologous seminal plasma.

Coital Dynamics Simulation. A method of simulating sex with a device called a Coital Dynamics

Simulator (CDS) was employed. This method has been previously described, and is a useful way of understanding the impact of simulated sex on the distribution of topical products, and based on that estimating the impact of real-life intercourse. The Coital Dynamics Simulator (CDS) was engineered as follows: a synthetic phallus of length 15.24 cmcm and glans width 3.5 cm (The

Naturals™, Doc Johnson Enterprises; Hollywood, CA) was modified via midline insertion of a triple lumen central intravenous catheter (TLC) (Arrow product no. AK‐14703, Arrow

International, Reading, PA) to simulate a urethra. The simulation process was as follows. The CDS was inserted into the rectum. Once within the rectum, the device was manipulated for five minutes at a frequency of 1 Hertz to simulate the physical stresses of coitus (guided by metronome for consistency). With the CDS device fully inserted in rectum, a volume of 3 mL of seminal fluid containing 99mTc-SC and 111In-labeled lymphocytes was administered by study staff simultaneously through two lumens of the TLC in the CDS, to simulate ejaculation, with subsequent dead-space flush to ensure administration of the entire volume. An additional 10 phallus cycles were performed at a frequency of 1 Hz, after which the device was removed. The rate and duration parameters for the coital simulation were selected based on focus group data describing typical coital experiences. Radiolabel remaining on syringes, gloves, and the CDS was assessed in a dose calibrator (CRC 15-W; Capintec, Ramsey, NJ).

Imaging. Single photon emission computed tomography (SPECT)/computed tomography (CT) was performed to assess both distribution (via extent of radiolabel through colon) and clearance

(via change in radiolabel signal over time). Images of the distribution of radiolabel were captured using a dual-head VG series system (GE Medical Systems, Waukesha, WI) integrated with a QE

Infinia Hawkeye 4 low-dose, helical CT scanner (GE Healthcare). SPECT/CT was performed at the

following time points: immediate (1 hour), 8 hours, and 24 hours post-dose. Detectors for both

99mTc and 111In were used.

Imaging Analysis & Tubefitting. Analysis of distinct 99mTc and 111In radiolabel distribution was performed as follows: Digital Imaging and Communications in Medicine (DICOM) images from the CT scan were joined via co-registration with images of radiolabel to form 3-D reconstruction images with radiolabel synchronized in space to bony anatomical landmarks, using the Xeleris platform (GE Healthcare). The images were attenuation corrected to correct for isotope disintegrations that are attenuated by incomplete passage through bone. On the sagittal view of the

3-D reconstruction, the most distal point at which radiolabel signal was seen was marked, as well as the coordinates of the anorectal junction. The anorectal junction was localized by finding the most distal slice in the transaxial plane which contained air-filled rectum, and visualizing, just under it, the pubococcygeal sling. The slice with the pubococcygeal sling was designated as the anorectal junction. (The anorectal junction is generally 4 cm above the anal verge; to arrive at distances that are more interpretable for endoscopists, adding 4 cm to the PK distance parameters we list would give distances relative to the anal verge).

Images were converted to raw disk image file format using the program MRICro, (63) and then analyzed via a tubefitting algorithm in R (The R Project for Statistical Computing) (64) that constructed a flexible principal curve algorithm through the center of the radiolabel. Concentration was computed as follows: Mass SPECT detected counts per minute (CPM), and this value was adjusted by detector efficiency to determine disintegrations per minute (DPM) (for each unstable isotope, the disintegrations represent mass). To arrive at volume measurements, the tube-fitting program moved a discoid of predetermined volume orthogonally along the previously determined centerline. At each step, the CPM within the discoid of a specified radius and thickness (hence

volume) were counted. The mass from SPECT divided by volume from tube-fitting program results in concentration at each discrete location along the centerline.

This tubefitting process generated a list of concentration-distance pairs which could be analyzed in

Phoenix WinNonLin (Certara®, Princeton, NJ) to arrive at general pharmacokinetic distance parameters, using distance as a surrogate for time. Pharmacokinetic distance parameters were defined as follows: Dmin (most distal signal, closest to the anorectal junction); DCmax (point of most intense signal); Dave (“average” or mean residence distance of total radiolabeled signal, similar to mean residence time [MRT]); and Dmax (most proximal signal, furthest from the anorectal junction). The previously measured distance between the anorectal junction and the start of radiolabeled signal was added to the distances computed, in order to arrive at distances relative to the anorectal junction.

Results

All of the SPECT CT scans displayed a limited rectosigmoid distribution of radiolabel, with signal not extending to the anus distally or beyond the pelvic bowl proximally. A high degree of co- localization between the two radiolabels was seen, with 91-97% of 99mTc signal found to coincide anatomically with 111In signal at one hour post-dose, and 84% signal overlap in most subjects at 4 hours post-dose. (30) Median minimum distance traveled from the anorectal junction (Dmin) for cell-associated (In) and cell-free (Tc) HIV surrogate was 0.95 cm (-0.08, 3.45) & 1.73 cm (-0.08,

2.92). Median (IQR) Dave was 6.13 (5.15, 8.44) for cell-associated HIV surrogate and 7.12 (5.23,

7.23) for cell-free surrogate. There were no significant differences in any PK distance distribution parameter between cell-free and cell-associated HIV surrogate. As can be seen in Table 1, median

(IQR) Dmax for cell-associated (In) and cell-free (Tc) radiolabeled HIV surrogate was 14.59 cm

(13.63, 15.78) & 16.46 cm (13.73, 16.92), respectively, indicating that the radiolabeled surrogates traveled these maximum distances through the colon from the anorectal junction. Median (IQR)

DCmax for cell-associated (In) and cell-free (Tc) HIV surrogate was 6.15 cm (5.22, 8.51) & 7.08 cm

(5.45, 7.57), respectively, indicating that these were the distances at which the maximum intensity of radiolabeled surrogates was observed. The median minimum distance traveled from the anorectal junction (Dmin) for cell-associated (In) and cell-free (Tc) HIV surrogate was 0.95 cm (-

0.08, 3.45) & 1.73 cm (-0.08, 2.92).. Finally, the median (IQR) Dave, which describes the average amount of distance traveled by each particle, was 6.13 (5.15, 8.44) for cell-associated HIV surrogate and 7.12 (5.23, 7.23) for cell-free surrogate. No significant differences were found between cell-free and cell-associated HIV surrogates for any of the distance parameters.

Table IIIa: Pharmacokinetic Distance Parameters for Distribution of 111In-Labeled Lymphocytes and 99Tc-labeled HIV Surrogate Particle Through Colorectal Space Cell-Associated Cell-Free (Sulfur colloid; Tc) P value* (Lymphocytes; In) PK Median Median Distance N (25-75 percentile) (25-75 percentile) Parameter (cm) (cm) at 1 hr

Dmin 6 0.95 (-0.08, 3.45) 1.73 (-0.08, 2.92) 0.75 Dave 6 6.13 (5.15, 8.44) 7.12 (5.23, 7.23) 0.77 Dcmax 6 6.15 (5.22, 8.51) 7.08 (5.45, 7.57) 0.73 Dmax 6 14.59 (13.63, 15.78) 16.46 (13.73, 16.92) 0.76 ______

*Wilcoxon Signed Rank Test In order to assess for a possible impact of time on distribution of radiolabeled surrogate, the individual participants’ distance parameters were plotted separately for each subject, and are displayed in Figure 1. While it is difficult to arrive at a clear interpretation from the individual plots, some common themes emerge. In the majority of participants, the Dmax decreased significantly over the period from 1 hour to 4 hours post-dose, indicating a slight anterograde recession of the “leading edge” of radiolabeled product over time. By the 8-hour timepoint, however, the Dmax was generally significantly larger than at the 4 –hour timepoint, particularly

for the cell-associated surrogate. Many of the other PK distance parameters remained fairly stable with time (Statistical comparisons displayed in Table 2).

Table IIIb. P-values (Direction of difference) for Comparison of PK Distance Parameters By Timepoint (Wilcoxon Rank Sum Test) Cell-Associated HIV Surrogate (Lymphocytes); In

Timepoints 4 vs 1 8 vs 1 8 vs 4 (hours) Dmin 0.026 (1>4) 0.203 0.026 (4>8)

Dave 0.026 (1>4) 0.203 0.026 (8>4)

DCMax 0.083 (1>4) 0.203 0.013 (8>4)

DMax 0.013 (1>4) 0.289 0.013 (8>4)

Cell-Free HIV Surrogate; Tc

Timepoints 4 vs 1 8 vs 1 8 vs 4

Dmin 0.391 0.391 0.289

Dave 0.133 0.026 (1>8) 0.203

DCMax 0.203 0.203 0.203

DMax 0.134 0.003 (1>8) 0.026 (4>8)

Figure IIIa. Distance Parameters Versus Time for Cell-Associated (left panels) and Cell-Free (right panels) HIV Surrogates. Rectosigmoid distribution over time for cell-sssociated (left panels) and cell-free (right panels) HIV surrogates. Plots indicate PK-distance parameters over time (non-proportional time on x-axis) for each research participant. Time is relative to simulated intercourse and distance is relative to the anorectal junction. Data is derived from 3-dimensional tube-fitting of HIV surrogate radioisotopes. a. b.

L014 In L014 Tc

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Discussion

In this study, the luminal colonic distribution of autologous seminal lymphocytes and seminal HIV surrogates was examined and described. The chief characteristic that determined surrogacy for cell- free HIV was size; sulfur colloid is a molecule of a similar diameter to an HIV-1 virion. Other properties of sulfur colloid, however, might differ enough so as to call into question its suitability as surrogate. These include charge (e.g., the V3 loop of HIV envelope gp 120 has a net positive charge of +2 to +4, whereas sulfur colloid is uncharged)(65), protein binding, tissue binding, movement through mucous, and interaction with immune cells, among others,. It is possible that virions interact differently (in a velocity-determining and distribution-determining way) with human tissues, by binding, than does sulfur colloid. As it was not ethically acceptable to administer allogeneic inactivated HIV to human subjects, a simulacrum (autologous semen and lymphocytes) was used, at the risk of suboptimal simulation of an infectious event (particularly given that the administered substances would not be recognized as foreign by the host immune system). Particles such as sulfur colloid, which do not generate an immune response, could have a more widespread distribution in the lumen because antibodies like secreted IgA will not affect their movements.

This study was limited in that it was assessing an indirect “surrogate” particle rather than HIV itself. In addition, while macroscopic luminal distribution is one parameter of interest, it must be

viewed in combination with tissue penetration and distribution parameters, which were assessed via endoscopic brushings and biopsies in this study and previously reported. (30) The impact of time on the distribution of radiolabel could be confounded by the degradation of radiolabeled lymphocytes or the spontaneous release of 111In from lymphocytes, (66) though previous work has shown that labeled lymphocytes maintain integrity for 24 hours, and the parameter of most interest

(DCmax) would be the most resistant to radioactive decay-induced changes.

Microbicide developers wishing to incorporate our data into conceiving of ideal product characteristics will likely aim to be conservative and target the worst-case scenario of HIV particle range with their product coverage. The fact that there is a very similar distribution for cell-free and cell-associated HIV is intriguing. Simultaneous injection of the two isotopes through separate ports in a double lumen catheter makes it possible that the two signals ended up exactly coincident in space. However, it is also important to consider possible confounders. Indium is a higher energy isotope than Technetium, and emits two gamma rays of varying energy for each disintegration.

Gamma rays from the lower energy emission may be detected and read by the scanner as a

Technetium disintegration. In preliminary phantom studies performed by nuclear medicine colleagues, about 5% of all Indium signal appeared in the Tc window. All images were processed to filter out this “cross-talk”, but even the filtered images were at times difficult to interpret.

In terms of correlation with plausible distances in the real world, the injection device was 6” (15.24 cm) in length. Allowing 3-4 cm for the thickness of the anus, and another 1-2 cm for not having the device fully inserted, the range of Dmax (allowing some migration after injection) and DCmax are anatomically consistent. It is possible that device manipulation, along with colonic muscular contractions, might distribute some of the signal distally (closer to the anorectal junction) or proximally. The device might trigger bidirectional (longitudinal and circumferential) colonic muscular contractions in addition to (possibly) other smooth muscle activity. Another unknown is

the impact of device on stretching both the width and length of the colon, and possibly straightening the sigmoid curve; we have seen clear differences of distribution measurements when comparing direct aspirates collected with sigmoidoscope and indirectly assessed by SPECT/CT.

Conclusions. Understanding distal colonic distribution of HIV, both cell-free and cell-associated, enables the rational development of microbicides that overlap its distribution. Cell-free and lymphocyte-associated HIV distribution throughout the colorectum can be quantified and characterized with temporospatial pharmacokinetic methods. Both autologous lymphocytes and

HIV surrogate particle in seminal plasma distribute to a maximal distance of around 15 cm from the anorectal junction, with a maximal signal intensity around 6 cm from the anorectal junction.

This represents and maps the ideal target distribution for rectal microbicides, in the setting of no other products in the colorectal space. Future studies with dual isotope imaging, where distribution of HIV surrogate and microbicide candidate are assessed simultaneously, stand to improve upon our understanding of optimal distribution characteristics.

Section III References. 1. Rosenberg ES, Grey JA, Sanchez TH, Sullivan PS. Rates of Prevalent HIV Infection, Prevalent Diagnoses, and New Diagnoses Among Men Who Have Sex With Men in US States, Metropolitan Statistical Areas, and Counties, 2012-2013. JMIR Public Health Surveill. 2016;2(1):e22. 2. Beyrer C, Baral SD, van Griensven F, Goodreau SM, Chariyalertsak S, Wirtz AL, et al. Global epidemiology of HIV infection in men who have sex with men. Lancet. 2012;380(9839):367-77. 3. (CDC) CfDC. Diagnoses of HIV Infection in the US and dependent areas. HIV Surveillance Report. 2016;26. 4. Baral SD, Poteat T, Stromdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis. 2013;13(3):214-22. 5. Vittinghoff E, Douglas J, Judson F, McKirnan D, MacQueen K, Buchbinder SP. Per- contact risk of human immunodeficiency virus transmission between male sexual partners. Am J Epidemiol. 1999;150(3):306-11. 6. Patel P, Borkowf CB, Brooks JT, Lasry A, Lansky A, Mermin J. Estimating per-act HIV transmission risk: a systematic review. AIDS. 2014;28(10):1509-19. 7. Misegades L, Page-Shafer K, Halperin D, McFarland W, Survey YWSSIGYWs. Anal intercourse among young low-income women in California: an overlooked risk factor for HIV? AIDS. 2001;15(4):534-5. 8. Baldwin JI, Baldwin JD. Heterosexual anal intercourse: an understudied, high-risk sexual behavior. Arch Sex Behav. 2000;29(4):357-73. 9. Erickson PI, Bastani R, Maxwell AE, Marcus AC, Capell FJ, Yan KX. Prevalence of anal sex among heterosexuals in California and its relationship to other AIDS risk behaviors. AIDS Educ Prev. 1995;7(6):477-93. 10. McGowan I, Cranston RD, Duffill K, Siegel A, Engstrom JC, Nikiforov A, et al. A Phase 1 Randomized, Open Label, Rectal Safety, Acceptability, Pharmacokinetic, and Pharmacodynamic Study of Three Formulations of Tenofovir 1% Gel (the CHARM-01 Study). PLoS One. 2015;10(5):e0125363. 11. Hiruy H, Fuchs EJ, Marzinke MA, Bakshi RP, Breakey JC, Aung WS, et al. A Phase 1 Randomized, Blinded Comparison of the Pharmacokinetics and Colonic Distribution of Three Candidate Rectal Microbicide Formulations of Tenofovir 1% Gel with Simulated Unprotected Sex (CHARM-02). AIDS Res Hum Retroviruses. 2015;31(11):1098-108. 12. Anton PA, Cranston RD, Kashuba A, Hendrix CW, Bumpus NN, Richardson-Harman N, et al. RMP-02/MTN-006: A phase 1 rectal safety, acceptability, pharmacokinetic, and pharmacodynamic study of tenofovir 1% gel compared with oral tenofovir disoproxil fumarate. AIDS Res Hum Retroviruses. 2012;28(11):1412-21. 13. Xiao P GS, Marzinke MA, Date AA, Hoang T, Hanes J, Ensign LM, Wang L, Rohan L, Cone R, Fuchs EJ, Hendrix CW, Villinger F. Hypoosmolar Rectal Douche Delivers Tenofovir to the Rectal Mucosa and Effectively Protects Macaques Against Repeated SHIV Challenges. HIVR4P October 23, 2018; Madrid, Spain2018. 14. Cao YJ, Caffo BS, Fuchs EJ, Lee LA, Du Y, Li L, et al. Quantification of the spatial distribution of rectally applied surrogates for microbicide and semen in colon with SPECT and magnetic resonance imaging. Br J Clin Pharmacol. 2012;74(6):1013-22. 15. Hendrix CW, Fuchs EJ, Macura KJ, Lee LA, Parsons TL, Bakshi RP, et al. Quantitative imaging and sigmoidoscopy to assess distribution of rectal microbicide surrogates. Clin Pharmacol Ther. 2008;83(1):97-105.

16. Patyka M, Malamud D, Weissman D, Abrams WR, Kurago Z. Periluminal Distribution of HIV-Binding Target Cells and Gp340 in the Oral, Cervical and Sigmoid/Rectal Mucosae: A Mapping Study. PLoS One. 2015;10(7):e0132942. 17. Burgener A, McGowan I, Klatt NR. HIV and mucosal barrier interactions: consequences for transmission and pathogenesis. Curr Opin Immunol. 2015;36:22-30. 18. Fisher BH, Richard P., Champe, Pamela C. . Lippincott's Illustrated Reviews: Microbiology. Hagerstown, MD: Lippincott Williams & Wilkins; 2007. 19. Rorden C, Brett M. Stereotaxic display of brain lesions. Behav Neurol. 2000;12(4):191- 200. 20. Team RC. R: A language and environment for statistical computing. Vienna, Austria2013 [Available from: http://www.R-project.org/. 21. Louissaint NA, Fuchs EJ, Bakshi RP, Nimmagadda S, Du Y, Macura KJ, et al. Distribution of cell-free and cell-associated HIV surrogates in the female genital tract after simulated vaginal intercourse. J Infect Dis. 2012;205(5):725-32. 22. Santangelo PJ, Rogers KA, Zurla C, Blanchard EL, Gumber S, Strait K, et al. Whole-body immunoPET reveals active SIV dynamics in viremic and antiretroviral therapy-treated macaques. Nat Methods. 2015;12(5):427-32. 23. Ensign LM, Hoen TE, Maisel K, Cone RA, Hanes JS. Enhanced vaginal drug delivery through the use of hypotonic formulations that induce fluid uptake. Biomaterials. 2013;34(28):6922-9. 24. ten Berge RJ, Natarajan AT, Hardeman MR, van Royen EA, Schellekens PT. Labeling with indium-111 has detrimental effects on human lymphocytes: concise communication. J Nucl Med. 1983;24(7):615-20.

Section IV:

Interest of Youth Living with HIV in Long-Acting Antiretrovirals

Ethel D. WELD, M.D.3, Md Sohel RANA, M.B.B.S., M.P.H.4, Ronald H. DALLAS, Ph.D.5,

Andres F. CAMACHO-GONZALEZ, MD, M.P.H.6,5, Patrick RYSCAVAGE, M.D., M.P.H.6,

Aditya H. GAUR, M.D.3, Rana CHAKRABORTY, M.D., M.Sc., D.Phil.4, 5 Susan SWINDELLS,

M.B.B.S.7, Charles FLEXNER, M.D.1, Allison L. AGWU, M.D., Sc.M.8

Publication citation: Weld ED, Rana MS, Dallas RH, Camacho-Gonzalez AF, Ryscavage P, Gaur AH, Chakraborty R, Swindells S, Flexner C, Agwu A. “Interest of Youth Living With HIV in Long-Acting Antiretrovirals” JAIDS 80(2):190-197. February 1, 2018.

Conflicts of Interests & Sources of Funding:

EDW is a co-investigator on a trial funded by ViiV-GSK under a clinical research contract managed by Johns Hopkins University. CF reports serving as a paid consultant for Cipla, Janssen, Merck, Mylan, and ViiV Healthcare, and was a co-investigator on a trial funded by Gilead

3 Divisions of Clinical Pharmacology & Infectious Diseases, Johns Hopkins University, Baltimore, MD, 21287, USA 4 Johns Hopkins Bloomberg School of Public Health, USA 5 Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, TN, USA 6 Division of Pediatric Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA 5 Ponce Family and Youth Clinic, Grady Infectious Diseases Program, Grady Health Systems 6 Division of Infectious Diseases, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA 7 Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA 8 Divisions of Adult & Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA

Sciences under a clinical research contract managed by Johns Hopkins University. RC and AG receive research support from Gilead as part of a clinical trial agreement between their respective institutions and Gilead Sciences. Andres Camacho-Gonzalez is a co-investigator on a trial funded by Janssen Pharmaceuticals under a clinical research contract managed by Emory University. SS reports research grants to her institution from ViiV and Merck. AA has served as a paid consultant for Gilead Sciences and Merck. For the remaining authors, no conflicts were declared.

Sources of Support: The Johns Hopkins University Center for AIDS Research (CFAR) under award number P30AI094189: Adolescent and Young Adult Scientific Working Group microgrant The National Institute of General Medical Sciences (NIGMS) of the National Institutes of Health (NIH) under T32 award numbers GM066691-11 & GM066691-12 The Johns Hopkins Clinical Research Scholars Program (KL2) The Pearl M. Stetler Research Award for Women Physicians The National Institute of Allergy and Infectious Diseases (NIAID) of the NIH (R24 AI 118397) The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Keywords

Adolescent HIV Treatment Long-Acting Antiretroviral Agents Patient Acceptance of Healthcare HIV Care Continuum

Abstract

Objectives: This study’s primary objective was to characterize attitudes to long-acting antiretrovirals (LAARV), among youth aged 13 to 24 years living with perinatally- and non- perinatally-acquired HIV (PHIV and NPHIV, respectively). Secondary objectives included: assessing whether those with detectable HIV RNA PCR viral load had higher enthusiasm for

LAARV compared to those with suppressed viral load, and examining characteristics associated with LAARV enthusiasm.

Methods: A cross-sectional survey of 303 Youth Living with HIV (YHIV) followed at four pediatric/adolescent HIV clinics in the USA was performed to determine interest in LAARV, using a modified survey instrument previously used in adults. Interest in LAARV across groups was compared. Poisson regression with robust variance was used to determine the impact of various characteristics on interest in LAARV.

1.12 [95% CI: 1.03 - 1.20]; p= 0.005). Female youth participants who had had past experience with implantable contraceptive methods had a significantly higher interest in LAARV (100% vs 85.5%; p=0.002). Proportion of respondents endorsing definite willingness to use was significantly higher with decreased injection frequency compared to increased injection frequency.

Interpretation: YHIV at four urban US pediatric/adolescent HIV clinics had high levels of enthusiasm for LAARV. LAARV should be given high priority as a potentially viable treatment option to improve clinical outcomes in YHIV.

Introduction Youth 13 to 24 years old comprise more than 1 in 5 of all incident US HIV infections, and are a high-risk group for non-adherence to antiretrovirals (ARV). (8, 67) Low rates of being linked to ongoing HIV care for those youth newly diagnosed with HIV is one of many factors leading to relatively low numbers of youth who achieve viral suppression nationwide and globally. Of note,

43% of U.S. youth who get linked to ongoing HIV care fail to sustain viral suppression. (67)

Almost half of adolescents who start a first line antiretroviral therapy (ART) regimen fail that regimen and require transition to a second-line regimen. (67, 68) Failure of second-line ART is more likely to be due to non-adherence to medications rather than development of viral resistance.(69) The overall 44% rate of viral suppression among adolescents and young adults living with HIV is the lowest of all age groups.(8) As a result, deepening HIV-related disparities in outcomes between youth and adults exist, with youth per se emerging as a dominant risk factor for sub-optimal adherence to ART.(70) Because younger age is a modifiable risk factor with the passage of time, novel and effective strategies to facilitate and improve adherence to ART in youth living with HIV (YHIV) are urgently needed.

Long-acting parenterally formulated nanosuspensions of selected ARV are currently in phase 3 testing for treatment of HIV, and stand to benefit YHIV particularly. Administration of long-acting cabotegravir and rilpivirine, in q 4 week or q 8 week intragluteal intramuscular (IM) injections to

HIV-infected, virally suppressed adults, maintains viral suppression as effectively as an oral combination ARV regimen over 96 weeks.(71) Because of the prolonged pharmacokinetic (PK)

“tail” of these compounds (i.e., concentrations after a single injection remain detectable in the body for longer than one year), any treatment regimen involving LAARV requires consistent follow-up in the context of ongoing access to care.(72) YHIV including those who struggle with sustaining

adherence to oral ARVs may be an ideal target population for such an intervention within the setting of a youth-friendly program.(73)

Critically absent from existing data is the youth perspective on LAARV technologies. There is a knowledge gap on the readiness of YHIV to adopt and adhere to LAARV. In order to assess this readiness, we surveyed the interest and attitudes of YHIV towards long-acting modalities of treatment. In addition, we examined the characteristics that confer greater enthusiasm for LAARV, to guide selection of the appropriate sub-populations in which to deploy LAARV. Prior work assessing interest and attitudes to LAARV for treatment among HIV-positive adults found a 73% overall rate of definite or probable willingness to use LAARV among 400 adults with a mean age of 47 years (range 18-71).(74) More recently, surveys of HIV-uninfected individuals have indicated interest in long-acting injectable forms of pre-exposure prophylaxis (PrEP) against HIV; it is estimated that if a licensed long-acting injectable was available for PrEP, it would increase overall uptake of PrEP by 24.5% compared to oral PrEP.(75-77) The acceptance of new technologies may differ across the age spectrum, and it is possible that youth may be more willing to adopt new technologies, particularly those that control underlying infection while conferring less intrusion in their daily lives. To our knowledge, this is the first effort to evaluate the attitudes of

U.S. youth towards the promising new technology of injectable or implantable LAARV. This will provide the pediatric and adolescent perspective currently absent from discussions about these technologies as well as inform decisions about deployment of LAARV in this key vulnerable population, especially surrounding design of research protocols and sample size and enrollment estimates.

Methods

Interest in LAARV was assessed in a population of 303 YHIV, 13 and 24 years of age, and receiving care at four pediatric & adolescent HIV clinics in the U.S.: St. Jude Children’s Research

Hospital in Memphis, TN; Emory University-Grady Infectious Disease Program in Atlanta, GA; and the University of Maryland and the Johns Hopkins Hospital in Baltimore, MD. The study was conducted at four sites, however only one participant was enrolled at the University of Maryland site. Therefore, for purposes of analysis and reporting, University of Maryland was grouped with

Johns Hopkins into a single group known as “Johns Hopkins”. The population included youth with both perinatally (PHIV) and non-perinatally acquired HIV (NPHIV), to assess the impact of mode of HIV transmission and length of time infected on possible pill fatigue and desire for non-daily modalities of HIV-treatment.

Institutional Review Boards (IRB) at all four institutions reviewed and approved this study.

Participants gave verbal informed consent at the time of the survey; those below the age of consent gave their assent to participate alongside their guardian’s consent. $10 gift cards were given as compensation for participants’ time and participation.

A one-time, cross-sectional Qualtrics® survey with 34 questions was administered on an electronic device to participants in clinic, between January 1, 2016 and April 1, 2017. The survey (See

Appendix) was adapted from one previously used in adults.(74) Demographic information, mode of

HIV acquisition, ARV treatment, variables related to adherence, marijuana, alcohol, and illicit drug use were all collected by self-report. Participants’ most recent HIV RNA PCR viral load was ascertained from the medical record for all sites except St. Jude Children’s Research Hospital, where

(per the requirements of that site’s IRB), subjects took an anonymous survey with no link to the medical record, and manually entered their most recent viral load from recall after being reminded about it by study staff prior to taking the survey.

Interest in intramuscular (IM) and subdermal (SD) LAARV (primary outcome), was measured via responses to a question ascertaining likelihood that the youth would use LAARV if it were available, using a four-point Likert-scale. Responses were dichotomized into interested yes/no. Participants who stated that they “definitely would” or “probably would” try LAARV were classified as interested, and those who stated that they “definitely would not” or “probably would not” try the new drug were classified as non-interested. Interest in LAARV should hereafter be understood to refer specifically to intramuscular LAARV, except where subdermal is explicitly stated. Site investigators were blinded to the participants’ responses, which were automatically extracted from the online survey form and exported into a data spreadsheet.

Demographic and other baseline characteristics were compared between PHIV and NPHIV participants using a Chi-squared test. The primary outcome (interest in LAARV) was analyzed with

Poisson regression with robust variance estimation, in both bivariate and multivariable analyses.

Since the prevalence of interest in both groups was more than 15%, Poisson regression instead of logistic regression was used, in order to approximate a Prevalence Ratio from the Relative Risk

(RR).[(78)]

The impact of relevant variables on youth participants’ unadjusted interest level was analyzed using a bivariate analysis. In a multivariable analysis, interest in LAARV was evaluated among youth with

PHIV and NPHIV, adjusting for variables that were considered clinically important or found to be significantly associated with the primary exposure (mode of HIV acquisition) in the Chi-squared test at a significance level of p=0.05. Statistical analyses were performed with Stata software, version

14.0 SE (Stata Corporation, College Station, Texas, USA).

The study also examined the impact of young women participants’ past experience with intramuscular injectable contraception such as medroxyprogesterone (Depo-Provera, hereafter called

Depo) and implantable long-acting reversible contraception (LARC) such as etonogestrel implant

(Implanon, Nexplanon), on their willingness to use long-acting technologies.

The continuous predictor variable of age and viral load were categorized into three categories each:

13-16; 17-20; and 21-24 years of age and undetectable (<40 copies/mL), low detectable (40 copies/mL to 1000 copies/mL) and high detectable (>1000 copies/mL), respectively. The race variable was analyzed as a binary variable (African-American vs. Non-African-American).

Role of the funding source

The study sponsors played no role in study design; in the collection, analysis and interpretation of the data; in the writing of the report; or in the decision to submit the paper for publication.

Results

Of the 303 participants enrolled, 79 (26.1%) were PHIV, and 224 (73.9%) NPHIV. Demographics and other baseline characteristics of these patients, split by mode of HIV acquisition, are presented in Table 1a. The Johns Hopkins Hospital had a significantly higher proportion of PHIV (32.9%) compared to the other sites, whereas St. Jude and Emory had a significantly higher proportion of

NPHIV (81.2%) (Appendix, Table 1b). Viral suppression was similar in PHIV and NPHIV.

Participants with PHIV were younger compared to the participants with NPHIV (27.8% vs. 1.8% in the 13-16 age group). The majority of participants with PHIV were female (68.4%), whereas the majority of those with NPHIV were male (83.0%). All eight transgender patients belonged to the group with NPHIV. The distribution of race and ethnicity was similar in PHIV and NPHIV participants, with the majority being African-American (87.2% and 87.4%, respectively) and non-

Hispanic patients (96.2% and 91.0%, respectively). Ninety-nine percent of PHIV participants and

94.2% of the NPHIV participants received ARV and both groups had a similar distribution of

participants who ever missed a pill. Both alcohol and marijuana use were more prevalent in the

NPHIV group. (See Table IV.1.)

Table IV.a. Baseline characteristics stratified by mode of HIV acquisition

Perinatal Non-Perinatal Total Variable (PHIV) (NPHIV) P-value† N N (%) N (%) Clinic 303 0.01 Emory 34 (43.0%) 99 (44.2%) Johns Hopkins* 26 (32.9%) 40 (17.9%) St. Jude 19 (24.1%) 85 (37.9%) Viral Load 289 0.69 Undetectable 53 (67.9%) 132 (62.6%) Low Detectable 8 (10.3%) 24 (11.4%) High Detectable 17 (21.8%) 55 (26.1%) Age Category 296 <0.001 13-16 years 22 (27.8%) 4 (1.8%) 17-20 years 27 (34.2%) 71 (32.7%) 21-24 years 30 (38.0%) 142 (65.4%) Gender 303 <0.001 Male 25 (31.6%) 186 (83.0%) Female 54 (68.4%) 30 (13.4%) Transgender M-F 0 (0.0%) 8 (3.6%) Race 0.96 African-American or black 68 (87.2%) 194 (87.4%) 300 Non-African-American 10 (12.8%) 28 (12.6%) Hispanic or Latino 0.13 No 76 (96.2%) 202 (91.0%) 301 Yes 3 (3.8%) 20 (9.0%) Missed Pills 303 0.76 Never missed 26 (32.9%) 78 (34.8%) Ever missed 53 (67.1%) 146 (65.2%) Alcohol Use 295 <0.001 Never Used 38 (49.4%) 53 (24.3%) Past 6 months 25 (32.5%) 137 (62.8%) Not in the past 6 months 14 (18.2%) 28 (12.8%) Marijuana Use 302 0.01 Never Used 34 (43.0%) 57 (25.6%) Used in past 6 months 30 (38.0%) 124 (55.6%) Used > 6 months ago 15 (19.0%) 42 (18.8%)

†P-values based on Chi-square test; * Since only one patient was enrolled at the University of Maryland, this participant was included as a Johns Hopkins participant for the purposes of analysis.

A total of 266 (88.1%) respondents stated that they would definitely or probably try injectable

LAARV; 70 (88.6%) participants from the PHIV group and 196 (87.9%) participants from the

NPHIV group. The prevalence of interest in LAARV in PHIV and NPHIV participants was not significantly different (PR 0.99 [95% CI: 0.90 – 1.09]; p= 0.86). While significantly lower compared to injectable LAARV, the overall interest in subdermal implantable LAARV among the youth surveyed was still high (78.7% vs. 88.1%; p=0.002; Figure IV.1.)

Figure IV.a: Youth Preference for intramuscular (IM) over subdermal (SD) Implantable LAARV

Interest level towards IM LAARV and SD Implant (N=303) 100% 88.08% 90% 78.67%* 80% (267/ 70% 303) (238/ 60% 303)

50%

40% Interest Interest level

30%

20%

10%

0% IM LAARV SC Implant

IM LAARV SC Implant

* t-test for proportions: p= 0.002

In order to get a sense of possible regional differences (Southeast versus mid-Atlantic United States) in youth interest, outcomes were analyzed by site. In the bivariate analysis (Table IV.2), participants from St. Jude Children’s Research Hospital had a significantly lower interest level in LAARV than subjects from the other clinics (81.7% interested at Saint Jude vs. 90.9% at Hopkins and 91.7% at

Emory; PR 0.89 [95% CI: 0.80 – 0.99]; p= 0.03). There was an impact of HIV RNA PCR viral load on interest level; participants with high detectable viral load were significantly more likely to be interested in LAARV (PR 1.12 [95% CI: 1.03 - 1.20]; p= 0.005) compared to subjects with undetectable viral load. Using bivariate analyses, there was no statistical difference in the proportion interested in LAARV based on age, gender, race, ethnicity, ART treatment, adherence, alcohol use, and marijuana use.

Table IV. b. Crude and adjusted Prevalence Ratio (PR) and 95% Confidence Interval of the interest level in Intramuscular LAARV by Poisson Regression with robust variance *Adjusted for the variables identified as statistically significant in table 1 (P-value is <0.05) and those were considered clinically relevant. N=274 for the adjusted analysis. Crude Adjusted* Prevalence Ratio P-value Prevalence P-value Variable (95% CI) Ratio (95% CI) Mode of HIV Acquisition (n= 302) Ref Ref Perinatally 0.99 (0.90 – 1.09) 0.86 1.00 (0.92 – 0.93 Non-perinatally 1.10) Clinic (n= 302) Emory Ref Ref Johns Hopkins* 0.99 (0.90 – 1.09) 0.86 0.97 (0.89 - 0.58 St. Jude 0.89 (0.80 - 0.99) 0.03 1.07) 0.03 0.89 (0.80 - 0.99) Viral Load (n= 288) Undetectable Ref Low Detectable 0.98 (0.84 - 1.15) 0.83 1.00 (0.86 – 0.99 High Detectable 1.12 (1.03 -1.20) 0.005 1.16) 0.03

1.09 (1.01 – 1.18)

Ref Ref Age Category (n= 295) 1.21 (0.97 – 1.50) 0.09 1.18 (0.93 – 0.18 13-16 years 1.14 (0.92 – 1.42) 0.24 1.51) 0.42 17-20 years 1.10 (0.87 – 21-24 years 1.40)

Ref Ref Gender (n= 302) 1.00 (0.91 – 1.10) 0.96 1.04 (0.94 – 0.42 Male 0.99 (0.76 – 1.30) 0.96 1.15) 0.78 Female 0.95 (0.67 – Transgender M-F 1.35) Race (n= 299) African-American or black Ref Non-African-American 1.02 (0.90 – 1.14) 0.80 Hispanic or Latino (n= 300) No Ref Yes 0.88 (0.71 – 1.10) 0.26

Missed Pills (n= 302) Ref Never missed 0.96 (0.89 – 1.04) 0.35 Ever missed Currently on HIV Drugs (n= 302) Ref No 1.04 (0.82 – 1.32) 0.73 Yes

Ref Ref Alcohol Use (n= 294) 1.00 (0.91 – 1.09) 0.90 0.93 (0.86 – 0.09 Never 0.95 (0.83 – 1.10) 0.50 1.01) 0.06 Past 6 months 0.86 (0.73 – Not in past 6 months 1.00) Ref Marijuana Use (n= 301) 1.10 (0.98 - Never Ref 1.24) Past 6 months 1.08 (0.97 – 1.20) 0.14 1.15 (1.01 – 0.09 Not in past 6 months 1.07 (0.94 – 1.22) 0.28 1.31) 0.03

*Since only one patient enrolled at the University of Maryland, this participant was included as a Johns Hopkins Hospital participant for the purposes of analysis.

In multivariable analysis (Table IV.2 & Figure IV.2), the interest level towards the injectable

LAARV between the PHIV and NPHIV groups was identical (PR 1.00 [95% CI: 0.92 – 1.10]; p=

0.93) after adjusting for viral load, clinic, age, gender, alcohol and marijuana use. The impact of site

(St. Jude vs. others) (interest level PR 0.89 [95% CI: 0.80 – 0.99]; p= 0.03) and viral load level (high detectable viral load versus undetectable viral load) (interest level PR 1.09 [95% CI: 1.01 – 1.18]; p= 0.03) remained significant even after adjusting for the above-mentioned variables. (Table IV.2 &

Figure IV.2 & Figure IV.3).

Figure IV.b: Adjusted Prevalence Ratio of High Interest in LAARV by Participant Characteristics.

Reference values for each category: Perinatal Acquisition; Viral Load Undetectable; Clinic: Emory; Age category: 13-16 years old; Gender: Male; Never Used EtOH; Never Used Marijuana. Interest in LAARV defined as “Probably would use” or “Definitely would use”, as compared to “Definitely would not use” or “Probably would not use”.

Participants who used marijuana more than six months ago were found to be more interested in

LAARV compared to those who never used or used in the past 6 months (PR 1.15 [95% CI: 1.01 –

1.31]; p= 0.03). (See Figure IV. 3). On the other hand, alcohol consumption was associated with borderline (non-significant) decreased interest, both in recent (PR 0.93 [95% CI: 0.86 – 1.01]; p=

0.09) and past users (PR 0.86 [95% CI: 0.73 – 1.00]; p= 0.06) as compared to never users. Possible interactions between marijuana use and alcohol use were explored, but no significant association was found. Furthermore, mode of acquisition, age, gender, race, ethnicity, and self-reported adherence level were not significantly associated with the participant’s interest level.

Figure IVc: Comparison of Interest in LAARV by Various Characteristics *p<0.05; significance tested by adjusted Poisson regression, robust variance. In Figure a), Viral loads were one-time, cross-sectional viral load results most proximal in time to the survey. Undetectable HIV viral load was defined as <20 copies or <40 copies, depending on site; Low detectable as >UD and <1000; High detectable > 1000 copies. For Figures b) and c), a binary interest level outcome was used, where Interested was “Probably would or Definitely would use” and Not Interested was “Definitely would not use” or “probably would not use”. a. By Viral Suppression b. By Marijuana Use

* *

c. By Site

Participants were queried about their level of concern about side effects of LAARV, and overall

52.9% of the respondents were very concerned or somewhat concerned about the potential side effects. Those who were interested in trying LAARV were less worried about side effects compared to those who were not interested. Eighteen participants (51.4%) from the binary non-interested group responded that they were very concerned about the side effects, whereas 77 participants (29.4%) from the interested group expressed concern about side effects, and this difference was statistically significant (p= 0.05).

We investigated the impact of young women participants’ past experience with intramuscular injectable contraception such as Depo and implantable LARC such as etonogestrel implant

(Implanon, Nexplanon) on their willingness to use long-acting technologies. As shown in Table IV.3, there was a greater willingness to use IM LAARV among those female participants who had previously used implantable long-acting reversible contraception (LARC), than among those who had never used LARC (14/14 (100%) versus 59/69 (85.5%); p=0.002). Likewise, there was a borderline significant increase in interest in SD implantable LAARV among those participants who had used LARC in the past (13/14 (92.9%) versus 54/69 (78.3%); p=0.081). In participants with past use of IM injectable contraceptive technologies, there was no difference in enthusiasm for either IM or SD implantable LAARV as compared to those with no past use of IM injectable contraception.

Table IV. c: Female participants’ willingness to try IM and implantable LAARV based on past experience with contraceptive technologies

Interest Never Ever P-value* Never Ever Depo P-value* Level High LARC LARC Depo IM 85.5% 100% 0.002 87.9% 88% 0.987 LAARV (59/69) (14/14) (29/33) (44/50) SD 78.3% 92.9% 0.081 81.8% 80% 0.837 Implant (54/69) (13/14) (27/33) (40/50) LAARV

*Poisson with robust variance; the impact of future willingness to use Long-Acting Reversible Contraception (LARC) or Depo on willingness to use subdermal (SD) or intramuscular (IM) Long- Acting Antiretrovirals (LAARV) was also tested and was not significant.

With respect to the timing of injections, interest level in intramuscular LAARV was found to increase with a decrease in frequency of injections. Only 49.6% of participants had probable or definite willingness to use LAARV when the injections were proposed once a week, 56.3% when once every two weeks, 86.1% when once a month, 86.8% when once every two months, and 90.2% when once every three months; many of these step-wise differences were significant (see Figure IV. 4a). When only definite willingness to use was assessed, a significantly higher proportion of respondents were willing to use IM LAARV if injection frequency was q3 months than q2 months, and q1 month was preferred over either q2 weeks or q1 week, but the enthusiasm for q 2 months and q monthly was not statistically different (see Figure IV. 4b).

Figure IV.d1: Gradient of Definite or Probable Willingness to Use Increases with Decreased Injection Frequency

Figure IVd.2: Proportion of Definite Willingness to Use Is Higher with Decreased Injection Frequency Compared to Increased Injection Frequency

Q 1 week Q 2 weeks Q 1 month Q 2 months Q 3 months Q 1 week NA 0.83 7.14 8.55 11.19 (p=0.407) (p<0.001) (p<0.001) (p<0.001) Q 2 weeks NA 6.34 7.77 10.43 (p<0.001) (p<0.001) (p<0.001) Q 1 month NA 1.51 4.36 (p=0.130) (p<0.001) Q 2 months NA 2.86 (p=0.004) Q 3 months NA Z-scores are displayed in table for a two sample proportion test (p values in parentheses). Significant values are in bold. The injection frequencies specified in the column headings are what is being compared to row headings (the reference).

Discussion Survey results indicate that the majority of YHIV surveyed are interested in taking LAARV to control their HIV. There was no difference in interest level between participants with PHIV and NPHIV.

Several behavioral and clinical characteristics were associated with a higher likelihood of interest in

LAARV in youth. Of note, participants with high-detectable viral load (indicating a degree of difficulty in adhering to their daily pills) were more enthusiastic about trying LAARV (which does not require daily pills) than participants who had attained and sustained virologic control on their current oral regimen. Those who have trouble adhering to daily oral pills represent an ideal target population for LAARV. Prior work has uncovered a panoply of reasons cited by YHIV for missing medications over the past month—forgetting, not being physically near medication, getting busy with other things, reluctance to be witnessed taking pills, etc.(79) All of this should point to the need for HIV suppression approaches that do not require youth to take daily pills.

Finding that almost 90% of the participants in our study were interested in trying injectable LAARV to control their HIV is encouraging evidence that LAARV may be a welcome strategy for achieving and maintaining viral suppression in this age group. The high enthusiasm was consistent with a previous cross-sectional study in New York among young men who have sex with men, where investigators also found that more than 80% of the participants were interested in the injectable

LAARV of pre-exposure prophylaxis (PrEP) for HIV.(76) In another similar study in adults, the interest level towards long-acting injectables was found to be 73%.(74)

Lifelong daily or nearly daily dosing of currently available oral ART is very difficult to maintain, especially for younger participants, as borne out in the poor rates of viral suppression in this group.(68) Unsurprisingly, a gradient of interest in long-acting technologies was demonstrated among youth respondents, with steadily and significantly increasing interest level as injection frequency declined, as shown in Figure 3. This aligns with data showing a high level of interest towards LAARV associated with less frequent dosing than the currently available oral ART.(80)

This finding (prospective hypothesized adherence) also corroborates that of previous studies where a linear decrease in actual adherence with increasing number of doses per day has been observed.(81-

83) A previous study among gay and bisexual men also revealed that fewer men found long acting injectable PrEP to be acceptable when the frequency of administration was every month rather than every three months.(84) This finding was echoed in our study, which found that interest in LAARV increases in a gradual gradient with increased spacing in between injections from q week to q 3 months, and that fewer youth found q1 month injections acceptable than q3 month injections. This makes a strong case for shoring up efforts to arrive at an injectable product with a q3month injection frequency, which would also have parallelism with Depo injection frequency. However, while every

3 month injection frequency would be desirable if available, it is worth noting that the steepest step- off in acceptability occurs with injection frequencies more frequent than once a month (i.e., once a

week or once every 2 weeks). Any injection frequency once monthly or less frequently was associated with an acceptability > 85% in these youth respondents.

The findings on the impact of past experience with long-acting contraceptive technologies on young women’s willingness to use LAARV imply an increased willingness to use both IM and SD LAARV among participants with past LARC use. These individuals may represent a niche population of early adopters of new technologies. That a similar finding was not observed among Depo users should not detract from the observation of extremely high rates of interest in IM LAARV among both Never

Depo (87.9%) and Ever Depo (88%) groups.

Youth were specifically asked about their concerns. Those who were interested in trying LAARV were less concerned about the possible side effects of IM and SD long-acting drugs compared to those with lower interest. A breakdown of the specific concerns of youth is displayed in Figure 4. In total, about half of the respondents in our study were worried about the potential side effects of the new drug. The interested group was found to have less concern about the side effects than the non- interested group. This study mirrors the findings of prior survey findings in adults where only 48% of overall participants were concerned with the side effects of IM LAARV.(74) Conversely, a high proportion (87.8%) of respondents in a previous survey study in young men who have sex with men

(MSM) voiced concern about the side effects of injectables.(76) The reason for this difference is not clear, but differing study populations is most likely: there was a quite narrow age distribution (mean age of 21.2 years (SD=0.8)) and high level of educational attainment in the previous study.

There is dramatic import to society of this inquiry into youth readiness for LAARV. The fact that the previously discovered high enthusiasm rate for LAARV in adults is not only replicated in youth, but increased, makes the strong case for the further study and eventual implementation of LAARV treatment strategies broadly in youth with HIV. The increased interest in LAARV among respondents

whose HIV is uncontrolled is an important observation given that adherence to currently available

ARV is likely to be sub-optimal. (85, 86) A more nuanced understanding of the characteristics associated with a greater interest level in LAARV may assist in planning future clinical studies and ultimately in choosing appropriate youth sub-populations for deployment of LAARV.

There were several limitations of this study. Firstly, only HIV positive individuals engaged in care were surveyed. Findings could have been different in individuals not receiving care. However, youth who do come to clinic but do not take daily pills precisely represent the population that may benefit from LAARV, (i.e., their engagement in care despite adherence difficulties opens up the way for health-setting-administered ART, which is only user-dependent in the sense that the patient must show up to clinic, and also demonstrates a possible willingness/ likelihood to return for subsequent injections.) Therefore, gauging the opinion of these youth about LAARV is most important.

Secondly, dichotomizing the outcome variable interest level into ‘‘interested’’ and ‘‘non-interested’’ and the quantitative adherence into “ever missed” and “never missed” might have resulted in a loss of questionnaire specificity. Thirdly, social desirability bias may have played a role in participants’ responses, particularly in self-reporting of risky behavior and interest level in non-anonymized surveys. Fourthly, participants were not given information about the prolonged length of time that injectable ART remains detectable in bodily fluids, or about the safety and efficacy implications of this prolonged PK tail; this might potentially have some impact on willingness to take up such technologies and could be viewed as a limitation of the study. Finally, the sample size was not large enough to perform certain subgroup analyses of interest. Future studies should target a larger sample size of populations not engaged in care, explore youth interest in LAARV as PrEP, and should incorporate detailed non-theoretical acceptability assessments among youth participants receiving

LAARV in clinical trials.

Conclusion

The vast majority of youth participants reported moderate or high interest in using LAARV. The enthusiasm among both PHIV and NPHIV youth for LAARV was identical. The interest also was not significantly impacted by other factors except for the clinic location, viral load, and marijuana use. Among patients who both have adherence difficulties and are engaged in care, these findings suggest that LAARV would be equally acceptable in all patients with HIV in this age group. If long- acting ART strategies are not ultimately deployed in populations with poor adherence, they will fall far short of their intended mark and fail to help the very populations they stand to benefit the most.

In sum, youth ages 13 to 24 who are struggling to adhere to oral daily medications are a vulnerable niche population in whom LAARV could serve as a critical strategy to improve clinical outcomes.

The current study suggests that implementation of this strategy was acceptable for such high-risk youth.

Author Contributions

EDW wrote the protocol, designed and adapted the survey tool, participated in the analysis, and prepared the manuscript for publication. MSR performed data cleaning and key portions of statistical analysis. AA participated in planning, design, and oversight of the study as well as guiding analysis and interpretation of results. CWF and SS served as advisors and provided information about the preceding survey study in adults. RD, ACG, PR, AG, and RC all served as site investigators.

Acknowledgements

We are deeply indebted to the youth participants who gave their time and efforts to this project, and are equally indebted to our funders. We also gratefully acknowledge the hard work, fortitude and contributions of study coordinators Jasper Hood, LaTeshia Thomas-Seaton, Kayla Herne, and

Crystal Stone.

IRB/ Ethics Committee Approval

Procedures followed in this study were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Institutional Review Boards (IRB) at all four institutions reviewed and approved this study. (Note: The University of Maryland’s IRB reviewed and approved the study, but that site only recruited one participant, so that participant’s data was combined with the data from the Johns Hopkins site, leading to the characterization of four sites mentioned in the text.)

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33. Hiruy H, Fuchs EJ, Marzinke MA, Bakshi RP, Breakey JC, Aung WS, et al. A Phase 1 Randomized, Blinded Comparison of the Pharmacokinetics and Colonic Distribution of Three Candidate Rectal Microbicide Formulations of Tenofovir 1% Gel with Simulated Unprotected Sex (CHARM-02). AIDS Res Hum Retroviruses. 2015;31(11):1098-108. 34. Hendrix CW, Fuchs EJ, Macura KJ, Lee LA, Parsons TL, Bakshi RP, et al. Quantitative imaging and sigmoidoscopy to assess distribution of rectal microbicide surrogates. Clin Pharmacol Ther. 2008;83(1):97-105. 35. McGowan I, Cranston RD, Duffill K, Siegel A, Engstrom JC, Nikiforov A, et al. A Phase 1 Randomized, Open Label, Rectal Safety, Acceptability, Pharmacokinetic, and Pharmacodynamic Study of Three Formulations of Tenofovir 1% Gel (the CHARM-01 Study). PLoS One. 2015;10(5):e0125363. 36. Anton PA, Cranston RD, Kashuba A, Hendrix CW, Bumpus NN, Richardson-Harman N, et al. RMP-02/MTN-006: A phase 1 rectal safety, acceptability, pharmacokinetic, and pharmacodynamic study of tenofovir 1% gel compared with oral tenofovir disoproxil fumarate. AIDS Res Hum Retroviruses. 2012;28(11):1412-21. 37. McGowan I, Hoesley C, Cranston RD, Andrew P, Janocko L, Dai JY, et al. A phase 1 randomized, double blind, placebo controlled rectal safety and acceptability study of tenofovir 1% gel (MTN-007). PLoS One. 2013;8(4):e60147. 38. Adriaens E, Remon JP. Mucosal irritation potential of personal lubricants relates to product osmolality as detected by the slug mucosal irritation assay. Sex Transm Dis. 2008;35(5):512-6. 39. Caffo BS, Crainiceanu CM, Deng L, Hendrix CW. A Case Study in Pharmacologic Colon Imaging Using Principal Curves in Single Photon Emission Computed Tomography. J Am Stat Assoc. 2008;103(484):1470-80. 40. Hudson HM, Larkin RS. Accelerated image reconstruction using ordered subsets of projection data. IEEE Trans Med Imaging. 1994;13(4):601-9. 41. Goldsmith J, Caffo B, Crainiceanu C, Reich D, Du Y, Hendrix C. Nonlinear Tube-Fitting for the Analysis of Anatomical and Functional Structures. Ann Appl Stat. 2011;5(1):337-63. 42. Cao YJ, Caffo BS, Fuchs EJ, Lee LA, Du Y, Li L, et al. Quantification of the spatial distribution of rectally applied surrogates for microbicide and semen in colon with SPECT and magnetic resonance imaging. Br J Clin Pharmacol. 2012;74(6):1013-22. 43. Morrow KM RR, Vargas S, Katz D, Joseph F, Kojic EM, Friend D, Rohan L, Ham A, Buckheit R. More...? Less...? Just right...? The role of perceived volume in gel and film perceptibility during intercourse, and its impact on product preference. AIDS Res Hum Retroviruses. 2014;30(Suppl 1: A145):A145. 44. Cronbach LJ. Coefficient alpha and the internal structure of tests. Psychometrika. 1951;16(3):297-334. 45. Cohen J. Statistical Power Analysis for the Behavioral Sciences, 2nd Edition. Hillside, N.J.: Lawrence Erlbaum; 1988. 46. DeVellis RF. Scale development: Theory and applications, 3rd Edition. Los Angeles, CA: SAGE; 2012. 47. Nunnaly JC. Psychometric Theory, 2nd Edition. New York, NY: McGraw-Hill; 1978. 48. Leyva F, Fuchs EJ, Bakshi R, Carballo-Dieguez A, Ventuneac A, Yue C, et al. Simultaneous Evaluation of Safety, Acceptability, Pericoital Kinetics, and Ex Vivo Pharmacodynamics Comparing Four Rectal Microbicide Vehicle Candidates. AIDS Res Hum Retroviruses. 2015;31(11):1089-97.

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Section V.

Overall Thesis Conclusions

Each of these projects attempted to examine critically a novel method of prevention or treatment on the grounds of either pharmacokinetic temporo-spatial distribution or behavioral and acceptability aspects.

Section II.

The study of volume comparison of placebo gel suggests that both volumes of the gel are safe and quite well tolerated, with high ratings of both acceptability and perceptibility (a measure that aims to assess several domains of the sensory experience of the product use). In addition, the two volumes appear to have similar distribution in the colorectal space, remaining confined to the rectum, within the pelvic bowl, with no significant difference in any of their PK distance distribution parameters. The pharmaceutical variable of volume is isolated in this study, and the findings support the advancement of either volume of microbicide gel candidate as a topical method of HIV PrEP in individuals whose primary risk factor is uRAI, and for whom the use of rectal gels or lubricants is already an existing behavior.

Section III

The second project (described in Section III) sought to understand the distribution of HIV surrogates, both cell-free and cell-associated, in the distal colon, in order to enable development of microbicides that overlap its distribution. The distribution of radiolabeled surrogates throughout the colorectum can and has been quantified with innovative temporospatial pharmacokinetic methods,

as described above, where the variable of “distance” is substituted for “time”, and concentration is computed based on detection of mass per fixed volume unit. Both autologous lymphocytes (here standing in for HIV incorporated within cells) and HIV surrogate particle (99Tc-labeled sulfur colloid) in seminal plasma distribute to a maximal distance of around 15 cm from the anorectal junction (or 19 cm from the anal verge), with a maximal signal intensity around 6 cm from the anorectal junction (or 10 cm from the anal verge). Candidate microbicides should aim to surpass the distribution of these surrogates, and ideally should remain present in the target anatomic distribution for longer than HIV itself. Future studies with dual isotope imaging will be important, as they enable simultaneous assessment of the joint distribution of HIV surrogates and a given microbicide candidate.

Section IV.

The findings of the third study (described in Section IV) suggest strong youth interest in long- acting methods of HIV treatment, and support the advancement and study of long-acting methods of ART for HIV treatment among youth. The dawning availability of long-acting antiretrovirals stands to help youth with adherence difficulties more than other populations, and the corresponding public health impact of lowering the community viral load could be large (given the established evidence for treatment as prevention (TasP).(87-89) The study and roll-out of novel, innovative technologies in non-adherent youth entails many challenges: if the youth are already by definition unable to adhere to daily medicines, how will they adhere to study protocols? Will they represent a group that is so hard to access that their response to these technologies cannot be documented? The answer to these challenges is to match the rollout of innovative biomedical strategies with innovative forms of youth-friendly support. Wraparound services that not only meet individuals where they are in the community, but also meet individuals where they are in a larger sense, can

serve to improve youth engagement and retention in both clinical care and clinical trials.

Ultimately, if long-acting strategies are not ultimately advanced among people with adherence struggles, they will fall short and fail to help the very populations they stand to benefit the most.

We hope that this work helps make the argument for considering them in youth.

Overall Conclusions

There are a wide variety of individual circumstances, preferences, behaviors, and risk contexts that influence an individual’s choices about prevention and treatment of HIV—the prevention and treatment communities must meet the challenge of this variety by exploring and developing just as wide a variety of prevention and treatment technologies. Margaret Atwood wrote, in Surfacing, that

Alaskan Native Peoples “have fifty-two names for snow, because it is important to them; there ought to be as many for love.” In an important sense, there ought to be as many for both prevention and treatment technologies, if curbing the HIV epidemic is important to us as a society. A multiplicity of technologies is not only nice; in fact, it is the key. As presented in a 2018 UNAIDS report, “mathematical modelling exercises consistently demonstrate that HIV prevention portfolios matched to the differing risks across populations and locations will accelerate reductions in new

HIV infections and produce better value for money”.(90) Only when multiplicity is met with multiplicity can the epidemic be stemmed.

APPENDIX Supplemental Content Appendix I: Survey Instrument for Assessing Interest and Attitudes of Youth Living with HIV Towards Long-acting Parenteral Nanoformulated Antiretroviral Therapy Please enter your Unique Identifier Here: ______

Start of Block: Default Question Block

Q1 Question 1 We are going to start by asking you some questions about yourself: 1. Below is a list of terms that people often use to describe their gender. Using the terms below, how would you best describe yourself? (Please check all that apply.)

o Male (1)

o Female (2)

o Transgender male-to-female (3)

o Transgender female-to-male (4)

o Other (5)

Display This Question: If Question 1 We are going to start by asking you some questions about yourself: 1. Below i... = Female

Q2 If you are female, in the past have you ever been on Depo-Provera (a “shot” of birth control which you get every 3 months from your doctor)?

o No (1)

o Yes (2)

Display This Question: If If you are female, in the past have you ever been on Depo-Provera (a “shot” of birth control whi... = Yes

Q3 If Yes, how did that go? (please describe whether you liked it or not, and what the problems were, if any):

______

Display This Question: If If you are female, in the past have you ever been on Depo-Provera (a “shot” of birth control whi... = Yes

Q4 Would you be willing to try Depo-Provera again?

o Yes (1)

o No (2)

Display This Question: If Question 1 We are going to start by asking you some questions about yourself: 1. Below i... = Female

Q5 Have you ever had an implantable form of birth control such as Implanon (this is a plastic "implant" that is surgically inserted under the skin of your arm and releases birth control hormones).

o Yes (1)

o No (3)

Display This Question: If Have you ever had an implantable form of birth control such as Implanon (this is a plastic "impla... = Yes

Q6 If yes, how did that experience of having the "implant" go? Please describe whether you liked it or not, and why.

______

Display This Question: If Have you ever had an implantable form of birth control such as Implanon (this is a plastic "impla... = Yes

Q7 If yes, would you be willing to try it again?

o Yes (1)

o Maybe (2)

o No (3)

Q8 Are you of Hispanic origin or Latino/ Latina?

o Yes (1)

o No (2)

Q9 What is your race?

o White or Caucasian (1)

o African-American or black (2)

o Asian or Pacific Islander (3)

o Native American or Alaska Native (4)

o Other (5)

Q10 In what year were you born?

______

Q11 In what year were you diagnosed with HIV?

______

Q12 How did you get HIV? (Please choose all that apply)

o From my mother when I was a baby (perinatally) (1)

o By using IV drugs (2)

o From sex with men (3)

o From sex with women (4)

o Other (5)

Q13 Where do you receive HIV care?

o St. Jude Children's Research Hospital, Memphis (1)

o University of Maryland (2)

o Johns Hopkins (3)

o Emory (4)

Display This Question: If Where do you receive HIV care? = St. Jude Children's Research Hospital, Memphis

Q14 What is your most recent HIV viral load?

______

Q15 The following questions ask about your drug use, past and current. All of your answers will be kept completely confidential. (For each drug listed, please tell us whether you have used

the drug within the past 6 months, used the drug in the past but NOT within the past 6 months, or never used.)

Used in past, but Used in past 6 NOT in the past 6 Never Used (3) months (1) months (2) Marijuana (pot, weed, ganja, blunt, 420, chronic) (1) o o o

Cocaine (powder, crack, blow, yayo) (2) o o o Heroin (smack, tar, chiba, junk, white, dragon, dope, boy) (3) o o o Amphetamines (meth, speed, crank, tina, tweak, ice) (4) o o o

Alcohol (5) o o o Prescription pain drugs (Oxy, Cotton, Percs, Vike, oxycodone, OxyContin, Dilaudid) o o o (6)

Ecstasy (MDMA, e, X, thizz, roll) (7) o o o Amyl nitrate/ poppers (8) o o o

Q16 Have you ever injected drugs into your body with a needle?

o Yes (1)

o No (2)

Display This Question: If Have you ever injected drugs into your body with a needle? = Yes

Q17 If Yes, have you used drugs intravenously within the past 6 months?

o Yes (1)

o No (2)

Q18 Are you currently in methadone or Suboxone (buprenorphine) treatment?

o Yes (1)

o No (2)

Display This Question: If Are you currently in methadone or Suboxone (buprenorphine) treatment? = No

Q19 Have you ever been in methadone or suboxone (buprenorphine) treatment?

o Yes (1)

o No (2)

Q20 Many people with HIV have lots of pills to take at different times during the day. Some people find it hard to always remember their HIV pills. Some people get busy and forget to carry their pills with them. Some people find it hard to take their pills exactly as prescribed (for example, three times a day, or “with food” (after eating a meal)). Some people decide to skip doses to avoid side effects or just to not be on pills for that day. We want to understand how young people with HIV are really doing with their HIV pills. Please tell us what you are actually doing. Don’t worry about telling us that you don’t take all your pills. We need to know what is really happening, not what you think we “want to hear.” Your answers will be kept strictly confidential. The next section asks about your HIV medications:

Q21 Are you currently being prescribed medication for your HIV?

o Yes (1)

o No (2)

Display This Question: If Are you currently being prescribed medication for your HIV? = Yes

Q22 How many HIV pills are you supposed to take each day and how often?

______

Q23 This part of the survey asks about HIV medications that you may have missed taking over the last four days. (If you took only a portion of a dose on one or more of these days, please report

the dose(s) as being missed.) When was the last time you missed any of your medications?

o Within the past week (1)

o 1-2 weeks ago (2)

o 3-4 weeks ago (3)

o 1-3 months ago (4)

o more than 3 months ago (5)

o I never skip medications (6)

Q24 During the past 4 days, on how many days have you missed taking any of your doses?

o None (1)

o One day (2)

o Two days (3)

o Three days (4)

o Four days (5)

Q25 Most anti-HIV medications need to be taken on a schedule, such as "2 times a day" or "3 times a day" or "every 8 hours". How often did you follow your specific schedule over the

last four days?

o Never (0 days out of 4) (1)

o Some of the time (1 day out of 4) (2)

o About half the time (2 days out of 4) (3)

o Most of the time (3 days out of 4) (4)

o All of the time (4 days out of 4) (5)

Q26 Do any of your anti-HIV medications have special instructions, such as "take with food" or "on an empty stomach" or "with plenty of fluids"?

o Yes (1)

o No (2)

Q27 How often did you follow those special instructions over the last four days?

o Never (0 days out of 4) (1)

o Some of the time (1 day out of 4) (2)

o About half of the time (2 days out of 4) (3)

o Most of the time (3 days out of 4) (4)

o All of the time (4 days out of 4) (5)

Q28 Some people find that they forget to take their pills on the weekends. Did you miss any of your anti-HIV medications last weekend— last Saturday or Sunday?

o Yes (1)

o No (2)

Q29 We are working to make a new way of taking a new kind of anti-HIV medication. Instead of taking pills every day, you would get an injection (or "shot") of the new medicine in your muscle at regular intervals. This would mean you would not have to take any pills.

If this new way of taking your medication was available as an option for you, how likely would you be to try this method?

o Definitely would try it (1)

o Probably would try it (2)

o Probably would not try it (3)

o Definitely would not try it (4)

Display This Question: If We are working to make a new way of taking a new kind of anti-HIV medication. Instead of taking p... = Definitely would try it Or We are working to make a new way of taking a new kind of anti-HIV medication. Instead of taking p... = Probably would try it

Q30 This new way of taking your medicine would require injections from time to time. How likely would you be to try this new method if you were required to come to the clinic for injections...

(Please mark one box in each row).

Definitely would Probably would Probably would Definitely would

try it (1) try it (2) not try it (3) not try it (4)

Once every week? (1) o o o o Once every two weeks? (2) o o o o Once every month? (3) o o o o Once every two months? (4) o o o o Once every three months? (5) o o o o

Q31 How concerned are you about each of the following things about this new way of taking your medication?

(Please mark one box in each row.)

Not at all A little Somewhat Very concerned

concerned (1) concerned (2) concerned (3) (4) Possibility of side effects (rash, upset o o o o stomach) (1) Might have to have 2 injections at once (2) o o o o Might cause skin swelling or pain at the place where the shot o o o o was (3) Side effects might last longer than side effects o o o o from a pill (4)

Q32 We are working to make a new way of taking another new kind of anti-HIV medication. Instead of taking pills every day, you would get a small plastic "implant" inserted surgically under the skin in your arm that would slowly release drug into your body. This would mean you would not have to take any pills.

If this new way of taking your medication was available as an option for you, how likely

would you be to try this method?

o Definitely would try it (1)

o Probably would try it (2)

o Probably would not try it (3)

o Definitely would not try it (4)

Q33 How concerned are you about each of the following things about this new way of taking your medication?

(Please mark one box in each row.)

Not at all A little Somewhat Very concerned

concerned (1) concerned (2) concerned (3) (4) Possibility of side effects (rash, upset o o o o stomach) (1) The medicine might not work to treat my HIV o o o o (2) Might cause skin swelling or pain at the site of the o o o o implant (3) Side effects might last longer than side effects o o o o from a pill. (4)

Q34 Do you have any other thoughts or concerns about these new ways of taking your medications that you would like to share with us? What else do you need to know, to decide

whether this new (injection or implant) way of taking medicine would work for you? Don't worry about spelling; just write down everything you can think of:

______

Q35 You're Done! Thank you so much! We really, really appreciate your time and thoughts!!

End of Block: Default Question Block

Appendix II: Supplementary Tables Table IV. 1b. Baseline characteristics stratified by Site Johns Total Emory St. Jude Variable Hopkins N P-value† n (%) n (%) n (%) Mode of Transmission 0.01 Perinatally 34 (25.6%) 26 (39.4%) 19 (18.3%) Non-perinatal 99 (74.4%) 40 (60.6%) 85 (81.7%) Viral Load 289 0.06 Undetectable 79 (60.3%) 38 (60.3%) 68 (71.6%) Low Detectable 11 (8.4%) 8 (12.7%) 13 (13.7%) High Detectable 41 (31.3%) 17 (27.0%) 14 (14.7%) Age in years (Mean (SD) 21.05 (2.28) 20.80 (2.91) 19.77 (2.42) 296 <0.001 Age Category 296 <0.001 13-16 years 7 (5.5%) 8 (12.1%) 11 (10.8%) 17-20 years 36 (28.1%) 12 (18.2%) 50 (49.0%) 21-24 years 85 (66.4%) 46 (69.7%) 41 (40.2%) Gender 303 0.04 Male 104 (78.2%) 39 (59.1%) 68 (65.4%) Female 28 (21.1%) 24 (36.4%) 32 (30.8%) Transgender M-F 1 (0.8%) 3 (4.5%) 4 (3.8%) Race 0.76 African-American or black 114 (86.4%) 56 (86.2%) 92 (89.3%) 300 Non-African-American 18 (13.6%) 9 (13.8%) 11 (10.7%) Hispanic or Latino 0.86 No 121 (91.7%) 61 (93.8%) 96 (92.3%) 301 Yes 11 (8.3%) 4 (6.2%) 8 (7.7%) Missed Pills 303 0.060 Never missed 39 (29.3%) 20 (30.3%) 45 (43.3%) Ever missed 94 (70.7%) 46 (69.7%) 59 (56.7%) Currently on HIV Drug 303 0.02 No 11 (8.3%) 2 (3.0%) 1 (1.0%) Yes 122 (91.7%) 64 (97.0%) 103 (99.0%) Marijuana Use 302 0.03 Never Used 35 (26.5%) 15 (22.7%) 41 (39.4%) Ever Used 97 (73.5%) 51 (77.3%) 63 (60.6%) Cocaine Use 292 0.09 Never Used 104 (83.9%) 59 (90.8%) 97 (94.2%) Past 6 months 9 (7.3%) 1 (1.5%) 3 (2.9%) Not in the past 6 months 11 (8.9%) 5 (7.7%) 3 (2.9%) †P-values based on Chi-square test

Table IV. 1c. Baseline characteristics stratified by viral load

High Total Undetectable Low Detectable Variable Detectable N P-value† n (%) n (%) n (%) Mode of Transmission 303 0.69 Perinatally 53 (28.6%) 8 (25.0%) 17 (23.6%) Non-perinatal 132 (71.4%) 24 (75.0%) 55 (76.4%) Clinic 303 0.06 Emory 79 (42.7%) 11 (34.4%) 41 (56.9%) Johns Hopkins 38 (20.5%) 8 (25.0%) 17 (23.6%) St. Jude 68 (36.8%) 13 (40.6%) 14 (19.4%) Age Category 296 0.09 13-16 years 19 (10.4%) 3 (10.0%) 2 (2.8%) 17-20 years 62 (33.9%) 13 (43.3%) 19 (26.8%) 21-24 years 102 (55.7%) 14 (46.7%) 50 (70.4%) Gender 303 0.69 Male 126 (68.1%) 21 (65.6%) 54 (75.0%) Female 56 (30.3%) 10 (31.3%) 16 (22.2%) Transgender M-F 3 (1.6%) 1 (3.1%) 2 (2.8%) Race 300 0.32 African-American or 160 (87.9%) 30 (93.8%) 60 (83.3%) black Non-African-American 22 (12.1%) 2 (6.3%) 12 (16.7%) Hispanic or Latino 301 0.44 No 168 (91.3%) 31 (96.9%) 67 (94.4%) Yes 16 (8.7%) 1 (3.1%) 4 (5.6%) Missed Pills 303 0.42 Never missed 67 (36.2%) 10 (31.3%) 20 (27.8%) Ever missed 118 (63.8%) 22 (68.8%) 52 (72.2%) Currently on HIV Drug 303 <0.001 No 4 (2.2%) 0 (0.0%) 10 (13.9%) Yes 181 (97.8%) 32 (100.0%) 62 (86.1%) Alcohol Use 295 0.27 Never Used 59 (32.8%) 13 (41.9%) 16 (22.9%) Past 6 months 99 (55.0%) 15 (48.4%) 41 (58.6%) Not in the past 6 months 22 (12.2%) 3 (9.7%) 13 (18.6%) Marijuana Use 302 0.005 Never Used 60 (32.4%) 14 (43.8%) 11 (15.5%) Ever Used 125 (67.6%) 18 (56.3%) 60 (84.5%) †P-values based on Chi-square test

Figure IV.6: Youth concerns about LAARV a. Intramuscular Injection

b. Subdermal Implant

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19. Rorden C, Brett M. Stereotaxic display of brain lesions. Behav Neurol. 2000;12(4):191- 200. 20. Team RC. R: A language and environment for statistical computing. Vienna, Austria2013 [Available from: http://www.R-project.org/. 21. Louissaint NA, Fuchs EJ, Bakshi RP, Nimmagadda S, Du Y, Macura KJ, et al. Distribution of cell-free and cell-associated HIV surrogates in the female genital tract after simulated vaginal intercourse. J Infect Dis. 2012;205(5):725-32. 22. Santangelo PJ, Rogers KA, Zurla C, Blanchard EL, Gumber S, Strait K, et al. Whole-body immunoPET reveals active SIV dynamics in viremic and antiretroviral therapy-treated macaques. Nat Methods. 2015;12(5):427-32. 23. Ensign LM, Hoen TE, Maisel K, Cone RA, Hanes JS. Enhanced vaginal drug delivery through the use of hypotonic formulations that induce fluid uptake. Biomaterials. 2013;34(28):6922-9. 24. ten Berge RJ, Natarajan AT, Hardeman MR, van Royen EA, Schellekens PT. Labeling with indium-111 has detrimental effects on human lymphocytes: concise communication. J Nucl Med. 1983;24(7):615-20.

Section IV. References 1. Servick K. Biomedicine. 'Nonadherence': a bitter pill for drug trials. Science. 2014;346(6207):288-9. 2. Breckenridge A, Aronson JK, Blaschke TF, Hartman D, Peck CC, Vrijens B. Poor medication adherence in clinical trials: consequences and solutions. Nat Rev Drug Discov. 2017;16(3):149-50. 3. Brown MT, Bussell JK. Medication adherence: WHO cares? Mayo Clin Proc. 2011;86(4):304-14. 4. Carballo-Dieguez A, Giguere R, Lentz C, Dolezal C, Fuchs EJ, Hendrix CW. Rectal Douching Practices Associated with Anal Intercourse: Implications for the Development of a Behaviorally Congruent HIV-Prevention Rectal Microbicide Douche. AIDS Behav. 2018. 5. CDC. Diagnoses of HIV infection in the United States and dependent areas, 2015. HIV Surveillance Report 2016. 2017;27. 6. Javanbakht M, Stahlman S, Pickett J, LeBlanc MA, Gorbach PM. Prevalence and types of rectal douches used for anal intercourse: results from an international survey. BMC Infect Dis. 2014;14:95. 7. Aziz M, Smith KY. Challenges and successes in linking HIV-infected women to care in the United States. Clin Infect Dis. 2011;52 Suppl 2:S231-7. 8. Prevention CfDCa. Diagnoses of HIV infection in the United States and dependent areas, 2016. HIV Surveillance Report, 20162017. 9. (CDC) CfDCaP. HIV testing and risk behaviors among gay, bisexual, and other men who have sex with men - United States. MMWR Morb Mortal Wkly Rep. 2013;62(47):958-62. 10. Kashuba AD, Gengiah TN, Werner L, Yang KH, White NR, Karim QA, et al. Genital Tenofovir Concentrations Correlate With Protection Against HIV Infection in the CAPRISA 004 Trial: Importance of Adherence for Microbicide Effectiveness. J Acquir Immune Defic Syndr. 2015;69(3):264-9. 11. Baeten JM, Palanee-Phillips T, Brown ER, Schwartz K, Soto-Torres LE, Govender V, et al. Use of a Vaginal Ring Containing Dapivirine for HIV-1 Prevention in Women. N Engl J Med. 2016.

12. Marrazzo JM, Ramjee G, Richardson BA, Gomez K, Mgodi N, Nair G, et al. Tenofovir- based preexposure prophylaxis for HIV infection among African women. The New England journal of medicine. 2015;372(6):509-18. 13. Abdool Karim Q, Abdool Karim SS, Frohlich JA, Grobler AC, Baxter C, Mansoor LE, et al. Effectiveness and safety of tenofovir gel, an antiretroviral microbicide, for the prevention of HIV infection in women. Science. 2010;329(5996):1168-74. 14. Dai JY, Hendrix CW, Richardson BA, Kelly C, Marzinke M, Chirenje ZM, et al. Pharmacological Measures of Treatment Adherence and Risk of HIV Infection in the VOICE Study. J Infect Dis. 2016;213(3):335-42. 15. FDA. Guidance for Industry: Vaginal Microbicides: Development for the Prevention of HIV Infection. 2014. 16. Leyva FJ, Bakshi RP, Fuchs EJ, Li L, Caffo BS, Goldsmith AJ, et al. Isoosmolar enemas demonstrate preferential gastrointestinal distribution, safety, and acceptability compared with hyperosmolar and hypoosmolar enemas as a potential delivery vehicle for rectal microbicides. AIDS research and human retroviruses. 2013;29(11):1487-95. 17. Fuchs EJ, Grohskopf LA, Lee LA, Bakshi RP, Hendrix CW. Quantitative assessment of altered rectal mucosal permeability due to rectally applied nonoxynol-9, biopsy, and simulated intercourse. J Infect Dis. 2013;207(9):1389-96. 18. Fuchs EJ, Lee LA, Torbenson MS, Parsons TL, Bakshi RP, Guidos AM, et al. Hyperosmolar sexual lubricant causes epithelial damage in the distal colon: potential implication for HIV transmission. The Journal of infectious diseases. 2007;195(5):703-10. 19. Arlander E, Cederlund T, Mare K. No volume effect on retrograde colonic spread of rectally-administered ropivacaine gel. Aliment Pharmacol Ther. 2003;18(6):655-60. 20. Otten MH, De Haas G, Van den Ende R. Colonic spread of 5-ASA enemas in healthy individuals, with a comparison of their physical and chemical characteristics. Aliment Pharmacol Ther. 1997;11(4):693-7. 21. Gionchetti P, Venturi A, Rizzello F, Corbelli C, Fanti S, Ferretti M, et al. Retrograde colonic spread of a new mesalazine rectal enema in patients with distal ulcerative colitis. Aliment Pharmacol Ther. 1997;11(4):679-84. 22. van Bodegraven AA, Boer RO, Lourens J, Tuynman HA, Sindram JW. Distribution of mesalazine enemas in active and quiescent ulcerative colitis. Aliment Pharmacol Ther. 1996;10(3):327-32. 23. Luckensmeyer GB, Keast JR. Distribution and morphological characterization of viscerofugal projections from the large intestine to the inferior mesenteric and pelvic ganglia of the male rat. Neuroscience. 1995;66(3):663-71. 24. Chapman NJ, Brown ML, Phillips SF, Tremaine WJ, Schroeder KW, Dewanjee MK, et al. Distribution of mesalamine enemas in patients with active distal ulcerative colitis. Mayo Clin Proc. 1992;67(3):245-8. 25. Almer S, Ekberg S, Strom M. Retrograde distribution of a new 5-aminosalicylic acid enema in patients with ulcerative colitis. Gastroenterol Clin Biol. 1992;16(6-7):564-8. 26. Kruis W, Bull U, Eisenburg J, Paumgartner G. Retrograde colonic spread of sulphasalazine enemas. Scand J Gastroenterol. 1982;17(7):933-8. 27. Carballo-Dieguez A, Exner T, Dolezal C, Pickard R, Lin P, Mayer KH. Rectal microbicide acceptability: results of a volume escalation trial. Sex Transm Dis. 2007;34(4):224-9. 28. Morrow KM, Fava JL, Rosen RK, Vargas S, Shaw JG, Kojic EM, et al. Designing preclinical perceptibility measures to evaluate topical vaginal gel formulations: relating user sensory perceptions and experiences to formulation properties. AIDS Res Hum Retroviruses. 2014;30(1):78-91.

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CURRICULUM VITAE The Johns Hopkins University School of Medicine

______Ethel D. Weld, MD 4/2/19

DEMOGRAPHIC AND PERSONAL INFORMATION

Born October 26, 1977, in Boston, MA, USA

Current Appointments

University 2016-present Assistant Professor of Medicine, Johns Hopkins University School of Medicine, Department of Medicine, Division of Clinical Pharmacology (Primary) & Infectious Diseases (Secondary)

Hospital 2016-present Faculty, Johns Hopkins Hospital, Department of Medicine, Division of Infectious Diseases

Personal Data Division of Clinical Pharmacology Department of Medicine The Johns Hopkins University School of Medicine 600 North Wolfe Street, Osler 508 Baltimore, MD 21287-5554 Tel 410 502 8129 Cell 773 263 6937 Fax 410 955 9708 E-mail [email protected]

Education and Training Undergraduate 9/95-6/99 B.A. History with Honors, New York University, NY, NY, magna cum laude

Doctoral/graduate 9/01-6/06 M.D., University of Chicago Pritzker School of Medicine

Postdoctoral Professional Experience 7/06-6/10 Resident & Chief Resident in Internal Medicine and Pediatrics, University of Maryland, Baltimore, MD 7/10-6/12 Instructor, Internal Medicine & Pediatrics, University of Maryland, Baltimore, MD 7/12-6/16 Fellowship, Infectious Disease, Johns Hopkins Hospital, Baltimore, MD 7/13-6/16 Fellowship, Clinical Pharmacology, Dr. Craig Hendrix, Johns Hopkins University School of Medicine, Baltimore, MD

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9/13-present Ph.D. candidate in Clinical Investigation at the Johns Hopkins University Bloomberg School of Public Health

PUBLICATIONS

Original Research & Reviews Mhatre A, Weld E, Lalwani AK. Mutation analysis of Connexin 31 (GJB3) in sporadic non- syndromic hearing impairment. Clinical Genetics 2003;63: 154-159. I performed the experiments and collaborated in writing and editing the article.

Weld ED, Eimer KM, Saharia K, Orenstein A, Hess JR. The expanding range and severity of babesiosis. Transfusion 2010;50(2): 290-291.

Simon JK, Maciel M, Weld ED. Antigen-specific IgA B memory cell responses to Shigella antigens elicited in volunteers immunized with live attenuated Shigella flexneri 2a oral vaccine candidates. Clinical Immunology. 2011;139(2): 185-192. I performed the experiment, wrote the article, and edited the final version.

Weld ED, Hiruy H, Guthrie KM, Fava J, Vargas S, Buckheit K, Buckheit R, Breakey J, Fuchs E, Hendrix C. "A Comparative Pre-Phase I Study of the Impact of Gel Vehicle Volume on Distal Colon Distribution, User Experience, and Acceptability" AIDS Research and Human Retroviruses. December 2016, ahead of print. doi:10.1089/aid.2016.0167.

Weld ED, Garcia-Prats AJ, Furin JJ, Bailey TC, Hesseling AC, Dooley KE. “The time has come: sparing injectables in pediatric MDR-TB” Lancet RM. 5(4): 245-246. April 2017.

Weld ED, Shieh EC, Fuchs EJ, Hiruy H, Buckheit KW, Buckheit Jr. RW, Breakey J, Hendrix CW. “Lubricant Provides Poor Rectal Mucosal HIV Coverage” AIDS Research And Human Retroviruses 33(8): 2017.

Garcia-Prats A, Svensson EM, Weld ED, Schaaf H, Hesseling A. “Current status of pharmacokinetic and safety studies of multidrug-resistant tuberculosis treatment in children” The International Journal of Tuberculosis and Lung Disease Supplement – Pediatric Landscapes. August 2017.

Seddon JA, Weld ED, Schaaf HS, Garcia-Prats AJ, Kim S, Hesseling AC. Conducting efficacy trials in children with MDR-TB: what is the rationale and how should they be done? Int J Tuberc Lung Dis. 2018;22(5):24-33.

Weld ED, Dooley KE, “State of the Art Review of HIV-TB Co-management in Special Populations” (Invited State of the Art Review), Clinical Pharmacology & Therapeutics 104(6): 1098-1109. December 1, 2018.

Weld ED, Rana MS, Dallas RH, Camacho-Gonzalez AF, Ryscavage P, Gaur AH, Chakraborty R, Swindells S, Flexner C, Agwu A. “Interest of Youth Living With HIV in Long-Acting Antiretrovirals” JAIDS 80(2):190-197. February 1, 2018.

Book Chapters, Monographs

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12/03 Weld ED, “Non-Ulcer Dyspepsia: A Resource for the Clinician” PEPID Primary Care Plus point-of-care reference. 2/18 Weld ED, Pau AK, Maartens G, Dooley KE, “Co-Treatment of Tuberculosis and HIV: Pharmacologic Considerations” in “TB and HIV: A Formidable Alliance”, Springer, NY. Manuscript submitted for publication. 7/1/18 Weld ED, Shoham S. “Epidemiology, Prevention, and Management of Occupational Exposure to Bloodborne Infections.” In Cameron & Cameron: Current Surgical Therapy, 13th edition. Manuscript submitted for publication.

Other Media (Videos, Websites, Blogs, Social Media, etc.) 8/17/97 Weld ED, “Watching the Web” The Asian Wall Street Journal 8/29/97 Weld ED, “Are the Lines Getting Longer?” The Asian Wall Street Journal 8/1/18 Weld ED, Agwu A, “HIV 2018: Evaluating New Therapies”. Webinar for Managed Care and Specialty Pharmacies. North American Center for Continuing Medical Education 8/15/18 Weld ED, “New and Emerging Therapies for HIV”. Johns Hopkins eLiterature Review, Newsletter, and Podcast presentation. eHIV Review, Volume 4.

FUNDING Johns Hopkins Clinical Research Scholars KL2 Award $90,000 salary support; 85% protected time Role: Principal Investigator

UM1 AI068632 (PI: Sharon Nachman) NIH DAIDS IMPAACT 2005 “A Phase I/II Trial of the Safety and Pharmacokinetics of Delamanid in Combination with Optimized Background Regimen for MDR-TB in Children with and without HIV infection” Role: Protocol Chair

UM1 AI068619 (PI: Susan Eshleman) NIH DAIDS HPTN Laboratory Core Role: Member, Pharmacology Core

U19 AI113127 (PI: Craig Hendrix) NIH “Development of Rectal Enema as Microbicide (DREAM): Project One” Role: Co-investigator

OPP1099837 (PI: Craig Hendrix) Gates Foundation Grant Pharmacostatistical Modeling and Simulation of Randomized Clinical PrEP Trials Role: Co-investigator

EXTRAMURAL Funding Research Extramural Funding – Previous 4/16-12/17 Youth Interest in Long-Acting Antiretrovirals Survey Study CFAR Supplement from Adolescent Scientific Working Group

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PI: Agwu, A. Role: Co-PI, 50%; project to assess readiness for long-acting nanoformulated antiretrovirals among adolescents with HIV at our 4 clinical sites.

7/1/15 – 6/30/16 Pearl M. Stetler Research Award for Women Physicians Sponsor: Pearl M. Stetler Research Fund 121153 Total direct cost: $65,000 PI: Ethel D. Weld, MD Role: 100%; combined several research projects under the theme of “Behaviorally congruent HIV Pre-Exposure Prophylaxis”

Educational Extramural Funding – Previous 7/1/13-6/30/15 Clinical Pharmacology T32 NIH T32 GM066691-11 and GM066691-12, NIGMS $55,000 PI: Theresa Shapiro, MD, Ph.D. Role: Trainee in Clinical Pharmacology and Clinical Research

CLINICAL ACTIVITIES

Clinical Focus I am involved in initiatives to optimize the treatment of MDR-TB in children, shorten and minimize the burdens of existing MDR-TB treatment regimens, and increase HIV Pre-Exposure Prophylaxis (PrEP) awareness and uptake among vulnerable high-risk groups with currently poor uptake. I design and implement clinically useful adherence support measures, particularly related to the possible application of novel and long-acting drug delivery methods, for the treatment and prevention of HIV.

Certification Medical, other state/government licensure 2010-present Maryland Medical License # D0071039 (Expires 9/30/19) 2017-present Pennsylvania Medical License #MD461516

Boards, other specialty certification 2010-2015 Board Certified, American Board of Pediatrics #676830 2011-present Board Certified, American Board of Internal Medicine #303376 2014-present Subspecialty Board Certified, Infectious Disease, American Board of Internal Medicine #303376 2016-present Subspecialty Board Certified, Clinical Pharmacology, American Board of Clinical Pharmacology #201606

Clinical (Service) Responsibilities, % Effort 2010-2012 Attending Hospitalist, University of Maryland Intermediate Medical Care Unit, 100%

2012-2015 Clinical Fellow in Infectious Disease, Transplant, General, and HIV Infectious Disease services, 20-100%

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2016-present Attending Infectious Disease Physician, Polk Service (Inpatient HIV Service) & Mann Service (General Infectious Disease Consultation), 15-20%

Clinical Productivity 2013-present I serve as an inpatient Infectious Disease consultant and primary teaching attending for the inpatient HIV/AIDS service at the Johns Hopkins Hospital, with a targeted clinical effort assignment of 15%.

EDUCATIONAL ACTIVITIES Educational Focus My overall educational focus is to improve the knowledge of fellows, residents, medical students, and patients relating to the prevention, diagnosis, and treatment of infectious illness, and to enhance understanding of the contribution of clinical pharmacological methods to the care of infectious diseases. In particular, I am interested in the well-informed incorporation of Therapeutic Drug Monitoring (TDM) and pharmacogenomic testing into clinical practice, where appropriate to strengthen therapy, improve outcomes, and prevent adverse drug events.

Teaching Classroom instruction Regional 2009-2010 Chief Resident, presented morning report case discussions for pediatric and Internal Medicine housestaff on rotation, including “Case Conundrum: A 50-year- old woman with lactic acidosis and stroke”, “Babesia awakened: a zebra slumbers”, “Buruli ulcers: The diagnosis and treatment of M. ulcerans”, and “Nutrient deficiencies & the physical exam: a focus on the fingernails”, University of Maryland Medical Center, Baltimore MD

2015-present Instructor, lead small group sessions on drug metabolism for the introductory course on Pharmacology for first-year medical students, Johns Hopkins University School of Medicine, Baltimore MD

International 2005 “Sepsis Treatment in Children in Gabon”, lecture given to the clinical staff of L’Hôpital Albert Schweitzer, in Lambaréné, Gabon, while serving as a Schweitzer fellow in pediatrics there during medical school. (French)

Clinical instruction Regional 2010-2012 Attending Physician, Inpatient IMC hospitalist service Code Team Supervision for Internal Medicine residents, 30 weeks per year, University of Maryland Medical Center

2011 Attending Physician, Inpatient pediatric service, supervised and taught pediatric residents, 5%, University of Maryland Medical Center

2013 Fellow, 2nd year residents; Inpatient Polk service (HIV) team supervision and care coordination. 6 weeks during fellowship, Johns Hopkins SOM

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CME instruction 2/16 Conference on Retroviruses and Opportunistic Infections, Conference presenter, attendee, Boston, MA 7/17 9th International AIDS Society Conference on HIV Care, Conference presenter, attendee, Paris, France 6/18 Guest Faculty, Webinar for pharmacy professionals on “Evaluating New Therapies in HIV”, supported by North American Center for Continuing Medical Education & DKBmed

Educational Program Building / Leadership 2009-2010 Chief Resident, designed and taught a novel curriculum for med-peds residents at Resident Retreat, including sessions on “Feedback on the Fly” and “The Med-Peds Resident as Teacher: Foolproof Strategies to Integrate Teaching into Clinical Care”, University of Maryland Medical Center, Baltimore MD

Educational Demonstration Activities to external audience 2013-14 JHH Infectious Disease Case Conference, videotaped and archived, observed by clinicians at global sister institutions through the Johns Hopkins Center for Global Health 2/18 IMPAACT 2005 Study Startup Meeting, led sessions on Visit Procedures Considerations and Clinical Management of MDR-TB- and HIV-co-infected study participants, Stellenbosch University, Capetown, South Africa

RESEARCH ACTIVITIES

Research Focus I am an internist-pediatrician specializing in infectious disease, who is strongly committed to patient-oriented clinical investigation as a long-term career focus within academic medicine. In particular I am focused on contributing to the existing body of knowledge about clinical pharmacologic aspects of the prevention and treatment of infectious illness. My overall research objective is to improve the prevention and treatment of HIV in children, adolescents, and adults with HIV or at high risk for HIV; and to improve treatment options for children with HIV and TB co-infection and children with multi-drug-resistant (MDR) or extensively drug-resistant (XDR) tuberculosis (TB) infection.

SYSTEM INNOVATION AND QUALITY IMPROVEMENT ACTIVITIES

System Innovation Focus: 2016-present Pharmacogenomic testing for the prevention of Adverse Drug Events

System Innovation and Quality Improvement efforts within JHMI: 2013-2014 Chair, Quality Improvement Initiative regarding Occupational Needlestick Exposures; author of JHBMC Needlestick Post-Exposure Prophylaxis Guidelines

2016-present Member, Pharmacogenomics Task Force (Initiative on Improvement of Personalized Medicine)

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2016-present Member, Department of Medicine Task Force on Women

System Innovation and Quality Improvement efforts outside of JHMI: 2016- present Member, AIDS Clinical Trials Group (ACTG) Antiretroviral Therapy Strategies Transformative Science Group: Less Frequent Dosing ART Working Group

ACTG Clinical Pharmacology Advisory Group (CPAG): Member

University of Maryland Medical Center, Baltimore, MD: 2009-2010 Chair, Task Force on Timely Discharge Dictations

System Innovation and Quality Improvement Program Building/Leadership: 2009-2010 Chair, Quality Improvement Initiative regarding Creation of a Med-Peds Transition of Care Clinic

ORGANIZATIONAL ACTIVITIES

Institutional Administrative Appointments University of Maryland Medical Center, Baltimore, MD: 2006-2010 Post-graduate Education Committee 2008-2010 Pediatric Education Workgroup 2009-2010 Committee on Clinical Competency

Professional Societies 2013-present Member, American Society of Clinical Pharmacology and Therapeutics (ASCPT) 2016-present Member, Infectious Disease Society of America (IDSA) 2017-present Member, Society of Bedside Medicine

RECOGNITION

Awards, Honors 1999 Rhodes Scholarship: Finalist selected to interview for the Massachusetts constituency 1999 NYU Faculty Memorial Award: For academic and extracurricular excellence 1999 NYU Jones Prize: For best Senior Honors Thesis in the Department of History 1999 NYU Trustee Merit Scholarship: $9,000 annual award 2004 Honorable Mention for Excellence for Original Research: NIH Pritzker Summer Research Conference 2005 Albert Schweitzer Fellowship: Selected to serve as clinical fellow at the Albert Schweitzer Hospital in Gabon 2006 Arnold P. Gold Humanism in Medicine Honor Society: Elected twice, by medical student peers, and as a resident honoree 2009 UMMS Department of Medicine Travel Scholarship: Selected by committee, for travel to Kipili, Tanzania 2010 Bradley Clinician’s Clinician Award: Presented to the graduating resident whom his/her peers would most trust with the medical care of their own children

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2011 Pediatric Senior Resident Research Award: Presented to the graduating pediatric resident with the best original research paper, for “Antigen-specific IgA B memory (BM) cell responses to lipopolysaccharide (LPS) and invasion plasmid antigen (Ipa) B among volunteers vaccinated with live-attenuated Shigella flexneri 2a vaccine candidates” 2015 Pearl M. Stetler Award for Women Physicians: $65,000 for salary support for a designated year of research in a postgraduate fellowship program 2018 W. Leigh Thompson, MD Excellence in Research: Clinical Research Faculty Award, Johns Hopkins Dept. of Medicine Research Retreat: Top Three Finalist

Invited Talks National 4/16 Weld ED, Bailey TC, “What We Talk About When We Talk About Plagues: Five Parables of Infectious Disease Control for a Deliberative Democracy”, Invited lecture, The Aggie Agora, Texas A & M, College Station, TX

9/17 Weld ED, “Update on Long-Acting Technologies for Treatment and Prevention of HIV”, Invited Lecture ANAC Conference, University of Maryland Medical Center, Baltimore, MD

5/18 Weld ED, “Microbicide HIV PrEP: The Case for Behavioral Congruence as Adherence Support”, Invited Lecture, Neuro AIDS Lecture Series, Johns Hopkins University School of Medicine

International 10/16 Weld ED, “Scientific and Clinical Rationale for the Substitution of a Novel TB Drug for the Injectable Agents in MDR-TB Treatment Regimens in Children”, Symposium Session 1540 at the 47th Union World Conference on Lung Health, October 28, 2016, Liverpool, United Kingdom

OTHER PROFESSIONAL ACCOMPLISHMENTS Posters 8/2/02 Weld ED, “Advance Directives & Quality of End of Life Care: How Well Do We Do It?” Original paper presented at Pritzker University of Chicago Summer Research Conference

4/1/08 Weld ED, “Acute Takotsubo Cardiomyopathy in the Setting of Uncontrolled Graves Disease”, poster presentation, American College of Physicians Maryland Regional Associates Meeting, Baltimore, MD

5/4/10 Simon JK, Weld ED et al., “Antigen-specific IgA B memory (BM) cell responses to lipopolysaccharide (LPS) and invasion plasmid antigen (Ipa) B among volunteers vaccinated with live-attenuated Shigella flexneri 2a vaccine candidates”, poster presentation, Pediatric Academic Societies meeting, Vancouver, B.C. [paper published as above.]

3/8/16 Weld ED, Shieh E, Fuchs EJ, Buckheit KW, Buckheit RW, Breakey J, Hendrix C, “Gel Applied as Anal Lube Without Applicator Provides Poor Rectal Mucosal

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HIV Coverage”, poster presentation, Johns Hopkins Department of Medicine Research Retreat, Baltimore, MD

10/19/16 Weld ED, Hiruy H, Guthrie KM, Fava JL, Vargas SE, Buckheit KW, Buckheit RW Jr., Spiegel H, Breakey J, Fuchs EJ, Hendrix CW, “Impact of Gel Vehicle Volume on Distal Colon Distribution, User Experience, & Acceptability”, poster presentation, HIV Research for Prevention (R4P) Conference, Chicago, IL

7/24/17 Weld ED, EJ Fuchs, et al., “Tenofovir Douche as HIV PrEP for Receptive Anal Intercourse: Safety, Pharmacokinetics, Pharmacodynamics, & Acceptability (DREAM 01 Study), Late Breaker Poster Session, 9th IAS Conference on HIV Science Paris, France

7/24/17 Weld ED, EJ Fuchs, et al., “Colorectal Distribution of Lymphocytes and Cell-Free HIV Surrogate in Autologous Seminal Plasma Following Simulated Anal Intercourse”, Late Breaker Poster Session, 9th IAS Conference on HIV Science Paris, France

7/25/17 Weld ED, Rana MS, et al., “Readiness of Youth Living with HIV for Long-Acting Nanoformulated Antiretrovirals”, Poster Session, 9th IAS Conference on HIV Science Paris, France

5/16/18 Weld ED, Fuchs EJ, Marzinke M, et al., “Tenofovir Douche as HIV Pre-Exposure Prophylaxis for Receptive Anal Intercourse: Safety, Pharmacokinetics, Pharmacodynamics, & Acceptability (DREAM 01)”, Poster Session, Johns Hopkins Department of Medicine Research Retreat, Baltimore, MD

Oral/Podium Presentations 2/25/16 Shieh E, Weld ED, Fuchs EJ, Buckheit KW, Buckheit RW, Breakey J, Hendrix C, “Gel Applied as Anal Lube Without Applicator Provides Poor Rectal Mucosal HIV Coverage”, Late-breaker oral abstract at Conference on Retroviruses and Opportunistic Infections (CROI) [Dr. Shieh gave the talk].

10/24/18 Weld ED, “DREAM-01 Study: Tenofovir Rectal Douche as HIV PrEP: Safety, PK, PD, & Acceptability”. Oral abstract at HIV Research for Prevention (HIVR4P) Conference, Madrid, Spain.

Languages: English (fluent); French (conversational & professionally competent); Spanish (conversational & professionally proficient); Mandarin Chinese (conversational)

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