Safety, pharmacokinetics, and immunological activities of multiple intravenous or subcutaneous doses of an anti-HIV monoclonal antibody, VRC01, administered to HIV-uninfected adults: Results of a phase 1 randomized trial

Background VRC01 is an HIV-1 CD4 binding site broadly neutralizing antibody (bnAb) that is active against a broad range of HIV-1 primary isolates in vitro and protects against simian-human immunodeficiency virus (SHIV) when delivered parenterally to nonhuman primates. It has been shown to be safe and well tolerated after short-term administration in humans; however, its clinical and functional activity after longer-term administration has not been previously assessed. Methods and findings HIV Vaccine Trials Network (HVTN) 104 was designed to evaluate the safety and tolerability of multiple doses of VRC01 administered either subcutaneously or by intravenous (IV) infusion and to assess the pharmacokinetics and in vitro immunologic activity of the different dosing regimens. Additionally, this study aimed to assess the effect that the human body has on the functional activities of VRC01 as measured by several in vitro assays. Eighty-eight healthy, HIV-uninfected, low-risk participants were enrolled in 6 United States clinical research sites affiliated with the HVTN between September 9, 2014, and July 15, 2015. The median age of enrollees was 27 years (range, 18–50); 52% were White (non-Hispanic), 25% identified as Black (non-Hispanic), 11% were Hispanic, and 11% were non-Hispanic people of diverse origins. Participants were randomized to receive the following: a 40 mg/kg IV VRC01 loading dose followed by five 20 mg/kg IV VRC01 doses every 4 weeks (treatment group 1 [T1], n = 20); eleven 5 mg/kg subcutaneous (SC) VRC01 (treatment group 3 [T3], n = 20); placebo (placebo group 3 [P3], n = 4) doses every 2 weeks; or three 40 mg/kg IV VRC01 doses every 8 weeks (treatment group 2 [T2], n = 20). Treatment groups T4 and T5 (n = 12 each) received three 10 or 30 mg/kg IV VRC01 doses every 8 weeks, respectively. Participants were followed for 32 weeks after their first VRC01 administration and received a total of 249 IV infusions and 208 SC injections, with no serious adverse events, dose-limiting toxicities, nor evidence for anti-VRC01 antibodies observed. Serum VRC01 levels were detected through 12 weeks after final administration in all participants who received all scheduled doses. Mean peak serum VRC01 levels of 1,177 μg/ml (95% CI: 1,033, 1,340) and 420 μg/ml (95% CI: 356, 494) were achieved 1 hour after the IV infusion series of 30 mg/kg and 10 mg/kg doses, respectively. Mean trough levels at week 24 in the IV infusion series of 30 mg/kg and 10 mg/kg doses, respectively, were 16 μg/ml (95% CI: 10, 27) and 6 μg/ml (95% CI: 5, 9) levels, which neutralize a majority of circulating strains in vitro (50% inhibitory concentration [IC50] > 5 μg/ml). Post-infusion/injection serum VRC01 retained expected functional activity (virus neutralization, antibody-dependent cellular cytotoxicity, phagocytosis, and virion capture). The limitations of this study include the relatively small sample size of each VRC01 administration regimen and missing data from participants who were unable to complete all study visits. Conclusions VRC01 administered as either an IV infusion (10–40 mg/kg) given monthly or bimonthly, or as an SC injection (5 mg/kg) every 2 weeks, was found to be safe and well tolerated. In addition to maintaining drug concentrations consistent with neutralization of the majority of tested HIV strains, VRC01 concentrations from participants’ sera were found to avidly capture HIV virions and to mediate antibody-dependent cellular phagocytosis, suggesting a range of anti-HIV immunological activities, warranting further clinical trials. Trial registration Clinical Trials Registration: NCT02165267


Ethical considerations
Multiple candidate HIV vaccines will need to be studied simultaneously in different populations around the world before a successful HIV preventive vaccine is found. It is critical that universally accepted ethical guidelines are followed at all sites involved in the conduct of these clinical trials. The HIV Vaccine Trials Network (HVTN) has addressed ethical concerns in the following ways:  HVTN trials are designed and conducted to enhance the knowledge base necessary to find a preventive vaccine, using methods that are scientifically rigorous and valid, and in accordance with Good Clinical Practice (GCP) guidelines.
 HVTN scientists and operational staff incorporate the philosophies underlying major codes [1][2][3], declarations, and other guidance documents relevant to human subjects research into the design and conduct of HIV vaccine clinical trials.
 HVTN scientists and operational staff are committed to substantive community input-into the planning, conduct, and follow-up of its research-to help ensure that locally appropriate cultural and linguistic needs of study populations are met. Community Advisory Boards (CAB) are required by DAIDS and supported at all HVTN research sites to ensure community input.
 HVTN clinical trial staff counsel study participants routinely on how to reduce HIV risk. Participants who become HIV-infected during the trial are provided counseling on notifying their partners and about HIV infection according to local guidelines. Staff members will also counsel them about reducing their risk of transmitting HIV to others.
 Participants who become HIV-infected during the trial are referred to medical practitioners to manage their HIV infection and to identify potential clinical trials they may want to join.
 The HVTN provides training so that all participating sites similarly ensure fair participant selection, protect the privacy of research participants, and obtain meaningful informed consent. During the study, participants will have their wellbeing monitored, and to the fullest extent possible, their privacy protected. Participants may withdraw from the study at any time.
 Prior to implementation, HVTN trials are rigorously reviewed by scientists who are not involved in the conduct of the trials under consideration.
 HVTN trials are reviewed by local and national regulatory bodies and are conducted in compliance with all applicable national and local regulations.
 The HVTN designs its research to minimize risk and maximize benefit to both study participants and their local communities. For example, HVTN protocols provide enhancement of participants' knowledge of HIV and HIV prevention, as well as counseling, guidance, and assistance with any social impacts that may result from research participation. HVTN protocols also include careful medical review of each research participant's health conditions and reactions to study products while in the study.
 HVTN research aims to benefit local communities by directly addressing the health and HIV prevention needs of those communities and by strengthening the capacity of the communities through training, support, shared knowledge, and equipment. Researchers involved in HVTN trials are able to conduct other critical research in their local research settings.
 The HVTN recognizes the importance of institutional review and values the role of in country Institutional Review Boards (IRBs) and Ethics Committees (ECs) as custodians responsible for ensuring the ethical conduct of research in each setting. This protocol minimizes risks to participants by (a) correctly and promptly informing participants about risks so that they can join in partnership with the researcher in recognizing and reporting harms; (b) respecting local/national blood draw limits; (c) performing direct observation of participants postinfusion and collecting information regarding side effects for several days postinfusion; (d) having staff properly trained in administering study procedures that may cause physical harm or psychological distress, such as blood draws, infusions, HIV testing and counseling and HIV risk reduction counseling; (e) providing HIV risk reduction counseling and checking on contraception use (for women); and (f) providing safety monitoring. 45  In all public health research, the risk-benefit ratio may be difficult to assess because the benefits to a healthy participant are not as apparent as they would be in treatment protocols, where a study participant may be ill and may have exhausted all conventional treatment options. However, this protocol is designed to minimize the risks to participants while maximizing the potential value of the knowledge it is designed to generate.

Equitable subject selection 45 CFR 46.111 (a) 3 and 21 CFR 56.111 (a) 3: Subject selection is equitable
This protocol has specific inclusion and exclusion criteria for investigators to follow in admitting participants into the protocol. Participants are selected because of these criteria and not because of positions of vulnerability or privilege. Investigators are required to maintain screening and enrollment logs to document volunteers who screened into and out of the protocol and for what reasons. 45  The protocol specifies that informed consent must be obtained before any study procedures are initiated and assessed throughout the trial (see Section 9.1). Each site is provided training in informed consent by the HVTN as part of its entering the HVTN. The HVTN requires a signed consent document for documentation, in addition to chart notes or a consent checklist. This protocol has extensive safety monitoring in place (see Section 11). Safety is monitored daily by HVTN Core and routinely by the HVTN 104 Protocol Safety Review Team (PSRT). In addition, the HVTN Safety Monitoring Board (SMB) or a Data and Safety Monitoring Board (DSMB) periodically reviews study data. 45  Privacy refers to an individual's right to be free from unauthorized or unreasonable intrusion into his/her private life and the right to control access to individually identifiable information about him/her. The term "privacy" concerns research participants or potential research participants as individuals whereas the term "confidentiality" is used to refer to the treatment of information about those individuals. This protocol respects the privacy of participants by informing them about who will have access to their personal information and study data (see Appendix A). The privacy of participants is protected by assigning unique identifiers in place of the participant's name on study data and specimens. In the United States, research participants in HVTN protocols are protected by a Certificate of Confidentiality from the US NIH, which can prevent disclosure of study participation even when that information is requested by subpoena. Participants are told of the use and limits of the certificate in the study consent form. In addition, each staff member at each study site in this protocol signs a Confidentiality Agreement with the HVTN and each study site participating in the protocol is required to have a standard operating procedure on how the staff members will protect the confidentiality of study participants.

Overview Title
A phase 1 clinical trial to evaluate the safety and drug levels of a human monoclonal antibody, VRC-HIVMAB060-00-AB (VRC01) administered in multiple doses intravenously and subcutaneously in different dosing schedules to healthy, HIVuninfected adults

Primary objectives
Primary objective 1: To evaluate the safety and tolerability of VRC01, administered intravenously (IV) and subcutaneously (SC), at multiple timepoints.

Primary objective 2 (Groups 1-3):
To evaluate the serum levels of VRC01, administered IV and SC in 3 different regimens, at Month 6.

Primary objective 3 (Groups 4 and 5):
To evaluate the serum levels of VRC01 at 2 timepoints after each IV administration.

Study products and routes of administration
 VRC01: human monoclonal antibody (mAb) VRC-HIVMAB060-00-AB in formulation buffer at pH 5.8. Administered IV in 100 mL of normal saline (Sodium Chloride for Injection 0.9%, USP) or administered SC by needle and syringe injection.
 IV placebo for VRC01: Sodium Chloride for Injection 0.9%, USP administered IV in 100 mL of normal saline (Sodium Chloride for Injection 0.9%, USP).

Background
Although the global incidence of new HIV infections peaked in the mid-1990s, UNAIDS has reported that 2.5 million new HIV infections occurred last year, for a global total of more than 34 million people living with HIV [4]. The wider availability of antiretroviral (ARV) therapy, mother-to-child transmission prevention programs, and a diverse array of other prevention programs have all contributed to turning the tide of the epidemic, but the magnitude of new infections remains a major concern, warranting the need for the development of safe and effective preventive vaccines.
The search for a globally effective HIV vaccine, as well as elucidation of biomarkers predictive of vaccine efficacy, continues. Modest success in preventing HIV acquisition has been achieved by the RV144 trial in Thailand with 31% efficacy [5]. Neutralizing antibodies (nAbs) were not substantially elicited by this vaccine regimen and were not found to be a correlate of risk in this modestly effective vaccine regimen [6]. However, most licensed vaccines elicit protective nAbs that correlate with vaccine efficacy. For HIV, it is possible that multiple immune mechanisms will be needed to prevent acquisition. In nonhuman primate (NHP) models, the presence of nAbs has been shown to prevent SHIV acquisition [7]. However, to date HIV vaccines have not been successful in generating nAbs effective against a wide variety of infecting strains [8][9][10]. In recent years, research has made progress in the discovery of broad and potent nAbs found in the sera of chronically HIV infected donors [11][12][13][14]. Knowledge gained from such discoveries holds promise for the development of new immunogens capable of eliciting broadly nAbs (bnAbs) at titers which could be potentially effective in protection against HIV-1 [15].
The Vaccine Research Center (VRC), NIAID, NIH has developed VRC01, a broadly neutralizing human mAbs which is targeted against the HIV-1 CD4 binding site [13]. This mAb was originally discovered in a participant infected with HIV-1 for more than 15 years who maintained viral control without use of ARV therapy [16]. By applying a novel method of isolating B cells that produce a specific antibody, and using recombinant DNA technology, the heavy and light chains encoding VRC01 were cloned and sequenced, allowing the synthetic production of codon-optimized genes encoding the variable region that was inserted into proprietary immunoglobulin G1 (IgG1) background sequences [13]. In the interim since the isolation of the VRC01 antibody, subsequent work evaluating longitudinal serum collected from HIV-1 infected individuals has indicated that although antibodies capable of binding to VRC01-like epitopes may be induced during HIV-1 infection, they occur in only a minority of HIV-infected individuals and may take years to develop [17].
The structure of VRC01 bound to HIV gp120 core has been determined. It binds to the HIV-1 gp120 envelope protein. VRC01 displays several unusual structural features. It is highly affinity-matured, has a disulfide link between complementarity-determining region (CDR) H1 and H3 and has a glycan in the variable (V) region of the light chain. However, none of these features appears to be required for binding affinity or neutralization [14]. VRC01 does not have an unusually long CDR-H3 region like some other HIV-1 nAbs. It is not self-or poly-reactive and lacks anti-phospholipid antibody activity [18]; these features are consistent with the hypothesis that VRC01 will be safe for human administration.
By in vitro testing, VRC01 has a half-maximal inhibitory concentration (IC 50 ) of < 50 mcg/mL against 91% of primary isolates of various HIV-1 clades and < 1 mcg/mL against 72% of these isolates. Several proof-of concept studies have been conducted to determine whether the in vitro neutralization capabilities of VRC01 translate into the ability to protect NHPs from challenge with virulent chimeric simian-human immunodeficiency virus (SHIV), which contains the HIV envelope in an SIV background. Protection against a single high-dose SHIV-SF162P3 (a CCR5 tropic strain of HIV) rectal challenge was demonstrated at a 20 mg/kg dose level and partial protection at 5 mg/kg in Rhesus macaques. Protection against vaginal challenge was also demonstrated at 20 mg/kg dose level, given intravenously (IV) [NHP studies by J. Mascola, et al; personal communication]. As tested in the SHIV model in infant macaques, passive transfer of IgG1b12 nAbs was protective, supporting the use of neutralizing antibodies in perinatal settings [19]. In addition, VRC01 at 20 mg/kg protected infant macaques from an oral SHIV challenge [Nancy Haigwood, personal communication].
The clinical use of mAbs to prevent the establishment of viral infections has been previously demonstrated. Monthly injections of palivizumab, a mAb that blocks respiratory syncytial virus (RSV) binding to pulmonary epithelia were found to be safe and well-tolerated, and effective in protecting neonates and infants with underlying pulmonary disease from developing clinically significant RSV infection necessitating hospital admission [20].

Rationale for trial concept
The rationale for HVTN 104 has evolved during the course of its development and implementation. Initially, in Version 1.0 with Groups 1-3, this trial was intended to collect safety and VRC01 trough level data from multiple doses of VRC01 administered over 6 months in dosing regimens hypothesized to result in drug levels consistently within the protective range, based on preclinical data. These goals are in support of potential future efforts in HIV prevention in infants (PMTCT) and adults. Subsequently, further clarity on the potential and distinct contributions that VRC01 may allow for the HIV vaccine field have come to the forefront and drive the modification of HVTN 104 to Version 2, with the inclusion of Groups 4 and 5 as well as the addition of more mucosal sampling timepoints. In these new groups, rather than maintain a consistently high VRC01 level, the goal is to allow the bnAb levels (i.e. neutralization titers) to drop to levels that are hypothesized to be within a range potentially inducible by a vaccine. For these groups, optimizing inter-subject variability between dosing intervals while maintaining VRC01 neutralization titers estimated within an IC50 <1mcg/ml (see Section 4.7) is the goal.
VRC01 drug levels and functional activity in serum and mucosal fluids will be evaluated by using multiple assays. Assessment of VRC01 drug levels in serum for the primary endpoint analysis will use an anti-idiotype assay specific for VRC01 (described in Section 10.4.1). Secondary endpoint analyses will assess VRC01 binding to Env antigens using the validated Binding Antibody Multiplex Assay (BAMA) (also described in Section 10.4.1). Additionally, we plan to assess the functional activity of VRC01 using the validated TZM-bl neutralization assay (described in Section 10.5.2).
Rationale for Version 1.0 (Groups 1-3): VRC01 has successfully prevented SHIV acquisition in the NHP challenge protection model. The next step is testing the concept in humans. The VRC is preparing for a large scale international test-of-concept study in infants assessing prevention of mother-tochild transmission of HIV-1. The VRC is conducting initial first-in-human dose escalation studies for safety, tolerability and pharmacokinetic assessments in HIV infected (VRC 601) and HIV un-infected (VRC 602) adults. Upon confirmation of maximum dose acceptability, additional safety and pharmacokinetic (PK) data collection from multiple doses in a larger cohort of adults interrogating a range of dosing regimens is then needed to support future test of concept studies.
HVTN 104 will provide additional supportive data for planned and postulated uses of VRC01 for prevention of HIV acquisition. The primary goal is to further validate the safety and tolerability of VRC01 administered multiple times over 6 months. The data from HVTN 104 will help support the dosing schedule and rationale for a planned test of concept infant study; which will be a staged phase 1/2b, randomized, double-blind, placebo-controlled, multi-dose, international trial in breastfed infants born to HIV infected mothers. The first stage of the infant study will assess safety and tolerability and PK parameters of multiple dosing while the second stage will assess efficacy with a primary endpoint being the prevention of HIV transmission at 24 weeks of life. The preliminary dosing planned is monthly SC administration of 20mg/kg after an initial loading dose of 40mg/kg administered shortly after birth.
The NIH Vaccine Research Center's VRC 601 and 602 clinical trials will provide initial safety and pharmacokinetic data for 1 mg/kg, 5 mg/kg, 20mg/kg, and 40mg/kg IV doses as well as 5 mg/kg SC doses in a small number of adult participants. In adults, the SC dose evaluation is limited to 5 mg/kg because the volume of product that would be needed to be delivered for a dosage ≥ 20 mg/kg SC is too large to be accommodated by the SC route. HVTN 104 is being conducted in a larger cohort of adults and began when safety data from the maximum tolerated dose tested in VRC 602 was available. Group 1 in HVTN 104 is testing the same regimen proposed in the phase 1/2b infant study, but is being administered IV in adults. Groups 2 and 3 in HVTN 104 will also test alternate dosing regimens that may be considered for later studies in infants or adults.
Another goal of this study is to assess the VRC01 trough levels reached by administering different doses of VRC01 in different frequencies and routes. Based on the preclinical studies, achievement of trough serum levels of approximately 40 or 50 mcg/mL may be sufficient for HIV prevention. Assessing the kinetics of a higher dose administered less frequently (bimonthly) alongside a moderate dose administered more frequently (monthly) by IV is useful to determine if either or both schedules can achieve trough levels in this range. There are obvious logistical and operational advantages to less frequent dosing intervals if this can achieve trough levels hypothesized to provide protection, for any route method, but especially for IV. For this objective, we propose Group 1 to be dosed at 40 mg/kg IV at Month 0 and then 20 mg/kg at Months 1, 2, 3, 4, 5, and Group 2 to be dosed at 40 mg/kg at Months 0, 2, 4. Due to the expected long halflife for VRC01 in humans, a loading dose is anticipated to be required to allow trough levels to reach adequate levels earlier than without a loading dose. Therefore, a loading dose is planned for Groups 1 and 3. Since the maximum dose planned for testing in humans is 40mg/kg, a higher loading dose will not be administered for Group 2.
In addition, evaluation of the kinetics of a smaller dosage of VRC01 given SC at more frequent intervals merits exploration. Studies on the kinetics of IV and SC administration of IgG immunotherapy in patients with immunodeficiency disorders have compared high doses given IV every 3 weeks to smaller doses given SC weekly. IVIG dosing results in high peak serum levels (up to 1000 mg/dL) that fall rapidly over few days and with a further slow decline from catabolism. However, use of smaller SC doses allowing a slow diffusion of IgG into the vasculature and lymphatics results in stable higher trough IgG serum levels which remain constant between consecutive SC IG infusions [21]. Both routes of administration display similar half-lives. Trough levels, rather than peak levels, are of greatest importance, rather than peak, for sufficient prevention of HIV acquisition during passive immunotherapy, and thus smaller doses given more frequently via the SC route may have the potential to result in sufficient and consistent trough levels as compared to higher IV doses given less frequently. For this objective, we are proposing a third active arm of 5mg/kg SC biweekly (after a loading dose of 40mg/kg IV).
VRC01 is formulated at 100 ± 10 mg/mL. Subcutaneous dosing in infants is the expected route of administration and is feasible at the doses planned as the volume administered will be sufficiently small to be administered in 1 or 2 SC injections. Due to the concentration of the VRC01, larger volumes are required for adult dosing at the higher doses; therefore IV administration will be used for the higher dosing in these initial studies.
Considering long term that SC dosing can be potentially self-administered (as it is with IgG immunotherapy), then biweekly SC dosing may be more accessible, less burdensome, less expensive, and preferred by patients (as it is for many IgG immunotherapy patients) than monthly or even bimonthly IV dosing. Reactogenicity has not been a significant concern with SCIG [21].

Rationale for Version 2.0 (Groups 4 and 5):
Major questions with respect to bnAbs and development of HIV vaccines include:  What is the range of protection afforded by a bnAb that blocks the binding of HIV gp120 to the cellular CD4 binding site? What is the dynamic range in concentration of antibody and neutralizing activity associated with protection? Can lower levels of neutralization activity, including levels potentially inducible by an HIV vaccine, afford protection or does in vivo protection require only high concentrations of antibodies to HIV CD4 binding site?
 Are non-neutralizing effector functions also predictive of efficacy in addition to neutralizing activity? What are the kinetics and functional activities (nonneutralizing) that are seen at low neutralization titers for VRC01?
 What is the PK profile of VRC01 in relation to different levels of neutralization over time? Do compartment-specific differences in blood and mucosal fluids affect the neutralizing and non-neutralizing functions of VRC01? These levels will allow us to model the HIV acquisition rates through a wide dynamic range of neutralization levels for VRC01.
To answer these questions, it will be necessary to evaluate bnAbs in later phase trials, evaluating protection and HIV acquisition endpoints at varying antibody levels in at-risk populations. Neutralizing antibodies to HIV have been shown to protect against experimental challenge in the NHP SHIV model [22][23][24][25][26][27][28][29]. In these studies the degree of protection has varied with the neutralizing potency of the antibodies and with the dose, route, and sensitivity of the challenge stocks. Low antibody concentrations have in some instances been quite protective, especially against repeat low dose mucosal challenges [30,31]. Recent studies have suggested that VRC01 concentrations as low as ~1-2 mcg/ml can achieve sterilizing immunity (see Section 4.9.4 and [32][33][34][35]). By adding Groups 4 and 5 to the HVTN 104 protocol, the study team will be able to assess the levels of VRC01 in blood and mucosal secretions when administered intravenously at 10 mg/kg or 30 mg/kg. Therefore, Groups 4 and 5 will inform the dose-selection for a phase 2b correlates trial aiming to evaluate the efficacy of a bnAb in high risk adults and to establish markers of passive immunoprophylaxis that correlate with protection against HIV infection. By using lower doses every 2 months (10 mg/kg IV in Group 4 and 30 mg/kg IV in Group 5), these newly added groups are evaluating dosing regimens that are expected to result in lower trough levels with large inter-subject variability between dosing intervals (see Section 4.7), necessary to accomplish these correlates goals.

Mucosal specimen collection
Mucosal samples will be collected in order to assess the dynamics of transudation of VRC01 into mucosal secretions, where the protective effects of the mAb against founder virions would be expected to be most significant. Collection will include salivary and rectal secretions in men and women, the collection of semen in men and cervicovaginal secretions in women. The mucosal specimens will be collected on day 84, to assess early levels of VRC01 in the mucosal compartments, as well as at day 168 and day 224, which correspond to final trough and late timepoints. With Version 2.0, mucosal secretion sampling is being added at additional timepoints: 3, 14 and 21 days after the 2 nd or last VRC01 dose administration (the 21 day collection timepoint for all groups except Group 3). These additional samplings will allow for better potential semi-quantitative analysis of serum:mucosal surface VRC01 levels and intra-as well as inter-individual variability for mucosal expression. Additionally, functional and neutralizing Ab activity within the mucosal secretions may potentially be assessed at differing VRC01 levels.

Anti-VRC01 antibodies
Production of anti-VRC01 antibodies may occur in some participants, yet are not expected to elicit hypersensitivity reactions. The package insert for Synagis ® (palivizumab), the licensed mAb product most analogous to the intended clinical use of the VRC mAb [20], describes the incidence of anti-palivizumab antibody production following the fourth injection to be 1.1% in the placebo group and 0.7% in the active group in the single season clinical trial of 1502 children. In children receiving Synagis ® for a second season, one of the fifty-six children had transient, low titer reactivity. This reactivity was not associated with adverse events or alteration in serum concentrations. Immunogenicity of Synagis ® was also assessed in a trial involving another 379 children that compared liquid to lyophilized formulations and observed 0.3% incidence of antipalivizumab antibodies. These data reflect the percentage of children whose test results were considered positive for antibodies to palivizumab using an enzyme-linked immunosorbent assay (ELISA) which has substantial limitations in detecting antipalivizumab antibodies in the presence of palivizumab. Immunogenicity samples tested with the ELISA assay were likely to have contained palivizumab at levels that may have interfered with the detection of anti-palivizumab antibodies. An electrochemical luminescence (ECL) based immunogenicity assay, with a higher tolerance for palivizumab presence compared to the ELISA, was used to evaluate the presence of antipalivizumab antibodies in subject samples from two additional clinical trials. The rates of anti-palivizumab antibody positive results in these trials were 1.1% and 1.5%. One objective of HVTN 104 is to assess for the presence of anti-VRC01 antibodies and if present, determine if they interfere with VRC01 levels. An electrochemical luminescence assay rather than ELISA will be used for the detection of anti-VRC01 antibodies (see Section 10.5.1). Briefly, using polymerase chain reaction (PCR) amplification and cloning of the heavy and light chain variable region genes, a mAb was initially isolated from a single B cell from an HIV-1 infected subject who displayed broadly neutralizing antibodies. VRC01 is an IgG1 antibody and is highly somatically mutated from the germline precursor. The heavy chain CDR3 region is 14 amino acids long, which is an average length relative to natural antibodies and the glycosylation pattern is derived from its production in a CHO cell line.

VRC01: VRC-HIVMAB060-00-AB
The potency and breadth of neutralization by VRC01 compared with b12 (mAb derived from an HIV-1 clade B-infected donor) were assessed on a comprehensive panel of viral envelope pseudoviruses. The panel of 190 viral strains represented the major circulating HIV-1 genetic subtypes (clades) and included viruses derived from acute and chronic stages of HIV-1 infection. The ability of VRC01 and b12 mAbs to neutralize such pseudoviruses is reported on the neutralization dendrograms in Figure 4-1 [13].
VRC01 has an IC50 of <50 mcg/mL against 91% of primary HIV-1 isolates and IC50 <1 mcg/mL against 72% of HIV-1 isolates tested in vitro Of Clade B and Clade C isolates, 95% and 97%, respectively, are sensitive in vitro at a VRC01 concentration of 50 mcg/ml, 94% and 96% respectively at 10 mcg/ml, and 80% and 82% respectively at 1 mcg/ml [13]. More details on VRC01 composition and manufacturing can be found in the IB. More details on the placebo composition and manufacturing can be found in the IB.

Sodium chloride placebo
Sodium Chloride for Injection 0.9%, USP administered IV in 100 mL of normal saline (Sodium Chloride for Injection 0.9%, USP).

Trial design rationale
HVTN 104 will evaluate the safety profiles and trough levels of 5 different regimens for the IV and SC administration of VRC01. For adults, the advantage of the IV regimens is they allow administration of a larger volume of VRC01 to achieve the higher dosage levels that may be needed for prevention of HIV acquisition. However, an advantage of the SC regimens is the shorter infusion time, potential for reduced technical burden of a needle and syringe injection compared to IV product administration. This is important in a resource-constrained environment, as well as for product administration to infants. In the long term development of the product, a SC injection regimen allows potential for self-administration. Testing both IV and SC administered regimens of VRC01 is also important because each route may have particular advantages in different prevention indications. To prevent mother-to-child HIV transmission in breast feeding infants, repeated SC dosing might be beneficial to maintain consistent levels given frequent exposure to HIV, while for postexposure prophylaxis after a sexual assault in an adult, a single higher dose administration may be of most value.
The dose considerations for the evaluation of drug levels were informed primarily by prior studies with Synagis ® (palivizumab), which is the only FDA-licensed mAb for which the target is a viral pathogen, but consideration was also given to other investigational mAbs directed at pathogens and preclinical studies with VRC01. For prevention of severe RSV, infants are treated with 15 mg/kg IM every month throughout the RSV season [20]. In the NHP preclinical studies with VRC01, dosing at 20 mg/kg was associated with prevention of SHIV infection (see Table 4-3 and the IB). Other investigational mAbs directed at pathogens that have been safely taken into efficacy trials include a mAb directed at Clostridium difficile toxin administered at a 10 mg/kg dosage [36] and a mAb directed at hepatitis C virus administered at a 50 mg/kg dosage [37]. Thus, the dose escalation plan in the first Phase 1 study (VRC 601) starts at least 10-fold lower than typical dosages for other mAb directed at pathogens and increases in a 5-fold, 4-fold, 2-fold dosage increase plan to the 40 mg/kg dose level, which is twice the level associated with VRC01 prevention of SHIV in an NHP model. Importantly, with regard to the potential use of VRC01 to further reduce mother-to-child HIV transmission, the use of palivizumab for prevention of RSV in infants also provides a well-established record of dosage levels that are effective against a viral pathogen in infants and a model for safe evaluation of a mAb in an infant population.
In adult volunteers Synagis ® had a pharmacokinetic profile similar to a human IgG1 antibody with regard to the volume of distribution and the half-life (mean 18 days). In pediatric patients, monthly intramuscular doses of 15 mg/kg achieved mean ±SD 30 day trough serum drug concentrations of 37 ± 21 mcg/mL after the first injection, 57 ± 41 mcg/mL after the second injection, 68 ± 51 mcg/mL after the third injection and 72 ± 50 mcg/mL after the fourth injection [20]. Thus, the selected monthly IV administration of 20 mg/kg or bimonthly IV administration of 40 mg/kg of VRC01 for evaluation in human clinical trials was selected based on an expectation that this would maintain trough concentrations at levels hypothesized to be in the effective range in humans.
Because SC administration of VRC01 is the planned route for the future infant efficacy trials which will utilize a placebo group, the placebo for VRC01 was developed only for SC administration to match the viscosity of VRC01 to prevent unblinding. The SC arm in HVTN 104 will include a placebo control group to enhance the safety and tolerability evaluations of this route and of both of these products. Normal saline is the placebo for IV administration because the higher doses of IV infused VRC01 will be diluted in normal saline. In order to be as parsimonious as possible, for Group 3 the randomization will be 5:1, i.e. 20 participants receiving VRC01 and 4 participants receiving the comparable placebo for VRC01. Since VRC01 levels will only be present in VRC01 recipients, a placebo group is not necessary for the PK goals of this trial.
However, a placebo group for each of the IV arms in this study is not considered necessary or particularly informative for safety assessments of the IV administrations.
The VRC 601 and 602 trials (see Section 4.10) will provide the initial safety data in participants receiving IV infusions and this trial will serve to confirm those findings.

Rationale for dose selections for Groups 1-5:
Mathematical simulations were conducted to inform dosing regimen selection for Groups 1-5. These simulations used a standard two compartment PK model with parameter values estimated from the combined VRC 601 and VRC 602 data of 19 IV-infusion participants and 6 SC-injection participants. These simulations assumed linear pharmacokinetics and PK parameters proportional to body weight. These assumptions appear to be reasonable in the preliminary individual-subject PK modeling of the drug concentration data in VRC 601 and VRC 602. Figure 4-2 shows the predicted median drug concentration for dosing regimens evaluated in Groups 1-3. Figure 4-3 shows the predicted drug concentration levels (5 th , 50 th and 95 th percentiles) for Group 4 dosing regimen (10 mg/kg IV every 8 weeksno loading dose). These simulation results demonstrated that reasonable trough levels could be achieved in all five groups; the most sparse regimen with 10 mg/kg IV every 2 months (Group 4) has approximately 90% chance of reaching a trough level > 1 mcg/mL (Dr. Edmund Capparelli, personal communication). In support of Group 5, interim PK data collected after one or two infusions of 20 mg/kg IV from a small number of subjects in VRC 602 suggest that trough levels are maintained above 10 mcg/mL for more than 8 weeks (Dr. Barney Graham, personal communication and Figure 4-4). At 30 mg/kg IV every 8 weeks, the trough level is anticipated to be intermediate compared to 20 mg/kg IV and 40 IV mg/kg every 8 weeks and spares product relative to the highest dose.
With respect to the loading dose considerations, Groups 1-3 have included the same loading dose of 40 mg/kg IV. This was done in order to allow the VRC01 drug levels to reach steady state more quickly to reflect application of a bnAb in a preventive setting. However, for Groups 4 and 5, in which the purpose is to understand the kinetics of drug concentrations and corresponding neutralization titers in the adult population, a slower achievement to a certain trough level is allowable and therefore no loading dose is included in Groups 4 or 5. In addition, the effect of a loading dose is abrogated in dosing regimens with the longer 8 week dosing interval (in Groups 2, 4 and 5).   As noted in Section 4.4, VRC01 has an IC50 of <50 mcg/mL against 91% of primary HIV-1 isolates and IC50 <1 mcg/mL against 72% of HIV-1 isolates tested in vitro. Also, the median IC50 against viruses neutralized with an IC50 is 0.32 for all clades, but varies somewhat by clade and by study (Table 4-1) (www.bnaber.org).

Dose and schedule
The proposed dosages for VRC 601 and 602 are based on the preclinical proof-ofconcept studies performed to date with VRC01, as well as publicly available data from human clinical trials experience with other mAb developed for use in prevention or treatment of human diseases, with attention to those directed at viral pathogens. In particular, the licensed product Synagis ® is directed against the viral pathogen, respiratory syncytial virus (RSV) [20,38], and the method and schedule by which it is administered to infants provide a model for the product development plan.
Group 1 comprises an IV infusion of 40 mg/kg VRC01 administered in 100 mL of normal saline at week 0, followed by IV infusions of 20 mg/kg of VRC01 administered in 100 mL of normal saline over 1 hour at weeks 4, 8, 12, 16, and 20.
Group 2 comprises an IV infusion of 40 mg/kg VRC01 administered in 100 mL of normal saline at weeks 0, 8, and 16.
Group 3 comprises an IV infusion of 40 mg/kg VRC01 or sodium chloride placebo administered in 100 mL of normal saline at week 0, followed by SC injection of 5 mg/kg VRC01 or placebo for VRC01 administered by injection every 2 weeks for 20 weeks.
Group 4 comprises an IV infusion of 10 mg/kg VRC01 administered in 100 mL of normal saline at weeks 0, 8, and 16.
Group 5 comprises an IV infusion of 30 mg/kg VRC01 administered in 100 mL of normal saline at weeks 0, 8, and 16.

Choice of control
The placebo for VRC01, VRC-PLAMAB068-00-AB, is comprised of components that are generally recognized as safe (GRAS), but the fully constituted placebo for VRC01 has not been tested in humans prior to the initiation of the VRC 602 study. This study agent is intended for use only as the placebo for SC evaluation of VRC01 and was developed to match the viscosity characteristics of VRC01 when formulated as a 100 mg/mL product.
The sodium chloride placebo used for the first IV infusion timepoint in the Group 3 placebo recipients will contain Sodium Chloride for injection 0.9%, USP serving as an inert control.

Plans for future product development and testing
The data that will be generated from this study will help to establish the safety of VRC01 in HIV-uninfected men and women and will help to inform the decisions about appropriate dosing regimens for future studies of the use of VRC01 to prevent mother-tochild HIV transmission, design of future vaccine trials, or other immuno-prophylaxis indications. Ultimately, data from future passive immunization trials of highly selective mAbs will further inform future HIV vaccine development by determining if HIVspecific antibodies are capable of preventing HIV acquisition in humans, the levels or titers necessary for doing so and the quality of the antibodies that may be successful. In addition, research is ongoing to explore the design of increasingly specific immunogens strategically employed in a series of successive vaccinations in order to expeditiously mimic the development of broadly nAbs as observed in HIV chronic infection [39].
The collection of simultaneous blood and anogenital secretion samples will advance the understanding of the diffusion of VRC01 between compartments, which may be relevant for selection of specific vaccine dosing regimens designed to generate broadly nAbs. It is conceivable that VRC01 could be part of a combined non-vaccine prevention modality (eg, antiretroviral prophylaxis) and vaccine approach, which would provide additional protection against HIV until an effective host immune response against HIV is generated. Finally, it is anticipated that there will be enough product for a phase 2b study in high risk/high incidence adult populations, and there is interest within the HVTN to participate in this endeavor.

Preclinical toxicology study of VRC01 in rats
A repeat dose toxicity study of IV and SC administration and a single dose pharmacokinetics (PK) study was performed by SRI International (Menlo Park, CA) with VRC01 in male and female Sprague-Dawley rats in accordance with U.S. FDA "Good Laboratory Practice (GLP) for Nonclinical Laboratory Studies." This study was conducted with a pre-GMP pilot lot of VRC01 manufactured at smaller scale using a similar purification process to that of the GMP clinical grade drug product.
For the safety assessment, various doses of VRC01 (4 mg/kg, 40 mg/kg, or 400 mg/kg) or a comparable vehicle was administered by tail vein infusion on Days 1 and 8 to Groups 1 through 4, respectively. An additional group (Group 5) received 40 mg/kg VRC01 via SC administration to the dorsal scapular region on Days 1 and 8. Each group contained 10 male and 10 female rats. Five animals per sex were sacrificed on Day 9, one day after the second administration, and the remaining animals were sacrificed on Day 30, 22 days after the second administration.
Results obtained showed that both routes of administration were well tolerated in the rats. All animals survived until their scheduled necropsy. No findings or changes were seen in clinical observation, body weight, food consumption, body temperature, infusion site irritation, hematology, coagulation, or organ weight evaluations that are attributed to administration of VRC01. VRC01 administration resulted in small, transient, dosedependent increases in aspartate aminotransferase (AST) and alkaline phosphatase (ALP) on Day 9. By Day 30, AST values had returned to normal, and ALP values were returning to normal.
Other than red discoloration of the administration site in one male in the SC group on Day 9, there were no other gross necropsy observations attributable to VRC01 administration. There were no histopathology findings that were considered related to IV administration of VRC01. However, histopathology evaluation revealed sub-acute inflammation at the SC injection site on Day 9, one day after infusion in all 10 rats administered VRC01 SC; dermal inflammation was usually minimal or mild while subcutaneous inflammation was usually mild, moderate, or marked. By Day 30, this inflammation had completely resolved, and the SC dose site was normal in all rats.
The pre-specified IV dose studied in rats was 400 mg/kg and SC was 40 mg/kg, which will greatly exceed the dose levels in the adult clinical studies. A "no observed effect level" (NOEL) was not determined in this study because transient elevations of AST and ALP were observed on Day 9 after IV administration and transient inflammation at the dose site was observed on Day 9 after SC administration. Because the elevated AST and ALP levels were transient and minor and did not correlate with histopathology findings, the no observed adverse effect level (NOAEL) for VRC01 by the IV route of administration in rats was 400 mg/kg, the highest dose used in this study. The systemic NOAEL for the SC route of administration of VRC01 in rats was 40 mg/kg, the only SC dose level examined in this study.
For the PK analysis, a separate cohort of rats received VRC01 on Day 1 at 4 mg/kg followed by 40 mg/kg by the IV route of administration and at 40 mg/kg by the SC route of administration. VRC01 levels in serum were determined using an enzyme-linked immunosorbent assay (ELISA) with samples collected predose from each animal and from an additional 3 males and 3 females to provide untreated control serum. Blood was collected from 3 rats/sex/PK group for a total of 4-5 collections per PK animal at each of the following postdose time points: After the peak concentration of VRC01 was achieved in the SC group, the serum levels decreased much more rapidly from 7 to 14 days than they did in the IV groups, and VRC01 concentrations in the SC group were not quantifiable at time points after 14 days. These data indicate that clearance of VRC01 in rats was markedly enhanced when it was administered by the SC route. The development of anti-drug antibodies that contribute to an increased rate of clearance is often observed in preclinical safety studies of proteinbased test articles when they are not tested in the species of origin. Although immunogenicity was not examined in this study, the presence of such antibodies might have possibly contributed to the increased rate of clearance of VRC01 after SC administration that was observed in this study [40,41].

Tissue Cross Reactivity GLP Study of VRC01 with Human Tissues In Vitro
A tissue cross-reactivity study of VRC01 using normal adult and neonatal human tissues in vitro (  28,1997)." In addition, the tissue cross-reactivity study used additional neonate/infant tissues suggested by the FDA to support future trials in infants.
To determine the cross-reactivity of VRC01 binding, VRC01 was applied to cryosections from a full panel of tissues from normal human adults and a limited panel of human neonatal tissues, immunohistochemically detected using a biotinylated rabbit anti-human IgG secondary antibody, and binding visualized with a streptavidin-horseradish peroxidase complex and a diaminobenzidine chromogen substrate. VRC01 binding was evaluated at concentrations of 5 and 50 mcg/mL. Specific VRC01 staining was not observed in any normal adult human or neonatal human tissues evaluated. Therefore, in vitro evaluation of cross-reactivity in tissue specimens did not identify potential tissue sites or organ systems to more thoroughly evaluate in subsequent preclinical studies, and it supports the possible future use of VRC01 in humans.

Other Toxicity Studies
Several in vitro studies were conducted to assess for the demonstration of antibody activity against self-antigens by VRC01. Several anti-HIV neutralizing mAbs will crossreact to lipid or nuclear antigens or Hep-2 cells [18,42]. Anti-lipid binding activity is understandable when considering that the HIV-1 gp41 protein is membrane-spanning and the epitopes (MPER: Membrane-Proximal External Region) recognized by some mAbs (e.g. 4E10 and 2F5) are membrane-proximal and likely extend into the membrane itself. Therefore, the ability (or lack thereof) of VRC01 to cross-react with lipids was assessed in collaboration with Dr. Barton Haynes of Duke University. Binding of antibody to cardiolipin was assessed in a luminescent assay, expressed in relative units. VRC01 was compared to 4E10, an anti-gp41 mAb known to bind to cardiolipin and nuclear antigens, and Synagis ® , a licensed anti-respiratory syncytial virus antibody used as a negative control. Synagis ® is included because it is the licensed mAb product most analogous to the intended clinical use of the VRC mAb [20].
Individual studies are summarized in Table 4-2. Unlike other anti-HIV neutralizing mAbs, VRC01 does not react to phospholipids or anti-nuclear antigens or Hep-2 cells. Additional details are provided in the IB. Several non-GLP studies of VRC01 have been completed in NHP to assess for plasma and secretion concentrations and for preclinical evidence of potential efficacy for prevention of HIV infection. Table 4-3 is a brief summary of the studies performed and supports the plan to evaluate up to 40 mg/kg dose administered IV as a dose range of potential interest for a preventive indication. The current assay being used to detect VRC01 in serum has a lower limit of detection in the range of 1.8-2 mcg/mL. Detectable concentrations of VRC01 were measured in vaginal, rectal, nasal and saliva samples after IV administration of 20 mg/kg of VRC01. Concentrations of VRC01 were lower in mucosal samples after IV administration of 5 mg/kg of VRC01. Please refer to the VRC01 IB for more details.  SHIV BaL is a more neutralization sensitive strain used in the rectal challenge study and showed partial efficacy at dosing of 0.3 mg/kg and serum VRC01 levels of 1-2 mcg/ml. SHIV SF162P3 is a more neutralization resistant strain, and results of that study indicated that a higher dose and serum level of VRC01 is needed to completely protect NHP from a rectal challenge (Table 4 -4). While the in vitro neutralization data and the NHP challenge studies are intriguing, the applicability of these results remains yet to be determined in humans.

Clinical studies
DAIDS is the sponsor of the investigational new drug application (IND) to evaluate the potential clinical uses of VRC01. VRC01's first evaluations in humans began in September 2013. The VRC01 initial development plan is directed towards an intended indication of prevention of HIV-1 infection through maternal transmission at birth or during breastfeeding. The safety, tolerability, dose effect, and PK of the VRC01 are being assessed in phase 1 trials in HIV-1 infected adults (in VRC 601) and in healthy HIVuninfected adults (in VRC 602) prior to evaluating the safety in infants in the US and internationally. Once the initial safety and PK data have been collected from these smaller dose escalation studies in adults, collection of additional safety data in larger numbers of adults from repeat doses will be used to support the infant studies. VRC 601 is the first study of the VRC01 mAb in HIV-infected participants. It is a doseescalation study to examine safety, tolerability, dose, PK, and anti-antibody immune responses. The hypothesis is that VRC01 will be safe for administration to HIV-1infected adults by the IV and SC routes and will not elicit hypersensitivity reactions. A secondary hypothesis is that VRC01 will be detectable in human sera and mucosal secretions with a definable half-life.
As shown in Table 4-5, there are 4 dose escalation groups for IV administration and 1 group for SC administration at 5 mg/kg planned for the study. During the dose escalation part of the study, each VRC01 infusion was administered in an inpatient unit and followed by intensive collection of samples for pharmacokinetic (PK) analysis. The study plan includes clinical blood tests for safety, clinician assessment of local reactions, solicitation of systemic symptoms for 3 days after each administration, HIV viral load, CD4, and blood samples to assess whether any human anti-VRC01 antibody is induced. In Groups 2, 3, 4 and 5, subjects who agree may have oral and rectal fluid samples collected and women may also have cervical fluid samples collected to determine if VRC01 is detectable in these mucosal samples. VRC 602 is the first study in healthy, HIV uninfected, adults of the VRC01 mAb. It is a dose-escalation study to examine safety, tolerability, dose, and pharmacokinetics of VRC01. The hypothesis is that VRC01 will be safe for administration to healthy adults by the IV and SC routes and will not elicit hypersensitivity reactions. A secondary hypothesis is that VRC01 will be detectable in human sera and mucosal secretions with a definable half-life. The SC route evaluation will be placebo-controlled and conducted in a single-blind manner to evaluate safety and tolerability of VRC01 and placebo (VRC-PLAMAB068-00-AB).
As shown in Table 4-6, there are 3 open-label, dose escalation groups (Groups 1, 2, and 3) for IV administration and 1 double-blinded, placebo-controlled group (Group 4) for SC administration. Enrollment started with subject randomization to Groups 1 and 4 in a 1:2 ratio. Within Group 4, subjects are randomized to SC infusions of VRC01 or placebo in a 1:1 ratio. After establishing the tolerability of the initial SC dose administered by a slow infusion with a controlled rate pump, the VRC 602 protocol was amended to allow the option of SC administration by needle and syringe injection with dividing the volume, as needed, into 2 or 3 SC injection sites. The study includes clinical blood tests for safety, clinical assessment of local reactions, solicitation of systemic symptoms for 3 days after each administration, and blood samples to assess whether any human anti-VRC01 antibody is induced. In all groups, when the subject agrees, oral and rectal fluid samples are obtained and women may also have cervical fluid samples collected to determine if VRC01 is detectable in these mucosal samples. The dose escalation to 40 mg/kg IV in the VRC 601 and VRC 602 studies was completed in a similar timeframe. As of January 9, 2015, cumulatively there have been 86 product administrations in 49 subjects in these two trials; including 21 subjects in VRC 601and 28 subjects in VRC 602. Of these 49 individuals, 9 subjects completed the one dose schedule, and of 40 subjects on a two dose schedule, 37 received two doses and 3 discontinued after one dose. Of the 3 subjects discontinued from study product administration, 1 was lost to follow-up, 1 was unable to comply with the study schedule and 1 experienced an unrelated adverse event (Streptococcal pharyngitis) that precluded timely administration.
Data from both HIV-infected and HIV-uninfected adults informs the questions of how to dose VRC01 to maintain a blood level in a range thought to be associated with a biological effect and to assess the safety of repeated exposure to VRC01. Both the IV and SC routes of administration are being evaluated. Ultimately, the best route for clinical use may depend upon the age of the recipient (adult or infant), stage of product development, formulation and important considerations related to volume needed and maintenance of a target VRC01 blood level considered to be in the therapeutic range.

Current status of HVTN 104
The first participant enrolled in HVTN 104 on September 9, 2014. As of January 20, 2015, a total of 42 participants (27 in Groups 1 and 2 and 15 in Group 3) have been enrolled across 6 sites in the US. The study product has been well tolerated with most participants experiencing no or mild reactions and there have been no SAEs.
Two participants in Group 3 (VRC01 or placebo) had mild symptoms resulting in study product discontinuation. One participant had a mild itchy rash in several places a few days after the injection considered related to study product. The rash lasted a few hours and went away on its own without any other symptoms. The other participant experienced a tight feeling in the chest with wheezing upon auscultation that started shortly after the injection and went away on its own and was considered related to study product.

Safety summary of VRC01
Cumulatively, across all studies as of January 9, 2015, there were no expedited safety reports to the FDA or study safety pauses for adverse events and, no reactions during the VRC01 or placebo product administration that resulted in an incomplete administration.
VRC01 SC administrations are sometimes associated with mild local reactions during the infusions, including pruritus (itchiness), redness and swelling, which resolve within a few minutes to a few hours after the administration is completed. The largest diameter for erythema or swelling events observed during infusions ranged up to about 5 cm.
Solicited local and systemic signs and symptoms following administration of VRC01 or placebo are generally none to mild. Less than 20% of subjects reported any moderate or greater solicited reactions after any product administration.
Adverse events attributed to study product administration for which study product administration was discontinued included one subject with chest discomfort and one subject with rash.
Other adverse events attributed to study product administration have included AST, ALT and creatinine elevation, decreased neutrophil count and pruritus at the administration site. The mild or moderate elevated transaminases were reported in about 20% of HIVinfected subjects (in association with ARVs, as well as, strenuous exercise and/or alcohol intake), and infrequently in HIV-uninfected subjects. These laboratory changes and pruritus events resolved and did not require discontinuation of study product administration.
Overall, VRC01 administration in the dose range from 1 to 40 mg/kg IV and at 5 mg/kg SC have been assessed as well-tolerated and safe for further evaluation.

Future studies of VRC01
The data from HVTN 104 will help inform the dosing schedule and rationale for several studies including a phase 2b trial exploring the range of protection from HIV infection by a bnAb in high risk adults. In addition, a trial to assess the safety of VRC01 administered to infants born to HIV-infected mothers in the US is being planned by the IMPAACT network. Another study of VRC01 is being planned by USMHRP in Thai participants who are acutely-infected with HIV. An efficacy trial evaluating VRC01 in infants born to HIV-infected African women is planned assuming that early studies of VRC01 demonstrate an adequate safety profile.

Potential risks of study products and administration
There is limited human experience with administration of the VRC01. VRC 601 and VRC 602 will evaluate the study agent prior to the start of HVTN 104.
In a preclinical study performed in rats, there was a small dose-dependent, but transient, increase in aspartate aminotransferase (AST) and alkaline phosphatase (ALP), but not in alanine aminotransferase (ALT) following IV administration. In rats, there were no histopathology findings following IV administration, but following SC administration there was minimal to marked dermal and SC irritation at the SC infusion site.
Thus far in VRC 601, there have been no SAEs or other safety concerns. Administration of mAb may have a risk of immune reactions such as acute anaphylaxis, serum sickness and the generation of antibodies, however, these reactions are rare and more often associated with mAb targeted to human proteins or with the use of murine mAbs which would have a risk of human anti-mouse antibodies [43]. In this regard, as VRC01 is targeted to a viral antigen and is a human mAb, it is expected to have a low risk of such side effects.
Typically, the side effects of mAbs are mild but may include fever, flushing, chills, rigors, nausea, vomiting, pain, headache, dizziness, shortness of breath, bronchospasm, hypotension, hypertension, pruritus, rash, urticaria, angioedema, diarrhea, tachycardia or chest pain. Clinical use of mAbs that are targeted to cytokines or antigens associated with human cells may be associated with an increased risk of infections [43]; however, this is not expected to be a risk for a mAb targeted to a viral antigen.
It is known from published experience with human mAb directed against the cell surface targets on lymphocytes, that infusion of a mAb may be associated with cytokine release, causing a reaction known as "cytokine release syndrome" (CRS) [44]. Most infusionrelated events occur within the first 24 hours after beginning administration. Severe reactions; such as anaphylaxis, angioedema, bronchospasm, hypotension, and hypoxia, are infrequent and more often associated with mAbs targeted to human proteins or when a non-human mAb, such as a murine mAb, is used [43]. Specifically, with regard to CRS reactions, these most commonly occur within the first few hours of beginning the infusion and are more common with the first mAb infusion received. This is because the cytokine release is associated with lysis of the cells targeted by the mAb and the burden of target cells is greatest at the time of the first mAb treatment. With licensed therapeutic mAbs, CRS is managed by temporarily stopping the infusion, administration of histamine blockers and restarting the infusion at a slower rate [45].
Delayed allergic reactions to a mAb may include a serum sickness type of reaction, which is characterized by urticaria, fever, lymph node enlargement, and joint pains. These symptoms may not appear until several days after the exposure to the mAb and is noted to be more common with chimeric types of mAb [43].
There are several FDA-licensed mAb for which reactions related to the rate of infusion have been described. Some symptoms may be treated by slowing or stopping the infusion. Supportive treatment may also be indicated for some signs and symptoms.
The published experience with mAb administered by the SC route is limited but there is experience with the SC route of administration of immunoglobulins, such as Hizentra® (CSL Behring LLC, Kankakee, IL), 20% immune serum globulin, for patients with primary immunodeficiency diseases. Comparison of the safety and PK of IVIG to subcutaneous immunoglobulin (SCIG) has been reported. The SC route of administration has a good safety profile. Tissue reactions are common but usually mild and tend to decline over time with repeated administrations [46]. The package insert for Hizentra ® notes that the most common adverse reactions (observed in ≥5% of study subjects) in clinical trials were local reactions (such as swelling, redness, heat, pain and itching at the infusion site), headache, vomiting, pain, and fatigue.
VRC01 is an antibody to an HIV protein. Therefore, it may be theoretically possible for a standard antibody-based HIV diagnostic test to detect VRC01 for a short time period postinfusion or postinjection. However, based on HVTN laboratory testing of HIV uninfected plasma samples spiked with VRC01 in the range of concentrations that mimic the likely range of concentrations (200 mcg/mL, 50 mcg/mL, and 1 mcg/mL) that may be observed in a clinical trial, VRC01 did not cause a positive test result in several standard antibody-based HIV-1/2 diagnostic tests used in the US.
Risks of Blood Drawing: Blood drawing may cause pain and bruising and may, infrequently, cause a feeling of lightheadedness or fainting. Rarely, it may cause infection at the site where the blood is taken. Problems from use of an IV for blood drawing are generally mild and may include pain, bruising, minor swelling or bleeding at the IV site and rarely, infection, vein irritation (called phlebitis), or blood clot.

Risks of Mucosal Sample Collection:
Collection of samples by swabs and wicks by rubbing them over the mucosal surfaces can cause momentary discomfort and, in some cases, minor bleeding.

Risks of Intravenous Infusion:
The placement of an intravenous catheter can allow for the development of bacteremia because of the contact between the catheter and unsterile skin when it is inserted. This will be prevented through careful decontamination of local skin prior to catheter placement and through the use of infection control practices during infusion. Product contamination will be prevented by the use of aseptic technique in the pharmacy and universal precautions during product administration.

Primary objectives and endpoints
Primary objective 1: To evaluate the safety and tolerability of VRC01 administered IV and SC at multiple timepoints.

Primary endpoints 1:
Local and systemic reactogenicity signs and symptoms, laboratory measures of safety, and AEs and SAEs.
Early discontinuation of infusions and reason(s) for discontinuation and early study termination.

Primary objective 2 (Groups 1-3):
To evaluate the serum levels of VRC01 at Month 6 administered IV and SC in 3 different regimens.

Primary objective 3 (Groups 4 and 5):
To evaluate the serum levels of VRC01 at 2 timepoints after each IV administration.

Primary endpoint 3:
Serum concentration of VRC01 28 and 56 days after each IV administration in Groups 4 and 5.

Secondary objectives and endpoints
Secondary objective 1: To evaluate the kinetics of in vitro neutralization in serum of a single VRC01 sensitive virus isolate

Secondary endpoint 1:
Magnitude of serum neutralization of a single VRC01 sensitive virus isolate as measured in the TZMbl assay at multiple timepoints

Secondary objective 2:
To further assess the serum levels of VRC01.

Secondary endpoint 2:
Serum concentration of VRC01 in each group at multiple timepoints.

Secondary objective 3:
To determine whether anti-idiotypic antibody (AIA) can be detected and whether there is a correlation of VRC01 levels and AIA levels in serum.

Secondary endpoint 3:
Serum concentration of anti-VRC01 antibodies in each group at multiple timepoints compared to corresponding VRC01 levels.

Secondary objective 4:
To determine if measurable levels of VRC01 can be found in genital, rectal, and oral secretions.

Secondary endpoint 4:
Mucosal levels of VRC01 in each group at multiple timepoints.

Secondary objective 5:
To evaluate the kinetics of in vitro neutralization in mucosal secretions of a single VRC01 sensitive virus isolate.

Secondary endpoint 5:
Magnitude of neutralization in genital, rectal, and oral secretions of a single VRC01 sensitive virus isolate as measured in the TZMbl assay at multiple timepoints.

Secondary objective 6:
To assess binding of VRC01 to multiple Env proteins.

Secondary endpoint 6:
Binding antibody multiplex assay will be used to assess VRC01 binding in serum and genital, rectal, and oral secretions to multiple Env proteins in each group at multiple timepoints.

Exploratory objectives
Exploratory objective 1: To evaluate the breadth of in vitro neutralization in the serum and mucosal secretions if detected with the primary VRC01 sensitive isolate.

Exploratory objective 2:
To compare the serum levels of VRC01 between groups at multiple timepoints

Exploratory objective 3:
To evaluate additional functional humoral activities in serum and genital, rectal, and oral secretions.

Exploratory objective 4:
To evaluate the effect of participant characteristics (i.e. sex and BMI) on serum levels of VRC01.

Exploratory objective 5:
To describe the acceptability of study product administration on all study participants 6 Statistical considerations 6

.1 Accrual and sample size calculations
Recruitment will target enrolling 88 healthy, HIV-uninfected adult participants into five groups. Groups 1, 2, 4, and 5 entail IV administration of VRC01 on two different schedules with a randomization ratio of 1:1 for n=20 participants in Groups 1 and 2 and n=12 participants in Groups 4 and 5. Group 3 entails one initial IV administration followed by multiple SC administrations of VRC01 (n=20) or placebo (n=4) with a treatment:control randomization ratio of 5:1. Sites will be encouraged to enroll at least approximately 40% of each sex within Groups 1 and 2 combined, Groups 4 and 5 combined, and separately within Group 3. Groups 1 and 2 are randomized together, Groups 4 and 5 are randomized together. Group 3 undergoes a separate randomization process from the other groups because Group 3 participants will need to specifically agree to participate in a more intense dosing and visit schedule.
Since enrollment is concurrent with receiving the first complete or incomplete study infusion, all participants will provide some safety data. However, for PK analyses, it is possible that data may be missing for various reasons, such as participants terminating from the study early or problems in shipping specimens. For this reason, the sample size calculations in Section 6.1.2 account for 10% enrolled participants having missing data for the primary lab data endpoint.

Sample size calculations for safety
The goal of the safety evaluation for HVTN 104 is to identify safety concerns associated with product administration. The ability of the study to detect SAEs can be expressed by the true event rate above which at least 1 SAE would likely be observed and the true event rate below which no events would likely be observed. Specifically, for an active arm of n=12, there is a 90% chance of observing at least 1 event if the true rate of such an event is 17.46% or more; and there is a 90% chance of observing no events if the true rate is 0.88% or less. For each active arm of n=20 , there is a 90% chance of observing at least 1 event if the true rate of such an event is 10.87% or more; and there is a 90% chance of observing no events if the true rate is 0.52% or less. For active IV administration arms combined (n=64), there is a 90% chance of observing at least 1 event if the true rate of such an event is 3.53% or more; and there is a 90% chance of observing no events if the true rate is 0.17% or less. For all active arms combined (n=84), there is a 90% chance of observing at least 1 event if the true rate of such an event is 2.70 % or more; and there is a 90% chance of observing no events if the true rate is 0.13 % or less. As a reference, in HVTN vaccine trials from December 2000 through December 2012, about 4% of participants who received placebos experienced an SAE.
Probabilities of observing 0, 1 or more, and 2 or more events among single arms or combined arms of sizes 12, 20, 64, and 84 are presented in Table 6-1 for a range of possible true AE or SAE rates. These calculations provide a more complete picture of the sensitivity of this study design to identify potential safety problems with the product. An alternative way of describing the statistical properties of the study design is in terms of the 95% confidence interval for the true rate of an adverse event based on the observed data. Table 6-2 shows the 2-sided 95% confidence intervals for the probability of an event based on a particular observed rate. Calculations are done using the score test method [47]. If none of 12 participants in an active arm (groups 4 or 5) experience a safety event, the 95% 2-sided upper confidence bound for the true rate of such events in the total vaccinated population is 24.25%. If none of 20 participants in an active arm (Groups 1, 2, or 3) experience a safety event, the 95% 2-sided upper confidence bound for the true rate of such events is 16.11%. If none of the 64 combined participants in Groups 1, 2, 4, and 5 experience a safety event, the 95% 2-sided upper confidence bound for the true rate of such events is 5.66%. For the total 84 participants in the active arms, the 95% 2-sided upper confidence bound for this rate is 4.37%.

Sample size calculations for drug levels of VRC01
The main goal of HVTN 104 regarding PK drug levels involves a preliminary estimation of the mean trough drug concentration after the administration series for each active arm. The precision with which the true concentration level can be estimated from the observed data depends on the standard deviation of measurements and the sample size. Two-sided 95% confidence intervals for the true mean drug level based on different observed average drug concentration levels in the active arms of size 12 and 20 are shown in Table  6-3, assuming a normal distribution for the log-transformed levels. The confidence intervals in the table are based on arm sizes of 10 and 18, which accounting for an assumed 10% loss of data from the original arms sizes. For example, if an average drug concentration of ln(15) and a standard deviation of 1.0 are observed based on the logtransformed drug levels among 18 participants, the 95% 2-sided upper confidence bound for the true mean drug concentration level is 24 mcg/mL. These calculations assume an approximate normal distribution for the mean of log-transformed drug concentration levels. The assumed mean and standard deviation are based on limited unpublished data from a study of a similar mAb built on the same isotype construct (personal communications). Since no individual-level data are available, first order Taylor expansions are used to approximate the mean and variance of the log-transformed data based on the reported mean and variance of the original scale data. Specifically, the natural log of the mean of the original scale data approximates the mean of the natural log-transformed data; the squared ratio between the variance and mean of the original scale data approximates the variance of the natural log-transformed data.

Randomization
The randomization sequence will be obtained by computer-generated random numbers and provided to each HVTN CRS through the SDMC via a Web-based randomization system. Groups 1-3 will be enrolled simultaneously. With the implementation of Version 2.0, Groups 4 and 5 will enroll simultaneously. The randomization will be done in blocks to ensure balance across Groups 1 and 2, across Groups 4 and 5, and within Group 3. Because the schedule for Group 3 is more intensive, participants will be given the choice of being randomized in Group 3 or, separately, into one of Groups 1, 2, 4, or 5. At each institution, the pharmacist with primary responsibility for dispensing study products is charged with maintaining security of the treatment assignments.

Blinding
Participants and site staff (except for site pharmacists) will be unblinded as to participant treatment assignments between Groups 1, 2, 4, and 5, but blinded as to treatment assignment (active vs. placebo) for Group 3. Study product assignments are accessible to those HVTN CRS pharmacists, DAIDS protocol pharmacists and contract monitors, and SDMC staff who are required to know this information in order to ensure proper trial conduct. Any discussion of study product assignment between pharmacy staff and any other HVTN CRS staff is prohibited. The HVTN SMB members also are unblinded to treatment assignment in order to conduct review of trial safety.
When a participant leaves the trial prior to study completion, the participant will be told he or she must wait until all participants are unblinded to learn his or her treatment assignment.
Emergency unblinding decisions will be made by the site investigator. If time permits, the HVTN 104 PSRT should be consulted before emergency unblinding occurs.

Statistical analysis
This section describes the final study analysis, unblinded as to treatment arm assignment. All data from enrolled participants will be analyzed according to the initial randomization assignment regardless of how many infusions they received. The analysis is a modified intent-to-treat analysis in that individuals who are randomized but not enrolled do not contribute data and hence are excluded. Because of blinding and the brief length of time between randomization and enrollment-typically no more than 4 working days-very few such individuals are expected.
Analyses will be performed using SAS and R. Other software may be used to perform additional exploratory pharmacokinetics analyses..
No formal multiple comparison adjustments will be employed for multiple safety endpoints.

Analysis variables
The analysis variables consist of baseline participant characteristic, safety, and laboratory measurements for primary-and secondary-objective analyses.

Baseline comparability
Treatment arms will be compared for baseline participant characteristics using descriptive statistics.

Safety/tolerability analysis
Since enrollment is concurrent with receiving the first infusion, all participants will have received at least 1 infusion and therefore will provide some safety data.

Reactogenicity
The number and percentage of participants experiencing each type of reactogenicity sign or symptom will be tabulated by severity and treatment arm and the percentages displayed graphically by arm. For a given sign or symptom, each participant's reactogenicity will be counted once under the maximum severity for all infusion visits. In addition, to the individual types of events, the maximum severity of local pain or tenderness, induration or erythema, and of systemic symptoms will be calculated. Wilcoxon rank-sum tests will be used to test for differences in severity between Groups 1 and 2.

AEs and SAEs
AEs will be summarized using MedDRA System Organ Class and preferred terms. Tables will show by treatment arm the number and percentage of participants experiencing an AE within a System Organ Class or within preferred term category by severity or by relationship to study product. For the calculations in these tables, a participant with multiple AEs within a category will be counted once under the maximum severity or the strongest recorded causal relationship to study product. Formal statistical testing comparing arms is not planned since interpretation of differences must rely heavily upon clinical judgment.
A listing of SAEs reported to the DAIDS Regulatory Support Center (RSC) Safety Office will provide details of the events including severity, relationship to study product, time between onset and last infusion, and number of infusions received.

Local laboratory values
Boxplots of local laboratory values will be generated for baseline values and for values measured during the course of the study by treatment arm and visit. Each boxplot will show the first quartile, the median, and the third quartile. Outliers (values outside the boxplot) will also be plotted. If appropriate, horizontal lines representing boundaries for abnormal values will be plotted.
For each local laboratory measure, summary statistics will be presented by treatment arm and time point, as well as changes from baseline for postenrollment values. In addition, the number (percentage) of participants with local laboratory values recorded as meeting Grade 1 AE criteria or above as specified in the DAIDS AE Grading Table (see Section  9.9) will be tabulated by treatment arm for each postinfusion time point. Reportable clinical laboratory abnormalities without an associated clinical diagnosis will be included in the tabulation of AEs described above.

Reasons for discontinuation of study product administration and early study termination
The number and percentage of participants who discontinue study product administration and who terminate the study early will be tabulated by reason and treatment arm.

Acceptability of study product or procedure
Acceptability of study product administration and injection procedures will be tabulated by reason and treatment arm.

General approach
For the statistical analysis of endpoints, data from enrolled participants will be used according to the initial randomization assignment regardless of how many infusions they received. Additional analyses may be performed, limited to participants who received all scheduled infusions per protocol. Assay results that are unreliable, from specimens collected outside of the visit window, or from HIV-infected participants postinfection will be excluded. Since the exact date of HIV infection is unknown, any assay data from blood draws 4 weeks prior to an infected participant's last seronegative sample and thereafter may be excluded. If an HIV-infected participant does not have a seronegative sample postenrollment, then all data from that participant may be excluded from the analysis.
For continuous assay data (eg, serum concentration of VRC01), graphical and tabular summaries of the distributions by treatment arm and timepoint will be made. The difference of continuous assay data at the primary time-points of interest (Month 6) between groups will be tested with a nonparametric Wilcoxon rank sum test if the data are not normally distributed and with a 2-sample t-test if the data appear to be normally distributed. An appropriate data transformation (e.g., log transformation) may be applied prior to testing to better satisfy assumptions of symmetry and homoscedasticity (constant variance).Inference from these analyses would be limited by the small sample sizes of the groups.
More sophisticated analyses of drug-level data and other assay data collected over time employing repeated measures methodology (for example, nonlinear mixed effects models or generalized estimating equations) may be utilized to incorporate outcome responses over several timepoints and to account for subject heterogeneity. In addition, noncompartment PK analysis will be performed to estimate PK parameters from individual time-concentration curves. All statistical tests will be 2-sided and will be considered statistically significant if p  0.05.
For qualitative assay variables (e.g., positive or negative), the analyses will be performed by tabulating the frequency of positive responses for each assay by group at each timepoint at which an assessment is performed. Crude response rates will be presented with their corresponding 95% confidence interval estimates calculated using the score test method [47] .
For the analysis of correlation between two continuous assay variables over time, graphical summary and tabular summary of the sample correlation at each given timepoint will be made. Cross-correlation of the two variables with different time-lags may also be calculated and visually displayed if there are at least 10 participants with no missing data over time from both variables. More details of the statistical analysis approaches will be described in a separate Statistical Analysis Plan document.
Based upon previous AIDS Vaccine Evaluation Group (AVEG) and HVTN trials, missing 10% of research samples' results for a specific assay is common due to study participants terminating from the study early, problems in shipping specimens, or low cell viability of processed peripheral blood mononuclear cells (PBMCs). To achieve unbiased statistical estimation and inferences with nonparametric tests and generalized linear models fit by generalized estimating equation (GEE) methods, missing data need to be missing completely at random (MCAR). MCAR assumes that the probability of an observation being missing does not depend upon the observed responses or upon any unobserved covariates but may depend upon covariates included in the model (eg, missing more among whites than nonwhites). When missing data are minimal (specifically if no more than 20% of participants are missing any values), then nonparametric tests and GEE methods will be used, because violations of the MCAR assumption will have little impact on the estimates and hypothesis tests. These models will include as covariates all available baseline predictors of the missing outcomes.
If a substantial amount of antibody-level data are missing (at least 1 value missing from more than 20% of participants), then using the methods that require the MCAR assumption may give misleading results. In this situation, analyses of the endpoints at a specific timepoint will be performed using parametric generalized linear models fit by maximum likelihood. These methods provide unbiased estimation and inferences under the parametric modeling assumptions and the assumption that the missing data are missing at random (MAR). MAR assumes that the probability of an observation being missing may depend upon the observed responses and upon observed covariates, but not upon any unobserved factors. Generalized linear models for response rates will use a binomial error distribution and for quantitative endpoints, a normal error distribution. For assessing repeated immunogenicity measurement, linear mixed effects models will be used. If the immunological outcomes are left-and/or right-censored, then the linear mixed effects models of Hughes [48] will be used, because they accommodate the censoring. In addition, secondary analyses of repeated immunogenicity measurements may be done using weighted GEE [49] methods, which are valid under MAR. All of the models described above will include as covariates all available baseline predictors of the missing outcomes.

Analyses prior to end of scheduled follow-up visits
Any analyses conducted prior to the end of the scheduled follow-up visits should not compromise the integrity of the trial in terms of participant retention or safety or immunogenicity endpoint assessments. In particular, early unblinded analyses by treatment assignment require careful consideration and should be made available on a need to know basis only.

Safety
During the course of the trial, unblinded analyses of safety data will be prepared approximately every 4 months during the main study, as defined in Section 3, for review by the SMB. Ad hoc safety reports may also be prepared for SMB review at the request of the HVTN 104 PSRT. The HVTN leadership must approve any other requests for unblinded safety data prior to the end of the scheduled follow-up visits.

Anti-VRC01 and other Laboratory Assessments
For Group 3, an unblinded statistical analysis by treatment assignment of a primary laboratory endpoint may be performed when all participants have completed the corresponding visit and data are available for analysis from at least 80% of these participants. Similarly, an unblinded statistical analysis by treatment assignment of a secondary or exploratory endpoint may be performed when all participants have completed the corresponding visit and data are available for analysis from at least 80% of these participants. The Laboratory Program will review the analysis report prior to distribution to the protocol chairs, DAIDS, vaccine developer, and other key HVTN members and investigators. Distribution of reports will be limited to those with a need to know for the purpose of informing future trial-related decisions. The HVTN leadership must approve any other requests for HVTN laboratory data analyses prior to the end of the scheduled follow-up visits.

Selection and withdrawal of participants
Participants will be healthy, HIV-uninfected (seronegative) adults who comprehend the purpose of the study and have provided written informed consent. Volunteers will be recruited and screened; those determined to be eligible, based on the inclusion and exclusion criteria, will be enrolled in the study. Final eligibility determination will depend on results of laboratory tests, medical history, physical examinations, and answers to self-administered and/or interview questions.
Investigators should always use good clinical judgment in considering a volunteer's overall fitness for trial participation. Some volunteers may not be appropriate for enrollment even if they meet all inclusion/exclusion criteria. Medical, psychiatric, occupational, or other conditions may make evaluation of safety and/or immunogenicity difficult, and some volunteers may be poor candidates for retention.
Determination of eligibility, taking into account all inclusion and exclusion criteria, must be made within 56 days prior to enrollment unless otherwise noted in sections 7.1 and 7.2.   Negative urine glucose, and  Negative or trace urine protein, and  Negative or trace urine hemoglobin (if trace hemoglobin is present on dipstick, a microscopic urinalysis with red blood cells levels within institutional normal range).

21.
Volunteers who were born female: negative serum or urine beta human chorionic gonadotropin (β-HCG) pregnancy test performed prior to infusion on the day of initial infusion. Persons who are not of reproductive potential due to having undergone total hysterectomy with bilateral oophorectomy (verified by medical records), are not required to undergo pregnancy testing.

Reproductive status: A volunteer who was born female must:
 Agree to consistently use effective contraception (see Appendix A) for sexual activity that could lead to pregnancy from at least 21 days prior to enrollment through the last required protocol clinic visit. Effective contraception is defined as using any of the following methods: 10. Serious adverse reactions to vaccines or to vaccine components including history of anaphylaxis and related symptoms such as hives, respiratory difficulty, angioedema, and/or abdominal pain. (Not excluded: a volunteer who had a nonanaphylactic adverse reaction to pertussis vaccine as a child.) 11. Immunoglobulin received within 90 days before first infusion, unless eligibility for earlier enrollment is determined by the HVTN 104 PSRT.
12. Autoimmune disease (Not excluded: Volunteer with mild, stable and uncomplicated autoimmune disease that does not require immunosuppressive medication and that, in the judgment of the site investigator, is likely not subject to exacerbation and likely not to complicate reactogenicity and AE assessments) 13. Immunodeficiency

Untreated or incompletely treated syphilis infection
15. Clinically significant medical condition, physical examination findings, clinically significant abnormal laboratory results, or past medical history with clinically significant implications for current health. A clinically significant condition or process includes but is not limited to:  A process that would affect the immune response,  A process that would require medication that affects the immune response,  Any contraindication to repeated infusions or blood draws,  A condition that requires active medical intervention or monitoring to avert grave danger to the volunteer's health or well-being during the study period,  A condition or process for which signs or symptoms could be confused with reactions to vaccine, or  Any condition specifically listed among the exclusion criteria below. 16. Any medical, psychiatric, occupational, or other condition that, in the judgment of the investigator, would interfere with, or serve as a contraindication to, protocol adherence, assessment of safety or reactogenicity, or a volunteer's ability to give informed consent 17. Psychiatric condition that precludes compliance with the protocol. Specifically excluded are persons with psychoses within the past 3 years, ongoing risk for suicide, or history of suicide attempt or gesture within the past 3 years.

Current anti-tuberculosis (TB) prophylaxis or therapy
19. Asthma other than mild, well-controlled asthma. (Symptoms of asthma severity as defined in the most recent National Asthma Education and Prevention Program (NAEPP) Expert Panel report).
Exclude a volunteer who:  Uses a short-acting rescue inhaler (typically a beta 2 agonist) daily, or  Uses moderate/high dose inhaled corticosteroids, or  In the past year has either of the following:  Greater than 1 exacerbation of symptoms treated with oral/parenteral corticosteroids;  Needed emergency care, urgent care, hospitalization, or intubation for asthma.
20. Diabetes mellitus type 1 or type 2, including cases controlled with diet alone. (Not excluded: history of isolated gestational diabetes.)

Hypertension:
 If a person has been found to have elevated blood pressure or hypertension during screening or previously, exclude for blood pressure that is not well controlled. Wellcontrolled blood pressure is defined as consistently ≤ 140 mm Hg systolic and ≤ 90 mm Hg diastolic, with or without medication, with only isolated, brief instances of higher readings, which must be ≤ 150 mm Hg systolic and ≤ 100 mm Hg diastolic. For these volunteers, blood pressure must be ≤ 140 mm Hg systolic and ≤ 90 mm Hg diastolic at enrollment.
 If a person has NOT been found to have elevated blood pressure or hypertension during screening or previously, exclude for systolic blood pressure ≥ 150 mm Hg at enrollment or diastolic blood pressure ≥ 100 mm Hg at enrollment.

22.
Bleeding disorder diagnosed by a doctor (eg, factor deficiency, coagulopathy, or platelet disorder requiring special precautions) 23. Malignancy (Not excluded: Volunteer who has had malignancy excised surgically and who, in the investigator's estimation, has a reasonable assurance of sustained cure, or who is unlikely to experience recurrence of malignancy during the period of the study) 24. Seizure disorder: History of seizure(s) within past three years. Also exclude if volunteer has used medications in order to prevent or treat seizure(s) at any time within the past 3 years.
25. Asplenia: any condition resulting in the absence of a functional spleen 26. History of hereditary angioedema, acquired angioedema, or idiopathic angioedema.

Participant departure from the study product administration schedule or withdrawal
This section concerns an individual participant's departure from the study product administration schedule. Pause rules for the trial as a whole are described in Section 11.3.

Delaying study product administration for a participant
Under certain circumstances, a participant's scheduled study product administration will be delayed. The factors to be considered in such a decision include but are not limited to the following:  Within 10 days prior to any study product administration  Prestudy product administration abnormal vital signs or clinical symptoms that may mask assessment of a study product reaction.
 Intercurrent illness that is not expected to resolve prior to the next scheduled study product administration which is assessed by the site principal investigator (or designee) to require delay or withdrawal from the study product administration schedule. The investigator may consult the HVTN 104 PSRT.
Study product administration should not be administered outside the visit window period specified in the HVTN 104 Study Specific Procedures.
In order to avoid study product administration delays and missed study product administrations, participants who plan to receive live attenuated licensed vaccines other than influenza vaccine, or systemic glucocorticoids should be counseled to schedule receipt of these substances, when possible, outside the intervals indicated above. The effects of these substances on safety and immunogenicity assessments and their interactions with study products are unknown.

Participant departure from study product administration schedule
Every effort should be made to follow the study product administration schedule per the protocol. If a participant misses a study product administration and the visit window period for the study product administration has passed, that study product administration cannot be given. The participant should be asked to continue study visits. The participant should resume the study product administration schedule with the next study product administration unless there are circumstances that require further delay or permanent discontinuation of study product administration (see Sections 7.3.1 and 7.3.3).

Discontinuing study product administration for a participant
Under certain circumstances, an individual participant's study product administrations will be permanently discontinued. Specific events that will result in stopping a participant's study product administration schedule include:  Co-enrollment in a study with an investigational research agent (rare exceptions allowing for the continuation of study product administration may be granted with the unanimous consent of the HVTN 104 PSRT).
 Clinically significant condition (ie, a condition that affects the immune system or for which continued study product administration and/or blood draws may pose additional risk), including but not limited to the following:  Pregnancy (regardless of outcome);  Any grade 4 local or systemic reactogenicity symptom, lab abnormality, or AE that is subsequently considered to be related to study product administration;  Any grade 3 lab abnormality or other clinical AE (exception: fever or vomiting and subjective local and systemic symptoms) that is subsequently considered to be related to study product administration; or  Clinically significant type 1 hypersensitivity reaction associated with study product administration. Consultation with the HVTN 104 PSRT is required prior to subsequent study product administration following any type 1 hypersensitivity reaction associated with study product administrations; or  Investigator determination in consultation with HVTN 104 Protocol Team leadership (eg, for repeated nonadherence to study staff instructions).
Such participants should be counseled on the importance of continuing with the study and strongly encouraged to participate in follow-up visits and protocol-related procedures per the protocol for the remainder of the trial, unless medically contraindicated.
In addition, study product administration will be stopped for participants diagnosed with HIV infection. HIV-infected participants will not continue in the trial after completing a 28 day safety follow-up period to the last prior study product administration, but will be monitored through other HVTN protocols (see Sections 7.3.4).

Participant termination from the study
Under certain circumstances, an individual participant may be terminated from participation in this study. Specific events that will result in early termination include:  Any condition where termination from the study is required by applicable regulations.

Study product preparation and administration
CRS pharmacists should consult the Pharmacy Guidelines and Instructions for DAIDS Clinical Trials Networks for standard pharmacy operations. The protocol schema is shown in Table 3-1. See the IB for further information about study products.

Study product regimen
The schedule of infusion is shown in Section 3 and additional information is given below.

Group 5 (OPEN-LABEL)
Treatment 5 (T5): VRC-HIVMAB060-00-AB 30 mg/kg to be administered IV in 100 mL of Sodium Chloride for Injection USP, 0.9% at Months 0, 2, and 4. VRC01 is a highly concentrated protein solution and may develop white-to-translucent particles after thawing. These particles have been observed in approximately 1-3% of the vials and generally disappear over a few hours at room temperature. This particle formation has no effect on product quality. If these particles are observed after the minimum of one hour thaw time as described in Section 8.3, the vials should be held at room temperature for another 30 to 60 minutes to enhance the rate of particle dissolution. Product, free of particles, stored at room temperature, or 2-8° C, should be administered within 12 hours.

NOTE: All calculations should be based on a concentration of VRC-HIVMAB060-00-AB of 100 mg/mL and a volume of 2 mL (equal to 200 mg) can be withdrawn from a vial.
The product label designates the long-term storage temperature as -35°C to -15°C. However, the Investigator's Brochure states that "Clinical site storage in a qualified, continuously monitored, temperature-controlled freezer with a temperature range of -45°C to -10°C is acceptable". The study products are described in further detail in the Investigator's Brochure (IB). The product label designates the long-term storage temperature as -35°C to -15°C. However, the Investigator's Brochure states that "Clinical site storage in a qualified, continuously monitored, temperature-controlled freezer with a temperature range of -45°C to -10°C is acceptable". The study products are described in further detail in the Investigator's Brochure (IB).

IV Placebo for VRC01 [Labeled as Sodium Chloride for Injection USP, 0.9%]
Sodium Chloride for Injection USP, 0.9% will be used as the IV Placebo for VRC01. It must be stored as directed by the manufacturer.

Preparation of study products
A new prescription MUST be sent to the pharmacy after the participant is weighed on the day of each visit during which study product will be administered. The prescription MUST contain the subject's weight and dose level prior to being sent to the pharmacy (this may NOT be communicated verbally). If this information is NOT on the prescription, the prescription will be returned to the clinic from the pharmacy to be completed appropriately prior to the pharmacist beginning preparation of study product. To prepare an IV infusion, the pharmacist will verify the dose [total milligrams needed (40 mg x participant's weight in kg)] and thaw the minimum number of vials needed to obtain the full dose. The pharmacist will determine the number of vials by dividing the total milligrams needed by 200. The result will be rounded UP to the next whole number. Note: It is expected that each vial may be used for about 2 mL withdrawal volume (200 mg VRC01).
Each vial must be thawed for a minimum of 1 hour at room temperature after removal from the freezer. After the 1 hour minimum, the pharmacist should gently swirl the vials before inspecting for particles. DO NOT SHAKE VIAL. Once swirled, the pharmacist, using aseptic technique, will add the calculated total milligrams needed to a 100 mL bag of normal saline (Sodium Chloride for Injection USP, 0.9%). Up to 50 mL of VRC01 may be added to a 100 mL bag of normal saline.
The pharmacist must note on the IV bag label the dose calculated (in mg) for the participant (eg, 2800 mg for a 70kg individual) as well as the final total volume of fluid in the IV bag (eg, 131 mL for the 70 kg individual). The IV bag should be labeled with a 12-hour expiration date and time from the time the vial is removed from the freezer. The IV bag should be stored at room temperature or refrigerated (2 o -8 o C) until administration.
Note: The Sodium Chloride for Injection bags referred to as "100 mL bags" in the IV administration instructions will typically have 103 mL volume before any VRC01 is added and this is acceptable in the context of the instructions.
Any empty vials, unused portion of entered vials, or unused IV solution which contains study product should be discarded in a biohazard containment bag and incinerated or autoclaved in accordance with institutional or pharmacy policy.

VRC-HIVMAB060-00-AB (20mg/kg IV) -OPEN LABEL ONLY (Group 1 Months 1 through 5)
To prepare an IV infusion, the pharmacist will verify the dose [total milligrams needed (20 mg x participant's weight in kg)] and thaw the minimum number of vials needed to obtain the full dose. The pharmacist will determine the number of vials by dividing the total milligrams needed by 200. The result will be rounded UP to the next whole number.
Note: It is expected that each vial may be used for about 2 mL withdrawal volume (200 mg VRC01).
Each vial must be thawed for a minimum of 1 hour at room temperature after removal from the freezer. After the 1 hour minimum, the pharmacist should gently swirl the vials before inspecting for particles. DO NOT SHAKE VIAL. Once swirled, the pharmacist, using aseptic technique will add the calculated total milligrams needed to a 100 mL bag of Sodium Chloride for Injection USP, 0.9%. Up to 50 mL of VRC01 may be added to a 100 mL bag of normal saline. Note: The Sodium Chloride for Injection bags referred to as "100 mL bags" in the IV administration instructions will typically have 103 mL volume before any VRC01 is added and this is acceptable in the context of the instructions.
Any empty vials, unused portion of entered vials, or unused IV solution which contains study product should be discarded in a biohazard containment bag and incinerated or autoclaved in accordance with institutional or pharmacy policy.

VRC-HIVMAB060-00-AB (40mg/kg IV) -DOUBLE BLIND (Group 3 T3)
To prepare an IV infusion, the pharmacist will verify the total dose [milligrams needed (40 mg x participant's weight in kg)] and thaw the minimum number of vials needed to obtain the full dose. The pharmacist will determine the number of vials by dividing the total milligrams needed by 200. The result will be rounded UP to the next whole number. Note: It is expected that each vial may be used for about 2 mL withdrawal volume (200 mg VRC01).
Each vial must be thawed for a minimum of 1 hour at room temperature after removal from the freezer. After the 1 hour minimum, the pharmacist should gently swirl the vials before inspecting for particles. After thawing, the vials should be gently swirled for 30 seconds to avoid foaming. DO NOT SHAKE VIAL. Once swirled, the pharmacist, using aseptic technique will add the calculated total milligrams needed to a 100 mL bag of normal saline (Sodium Chloride for Injection USP, 0.9%). Up to 50 mL of VRC01 may be added to a 100 mL bag of normal saline.
The pharmacist must note on the IV bag label the volume of study product added to the bag as well as the final total volume of fluid in the IV bag (eg, 28 mL VRC01 or Placebo Note: The Sodium Chloride for Injection bags referred to as "100 mL bags" in the IV administration instructions will typically have 103 mL volume before any VRC01 is added and this is acceptable in the context of the instructions.
Any empty vials, unused portion of entered vials, or unused IV solution which contains study product should be discarded in a biohazard containment bag and incinerated or autoclaved in accordance with institutional or pharmacy policy.

IV Placebo for VRC01 -DOUBLE BLIND (Group 3 C3)
To prepare an IV infusion, the pharmacist will calculate the volume of Sodium Chloride for Injection USP, 0.9% needed by multiplying the participant's weight in kg by 0.4 mL. The pharmacist, using aseptic technique will add the calculated volume of Sodium Chloride for Injection USP, 0.9% needed to a 100 mL bag of normal saline (Sodium Chloride for Injection USP, 0.9%). Up to 50 mL of Sodium Chloride for Injection USP, 0.9% may be added to a 100 mL bag of normal saline.
The pharmacist must note on the IV bag label the volume of study product added to the bag as well as the final total volume of fluid in the IV bag (eg, 28 mL VRC01 or Placebo (IV) and Total Volume of 131 mL for the 70kg individual). The IV bag should be labeled with a 12-hour expiration date and time. The IV bag should be stored at room temperature or refrigerated (2 o -8 o C) until administration.
Note: The Sodium Chloride for Injection bags referred to as "100 mL bags" in the IV administration instructions will typically have 103 mL volume before any Sodium Chloride for Injection USP, 0.9% is added and this is acceptable in the context of the instructions.
Any unused IV solution which contains study product should be discarded in a biohazard containment bag and incinerated or autoclaved in accordance with institutional or pharmacy policy.

VRC-HIVMAB060-00-AB (5 mg/kg SC) DOUBLE BLIND (Group 3 T3)
To prepare a SC administration, the pharmacist will verify the total dose [milligrams needed (5 mg x participant's weight in kg)] and thaw the minimum number of vials needed to obtain the full dose. The pharmacist will determine the number of vials by dividing the total milligrams needed by 200. The result will be rounded UP to the next whole number. Note: It is expected that each vial may be used for about 2 mL withdrawal volume (200 mg VRC01).
Each vial must be thawed for a minimum of 1 hour at room temperature after removal from the freezer. After the 1 hour minimum, the pharmacist should gently swirl the vials before inspecting for particles. DO NOT SHAKE VIAL. Once swirled, the pharmacist, using aseptic technique will draw the calculated total milliliters needed into sterile syringe. If more than one syringe is needed, then the total dose should be divided as equally as possible between 2-4 syringes. The pharmacist will apply an overlay to each syringe.
The pharmacist must note on the label the final total volume of fluid in each syringe. The syringe(s) should be labeled with a 12-hour expiration date and time from the time the vial is removed from the freezer . The syringe should be stored at room temperature or refrigerated (2 o -8 o C) until administration.
Any empty vials, unused portion of entered vials, or expired prefilled syringes which contain study product should be discarded in a biohazard containment bag and incinerated or autoclaved in accordance with institutional or pharmacy policy.

SC Placebo for VRC01 (VRC-PLAMAB068-00-AB) DOUBLE BLIND (Group 3 C3)
To prepare a SC administration, the pharmacist will calculate the total volume needed (0.05 mL x participant's weight in kg) and thaw the minimum number of vials needed to obtain the full dose. Note: It is expected that each vial may be used for about 2 mL withdrawal volume.
Each vial must be thawed for a minimum of 1 hour at room temperature after removal from the freezer. After the 1 hour minimum, the pharmacist should gently swirl the vials before inspecting for particles. DO NOT SHAKE VIAL. Once swirled, the pharmacist, using aseptic technique will draw the calculated total milliliters needed into a sterile syringe. If more than one syringe is needed, then the total dose should be divided as equally as possible between 2-4 syringes. The pharmacist will apply an overlay to each syringe.
The pharmacist must note on the label the final total volume of fluid in each syringe. The syringe should be labeled with a 12-hour expiration date and time from the time the vial is removed from the freezer . The syringe should be stored at room temperature or refrigerated (2 o -8 o C) until administration.
Any empty vials, unused portion of entered vials, or expired prefilled syringes which contain study product should be discarded in a biohazard containment bag in accordance with institutional or pharmacy policy.

VRC-HIVMAB060-00-AB (10mg/kg IV) -OPEN LABEL ONLY (Group 4 Months 0, 2, and 4)
To prepare an IV infusion, the pharmacist will verify the dose [total milligrams needed (10 mg x participant's weight in kg)] and thaw the minimum number of vials needed to obtain the full dose. The pharmacist will determine the number of vials by dividing the total milligrams needed by 200. The result will be rounded UP to the next whole number. Note: It is expected that each vial may be used for about 2 mL withdrawal volume (200 mg VRC01).
Each vial must be thawed for a minimum of 1 hour at room temperature after removal from the freezer. After the 1 hour minimum, the pharmacist should gently swirl the vials before inspecting for particles. DO NOT SHAKE VIAL. Once swirled, the pharmacist, using aseptic technique will add the calculated total milligrams needed to a 100 mL bag of Sodium Chloride for Injection USP, 0.9%. Up to 50 mL of VRC01 may be added to a 100 mL bag of normal saline. Note: The Sodium Chloride for Injection bags referred to as "100 mL bags" in the IV administration instructions will typically have 103 mL volume before any VRC01 is added and this is acceptable in the context of the instructions.
Any empty vials, unused portion of entered vials, or unused IV solution which contains study product should be discarded in a biohazard containment bag and incinerated or autoclaved in accordance with institutional or pharmacy policy.

VRC-HIVMAB060-00-AB (30mg/kg IV) -OPEN LABEL ONLY (Group 5 Months 0, 2, and 4)
To prepare an IV infusion, the pharmacist will verify the dose [total milligrams needed (30 mg x participant's weight in kg)] and thaw the minimum number of vials needed to obtain the full dose. The pharmacist will determine the number of vials by dividing the total milligrams needed by 200. The result will be rounded UP to the next whole number. Note: It is expected that each vial may be used for about 2 mL withdrawal volume (200 mg VRC01).
Each vial must be thawed for a minimum of 1 hour at room temperature after removal from the freezer. After the 1 hour minimum, the pharmacist should gently swirl the vials before inspecting for particles. DO NOT SHAKE VIAL. Once swirled, the pharmacist, using aseptic technique will add the calculated total milligrams needed to a 100 mL bag of Sodium Chloride for Injection USP, 0.9%. Up to 50 mL of VRC01 may be added to a 100 mL bag of normal saline. Note: The Sodium Chloride for Injection bags referred to as "100 mL bags" in the IV administration instructions will typically have 103 mL volume before any VRC01 is added and this is acceptable in the context of the instructions.
Any empty vials, unused portion of entered vials, or unused IV solution which contains study product should be discarded in a biohazard containment bag and incinerated or autoclaved in accordance with institutional or pharmacy policy.

Administration
For additional information regarding study product administration refer to the HVTN 104 Study Specific Procedures.

For Groups 1, 2, 4, and 5 (open label):
The IV bag prepared by the pharmacy will include the total amount (mg) of VRC01 added to the 100 mL normal saline bag and the final volume of the bag. The clinician responsible for administration and another clinician will each check the bag label and confirm that the identifier is correct and that the correct total milligrams to be administered is shown based on subject weight and dosage level before beginning the IV administration. The investigational study product solution will typically be administered IV over 60 minutes using a volumetric pump. The rate of infusion (mL/hr) will vary based on the total volume needed to administer the full dose. The total time needed to administer the dose may be longer based on factors such as subject tolerance.

VRC01 or IV Placebo (Intravenously)
For Group 3 Month 0 (blinded): The IV bag prepared by the pharmacy will include the total amount (mL) of VRC01 or IV Placebo for VRC01 (Sodium Chloride for Injection 0.9%, USP) added to the 100 mL normal saline bag and the final volume of the bag. The clinician responsible for administration and another clinician will each check the bag label and confirm that the identifier is correct and that the correct total milliliters to be administered is shown based on subject weight and dosage level before beginning the IV administration.
The investigational study product solution will typically be administered IV over 60 minutes using a volumetric pump. The rate of infusion (mL/hr) will vary based on the total volume needed to administer the full dose. The total time needed to administer the dose may be longer based on factors such as subject tolerance.

VRC01 or SC Placebo (Subcutaneously)
The SC syringe(s) prepared by the pharmacy will include the total amount (mL) of VRC01 or SC Placebo (VRC-PLAMAB068-00-AB). At the time of administration, the clinician and participant will again discuss the administration site(s) (abdomen, upper arm, or thigh) and deem the one selected to be acceptable.
If more than one syringe is needed, the ziplock bag containing the syringes will show the total volume to be administered. The clinician responsible for administration and another clinician will each check the syringe/ziplock bag label and confirm that the identifier is correct and that the correct total milliliters to be administered is shown based on the participant's weight and dosage level before administering the SC injection(s).
All SC injections must be at least 2 inches apart.
When preparing a dose in a syringe and administering the dose, consideration should be given to the volume of solution in the needle before and after the dose is administered. Particularly if the needle used to withdraw the product is replaced prior to product administration, consideration should be given to conserving the full dose of product. The pharmacy and clinic staff members are encouraged to work together to administer the dose specified in the protocol.
IV Placebo for VRC01 (Sodium Chloride for Injection USP, 0.9%) will not be provided through the protocol and must be obtained by the site.
Once an HVTN CRS is protocol registered, the pharmacist can obtain study products from the NIAID Clinical Research Products Management Center (CRPMC) by following the ordering procedures given in Pharmacy Guidelines and Instructions for DAIDS Clinical Trials Networks.

Pharmacy records
The HVTN CRS pharmacist is required to maintain complete records of all study products. The pharmacist of record is responsible for maintaining randomization codes and randomization confirmation notices for each participant in a secure manner.

Final disposition of study products
All unused study products must be returned to the CRPMC after the study is completed or terminated unless otherwise instructed by the CRPMC. The procedures and relevant form are included in the Pharmacy Guidelines and Instructions for DAIDS Clinical Trials Networks.

Clinical procedures
The schedules of clinical procedures are shown in Appendix H and Appendix I and Appendix J.

Informed consent
Informed consent is the process of ensuring that participants fully understand what will and may happen to them while participating in a research study. The HVTN informed consent form documents that a participant (1) has been informed about the potential risks, benefits, and alternatives to participation, and (2) is willing to participate in an HVTN study. Informed consent encompasses all written or verbal study information HVTN CRS staff provide to the participant, before and during the trial. HVTN CRS staff will obtain informed consent of participants according to HVTN policies and procedures.
The informed consent process continues throughout the study. Key study concepts should be reviewed periodically with the participant and the review should be documented. At each study visit, HVTN CRS staff should consider reviewing the procedures and requirements for that visit and for the remaining visits. Additionally, if any new information is learned that might affect the participants' decisions to stay in the trial, this information will be shared with trial participants. If necessary, participants will be asked to sign revised informed consent forms.
An HVTN CRS may employ recruitment efforts prior to the participant consenting. For example, some HVTN CRSs use a telephone script to prescreen people before they come to the clinic for a full screening visit. Participants must sign a screening or protocolspecific consent before any procedures are performed to determine eligibility. HVTN CRSs must submit recruitment and prescreening materials to IRB/EC and any applicable Regulatory Entity (RE) for human subjects protection review and approval.
Note: As defined in the DAIDS Protocol Registration Manual, an RE is "Any group other than the local IRB/EC responsible for reviewing and/or approving a clinical research protocol and site-specific ICFs prior to implementation at a site." CRSs are responsible for knowing the requirements of their applicable REs.

Screening consent form
Without a general screening consent, screening for a specific study cannot take place until the site receives protocol registration from the DAIDS Protocol Registration Office's Regulatory Support Center (RSC).
Some HVTN CRSs have approval from their IRB/EC and any applicable RE to use a general screening consent form that allows screening for an unspecified HIV prevention trial. In this way, HVTN CRS staff can continually screen potential participants and, when needed, proceed quickly to obtain protocol-specific enrollment consent. Sites conducting general screening or prescreening approved by their IRB/EC and any applicable RE may use the results from this screening to determine eligibility for this protocol, provided the tests are conducted within the time periods specified in the eligibility criteria.

Protocol-specific consent forms
The protocol-specific consent forms describe the study products to be used and all aspects of protocol participation, including screening and enrollment procedures. A sample protocol-specific consent form for the main study is located in Appendix A. A separate sample consent form for other uses of specimens is located in Appendix C.
Each HVTN CRS is responsible for developing a protocol-specific consent form(s) for local use, based on the sample protocol-specific consent forms in Appendix A and Appendix C. The consent form(s) must be developed in accordance with requirements of the following: Study sites are strongly encouraged to have their local CABs review their sites-specific consent forms. This review should include, but should not be limited to, issues of cultural competence, local language considerations, and the level of understandability.
The sample informed consent form includes instructions throughout the document for developing specific content.
Sites should follow the instructions in the Protocol-specific Official Memo distributed along with this protocol regarding when they may begin using their site-specific protocol consent forms.
Regarding protocol registration, sites should follow procedures outlined in the current version of the DAIDS Protocol Registration Manual.

Assessment of Understanding
Study staff are responsible for ensuring that participants fully understand the study before enrolling them. This process involves reviewing the informed consent form with the participant, allowing time for the participant to reflect on the procedures and issues presented, and answering all questions completely.
An Assessment of Understanding is used to document the participant's understanding of key concepts in this clinical trial. The participant must complete the Assessment of Understanding before enrollment. Staff may provide assistance in reading and understanding the questions and responses, if necessary. Participants must verbalize understanding of all questions answered incorrectly. This process and the participant's understanding of the key concepts should be recorded in source documentation at the site.
IRB/EC and any applicable RE may require that a participant has signed either a screening or protocol-specific consent document prior to administering the Assessment of Understanding. The consent process (including the use of the Assessment of Understanding) should be explained thoroughly to the IRB/EC and any applicable RE, whose recommendations should be followed.

Pre-enrollment procedures
Screening may occur over the course of several contacts/visits, up to and including before infusion on day 0. All inclusion and exclusion criteria must be assessed within 56 days before enrollment, unless otherwise specified in the eligibility criteria (or below in this section).
After the appropriate informed consent has been obtained and before enrollment, the following procedures are performed:  Discussion of pregnancy prevention. A pregnant or breastfeeding person may not be enrolled in this trial. Specific criteria and assessment of contraception and pregnancy status are described in study inclusion criteria. Discussion of pregnancy prevention includes advising a participant who was born female and who reports no current sexual activity that could lead to that participant becoming pregnant to have a plan to begin adequate birth control. This plan would be put to use if, during the study, the participant becomes sexually active in a way that could lead to that participant becoming pregnant.

Use of screening results from another HVTN study
If a participant screens for an HVTN study at the same HVTN CRS but then does not join that study, screening results from that effort may be applied to the screening for this protocol, as long as the screening was done under participant consent, the participant has signed a consent form to begin screening for this study, and the tests were conducted within the time periods specified in the eligibility criteria (see Sections 7.1 and 7.2).

Enrollment and study product administration visits
Enrollment is simultaneous with first infusion. The time interval between randomization and enrollment should not exceed 4 working days. The HVTN CRS registers the participant by scheduling the day 0 visit (enrollment) via the Web-based randomization system, and requests the randomization assignment. Circumstances may require a participant's enrollment visit to be changed. This may exceed the 4-day randomization time limit.
At all study product administration visits, the following procedures are performed before study product administration:  Abbreviated physical examination, including weight, vital signs, and a symptomdirected evaluation by history and/or appropriate physical exam based on participant self-reported symptoms or complaints;  Assessment of baseline reactogenicity parameters;  Assessment of concomitant medications (as described in Section 9.2);  Assessment of any new or unresolved AEs/intercurrent illnesses; and  Urine or serum pregnancy test (for participants who were born female). Persons who are not of reproductive potential due to having undergone total hysterectomy with bilateral oophorectomy (verified by medical records), are not required to undergo pregnancy testing.
Following completion of all procedures in the preceding list and results indicate that study product administration may proceed, the study products are prepared and administered (see Sections 8.3 and 8.4).
Immediately following study product administration, the participant remains in the clinic for observation. An initial reactogenicity assessment is made at a target of 60 minutes after all IV infusions and the first SC injection (visit 3) in Group 3, with an acceptable range of 60-120 minutes. For subsequent SC injections in Group 3, an initial reactogenicity assessment is made at a target of 30 minutes, with an acceptable range of 25-60 minutes. Before leaving the clinic, the participant is given the postproduct symptom log and is instructed on how to complete it. The site will make arrangements to obtain daily reports of reactogenicity events from the participant during the reactogenicity period (as described in Section 9.9).
The following procedures will be performed at all study product administration visits. These procedures may be performed prior to or following study product administration:  Risk reduction counseling (as described in Section 9.6);  Pregnancy prevention assessment (as described in Section 9.2 and 9.7); and  Assessment of new or unresolved social impacts (site staff will ask participant about the status of any unresolved social impacts and if s/he has experienced any new social impacts as a result of the trial participation).
The following procedure will be performed at all study product administration visits. This procedure must be performed following study product administration:  Administration of the acceptability questionnaire (level of discomfort with the procedures, willingness to undergo procedures in a "real world" setting; level of pain, and level of anxiety).
Additional procedures will be performed at scheduled visits as specified in Appendix H and Appendix I and Appendix J:  Confirm that participants received HIV test results from previous visit. If not, provide test results and post-test counseling as appropriate; and  Specimen collection (to be completed prior to study product administration).

Follow-up visits
The following procedures are performed at all scheduled follow-up visits:  Risk reduction counseling (as described in Section 9.6);  Pregnancy prevention assessment (as described in Section 9.2 and 9.7); and  Assessment of new or unresolved social impacts (site staff will ask participant about the status of any unresolved social impacts and if s/he has experienced any new social impacts as a result of the trial participation);  Administration of the acceptability questionnaire (level of discomfort with the procedures, willingness to undergo procedures in a "real world" setting; level of pain, and level of anxiety);  Assessment of new or continuing concomitant medications (as described in Section 9.2); and  Assessment of new or unresolved AEs/intercurrent illnesses.
Additional procedures will be performed at scheduled follow-up visits as specified in Appendix H and Appendix I and Appendix J:  Administration of the social impact assessment questionnaire (types of impacts assessed involve personal relationships, health insurance, life insurance, educational or employment opportunities, housing, immigration, or travel);  Participants in Group 3 will also be asked whether they believe they received the active study product or the control;  HIV infection assessment including pretest counseling. A subsequent follow-up contact is conducted to provide posttest counseling and to report results to participant;  Urine or serum pregnancy test (for participants who were born female); Persons who are not of reproductive potential due to having undergone total hysterectomy with bilateral oophorectomy (verified by medical records), are not required to undergo pregnancy testing.

Mucosal secretion sampling
Mucosal secretion samples will be collected from all study participants who agree to these procedures at timepoints indicated Appendix H and Appendix I and Appendix J (see also HVTN 104 Study Specific Procedures). These samples include saliva, rectal secretions, semen (only for people born male), or cervical secretions (only for people born female).
Mucosal sampling must be performed prior to study product administration.
For participants born female providing cervical and/or rectal samples, a pregnancy test must be performed and must be negative prior to any mucosal sampling. Persons who are not of reproductive potential due to having undergone total hysterectomy with bilateral oophorectomy (verified by medical records), are not required to undergo pregnancy testing.
The following conditions apply to mucosal sampling. Study participants are advised of these in the study informed consent form (see Appendix A): Salivary fluid sampling: Participants willing to provide salivary samples should abstain from smoking, eating, or drinking anything other than water, brushing their teeth, using mouthwash, chewing gum or tobacco, or engaging in intimate oral activity for one hour prior to sample collection.
Rectal fluid sampling: Participants who consent to provide rectal samples are subject to the following exclusion criteria:  Participant is pregnant. For participants born female, a pregnancy test must be performed and be negative prior to any rectal mucosal sampling.
 Participant has engaged in receptive anal intercourse or insertion of any foreign object or substance into the anus for 48 hours prior to sample collection. Foreign objects include, but are not limited to cleaning products (creams, gels, lotions, pads, etc.), lubricant, enemas, and douching, even with water.
 Participant has used any perianal or intra-anal steroid or other anti-inflammatory creams for 48 hours prior to sample collection.
 Participant has any active infection or inflammation of the colorectal area (such as an HSV-2 outbreak or inflamed hemorrhoids or colitis/diarrhea).
 Participant has any active Genital Tract Infections (GTI), including untreated syphilis. If participant has received treatment for syphilis, documentation of resolution must be obtained prior to sampling. Semen sampling: Participants born male who consent to provide semen samples are requested to refrain from ejaculation for at least 48 hours prior to specimen collection. In addition, participants are subject to the following exclusion criteria:  Participant has any active Genital Tract Infections (GTI), including untreated syphilis. If participant has received treatment for syphilis, documentation of resolution must be obtained prior to sampling.

HIV counseling and testing
HIV counseling will be performed in compliance with the CDC's guidelines or other local guidelines for HIV counseling and referral. HIV testing will be performed in accordance with the current HVTN HIV testing algorithm following enrollment.
Participants will be counseled routinely during the trial on the avoidance of HIV infection and on the potential negative social impacts of the theoretical possibility of testing antibody positive due to the study product. They will also be counseled on the risks of HIV antibody testing outside of the HVTN CRSs and will be discouraged from doing so during study participation and/or during any period of study product reactive serology.
Study staff will take particular care to inform study participants of the likelihood of routine HIV testing being offered or performed outside the study CRS at emergency rooms, clinics, and medical offices. Such testing has become more likely due to the CDC's revised guidelines for HIV counseling and testing, as well as policy changes in many countries to make HIV testing more frequent and routine. CRS staff should inform participants of their right to opt out of HIV testing outside the study site. CRS staff should inform study participants if local and/or state policies and regulations permit medical providers to perform HIV testing without first informing patients. If this is the case, then CRS staff should advise study participants that they may decline testing preemptively. CRS staff should also inform participants if positive results must be reported to local public health authorities. CRS staff should also inform participants of the need to maintain study blinding by getting HIV testing only at the study CRS. CRS staff should provide participants with CRS contact information and should encourage participants to ask medical providers to contact the CRS. The CRS can verify that the participant is in an HIV vaccine clinical trial and should only be tested at the study CRS.
Potential participants identified as being HIV infected during screening are not enrolled. All participants who become HIV infected during the study will be terminated from this study. Potential and enrolled participants identified as HIV infected will be referred for medical treatment, counseling, and management of the HIV infection. These individuals may also be referred to appropriate ongoing clinical trials or observational studies.

Distinguishing intercurrent HIV infection from study product reactive serology
The following procedures will be conducted in order to assess study product reactive serology:  Participants will have physical examinations at visits specified in Appendix H and Appendix I and Appendix J. Signs or symptoms of an acute HIV infection syndrome, an intercurrent illness consistent with HIV-1 infection, or probable HIV exposure would prompt a diagnostic workup per the HVTN algorithm for Recent Exposure/Acute Infection Testing to determine HIV infection.
 HIV testing will be performed at multiple timepoints throughout the study (see Appendix E and Appendix F and Appendix G). The Laboratory Program (or approved diagnostic laboratory) will follow the HVTN HIV testing algorithm (as described in the HVTN Site Lab Reference Manual), which is able to distinguish study product reactive serology responses from actual HIV infections.
 All participants can receive HIV-1 diagnostic testing from the site following their last scheduled visit until they are told that they did not receive VRC01 or that antibodybased HIV diagnostic tests are not reactive.
 All participants who received VRC01 and who have VRC01-induced positive or indeterminate HIV-1 serology (as measured by the standard anti-HIV antibody screening tests) at or after the study is unblinded will be offered poststudy HIV-1 diagnostic testing (per the HVTN poststudy HIV-1 testing algorithm) periodically and free of charge as medically/socially indicated (approximately every 6 months).

Contraception status
Contraception status is assessed and documented at every scheduled clinic visit for a participant who was born female and who is sexually active in a way that could cause that participant to become pregnant. Prior to enrollment and throughout the study, staff will ask participants to verbally confirm their use of adequate contraceptive methods. A participant who was born female and is sexually active in a way that could cause that participant to become pregnant should be reminded at all scheduled clinic visits of the importance of using contraception and should be referred to specific counseling, information, and advice as needed. (Specific contraception requirements are listed in Section 7.1). This reminder should be documented in the participant's study record.
Self-reported infertility-including having reached menopause (no menses for 1 year) or having undergone hysterectomy, bilateral oophorectomy, or tubal ligation-must be documented in the participant's study record.

Urinalysis
Dipstick testing may be performed in the clinic or the lab, as long as the required elements (glucose, protein, and hemoglobin) are tested. The examination is performed on urine obtained by clean catch.
If the screening dipstick is transiently abnormal due to menses or infection, document this issue in the participant's source documentation. For infection, provide appropriate treatment and/or referral. Following resolution, repeat the dipstick and, if within the eligibility limits specified in the protocol, the participant may be enrolled.
Follow-up urinalysis should be deferred if a participant is menstruating, but should be performed as soon as possible. If a follow-up dipstick is abnormal due to a participant's menstrual period, document in the comment section of the case report form (CRF) and repeat the dipstick once the participant is no longer menstruating; a micro-urinalysis is not required.

Assessments of reactogenicity
For all participants, baseline assessments are performed before and reactogenicity assessments are performed after each study product administration. All reactogenicity symptoms are followed until resolution and graded according to the Division of AIDS The reactogenicity assessment period is 3 full days following each study product administration per the assessment schedule shown in Table 9-1. Participants are instructed to record symptoms using a post product symptom log and to contact the site daily during the assessment period. Clinic staff will follow new or unresolved reactogenicity symptoms present at day 3 to resolution. Participants are instructed to contact the clinic for events that arise during the period between study product administration and the next scheduled visit. In general, a participant who self-reports any post administration reaction greater than mild is seen by a clinician within 48 hours after onset, unless the reaction is improving and/or has completely resolved.
Reactogenicity events are reported using CRFs that correspond to the time of assessment in Table 9-1. Reactogenicity assessments include assessments of systemic and local symptoms, and study product-related lesions. Events not listed on a CRF, or with an onset after the reactogenicity assessment period (day of study product administration and 3 full days after), or those meeting SAE/adverse events requiring expedited reporting to DAIDS criteria, are recorded on an adverse experience log form. Between 12:00am and 11:59pm day 3 HVTN CRS staff or participant a Day of study product administration b New or unresolved reactogenicity symptoms present on day 3 are followed until resolution

Assessment of systemic and local symptoms
Typical study product administration site reactions are erythema/induration/swelling/edema. The maximum horizontal and maximum vertical measurements for all study product administrationsite reactions are recorded.
Body temperature is measured by oral or infrared thermometry and reported in degrees Celsius. If temperature is measured in Fahrenheit, the conversion to Celsius should be documented in the participant's chart note. A measurement is taken once daily during the assessment period and should be repeated if participant is feeling feverish.

Assessment of the study product administration site
Typical study product administration site reactions are erythema/induration/swelling/edema. The maximum horizontal and maximum vertical measurements for all study product administration site reactions are recorded.
All study product administration site reactions are monitored until resolution. Areas greater than 25 cm 2 are followed daily; otherwise, the frequency of follow-up is based on clinician judgment.

Visit windows and missed visits
Visit windows are defined in HVTN 104 Study Specific Procedures. For a visit not performed within the window period, a Missed Visit form is completed. If the missed visit is one that required safety assessments or local safety labs, HVTN CRS staff should attempt to bring the participant in for an interim visit as soon as possible.
Procedures performed at an interim visit are usually toxicity/safety assessments (including local safety labs) and HIV testing. With the exception of HIV testing, these procedures are performed only if they were required at the missed visit or if clinically indicated. HIV testing may be performed as deemed appropriate by the study staff. Blood samples for immunogenicity assays are not typically collected at interim visits.
If a missed visit required study product administration, please refer to Section 7.3.2 and Section 7.3.3 for resolution.

Early termination visit
In the event of early participant termination, site staff should consider if the following assessments are appropriate: a final physical examination, clinical laboratory tests (including urine dipstick, CBC with differential, platelet count, and chemistry panel), pregnancy testing, social impact assessment, and HIV test.

Pregnancy
If a participant becomes pregnant during the course of the study, no more administrations of study product will be given, but remaining visits and study procedures should be completed unless medically contraindicated or applicable regulations require termination from the study. In case of required termination, enrollment in an observational study should be offered to the participant. If the participant terminates from the study prior to the pregnancy outcome, the site should make every effort to keep in touch with the participant in order to ascertain the pregnancy outcome.

HVTN CRS laboratory procedures
The HVTN Site Lab Reference Manual provides further guidelines for operational issues concerning the clinical and processing laboratories. The manual includes guidelines for general specimen collection, special considerations for phlebotomy, specimen labeling, whole blood processing, HIV screening/diagnostic testing, and general screening and safety testing.
Tube types for blood collection are specified in Appendix E and Appendix F and Appendix G. For tests performed locally, the local lab may assign appropriate tube types.
In specific situations, the blood collection tubes may be redirected to another laboratory or may require study-specific processing techniques. In these cases, laboratory special instructions will be posted on the protocol-specific section of the HVTN website.

Total blood volume
Required blood volumes per visit are shown in Appendix E and Appendix F and Appendix G. The FHCRC laboratory will further specify the tube type and collection volumes in special instructions posted to the protocol-specific section of the HVTN website.) Not shown is any additional blood volume that would be required if a safety lab needs to be repeated, or if a serum pregnancy test needs to be performed. The additional blood volume would likely be minimal. The total blood volume drawn for each participant will not exceed 500 mL in any 56-day (8-week) period.

Primary timepoint
The primary timepoint in this study is at visit 19 (day 168) (ie, 4 weeks after the 6 th study product administration) for Group 1; visit 19 (day 168) (ie, 8 weeks after the 3 rd study product administration) for Groups 2, 4, and 5; and visit 19 (day 168) (2 weeks after the 12 th study product administration) for Group 3. Other time points may also be examined to better understand how serum concentrations of VRC01 change. The schedules are shown in Appendix E and Appendix F and Appendix G.

VRC01 mAb levels
VRC01 levels will be measured in serum and mucosal secretions including saliva, semen, cervical secretions, and rectal secretions. An ELISA will be used to determine the concentration of the VRC01 antibody in the serum. The ELISA employs the VRC01 Fabspecific 5C9 mAb, which is an anti-idiotype antibody cloned from a single B cell that was sorted by flow cytometry using a VRC01 scFv probe. ELISA will also be used to detect the presence of VRC01 antibody in various mucosal secretions. The 4-parameter logistic curve regression of a standard curve of VRC01 covering the range from 0.031 to 1.0 mcg/mL is utilized in this assay to quantitate the sample concentrations based upon the average of sample dilutions within the range of the assay. This assay has been qualified but not formally validated. The functional sensitivity for the generation of the ELISA assay format, which is currently used at NVITAL, is 2 mcg/ml; and as the technology for this assay continues to develop, an updated assay may be utilized Binding multiplex antibody assay (BAMA) may also be used to assess binding of VRC01 from serum and mucosal secretions to various Env proteins, including Consensus gp120, Consensus gp140 and CD4 binding site proteins. The lower limit of detection will be determined for the matched lot of VRC01 study product prior to assessment of VRC01 binding in HVTN 104 participants. However, historical control assays carried out under GCLP validated assay conditions indicate that the lower limit of detection for VRC01 is at least 1-10 ng/ml.

Anti-VRC01 antibody assay
Assessment for development of anti-VRC01 antibodies in subjects will be performed using the Forte Bio Octet BioLayer Interferometry (BLI) technology. The assay uses VRC01 immobilized to a biosensor. The biosensor is dipped into patient serum samples and antibodies against VRC01 are directly measured. The binding response is directly proportional to the anti-drug concentration as determined against a calibration curve using the 5C9 antibody.

Neutralizing antibody assay
Depending upon the concentrations measured in collected specimens, further evaluation of the research samples to assess for functional capacity to neutralize HIV in blood and mucosal secretions may be evaluated by an in vitro cell-based virus neutralization assay [50][51][52] using pseudotyped viruses.
One or more viruses that are among the most sensitive to VRC01 (e.g. MN.3 and MW965.26) will be assayed. The IC50 of VRC01 against both of these viruses is 0.01 -0.03 mcg/ml and the IC90 of VRC01 against both of these viruses is 0.2 mcg/ml. The TZM-bl assay is validated for this level of sensitivity.

Genotyping
Molecular human leukocyte antigen (HLA) typing may be performed on enrolled participants using cryopreserved PBMC collected at baseline. Other participants (including control recipients) may be HLA-typed to support future studies of immunological interest at the discretion of the HVTN Laboratory Program. Other markers, such as genes associated with immune responses or HIV-1 disease progression may also be assessed.

Exploratory studies
Samples may be used for other testing and research related to furthering the understanding of HIV immunology or vaccines. In addition, cryopreserved samples may be used to perform additional assays to support standardization and validation of existing or newly developed methods.

Other use of stored specimens
The HVTN stores specimens from all study participants indefinitely, unless a participant requests that specimens be destroyed or if required by IRB/EC, or RE.
Other use of specimens is defined as studies not described in the protocol.
This research may relate to HIV, vaccines, the immune system, and other diseases. This could include limited genetic testing and, potentially, genome-wide studies. This research is done only to the extent authorized in each study site's informed consent form, or as otherwise authorized under applicable law. Other testing on specimens will occur only after review and approval by the HVTN, the IRB/EC of the researcher requesting the specimens, and the CRS's IRBs/ECs if required.
The protocol sample informed consent form is written so that the participant either explicitly allows or does not allow their samples to be used in other research when they sign the form. Participants who initially agree to other use of their samples may rescind their approval once they enter the study; such participants will remain in this study and their samples will only be used for the studies described in this protocol. If a participant decides against allowing other research using his or her samples, or at any time rescinds prior approval for such other use, the study site investigator or designee must notify HVTN Regulatory Affairs in writing. In either case, HVTN Regulatory Affairs directs the HVTN Lab Program not to use samples from these participants for such other uses.
CRSs must notify HVTN Regulatory Affairs if institutional or local governmental requirements pose a conflict with or impose restrictions on other use of specimens.

Biohazard containment
As the transmission of HIV and other blood-borne pathogens can occur through contact with contaminated needles, blood, and blood products, appropriate precautions will be employed by all personnel in the drawing of blood and shipping and handling of all specimens for this study, as currently recommended by the CDC and the NIH or other applicable agencies.
All dangerous goods materials, including Biological Substances, Category A or Category B, must be transported according to instructions detailed in the International Air Transport Association Dangerous Goods Regulations. The clinician members of HVTN 104 PSRT are responsible for decisions related to participant safety.
The Protocol Team clinic coordinator, project manager, vaccine developer representative, clinical trial manager, and others may also be included in HVTN 104 PSRT meetings.

HVTN SMB
The SMB is a multidisciplinary group consisting of biostatisticians, clinicians, and experts in HIV vaccine research that, collectively, has experience in the conduct and monitoring of vaccine and drug trials. Members of the SMB are not directly affiliated with the protocols under review.
The SMB reviews safety data, unblinded as to treatment arm, approximately every 4 months. The reviews consist of evaluation of cumulative reactogenicity events, AE, laboratory safety data, and individual reports of adverse events requiring expedited reporting to DAIDS. To increase the sensitivity for detecting potential safety problems, the SMB will review safety data aggregated across multiple protocols that use the same or similar vaccine candidates. The SMB conducts additional special reviews at the request of the HVTN 104 PSRT.
Study sites will receive SMB summary minutes and are responsible for forwarding them to their IRB/EC and any applicable RE.

SDMC roles and responsibilities in safety monitoring
The roles and responsibilities of the SDMC in relation to safety monitoring include:  Maintaining a central database management system for HVTN clinical data;  Providing reports of clinical data to appropriate groups such as the HVTN 104 PSRT and HVTN SMB (see Section 11.1.2).

HVTN Core roles and responsibilities in safety monitoring
The roles and responsibilities of HVTN Core in relation to safety monitoring include:  Daily monitoring of clinical data for events that meet the safety pause and HVTN 104 PSRT AE review criteria (see Section 11.3);  Notifying HVTN CRSs and other groups when safety pauses or planned holds are instituted and lifted (see Section 11.3);  Querying HVTN CRSs for additional information regarding reported clinical data; and  Providing support to the HVTN 104 PSRT.

Submission of safety forms to SDMC
Sites must submit all safety forms (eg, reactogenicity, adverse experience, urinalysis, local lab results, and concomitant medications) before the end of the next business day after receiving the information. The forms should not be held in anticipation of additional information at a later date. If additional information is received at a later date, the forms should be updated and refaxed before the end of the next business day after receiving the new information.

AE reporting
An AE is any untoward medical occurrence in a clinical investigation participant administered a study product/procedure(s) and which does not necessarily have a causal relationship with this treatment. An AE can therefore be any unfavorable and unintended sign (including an abnormal laboratory finding), symptom, or disease temporally associated with the use of an investigational study product/procedure(s), whether or not related to the investigational study product/procedure(s). All AEs are graded according to the Division of AIDS  (2) if the AE meets the criteria for a safety pause/prompt AE review (Section 11.3).
Sites are expected to notify the CSS of any serious safety concern requiring their attention (see Table 11 In the case of email notification, the CSS will reply during working hours (US Pacific Time) to confirm that the email has been received and reviewed. If email service is not available, the HVTN CRS should notify the CSS of the event by telephone, then submit CRFs.
In addition, site investigators are required to submit AE information in accordance with IRB/EC and any applicable RE requirements.

Expedited reporting of adverse events to DAIDS
Requirements, definitions and methods for expedited reporting of AEs are outlined in Version 2.0 (January 2010) of the Manual for Expedited Reporting of Adverse Events to DAIDS (DAIDS EAE Manual), which is available on the RSC website at http://rsc.techres.com/safetyandpharmacovigilance/. The SAE Reporting Category will be used for this study.
The internet-based DAIDS Adverse Event Reporting System (DAERS) must be used for expedited AE reporting to DAIDS. In the event of system outages or technical difficulties, expedited AE reports may be submitted via the DAIDS EAE Form. For questions about DAERS, please contact DAIDS-ESSupport@niaid.nih.gov or from within the DAERS application itself.
Sites where DAERS has not been implemented will submit expedited AE reports by documenting the information on the current DAIDS EAE Form. This form is available on the RSC website: http://rsc.tech-res.com/safetyandpharmacovigilance/. For questions about expedited AE reporting, please contact the RSC (DAIDSRSCSafetyOffice@techres.com).
The study products for which expedited reporting are required are: While the participant is in the study reporting period (See Section 3), the SAE Reporting Category will be used.
After the protocol-defined AE reporting period for the study, unless otherwise noted, only Suspected, Unexpected Serious Adverse Reactions as defined in Version 2.0 of the DAIDS EAE Manual must be reported to DAIDS, if the study staff become aware of the events.
The NIAID/DAIDS will report all unexpected SAEs related to the study products observed in this clinical trial to the FDA in accordance with 21 CFR 312.32 (IND Safety Reports). However, because safety is a primary study endpoint, the Sponsor Medical Officer will not be unblinded to study treatment assignment when there is an assessment of relatedness of the SAE with the study product(s); and the safety report will be sent to the FDA based on the blinded attribution assessment.
If the PSRT believes unblinding of the site PI to treatment assignment will assist with the clinical management of the SAE, the PSRT will consult the independent HVTN SMB for a recommendation. In the event the HVTN SMB determines that unblinding is indicated, the SMB will inform the site physician of the participant's treatment assignment in such a manner as to maintain the study blind of the PSRT and study team. For additional impact and management of SAEs on the study, refer to Section 11.3.

Safety pause and prompt PSRT AE review
When a trial is placed on safety pause, all enrollment and administration with the product related to the event that triggered the pause will be held until further notice. The AEs that will lead to a safety pause or prompt HVTN 104 PSRT AE review are summarized in  Once a trial is paused, the HVTN 104 PSRT reviews safety data and decides whether the pause can be lifted or permanent discontinuation of study product administration is appropriate, consulting the SMB if necessary. HVTN Core notifies the participating HVTN CRSs, HVTN Regulatory Affairs, DAIDS PAB, DAIDS RAB, and DAIDS SPT of the decision regarding resumption or discontinuation of study product administrations. Based on the HVTN 104 PSRT assessment, DAIDS RAB notifies the FDA as needed.
If an immediate HVTN 104 PSRT notification or prompt HVTN 104 PSRT AE review is triggered, HVTN Core notifies the HVTN 104 PSRT as soon as possible during working hours (US Pacific Time)-or, if the information was received during off hours, by the morning of the next work day. If a prompt HVTN 104 PSRT AE review cannot be completed within 72 hours of notification (excluding weekends and US federal holidays), an automatic safety pause occurs.
The HVTN requires that each CRS submit to its IRB/EC protocol-related safety information (such as IND safety reports, notification of vaccine holds due to the pause rules, and notification of other unplanned safety pauses). CRSs must also follow all applicable RE reporting requirements.
In addition, all other AEs are reviewed routinely by the HVTN 104 PSRT (see Section 11.4.2).

Review of cumulative safety data
Routine safety review occurs at the start of enrollment and then throughout the study.
Reviews proceed from a standardized set of protocol-specific safety data reports. These reports are produced by the SDMC and include queries to the HVTN CRSs. Events are tracked by internal reports until resolution.

Daily review
Blinded daily safety reviews are routinely conducted by HVTN Core for events requiring expedited reporting to DAIDS, and events that meet safety pause criteria or prompt HVTN 104 PSRT AE review criteria.

Weekly review
During the study product administration phase of the trial, the HVTN 104 PSRT reviews clinical safety reports on a weekly basis and conducts calls to review the data as appropriate. After the study product administrations and the final 2-week safety visits are completed, less frequent reporting and safety reviews may be conducted at the discretion of the HVTN 104 PSRT. HVTN Core reviews reports of clinical and laboratory AEs. Events identified during the review that are considered questionable, inconsistent, or unexplained are referred to the HVTN CRS clinic coordinator for verification.

Study termination
This study may be terminated early by the determination of the HVTN 104 PSRT, HVTN SMB, FDA, NIH, Office for Human Research Protections (OHRP), or study product developer. In addition, the conduct of this study at an individual HVTN CRS may be terminated by the determination of the IRB/EC and any applicable RE.

Protocol conduct
This protocol and all actions and activities connected with it will be conducted in compliance with the principles of GCP (ICHe6), and according to DAIDS and HVTN policies and procedures as specified in the HVTN Manual of Operations, DAIDS Clinical Research Policies and Standard Procedures Documents including procedures for the following:  Protocol registration, activation, and implementation;  Informed consent, screening, and enrollment;  Study participant reimbursement;  Clinical and safety assessments;  Safety monitoring and reporting;  Data collection, documentation, transfer, and storage;  Participant confidentiality;  Study follow-up and close-out;  Unblinding of staff and participants;  Quality control;  Protocol monitoring and compliance;  Advocacy and assistance to participants regarding negative social impacts associated with the vaccine trial;  Risk reduction counseling;  Specimen collection, processing, and analysis;  Ancillary studies, and  Destruction of specimens.
Any policies or procedures that vary from DAIDS and HVTN standards or require additional instructions (eg, instructions for randomization specific to this study) will be described in the HVTN 104 Study Specific Procedures.

Social impacts
Participants in this study risk experiencing discrimination or other personal problems, resulting from study participation. The HVTN CRS is obliged to provide advocacy for and assistance to participants regarding these negative social impacts associated with the vaccine trial. If HVTN CRS staff have questions regarding ways to assist a participant dealing with a social impact, a designated NIAID or HVTN Core representative can be contacted.
Social harms are tabulated by the SDMC and are subjected to descriptive analysis. The goal is to reduce their incidence and enhance the ability of study staff to mitigate them when possible.
Summary tables of social impact events will be generated weekly, and made available for review by the protocol chairs, protocol team leader, and the designated NIAID representative.

Emergency communication with study participants
As in all clinical research, this study may generate a need to reach participants quickly to avoid imminent harm, or to report study findings that may otherwise concern their health or welfare.
When such communication is needed, the CRS will request that its IRB/EC and any applicable RE expedite review of the message. If this review cannot be completed in a timeframe consistent with the urgency of the required communication, the site should contact the participant first, and then notify the IRB/EC and any applicable RE of the matter as soon as possible.

Version history
The Protocol Team may modify the original version of the protocol. Modifications are made to HVTN protocols via clarification memos, letters of amendment, or full protocol amendments.
The version history of, and modifications to, Protocol HVTN 104 are described below. Thank you for your interest in our research study. Please read this consent form or ask someone to read it to you. If you decide to join the study, we will ask you to sign or make your mark on this form. We will offer you a copy to keep. We will ask you questions to see if we have explained everything clearly. You can also ask us questions about the study.
Research is not the same as treatment or medical care. The purpose of a research study is to answer scientific questions.

About the study
The HIV Vaccine Trials Network (HVTN) and [Insert site name] are doing a study to test an antibody against HIV. HIV is the virus that causes AIDS. Antibodies are one of the ways the human body fights infection. Antibodies are natural proteins that the body can make to prevent infectious agents such as bacteria and viruses from making you sick. Antibodies can also be manufactured like a drug and infused or injected into the body. This approach has been successfully used to prevent or treat some other diseases.
About 88 people will take part in this study at multiple sites. The researcher in charge of this study at this clinic is [Insert name of site PI]. The US National Institutes of Health (NIH) is paying for the study.

We are doing this study to answer several questions.
 Are the study products safe to give to people?
 Are people able to take the study products without becoming too uncomfortable?
 How do people's bodies respond to the study products?
 How much of the antibody remains in your body as time passes?
 How does the body's response to the study products change depending on the amount and timing of the doses?
 Does the method of giving the antibody change the body's response?

The study products cannot give you HIV.
It is impossible for the study products to give you HIV. Also, they cannot cause you to give HIV to someone else. However, we do not know if the study products will decrease, increase, or not change your chance of becoming infected with HIV if you are exposed to the virus.

These study products are experimental.
The antibody being tested is called VRC-HIVMAB060-00-AB. It is an antibody against the HIV virus. From here on, we will call it VRC01 or the antibody. We will also be testing the placebo. The placebo is made from inactive ingredients made to look like the antibody. Together we will call them the study products.
They are experimental. That means we do not know if they will be safe to use in people, or if the antibody will work to prevent HIV infection. They are used only in research studies.
The study products were developed by the NIH. They were both made using the controlled, sterile conditions used for drug manufacturing.
In laboratory and animal studies, VRC01 attached to and disabled many kinds of HIV viruses. We do not know if the antibody will act the same way when given to people. It will take many studies to learn if the products will be useful for prevention of HIV or treatment of HIV. This study alone will not answer these questions.

Risks of VRC01:
VRC01 has been given to more than 40 participants in clinical trials at the NIH Clinical Center. The study products have been tested in one study with HIV-infected participants and in one study with HIV-uninfected participants. Over 40 participants have received VRC01 in HVTN 104 also. So far the antibody is generally well tolerated; the majority of participants had no or mild side effects; a few reported moderate or severe subjective symptoms such as malaise/fatigue or muscle aches. When injected into skin there may be mild redness, swelling, and itching at the injection site that resolves within a few minutes to hours. Some participants had a temporary change in a laboratory test that required additional tests. These lab changes did not cause symptoms and went away on their own.
Two participants had some mild side effects after injections. One person had a mild itchy rash in several places a few days after the injection. The rash lasted a few hours and went away on its own. The other person had a tight feeling in their chest and some wheezing that started shortly after the injection and went away on its own. We do not know yet if these participants got VRC01 or the placebo, so we decided not to give them any more of the study products.
With antibody products, most side effects tend to occur within the first 24 hours.
In general, side effects of antibody products are mild, but may include fever, chills, shaking, nausea, vomiting, pain, headache, dizziness, trouble breathing, high or low blood pressure, itchiness, rash, hives, lip or face swelling, diarrhea, racing heartbeat or chest pain.
In a study where VRC01 was given to animals, there was a small increase in two liver lab tests. This increase lasted for a short period of time. No sign of liver damage was seen in the animals. There were no abnormal findings in the animals' organs except for irritation at the location where the antibody was given.
VRC01 may have other side effects that we do not know about yet.
Some antibody products have a small risk of causing serious drug reactions. These reactions may be life-threatening.
 One type of reaction may occur soon after an antibody product is given. It includes difficulty breathing possibly leading to low blood oxygen, low blood pressure, hives or rash, and/or swelling in the mouth and face.
 A second type of reaction may occur several days to three weeks after an antibody product is given. It includes having hives or a rash, fever, big lymph nodes, muscle pains, joint pains, chest discomfort and shortness of breath.
When antibodies are given to a person by infusion or injection they do not last in the body more than a few months. Any antibody given to you in this study will be gone from your body several months after your last dose.

Risks of placebo:
The placebo does not contain antibodies and is made of inactive ingredients. These are generally recognized as safe but there may be unknown risks associated with the placebo.
Joining the study 4. It is completely up to you whether or not to join the study.
Take your time in deciding. If it helps, talk to people you trust, such as your doctor, friends or family. If you decide not to join this study, or if you leave it after you have joined, your other care at this clinic and the benefits or rights you would normally have will not be affected.
If you join this study, you may not be allowed to join other HIV vaccine or HIV prevention studies now or in the future. You cannot be in this study while you are in another study where you receive a study product. Also during the study, you should not donate blood or tissue.
If you choose not to join this study, you may be able to join another study.
Site: Remove item 5 if you use a separate screening consent that covers these procedures.

5.
If you decide to join the study, we will screen you to see if you are eligible.
Screening involves a physical exam, HIV test and health history. A physical exam may include, but is not limited to:  Checking your weight, and height, temperature and blood pressure  Looking in your mouth and throat  Listening to your heart and lungs  Feeling your abdomen (stomach and liver)  Checking your veins to assess how easy it might be to start an IV We will also do blood and urine tests. These tests tell us about some aspects of your health, such as how healthy your kidneys, liver, and immune system are. We will ask you about medications you are taking. We will also test you for syphilis, Hepatitis B, and Hepatitis C. We will ask you about behaviors that might put you at risk for getting HIV. If you were born female, we will test you for pregnancy. People who have had a complete hysterectomy (removal of the uterus and ovaries, verified by medical records), are not required to have a pregnancy test.
We will review the screening results with you, and offer you counseling and referral if you need medical care. We will not pay for this medical care. The screening results may show you are not eligible to join the study, even if you want to.
6. If you were born female and could become pregnant, you must agree to use birth control to join this study.

Site: List approved birth control methods here if you do not want to hand out the separate Approved Birth Control Methods sheet.
You should not become pregnant during the study because we do not know how the study products could affect the developing baby. You must agree to use effective birth control from 21 days before you first receive study products until your last required clinic visit. We will talk to you about effective birth control methods. They are listed on a handout that we will give to you. Site: Delete the preceding sentence if you include the birth control sheet in this consent form. If you join the study, we will test you for pregnancy at some visits.

Being in the study
If you meet the study requirements and want to join, here is what will happen:

Visits can last from [#] to [#] hours.
You may have to come for more visits if you have a lab or health issue.
We may contact you after the main study ends (for example, to tell you about the study results).
The high, medium, and low doses of the study products that are used in all groups will be adjusted for your body weight. We will weigh you on the day of each dose to determine the amount you will get. The night after each infusion or injection, and for three more days, you will need to write down how you are feeling and if you have any symptoms. Contact the clinic staff if you have any issues or concerns after receiving an infusion or injection. If you have a problem, we will continue to check on you until it goes away.
10. We will give you either the antibody or the placebo.
Not everyone in this study will get the antibody.
Groups 1, 2, 4, and 5: All of the people in these groups will get the antibody.
Group 3: 20 of the people in group 3 will get the antibody. The other 4 people in group 3 will get the placebo.
In Group 3, there is one placebo for the infusion given by IV, and another placebo for the SC injection. Neither you nor the clinic staff will know if you are getting the antibody or placebo. Only the pharmacist at your site will have this information while the study is going on. We will compare the results from people who got the placebo with results from people who got the antibody.
We will also compare the results from people who got the antibody in all 5 groups.
If you are in Group 3, you will have to wait until everyone completes their final study visits to find out whether you got the antibody or the placebos. This could be more than a year. But, if you have a serious medical problem and need to know what you got before the end of the study, we can tell you.

You will be assigned to a group.
Based on your screening visit and schedule, you and the study staff will discuss which group is best for you. Group 3 has more study visits, so you will need to decide if this fits your schedule. If you prefer a less frequent visit schedule, we will assign you to Group 1, 2, 4, or 5 randomly, like flipping a coin. You will be in the same group the whole time you are in the study.
12. In addition to giving you the antibody or placebo, we will:  Ask questions about your health, including medications you may be taking;  Ask questions about your experience of getting the antibody or placebo;  Ask questions about any personal problems or benefits you may have from being in the study.
When we take blood, the amount will depend on the lab tests we need to do. It will be some amount between 20 mL and 120 mL (a little more than 1 tablespoon to about ½ cup). Your body will make new blood to replace the blood we take out. We will be looking for side effects. We will review the results of these procedures and tests with you at your next visit, or sooner if necessary. If any of the results are important to your health, we will tell you. We will also offer you counseling and referral for needed care.
13. If you agree, we will also collect saliva, rectal and semen or cervical samples.
Because most people are exposed to HIV in their mouth, or on their rectum, penis, or vagina, it is important to learn if antibodies are found in these locations after getting infusions or injections. For this reason, we want to collect saliva, rectal and semen or cervical samples to look for antibodies. Depending on which group you are in, we will collect these samples at 7 or 8 visits. We will do this only if you agree and are able to provide the samples.
At the end of this consent form, we will ask if you allow us to collect these samples. You can decide not to give us these samples and still be in the study. You can decide to provide some of these samples and not others. If you agree to provide these samples, you can change your mind at any time during the study.

About saliva samples
For participants who agree to give saliva samples, we will ask you to spit into a container.
We want to collect about a teaspoon of saliva. Please avoid the following for 1 hour before your visit:  smoking,  eating,  chewing gum or tobacco,  drinking anything but water,  intimate oral activity, and  brushing your teeth or using mouthwash.

About rectal samples
For participants who agree to give rectal samples, we will collect rectal fluids by placing a small absorbent sponge in the rectum using a plastic tube about as wide as a pencil. This will take about 5 minutes. We will not collect the sample if you have an active infection, inflamed hemorrhoids, or colitis/diarrhea. We will:  perform a pregnancy test for participants born female; people who have had a total hysterectomy (removal of the uterus and ovaries, verified by medical records), are not required to undergo pregnancy testing. We do not do most study procedures on pregnant women, so we will do a pregnancy test first.
 not collect the sample if you have had receptive anal intercourse or inserted anything into your anus for 48 hours (2 days) before the visit.
 not collect the sample if you have used steroids or other anti-inflammatory creams in or around your anus for 48 hours (2 days) before the visit.

About semen samples
For participants who were born male and who agree to give semen samples, you may provide the samples at home or at the clinic. We will ask you:  not to ejaculate for 48 hours (2 days) before the visit. This will help make sure the samples you provide give accurate lab readings.
 to ejaculate into a plastic cup that we will give to you.
 to bring the semen sample to the clinic within 2 hours after collection, if the sample is collected outside of the clinic.

About cervical samples
For participants who were born female and who agree, we will collect cervical fluid. To collect cervical fluid, we will insert a speculum (a device that opens the vagina) into your vagina. Then we will place a small sponge in the opening of the cervix for about a minute to absorb the fluid. We will not collect the sample if you have any active genital infections or sores. We will:  perform a pregnancy test for participants born female; persons who have had a total hysterectomy (removal of the uterus and ovaries, verified by medical records), are not required to undergo pregnancy testing. We do not do most study procedures on pregnant women, so we will do a pregnancy test first.
 not collect the sample if you are menstruating.
 not collect the sample if you have had vaginal intercourse or inserted anything into your vagina for 48 hours (2 days) before the visit.
 not collect the sample if you have used any spermicide, lubricants or topical/intravaginal medications (such as topical yeast infection treatments), including douching, within 48 hours (2 days) before the visit.
 require a Pap smear if you have not had one within 3 years before enrollment (depending on your age), with the latest result reported as normal. We can give you a Pap smear if you have not had one within that timeframe.
14. We will counsel you on avoiding HIV infection.
We will ask you personal questions about your HIV risk factors such as sexual behavior and drug use. We will talk with you about ways to keep your risk of getting HIV low. Some topics we may discuss include:  What you think may cause risky behavior for you.
 Methods to avoid getting HIV.
These may include not having sex, using condoms, or behavior changes, such as cutting down on alcohol. We will talk with you about new methods of HIV prevention and can give you information on how to access them.

We will test your samples for this study.
We will send your samples (without your name) to a lab to see how your body responds to the antibody or placebo. The researchers may:  Take cells from your samples and grow more of them. We may grow more of your cells over time, so that they can continue to contribute to this study.
 Do limited genetic testing. Your genes are passed to you from your birth parents. They affect how you look and how your body works. The difference in people's genes can help explain why some people get a disease while others do not. Limited genetic testing involves only some of your genes, not all of your genes (your genome). The researchers will not look at all of your genes, only the genes related to the immune system and diseases.
These tests are for research purposes only. The lab will not give the results to you or this clinic, and the results will not become part of your study record. What information is shared with other researchers? The samples and limited information will be labeled with a code number. Your name will not be part of the information. However, some information that we share may be personal, such as your race, ethnicity, gender, health information from the study, and HIV status. We may share information about the study products you received and how your body responded to the study products.

What kind of studies might be done with my extra samples and information?
The studies will be related to HIV, vaccines, the immune system and other diseases. The researchers may:  Take cells from your samples and grow more of them. This means the researchers may keep your cells growing over time.
 Do limited genetic testing, which involves only looking at some of your genes, not all of your genes.
If you agree, your samples could also be used for genome wide studies. In these studies, researchers will look at all of your genes (your genome). The researchers compare the genomes of many people, looking for common patterns of genes that could help them understand diseases. The researchers may put the information from the genome-wide studies into a protected database so that other researchers can access it. Usually, no one would be able to look at your genome and link it to you as a person. However, if another database exists that also has information on your genome and your name, someone might be able to compare the databases and identify you. If others found out, it could lead to discrimination or other problems. The risk of this is very small.

Who will have access to my information in studies using my extra samples?
People who may see your information are:  Researchers who use your stored samples and limited information for other research  Government agencies that fund or monitor the research using your samples or information  The researcher's Institutional Review Board or Ethics Committee  The people who work with the researcher All of these people will do their best to protect your information. The results of any new studies that use your extra samples or information may be published. No publication will use your name or identify you personally.

We will do our best to protect your private information.
Sites: Check HIPAA authorization for conflicts with this section.
Your study records and samples will be kept in a secure location. We will label all of your samples and most of your records with a code number, not your name or other personal information. However, it is possible to identify you, if necessary. We will not share your name with the lab that does the tests on your samples, or with anyone else who does not need to know your name.
Clinic staff will have access to your study records. Your records may also be reviewed by groups who watch over this study to see that we are protecting your rights, keeping you safe, and following the study plan. These groups include: We have a Certificate of Confidentiality from the US government, to help protect your privacy. With the certificate, we do not have to release information about you to someone who is not connected to the study, such as the courts or police. Sometimes we can't use the certificate. Since the US government funds this research, we cannot withhold information from it. Also, you can still release information about yourself and your study participation to others.
The results of this study may be published. No publication will use your name or identify you personally.
We may share information from the study with other researchers. We will not share your name or information that can identify you.
When the study is done, we may share the information from the study with others so they can see it and use it. We will not share any information that will let someone identify you.

We may stop your infusions or injections or take you out of the study at any time. We may do this even if you want to stay in the study and even if you were scheduled for additional infusions or injections.
This may happen if:  you do not follow instructions,  the researcher thinks that staying in the study might harm you,  you get HIV,  you enroll in a different research study where you receive another study product, or  the study is stopped for any reason.
If we stop your infusions or injections, we may ask you to stay in the study to complete other study procedures.
19. If you become pregnant during the study, we will continue with some procedures but not infusions or injections.
We will do this for as long as it is safe for you and your developing baby.
If you leave the study while you are still pregnant, we will contact you after your due date to ask some questions about your pregnancy and delivery.
20. If you get infected with HIV during the study, we will help you get care and support.
You will not be able to stay in this study. We will counsel you about your HIV infection and about telling your partner(s). We will tell you where you can get support and medical care, and about other studies you may want to join. Site: Modify the following sentence as appropriate. We will not provide or pay for any of your HIV care directly.

There are other risks to being in this study.
This section describes the other risks and restrictions we know about. There may also be unknown risks, even serious ones. We will tell you if we learn anything new that may affect your willingness to stay in the study.

Risks of routine medical procedures:
In this study, we will do some routine medical procedures like taking blood. These procedures can cause bleeding, bruising, pain, fainting, soreness, redness, swelling, itching, muscle damage, and (rarely) infection where the needle was inserted or blood clot. Taking blood can cause a low blood cell count (anemia), making you feel tired.

Risks of IV infusion and SC injection procedures:
Receiving an infusion or injection through a needle may cause stinging, discomfort, pain, soreness, redness, bruising, itching, rash and swelling at the location where the needle goes into the skin. Rarely, needlesticks can result in infections.

Risks of sampling saliva, rectal and genital fluids
We will ask you to stop some behaviors related to your mouth, rectum, and genitals for a short time before we collect samples from these areas. You may find this inconvenient. These sample collections may also cause some anxiety, temporary discomfort, and embarrassment. For women, the collection of cervical fluid may cause discomfort similar to what happens during a Pap smear. We will try to make you as comfortable as possible.
Personal problems/discrimination/testing HIV antibody positive: About 10 to 20% of people who join HVTN studies report personal problems or discrimination because of joining an HIV vaccine study. Although this is not a vaccine study, it may raise similar concerns. Family or friends may worry, get upset or angry, or assume that you are infected with HIV or at high risk and treat you unfairly as a result. Rarely, a person has lost a job because the study took too much time away from work, or because their employer thought they had HIV.

Risks of disclosure of your personal information:
We will take several steps to protect your personal information. Although the risk is very low, it is possible that your personal information could be given to someone who should not have it. If that happened, you could face discrimination, stress, and embarrassment. We can tell you more about how we will protect your personal information if you would like it.

Risks of genetic testing:
The genetic testing could show you may be at risk for certain diseases. If others found out, it could lead to discrimination or other problems. However, it is almost impossible for you or others to know your test results from the genetic testing. The results are not part of your study records and are not given to you.
In the very unlikely event that your genetic information becomes linked to your name, a federal law called the Genetic Information Nondiscrimination Act (GINA) helps protect you. GINA keeps health insurance companies and employers from seeing results of genetic testing when deciding about giving you health insurance or offering you work. GINA does not help or protect you against discrimination by companies that sell life, disability or long-term care insurance.

Unknown risks:
We do not know if the study products will increase, decrease, or not change your risk of becoming infected with HIV if you are exposed to the virus. If you get infected with HIV, we do not know how the study products might affect your HIV infection or how long it takes to develop AIDS.
We do not know if getting these study products will affect how you respond to a future approved HIV vaccine. It could be that a future HIV vaccine may not work as well for you because you got these study products. Currently, no HIV vaccine has been approved for use.
We do not know how the study products will affect a pregnant participant or a developing baby.

The study may not benefit you.
We do not know whether getting the study products might benefit you in any way. However, being in the study might still help you in some ways. The counseling that you get as part of the study may help you avoid getting HIV. The lab tests and physical exams that you get while in this study might detect health problems you don't yet know about.
This study may help in the search for a way to prevent HIV. However, if the study products later become approved and sold, there are no plans to share any money with you.

Your rights and responsibilities
23. If you join the study, you have rights and responsibilities.
You have many rights that we will respect. You also have responsibilities. We list these in the Participant's Bill of Rights and Responsibilities. It was written for participants in HIV vaccine studies. We will give you a copy of it and will tell you how some of the rights and responsibilities are different because you are not getting a vaccine in this study.

Tell us if you decide to leave the study.
You are free to leave the study at any time and for any reason. Your care at this clinic and your legal rights will not be affected, but it is important for you to let us know.
We will ask you to come back to the clinic one last time for a physical exam, and we may ask to take some blood and urine samples. We will also ask about any personal problems or benefits you have experienced from being in the study. We believe these steps are important to protecting your health, but it is up to you whether to complete them.

If you get sick or injured during the study, contact us immediately.
Your health is important to us. We will help you get the medical care you need.
You could get sick or injured by the study products and/or procedures. If this happens, the HVTN has limited funds from the U.S. government to pay for your treatment.
If someone gets sick or injured in an HVTN study, the HVTN decides whether the injury is probably related to the study products and/or procedures. If the HVTN decides it was more likely due to the study products and/or procedures than any other cause, then the HVTN will use its funds to pay for treatment. The HVTN expects to cover the entire costs for the treatment of simple, temporary study related injuries. If your injuries are more severe or chronic, the HVTN funds may not be enough. If needed, the HVTN will seek more funds, but cannot guarantee them. If the HVTN cannot pay the entire cost of your treatment, you or your health insurance company would be responsible for any additional costs. Some health insurance companies will not pay for study related injuries.
[Sites: insert locale-appropriate medical insurance language in the preceding paragraph.] If the HVTN decides the injury is likely not due to the study products and/or procedures, then you or your health insurance would be responsible for treatment costs.
[Sites: insert locale-appropriate medical insurance language in the preceding sentence.]You may disagree with the decision the HVTN makes about your injuries. At your request the HVTN will ask experts who are not connected with the HVTN to review its decision. No matter what, you still have the right to use the court system to address payment for your injuries if you are not satisfied.
Some injuries are not physical. For example, someone might be harmed psychologically or emotionally by being in an HIV related study. Or they might lose wages from injuries because they could not go to work. No funds have been set aside to pay for nonphysical injuries, even if they are related to participation in the study.

If you have questions or problems at any time during your participation in this study, use the following important contacts.
If you have questions about this study, contact [name and telephone number of the investigator or other study staff].
If you have any symptoms that you think may be related to this study, contact [name and telephone number of the investigator or other study staff].
If you have questions about your rights as a research participant, or problems or concerns about how you are being treated in this study, contact [name/title/phone of person on IRB or other appropriate organization].
If you want to leave this study, contact [name and telephone number of the investigator or other study staff].
Your permissions and signature 27. In Section 13 of this form, we told you about collecting saliva, rectal, and semen or cervical samples. Please write your initials or make your mark in the boxes next to the options you choose.
I agree to provide rectal samples.
I do not agree to provide rectal samples.
I agree to provide semen or cervical samples.
I do not agree to provide semen or cervical samples.
I agree to provide saliva samples.
I do not agree to provide saliva samples. 29. If you agree to join this study, you will need to sign or make your mark below. Before you sign or make your mark on this consent form, make sure of the following:  You have read this consent form, or someone has read it to you.
 You feel that you understand what the study is about and what will happen to you if you join. You understand what the possible risks and benefits are.
 You have had your questions answered and know that you can ask more.
 You agree to join this study.
You will not be giving up any of your rights by signing this consent form.

How do other researchers get my samples and information?
When a researcher wants to use your samples and/or information, their research plan must be approved by the HVTN. Also, the researcher's institutional review board (IRB) or ethics committee (EC) will review their plan.

What information is shared with other researchers?
The samples and limited information they receive will be labeled with a code number. Your name will not be part of the information. However, some information that we share may be personal, such as your race, ethnicity, gender, health information from the study, and HIV status. We may share information about the study products you received and how your body responded to the study products.

What kind of studies might be done with my extra samples and information?
The studies will be related to HIV, vaccines, the immune system and other diseases. The researchers may also:  Take cells from your samples and grow more of them. This means the researchers may keep your cells growing over time.
 Do limited genetic testing, which involves only looking at some of your genes, not all of your genes.
If you agree, your samples could also be used for genome wide studies. In these studies, researchers will look at all of your genes (your genome). The researchers compare the genomes of many people, looking for common patterns of genes that could help them understand diseases. The researchers may put the information from the genome-wide studies into a protected database so that other researchers can access it. Usually, no one would be able to look at your genome and link it to you as a person. However, if another database exists that also has information on your genome and your name, someone might be able to compare the databases and identify you. If others found out, it could lead to discrimination or other problems. The risk of this is very small.

What are the risks of genetic testing?
The genetic testing could show you may be at risk for certain diseases. If others found out, it could lead to discrimination or other problems. However, it is almost impossible for you or others to know your test results from the genetic testing. The results are not part of your study records and are not given to you.
In the very unlikely event that your genetic information becomes linked to your name, a federal law called the Genetic Information Nondiscrimination Act (GINA) helps protect you. GINA keeps health insurance companies and employers from seeing results of genetic testing when deciding about giving you health insurance or offering you work. GINA does not help or protect you against discrimination by companies that sell life, disability or long-term care insurance.

Who will have access to my information in studies using my extra samples?
Some people will be able to see the research records from any new study that uses your extra samples and information. Remember that your name will not be part of the information.
People who may see your information are:  Researchers who use your stored samples and limited information for other research  Government agencies that fund or monitor the research using your samples or information  The researcher's Institutional Review Board or Ethics Committee  The people who work with the researcher All reviewers will take steps to keep your records private. The results of any new studies that use your extra samples or information may be published. No publication will use your name or identify you personally.

If you have questions or problems about allowing your samples and information to be used in other studies, use the following important contacts.
If you have questions about the use of your samples or information or if you want to change your mind about their use, contact [name and telephone number of the investigator or other study staff].
If you think you may have been harmed because of studies using your samples or information, contact [name and telephone number of the investigator or other study staff].
If you have questions about your rights as a research participant, contact [name/title/phone of person on IRB or other appropriate organization].

Please write your initials or make your mark in the box next to the option you choose.
I allow my extra samples combined with limited information for other studies related to HIV, vaccines, the immune system, and other diseases. This may include limited genetic testing and keeping my cells growing over time.