A Randomized, Placebo Controlled, Double Masked Phase IB Study Evaluating the Safety and Antiviral Activity of Aprepitant, a Neurokinin-1 Receptor Antagonist in HIV-1 Infected Adults

Background Neurokinin-1 receptor (NK1R) antagonists have anti-HIV activity in monocyte-derived macrophages, decrease CCR5 expression and improve natural killer cell function ex vivo. Aprepitant is a NK1R antagonist approved by FDA as an antiemetic. Methods We conducted a phase IB randomized, placebo controlled, double masked study to evaluate the safety, antiviral activity, pharmacokinetics and immune-modulatory effects of aprepitant in HIV-infected adults not receiving antiretroviral therapy, with CD4+ cell count ≥350 cells/mm3 and plasma viral load ≥2,000 copies/ml. Subjects were stratified by viral load (< vs. ≥20,000 copies/ml) and randomized within each stratum to receive aprepitant at 125 mg QD(Low), or 250 mg QD(High), or placebo(PL) for 14 days, and followed for 42 days. Results Thirty subjects were randomized and 27 completed treatment (9, 8, 10 subjects in 125 (Low), 250 (High), and PL groups). 63% were male; 37% white; mean (SD) age 43 (9.3) years. Geometric mean baseline viral load (copies/ml) for Low, High, and PL was 15,709, 33,013, and 19,450, respectively. Mean (95%CI) change in log10 viral load at day 14 for Low, High, and PL was −0.02(−0.24,+0.20), −0.05(−0.21,+0.10), and +0.04(−0.08,+0.16), respectively. The number of subjects with AEs was 4(44.4%), 5(62.5%), and 1(10%) for Low, High, and PL. No Grade 4 AEs occurred. Conclusions Adverse events of aprepitant were more common in the treated groups. At the dose used in this two-week phase IB study, aprepitant showed biological activity, but no significant antiviral activity. Trial Registration ClinicalTrials.gov NCT00428519


Hypothesis
Aprepitant is safe, tolerable and has antiviral activity in HIV infected individuals.

1.2
Primary Objectives 1.2.1 To assess the safety and tolerability of aprepitant for 2 weeks at two different doses. 1.2.2 To assess the response of plasma HIV-1 RNA to two different doses of aprepitant compared with baseline.

Current paradigm of HIV infection treatment
The current paradigm of HIV therapy is the continuous use of multiple antiretroviral drugs that target the reverse transcriptase or the protease of HIV in order to suppress plasma HIV RNA levels below the level of detection. New drugs are being developed that target the entry This strategy has been associated with a substantial decreases in the mortality associated with HIV infection, especially when used in patients with low CD4+ T cell counts 1 . This approach, however, requires a high level of adherence and is associated with a high virologic failure rate and an increasing array of long-term complications 2 . The increased awareness about these problems, together with the observational data failing to show clinical benefit when treatment is started early, treating HIV infection in patients with high CD4+ T cell counts [3][4][5] , has had a significant impact in our approach to HIV therapy. Current antiretroviral guidelines have become more conservative, and now recommend delaying antiretroviral therapy until CD4+ T cell count levels are below 350 CD4 + T cells/mm 3 6 . The WHO guidelines 7 for the developing world are even more conservative recommending the initiation of antiretroviral therapy for symptomatic patients or at 200 CD4 cells/mm3. This creates a unique opportunity, as many patients with high CD4 cells counts wait off antiretrovirals before initiating HAART. This antiretroviral naïve population is the population that we will use in this proof of concept study.

Limitation of current antiretroviral regimens and the need for new antiretroviral drugs
In spite of the success of antiretroviral therapy in maintaining control of HIV viral replication, treatment failure occurs in many patients. A recent study suggested that more than 50% of the individuals on treatment harbor HIV virus with evidence of resistance to one or more drugs 8 .
Numerous factors contribute to treatment failure, including suboptimal adherence, side effects, suboptimal pharmacokinetics, complicated dosing regimens, drug-drug interactions, and preexisting antiretroviral drug resistance. Virologic failure leads to antiretroviral drug resistance, and cross-resistance among the currently available treatments 9 .
With the number of patients experiencing failure on ART, there is a desperate need for antiretroviral agents with new mechanisms of action and activity against drug-resistant virus. Alternative paradigms for the treatment of HIV infection also need to be explored. The use of immunomodulators acting at the cellular level, rather than at the HIV virus level might be useful in delaying the need to initiate antiretroviral therapy or prolong the time off antiretrovirals in intermittent antiretroviral CD4 driven treatment strategies. The use of neurokinin-1 receptors (substance P preferring) antagonists in the management of HIV infection can serve both purposes, as these compounds may have both antiviral and immunomodulatory effects. This is the group of compounds that we will focus our efforts in this project.

Substance P
Substance P is a member of the tachykinin family 10 , an undecapeptide neuropeptide secreted by neurons both in the central and the peripheral nervous system, especially in neurons that innervate the brainstem nucleus tractus solitarius and the area postrema, two areas intimately involved in the induction of vomiting. There are three known members of this group: substance P, neurokinin (NK) A, and NK B. The effects of substance P are mediated through the neurokinin-1 (NK1) receptor, a member of the G protein-coupled receptor superfamily.
Substance P also plays a central modulator role in neuroimmunoregulation, in particular, the immune functions of mononuclear phagocytes, but other immune cells including lymphocytes, neutrophils and mast cells are also able to produce this molecule and had specific receptors for it in their surfaces and a variety of effects have been elicited in vitro 11 . There are complex bidirectional interactions between the immune system and the central nervous system (recently reviewed by Steinman 12 ). These two elaborate systems both sense danger and mount a counterattack to potential threats for individual. Substance P is one of the many molecules involved in this complex process. Substance P significantly influences the host response to a variety of viral pathogens. Infection with RSV and parinfluenza virus induce the production of substance P and contribute to the pathologic effects of those organisms 13 . Mice treated with substance P antibodies with anti F glycoprotein before and during RSV infections had a shorter course of disease and prompt reduction of pulmonary inflammatory cell infiltration and decreased the number of cells expressing proinflammatory cytokines 14 .
In humans substance P has been implicated in depression 15 and anxiety. Outside the CNS the gut is very rich in substance P expressing neurons where it has been suggested that they play a dual role, transmitting nocioceptive information to the brain and regulating the inflammatory and immune response to that information 16 . Substance P has also been implicated in various chronic inflammation conditions like asthma 17 , pancreatitis 18 rheumatoid arthritis, inflammatory bowel disease and ulcerative colitis 19,20 .
Supporting the notion that substance P plays an important role in human physiology are the results of studies using substance P antagonists. Several substance P antagonists, peptidic and non peptidic, have been developed 21 , and one of them, apprepitant has been FDA approved as an antiemetic (see below). Substance P antagonists have been studied as antidepressants 15,[22][23][24][25][26][27] , and for multiple other indications 21 . Recent preclinical data, as well as relevant clinical findings, support the potential therapeutic value of NK1 receptor antagonist also as analgesic anti-inflammatories in diseases like asthma, irritable bowel syndrome and cystitis, and even as tumor suppressants and haematopoietic agents 28 . These large clinical data sets showed an excellent safety profile, supporting the use of these compounds in HIV infected individuals.

Depression, immunity and HIV infection
The prevalence of depression and other psychiatric disorders is very high among HIV infected individuals 29 . Depression and stress have been associated in multiple studies with HIV disease progression, CD4 decline [30][31][32] and mortality 33,34 . However other studies including the Multicenter AIDS Cohort Study did not observe this association, perhaps attributable to more limited psychiatric assessments 35 . Depression has also been associated with decreased adherence to HAART, the main predictor of treatment success 36,37 .
Stress and depression have has been associated with decreased natural killer (NK) cell function in HIV infected men 38,39 and women 40 . Individuals with depression have significant reductions in natural killer cell activity, increases in activated CD8 and increases in HIV RNA viral load, markers that have been associated with an increased likelihood of disease progression 41,42 . These immunologic effects of depression may be the important biological links that are related to the associations between altered NK function and HIV progression.
NK-1R antagonists have a significant impact in depressive symptoms and are being explored as a new class of drugs for the treatment of depression 15,[22][23][24][25][26][27] . As depressive symptoms are clearly associated with NK cell dysfunction we want to explore the impact of NK-1R antagonists in NK cell function in HIV infected individuals. This clinical study, the first that will administer NK-1R antagonists to HIV infected individuals, men and women, provides a unique opportunity to investigate these pathways of HIV immunopathogenesis.

NK cell function and HIV infection
NK cells are lymphocytes of the innate immune system that possess the capacity to recognize virally infected host cells using germline encoded activating receptors [43][44][45] . As a result they are generally an important part of the early immune response generated during a variety viral infections 46 . In the case of HIV, however, there is a notable decrease in NK cell function early after infection that persists and becomes more pronounced upon progression to AIDS 47 . Numerous experimental and clinical studies have documented this finding [48][49][50][51][52][53] . The HIV infection-associated negative effects upon NK cells are pervasive and involve both the quantity and functions of NK cells. These impairments of NK cells have been proposed to result in susceptibility to opportunistic infection and tumorigenesis as well as decreased control of HIV replication 47,54 . In general HAART has been found to reverse the NK deficiencies found in patients [55][56][57] , but defects persist as long as viral replication can be measured 55 . Moreover, in some studies, in particular in adolescents, reduction in NK cell numbers have been associated with antiretroviral therapy 58 .
The mechanisms underlying NK cell impairments in HIV disease have been somewhat elusive. The effect of HIV may be in part due to the direct viral infection of NK cells, but this probably represents only a minor impairment, as most NK cells do not express CD4 or CCR5 59 . Other experimentally rigorous mechanisms have been proposed and include selective maintenance of inhibitory class-I MHC molecules in infected cells as well as blockade of NK cell activating receptor functions by HIV gene products [60][61][62][63] . In particular, HIV nef has the ability to selectively inhibit the expression of HLA-A and HLA-B alleles while preserving the expression of HLA-C  and HLA-E alleles, which are ligands for NK cell inhibitory receptors 62 . Thus, HIV infection  can suppress NK cell activation systems while preserving and exploiting the function NK cell  inhibitory systems. More recent studies reflecting an improved understanding of NK cell activation have shed additional light upon the decline of NK cell function found in AIDS patients. They have shown active HIV disease (defined by virema) is associated with a selective downmodulation of certain NK cell activating receptors; the natural cytotoxicity receptors (NCR) NKp30, NKp44 and NKp46 64,65 . In contrast, the expression and function of NK cell inhibitory receptors are preserved 65 . Since NK cells are not a major target for HIV infection, the mechanism underlying the suppression of NCR expression is probably indirect and has been proposed to be due to soluble factors.

Substance P and HIV infection
Human immune cells express SP and its receptor 66 . We have shown that HIV infection upregulates SP expression in mononuclear phagocytes and T lymphocytes isolated from human peripheral and placental cord blood 67 . Binding of HIV gp120 to CD4 receptors on macrophages is sufficient for up-regulation of SP mRNA expression suggesting that gp120 shed from HIV-infected macrophages may play an important role in HIV-induced SP expression in these cells. The presence of substance P seems to augment the ability of the HIV virus to replicate, both in vitro 68,69 and in vivo 58 . Several studies have demonstrated that SP and its receptor, NK-1R, may be important and have modulatory effects in HIV infected individuals. Azzari et al. demonstrated in a small study that HIV positive children have higher levels of substance P than HIV-negative children, and that the levels of substance P correlate with immunoglobulin levels 70 . Our group has demonstrated elevated plasma levels of SP in HIV-positive men in comparison with high-risk HIV-negative men 58 (see Figure 1), and more recently in HIV infected women (unpublished results, S.D. Douglas) SP enhanced HIV replication in human blood-isolated mononuclear phagocytes, whereas the nonpeptide SP antagonist (CP-96,345) potently inhibited HIV infectivity of these cells in a concentration-dependent fashion 69 (See below). The mechanism/s that mediates the antiviral activity of SP antagonists are only partially understood. They may involve chemokine receptor expression 69 . Substance P antagonist decrease the expression of CCR5 in macrophage cells, a mechanism that may explain, at least in part the anti HIV activity of these compounds 69 .
Other groups have recently shown that the addition of substance P increases the expression of CCR5 in an in vitro system of Dendritic/langerhans cells 71 .
The importance co-receptor usage and disease progression.
The life cycle of HIV starts with the viral entry into target cells. The first step is binding of the viral surface glycoprotein gp120 to receptors on the surface of target cells. CD4 is the primary cellular receptor for HIV. However, CD4 alone is not sufficient to mediate viral infection; other factors present in human cells are necessary for entry and requires the presence of corecetptors. CCR5 is the major co-receptor that allows cellular entry together with CD4 in macrophage tropic variants of HIV-1 72 . A homozygous deletion of the coding sequence of the CCR5 gene from position 794 to 825 (CCR5Δ32) results in a non functional chemokine receptor that has been linked to resistance to HIV-1 infections in adults 73 . Heterozygosity for this deletion does not protect against HIV infection, but increases the survival of HIV infected individuals by delaying the progression to clinical ADS, although other studies have not confirmed this observation 74,75 . CCR5Δ32 heterozygous individuals have decreased density and expression of CCR5 in T cells 76,77 . The decreased expression of CCR5 in the surface of T cells probably plays a central role in the slower progression of disease among these individuals. CCR5 32 is common among Caucasians ( 10% allele frequency in North America) but is absent or present at a very low frequency in native African and Asian populations 78 .
Depending on their co-receptor usage HIV-1 strains are classified as R5 (or macrophage tropic) if they use the CCR5 co-receptor or X4 if they use the CXCR4 co-receptor. It is well recognized that R5 viruses are preferentially transmitted (>90%) and predominate from initial infection throughout the course of disease 79,80 . As clinical disease progresses a significant percentage of individuals change the tropism of their HIV-1 quasispecies from R5 to X4. This change in tropism is associated with a change in the phenotype of the virus from non-syncytia inducing to syncytia inducing and probably with acceleration of clinical progression 79,80 . Our in vitro data 69 suggest that SP antagonists will decrease the expression of CCR5 in the surface of macrophages to levels at least similar to those observed in patients heterozygous for the CCR5 32 mutation. Together with a direct potential antiviral effect this could alter disease progression. As the SP antagonist CP-96,345 seems to work at the cellular level (decreasing the expression of CCR5 mRNA and protein), rather than blocking the attachment process, it is tempting to speculate that it will be difficult to the virus to develop resistance to these compounds. Individuals heterozygous for the CCR5 32 mutation do not have a significant higher frequency of X4 viruses in their system. These classes of drugs could be used as immunomodulators altering the natural history of HIV infection.
CCR5 is a promising antiviral target for HIV therapy. One of the concerns raised during the development of compounds that target this molecule is the potentially increased risk of driving the virus co receptor usage to a potentially a more pathogenic X4 strain. However, in addition to presumed natural mechanisms for prolonged selective suppression of X4 viral replication 81 , CCR5 antagonists used in combination with ART should also minimize the probability of phenotypic change to X4 viruses by restricting HIV replication and reducing the accumulation of the necessary mutations.
Given this concern for chemokine receptor enhancement or change we have decided in this proof of concept study to select for individuals with relative early infection, with CD4 cell counts greater than 350 CD4 cells-mm 3 , that according to the current guidelines of antiretroviral therapy would not receive treatment, and would be followed closely clinically 6 . This population of individuals represents approximately 10% of the subjects in care based in a query of our CFAR clinical database of more than 2000 individuals. Epidemiologic studies have shown that the frequency of R5 viruses at CD4 levels greater than 350 cells/mm 3 is greater than 90%. The tropism of the participants' virus will be evaluated at baseline and after 2 weeks of treatment with the SP antagonist aprepitant.. The envelope will also be sequenced to assess viral tropism and any change induced by the treatment with aprepitant.
Another potential concern of using SP antagonists and producing a significant decrease in the expression of CCR5 would be the potential immunologic effect of this. -chemokines (MIP-1, MIP-1, and RANTES), are he natural ligands of these receptors, and probably serve as soluble mediators of immune responses to pathogens. Blocking CCR5 could theoretically block host responses to infection. However individuals harboring the 32-base pair deletion mutation of CCR5, which renders this receptor nonfunctional, are immunologically normal and do not have an increased risk of infection or related co morbidities; but on the other hand, the immunologic effects of decreasing the expression of CCR5 in persons who have had this receptor available previously may differ from those who lack this receptor from birth. In a four week study this phenomenon probably will not be clinically significant, but in the future, if this class of drugs is developed it will be important to monitor the occurrence of HIV-related and non-HIV-related infections in individuals treated with these compounds. In the phase II clinical trial conducted in immunosupressed oncology patients receiving chemotherapy that was used to select the final dosage of aprepitant as antiemetic there was an increase 82 in the incidence of infection in the aprepitant 125/80-mg group (13%) compared with the standard therapy group (4%). This increased risk of infection were assumed to be due to elevated dexamethasone levels as a result of the pharmacokinetic interaction 83 and have not been confirmed in the larger Phase III trials that have been conducted 84,85 . During the phase 3 studies using aprepitant as an antidepressant for prolonged periods of time, no significant immunologic side effects were observed.

The antiviral effects of substance P antagonists on HIV replication
In Preliminary in vitro data suggest that aprepitant, the only approved substance P antagonist behaves similarly to SP-96,345 in the same in vitro system.

The effects of SP and NK-1 receptor antagonists on NK cell function
Since it has been proposed that immunosuppressive soluble factors induced during HIV disease may be responsible for depression of NK cell function we sought to determine whether SP has a role in this activity. SP is produced at increased levels during HIV infection. Patients with the highest SP levels have the most severely affected NK cell populations 50 . Further, when depression is resolved in HIV infected individuals NK cell function improves. Specifically, improvement in depressive diagnostic status and HAMD-17 score are positively associated with increases in NK cell function (p=0.0059 and p=0.042). Although these associations between HIV, depression, SP and NK cells are intriguing, they have not been investigated directly at a mechanistic level. One study has evaluated the effects of SP on NK cells, but the concentrations of SP evaluated were supraphysiologic by several logs and therefore cannot be related to our ex vivo observations 86 .
Receptors for SP are G protein-coupled receptors of which there are two broad families known to be expressed in NK cells. These include chemokine recptors and lysophospholipid receptors. Ligands for both families of receptors are capable of inducing the motility and recruitment of, and production of cytokines by NK cells 87 88, 89 . Chemokines are also capable of enhancing NK cell cytotolytic activity. In contrast, lysophospholipids inhibit NK cell cytotoxicity 90 . Thus, although all G protein-coupled receptors have certain stimulatory activities in NK cells, there is a dichotomy as some also possess inhibitory properties. If NK-1R receptors are present in NK cells, it is possible that they may impart selective inhibitory properties under physiologic conditions. If NK-1R (SP preferring) receptors were expressed in NK cells and imparted inhibitory functions, it is likely that SP produced during HIV infection impairs NK cell function. In this case, the use of an NK-1R antagonist may serve an important immunomodulatory function for NK cells and result in increased cytotoxic functions that might improve the ability of infected individuals to fight infections and control their viral burden.

Aprepitant pharmacology
Aprepitant was approved by the Federal Drug Administration as an antiemetic in 2003. Aprepitant is a substance P preferring neurokinin 1 (NK1) receptor antagonist, the only currently approved drug of its class. Aprepitant is currently offered in two capsule formulations either 80 mg or 125 mg. This drug has been approved by the Federal Drug Administration as an antiemetic for emesis induced by chemotherapeutic agents like cisplatin 82,84,85 . The main mechanism of action is via the central nervous system 91 . Aprepitant is a selective high-affinity antagonist of human substance P neurokinin 1 (NK1) receptors 92 . Aprepitant has little or no affinity for serotonin (5-HT3), dopamine, and corticosteroid receptors. Aprepitant augments the antiemetic activity of the 5-HT3-receptor antagonist ondansetron and the corticosteroid dexamethasone and inhibits both the acute and delayed phases of cisplatin induced emesis 91 .

Absorption and PK parameters
Aprepitant is orally bioavailable (60 to 65%). Peak concentrations are reached after 5 hours of administration. The absorption is independent of the co-administration of food. The pharmacokinetics of aprepitant are non-linear across the clinical dose range. In healthy young adults, the increase in AUC0-¥, was 26% greater than dose proportional between 80-mg and 125-mg single doses administered in the fed state. Following oral administration of a single 125-mg dose of aprepitant on day 1 and 80 mg once daily on days 2 and 3, the AUC0-24hr was approximately 19.6 mcg.hr/mL and 21.2 mcg.hr/mL on Day 1 and Day 3, respectively. Distribution Aprepitant is greater than 95% bound to plasma proteins. The mean apparent volume of distribution at steady state (Vd,,) is approximately 70 L in humans. Aprepitant crosses the placenta in rats and rabbits and crosses the blood brain barrier in humans.

Metabolism
Aprepitant is metabolized primarily by CYP3A4 with minor metabolism by CYPlA2 and CYP2C19. Metabolism is largely via oxidation at the morpholine ring and its side chains. Seven metabolites of aprepitant, which are only weakly active, have been identified in human plasma [93][94][95][96] . This metabolic pathway suggest that aprepitant will interact favorably with ritonavir, as do many of the current available antiretrovirals.

Excretion
Following administration of a single IV 100-mg dose of [14C]-aprepitant prodrug to healthy subjects, 57% of the radioactivity was recovered in urine and 45% in feces. A study has not been conducted with radiolabeled capsule formulation. The results after oral administration may differ. Aprepitant is eliminated primarily by metabolism; aprepitant is not renally excreted.

Pharmacokinetics in special populations
The table below summarizes the known effects of aprepitant in different populations.

Rationale
Our preliminary studies indicate that NK-1R substance P antagonists have a significant antiviral activity in vitro. This proof of concept proposal is centered on addressing the safety and antiviral activity of using aprepitant, a NK-1R substance P antagonist as an antiviral agent for the treatment of HIV infection.
The Novel HIV Therapies: Integrated Preclinical/Clinical Program (IPCP) supports (1) the discovery and preclinical development of new anti-HIV drugs and therapeutic concepts; and (2) the translation of innovative preclinical findings to the clinic via small clinical studies. This grant program funds consortia of investigators from academia and the private sector, working collaboratively on the development of a defined therapeutic concept identified and proposed by the collaborative group. This mechanism is particularly appropriate for highly experimental therapeutic strategies that are new or otherwise not yet ready for large clinical trials. The PO1-MH76388-01-project "Neurokinin1-R antagonists for HIV therapy" is a NIMH sponsored IPCP project that will evaluate the role of Neurokinin-1 receptor antagonist as potential antiretroviral agents.
Understanding the pharmacokinetics and pharmacodynamics of aprepitant in HIV infected individuals and its relationship with its potential antiviral effect is a critical part of this project.
Our preliminary studies in vitro suggest that the antiviral activity of SP antagonists might involve chemokine receptor expression 69 . Substance P antagonist decrease the expression of CCR5 in macrophage cells, a mechanism that might explain, at least in part the anti HIV activity of these compounds 69 . Our preliminary also suggest that SP may have direct effects upon NK cells as determined using a clonal NK cell line (see preliminary results section). Since we have found that SP antagonism can prevent some of this activity, it is alluring to speculate that SP antagonism may serve to reverse the impairment of NK cell function found in HIV infection. This study will provide a unique opportunity to evaluate the in vivo effects of aprepitant on CCR5 expression and message in human monocytes and lymphocytes and to study NK cell function after the administration of this drug. We will also conduct in the laboratory of Dr. Jordan Orange in vitro experiments to better understand the effects of SP and its antagonism in NK cells as well as the mechanism of these activities.
HIV infection has a significant impact of depression and anxiety disorder symptoms. In women with HIV infection the proportion of major depression is four times higher than in HIV-negative women (19.4 vs 4.8%) 97 . This study provides a unique opportunity to explore the effects of NK-1 receptors antagonists on depression, anxiety and sleep in HIV infected subjects.

STUDY DESIGN
This is randomized, placebo controlled, double blind study to determine the antiviral activity of aprepitant by comparing the change in HIV RNA viral load after 2 weeks of aprepitant monotherapy.
27 patients with HIV-1 infection, not receiving antiretroviral therapy and with CD4+ cell count ≥ 350/mm 3 and plasma HIV-1 RNA of ≥2000 copies/mL will be stratified by viral load to 2 strata: <20,000 copies/mL vs > 20,000 copies/mL and randomized within stratum 1:1:1 to receive two different doses of aprepitant (Emend®) or placebo.
Arm A: Placebo Arm B: Aprepitant 125 mg QD Arm C: Aprepitant 250 mg QD Additionally, blood samples will be collected from each study participant during the clinical phase of this study for pharmacokinetic assessment. Samples will be drawn at 0, 30 minutes, 1, 2, 4 and 8 hours after the administration of aprepitant will be collected for all subjects on days 0, and 14 of the study for pharmacokinetic analysis. Trough concentration (pre-dose) will be assessed on days 3, 7 and 10 as well. Participants will be admitted to the General Clinical Research Center of the University of Pennsylvania for the more intensive PK evaluations. If participating in sexual activity that could lead to pregnancy, the female study subject must use at least one of the forms of contraception listed below while receiving the protocol-specified medication and for 30 days after stopping the medication.  Condoms (male or female) with or without a spermicidal agent  Diaphragm or cervical cap with spermicide  IUD Female subjects, who are not of reproductive potential defined as women who have been post-menopausal for at least 24 consecutive months, or women who have undergone surgical sterilization, (e.g. hysterectomy, bilateral oophorectomy, or salpingotomy) are eligible without requiring the use of contraception. Subject reported history is acceptable for documentation of sterilization, other contraceptive methods, menopause and a child's reproductive potential.

Study Enrollment Procedures
4.3.1 Prior to implementation of this protocol, the site must have the protocol and consent form approved by their local institutional review board (IRB). IRB approval must occur before any subjects can be enrolled in this study.
Once a candidate for study entry has been identified, details will be carefully discussed with the subject. The subject (or legal guardian) will be asked to read and sign the consent form that was approved by the site's IRB.

Information on Randomization
Patients will be randomized in permuted blocks of size 3. A randomization schedule within stratum will be prepared prior to the start of the study. Sealed envelopes containing the treatment assignments will be given to the pharmacist who will retain the envelopes at all times. The pharmacist will only open the next envelope in the stratum when a patient is randomized and the pharmacist is requested to dispense study medication. Randomized treatment records will be kept with the pharmacist. All other study staff (nurse, PI, etc.) will be blinded for the duration of the trial.
If a patient is randomized, but withdraws consent prior to treatment or does not receive treatment due to any reason, the patient ID. and treatment assignment will NOT be reused. .

Coenrollment Guidelines
Patients will not be allowed to coenroll in other antiretroviral or immunomodulator studies for the duration of this study

Regimens, Administration, and Duration
Subjects will be randomized to one of three study arms: placebo, 125 mg aprepitant or 250 mg aprepitant QD for a total of 14 days.
Dose modification and treatment modification will not be allowed. No dose modification according to weight is considered for this study.

Product Formulation and Preparation
This study will provide capsules of aprepitant 125 mg and matching placebo. Aprepitant capsules will be overencapsulated with an empty, red, size,0 gelatin capsule (without lactose as filler). Matching placebo capsules will be manufactured by the site pharmacy in a designated compounding area. Lactose (supplied by Spectrum) and red, size 0 gelatin capsules distributed by Apothecary Products, will be utilized for compounding placebo capsules. The aprepitant and the placebo for aprepitant must be stored under controlled room temperature 20-25°C (68-77°F) and protected from light, humidity and excessive heat.
Once the pharmacist opens the randomization envelope and knows the randomization assignment, the pharmacist will dispense the appropriate dosage (two placebo capsules; one-125 mg aprepitant capsule + one placebo capsule; or two aprepitant 125 mg capsules). The capsules will be placed in a blister pack adherence medication card **. Only 14 days' of medication are dispensed for the duration of the study. All prescription labels will have preprinted hospital's address and the Infectious Disease CTU office phone number as well as the "Caution: New Drug. Limited By Federal Law to Investigational Use" warning. The labels will also have the following: a. patient's name b. SID and/or PID number c. Rx number and date of clinic visit d. directions for proper use e. principal investigator's name f. quantity dispensed g. medication dispensed will be labeled as "Aprepitant 125 mg/placebo" to maintain the blinded treatment **The blister pack adherence card is NOT child resistant and should be labeled as such.
Patients must be counseled about keeping the medication card out of the reach of children.

Study Product Acquisition
Aprepitant 125 mg (and matching placebo) will be purchased and supplied through the ACTU pharmacy of the University of Pennsylvania. Study agent and placebo were compounded since the commercial manufacturer of aprepitant would not provide study agent and matching placebo.

Study Product Distribution
Study products will be available through the Infectious Disease CTU pharmacy. The Infectious Disease CTU pharmacist can obtain the study products as outlined in section 5.2.

Study Product Accountability
The site pharmacist is required to maintain complete records of all study products compounded and subsequently dispensed. All unused study products must be returned to the pharmacist after the study is completed or terminated.

Randomization Accountability
When the study is completed, all unused randomization envelopes will be returned to the study statistician for quality assurance of all randomization .

Concomitant Medications
Please refer to the study medication's most recent package insert to access additional current information on prohibited and precautionary medications. Ifosfamide, Imatinib, Vinorelbine, Vinblastine, Vincristine )  Any antiretroviral agent  Any medications that are metabolized by the CYP2C9, such as warfarin and phenytoin.

Adherence Assessment
Study medication will be dispensed at the entry visit. Beginning at the day 3 visit, adherence will be determined at each study visit using a pill count of study medication. Pill counts are not required after day 14 or after a subject discontinues treatment. The number of remaining pills and the number of missed doses since the last pill count will be recorded on the CRFs. Pittsburgh Sleep Quality Index Score X X X X .

Pre-randomization Evaluations
Occur prior to the subject taking any study medications, treatments, or interventions.

24
Version 2.0 1/24/08 Screening Screening evaluations to determine eligibility must be completed within 30 days of study entry unless otherwise specified. A screening log will be maintained with a screening i.d. only, and for excluded or refusing consent study candidates, the log will contain the reasons(s) for ineligibility or whether refused consent or were unable to participate due to another reason. No identifiers will be listed in the screening log and the screening i.d. will be different from the study i.d. for the study participants.

Entry
Evaluations must occur at least 24 hours after screening evaluations unless otherwise specified. Subject must begin treatment within 48 hours of randomization.

On-Study Evaluations
Evaluations should occur after randomization/registration. Study visits must be scheduled on the weeks indicated in the schedule of events  (1) day for days 0-7 and  (3) days for days 10 -42.

Treatment Discontinuation Evaluations
Subjects who permanently discontinue study treatment prior to completion of the study will have all final evaluations performed according to the schedule of evaluations.

Documentation of HIV
HIV-1 infection, as documented by any licensed ELISA test kit and confirmed by Western blot at any time prior to study entry. HIV-1 culture, HIV-1 antigen, plasma HIV-1 RNA, or a second antibody test by a method other than ELISA is acceptable as an alternative confirmatory test.

Medical History
A medical history must be present in source documents to include history of HIVrelated and non-HIV-related diagnoses, prior anti-HIV therapies (if any), immunomodulatory therapies and vaccines, current prescription medications and lab reports concerning year of diagnosis and available viral loads or CD4 cell counts. History of opportunistic infections will be obtained. Any allergies to any medications and their formulations also must be documented.

Medication History
A medication history including start and stop dates for all medications taken within 30 days prior to entry must be present in source documents for each of the following: All concomitant medications taken since the last report will be recorded in the source documents and CRFs.
All modifications to study drug including initial doses, subject-initiated, missed doses, and permanent discontinuation of treatment will be recorded on the CRFs at each visit. Subject-initiated and protocol-mandated modifications include both inadvertent and deliberate interruptions of study drug doses.

Signs and Symptoms
At baseline, record all signs/symptoms on the CRF. For post-baseline assessments, all Grade 2 or higher signs/symptoms or any signs or symptoms that led to a change in treatment, regardless of grade, must be recorded on the CRFs.

Diagnoses
Record all diagnoses identified by the ACTG criteria for clinical events and other diseases. All confirmed and probable diagnoses made since the last visit will be recorded in the source documents and CRF, including current status at the time of study visit.
Targeted Physical Exam For Screening, a targeted physical examination will be driven by any signs or symptoms previously identified that the subject has experienced within 30 days of entry. At entry and throughout the study, a targeted physical exam will be driven by any signs or symptoms identified that the subject has experienced since screening.
Vital Signs Temperature, pulse, and blood pressure collected at all visits.
Height and Weight Include weight at entry, day 14 and day 42, and height at entry only.

Laboratory Evaluations
At entry and throughout the study, all laboratory values, regardless of grade, must be recorded on the CRFs.
Refer to the Division of AIDS

Immunologic Studies
Eligibility for study participation will be determined by a measurement obtained within 90 days prior to entry and performed at any CLIA-certified laboratory. If no CD4+/CD8+ results obtained within 90 days prior to study entry are available, then the subject must come in for a screening visit and have a sample drawn to determine eligibility. These results must be entered on the eligibility checklist.
NOTE: If the screening CD4+ count is < 350 cells/mm 3 , the potential subject will be counseled that s/he may need ARV soon.
Beginning at screening, evaluations for CD4+ and CD8+ cell counts and subset percentages should be performed at the same CLIA certified (or equivalent ) laboratory for all tests on an individual subject for comparison of the baseline calculated value and those obtained throughout the course of the study. (The baseline value is defined as the average of the screening and entry values.) Because of the diurnal variation in CD4+ and CD8+ cell counts, determinations for individual subjects should be obtained consistently in either the morning or the afternoon throughout the study, if possible.
Note: Each time a CD4+/CD8+ measurement is obtained, the local laboratory must perform a WBC and differential from a sample obtained at the same time.  98 , is an instrument designed to evaluate affective disorders of depressive type (Appendix V). It is used for quantifying the results of an interview and its value might be affected by the skill of the interviewer in eliciting the necessary information (only properly trained interviewers will be used during this study). The scale contains 17 variables measured on either a five-point or a three-point rating scale, the latter being used where quantification of the variable is either difficult or impossible. Among the variables are: depressed mood, suicide, work and loss of interest, retardation, agitation, gastro-intestinal symptoms, general somatic symptoms, hypochondriasis, loss of insight, and loss of weight. This scale has been modified to delete physical symptoms potentially related to HIV disease (HAM-D11). However in this protocol participants will have CD4 cell counts greater than 350 cells/mm 3 and no physicals symptoms associated with HIV infection, hence the HAM-D17 questionnaire will be used.

CCR5 Expression
Participants that meet criteria for major depression will be referred for treatment. Any subject judged to be suicidal will be referred for immediate treatment. Only toxicities considered to be possibly, probably, or definitely related to the study drug will be considered for toxicity management, except as noted below. Dosage reductions are not permitted.
Any subject experiencing intolerable toxicity as determined by the site study physician, a Grade ≥3 adverse event (AE), or a Grade > 2 rash considered to be possibly, probably, or definitely related to study drug as defined in the Division of AIDS All Grade >3 toxicities for which treatment discontinuation is not mandated (those not attributed to study drug by the site study investigator) will be reviewed on a case-by-case basis by the safety monitoring committee and team.

Dose interruption
Subjects who develop a study drug-related Grade 3 or 4 adverse event or laboratory abnormality (with the exception of hyperglycemia, hypertriglyceridemia, hypercholesterolemia, or Grade 3 AST/ALT elevations in hepatitis co-infected individuals) should interrupt study medications.
If the abnormalities resolve to within one grade (not to exceed Grade 2) of the baseline level within 7 days of study drug interruption, reintroduction of treatment should begin.
If the abnormalities have not resolved to within one grade (not to exceed Grade 2) of he baseline level within 7 days of study drug interruption, the subject should be discontinued from the study.

Randomization and Stratification
Subjects will be assigned with equal probability to one of the three treatment regimens using permuted blocks of size 3 within each stratum. Stratification is by viral load at screening: <20,000 copies/mL versus > 20,000 copies/mL.

Sample Size and Accrual
This is a Phase Ib study and hence not a comparative study. For assessing the primary endpoint of change in viral load, we will use confidence intervals. With 9 patients within a group, a 95% confidence interval for the mean change in log10 HIV-1 RNA from baseline to day 14, with 90% coverage will be approximately 2 standard deviations wide. For a preliminary pilot study, this will give a sense of approximately where viral load values are expected to be after 4 weeks of treatment.
For the safety endpoint, with a group of 9 subjects within a dose group, there is 95% probability that we will observe during the study at least one adverse event of a particular kind provided that the true underlying event rate within the group is <30%. Thus, within a single dose group, we will only see events that are reasonably frequent. However, if there is an event that is unique to aprepitant and may occur at the same rate in both dose groups, any event with an underlying true rate of 15% or less, will occur with 95% confidence at least once in 18 subjects.

32
Version 2.0 1/24/08 A Data Safety Monitoring Board (DSMB) will be constituted at the University of Pennsylvania and will review trial data on an annual basis, starting in October 2007. This Committee will be comprised of no less than three members who are not affiliated with the study, one of whom is a biostatistician. This committee will have a mechanism in place to immediately notify the PI regarding findings relevant to the safety of study participants, and will have criteria to recommend for stopping the study, should that become necessary. The DSMB will be provided reports that summarize demographics, enrollment and safety information. Specialized reports requested by the DSMB be prepared as required. The DSMB will produce an annual report for the IRB. This report will include: 1) Protocol title, HSC protocol number, and activation date of the study.
2) Number of patients enrolled to date on each cohort 3) Date of first and most recent patient enrollment 4) Summary of all adverse events regardless of grade 3 and attribution for to each cohort 5) Summary of any recent literature that may affect the ethics of the study.

Stopping rules
Stopping rules guidelines are based on exact 95% binomial intervals. If the lower bound of the exact 95% binomial interval exceed 20% at any point, either within a treatment cohort or across cohorts combined, the study will be suspended to further accrual pending DSMB review. So, for example if 4 of the first 5 or 6 subjects within a treatment cohort have a serious adverse event requiring discontinuation, the study will be suspended. However, if 4 of the first 7 subjects within a cohort are discontinued, the study will not be suspended, since a toxicity rate of <20% cannot be ruled out with 95% confidence. If the frequency of serious adverse events that warrants treatment discontinuation is greater than 33% (4 subjects) in any given arm, that arm will be closed. The events will include too the development of a new opportunistic infection, such as tuberculosis, a significant drop (greater than 50% of the CD4 + cell count and an increase in the HIV-RNA viral load greater than 1 log.
As the investigators will be blinded to the patient treatment assignment this will be done by the DSMB.

Primary Analysis
Although viral load will be measured twice weekly, the reason for these frequent measurements is monitoring of safety. For the purposes of assessing the primary analysis of efficacy of aprepitant in reducing viral load we will be assessing the difference between the log 10 viral load at baseline and at 4 weeks, and constructing a 95% confidence interval around this mean difference within each dose group. For the purposes of the primary analysis, if a subject discontinued prior to Day 14, the subject's last observation will be carried forward (LOCF) and will be used in lieu of the Day 14 value. The confidence interval will be compared to the confidence interval of the difference in the control/placebo group. It is expected that the confidence interval for the placebo control group will include 0, since no changes are expected in the viral load and the confidence intervals for either of the two doses will not include 0, if 33 Version 2.0 1/24/08 aprepitant has an effect in reducing viral load.
Exact binomial confidence intervals will be calculated around the event rates for any individual adverse events that occur and for the overall rate of adverse events within each body system. For each patient the highest grade occurring adverse event within each body system will be assessed. Tables for adverse events by body system and severity of adverse event will be constructed. The distribution of the most severe adverse event rank per patient will be compared between the treatment groups using an exact Kruskal-Wallis test, to explore whether aprepitant or a particular dose of aprepitant is associated with a more severe profile of adverse events. 9.6.2 Secondary Analysis 9.6.2.1. Time trends Since viral loads will be measured twice weekly initially and then weekly, a secondary analysis of these data will be a mixed-effects linear model with fixed effects of baseline viral load, time, treatment, and treatment by time interaction, with patient random effects for the intercept and the slope. With measurements done twice weekly, both a linear trend and a quadratic time effect can be evaluated even in this modest sample size. The variance structures will be either based on compound symmetry or autoregressive, but not unstructured. We will also explore whether adding other covariates, such as demographics or baseline CD4 counts has any impact on the model. Finally, we will add the 42 day measurement to the model, in a separate analysis.

Viral dynamics
Although the sample size is small, it may be sufficient to do some viral dynamics modeling.

Pharmacokinetics
Individual patient data will be summarized using a noncompartmental analysis (NCA) approach as well as a model-based approach. The NCA approach is based on statistical moment theory and is dependent on adequate data density within an individual subject. The NCA analysis will be analyzed using WinNonlin Professional version 4.0.1 and SAS version 9 for PC Windows.
Population pharmacokinetic model parameters (fixed and random) will be estimated via nonlinear mixed-effects modeling using NONMEM v. 5 (Globomax LLC, Hanover, MD). An appropriate compartmental model structure model will be developed for aprepitant based on the PK data collected in this study and previous pharmacokinetic experience with aprepitant in non-HIV patients (Aprepitant NDA). The effects of clinical and demographic factors on PK model parameters will be investigated using a backward stepwise elimination procedure in NONMEM. If model convergence is possible, the FOCE estimation method with eta-epsilon interaction will be employed. Model based 1/24/08 statistical inferences will be drawn using the Likelihood Ratio Test with a nominal pvalue of 0.005 (which corresponds to a change of 7.88 in minimum objective function value for 1 degree of freedom and has been adjusted for multiple comparisons) 101 .
Specific covariate effects to be investigated include indices of body size and composition, tissue distribution/binding, disease stage and severity, age, race, concomitant medications and gender. All covariate effects will be combined into a full model, which will serve as the starting point for the backward elimination procedure. The likelihood approximations used in nonlinear mixed-effects estimation methods often result in inaccurate ratios, and consequently, false-positive covariate effects 102 . If drug interaction parameters are found to be significant at the nominal p-value, a randomization test will be conducted to determine the actual significance for that parameter 102,103 .
Individual predicted PK parameter estimates based on the final model will be used to explore the relationship between various PK endpoints and clinical outcomes. Using a logistic regression, the probability of positive (or negative) outcomes will be predicted based on various PK metric expressions (i.e. Cmax, AUC). In this manner, we can explore the sensitivity of toxicity outcomes to amplitude or exposure as well as the occurrence of any time-dependent toxicities.
Clinical trial simulation will be employed to judge the projected performance of aprepitant in a phase IIa proof-of-concept trial. Design aspects to be examined will include the number of total subjects, the additional agents and regimens to be studied as part of HAART therapy, the number of plasma samples collected, the nominal sampling times for plasma concentrations, dose amounts and ranges, clinical response (viral load targets) and the likelihood of developing severe toxicities. The principal methodology employed for clinical trial simulation is Monte Carlo simulation 104 . Nonlinear mixed effect modeling may be used to generate parameter estimates (mean and variance) for PK and PK-PD models. The analysis of replicates of virtual trials will require the same statistical methodology and consideration as the single occurrence of an actual trial. These methods will be defined in the simulation analysis plan once the design options have been considered. An empirical determination of error rate will be made via a likelihood ratio test (implemented in NONMEM). A variety of graphical techniques including co-plots, MAE% (mean absolute error %) versus sample size plots, histograms (i.e., Likelihood ratio chi-square values for showing the percentage of trials falling within an interval) and box plots will be used to summarize the results of simulated trials.
The Laboratory for Applied PK-PD in the Pharmacology and Statistics Core processes all data on a PC platform (Pentium IV; 2.6 GHz processor) under Dr. Barrett's direction.  For the purposes of this part of the analysis the effects of aprepitant in changing immunologic parameters will be assessing the difference between the absolute and percent counts at baseline and at 14 days, and constructing a 95% confidence interval around this mean difference within each dose group. For the purposes of this analysis, if a subject discontinued prior to Day 14, the subject's last observation will be carried forward (LOCF) and will be used in lieu of the Day 14 value. The confidence interval will be compared to the confidence interval of the difference in the control/placebo group. It is expected that the confidence interval for the placebo control group will include 0, since no changes are expected in the immunolgogic parameters in the control group and the confidence intervals for either of the two doses will not include 0, if aprepitant has an effect in reducing immunologic parameters.
A similar analysis to the one proposed for HIV RNA viral load will be conducted to evaluate time trends of immunologic parameters.

Neurology
Because of the preliminary nature of these data, it will be important to use graphics to plot the individual changes from baseline to 14 days for these subjects in the HAM-D 17 Depression Rating Scale score, the HAM-A, and the PSQI. We will also plot scatterplots for visual assessment of relationships between changes in depression, anxiety, sleep, viral load and CD4 counts. The scatterplots will be by treatment group (2 aprepitant doses and placebo). We will examine these difference scores for normality, and transform, if needed and possible, to achieve normality. As noted, this is a small study and the aim is exploratory, therefore we will not perform comparisons between the treatment arms, but rather evaluate each treatment arm separately. We will use either a one-sample t-test or the Wilcoxon Signed-Rank test to examine differences before and after treatment for each of the three treatment arms separately.

36
Version 2.0 1/24/08 All null hypotheses are two-sided and all tests will be performed at a 0.05 significance level. We do not adjust the significance level for multiple testing because these analyses are exploratory. Although we do not expect loss to follow-up in 2 weeks of treatment and patients with CD4>350/ mm 3 , if we do have any loss to follow-up, we will explore the potential effect of bias due to loss to follow-up and missing data thoroughly in a sensitivity analysis.
We will also explore the relationship between these outcome parameters and viral load, CD4 and NK function. In all cases, we will plot the baseline values with scatterplots to assess relationships visually (e.g., between HAM-D and viral load) and calculate a correlation. We will use a Pearson correlation if we were able to achieve approximate normality for all parameters. Otherwise, in order to maintain the ability to look at all parameters and relationships as a whole, we will use Spearman correlations. At the second step, once baseline correlations are assessed, we will look at the correlations between the changes from baseline of these parameters, in a similar fashion. As a third step, we will model the change in depression, anxiety or sleep outcome as a function of the change in viral load (if there was one) and the baseline score of depression, anxiety or sleep outcome in a multiple linear regression model. The multiple linear regression model will either use all subjects or at least the two treatment group subjects (depending on the scatterplots and correlations results) and use an indicator variable in the model for group membership. With this small number of subjects, we do not expect to be able to include in the model more than baseline and group memberships as a covariate as well as the single predictor variable we are focusing on. With three outcomes (depression, anxiety, sleep) and three predictors (viral load, CD4, NK function), we will have nine models. If any result is significant, it will only be considered as an indicator for the need of continuing in this line of research, but not inferential from this small study

Records to Be Kept
Case report forms (CRFs) will be created by the Biostatistics and Pharmacology Core of the IPCP. Subjects will not not be identified by name on any CRFs. Subjects will be identified by the patient identification number (PID) only at randomization.

Role of Data Management
Instructions concerning the recording of study data on CRFs will be provided by the Biostatistics and Pharmacology Core of the IPCP.. It will be the responsibility of the principal Investigator and the University of Pennsylvania Clinical Trials Unit Data Manager to monitor on a real time basis the individual subject records, including consent forms, CRFs, supporting data, laboratory specimen records, and medical records (physicians' progress notes, nurses' notes, individuals' hospital charts), to ensure protection of study subjects, compliance with the protocol, and accuracy and completeness of records.

Clinical Site Monitoring and Record Availability
An external certified monitor will be responsible for performing routine monitoring visit to the study site (Appendix IV, Data Safety Monitoring Plan). These monitoring visits will occur after the enrollment of the ninth, eighteenth, and last subjects to the study. The monitor will visit the clinical research unit to review the individual subject records, including consent forms, CRFs, supporting data, laboratory specimen records, and medical records (physicians' progress notes, nurses' notes, individuals' hospital charts), to ensure protection of study subjects, compliance with the protocol, and accuracy and completeness of records. In addition, the clinical trial site monitors also will inspect the site's regulatory files to ensure that all appropriate regulatory documents are present and regulatory requirements are being followed. An audit of the pharmacy will also be conducted to assure that standard operating procedures are being followed. The audit will include a review of IP storage and management.
The investigator will make study documents (e.g., consent forms, drug distribution forms, CRFs) and pertinent hospital or clinic records readily available for inspection by the University of Pennsylvania IRB, Office of Human Research of the University of Pennsylvania, the site monitors, the Food and Drug Administration (FDA), the NIMH, the Office for Human Research Protections (OHRP), for confirmation of the study data.

Adverse Event
An adverse event (AE) is any symptom, sign, illness or experience that develops or worsens in severity during the course of the study. Intercurrent illnesses or injuries should be regarded as adverse events. Abnormal results of diagnostic procedures are considered to be adverse events if the abnormality:  results in study withdrawal  is associated with a serious adverse event  is associated with clinical signs or symptoms  leads to additional treatment or to further diagnostic tests  is considered by the investigator to be of clinical significance

Serious Adverse Event
Adverse events are classified as serious or non-serious. A serious adverse event is any AE that is:  fatal  life-threatening  requires or prolongs hospital stay  results in persistent or significant disability or incapacity  a congenital anomaly or birth defect 38 Version 2.0 1/24/08  an important medical event Important medical events are those that may not be immediately life threatening, but are clearly of major clinical significance. They may jeopardize the subject, and may require intervention to prevent one of the other serious outcomes noted above. For example, drug overdose or abuse, a seizure that did not result in in-patient hospitalization, or intensive treatment of bronchospasm in an emergency department would typically be considered serious.
All adverse events that do not meet any of the criteria for serious should be regarded as nonserious adverse events.

Expedited adverse event
Is an adverse event that meets the criteria for expedited reporting.

Adverse Event Reporting Period
The study period during which adverse events must be reported is normally defined as the period from the initiation of any study procedures to the end of the study treatment and followup. For this study, The expedited adverse event (EAE) reporting period will be the entire study duration for an individual subject (from study enrollment until study completion or discontinuation of the subject from study participation for any reason and at least 30 days after the last dose of study drug is given).

Preexisting Condition
A preexisting condition is one that is present at the start of the study. A preexisting condition should be recorded as an adverse event if the frequency, intensity, or the character of the condition worsens during the study period.

General Physical Examination Findings
At screening, any clinically significant abnormality should be recorded as a preexisting condition. At the end of the study, any new clinically significant findings/abnormalities that meet the definition of an adverse event must also be recorded and documented as an adverse event.

Post-study Adverse Event
All unresolved adverse events should be followed by the investigator until the events are resolved, the subject is lost to follow-up, or the adverse event is otherwise explained. At the last scheduled visit, the investigator should instruct each subject to report any subsequent event(s) that the subject, or the subject's personal physician, believes might reasonably be related to participation in this study. The investigator will notify the NIMH, FDA, IRB, and DSMB of any death or adverse event occurring at any time after a subject has discontinued or terminated study participation that may reasonably be related to this study. The NIMH, FDA, IRB, and DSMB will also be notified if the investigator should become aware of the development of cancer or of a congenital anomaly in a subsequently conceived offspring of a subject that has participated in this study.

Abnormal Laboratory Values 39
Version 2.0 1/24/08 A clinical laboratory abnormality should be documented as an adverse event if any one of the following conditions is met:  The laboratory abnormality is not otherwise refuted by a repeat test to confirm the abnormality  The abnormality suggests a disease and/or organ toxicity  The abnormality is of a degree that requires active management; e.g. change of dose, discontinuation of the drug, more frequent follow-up assessments, further diagnostic investigation, etc.

Hospitalization, Prolonged Hospitalization or Surgery
Any adverse event that results in hospitalization or prolonged hospitalization will be documented and reported as a serious adverse event unless specifically instructed otherwise in this protocol. Any condition resulting in surgery should be documented as an adverse event if the condition meets the criteria for an adverse event.
Neither the condition, hospitalization, prolonged hospitalization, nor surgery are reported as an adverse event in the following circumstances:  Hospitalization or prolonged hospitalization for diagnostic or elective surgical procedures for a preexisting condition. Surgery should not be reported as an outcome of an adverse event if the purpose of the surgery was elective or diagnostic and the outcome was uneventful.
 Hospitalization or prolonged hospitalization required to allow efficacy measurement for the study.
 Hospitalization or prolonged hospitalization for therapy of the target disease of the study, unless it is a worsening or increase in frequency of hospital admissions as judged by the clinical investigator.

Grading Severity of Events
The Division of AIDS Table for Grading the Severity of Adult and Pediatric Adverse Events (DAIDS AE Grading Table), Version 1.0, December 2004, must be used and is available on the RCC Web site: http://rcc.tech-res-intl.com/.

Study Sponsor Notification by Investigator
The expedited adverse event (EAE) reporting requirements and definitions for this study and the methods for expedited reporting of adverse events (AEs) to the IRB of the University of Pennsylvania are defined in the Penn Manual for Clinical Research http://www.med.upenn.edu/pennmanual. AEs reported on an expedited basis must be documented on the "Serious Adverse Event Report" IPCP study specific form.
The Table for Grading Adult Adverse Experiences, located on the DAIDS Regulatory Compliance Center Web site will be used: http://rcc.tech-res-intl.com The EAE reporting 40 Version 2.0 1/24/08 period will be the entire study duration for an individual subject (from study enrollment until study completion or discontinuation of the subject from study participation for any reason).
After the end of the Protocol-defined EAE Reporting Period stated above, the site must report serious, unexpected, clinical suspected adverse drug reactions if the study site staff becomes aware of the event on a passive basis, i.e., from publicly available information.
A Serious Adverse Event (EAE) form must be completed by the investigator and faxed to the FDA per the guidelines below. The investigator will keep a copy of this EAE form on file at the study site. At the time of the initial report, the following information should be provided:  Study identifier  Study Center  Subject number  A description of the event  Date of onset  Current status  Whether study treatment was discontinued  The reason why the event is classified as serious  Investigator assessment of the association between the event and study treatment Within the following 48 hours, the investigator must provide further information on the serious adverse event in the form of a written narrative. This should include a copy of the completed Serious Adverse Event form, and any other diagnostic information that will assist the understanding of the event. Significant new information on ongoing serious adverse events should be provided promptly to the study sponsor

IRB Notification by Investigator
Reports of all serious adverse events (including follow-up information) must be submitted to the IRB within 10 working days. Copies of each report and documentation of IRB notification and receipt will be kept in the Clinical Investigator's binder.

FDA Notification by Sponsor
The study IND holder (Pablo Tebas, MD) shall notify the FDA by telephone or by facsimile transmission of any unexpected fatal or life-threatening experience associated with the use of the drug as soon as possible but no later than 7 calendar days from the sponsor's original receipt of the information.
If a previous adverse event that was not initially deemed reportable is later found to fit the criteria for reporting, the study sponsor will submit the adverse event in a written report to the FDA as soon as possible, but no later than 15 calendar days from the time the determination is made.

NIMH Medical officer (MO)/ Program Officer notification by Investigator
Copies of safety reports submitted to the FDA by Pablo Tebas, MD should be sent to the MO within 48 hours of FDA notification.

DSMB Notification by Investigator 41
Version 2.0 1/24/08 The DSMB will be notified at the same time as the IRB, i.e. within 10 working days of becoming aware of the serious adverse event.

Institutional Review Board (IRB) Review and Informed Consent
This protocol and the informed consent document (Appendix II) and any subsequent modifications will be reviewed and approved by the IRB or ethics committee responsible for oversight of the study. A signed consent form will be obtained from the subject (or parent, legal guardian, or person with power of attorney for subjects who cannot consent for themselves, such as those below the legal age). The consent form will describe the purpose of the study, the procedures to be followed, and the risks and benefits of participation. A copy of the consent form will be given to the subject, parent, or legal guardian, and this fact will be documented in the subject's record.

Subject Confidentiality
All laboratory specimens, evaluation forms, reports, and other records that leave the site will be identified by coded number only to maintain subject confidentiality. All records will be kept locked. All computer entry and networking programs will be done with coded numbers only. Clinical information will not be released without written permission of the subject, except as necessary for monitoring by IRB, the FDA, the NIMH, the OHRP, or the study DSMB.

Study Discontinuation
The study may be discontinued at any time by the IRB, the NIMH, the DSMB, the FDA, or other government agencies as part of their duties to ensure that research subjects are protected.

PUBLICATION OF RESEARCH FINDINGS
Publication of data will not identify subjects by name.

BIOHAZARD CONTAINMENT
As the transmission of HIV and other blood-borne pathogens can occur through contact with contaminated needles, blood, and blood products, appropriate blood and secretion 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 Centers for Disease Control and Prevention and the National Institutes of Health.
All dangerous goods materials, including diagnostic specimens and infectious substances, must be transported according to the instructions detailed in the International Air Transport Association (IATA) Dangerous Goods Regulations" Normal; no complaint; no evidence of disease.

90
Able to carryon normal activity; minor signs or symptoms of disease.

80
Normal activity with effort; some signs or symptoms of disease.

70
Cares for self, unable to carryon normal activity or to do active work.

60
Requires occasional assistance but is able to care for most of needs.

50
Requires considerable assistance and frequent medical care. 40 Disabled, requires special care and assistance.

30
Severely disabled; hospitalization is indicated although death is not imminent.

20
Very sick; hospitalization necessary; active supportive treatment is necessary. 10 Moribund, fatal processes progressing rapidly.

INTRODUCTION
You are being asked to take part in this research study because you are infected with HIV, the virus that causes AIDS, and you are not taking anti-HIV drugs (not on any antiretroviral therapy now or in the 16 weeks prior to entry or planning to start therapy in the next 60 days) and have a CD4 count of at least 350 cells. This study is sponsored by the National Institute of Mental Health (NIMH). The doctor in charge of this study at this site is Pablo Tebas, MD. Before you decide if you want to be a part of this study, we want you to know about the study. This is a consent form. It gives you information about this study. The study staff will talk with you about this information. You are free to ask questions about this study at any time. If you agree to take part in this study, you will be asked to sign this consent form. You will get a copy to keep.

WHY IS THIS STUDY BEING DONE?
This study is being done to evaluate the anti-HIV activity (if the level of HIV in your blood can be lowered), and the safety and tolerability of the drug aprepitant. In the test tube, aprepitant has an affect on HIV and inhibits its replication. This is the first time aprepitant is being given to HIVinfected people and therefore is being used in an investigational manner (not U.S. Food and Drug Administration (FDA)-approved for HIV treatment). The FDA has approved aprepitant for the prophylactic treatment of vomiting and nausea in patients starting chemotherapy. Aprepitant has also been studied as a possible treatment for depression. This study will use two doses of aprepitant, 250 mg and 125 mg given once a day. Several questionnaires involving depression and anxiety will also be administered to see if aprepitant has any effects on these parameters.

WHAT DO I HAVE TO DO IF I AM IN THIS STUDY?
Version 2.0 1/24/08 50 All study visits will be conducted in the General Clinic Research Center (GCRC) on 1 Dulles in the Hospital of the University of Pennsylvania.

Screening Visit
You will be asked to come to the GCRC to see if you are eligible to participate in the trial. At this screening visit, you will be asked to sign this consent form that explains the study and what will be expected of you. The study nurse will ask you questions about your medical history and medications you have taken in the past and are currently taking. You will have your vital signs and weight taken and will be asked about how you are feeling. After that you will have about 3 tablespoons of blood drawn for hematology (blood counts), chemistries (tests to see how well your liver and kidneys are working), pregnancy test (if you are a woman), HIV viral load and CD4 cell count. If there is no documentation available, a test to confirm that you are HIV positive will also be done. In addition, you will have some blood will be used for specialized immunology and virology tests, including genotype and phenotype some of the components of the HIV virus. A urinalysis will also be done.
In addition, your phone number or other contact information will be requested, so that the clinic can contact you and remind you of follow-up visits.

Entry Visit (Day 0)
You will come to the Entry visit having fasted (nothing to eat or drink 8 hours before your visit with the exception of water). You will have a brief physical exam and will be asked about any medicine changes since your last visit as well as any symptoms you may have. You will have about 7 tablespoonfuls of blood drawn for routine safety labs (hematology, chemistries with liver functions tests, fasting lipid panel), CD4 and HIV viral load test will be performed. If you are a woman able to become pregnant, you will have a pregnancy test. You will also be asked to complete three questionnaires about depression, anxiety and your sleep patterns.
You will then be randomized (as in the flipping of a coin) 2:1 to receive aprepitant or placebo (a pill that looks like the study drug but contains an inactive substance), respectively.
Therefore, you have a 66% chance of getting active drug. The study will be blind, what means that neither you, nor we, will know exactly what you are receiving. Only the pharmacist will know exactly. You could get:  125 mg (1 aprepitant pill plus two placebos) or 250 mg (2 aprepitant pills) of study drug by mouth per day for 14 days  Matching Placebo (3 placebos) A small thin tube for drawing blood samples will be placed into a vein in your arm and left in place during your stay in the clinic. You will have a pre-dose blood sample (approximately 1 teaspoon) drawn and then will take your first dose of study medication in the clinic. A small sample of blood (one teaspoon at each time point) will be taken to test for the level of drug in your blood at 30 minutes, 1 hour, 2 hours, 4 hours and 8 hours after taking the medication. The total amount of blood drawn for the PK portion of your visit will be about 2 tablespoons.
You will be given a bottle of study drug. You will bring your study pill bottle with you to all study visits.

Study Visits
After your Entry visit, you will come to the GCRC for study visits on days 3, 7, 10 and 14. You will be called a couple of days before each visit to remind you of your appointment, to come to the clinic in a fasting state for your study visit, and to bring your study pill bottles with you. The research staff will check your study pill bottle and count any remaining pills.
Most importantly, you will be reminded NOT to take your study medicine in the morning of all of your study visits, as a blood sample will be drawn in the clinic to measure the level of the study drug.

Days 3, 7,and 10
At these visits, you might have a brief physical exam performed, your vital signs will be taken and you will be asked about your health and if you have any side effects from the study drug. You will also be asked about any other medicines you may be taking. Routine safety labs (chemistries and hematology), HIV viral load, and CD4 count will be checked at all visits and will require about 2 tablespoons of blood. These visits should last less than an hour.

Day 14
In addition to the procedures and laboratory evaluations done above, additional laboratory evaluations will be done at Day 14, including specialized immunology and virology testing, as well as a fasting lipid panel, pregnancy test and PK analyses.
The PK (Pharmacokinetic tests) will be performed exactly as they were at the entry visit. A small thin tube for drawing blood samples will be placed into a vein in your arm and left in place during your stay in the clinic. You will have a pre-dose blood sample drawn (approximately 1 teaspoon) and then will take your first dose of study medication in the clinic. A small sample of blood (1 teaspoon at each time point) will be taken to test for the level of drug in your blood at 30 minutes, 1 hour, 2 hours, 4 hours and 8 hours after taking the medication.
These extra tests will require about 3 tablespoons of blood, so 5 tablespoons will be drawn at these visits.
On Day 14, you will be asked to complete the same questionnaires regarding anxiety, depression and sleep patterns that you completed at the enrollment visit.
On Day 14, you can be expected to be in the GCRC for at least 8 hours; meals will be provided to you on a regular schedule to coincide with the blood draws for the PK sampling.
If you miss too many doses of study medicine, you will stop study medicine and withdraw from the study. You will be asked to complete the evaluations listed above for the Day 14 visit.

Final Study Visit (Day 42)
Finally, you will return to clinic on day 42, about 6 weeks after entering the trial. You will be asked about your health and have about 7 tablespoons of blood drawn for routine safety labs, HIV viral load, CD4, special immunology and virology samples. You will be asked to complete the same questionnaires regarding anxiety, depression and sleep patterns that you completed at the enrollment and Day 14 visits. This visit may last an hour.

HOW MANY PEOPLE WILL TAKE PART IN THIS STUDY?
About 27 people will take part in this study; 9 people in each of the groups. The University of Pennsylvania is the only center participating in this study; all 27 participants will be enrolled here.

HOW LONG WILL I BE IN THIS STUDY?
You will take the study drug for 14 days and then come in for a follow-up visit on or about day 42, which is about 6 weeks after starting the study.

WHY WOULD THE DOCTOR TAKE ME OFF THIS STUDY EARLY?
The study doctor may need to take you off the study early without your permission if:  the study is cancelled by the U.S. Food and Drug Administration (FDA), National Institute of Mental Health (NIMH), the Safety Monitoring Committee for this study, or the University of Pennsylvania's Institutional Review Board (IRB). (An IRB is a committee that watches over the safety and rights of research subjects.)  you are not able to attend the study visits as required by the study.
The study doctor may also need to take you off the study drug without your permission if:  continuing the study drug may be harmful to you  you need a treatment that you may not take while on the study  you are not able to take the study drug as required by the study.  you become pregnant.
If you must stop taking the study drug before the study is over, you will be asked to come in for a final visit. Risks of Blood Draw and -IV line:

WHAT ARE THE RISKS OF THE STUDY
The process of drawing blood in some cases may cause bleeding, bruising, pain, blood clots, lightheadedness, and some minor swelling around the area of the needle sticks. Occasionally an infection or bleeding may develop where the needle was placed in the vein. The iv line may need to be replaced during the PK visit due to repeated blood draws. In rare instance, fainting may occur.
In addition, the multiple blood draws and visits to the research center may be time consuming and inconvenient.

ARE THERE RISKS RELATED TO PREGNANCY?
In studies with rats, no effect on fertility or embryonic development was noted. However, there have been no studies conducted in humans and therefore, if you are pregnant you will not be able to participate in this study. If you become pregnant while on study, you will be asked to stop taking the study medication.
All subjects are requested not to participate in a conception process while on study, ie. no egg or sperm donations and for all subjects able to become pregnant, use of at least one of the forms of contraception listed below while receiving the protocol-specified medication and for 30 days after stopping the medication.
 Condoms (male or female) with or without a spermicidal agent  Diaphragm or cervical cap with spermicide  IUD

ARE THERE BENEFITS TO TAKING PART IN THIS STUDY?
If you take part in this study, your HIV viral load may go down while you are receiving aprepitant, but it will very likely return to where it started (the baseline level) once the drug is stopped. Aprepitant may also have no effect on the HIV in your blood. You may receive no benefit from being in this study, but the information learned from this study may help others who have HIV and lead to a new way to treat HIV infection.

WHAT OTHER CHOICES DO I HAVE BESIDES THIS STUDY?
Instead of being in this study you have the choice of:  treatment with prescription drugs available to you  treatment with experimental drugs, if you qualify  no treatment Please talk to your doctor about these and other choices available to you. Your doctor will explain the risks and benefits of these choices.

WHAT ABOUT CONFIDENTIALITY?
By signing this Consent/Authorization Form you are permitting the University of Pennsylvania Health System and the School of Medicine to use your personal health information collected about you for research purposes within our institution. You are also allowing the University of Pennsylvania Health System and the School of Medicine to disclose that personal health information to outside organizations or people involved with the processing of this study.

What personal health information is collected and used in this study, and also might be shared?
Personal health and contact (phone number, address) information collected as part of this study is recorded in your clinical trial chart. This record is separate from your medical chart. Data collected for the study is reported to the study team on a case report form, which includes the information listed below, but not your name or other identifying information. Results of laboratory tests or study procedures will be copied and sent to your primary care physician by name, at your request only.
Personal health information that is collected and will be disclosed to the agencies listed on the following page as part of this research study is: -Demographics (Race, Gender) -Study medication compliance and toxicities -Signs and symptoms you experience while on the study -Current and past medical diagnoses; allergies -Current and past medications and therapies -Information from a physical exam: weight, blood pressure, heart rate, temperature -Data from laboratory tests (blood chemistry and hematology tests), CD4 count, viral load, tropism assays; immunology studies; virology studies, genotyping/phenotyping studies -Data from pharmacokinetic studies (drug levels in your blood)

Why is your personal health information being used?
Personal contact information, such as phone number and address, will be used only by clinical trial staff to get in touch with you while you are participating in this study. Your health information and results of tests and procedures are being collected as part of the research study and for the advancement of medicine and clinical care. The Principal Investigator will use the results to monitor your safety and ability to tolerate the study medications.

Which of our personnel may use or disclose your personal health information?
The following individuals and organizations may use or disclose your personal health information for this research project: -The Principal Investigator and other University staff associated with this study; -The University of Pennsylvania Institutional Review Boards (the Committees charged with overseeing research on human subjects) and the University of Pennsylvania Office of Regulatory Affairs -Authorized members of the University of Pennsylvania and the University of Pennsylvania Health System and School of Medicine work force who may need to access your information in the performance of their duties, for example, to provide treatment, to ensure the integrity of the research, accounting or billing matters, etc.

Who, outside of the University of Pennsylvania Health System and the School of Medicine, might receive your personal health information?
As part of the study the Principal Investigator, study team and others listed above, may disclose your personal health information, including the results of the research study tests and procedures to the following: -Pharmaceutical Sponsors: Drug companies (Merck Pharmaceuticals) who supply treatment for the study will have access to safety information. -Government Agencies: Data from this study will be made available to the Food and Drug Administration and the National Institute of Mental Health, for them to evaluate the safety and efficacy of the treatments being used in this study.
Study staff will inform you if there are any changes to this list above during your active participation in the trial. Once information is disclosed to others outside the University of Pennsylvania Health System or School of Medicine the information may no longer be covered by federal privacy protection regulations.
In all disclosures outside the University of Pennsylvania Health System or School of Medicine, you will not be identified by name, social security number, address, telephone number, or any other direct personal identifier, unless disclosure of the direct identifier is required by law. Personal health information will be disclosed by a unique code number. Only study staff can break the code and identify you to your code.

How long will the University of Pennsylvania Health System and the School of Medicine be able to use or disclose your personal health information?
Your authorization for use of your personal information for this specific study does not expire. This information may be stored in a database (research repository). However, the University of Pennsylvania Health System and the School of Medicine may not re-use or re-disclose your personal health information collected for this study for another purpose other than the research described in this consent form unless you have given written permission to the Principal Investigator to do so. However, the University of Pennsylvania Institutional Review Board may grant permission to the Principal Investigator or others to use your information for another purpose after ensuring that appropriate safeguards are in place. The Institutional Review Board is a committee whose job is to protect the safety and privacy of research subjects. Results of all tests and procedures done solely for this research study and not as part of your regular care will not be included in your medical record unless you want them to be sent to your primary care provider. You will need to complete a medical records release of information to allow us to provide study data to your doctor.
Will you be able to access your records? You will be able to request access to your medical record when the study is completed. During your participation in the study, you will not be able to access your medical records. This will be done to prevent the knowledge of study results affecting the reliability of the study. Your information will be available should an emergency arise that would require your treating physician to know the information to best treat you. You will have access to your medical record and study information that is part of that record when the study is over. The Investigator is not required to release to you research information that is not part of your medical record.

Can you change your mind?
You may withdraw your permission for the use and disclosure of any of your personal information for research, but you must do so in writing to the Principal Investigator at 502 Johnson Pavilion. Even if you withdraw your permission, the Principal Investigator for the research study may still use your personal information that was collected prior to your written request if that information is necessary to the study. If you withdraw your permission to use your personal health information that means you will also be withdrawn from the research study.

WHAT ARE THE COSTS TO ME?
The study drug, exams, and blood tests will be provided for free. In the event of any physical injury resulting from research procedures, medical treatment will be provided without cost to you, but financial compensation is not otherwise available from the University of Pennsylvania. If you have an illness or injury during this research trial that is not directly related to your participation in this study, you and/or your insurance will be responsible for the cost of the medical care of that illness or injury.

WHAT ARE MY RIGHTS AS A RESEARCH SUBJECT?
Taking part in this study is completely voluntary. You may choose not to take part in this study or leave this study at any time. You will be treated the same no matter what you decide.
We will tell you about new information from this or other studies that may affect your health, welfare, or willingness to stay in this study. If you would like the results of the study, let the study staff know.

WHAT DO I DO IF I HAVE QUESTIONS OR PROBLEMS?
For questions about this study or a research-related injury, contact:

Purpose
The monitoring of a clinical trial is an essential element of study processes designed to ensure the protection of the subject's rights, the safety of subjects enrolled in the trial and the integrity and quality of the resulting data. This monitoring plan details the Case Report Form (CRF) and source data verification of efficacy and safety parameters, the frequency of monitoring visits, regulatory document review, drug accountability and compliance review.
Monitoring will be conducted according to the University of Pennsylvania Sponsor-Investigator Standard Operating Procedures.

Protocol Summary
Preliminary studies indicate that NK-1R substance P antagonists have a significant antiviral activity in vitro. This proof of concept proposal is centered on addressing the safety and antiviral activity of using aprepitant, a NK-1R substance P antagonist as an antiviral agent for the treatment of HIV infection. Understanding the pharmacokinetics and pharmacodynamics of aprepitant in HIV infected individuals and its relationship with its potential antiviral effect is a critical part of this project.
In vitro studies suggest that the antiviral activity of SP antagonists might involve chemokine receptor expression. Substance P antagonists decrease the expression of CCR5 in macrophage cells, a mechanism that might explain, at least in part the anti HIV activity of these compounds. Our preliminary data also suggest that SP may have direct effects upon NK cells as determined using a clonal NK cell line. Since we have found that SP antagonism can prevent some of this activity, it is alluring to speculate that SP antagonism may serve to reverse the impairment of NK cell function found in HIV infection. This study will provide a unique opportunity to evaluate the in vivo effects of aprepitant on CCR5 expression and message in human monocytes and lymphocytes and to study NK cell function after the administration of this drug. We will also conduct in the laboratory of Dr. Jordan Orange in vitro experiments to better understand the effects of SP and its antagonism in NK cells as well as the mechanism of these activities.
HIV infection has a significant impact of depression and anxiety disorder symptoms. In women with HIV infection the proportion of major depression is four times higher than in HIV-negative women (19.4 vs 4.8%). This study provides a unique opportunity to explore the effects of NK-1 receptors antagonists on depression, anxiety and sleep in HIV infected subjects.
The objective of this randomized, placebo controlled, double blind study is to determine the antiviral activity of aprepitant by comparing the change in HIV RNA viral load after 2 weeks of aprepitant monotherapy.

Monitor Selection and Training
One monitor will be assigned for this trial and will be responsible to complete the monitoring process. The monitor is someone who is independent from the trial and the study team. The monitor will be selected from one of the preferred vendors already working with the University of Pennsylvania.
A CV for the monitor will be obtained and updated annually. The CV will be kept on file in the Sponsor section of the Regulatory Binder to document the qualifications of the monitor.
The monitor will receive a monitoring manual, which will include a copy of the protocol, the approved informed consent form, approved CRFs, and this monitoring plan. A training session will be scheduled as soon as is practicable that will include the PI giving an overview of the protocol, and the study statistician providing training on the actual monitoring plan, including reviewing the CRFs with the monitor. It is estimated that the training session will take a half day.

Study Initiation
The Principal Investigator will be responsible for assuring through personal contact between the coinvestigators, the monitor and the clinical staff that each clearly understands and accepts the obligations incurred in the undertaking of this clinical trial.
The Principal Investigator should ensure that the clinical staff fully understand the nature of the protocol and the requirements for an adequate and well-controlled study; the obligation to conduct the clinical investigation in accordance with the applicable federal regulations; the obligation to obtain informed consent in accordance with 21 CFR Part 50; the obligation to obtain IRB review and approval of a clinical investigation before the investigation may be initiated and to ensure continuing review of the study by the IRB in accordance with 21 CFR Part 56.
A check list containing the elements of study initiation as described in the CFR and ICH GCPs will be completed by the study staff prior to the first the monitoring visit and placed in the Sponsor section of the Regulatory Binder.

FREQUENCY
Enrollment will be complete when 27 subjects are enrolled into the trial. Approximately 1-2 subjects will be enrolled per month. Monitoring visits will be conducted periodically throughout the study as described below. (Note: The specific data to be reviewed at each visit is indicated in Section 5.2)  The first monitoring visit will occur when one-third of the subjects have been enrolled (n=9).
 A second monitoring visit will be conducted when approximately two-thirds of the subjects have been enrolled (n=18).
Version 2.0 1/24/08 62  A third monitoring and closeout visit will be conducted after 100% of the subjects have been enrolled (n=27). This visit will be conducted after the subjects have completed the study and will also serve as the close-out monitoring visit (as required by GCPs and described in section 10).

DATA REVIEW FOR MODERATE RISK STUDY
The following variables will be source data verified:

REGULATORY DOCUMENTS REVIEWED
The Regulatory Documents will be maintained in the Regulatory Binder. The Regulatory Binder will be reviewed by the monitor in an ongoing manner at the time of each monitoring visit. The monitor will review the regulatory binder for completeness and will assure that the CRFs are being completed in a timely manner.

Monitoring Log
The monitor is required to sign and date the monitoring log documenting the dates of the monitoring visit. The Monitoring Log will be filed in the Regulatory Binder.

Monitoring Report
All monitoring visits will be documented on the Monitor's Report and Visit Checklist. The original report for each visit will be filed in the Sponsor section of the Regulatory Binder and copies of the report will be sent to: 

Drug Accountability
Study drug for this trial consists of Aprepitant 125 mg and matching placebo which are supplied and available through a licensed pharmacist at the University of Pennsylvania, Deborah Kim. All study drug/placebo are stored in the pharmacy at the Clinical Trials Office at the University of Pennsylvania. The aprepitant and the placebo for aprepitant must be stored under controlled room temperature, 20-25°C (68-77°F) and protected from light, humidity and excessive heat. The pharmacist is required to maintain complete records of all study products.
The monitor will perform 100% drug accountability in an ongoing manner at the time of each monitoring visit. The monitor will confirm the receipt, dispensation, and return of drug. The pharmacist will retain returned drug until the monitor can verify the returns which can then be destroyed. Destruction will be conducted by placing returns in a red biohazard bag, which is then incinerated by Stericycle Company.

Medical Monitoring
Patient safety will be monitored continuously by the Medical Monitor, Ian Frank, MD, who is delegated and qualified to review medical safety data for the duration of the study.
The Principal Investigator has the front-line responsibility for identifying potential adverse events experienced by study participants, adjusting the intervention accordingly and reporting the experience. The Principal Investigator is responsible for tracking these reports and relaying them as required to the FDA, University of Pennsylvania IRB, the Data and Safety Monitoring Board (see Section 9) and the Program Project Principal Investigator, Steven D. Douglas, MD.

Data and Safety Monitoring Board
This study has a Data and Safety Monitoring Board (DSMB) comprised of three members: Greg Bisson, MD (chair), Harvey Friedman, MD, Knashawn H Morales, PhD (statistician). The DSMB is charged with reviewing the trial data in an ongoing basis. If the committee reviews findings relevant to the safety of study participants, it will immediately notify the PI regarding those, and will have criteria to recommend for stopping the study, should that become necessary. The DSMB will be provided reports as it requests and the DSMB will produce an annual report for the IRB. This report to the DSMB will include the number of patients enrolled to date in each stratum, the dates of first and most recent patient enrollment, a summary of all adverse events regardless of grade and attribution for to each cohort, and by treatment, and a summary of any recent literature that may affect the ethics of the study. The summary of adverse events by treatment will be provided by the study statistician directly to the committee and not as part of the report provided to study PI, since this study is a randomized blinded study.