Time to treatment disruption in children with HIV-1 randomized to initial antiretroviral therapy with protease inhibitors versus non-nucleoside reverse transcriptase inhibitors

Background Choice of initial antiretroviral therapy regimen may help children with HIV maintain optimal, continuous therapy. We assessed treatment-naïve children for differences in time to treatment disruption across randomly-assigned protease inhibitor versus non-nucleoside reverse transcriptase inhibitor-based initial antiretroviral therapy. Methods We performed a secondary analysis of a multicenter phase 2/3, randomized, open-label trial in Europe, North and South America from 2002 to 2009. Children aged 31 days to <18 years, who were living with HIV-1 and treatment-naive, were randomized to antiretroviral therapy with two nucleoside reverse transcriptase inhibitors plus a protease inhibitor or non-nucleoside reverse transcriptase inhibitor. Time to first documented treatment disruption to any component of antiretroviral therapy, derived from treatment records and adherence questionnaires, was analyzed using Kaplan-Meier estimators and Cox proportional hazards models. Results The modified intention-to-treat analysis included 263 participants. Seventy-two percent (n = 190) of participants experienced at least one treatment disruption during study. At 4 years, treatment disruption probabilities were 70% (protease inhibitor) vs. 63% (non-nucleoside reverse transcriptase inhibitor). The unadjusted hazard ratio (HR) for treatment disruptions comparing protease inhibitor vs. non-nucleoside reverse transcriptase inhibitor-based regimens was 1.19, 95% confidence interval [CI] 0.88–1.61 (adjusted HR 1.24, 95% CI 0.91–1.68). By study end, treatment disruption probabilities converged (protease inhibitor 81%, non-nucleoside reverse transcriptase inhibitor 84%) with unadjusted HR 1.11, 95% CI 0.84–1.48 (adjusted HR 1.13, 95% CI 0.84–1.50). Reported reasons for treatment disruptions suggested that participants on protease inhibitors experienced greater tolerability problems. Conclusions Children had similar time to treatment disruption for initial protease inhibitor and non-nucleoside reverse transcriptase inhibitor-based antiretroviral therapy, despite greater reported tolerability problems with protease inhibitor regimens. Initial pediatric antiretroviral therapy with either a protease inhibitor or non-nucleoside reverse transcriptase inhibitor may be acceptable for maintaining optimal, continuous therapy.

2 PENPACT 1 VERSION 3.1 FINAL 07/11/07 FOREWORD The PACTG and the PENTA teams wrote this protocol document with the idea of establishing the first of many possible joint studies between these two organizations. PENPACT 1 offers the opportunity of one document for actually two different studies, PACTG 390 at PACTG affiliated domestic and international sites, and PENTA 9 in Europe. PENPACT 1 will combine the data from these two studies, for a larger sample size and to achieve higher statistical power. Although this document will be used by both PACTG and PENTA as the official protocol, each group will manage its own approval process through its own scientific and regulatory committees.
The FDA will be the regulatory agency granting the IND for the PACTG 390 study and will cover those children enrolled at domestic and international sites affiliated with the PACTG. The PENTA 9 study will be submitted for regulatory and ethical approval in each PENTA country involved, including Brazil where the protocol will be submitted for regulatory and ethical approval at the local and national levels. Additionally, scientific review of the PENTA 9 will be conducted by the Medical Research Council (MRC) in the UK and the Agence Nationale de Recherches sur le SIDA (ANRS) in France. The PENPACT 1 Team believes that the number of children, who will enroll in PACTG 390 will be approximately 128 or half of the targeted accrual number.
Throughout the body of this document, both the common and unique items for the two research organizations are clearly explained. All appendices are labeled as either applicable to both organizations or to one of the two groups.
Both groups will always follow the current version of the protocol document; any amendment requested by either one of the two organizations will affect the other organization. Amendments will follow the established approval procedures for each organization and will not be implemented until both organizations have finalized their approvals.
All the study medications will be given by prescription. The children, their parent(s) or legally authorized representative (LAR), the children's health insurance, and/or, in Europe, the healthcare provider, are responsible for purchasing the study medications. However, only the medicines, doses, and regimens described in this document will be allowed as the children's antiretroviral therapy. Any new medication, dose, or regimen will be considered for incorporation into PENPACT 1; however, an amendment will be necessary before prescription of the new medicine, dose, or regimen is allowed.
The PENPACT 1 Team thoroughly discussed during protocol development the existence of some variations in the dosing guidelines for some of the drugs between the USA and Europe. Therefore, the protocol team developed a single appendix to describe all the allowed drugs and dosing for the protocol, Appendix IX "ALLOWED ANTIRETROVIRAL THERAPY • To compare the combination of 2 NRTIs plus a protease inhibitor (PI) versus 2 NRTIs plus a non-nucleoside reverse transcriptase inhibitor (NNRTI) as initial therapy, followed by secondline therapy if virologic failure occurs, in terms of their effects on a long-term virologic endpoint.
• To compare two different viral load criteria for switching from first-line to second-line therapy.

SECONDARY OBJECTIVES
• To evaluate and compare the safety and tolerability of each drug combination (including firstand second-line therapies).
• To compare the long-term clinical and immunologic outcomes (by the initial randomization).
• To compare the proportions of children who have undergone one regimen switch or reached study end-point (by the initial randomization).
• To compare time from randomization to virologic failure (RNA >400 copies/mL at or after Week 24) of the first-line therapy analyzed by initial randomization to either protease inhibitor (PI) or NNRTI containing regimens.
• To compare time from randomization to virologic failure of the second line therapy (RNA >30,000 copies/mL) analyzed by the initial randomization.
• To compare the proportion of children with plasma HIV-1 RNA <400 copies/mL at 4 years (by the initial randomization).
• To describe resistance patterns at four years (by the initial randomization).

VIROLOGIC ENDPOINT DEFINITION
The virologic endpoint is change in HIV-1 RNA viral load between baseline and four years post randomization. It is likely that by four years post-randomization, nearly all children will have POPULATION HIV-1 infected children who are antiretroviral naïve or who have received less than 56 days of antiretroviral drugs used on consecutive days after birth to prevent mother-to-infant HIV transmission. Prior exposure to NVP, including for prevention of mother-to-child transmission, is exclusionary.

RANDOMIZATION AND STRATIFICATION
Children will be randomized to one of four groups and stratified by age (<3 years versus ≥3 years), origin (PACTG site or PENTA site), and exposure versus no exposure to antiretroviral therapy perinatally.

FIRST-LINE THERAPY
All study medications will be given by prescription (the child, child's parent(s)/legally authorized representative (LAR), the child's health insurance, and/or, in Europe, the healthcare provider, are responsible for purchasing the study medications).
Children are randomized to one of four groups that are defined by the initial therapy to be given to a child as well as the virologic criterion for switching from first-line therapy (defined below) to second-line therapy: • Group 1(A): Initial therapy is 2 NRTIs + PI (switch to second-line therapy when HIV-1 RNA is ≥1,000 copies/mL) • Group 1(B): Initial therapy is 2 NRTIs + PI (switch to second-line therapy when HIV-1 RNA is ≥ 30,000 copies/mL) • Group 2(A): Initial therapy is 2 NRTIs + NNRTI (switch to second-line therapy when HIV-1 RNA is ≥1,000 copies/mL) • Group 2(B): Initial therapy is 2 NRTIs + NNRTI (switch to second-line therapy when HIV-1 RNA is ≥30,000 copies/mL) First-line therapy includes the initial therapy to which a child is randomized as well as any 20 PENPACT 1 VERSION 3.1 FINAL 07/11/07 antiretroviral therapies to which the child changes due to non-virologic reasons (e.g. toxicity, intolerability, request of child or child's parent(s)/LAR, etc.) prior to reaching the HIV-1 RNA switch criterion (≥1,000 copies/mL or ≥30,000 copies/mL, depending on the initial randomization). Whenever possible, changes within first-line therapy should involve substitutions of one or more drugs in the initial therapy by drugs from the same class or classes.
It is important to emphasize that the protocol will allow low doses of ritonavir as a boosting agent, creating drug combinations that will be counted as a single PI.

SECOND-LINE THERAPY
Second-line therapy will be initiated when the HIV-1 RNA switch criterion (≥ ≥ ≥ ≥1,000 copies/mL or ≥ ≥ ≥ ≥30,000 copies/mL, depending on the initial randomization) is reached. The following suggested drug regimens will be strongly encouraged as a second-line therapy for all children failing first-line therapy (when HIV-1 RNA is ≥1,000 copies/mL or when HIV-1 RNA is ≥30,000 copies/mL, depending on the initial randomization), particularly those children who have remained on their initial (randomized) therapy: • For PI-containing Groups 1(A) and 1(B): two new NRTIs and an NNRTI • For NNRTI-containing Groups 2(A) and 2(B): two new NRTIs and a PI However, these regimens do not constitute the only options. Current clinical care guidelines will prevail over protocol guidelines, (e.g. a fourth drug as part of second-line therapy).
The protocol will allow low doses of ritonavir as a boosting agent, creating drug combinations that will be counted as a single PI.
PENPACT 1 FOLLOW-UP PERIOD All children will be followed until the last child enrolled has reached 204 weeks on study treatment from his/her original randomization. This last patient could be from a PACTG or PENTA site.
After Week 204 of treatment until the study ends, children will continue on study follow-up with regular study visits every 12 weeks as described in Appendix 1. This follow-up period will be used to address long-term time-to-event secondary objectives of the study.

PENPACT 1 COMPARISON FOR ALL CHILDREN IN THE STUDY
• PI versus NNRTI as part of the initial therapy • Switching to second-line therapy at an HIV-1 RNA level of ≥1,000 copies/mL versus switching at HIV-1 RNA level of ≥30,000 copies/mL 21 PENPACT 1 VERSION 3.1 FINAL 07/11/07 1.0 BACKGROUND AND RATIONALE

General Background
Studies of viral dynamics, and the knowledge of the high mutation rate of the HIV virus, coupled with clinical experience, have all confirmed that combination antiretroviral therapy is needed to achieve inhibition of viral replication. Several published studies in children have demonstrated the advantages of dual therapy compared with monotherapy. However, it has also become clear that dual therapies achieve long-term viral suppression in only a very small proportion of individuals (1)(2)(3)(4)(5).
There are no data defining a particular highly active antiretroviral therapy (HAART) strategy as being optimal first-line therapy for children or adults. Thus, numerous adaptations exist that fall broadly into three HAART therapy groups: (1) Two nucleoside reverse transcriptase inhibitors (NRTIs) + one protease inhibitor (PI) (2) Two NRTIs + one non-nucleoside reverse transcriptase inhibitor (NNRTI) (

3) Three NRTIs
Each strategy has strengths and weaknesses. The first therapy group was the first to achieve complete and sustained viral inhibition in adults, and initially was viewed as the most potent HAART cocktail (6). However, there is increasing recognition of the longer term adverse effects of PIs on lipid metabolism and body fat distribution in a significant proportion of individuals (7). The PIs as a class are not easily formulated in solution and taste extremely bitter. Thus, for children who cannot swallow capsules, these drugs can be difficult for parents and caregivers to administer long-term.
The second therapy group has been perceived until recently as less potent, and most drugs in the NNRTI class are associated with skin rash in up to 20% of individuals. However, for children particularly, provided they do not experience an early drug allergy, palatable formulations exist that can be given once daily and that appear to be very well tolerated long-term. Initial data from adult trials have suggested comparable reductions in viral load in adults randomized to triple regimens including either an NNRTI or a PI (8,9).
The third group of therapy, because it consists of NRTIs only, has the distinct advantage of sparing the two other classes of drugs, allowing room for maneuver in subsequent treatment options. There is more limited long-term experience with this HAART option compared to the other two groups of therapy. However, equivalent efficacy is being reported (8,10). The NRTIs are available as palatable formulations for children, and many have been in use for longer than either NNRTIs or PIs. Thus, their individual side effect profiles are more familiar. Cross-class resistance may mean that a child failing a regimen containing only NRTIs will have little chance of benefit from any other drugs of this class. Severe hypersensitivity reactions to abacavir have been reported in up to 3% 22 PENPACT 1 VERSION 3.1 FINAL 07/11/07 of individuals. In a recently reported study of abacavir in treatment-experienced children, two of 205 children were withdrawn because of suspected hypersensitivity (11).

Study Rationale
PENPACT 1 is designed to evaluate the long-term efficacy, as measured by HIV-1 RNA over four years, of different initial HAART combinations in children and different strategies for switching therapy.
It is recognized that there are insufficient numbers of antiretroviral-naïve HIV-infected children at participating study sites to investigate all three of the HAART groups outlined above. Therefore, PENPACT 1's primary objective is the comparison of the combination of two NRTIs + one PI versus two NRTIs + one NNRTI as initial therapy followed by second-line therapy if failure occurs as defined by a long-term virologic endpoint.
It is not known which of the above combinations will have the most sustained impact on reducing viral load. Adult studies have shown similar or even improved efficacy with initial regimens utilizing two NRTIs and one NNRTI versus two NRTIs and one PI. A study with antiretroviral naïve adults treated with efavirenz plus zidovudine and lamivudine showed an improvement in virologic outcome, compared to those treated with indinavir plus zidovudine and lamivudine (14). The baseline viral load did not affect the virologic outcome. Another study comparing triple NRTI therapy to two NRTIs plus one PI showed decreased virologic efficacy in adults whose baseline plasma RNA levels were >100,000 copies/mL (15). As children generally have higher baseline plasma RNA levels than adults, it is possible that a regimen with two NRTIs and one NNRTI may show less efficacy particularly in younger children. However, NNRTI medications are generally better tolerated than PI medications by both adults and children. The potential decrease in potency may be offset by an increase in tolerability and thus adherence.
Additionally, it is unknown if the order in which antiretroviral agents are utilized will have an effect on long-term virologic efficacy. For example, there are data to suggest that d4T has decreased efficacy when a patient has been previously treated with zidovudine (16). The goal of antiretroviral therapy in children is to prolong clinical and immunologic health until adulthood. Therefore, the antiretroviral medications chosen for the initial regimen should be selected with a long-term plan in mind. PENPACT 1 will investigate if treatment with one NNRTI versus one PI in the initial therapy affects the subsequent potency of the second-line therapy. The first objective of PENPACT 1 therefore, is to compare the long-term efficacy of a combination of two NRTIs plus one PI versus two NRTIs plus one NNRTI as initial therapy, followed by second-line therapy if virologic failure occurs.
The optimal criteria for switching therapy have yet to be defined. Continued viral replication while under antiretroviral drug pressure results in the accumulation of mutations associated with antiretroviral drug resistance. Therefore, there is a logical 23 PENPACT 1 VERSION 3.1 FINAL 07/11/07 argument in favor of strict control of viral replication. Strict control dictates that as soon as virus becomes detectable in the circulation (or if plasma viral load fails to reach undetectable limits), then a switch should be made to a different, and probably more intensive, regimen. The problem with this approach, given the limitations of drugs available to children, is that this policy may rapidly exhaust all available options for therapy. As children with plasma HIV-1 RNA levels less than 100,000 copies/mL are at relatively low risk for disease progression (17,18,19), an alternative approach, which may be equally valid over a long period of follow-up, would be to try to maximize the benefit of each regimen and switch only when the viral load is consistently above a higher threshold. This strategy may preserve options longer. Although with this strategy, the virus could continue to accumulate resistance mutations, there is some evidence that virus replicating in the presence of HAART may be less pathogenic in-vivo (12,13). Therefore, the second primary objective of PENPACT 1 is to investigate the long-term efficacy of utilizing a strategy of "tight" virologic control (switching first-line therapy when viral load rises above 1,000 copies/mL) versus "looser" virologic control (switching therapy when the viral load rises above 30,000 copies/mL). The long-term nature of this study should clarify whether early switching improves immunologic and virologic outcomes or results in a more rapid exhaustion of treatment options.
Unfortunately, there are few clinical data on which to base the two threshold RNA values selected by the PENPACT 1 Team to mandate therapeutic changes. However, after much deliberation, the lower threshold was chosen to be 1,000 copies/mL and the higher threshold was chosen to be 30,000 copies/mL. The lower of the two thresholds, 1,000 copies/mL (3.0 logs), represents clear escape from complete virologic suppression. However, it is still at a limited level of replication. Thus, a second-line therapy may have a higher likelihood of achieving complete suppression. The upper threshold, 30,000 copies/mL (4.5 logs), was chosen because it is distant enough from 1,000 copies/mL (3.0 logs) to be considered a clinically and statistically significant change, yet at this RNA level, the risk of disease progression remains relatively low (19

2.22
To compare the long-term clinical and immunologic outcomes (by the initial randomization).

2.23
To compare the proportions of children who have undergone one regimen switch or reached study end-point (by the initial randomization).

2.24
To compare time from randomization to virologic failure (RNA >400 copies/mL at or after Week 24) of the first-line therapy analyzed by initial randomization to either protease inhibitor (PI) or NNRTI containing regimens.

2.25
To compare time from randomization to virologic failure of the second-line therapy (RNA >30,000 copies/mL) analyzed by the initial randomization.

2.26
To compare the proportion of children with plasma HIV-1 RNA <400 copies/mL at 4 years (by the initial randomization).

2.27
To describe resistance patterns at four years (by the initial randomization).

STUDY DESIGN
This is an international, multi-center, Phase II/III, randomized, open-label, factorial (2x2) trial. This study will enroll 256 HIV-1 infected children who are antiretroviral naïve or who have received less than 56 days of antiretroviral drugs used on consecutive days after birth to prevent mother-to-infant HIV transmission. Approximately 50 % of the children will be from PACTG sites and 50 % will be from PENTA sites.
Children will be randomized to one of four groups stratified by age (<3 years versus ≥3 years), origin (PACTG site or PENTA site), and exposure versus no exposure to antiretroviral therapy perinatally. The groups are defined by the initial therapy to be given to a child as well as the virologic criterion for switching from first-line therapy (defined below) to second-line therapy.
• Group 1(A): Initial therapy is 2 NRTIs + PI (switch to second-line therapy when HIV-1 RNA is ≥1,000 copies/mL) • Group 1(B): Initial therapy is 2 NRTIs + PI (switch to second-line therapy when HIV-1 RNA is ≥30,000 copies/mL) • Group 2(A): Initial therapy is 2 NRTIs + NNRTI (switch to second-line therapy when HIV-1 RNA is ≥1,000 copies/mL) • Group 2(B): Initial therapy is 2 NRTIs + NNRTI (switch to second-line therapy when HIV-1 RNA is ≥30,000 copies/mL) PENPACT 1 VERSION 3.1 FINAL 07/11/07 First-line therapy includes the initial therapy to which a child is randomized as well as any antiretroviral therapies to which the child changes due to non-virologic reasons (e.g. toxicity, intolerability, request of child or child's parent(s)/legally authorized representative (LAR), etc.) prior to reaching the HIV-1 RNA switch criterion (≥1,000 copies/mL or ≥30,000 copies/mL, depending on the initial randomization). Whenever possible, changes within firstline therapy should involve substitutions of one or more drugs in the initial therapy by drugs from the same class or classes.
The following suggested drug regimens will be strongly encouraged as a second-line therapy for all children failing first-line therapy (when HIV-1 RNA is ≥1,000 copies/mL or when HIV-1 RNA is ≥ 30,000 copies/mL, depending on the initial randomization), particularly those children who have remained on their initial (randomized) therapy: • For PI-containing Groups 1(A) and 1(B): The second-line therapy will be two new NRTIs + NNRTI • For-NNRTI containing Groups 2(A) and 2(B): The second-line therapy will be two new NRTIs + PI All children will be followed until the last child enrolled has reached 204 weeks on study treatment from his/her original randomization.
There will be two pair wise comparisons for all children: PI-containing versus NNRTIcontaining therapy as initial therapy, and switching therapy at an HIV-1 RNA level of ≥1,000 copies/mL versus ≥30,000 copies/mL. However, the PENTA Executive Committee has the right to question any of the possible changes/updates before their implementation in PENPACT 1 at PACTG and PENTA sites. If this occurs, PENPACT 1 will continue to accrue at both PACTG and PENTA sites, using the latest accepted definition by the PENPACT 1 Team until a new specific definition is adopted for all PACTG and PENTA sites.

Inclusion
3.13 Female subjects who are sexually active and able to become pregnant must agree to use the approved birth control methods for the assigned drug regimen under PENPACT 1. In most cases, drug regimens mandate the use of two methods of birth control. In these instances, hormonal birth control alone would not be considered adequate or effective. A medically accepted barrier method of contraception (e.g., condom) must also be used during the study. The interaction between study drugs and hormonal birth control has not been studied.
3.14 Parent/legally authorized representative and child, where appropriate, must be able to provide written informed consent, and assent.
3.15 Antiretroviral naïve (or have received less than 56 consecutive days after birth of antiviral drugs used to prevent mother-to-infant transmission) infants, children, and adolescents.
NOTE: Prior exposure to NVP is exclusionary; refer to Section 3.21.

Exclusion Criteria
3.21 Infant or maternal peripartum NVP exposure for prevention of mother-to-child HIV transmission.
3.22 Current Grade 3 or 4 clinical or laboratory toxicity as defined by age appropriate toxicity tables in Appendices IV and V (Grade 3 and 4 thrombocytopenia will be allowed only if it is of immunological origin).
3.23 Active opportunistic infection and/or serious bacterial infection at the time of study entry. (Children may be enrolled after the acute phase).
3.24 History of clinical pancreatitis, peripheral neuropathy, or other clinical, hematologic, hepatic, or renal contraindications to receiving the trial therapies (i.e. impossibility to identify both a 2 NRTI + PI regimen and a 2 NRTI + NNRTI regimen that the child can take).
3.25 Current treatment with any medication known to be contraindicated with any of the drugs to be prescribed for the patient's initial therapy (one of the NNRTIs or the selected PI; refer to Appendix IX).
3.26 Receipt of any cytotoxic therapy for malignancy.

Co-Enrollment Guidelines
Children from PACTG sites may co-enroll in PACTG opportunistic infection, pharmacokinetics, or quality of life protocols, in which the study drugs offered are not contraindicated by PENPACT 1.
Co-enrollments require the assent of the Protocol Chairs of PENPACT 1 and the Chairs of the protocol(s) in which the child is co-enrolling. Co-enrollment in PACTG 219 is encouraged.
Co-enrollment in PENPACT 1-B Sub-Study will be only for PENTA children as part of the PENTA 9 study (see Appendix III). PACTG 390 children will not participate in this substudy.

Information and Informed Consent Forms
Separate sample informed consent forms will be designed for PACTG sites and PENTA sites. These sample consent forms will comply with all the applicable regulations in each country. All parents/guardians and children, where appropriate, will be given information about the intent and rationale of the study (Appendices XVI and XVII).
Written informed consent must be obtained from all participants and/or their parent(s)/guardian(s) (including LAR). Assent must be obtained from children, if appropriate, after explanation of the aims, methods, benefits, and potential hazards of the trial, and before any trial specific procedures are performed.
It must be made completely and unambiguously clear to parents that they are free to refuse to allow their children to participate in the trial. Moreover, that they are free to withdraw their consent at any time and for any reason, without incurring any penalty or affecting the treatment of their children.
For both PACTG and PENTA, signed informed consent forms must be kept by the site investigators and documented in the case report forms. A copy of the consent form will be given to the parent(s) or LAR (and child, if appropriate).

Eligibility
Potentially eligible patients should be seen for a screening visit (Week -2) within the two weeks before trial entry (Week 0). Eligibility should be confirmed and clinical and laboratory assessments undertaken (see Appendix I). Eligible children will be randomized at Week 0, according to a computer-generated randomization list. The randomization code will be held by a statistician and a systems analyst at PACTG and at each European Trials Center.

4.4
Study Treatment for First-Line Therapy: Children will be randomized to one of four groups that are defined by the initial therapy to be given to a child as well as the virologic criterion for switching from first-line therapy (defined below) to second-line therapy: • Group 1(A): Initial therapy is 2 NRTIs + PI (switch to second-line therapy when HIV-1 RNA is ≥1,000 copies/mL) • Group 1(B): Initial therapy is 2 NRTIs + PI (switch to second-line therapy when HIV-1 RNA is ≥30,000 copies/mL) • Group 2(A): Initial therapy is 2 NRTIs + NNRTI (switch to second-line therapy when HIV-1 RNA is ≥1,000 copies/mL) • Group 2(B): Initial therapy is 2 NRTIs + NNRTI (switch to second-line therapy when HIV-1 RNA is ≥30,000 copies/mL) First-line therapy includes the initial therapy to which a child is randomized as well as any antiretroviral therapies to which the child changes due to non-virologic reasons (e.g. toxicity, intolerability, request of child or child's parent(s) or LAR, etc.) prior to reaching the HIV-1 RNA switch criterion (≥ ≥ ≥ ≥1,000 copies/mL or ≥ ≥ ≥ ≥30,000 copies/mL, depending on the initial randomization). Whenever possible, changes within first-line therapy should involve substitutions of one or more drugs in the initial therapy by drugs from the same class or classes.
It is important to emphasize that the protocol will allow low doses of ritonavir as a boosting agent, creating drug combinations that will be counted as a single PI.
Below is a list of antiretrovirals allowed in PENPACT 1. All antiretrovirals will be obtained by prescription. The child, child's parent(s)/LAR, the child's health insurance, and/or, in Europe, the healthcare provider, are responsible for purchasing the study medications. NRTIs: • Appendix IX serves as a treatment guideline for clinicians, and gives background and dosing information for all the allowed medications, doses, and regimens. All the information in this appendix is to be used as a guideline for prescribing the child's regimen. However, complete and detailed prescribing and toxicity information, on all antiretroviral drugs, is available from the drug manufacturer in the USA and in Europe. Clinicians must review manufacturer's product information before prescribing any of these drugs, and contact the protocol team at actg.penpact1@fstrf.org with any discrepancies or queries.
The PENPACT 1 Team will review and update Appendix IX whenever new drugs, drug combinations, drug dosing, and/or drug-regimens are approved by the FDA and/or EMEA to ensure that clinicians have the most current options available for prescribing children's ARV regimens.
In general, dosage based on weight or body surface area will be recalculated at least every 12 weeks. When the weight or body surface area (BSA) changes so that the dose (in mg) differs by >10% from the previously dispensed dose, the dose must be adjusted. Doses may be changed at <10% difference based on site preference.

4.5
Study Treatment for Second-Line Therapy Second-line therapy will be initiated when the HIV-1 RNA switch criterion (≥ ≥ ≥ ≥1,000 copies/mL or ≥ ≥ ≥ ≥30,000 copies/mL, depending on the initial randomization) is reached. Section 5.0 describes the patient management criteria for therapy switch. The following suggested drug regimens will be strongly encouraged as second-line therapy for all children failing first-line therapy (when HIV-1 RNA is ≥1,000 copies/mL or when HIV-1 RNA is ≥30,000 copies/mL, depending on the initial randomization), particularly those children who have remained on their initial (randomized) therapy. Those antiretrovirals listed in Section 4.4 and Appendix IX will be used in selecting second-line therapy for each child.
• For PI containing Groups 1(A) and 1(B): two new NRTIs and an NNRTI • For NNRTI containing Groups 2(A) and 2(B): two new NRTIs and a PI However, these regimens do not constitute the only options. Current clinical care guidelines will prevail over protocol guidelines, (e.g. a fourth drug as part of second-line therapy). The protocol will allow low doses of ritonavir as a boosting agent, creating drug combinations that will be counted as a single PI.

Changes to First-Line Therapy
First-line therapy includes the initial therapy to which a child is randomized as well as any antiretroviral therapies to which the child changes due to non-virologic reasons (e.g. toxicity, intolerability, request of child or child's parent(s) or LAR, etc.) prior to reaching the HIV-1 RNA switch criterion (≥ ≥ ≥ ≥1,000 copies/mL or ≥ ≥ ≥ ≥30,000 copies/mL, depending on the initial randomization). Whenever possible, changes within first-line therapy should involve substitutions of one or more drugs in the initial therapy by drugs from the same class or classes.
If a child does not start their initial therapy as randomized, then any antiretroviral therapy that he/she starts constitutes his/her first-line therapy.
Regardless of the specific drugs being taken as part of the first-line therapy (including any changes from the initial therapy), a child should be followed on firstline therapy until he/she reaches the HIV-1 RNA criterion for switching to secondline therapy (as randomized).

5.2
Criteria for Changing from First-Line Therapy to Second-Line Therapy While on first-line therapy, a child who: • fails to achieve his/her randomized HIV-1 RNA level for switching therapy by Week 24 (i.e. to <1,000 or to <30,000 copies/mL), or • experiences an initial decline in plasma HIV-1 RNA levels by Week 24 or later, and subsequently has an HIV-1 RNA level at or above his/her randomized level for switching therapy (i.e. at HIV-1 RNA either ≥1,000 or at ≥30,000 copies/mL), PENPACT 1 VERSION 3.1 FINAL 07/11/07 must have a confirmatory HIV-1 RNA determination obtained between 14 and 35 days post initial HIV-1 RNA determination. If the confirmatory value is below the randomized HIV-1 RNA level for switching therapy, first-line therapy and the schedule of evaluations for first-line therapy should be continued as per Appendix I. If the confirmatory value is greater than or equal to the randomized HIV-1 RNA level for switching therapy, the child should switch to second-line therapy. However, if poor adherence is suspected as a possible reason for an increase in HIV-1 RNA above the randomized HIV-1 RNA level for switching therapy, then the site should try to improve adherence and subsequently obtain the confirmatory HIV-1 RNA value. This should be accomplished within a five week time frame.
Additionally, if at or after 24 weeks of first-line therapy a child experiences clinical disease progression (i.e. a new CDC Category C diagnosis) or experiences other clinical progression (such that the treating clinician believes that changing therapy is required prior to reaching the randomized HIV RNA viral load switch point), then the child should switch to second-line therapy.
PACTG sites should contact one of the PACTG 390 Protocol Co-Chairs to discuss and request authorization for switching therapy, including intentions to try to improve adherence before making the decision to switch therapy. PENTA sites should contact the appropriate Trials Center prior to switching therapy. Sites should e-mail or fax this request to the PENPACT 1 Team log-on (actg.penpact1@fstrf.org) and copy either the PACTG 390 Protocol Co-Chairs or the appropriate PENTA Trials Center.
This request for switching therapy must clearly describe the patient's clinical evaluation and clinician's choice(s) for second-line therapy. All supportive clinical, laboratory, and medical history records must be included in this request. The PACTG 390 Protocol Co-Chairs or the PENTA Trials Center will respond to this request upon receipt. A telephone conversation may be needed to finalize the choice for second-line therapy. However, the PACTG 390 Protocol Co-Chairs or the PENTA Trials Center must send an e-mail to the patient's clinician with a copy to the PENPACT 1 Team log-on (actg.penpact1@fstrf.org) stating the final choice of and rationale for second-line therapy. This notification/consultation is required by the protocol to enable the PENPACT 1 Team to have better control of the study (e.g., double checking that the switching point has indeed been reached and that second-line therapy has been selected correctly).
For children starting second-line therapy, restart the schedule of evaluations from the Entry visit (Week 0). Note that certain evaluations may not be required on second-line therapy; please pay special attention to all Appendix I footnotes.

Criteria for Discontinuing First-Line Therapy
It is intended that children will be followed on their first-line therapy until they meet the criteria for switching to second-line therapy, regardless of any changes in ARVs constituting their initial therapy. If, at the time the child meets the virologic switch criterion, and the child, child's parent(s) or LAR choose not to switch to second-line therapy, then the subject will be considered to be off study treatment but on study, and will continue to be followed according to the schedule of evaluations.

5.4
Criteria for Discontinuing Second-Line Therapy: Second-line therapy includes any antiretroviral therapy that the child receives after failing first-line therapy (according to the criteria defined in Section 5.2) until the child next experiences virologic failure or disease progression as defined below. Wherever possible, changes in second-line therapy should involve substitutions of one or more drugs from the same class or classes as the child is already taking.
While on second-line therapy, a child who: • fails to achieve <30,000 copies/mL HIV-1 RNA by Week 24 of second-line therapy, or • experiences initial decline in plasma HIV-1 RNA by Week 24 of second-line therapy, and subsequently has an HIV-1 RNA level >30,000 copies/mL must have a confirmatory HIV-1 RNA determination obtained between 14 and 35 days post initial HIV-1 RNA determination. If the confirmatory value is also >30,000 copies/mL, then the child will be considered to have failed second-line therapy.
Additionally, if at or after 24 weeks of second-line therapy, a child experiences clinical disease progression (i.e. a new CDC Category C diagnosis) or experiences other clinical progression (such that the treating clinician believes that changing therapy is required prior to reaching the randomized HIV-1 RNA viral load switch point), then the child will also be considered to have failed second-line therapy.
When a child fails second-line therapy (except as defined below) the child will discontinue study treatment, but continue on study follow-up. The child should then be offered the best available, individualized therapy at the discretion of the child's clinician and parent(s) or LAR. This new therapy will not be managed as part of PENPACT 1. However, if in the clinician's opinion the second-line therapy is the best available therapy (despite an HIV-1 RNA value ≥ ≥ ≥ ≥30,000 copies/mL), the patient will be allowed to continue on study treatment for as long as the clinician deems appropriate.
Children who discontinue second-line therapy for any reason should, if possible, The PACTG and PENTA teams will exchange and review data regarding serious adverse events every three months. The data will include, at minimum, event description, start and resolution dates, grade of the clinical or laboratory abnormality, classification of the AE for PACTG and PENTA, and action taken. These data exchanges will be coordinated by the PENPACT 1 protocol statisticians at SDAC (Statistical and Data Analysis Center) for PACTG sites and MRC and INSERM for PENTA sites.

6.2
Criteria for Management of Adverse Events/Toxicity and Dose Modification Both PACTG and PENTA sites will manage any adverse event/toxicity following the guidelines described in this section and in Appendix X "Management of Specific Adverse Events for PACTG and PENTA". Furthermore, both PACTG and PENTA sites will refer to the Division of AIDS Toxicity Tables for Grading Severity of Adverse Experiences in Appendices IV and V for severity grades associated with toxicity management and dose modification and/or discontinuation.
Only Grade >2 toxicities or higher will be collected on PENPACT 1 (PACTG 390 or PENTA 9) study forms.
For all questions regarding any toxicity, consult the PACTG 390 Protocol Co-Chairs (PACTG sites) or Trials Center (PENTA sites). Send an e-mail message to actg.penpact1@fstrf.org, including the PID, the SID, the question, and a brief, relevant history and the appropriate team member will answer.
6.21 Management of Specific Adverse Events: The following specific adverse events must be managed as per Appendix X: • All antiretrovirals prescribed for first-line and second-line therapies will be considered study drugs. Alternate explanations for clinical or laboratory abnormalities that may at first appear to be related to study treatment must be sought. The use of reduced doses of the study medications is discouraged and should be avoided.
Management of any other adverse event/toxicity that is not covered by Appendix X must be done as per the following criteria. For abnormal clinical or laboratory observations of: 6.221 Grade 1 • Continue study drugs.
• Monitor closely with more frequent visits (i.e. every two weeks).
• Work-up to exclude other causes. • Subjects should continue taking study drugs pending receipt of the confirmatory laboratory tests.
• Work-up to exclude other causes.
• Clinician has the option of immediately stopping the study drugs if a repeat confirmatory laboratory test cannot be performed within 72 hours, or if the clinician determines that the continuation of study drugs is unsafe while awaiting test results.
• Subjects will be allowed to interrupt study treatment for up to 14 days.
• If toxicity persists at Grade 3 for more than 14 days, recurs on rechallenge, or after replacing a specific drug, all study drugs must be permanently discontinued. If the child was on first-line therapy at the time of drug discontinuation, then a new first-line regimen may be initiated and the child should continue to be followed on first-line therapy. The selection of the new regimen will be done PENPACT 1 VERSION 3.1 FINAL 07/11/07 while the child is off study drugs. Clinicians must discuss regimen options with the PACTG 390 Protocol Co-Chairs (PACTG sites) or Trials Center (PENTA sites). Send an e-mail message to actg.penpact1@fstrf.org including the new drug options. The appropriate PENPACT 1 team member will respond. This change in therapy due to toxicity will not constitute a "switch" from firstline to second-line therapy. If the child was on second-line therapy at the time of drug discontinuation, then a new second-line regimen may be initiated and the child should continue to be followed on second-line therapy.

Specific for All Confirmed Grade 3 Toxicities
• That can not be attributable to only one of the study drugs, stop all study drugs until toxicity resolves to ≤Grade 2, then re-start therapy (all study medications).
• That can be clearly attributable to a specific drug in one class (NRTI, PI or NNRTI), stop all study drugs until toxicity resolves to ≤Grade 2. Then, restart therapy but discontinue the implicated drug permanently and continue all other medications. Replace the specific drug with another in the same class.
The selection of the new drug for this replacement will be done while the child is off study medications. Clinicians must discuss the drug options with the study Co-Chairs (PACTG sites) or Trials Center (PENTA sites). Send an E-mail message to actg.penpact1@fstrf.org establishing the new drug options. The appropriate PENPACT 1 Team member will respond. This change in therapy due to toxicity will not constitute a discontinuation of first-line or second-line therapy.

Grade 4 (See Clarification Note)*
• Hold study drugs and notify study team to determine course of action • For all confirmed Grade 4 toxicities that can be undeniably and clearly attributable to a specific drug in one class (NRTI, PI or NNRTI), stop all study drugs until toxicity resolves to ≤Grade 2. Then, restart therapy but discontinue the implicated drug permanently and continue PENPACT 1 VERSION 3.1 FINAL 07/11/07 all other medications. Replace the specific drug with another in the same class. The selection of the new drug for this replacement will be done while the child is off study medications. Clinicians must discuss the drug options with the study Co-Chairs (PACTG sites) or Trials Center (PENTA sites). Send an E-mail message to actg.penpact1@fstrf.org establishing the new drug options. The appropriate PENPACT 1 Team member will respond. This change in therapy due to toxicity will not constitute a discontinuation of firstline or second-line therapy.
• Subjects will be allowed to interrupt study treatment for up to 14 days • If toxicity persists at Grade 4 for more than 14 days, recurs on rechallenge, or recurs after replacing a specific drug, all study drugs must be permanently discontinued. If the child was on first-line therapy at the time of drug discontinuation, then a new first-line regimen may be initiated, and the child should continue to be followed on first-line therapy. The selection of the new regimen will be done while the child is off study drugs. Clinicians must discuss regimen options with the PACTG 390 Co-Chairs (PACTG sites) or Trials Center (PENTA sites). Send an e-mail message to actg.penpact1@fstrf.org including the new drug options. The appropriate PENPACT 1 team member will respond. This change in therapy due to toxicity will not constitute a "switch" from firstline to second-line therapy. If the child was on second-line therapy at the time of drug discontinuation, then a new second-line regimen may be initiated and the child should continue to be followed on second-line therapy. Case Report Forms (CRF) will be provided for each child. Children must not be identified by name on any study documents, but by trial number for PENTA sites and by the PID and SID provided by the ACTG Data Management Center for the PACTG sites at randomization.
All data on the CRFs must be legibly recorded in black ink or typed. A correction should be made by striking through the incorrect entry with a single line and entering the correct information adjacent to it. The correction must be initialed and dated by the investigator or a designated, qualified individual. Any requested information that is not obtained as specified in the protocol should have an explanation noted on the CRF as to why the required information was not obtained.
Instructions concerning the recording of study data or the entry of such data into the computerized data base will be provided by the ACTG Data Management Center (PACTG sites) and by the Trials Centers (PENTA sites).

Trial Coordination
At sites affiliated with the PACTG, the trial will be coordinated by Frontier Science and Technology Research Foundation.
In Europe, the trial will be coordinated jointly by two coordinating Trials Centers at the MRC Clinical Trials Unit, London, and at INSERM, SC10, Paris, under the auspices of PENTA. The liaison between the coordinating trial centers and centers in each country for running the study will be similar to that organized for other PENTA trials, with a combination of direct liaison and liaison via local coordinating centers.
The lead study statisticians from both PACTG and PENTA will be jointly responsible for defining the structure of the merged data (PENPACT 1) and the contents of the interim and final analysis and statistical reports.
The responsibility for finalizing the merged data, undertaking the statistical analysis, and preparing and distributing the report for each interim analysis to the DSMB will alternate between the PACTG and PENTA statistical centers. The lead statisticians from both organizations will attend all DSMB meetings.

Regional Monitoring
Monitors under contract to NIAID or NICHD will visit PACTG-affiliated clinical sites.
In Europe, for PENTA sites, monitoring will be undertaken by each clinical center under the guidelines and supervision of the MRC or INSERM depending on the country.

39
PENPACT 1 VERSION 3.1 FINAL 07/11/07 PACTG and PENTA monitors will review the research records for accuracy, completeness, and legibility. They will inspect sites' regulatory files and pharmacies to ensure that regulatory requirements are being met, and will review all research records for the status of new enrollments to determine if any improvements are needed at a specific site. For confirmation of the study data, site investigators must make study documents (e.g., consent forms, drug distribution forms, and CRFs), and pertinent hospital or clinic records readily available for inspection by the site monitors, the FDA (PACTG affiliated sites), and the EMEA (European sites).
Site visits will be made at main units and the larger sub-units at regular intervals or more frequently as directed by NIAID, NICHD or PENTA.
8.0 DRUG ACCOUNTABILITY AND ADHERENCE

Accountability
For PACTG sites accountability records will not be needed. Study medications will not be provided by the study but by prescription (the child, child's parent(s)/LAR, the child's health insurance, and/or, in Europe, the healthcare provider, are responsible for purchasing the study medications).
For PENTA sites, the trial pharmacist is required to maintain complete records of all study medication dispensed. The procedures to be followed will be sent directly to the trial pharmacist and will adhere to the Good Clinical Practices (GCP) guidelines on drug accountability.

Adherence
To date, there is no gold standard for the assessment of adherence. Adherence assessment strategies commonly used are self-report, pill counts, electronic monitoring, urine and serum assays, and the addition of tracers to liquid medications. Each of these methods is imperfect and subject to error.
The more accurate methods are more expensive and labor intensive, as are combinations of these methods. However, due to the critical nature of the problem, the PACTG Adherence Subcommittee has piloted two measures of self-reported adherence: Adherence Modules 1 and 2. The PENTA group has also piloted an adherence questionnaire for self-completion.
Self-reported data are clearly subject to a number of biases, but, within the context of large clinical trials, self-reporting provides pragmatic means for estimating adherence rates.
In PENPACT 1, the parent(s)/LAR will receive instructions as to the appropriate administration of study drugs and must demonstrate the ability to dispense the study drugs prior to receiving the child's drug supply.

General Design Issues
This is an international, multi-center Phase II/III, randomized, open-label, clinical trial. It uses a factorial (2x2) design to allow separate comparisons, specified in the primary and secondary objectives, to be evaluated.

Primary Outcome Measure
The primary outcome measure to be used in addressing the two primary objectives is change in viral load measured in log 10 HIV-1 RNA copies/mL between baseline and four years post-randomization.
The average of the pre-entry and entry values will be used for baseline, and the average of the values obtained at Weeks 192 and 204 will be used for the concluding viral load. Missing values will be handled as defined later in this statistical section.

Secondary Outcome Measures
The following outcome measures are those required to evaluate each of the secondary objectives: • Number of Grade 3 or higher signs, symptoms, or laboratory abnormalities experienced.
• Change in immunologic outcome will be defined as the change in CD4% from baseline (mean of pre-entry and entry values) to four years (mean of values at Weeks 192 and 204).
• Time to a significant HIV-related clinical event will be defined as the time to first new CDC Category C diagnosis (except for re-current bacterial infections).
• Whether or not a child switched regimens.
• Time to HIV-1 RNA >400 copies/mL during first line-therapy or permanent discontinuation of first-line therapy. Defined as time from randomization to first of two consecutive evaluations after Week 24 with measurement of >400 copies/mL while on first-line therapy, or to permanent discontinuation of the first-line therapy for any reason, whichever event comes first.
• Time to HIV-1 RNA ≥ 30,000 copies/mL during second line-therapy or permanent discontinuation of second-line therapy. Defined as time from randomization to the first of two consecutive evaluations with measurement >30,000 copies/mL while on the second-line therapy, or to permanent discontinuation of the second-line therapy PENPACT 1 VERSION 3.1 FINAL 07/11/07 for any reason, whichever event comes first.
• Whether or not a child has an HIV-1 RNA level <400 copies/mL at Week 24 and has not permanently discontinued first-line therapy prior to that week.
• Whether or not a child has an HIV-1 RNA level <400 copies/mL at Week 204 regardless of therapy at that time.
There will be a continued statistical follow-up beyond 204 weeks of treatment, which will be used to address time-to-event secondary objectives of the study.

Randomization and Stratification
Children will be randomized to four groups stratified by age (<3 years versus ≥3 years), origin (PACTG sites or PENTA sites), and exposure versus no exposure to antiretroviral therapy perinatally.
Thus, PENPACT 1 children will be randomized to one of four groups, in a 2x2 factorial design. The randomization will be stratified by: (1) age (prior to 3 rd birthday versus on or after 3 rd birthday), (2) site (PACTG versus PENTA), and (3) perinatal exposure to antiretroviral therapy (exposed, defined as less than 56 consecutive days after birth of antiviral drugs used to prevent mother-to-infant transmission) versus naïve or not exposed.
There will be no limits on the number accrued to each stratum.

Sample Size and Accrual
The study is designed to accrue a total of 256 children. Each of the pairwise comparisons of randomized groups in the factorial design will therefore involve comparisons between two groups each of size 128 children.
The power to detect a difference in mean change in HIV-1 RNA from baseline to four years will depend on the proportion of children who have HIV-1 RNA levels below the limit of quantification of the assay (400 copies/mL) at that time. If no child has a level below this limit, then it is estimated that there will be at least 90% power to detect a difference between groups of 0.3 log 10 HIV-1 RNA copies/mL using an 0.05 level of significance, and assuming up to 10% of children will have no HIV-1 RNA measurements at 4 years.
This estimate of power is based upon a standard deviation of 0.7 log 10 HIV-1 RNA copies/mL at four years post-randomization, after adjusting for baseline viral load. This standard deviation was obtained in the Delta study among 330 adults at 96 weeks, and in PACTG 152 among 47 children at 144 weeks, treated with NRTIs. If the standard 42 PENPACT 1 VERSION 3.1 FINAL 07/11/07 deviation is larger than 0.7 log 10 copies/ml, then there will still be good power to detect small but clinically relevant differences in pair-wise comparisons. For example, if the standard deviation is 0.8, 0.9 or 1.0 log 10 copies/ml, then there will be at least 90% power to detect differences of 0.34, 0.38 and 0.43 log 10 copies/ml, respectively.
With moderate proportions of children in either or both groups with HIV-1 RNA levels below the limit of quantification of the assay, the power will be reduced modestly. For example, using results presented by Hughes (21) with 40% of children with censored measurements (HIV RNA below the lower limit of detection or above the upper limit of detection), there will be at least 90% power to detect a difference between groups of about 0.5 log 10 copies/mL. This number of children will also allow detection of a minimal difference of 3.2% for change in CD4% from baseline to 4 years post-randomization between each of the pair wise comparisons with the same power and alpha levels, assuming the standard deviation of the change in CD4% from baseline to 4 years is 7.5% (the standard deviation of the change in CD4% from baseline to Week 96 in PACTG 338).

Routine Monitoring
Routine monitoring will be conducted to keep the study team informed about progress of the study without revealing information on efficacy outcomes.
During the accrual phase of the study, routine reports summarizing accrual, losses to followup, and completeness of data collection pooled across all randomized Groups will be reviewed by the study team on a monthly basis.
When accrual is complete, the frequency of reporting will be reduced to every three months.
In the event that the team is notified of any serious adverse experiences or deaths that cause concern to the team, then a review by the Data and Safety Monitoring Board will be requested.

Interim Analyses
An independent Data and Safety Monitoring Board (DSMB) will be established, PENPACT 1-DSMB. There will be equal representation of PACTG and PENTA nominees on the DSMB. PENTA will provide the names of three PENTA representatives to the DSMB, and DAIDS will name three representatives from the current DAIDS Therapeutic DSMB (TDSMB).
PENPACT 1-DSMB will review the study data at least once a year and may request 43 PENPACT 1 VERSION 3.1 FINAL 07/11/07 more frequent interim safety or efficacy reviews as needed. The PENPACT 1 Team may request additional DSMB safety reviews if needed. The PENPACT 1-DSMB will follow the SOP of the DAIDS Therapeutic DSMB (TDSMB).
No member of the U.S./European executive committee for the trial, and no clinician (investigator) responsible for the clinical care of trial patients, involved in PENPACT 1 will be a member of the PENPACT 1-DSMB.
The PENPACT 1-DSMB will review study data every 12 months (or as often as needed), in strict confidence, on the activity, efficacy, and toxicity measures by treatment allocation and will advise the PENPACT 1 Team on whether the number of individuals to be recruited is appropriate.
The PENPACT 1-DSMB may initiate interim analyses for activity, efficacy, and toxicity. One detailed interim analysis will be undertaken when half the children have been followed for two years.
The PENPACT 1-DSMB will also consider the findings from other relevant studies and will advise the executive committee if, in their view, the data have provided both: • Proof beyond reasonable doubt 4 that one of the randomized factors is better in terms of the primary outcome, and • Evidence that might be reasonably expected to materially alter the uncertainties of clinicians, who are already aware of the results of other trials.

Analysis
All analyses will be based on intention to treat except for toxicity analyses, when followup will be censored eight weeks after treatment is stopped.

Primary Analysis
Primary comparisons (NNRTI versus PI; 1,000 versus 30,000 HIV-1 RNA copies/mL for change of treatment) with respect to change in HIV-1 RNA from baseline to four years will be performed using analysis of covariance. The analysis will adjust for baseline viral load and the three stratification factors. As values below the limit of quantification of the assay will be considered as censored measurements, the analysis will use likelihood-based methods for censored data.
PENPACT 1 VERSION 3.1 FINAL 07/11/07 The above analysis will include children who die from HIV-related causes before completing four years in the study taking their baseline HIV-1 RNA level as their measurement at four years, but otherwise will exclude subjects who have missing values for HIV-1 RNA at four years, and may be sensitive to the handling of censored measurements if the proportion of censored measurements is high. However, the sensitivity of the conclusions of the study to these two issues will be evaluated using two methods: • For a child with missing viral load at 4 years, let T be the time from randomization to the last available HIV-1 RNA measurement. The extrapolated value of viral load at 4 years can be taken as the viral load predicted from the linear regression model for viral load measurements from baseline to time T extrapolated out to 4 years, using data from all children in the same treatment group.
These extrapolations, which assume missing at random but not necessarily missing completely at random, will lead to a slight underestimation of the standard error of the treatment effect, which can be ignored if the proportion of children dead or lost to followup is small. Alternatively, multiple imputation methods can be used to adjust standard errors.
• A rank based analysis will be undertaken. Children will be ranked according to their HIV-1 RNA level, including censored measurements, at four years. Children who died prior to four years will be ranked as worse outcomes than any child who survives to four years, with a worse ranking for deaths closer to the date of randomization.
The sensitivity of results to children who are lost to followup will then be investigated by three different approaches: ranking loss to followup at time T as equivalent to death at time T (this is a severe approach), using the average of the last two observations carried forward, and using the linear regression model of a subject's measurements over the period baseline to time T to give an extrapolation to time T.

Secondary Analyses
Prior to any formal interim analysis and to the final analysis, a detailed analysis plan will be prepared. The following summarizes the general approach to analysis that will be used for the different types of secondary outcome measures.
For continuous outcomes (e.g. CD4%), analysis of covariance in a similar way to that described above for changes in HIV-1 RNA will be used. For repeated measurements over time, the area under the curve will also be calculated and compared between randomized Groups. 45 PENPACT 1 VERSION 3.1 FINAL 07/11/07 For binary outcome measures (e.g. whether or not a child switched regimens), chi-squared tests (stratified by factors used in the randomization) will be used to compare randomized Groups, and logistic regression adjusted for these stratification variables will be used to provide estimates of effect.
For counts of events (e.g. number of adverse experiences, or number of regimen switches), stratified chi-square tests or Wilcoxon tests will be used to compare randomized Groups, and Poisson regression adjusted for stratification variables and duration of followup will be used to provide estimates of effect.
For time-to-event outcome measures (e.g. time to HIV-1 RNA ≥400 copies/mL or treatment discontinuation while on first-line therapy), stratified log-rank tests will be used to compare randomized Groups, and Kaplan-Meier estimates and stratified proportional hazards modeling will be used to provide estimates of effects.

Declaration of Helsinki
The PENTA 9 trial (the European portion of PENPACT 1) will conducted in full conformance with the principles of the Declaration of Helsinki (as amended in Tokyo, Venice, Hong Kong and Edinburgh), and with the local laws and regulations concerning clinical trials.

PACTG Institutional Review Board (IRB) Review and Informed Consent
This protocol document and the PACTG sample informed consent documents (Appendices XVII and XVIII), as well as any subsequent modifications, will be reviewed and approved by the IRBs or ethics committees responsible for oversight of the study.

Each site which receives US HHS funding and follows the United States Code of Federal Regulations Title 45 -Public Welfare, Part 46 -Protection of Human
Subjects (also known as the Common Rule) should have on record at the site a plan that detects and addresses any change in guardianship occurring in pediatric subjects and determines when a study subject must have a consent process which involves a LAR other than a family member with guardianship. The plan will include how the site determines when a LAR is initially or no longer needed and how frequently the LAR resigns the consent. The plan should follow all IRB, local, and state guidelines. Confirmation of such a plan at a site should be submitted with protocol registration materials. At each center, one pediatrician (the investigator) will take on overall responsibility for the conduct of the trial. He/she will submit the protocol and any subsequent amendments to the ethics committee.
This protocol, the informed consent documents and adherence questionnaire will be formally approved by the relevant ethics committee of each clinical center. Before the study can start, the center must send a signed copy of the Investigator's Agreement to Participate. The study will not commence in any country until appropriate approval has been obtained from the appropriate Regulatory Approval.

Confidentiality
All laboratory specimens, evaluation forms, reports, and other records will be identified only by a coded number to maintain confidentiality. All records will be kept in locked file cabinets. All computer entry and networking programs will be done with coded numbers only. Clinical information will not be released without written permission, except as necessary for monitoring by the trial monitors, the FDA, the NIAID or the EMEA.

PACTG Study Discontinuation:
The PACTG 390 portion of PENPACT 1 study may be discontinued at any time by the NIAID, the FDA, or the PACTG Protocol 10.6 PENTA Study Discontinuation: The PENTA 9 portion of PENPACT 1 study may be discontinued at any time by the EMEA or the PENTA Executive Committee.

PUBLICATION OF RESEARCH FINDINGS
The PENPACT 1 Team will be responsible for preparing the manuscript for rapid publication. The authorship will be under PENPACT 1 Team. No other publications, either written or verbal, will be made before the definitive manuscript has been accepted for publication without approval of the PENPACT 1 Team.
PACTG and PENTA will share all the data from PACTG 390 and PENTA 9. The merged data will be the property of both organizations, and this policy will be reflected in all publications deriving from these data. Publication of unmerged PENPACT 1 data, data from PACTG 390, PENTA 9, or PENPACT 1 manuscript, will be allowed independently from the main PENPACT 1 manuscript, but only after approval review by the PENPACT 1 Team.

PENPACT 1 VERSION 3.1 FINAL 07/11/07
The data from PENTA 9--PENPACT 1-B Sub-study of lipodystrophy will be the property of PENTA, but will be shared with the whole PENPACT 1 Team before publication.

SAMPLES CLARIFICATION
All laboratory samples collected at PACTG sites will be managed and/or stored as per PACTG guidelines.
All laboratory samples collected at PENTA sites will be managed and/or stored as per PENTA guidelines following the corresponding country laws and regulations.
There will be no exchange, aliquoting, or storing of PACTG samples with PENTA or vice-versa. Samples will be used for tests described in the samples informed consent for each organization. Testing of samples for non-authorized assays other than what is signed in the informed consent will not be allowed. Both informed consents clearly state that testing of stored samples will be for future PACTG or PENTA approved AIDS related research; no other testing will be allowed.

BIOHAZARD CONTAINMENT
Transmission of HIV and other blood-borne pathogens can occur through contact with contaminated needles, blood, and blood products. Appropriate blood and secretion precautions must be employed by all personnel when drawing blood, shipping and/or handling of all specimens for this study, as currently recommended by the CDC.
For PACTG sites, since the International Air Transportation Association (IATA) regulations for the shipment of HIV containing specimens are currently being updated (March 2003), please refer to the each individual carrier gudelines (e.g. FedEx, Airborne) and the ACTG Website for specific instructions and shipping guidelines for these specimens.

PENTA CENTERS LIABILITY/INSURANCE
In consideration of the agreement by the Principal Investigator at each site to supervise the trial, the PENTA Group undertake to indemnify the Principal Investigator at each site and the institutions which participate in the trial and their servants and agents in respect of any claims made against them by any third party which arises out of or as a result of the supervision or conduct of the trial (including any claim arising in respect of the technical procedures described in the protocol which patients/subjects would not have been exposed but for their participation in the trial). Full details of the Indemnity agreement are given in a separate document.  Signed Consent X Hematology ( Max. Blood (mL) 10.
Hematology ( Max. Blood (mL) 10.5 6.5 10.5 6.5 10.5 6.5 10.5 6.5 10.5 6.5 15.5 10.5 (1) The physical exam includes height and weight determinations (for PACTG sites, follow instructions in Appendix XIV; for PENTA sites, follow procedures described in Appendix III), head circumference (only for children <3 years of age, and should be done for both PACTG and PENTA sites, as per Appendix XIV), and HIV assessment.
(2) The Tanner Scale evaluation will be applied to any child (a) weighing ≥30 kg or (b) >9 years of age (see Appendix XV).
(3) A neurological exam will be performed for children at domestic and international PACTG sites only at indicated time points and whenever there is a neurological problem. For those subjects who are off study treatment but on study follow-up, the neurological examination only needs to be completed whenever there is a neurological problem.
(4) The pregnancy test can be either a urine sample or blood sample test (HCG). This test will be performed for all females of childbearing PENPACT 1 VERSION 3.1 FINAL 07/11/07 APPENDIX I (Cont) potential at indicated time points. The initial pregnancy test must be done within 72 hours of enrollment and the results must be received before starting study medications. (5) The hematology blood samples should be collected in EDTA tubes. These samples will be analyzed for complete blood counts, cell differential, and platelet counts. (6) The chemistry blood samples should be collected in anticoagulant free tubes. These samples will be analyzed for creatinine, total bilirubin, ALT (SGPT), AST (SGOT), triglyceride, cholesterol, glucose, and total amylase levels. (7) The lymphocyte subset blood samples should be collected in EDTA, Hep, or ACD tubes. These samples will be analyzed for CD3+4, +CD3+8, and CD19, if possible. For both PACTG and PENTA sites: The stored plasma and PBMC specimens will be used for PACTG and PENTA-approved AIDSrelated assays. Follow Appendices VII and VIII for collection, processing, and shipping instructions.
(11) An extra 5 mL (9 mL total) EDTA blood sample will be collected at Switching Therapy/Study Termination. These samples will be used for genotyping and pharmacokinetic assays for retrospective analysis, as determined by the PENPACT 1 Team. These samples will be processed to collect plasma and PBMC for storage. (12) The urinalysis test will be performed using the reagent strip method. (13) For PACTG sites, adherence will be determined by Adherence Modules 1 and 2. For PENTA sites, adherence will be determined by the Self-Completion Adherence Questionnaire. (15) For children <3 years of age at study entry, any assessment that included the Bayley, and was done under clinical care within 20 weeks before the Entry visit, will be acceptable. For children ≥ 3 years of age at study entry, any assessment that included the WPPSI-III, WISC-III, or WAIS-III, and was done under clinical care within 20 weeks before the Entry visit, will be acceptable. However, if the test results found the child neurologically unstable, a new neuropsych assessment must be performed at the Entry visit. If a new neuropsych assessment is necessary based on the above criteria, it must be completed within +/-30 days of the Entry visit.
PENPACT 1 VERSION 3.1 FINAL 07/11/07 APPENDIX I (Cont) (16) The neuropsych assessment will be repeated at Week 24 for children who are <6 years of age at the initial assessment. Children who are >6 years of age at the time of assessment will have neurodevelopment testing every 48 weeks. Children who are >6 years of age, after week 48 assessment, will have neurodevelopment assessment testing every 96 weeks. (See Appendix XIII). For children <6 years of age at the time of the actual study visit, any neuropsych testing performed within 8 weeks of the actual visit will be acceptable. For children ≥ 6 years of age at the time of the actual study visit, any neuropsych testing performed within 16 weeks of the actual visit will be acceptable. The interval between any two consecutive neuropsych evaluations should be at least 20 weeks.
(17) Any child enrolled in the study under Version 1.0 who was assessed with the WPPSI-R, the CPRS-48, or the CES-D test should continue being evaluated with same test for the rest of the study, as long as it is age appropriate. Otherwise, the new guidelines should be used. All other tests should be changed to the evaluations in Appendix XIII.
(18) Yearly testing for children ≤ 3 years age and every other year for children >3 years of age at the time of testing. (19) The screening visit should be completed within 14 days before randomization (samples can be taken as early as 24 hours prior to study entry visit).
(20) For PACTG sites, the Entry visit for initial therapy must be completed within 72 hours of randomization, and the study regimen must also be started within 72 hours of randomization. For PENTA sites, the Entry visit for initial therapy must be completed within 72 hours of randomization; however, the study regimen may start within two weeks of randomization.
(21) From the Week 4 study visit on, a 2 week window (+/-1 week) for the study visit will be allowed (e.g. Week 4 visit could be at Week 3, 4, or 5).
(22) All children will remain in the study until the last child enrolled into PENPACT 1 has reached 204 weeks on treatment from his/her original randomization. This last patient could be from a PACTG or PENTA site. Thus, the study visit may be longer than 360 weeks for the early enrollees. After subjects have initiated second-line therapy, the schedule for study visits re-starts at the Entry visit as per first-line therapy.

NOTES:
• For Screening and Entry visits, all necessary blood samples must be collected for all laboratory tests and for storage.
• For insufficient blood draws at all other study visits, priorities are as follows: (1) RNA (particularly aliquots at key time points noted in footnote 9), (2) hematology, (3) chemistries, (4) plasma for storage, and (5) lymphocyte subsets. • When subjects stop initial or second-line therapy, all clinical, virology, and immunology evaluations should be performed. Furthermore, when subjects start second-line therapy after more than two weeks of stopping initial therapy, all of these evaluations should be performed again.

Introduction
Since 1998 a newly described syndrome has emerged in HIV-infected patients treated by antiretroviral therapy (ART) [1][2][3]. Although a case definition has not been formally agreed, the lipodystrophy syndrome encompasses a variety of abnormalities including: -abnormal distribution of adipose subcutaneous tissue with the development of abdominal adiposity and peripheral wasting -changes in glucose tolerance with insulin-resistance and severe dyslipidaemia.
The role of the different antiretroviral drug classes is still a matter of debate. Although it seems likely that treatment strategies such as 3 or 4 drug Antiretroviral Therapy (ART) contribute to the development of the syndrome, in adults non drug related host and disease factors have also been identified to be important in both fat accumulation and fat loss [4,5]. Whilst a number of studies have reported the use and duration of either protease inhibitors (PI) and/or nucleoside analogue reverse transcriptase inhibitors (NRTI) to be associated with lipodystrophy [2,6,7], whether these drugs should be regarded as promoting factors or direct toxic agents remains to be clarified.
One of the difficulties is assessing causal factors is that the lipodystrophy syndrome has been mostly studied through cross-sectional studies of patients with different duration of infection and treatment regimens. Prevalence of fat redistribution of up to 60% of adults on 3 or 4 DRUG ART has been reported, although the frequencies vary enormously with the study population. In adults under treatment for at least 2 years prevalences of around 40-50% have been reported in adults receiving PI-based ART compared with around 25-30% of those not receiving non-PI based ART, and around 5% in naive persons. Clearly, the lack of a validated case definition hampers comparison across different studies. Further, assessment of determinants of lipodystrophy is complicated by the different methodologies and scales of severity used to assess its components across studies.
In children, the European Collaborative Study estimated a 28% prevalence of fat redistribution in 374 children based on clinical report [8]. Similar prevalences have been reported in 49 children in Spain based on dual X-ray absorptiometry (DEXA) (24%) [9]. The systematic observation of 128 children at Hôpital Necker suggested that the lipodystrophy syndrome occurred as frequently in children as in adults (50%), the major difference being that all symptoms were observed with a lesser degree of severity (Levy Marchal, personal communication). Both clinical lipodystrophy and metabolic abnormalities, primarily insulin-resistance, have been reported to worsen at puberty.
The first lipodystrophy case definition study has recently been completed (the HIV LD Case Definition Study) [10]. It identified 10 parameters (measured locally) which could diagnose lipodystrophy in adults with 79% sensitivity and 80% specificity; age, gender, HIV duration, CDC stage, waist:hip ratio, anion gap, HDL cholesterol, trunk:peripheral fat ratio and leg fat percentage on DEXA, and visceral:subcutaneous abdominal fat ratio (VAT:SAT) by CT at the L4 level. Waist:hip ratio is not thought useful in children because of differing body shapes. MRI is preferred to CT in children due to the radiation dose. Although the proposed adult case definition includes measurements based on both DEXA and CT [10], work refining a clinical definition is continuing. Systematic documentation of clinical features of paediatric lipodystrophy will enable comparisons to be made with future clinical adult definitions.

Primary objectives
The primary objective of the sub-study is to document the development and the progression of the lipodystrophy syndrome in the European children included in PENPACT-1, considering body fat redistribution, dyslipidaemia and insulin-resistance.
The specific objectives are • to calculate the incidence of lipodystrophy syndrome in ART-naïve children initiating 3 or 4 drug ART • to compare incidence rates between children receiving PI versus NNRTI based ART as their first regimen (both on a dual NRTI backbone)

Secondary objectives
Secondary objectives are • to determine the host and disease-related factors influencing the progression rate of fat redistribution and metabolic changes jointly and separately in children, with particular interest in the role of puberty • to assess the role of different approaches (questionnaires, circumferences, skinfolds and clinical investigations) in the evaluation of lipodystrophy in children

Sub-study Participants
All children aged 30 days to 18 years enrolled in the European centres of PENPACT-1 are eligible for this sub-study.
Clinicians are strongly encouraged to enrol all children entering PENPACT-1 into the minimal investigations part of the lipodystrophy sub-study (see sections 4.1 and 4.2). At baseline and then every 24 weeks, this will involve a questionnaire for the carer and physician; waist, mid-arm and mid-thigh circumferences; and lipids (including fractions wherever possible) and glucose. Metabolic measurements should be taken fasted wherever possible. Where a clinical centre is able to commit to more intensive investigations, all children from this centre enrolled in PENPACT-1 should be included in the maximal investigations part of the lipodystrophy sub-study; which, in addition to the measurements detailed above, includes 4 skinfold measurements at baseline and each 24-weekly visit (see sections 4.1 and 4.2). Centres should ensure that there is one or more members of staff with an active interest in performing these skinfold thicknesses, with the intention of carrying out all longitudinal measurements in this PENPACT-1 substudy.
Finally, L4 MRI and/or DEXA should be performed at baseline and then annually where feasible on an individual child basis, for children enrolled in either minimal or maximal parts of the substudy. Baseline scans should be obtained if at all possible. Clinical assessments are obviously useful, but tend to be operator-dependent. In contrast, investigations such as MRI provide a quantitative assessment of both subcutaneous and visceral adipose tissue. All assessments should be performed at baseline if at all possible, particularly clinical investigations (MRI and DEXA) since any subsequent investigations should ideally be compared to pre-therapy. Photographs may provide a reference to compare against a clinical diagnosis of lipodystrophy or reported signs and symptoms, although care must be taken to standardise conditions such as lighting and distance.
As many of the individual procedures should be performed as possible, according to the order below if there are constraints of time or other resources. See Appendix 3 and 4 for details of circumference and skinfold thickness measurement respectively. Appendix 5 provides guidelines for standardised MRI and DEXA assessment. Whilst height and weight are recorded as part of the main study, standardised methods of measurement should be used wherever possible (Appendix 6). CRFs with carer and physician assessment and details of other procedures required are in Appendix 8.
Fasting plasma glucose and serum insulin (see section 4.3) 3.
Photographs (Appendix 7) On both baseline and follow-up forms, the carer should complete their assessment of the child's body shape before all other information is completed.
Photographs should be stored in the clinic notes and not sent to the National Trials Centres with forms. If they are subsequently required for blinded central review, they must be anonymised before sending.
Demographic data is collected as part of the main PENPACT-1 trial data.

Fasting
Fasting is defined as no intake other than water for the last 6 hours (4 hours for children under 2 years). If possible, given dosing schedules, antiretroviral medication should be taken after fasting measurements have been performed. Regardless, the time of last dose of antiretroviral drugs should be recorded.
If the child is not fasted, the lipid profile and other metabolic measurements should still be performed, with time of last intake recorded.

Quality Assurance and Quality Control
As clinical investigations will be performed locally, it is important to record make and models of scanners and wherever possible to ensure the same machine is used at each assessment visit to ensure valid comparisons over time. Copies of electronic scan data should be retained by the clinic. Please contact Dr Alessandra Viganò if interpretation of electronic scan data is required. The necessity for centralised reading of all scan data will be considered at the end of PENPACT-1.

Regulatory and Ethics Approval
This substudy will be reviewed and approved by the relevant Ethics Committee for each participating centre before children are enroled. The patient information sheet is attached (Appendix 1). Written informed consent will be obtained from each child or their representative according to age and knowledge of HIV status (Appendix 2).

Finance
As this sub-study has not received additional funding, there is no reimbursement for any of the procedures.

Statistical analyses
There is currently no consensus definition of the lipodystrophy syndrome: however, case definition studies are ongoing [10], and any validated definition based on measurements taken in this substudy will be used in the final analysis. Otherwise, each anomaly will initially be described separately; subsequently each component of lipodystrophy (fat redistribution, metabolic abnormalities) will be considered separately with any abnormality in each component regarded as evidence of lipodystrophy.
Anthropometric measurements will be expressed in percentiles of the reference distribution for age and gender [11,12]. These values will be regarded as abnormal if ≥95 th percentile. Lipid measurements will be considered abnormal according to standard toxicity tables used in PENPACT-1. Insulin resistance will be estimated from fasting insulin and glucose measurements by using a homeostasis model assessment (HOMA) [13].
The effect of the following risk factors at trial entry on the incidence of lipodystrophy will be tested using standard time to event methods (logrank and Cox proportional hazards models): gender, age, BMI, family history, percentage and absolute CD4, and HIV-1 RNA. The effect of initial response to ART on subsequent development of lipodystrophy will also be considered. It is unclear which antiretroviral drugs or combination of antiretroviral drugs are causing these changes. It might be that only certain people are likely to experience them. It is also possible that puberty might make these changes worse.
WHAT ARE THE AIMS OF THE PENPACT 1 SUBSTUDY ?
The PENPACT 1 trial plans to include 256 HIV infected children who are starting taking antiretroviral therapy for the first time. Children enrolled in PENPACT 1 will be followed for at least 4 years from when they start therapy. It is extremely to important to monitor for the development of symptoms of lipodystrophy in these children. It is hoped that most of the children who join the study through PENTA (Paediatric European Network for Treatment of AIDS) will also join this lipodystrophy substudy so it will help us understand whether some drugs are more likely to cause lipodystrophy and whether certain children are more likely to suffer from it. This will help doctors know which are the safest antiretroviral drugs to give children in the future.
Most of the children enrolled in PENPACT 1 in the USA will also join a similar, but separate, substudy.
WHAT WILL JOINING THE SUBSTUDY MEAN FOR MY CHILD ? As it is not yet clear which are the best ways of detecting lipodystrophy, a number of extra tests need to be performed. We will measure weight and height and the circumference of arms, waist and thighs on all children at the time of joining the PENPACT 1 trial and then every 6 months. Your child's doctor will ask you a few questions about any changes you might have noticed. We will also take a little extra blood (3ml) for further investigations to understand lipodystrophy.
It is easier to interpret the results of these blood tests when no food has been taken (fasting) so if possible your child should not eat or drink anything other than water in the 6 hours before coming up to clinic. If your child is under 2, they only need to fast for 4 hours.
We would also like to be able to ask you whether any of your child's family have suffered from diabetes or heart disease to see if this increases the chances of your child getting lipodystrophy.
PENPACT 1 VERSION 3.1 FINAL 07/11/07 APPENDIX III (Cont.) In some clinics we are able to perform some further investigations and your child's doctor may discuss the possibility of performing these investigations with you. These are: Measurement of skinfold thickness: this is a way of assessing body fat. Calipers are used to measure skinfold thickness in the top part of the arm, the thigh and above and below the shoulder blade. Some younger children may be a little wary of their caliper measurements, however we do not expect them to cause any discomfort. Your doctor will not continue with any measurements if your child becomes distressed.
Photographs: as lipodystrophy can be difficult to diagnose from clinical symptoms, it will be very useful to have photographs for reference. Your child will not be identifiable in the photograph.
Imaging tests such as DEXA scan or MRI provide the best ways of looking at fat under the skin. These investigations will only be performed at the start of the trial then every 12 months. Your doctor will give you the information sheet from the radiology department in your hospital if these tests are available.

CONFIDENTIALITY
All information collected about your child during PENPACT 1 will be confidential. Names will not be used on any data collection forms, samples or photographs. Your child will be identified by a study number only.

PARTICIPATION
Participation in this substudy is entirely voluntary. If you decide that you do not wish your child to take part in the substudy, or in certain parts of the substudy, that is entirely your right. Your decision will in no way affect any present or future treatment for your child. You can withdraw your child from the substudy at any time without giving a reason. This will not affect your child's medical care.

WHAT ELSE DO I NEED TO KNOW ?
The Ethics Committee of your hospital has given approval for this substudy to be conducted at your clinic. PENTA, which is funded by the European Union, has made agreements for compensation should your child come to any harm during the trial. Your doctor will be able to tell you about this.
Thank you for taking time to consider this substudy for your child. Please ask any questions and let us know if there are things that you do not understand, or would like more information about. In order to reduce inter-operator and inter-visit variability, a standardised procedure with prespecified positions for measurement and multiple measurements should be followed.
1. Child should be dressed in underwear, socks, and a hospital gown; all outer clothing should be removed. 2. Use nonstretchable, cloth or vinyl measuring tape that measures in centimeters or millimeters and is at least one half inch in width. 3. Make sure the tape does not compress the tissues during the measurement. 4. Measuring tape should always be read at eye level. 5. All measurements should be made in triplicate and all values recorded.
Waist Circumference: 6. The child should be standing erect but relaxed. 7. Ask the child not to try to hold in their stomach during the measurements. 8. All measurements should be made after child has exhaled. 9. The usual method is to measure the smallest circumference around the waist. However, this measurement is not sufficient in individuals with increased abdominal girth. Therefore, place the measuring tape around the child at the level of the navel, holding the tape horizontal to the floor (the umbilicus waist). 10. Record measurement in cm to the nearest mm. 11. Repeat the circumference measurement twice more and record. In all, the measurement should be made 3 times.
Midarm Circumference: 12. All measurements should be performed on the right arm unless there is a specific reason why this is not possible. At the time of the first measurement, note the side used in the notes and use the same side for all subsequent measurements. To correctly locate the midarm region, upper arm length should first be measured. 13. Ask the child to bend the arm at right angle with the palm facing upward. 14. Locate the acromial process on shoulder blade. It may help to slide your fingers along the clavicle to find the acromial process. 15. Locate the olecranon process, which is the tip of the elbow. 16. Using a measuring tape, measure down the posterior aspect of the arm between these two points, being careful to keep the tape straight by holding it slightly away from the two end points if necessary. 17. Divide the length by 2, and mark this midpoint on the arm with a pen. 18. Ask the child to relax the arm at his/her side with the palm facing inward. Make certain that the child is not flexing the muscles in the arm. 19. Place the measuring tape around the arm at this midpoint, holding the tape horizontal to the floor (and, therefore, perpendicular to the length of the arm). 20. The tape should be touching the skin continuously and should follow the contours of the tissue (i.e., no gaps), but it should not compress the skin or tissue. 21. Record measurement in cm to the nearest mm. 22. Repeat the circumference measurement twice more and record. In all, the measurement should be made 3 times. landmark is the tendon that moves when the leg is flexed upward slightly. 27. Measure the length between these two marks. 28. Divide the length by 2, and mark this midpoint on the top of the thigh, making sure the tape measure remains straight. 29. Ask the child to stand, with the foot of the right leg slightly forward from that of the left leg.
The knee of the right leg should be flexed slightly, and all of the weight should be on the left leg. 30. Ask the child not to flex the muscles in the thigh. 31. Measure circumference across the midpoint, holding the tape perpendicular to the length of the thigh. 32. Record measurement in cm to the nearest mm. 33. Repeat the circumference measurement twice more and record. In all, the measurement should be made 3 times. In order to reduce inter-operator and inter-visit variability, a standardised procedure following Loeman et al in the Anthropometric Standardization Manual with pre-specified positions for callipers and multiple measurements should be followed. Holtain callipers provided by PENTA for PenPact-1 should be used.
1. Child should be dressed in underwear, socks, and a hospital gown where appropriate; all outer clothing should be removed. 2. All measurements should be performed on the right side unless there is a specific reason why this is not possible. At the time of the first measurement, note the side used in the source document and use the same side for all subsequent measurements. 3. All measurements should be made in triplicate in the order below and all values recorded.
Triceps: 4. The child should be standing erect but relaxed. 5. The site of the triceps skinfold is located in the midline of the posterior aspect of the arm while the elbow is flexed to 90° and the palm is facing upwards, over the triceps muscle, at a point midway between the lateral projection of the acromion process of the scapula and the inferior margin of the oclecranon process of the ulna (see below). 6. The tape is placed with its zero mark on the acromion and stretched along the upper arm, extending below the elbow. 7. The midpoint is marked on the lateral side. 8. The skinfold is measured with the arm hanging loosely and comfortably at the child's side and palm facing the thigh. The site of measurement must be in the midline posteriorly. 9. The measurer stands behind the child and places the palm of his/her hand on the child's arm proximal to the marked level, with the thumb and finger directed inferiorly. 10. The triceps skinfold is picked up with the thumb and index finger, approximately 1cm proximal to the marked level, and the tips of the calipers are applied to the skinfolds at the marked level. The skinfold must be parallel to the long axis of the upper arm and the caliper must be applied at the mark 90° to the long axis of the upper arm (see below). 11. Record the measurement in cm to the nearest mm. 12. Repeat the measurement twice more, pausing each time to prevent sustained compression of the tissue and record all three measurements.  19. The child should be standing erect with body weight evenly distributed on both feet. 20. The child should relax the abdominal wall musculature as much as possible during the procedure and breath normally. 21. The child may be asked to hold their breath near the end of expiration if there is substantial movement of the abdominal wall with normal respiration. 22. Select a site 5cm below the midpoint of the umbilicus and 3cm to the right (see below). 23. Raise a horizontal skinfold with one hand and measure its thickness. 24. Record the measurement in cm to the nearest mm. 25. Repeat the measurement twice more, pausing each time to prevent sustained compression of the tissue and record all three measurements.
Thigh: 26. The child should be standing with the body weight shifted to the left foot while the right leg is relaxed with the knee flexed and the right foot is flat on a stool or bench less than 30cm in height. 27. If maintaining balance is a problem, the child holds the top of the measurer's shoulder, a countertop, or a high-backed chair. 28. The child flexes the hip and knee to assist location of the inguinal crease and the proximal border of the patella. 29. The thigh skinfold is located in the midline of the anterior aspect of the thigh, midway between the inguinal crease and the proximal border of the patella. 30. The thickness of a vertical fold is measured while the participant is still in the position above. 31. The caliper jaws are applied about 1cm distal to the fingers holding the fold (see below). 32. Record the measurement in cm to the nearest mm. 33. Repeat the measurement twice more, pausing each time to prevent sustained compression of the tissue and record all three measurements. Procedures for Performing DEXA Scans The following is a summary of procedures. Please follow the manufacturer's instructions for operating your instrument. Total body scans should be done using standard operating procedures defined by the manufacturer in order to allow comparability between study sites as well as generalisability to children outside of the study conditions. The child should be questioned and examined for metal that could be in the scan path. Typical things to look for are earrings, spectacles, wristwatches, coins, rings, buttons, buckles, zippers, and support braces. The child should remove shoes and it may be necessary to remove skirts, trousers, etc. If in doubt, it is best to remove the object in question. If clothes are removed, a child gown will be provided and a sheet available to place over the child during the scan. Rings that cannot be removed can be left on, but should be noted and should always be left on in subsequent scans. Small objects removed from the child should be placed in a small box to keep them together and the box left in the room with the child. After the scan is performed the objects should be returned to the child and the child queried to make sure s/he has received back all objects.
Child Positioning Techniques and Whole Body Scan Acquisition For any system, the calibration procedure and quality control checks should be performed daily. Use the recommended "whole body scan" setting of the particular DEXA machine available, depending on the size of the child. 1. When prompted by the program, ask the child to lie down on the scan The child's feet should be held together using a Velcro strap, and the child asked not to move until directed to do so. Feet should be held maximally dorsiflexed for consistency. 9. Continuing the scan will cause the x-ray tube to ramp up to the appropriate current and voltage. The operator should check to make sure the orange "X-Ray On" light is lit, and remain in the room to check the progress of the scan acquisition as it appears on the screen. PENPACT 1 VERSION 3.1 FINAL 07/11/07 APPENDIX III (Cont.) 10. The child's head should appear on the screen with a few blank scan lines above it. As the scan proceeds, the total-body image should be in a straight line vertically on the screen. If these conditions are not met, the scan should be stopped. The scan arm will move to the original start position and the localizer light will come on. The child should be repositioned as needed. 11. When the detector goes past the child's feet, the auto stop feature will interrupt the scan and close the shutter. A message will appear on the screen, allowing the operator to continue the scan or shut down the system. After the scan ends the shutter will close, the voltage and current ramp down, and a messages appear for the operator to wait. The scan arm will move to the home position and a screen message will appear to inform the operator that the scan is over and to remove the child from the Analysis of DEXA Scan Positioning of cuts is the same regardless of the guidelines for scan analysis for different machines. Note that the cuts used are not the same as those utilised for bone density. When drawing regions try to ensure correct allocation of soft tissue. It is easier to position the cuts to include soft tissue if the grey scale is adjusted and a combined bone and soft tissue display is used. Soft tissue cuts are as follows 1. Arm: The cut should be positioned so it passes through the centre of the arm socket. It should be as close to the body as possible, without touching the ribs, pelvis or greater trochanter. The arm should be included in the cut. 2. Rib: Position the cut as close to the spine as possible, without including spine data in the rib region. 3. Centre: divide the body lengthways and position the cut such that it passes though the centre of the body. 4. Pelvis: position the cut such that the top horizontal line is just above the top of the pelvis without touching it. The two angled lines bisect the femoral necks. 5. Dorsal: position the cut in T12-L1 disc space. T12 may be identified by the rib extending from it. The following data are required for the each of the total body, the arms, legs and trunk: fat kg and percentage, lean mass kg and percentage.
Procedures for Performing L4 MRI Scans Single cut abdominal MRI at the mid L4 level must be performed using a manual tracing method to estimate visceral abdominal (cm 2 ) and subcutaneous abdominal fat (cm 2 ). 1. Place the child in a supine position with their head straight, shoulders relaxed and arms raised above the head. Movement of the child should be minimal throughout the procedure. All soft tissue must be included in the MRI field of view. 2. Place a metallic marker at the level of the mid L4 and take a scout film of the area. The child should be standing with the device centered down the middle of the body and should be standing with heels together and heels, buttocks, and shoulders touching the wall. The child should tuck his/her chin down into the chest and stand as tall as possible. If the measuring device has a horizontal bar to assist with the measurement, the bar should be raised above the child's head and lowered until it just touches the head (the skull; not just the hair). It is important to make certain that the bar is completely horizontal. If the bar is at an angle greater or less than 90° to the wall, the measurement of height will be inaccurate. 4. If the measuring device does not have a horizontal bar, an alternative device should be constructed to make certain that height is recorded from the point on the measuring device that is exactly horizontal to the top of the center of the head. A plastic right triangle or two pieces of wood attached at a 90_ angle could serve this purpose. 5. Height should be reported in cm to the nearest mm.
Weight: NOTE: The same scale should be used for all measurements performed for this substudy. The scale should be calibrated monthly. (Instructions for calibration are listed below). 1. Children should be weighed while wearing only a hospital gown, underwear, and socks. All other clothing, including shoes, should be removed. 2. Children should be asked to void before weight is measured. 3. Children should not engage in strenuous exercise for 8 hours preceding the measurements, because of its potential effect on hydration status. 4. Before the child is weighed, make certain that the scale is in balance if it is a beam-balance scale or reads zero if it is an electronic scale. 5. Instruct the child to stand with both feet centered on the scale with arms at the sides. The child should not move or hold onto anything during the measurement. 6. Allow the scale to stabilize and record the weight in kg to the nearest 0.1kg.
Standardisation of Weight Scales 1. The scales should be standardised monthly. Procedures for standardisation are described below. 2. Scales should be standardised before the first child is screened and monthly throughout the study. To standardise, select an object or objects whose combined weight is at least 50 lbs. or 23 kg and that will be available, unaltered, throughout the study. (Example of objects might be standard weights, which might be available through your institution's engineering facility, weights used with exercise equipment, or simply gallon bottles filled with water and well-sealed. In order to reduce inter-visit variability, a standardised procedure with pre-specified positions for photographs should be followed. Ideally all photographs should be taken under the same lighting conditions (for example, in the same clinic rooms).
Lower arm 1. All photographs should be taken of the right arm unless there is a specific reason why this is not possible. At the time of the first photograph, note the side used in the notes and use the same side for all subsequent photograph. 2. The child should sit at a table or desk and extend their lower arm palm down on the table, with their upper arm at a 90º angle. 3. Photograph the child's arm looking straight down through the camera from a distance of approximately 70cm, with the arm from wrist to elbow in centre of view. 4. The child should then turn their arm over, palm up, for a second photograph at the same distance.
Thigh 5. All photographs should be taken of the right thigh unless there is a specific reason why this is not possible. At the time of the first photograph, note the side used in the notes and use the same side for all subsequent photograph. 6. The child should stand straight with their back against a wall. 7. Photograph the child's thigh looking horizontally across through the camera from a distance of approximately 1m, with the leg from knee upwards in centre of view. Side profile 10. Whilst remaining by the wall, the child should turn to their left so that their left shoulder and left leg is against the wall, standing straight. 11. Photograph the child's side profile looking horizontally across through the camera to their waist from a distance of approximately 3m, with waist in centre of view.   Both amylase and lipase must be elevated to the same grade or higher (i.e. if total amylase is Grade 4, but lipase is only Grade 1, the Toxicity Grade is 1. In pediatric HIV patients, the most common source of serum amylase is the salivary glands. Salivary amylase elevations are generally not clinically significant. When amylase is released from damaged pancreatic cells, it can be a marker of pancreatitis. In most cases of clinical pancreatitis, lipase will also be elevated. However, lipase is also a non-specific marker. Combined elevation of amylase and lipase (each >5 x normal) often indicates pancreatic disease and requires evaluation. However, in the absence of pancreatic disease, drug can be resumed even at Grade 3 and 4 toxicities. Infectious agents other than HIV can precipitate a neuropathy and should be considered, especially CMV. Neuropathies which do not resolve after dose reduction or discontinuation should be pursued for alternative infectious or non-infectious etiologies, since drug-related neuropathies will usually resolve after dose reduction or drug discontinuation. It should be borne in mind that many subjects will worsen for up to one month after drug discontinuation prior to improvement ("coasting"). Abnormalities should be confirmed by nerve conduction studies (NCS) +/-electromyographic studies (EMG). • Gently invert tubes several times to mix. Do not shake.

Myopathy or Neuromuscular Junction Impairment
• Specimen should be identified as to patient ID# (PID), study ID# (SID), site ID#, visit ID#, date and time of collection, and specimen type.
• Specimen should be kept at room temperature (18°-24°C) and processed as quickly as possible, preferably within 4 to 6 hours of collection.

Plasma aliquots from specimens collected at Screening, Entry, Week 24, time of therapy switch, Week 192, Week 204, and end of study must be reserved; these aliquots will be batched and shipped to the University of North Carolina prior to study completion according to the instructions below. 6. If there is no local DAIDS VQA certified laboratory available for HIV RNA testing, specimens can be sent real-time to the University of North Carolina.
PLASMA AND PBMC FOR STORAGE-Please follow the consensus methods on the ACTG website at http://aactg.s-3.com/pub/download/SpecimenProcessingGuide.doc and http://aactg.s-3.com/pub/download/vir/freezingprotocol.doc 1. Specimens must be logged into the LDMS and labeled with the LDMS specimen #, PID, date, time of collection and derivative information.  • Gently invert tubes several times to mix. Do not shake.
• Add trial number, date and time of collection, and specimen type to PENTA ID labels. Complete details on laboratory request form.
• Specimen should be kept at room temperature (18°-24°C) and processed as quickly as possible, preferably within 4 to 6 hours of collection. This appendix establishes the allowed antiretrovirals that could be prescribed for PENPACT 1 children, and was written to assist clinicians in selecting each child's regimen by using FDA/EMEA approved dosing or the PENPACT1 dosing recommendations.
All the information in this appendix is to be used as a guideline for prescribing the child's regimen. However complete and detailed prescribing and toxicity information, on all antiretroviral drugs, is available from the drug manufacturer's in the USA and in Europe. Clinicians must review manufacturer's product information before prescribing any of these drugs, and contact the protocol team at actg.penpact1@fstrf.org with any discrepancies or queries.
The PENPACT1 Team will update this appendix, whenever new drugs, drug combinations, drug dosing, and/or drug-regimens, are/is approved by the FDA and/or EMEA. Thus, clinicians in both IMPAACT/PACTG and PENTA sites must follow the approved version of this appendix when prescribing. The PENPACT1 Team will review and update this appendix as needed to guarantee that clinicians have the most current options for prescribing the children's ART-regimens.
For PENPACT1, adolescents in early puberty (Tanner I-II -Appendix XV) should be dosed using pediatric schedules, and adolescents in late puberty (Tanner V -Appendix XV) should be dosed using adults schedule. Children who are in the midst of their growth spurt (Tanner III females, Tanner IV males -Appendix) should be closely monitored for medication efficacy and toxicity when choosing either adult or pediatric dosing guidelines. Clinicians should alert the protocol team of the selected dosing schedule when reporting virologic failure or toxicities in these children.
The appendix is divided into one to three sections for each drug, and the drugs are listed in alphabetical order, rather than by class. These three sections are:  FINAL 07/11/07 APPENDIX IX These dosing recommendations can be followed by all sites participating in the study, IMPAACT/PACTG and PENTA sites. However, clinicians may opt to prescribe only the approved dosing guidelines issued by their own regulatory agency, either FDA or EMEA. Thus, the current FDA approved dosing guidelines for IMPAACT/PACTG sites are for all USA sites participating in IMPAACT 390, and the current EMEA approved dosing guidelines for PENTA sites are for all European PENTA countries participating in PENTA 9.
In Germany and Switzerland when a drug, a drug dose, or a drug-formulation is not approved by the EMEA but it is approved by the FDA, this drug dose or drug formulation can be prescribed based on the FDA's approval. This section informs site personnel of some of the well-known side effects of a given drug. A complete list of risks is available for each drug in its package insert. These risks must be explained and made available to the children and/or care-givers during the informed consent process.

IMPORTANT NOTES
• Dosing of children with hepatic and/or renal insufficiency, as well as children receiving special dosing due to toxicity, must be done as per drug manufacturer's package insert information and/or toxicity management guidelines in this document. Clinicians must contact the protocol team at actg.penpact1@fstrf.org with any dosing concerns regarding special requirements of a given child. • For both initial-and second-line therapies, it is important to emphasize that PENPACT 1 will allow low doses of ritonavir as a boosting agent, creating drug-combinations that will be counted as a single protease inhibitor. • Combivir (300 mg zidovudine + 150 mg lamivudine) dosing can be found under lamivudine and zidovudine sections. Major toxicities for this drug combination should be reviewed as per individual drug components. • Neonatal dose: Not approved for infants less than three months of age.
• FDA/EMEA pediatric/adolescent dose: 3 months to 16 years of age: 8 mg/kg of body weight twice daily, maximum dose 300 mg twice daily.

Non FDA/EMEA-Approved PENPACT 1 Dosing Recommendations
Children < 3 months of age: Abacavir has been studied in children > 30 days and children < 2 years of age through PACTG 356. In this study, abacavir dosage was 8 mg/kg po q12h. PACTG 356 is an ongoing study that is evaluating antiretroviral activity and the durability of viral suppression using early intensive antiretroviral combination therapy in HIV-1-infected infants and children. In cohorts 3 and 4, infants > 30 days and children < 2 years of age received quadruple therapy; abacavir, zidovudine, lamivudine and nevirapine.
Once daily dosing: Once daily dosing of abacavir was studied in children aged 2-12 in PENTA 13. In this cross-over PK study, the AUC0-24 and C max of abacavir given 1 6mg/kg po q24h were not inferior to q12h dosing. Virological data did not indicate a marked difference in antiviral activity between q12h and q24h regimens.
Once daily dosing of abacavir can be considered for children enrolled in PENPACT 1 who have reached a stable nadir in viral load (ideally <50 copies/ml). We would not recommend starting therapy with once daily abacavir in children, particularly where the initial viral load is high. It is important to ensure that once daily doses are given at approximately the same time each day (optimally within an hour either side of a given time).

Major Toxicities
In ongoing clinical trials, hypersensitivity reactions have been reported in approximately 5% of pediatric patients receiving abacavir. Fatal hypersensitivity reactions have been associated with therapy with abacavir in adults. Refer to the manufacturer's product information for the management of subjects, and to Appendix X for management of any hypersensitivity reaction. Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been reported with the use of nucleoside analogues alone or in combination, including abacavir and other antiretrovirals. The caregiver (subject) should receive the warning card and medication guide that are included in the manufacturers packaging. As the subject is enrolled the study the site must ensure that: 1) the caregiver (subject) receives the abacavir warning card, 2) the designated health care provider reviews the signs and symptoms of hypersensitivity reaction with the caregiver (subject), 3) the caregiver (subject) verbalizes an understanding of the steps to take in the event of a suspected hypersensitivity reaction, including when and how to contact the study site.
References:  • FDA adolescent dose (≥50 kg): For children 13 to 16 years of age weighing more than 50 kg: Oral solution: 1400 mg bid.

Major Toxicities
Amprenavir has been generally well tolerated in clinical studies. Vomiting, nausea, diarrhea, perioral paresthesias, and rash have been reported. Life-threatening rash, including Stevens-Johnson syndrome has been seen in 1% of patients. Other less common side effects have included increased cholesterol levels, new onset diabetes mellitus, hyperglycemia, exacerbation of pre-existing diabetes mellitus, hemolytic anemia, and spontaneous bleeding in hemophiliacs. The FDA approved oral solution formulation of amprenavir contains significant amounts of propylene glycol and therefore is not suitable for use in infants. • Adolescent (> 16 years)/adult dose:

Antiretroviral-naïve patients: 400 mg once daily. Low-dose ritonavir boosting may be considered for adolescents because adequacy of the unboosted atazanavir adult dose for adolescents has not been established.
Antiretroviral-experienced patients: 300 mg atazanavir with 100 mg ritonavir once daily.
• Atazanavir in combination with efavirenz (adults): 300 mg atazanavir with 100 mg ritonavir and 600 mg efavirenz, all once daily. Only atazanavir boosted with ritonavir should be used in combination with efavirenz.
• Atazanavir in combination with tenofovir DF (adults): 300 mg atazanavir with 100 mg ritonavir and 300 mg tenofovir DF, all once daily. Only atazanavir boosted with ritonavir should be used in combination with tenofovir DF.

EMEA dosing recommendations:
• Adults: 300 mg once daily taken with ritonavir 100 mg once daily and with food. Ritonavir is used as a booster of atazanavir pharmacokinetics.
• Atazanavir in combination with efavirenz (adults): 400 mg atazanavir with 100 mg ritonavir and 600 mg efavirenz, all once daily.
• If Reyataz ® with ritonavir is co-administered with didanosine, it is recommended that didanosine be taken 2 hours after Reyataz ® with ritonavir taken with food. • • Pediatric powder for oral solution (when reconstituted as solution containing antacid, 2 g and 4 g bottles): 10 mg/mL (not licensed in Europe).

P1020A "A Phase I/II Open Label Pharmacokinetic and Safety Study of A Novel Protease Inhibitor (BMS 232632) in Combination Regimens in ART Naive and Experienced HIV-infected Infants, Children and Adolescents
• Chewable tablets with buffers: 100 mg • FDA/EMEA adult dose: 600 mg once daily (EFV as a 600 mg tablet can be taken once daily, in combination with a PI and/or NRTIs).
• FDA adult (>18 years) dose: Atripla ® one tablet once daily. Dosing at bedtime may improve the tolerability of nervous system symptoms.

Major Toxicities
Treatment with efavirenz has been associated with skin rash and increased aminotransferase levels. In some patients, central nervous system effects (somnolence, insomnia, abnormal dreams, confusion, abnormal thinking, impaired concentration, amnesia, agitation, depersonalization, hallucinations, and euphoria), have been reported. The central nervous system effects have been seen primarily in adults. Efavirenz is teratogenic in primates (use in pregnancy should be avoided and women of childbearing potential should undergo pregnancy testing before initiating therapy).
Because Atripla ® is a fixed-dose combination, it should not be prescribed for patients requiring dosage adjustment or those with creatinine clearance <50 mL/min.

Current Preparations and Dosages Including FDA Approved Dosing Guidelines
Atripla ® is not EMEA licensed.

Major Toxicities:
PENPACT 1 VERSION 3.1 FINAL 07/11/07 APPENDIX IX Adverse effects in patients treated with emtricitabine have included headache, dizziness, tiredness, inability to sleep, unusual dreams, loose or watery stools, nausea or vomiting, abdominal pain, rash, itching, allergic reactions, skin darkening of the palms and/or soles, and increased LFTs, amylase, triglycerides or CPK. Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been reported with the use of nucleoside analogues alone or in combination, including emtricitabine and other antiretrovirals in adults.
Because Atripla ® is a fixed-dose combination, it should not be prescribed for patients requiring dosage adjustment or those with creatinine clearance <50 mL/min. The Protocol Team recommends that fosamprenavir be boosted with ritonavir.
• Protease inhibitor-experienced adult dose: Fosamprenavir 700 mg twice daily plus ritonavir 100 mg twice daily.  When administered without ritonavir, the adult regimen of fosamprenavir tablets 1400 mg twice daily may be used for pediatric patients weighing at least 47 kg.
When administered in combination with ritonavir, fosamprenavir tablets may be used for pediatric patients weighing at least 39 kg; ritonavir capsules may be used for pediatric patients weighing at least 33 kg.

Patients with Hepatic Impairment:
o Mild hepatic impairment (Child-Pugh score ranging from 5 to 6): Fosamprenavir calcium should be used with caution at a reduced dosage of 700 mg twice daily without ritonavir (therapy-naïve) or 700 mg twice daily plus ritonavir 100 mg once daily (therapy-naïve or PIexperienced).
o Moderate hepatic impairment (Child-Pugh score ranging from 7 to 9): Fosamprenavir calcium should be used with caution at a reduced dosage of 700 mg twice daily (therapy-naïve) without ritonavir, or 450 mg twice daily plus ritonavir 100 mg once daily (therapy-naïve or PIexperienced).
o Severe hepatic impairment (Child-Pugh score ranging from 10 to 12): Fosamprenavir calcium should be used with caution at a reduced dosage of 350 mg twice daily without ritonavir (therapy-naïve). There are no data on the use of fosamprenavir calcium in combination with ritonavir in patients with severe hepatic impairment.

EMEA dosing recommendations:
• Adults (>18 years): For antiretroviral naïve and experienced patients the recommended dose is 700 mg fosamprenavir twice daily with 100 mg ritonavir twice daily, in combination with other antiretroviral medicinal products. Caution is advised if the recommended doses of fosamprenavir with ritonavir detailed above are exceeded.
• Children (<12 years) and adolescents (12 to 17 years): Fosamprenavir with ritonavir is not recommended for use in children below age 12 and adolescents age 12 to 17 due to lack of data on safety and efficacy.  • Neonatal dose: Unknown. Due to side effect of hyperbilirubinemia, should not be given to neonates until further information is available.
• Routinely used pediatric dose in clinical setting: 500 mg per m 2 of body surface area every eight hours. However, children with small body surface areas: 300-400 mg/m 2 every 8 hours.
• FDA adult dose: 800 mg every eight hours.
• The EMEA recommended dosage for children and adolescents (4 to 17 years of age) is 500 mg per m 2 (dose adjusted by BSA) every eight hours (maximum dose of 800 mg every eight hours).
• EMEA adult dose: 800 mg every eight hours.

PENPACT 1 Dosing Recommendations
Dosing recommendations for children: The indinavir dose used in PACTG 395 Version 2.0 was 500 mg/m 2 /dose given orally q8h. An oral formulation for administration to younger children and infants, particularly those not able to swallow capsules and who require doses less than 100 mg, is not available at this time.

Major Toxicities
Adverse effects include changes in hematologic and hepatic function tests, nephrolithiasis (kidney stones), abdominal pain, asthenia/fatigue, diarrhea, headache, dizziness, insomnia, nausea, back and side pain, rash, vomiting, acid regurgitation (backflow of stomach acid to the esophagus), and taste perversion. Indirect hyperbilirubinemia has occurred frequently with indinavir administration and has sometimes been associated with increases in serum transaminases. Both hyperbilirubinemia and nephrolithiasis occurred more frequently at doses exceeding 2.4 g/day compared to doses = 2.4 g/day. Adequate hydration (comparable to at least 1.5 liters/adult/24 hours) is required in all patients treated with indinavir.
References:  • Routinely used neonatal dose in clinical setting (infants aged <30 days): 2 mg per kg of body weight twice daily.
• EMEA adolescents aged >12 years: 30 mL or 300 mg once a day, or 15 mL or 150 mg BID.
• FDA adolescent/adult aged > 16 years of age dose: 300 mg once daily or 150 mg twice daily. Maximum dose is 150 mg twice daily.
• FDA/EMEA pediatric/adolescent dose: 3 months to 16 years of age: 4 mg per kg of body weight twice daily. Maximum dose is 150 mg twice daily.
• FDA/EMEA adolescent/adult dose of Combivir ® : one tablet twice daily.

PENPACT 1 Dosing Recommendations
Dosing in infants <3 months of age: Lamivudine at 4mg/kg po q12h has been used in PACTG 356 and PACTG 345 for infants >29 days of life to 2 years of age.
Once daily dosing in children under 13: once daily dosing of lamivudine was studied in children aged 2 to 12 years in PENTA 13. In this cross-over PK study, the AUC 0-24 and C max of lamivudine given 8mg/kg po q24h were not inferior to q12h dosing. Virological data did not indicate a marked difference in antiviral activity between q12h and q24h regimens.
Once daily dosing of lamivudine can be considered for children enrolled in PENPACT 1 VERSION 3.1 FINAL 07/11/07 APPENDIX IX PENPACT 1 who have reached a stable nadir in viral load (ideally <50 copies/mL). We would not recommend starting therapy with once daily lamivudine in children, particularly where the initial viral load is high. It is important to ensure that once daily doses are given at approximately the same time each day (optimally within an hour either side of a given time).

Major Toxicities
Pancreatitis, which has been fatal in some cases has been observed in antiretroviral nucleoside-experienced pediatric patients receiving lamivudine alone or in combination with other antiretroviral agents. In pediatric studies paresthesias and peripheral neuropathies were reported in <1% to 15% of patients. Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been reported with the use of nucleoside analogues alone or in combination, including lamivudine and other antiretrovirals in adults. • Neonatal dose: 300 mg/m 2 LPV/r twice daily has been studied in PACTG P1030.
• FDA pediatric dose for individuals not receiving concomitant nevirapine or efavirenz: 230 mg per m 2 lopinavir/57.5 mg per m 2 ritonavir twice daily with food, up to a maximum of 400 mg lopinavir/100 mg ritonavir. These subjects can also be dosed as per the following table: Six months to 12 years of age (Dosing without NVP or EFV) 7 to <15 kg 12 mg per kg lopinavir/3 mg per kg ritonavir twice daily with food. 15 to 40 kg 10 mg per kg lopinavir/2.5 mg per kg ritonavir twice daily with food. >40 kg 400 mg lopinavir/100 mg ritonavir (two tablets or 5 mL solution) twice daily with food (same as adult dose).
• FDA adult/adolescent dose not receiving concomitant nevirapine or efavirenz: 400 mg lopinavir/100 mg ritonavir (two tablets or 5 mL solution) twice daily with food.
• FDA pediatric dose for individuals receiving concomitant nevirapine or efavirenz (which induces lopinavir metabolism, reduces plasma levels and requires increased lopinavir/ritonavir dosing) and/or treatment experienced patients where reduced susceptibility to lopinavir is suspected (such as those with prior treatment with other PIs): 300 mg per m 2 lopinavir/75 mg per m 2 ritonavir twice daily with food up to a maximum of 600 mg lopinavir/150 mg ritonavir (three tablets or 6.5 mL solution) twice daily with food. These PENPACT 1 VERSION 3.1 FINAL 07/11/07 APPENDIX IX subjects can also be dosed as per the following table: Six months to 12 years of age (Dosing giving with NVP or EFV) 7 to <15 kg 13 mg per kg lopinavir/3.25 mg per kg ritonavir twice daily with food. 15 to 50 kg 11 mg per kg lopinavir/2.75 mg per kg ritonavir twice daily with food. >50 kg 600 mg lopinavir/150 mg ritonavir (three tablets or 6.5 mL solution) twice daily with food (same as adult dose).
• The EMEA does not recommend Kaletra ® for use in children less than 2 years of age because of limited efficacy and safety data.
• EMEA pediatric dose (2 years of age and above) (covers adolescent/adult dosing): the recommended dosage of Kaletra ® for children with a body surface area of 1.3 m 2 or greater, is 3 capsules twice daily taken with food (maximum 400 mg lopinavir/100 mg ritonavir). Notes: • For children with a body surface area of less than 1.3 m 2 , Kaletra ® oral solution is recommended.

Non-EMEA Approved PENPACT 1 Dosing Recommendations
The FDA approved dose (230 mg/m 2 lopinavir + 57.5 mg ritonavir/m 2 ) for children six months to two years of age should be prescribed.

Major Toxicities
Adverse effects in patients treated with Kaletra ® have included pancreatitis, elevated levels of total cholesterol and triglycerides, nausea, diarrhea, abdominal pain, rash, headache, asthenia, and ECG changes (heart block). • FDA pediatric dose (children 2 to 13 years of age): 20 to 30 mg per kg of body weight three times a day.
• Neonatal dose routinely used in clinical setting: doses as high as 45 mg/kg every 8 hours.
• EMEA dose is licensed as for children ≥3 years of age: 25 to 30 mg/kg every 8 hours.

PENPACT 1 Dosing Recommendations
Alternate recommended dosing: Nelfinavir 110 mg/kg/day divided q12 hours was shown in PACTG 377 to provide improved serum levels in children greater than age 2.
• Dosing recommendations for children 1 to 2 years of age: A dose between 120 -150 mg/kg/day (q12) in the second year of life is advised.

Major Toxicities
Diarrhea is commonly associated with nelfinavir usage. The diarrhea generally improves after several weeks of therapy. Less common side effects include asthenia, abdominal pain, rash, and exacerbation of chronic liver disease. Rarely, nelfinavir treatment has been associated with spontaneous bleeding episodes in hemophiliacs, hyperglycemia, keto-acidosis, and diabetes. NVP is initiated at a lower dose and increased in a step-wise fashion. This allows induction of cytochrome P450 3A that results in increased clearance of drug. The occurrence of rash may be diminished by the stepwise increase in dosage. The following suggested incremental increases in dose are given for days on treatment (not age).
• Neonatal dose (through age two months): Under study in PACTG 356: 5 mg/kg of body weight or 120 mg/m 2 of body surface area once daily for 14 days, followed by 120 mg/m 2 of body surface area every 12 hours for 14 days, followed by 200 mg/m 2 of body surface area every 12 hours.
• Pediatric dose (age ≥2 months): 120-200 mg/m 2 every 12 hours. Initiate therapy with 120 mg/m 2 (maximum 200 mg) administered once daily for 14 days. Increased to full dose (120-200 mg/m 2 ) administered every 12 hours (maximum 200 mg every 12 hours) if no rash or other untoward effects. These subjects can also be dosed as per the following FDA/EMEA approved dosing Dosing recommendations for <2 months: Nevirapine at 120 mg/m 2 once every day for 14 days, followed by an increase to full dose nevirapine 200 mg/m 2 every 12 hours if there were no rashes of other untoward effects. was used in PACTG 356 for infants >30 days to <2 years receiving triple or quadruple therapy including nevirapine.

Major Toxicities
Severe, life-threatening, and in some cases fatal hepatotoxicity, including fulminant and cholestatic hepatitis, hepatic necrosis and hepatic failure, has been reported in patients treated with nevirapine. In some cases, patients presented with non-specific prodromal signs or symptoms of hepatitis and progressed to hepatic failure. Some events occurred after short-term exposure to nevirapine. Patients with signs or symptoms of hepatitis must seek medical evaluation immediately and should be advised to discontinue nevirapine.
Severe, life threatening skin reactions, including fatal cases, have occurred in patients treated with nevirapine. These have included cases of Stevens-Johnson syndrome, toxic epidermal necrolysis, and hypersensitivity reactions characterized by rash, constitutional findings, and organ dysfunction. Patients developing signs or symptoms of severe skin reactions or hypersensitivity reactions must discontinue nevirapine as soon as possible.
The first 12 weeks of therapy with nevirapine are a critical period during which intensive monitoring of patients is required to detect potentially life-threatening Clarification Notes: • The majority of clinical trials involving infants and children utilized the 120 -200 mg/m 2 dosing regimen. The new FDA approved regimen, which uses mg/kg dosing, is based on pharmacokinetic modeling designed to achieve similar plasma concentrations as dosing of 150 mg/m 2 .
• NVP clearance is highest during the first two years of life, decreasing gradually after eight to 12 years of age and approaching adult clearance rates. The new dosing regimen accounts for the changes in clearance that occurs after eight years of age. However, the changes in clearance are gradual and the new mg/kg dosing regimen results in an abrupt 43% decrease in dose size when the 8th birthday is reached.
• Some clinicians may prefer the mg/m 2 dosing that was utilized in clinical trials.
Nevirapine-attributable rash occurred in 16% of patients on combination regimens in Phase II/III controlled studies. Thirty-five percent of patients treated with the nevirapine-containing regimen experienced rash compared to 19% of control group patients treated with either zidovudine plus didanosine or zidovudine alone. Severe or life-threatening rash occurred in 6.6% of nevirapine-treated patients compared with 1.3% of patients treated in the control groups.
Rashes are usually mild to moderate, maculopapular erythematous cutaneous eruptions, with or without pruritis, located on the trunk, face and extremities. In adult Phase II/III clinical trials, the majority of rashes occurred within the first 6 weeks of therapy. Severe rashes occurred most frequently within the first 28 days of treatment; 25% of the patients with severe rashes required hospitalization; and one patient required surgical intervention. Overall, 7% of patients discontinued NVP due to rash.
In one clinical trial, concomitant use of prednisone to prevent nevirapineassociated rash increased the incidence and severity of rash during the first 6 weeks of NVP therapy. The use of prednisone to prevent nevirapine-associated rash is not recommended.
Subjects should be advised to promptly notify their health care provider if they develop any rash or signs and symptoms of a hypersensitivity reaction. Signs and symptoms of hypersensitivity include, but are not limited to severe rash or rash accompanied by fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, facial edema, and/or hepatitis, eosinophilia, granulocytopenia, and renal dysfunction.
As always, please see the Viramune ® package insert for additional information regarding the use of nevirapine.
References: • FDA pediatric dose: 2 years of age and older, 400 mg/m 2 of body surface area every 12 hours with a maximum of 600 mg bid.

Note:
To minimize nausea/vomiting, initiate therapy starting at 250 mg/m 2 of body surface area every 12 hours and increase stepwise to full dose over five days as tolerated.
• EMEA pediatric dose: 350 mg/m 2 of body surface area every 12 hours with a maximum of 600 mg bid.
• FDA/EMEA pediatric dose range: 250 to 400 mg/m 2 of body surface area every 12 hours.

PENPACT 1 Dosing Recommendations
Dosing recommendations for children < 2 years: 350-450 mg/m 2 of body surface area twice daily (not to exceed 600 mg per dose). To minimize nausea/vomiting, initiate therapy starting at 250 mg/m 2 of body surface area every 12 hours and increase at 2-to 3-day intervals by 50 mg/m 2 of body surface area twice daily to full dose as tolerated. If patient does not tolerate 400 mg/m 2 of body surface area twice daily due to adverse effects, the highest tolerated dose may be used for maintenance therapy in combination with other antiretroviral agents; however, an alternative PI should be considered. • Neonatal dose: Not approved for use in neonates/infants.

• Adolescent (>16 years)/adult dose:
Saquinavir in combination with ritonavir 1,000 mg SQV + 100 mg RTV, both given twice daily. Should be taken within 2 hours of a meal.
Note: Saquinavir should only be used in combination with RTV or LPV/r (never unboosted). Dosing recommendations for children <16 years: ACTG 397 is a trial that evaluated two saquinavir containing regimens in children 3 to 16 years of age who weigh at least 8 kg and can swallow capsules. Saquinavir dosing is 50 mg/kg po bid up to a maximum of 1200 mg po bid when given with ritonavir (75-150 mg/m 2 BID) plus one or two NRTIs.

Major Toxicities
Saquinavir appears to be well tolerated. The most frequently reported adverse events among patients receiving saquinavir were diarrhea, abdominal discomfort and nausea. Other reactions reported in trial of saquinavir, alone and with zidovudine and zalcitabine, include the following: dyspepsia, mucosa damage, headache, paresthesia, extremity numbness, dizziness, peripheral neuropathy, musculoskeletal pain, myalgia, asthenia, appetite disturbances, rash, and pruritis. • FDA/EMEA adolescent/adult dose: Body weight ≥60 kg: 40 mg twice daily, body weight <60 kg: 30 mg twice daily.
• FDA dose for extended release capsule formulation: 100 mg once daily for individuals weighing at least 60 kg and 75 mg once daily for individuals weighing less than 60 kg.

Major Toxicities:
Peripheral neuropathy, manifested by numbness, tingling or pain in hand or feet, that has been reported in patients receiving stavudine and cases of lactic acidosis/ severe hepatomegaly with steatosis (a majority of these cases have been in women) have been reported, some cases were fatal. Fatal and nonfatal pancreatitis has occurred during therapy when stavudine was part of a combination regimen that included didanosine, with or without hydroxyurea, in both treatment naïve and treatment experienced patients regardless of degree of immunosuppression.
• FDA/EMEA adult dose of Truvada ® : one tablet daily.
• FDA adult (>18 years) dose of Atripla ® : One tablet once daily. Dosing at bedtime may improve the tolerability of nervous system symptoms. Renal impairment: Because Atripla ® is a fixed-dose combination, it should not be prescribed for patients requiring dosage adjustment such as those with creatinine clearance <50 mL/min.

Non FDA/EMEA Approved PENPACT 1 Dosing Recommendations
Children aged 2 to 8 years: 8 mg/kg of body weight once daily. Children aged >8 years: Median dose of 210 mg/m 2 of body surface area once daily, maximum dose of 300 mg once daily.

Major Toxicities:
More common: Nausea, diarrhea, vomiting, and flatulence. Less common (more severe): Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been reported. TDF caused bone toxicity (osteomalacia and reduced bone density) in animals when given in high doses. Decreases in bone mineral density have been shown in both adults and children taking TDF for 48 weeks; the clinical significance of these changes is not yet known. Evidence of renal toxicity, including increases in serum creatinine, blood urea nitrogen, glycosuria, proteinuria, phosphaturia, and/or calciuria and decreases in serum phosphate has been observed in animal studies at high exposure levels. Several cases of renal tubular dysfunction have been reported in patients receiving TDF; patients at increased risk of renal dysfunction should be closely monitored. • Syrup: 10 mg/mL • Capsule: 100 mg • Tablet: 300 mg • Concentrate for injection/for intravenous infusion: 10 mg/mL • Tablets in combination with lamivudine: Combivir ® : 300 mg zidovudine and 150 mg lamivudine. Dosages: • Dose for premature infants: (Standard neonatal dose may be excessive in premature infants). 1.5 mg/kg of body weight (intravenous) or 2 mg/kg of body weight (oral) every 12 hours, increased to every 8 hours at 2 weeks of age (neonates >30 weeks gestational age) or at 4 weeks of age (neonates <30 weeks gestational age).
• FDA neonatal dose (infants aged <90 days) (accepted in Europe by recognition of FDA approval): Oral: 2 mg per kg of body weight every six hours. Intravenous: 1.5 mg per kg of body weight every six hours.
• FDA pediatric dose (accepted in Europe by recognition of FDA approval) 6 weeks to 12 years of age: Oral: 160 mg per m 2 of body surface area every eight hours.
Intravenous (intermittent infusion): 120 mg per m 2 of body surface area to 180 mg per m 2 of body surface area every six to eight hours.

Major Toxicities:
Zidovudine may be associated with hematologic toxicity including granulocytopenia and severe anemia particularly in patients with advanced HIV disease. Prolonged use has been associated with symptomatic myopathy similar to that produced by human immunodeficiency virus. Rare occurrences of potentially fatal lactic acidosis in the absence of hypoxemia, and sever hepatomegaly with steatosis have been reported with the use of certain antiretroviral nucleoside analogues. Whenever a toxicity grade includes the use of the "ULN", as part of the calculation of the toxicity grade itself, sites must follow:

Reference
⇒ "ULN" values reported by the laboratory report for the test, or ⇒ "ULN" values routinely used/established by the site, or ⇒ "ULN" values (and/or calculations) as per the Harriet Lane Handbook.

Description of an ABC Hypersensitivity Reaction
In clinical studies, approximately 3-5% of patients receiving abacavir develop a hypersensitivity reaction which in rare cases has proved fatal. This is characterized by the appearance of symptoms indicating multi-organ/body system involvement. Symptoms usually appear within the first six weeks of initiation of treatment with abacavir (median time to onset is 11 days) and most often include fever, rash, gastrointestinal symptoms (nausea, vomiting, diarrhea, or abdominal pain), and lethargy or malaise. Other signs and symptoms may include respiratory symptoms (dyspnea, sore throat, cough), musculoskeletal symptoms (myalgia, rarely myolysis, arthralgia), headache, paresthesia and oedema. Some patients with hypersensitivity reactions were initially thought to have respiratory disease (pneumonia, bronchitis, pharyngitis) or a flu-like illness. This delay in diagnosis of hypersensitivity has resulted in abacavir being continued or re-introduced, leading to more severe hypersensitivity reactions or death. Therefore, the diagnosis of hypersensitivity reaction should be carefully considered for patients presenting with symptoms of these diseases. Renal failure and anaphylaxis have also been reported in association with hypersensitivity reactions.
Physical findings include lymphadenopathy and, occasionally, mucous membrane lesions (conjunctivitis and/or mouth ulceration) and hypotension. The rash is variable and may be absent, but often appears maculopapular or urticarial. Laboratory abnormalities that may accompany abacavir hypersensitivity include elevated liver function tests or creatine phosphokinase, creatinine or lymphopenia.
Symptoms related to this hypersensitivity reaction worsen with continued therapy and usually resolve upon discontinuation of abacavir. Restarting abacavir following a hypersensitivity reaction results in a prompt return of symptoms within hours.
This recurrence of the hypersensitivity reaction may be more severe than on initial PENPACT 1 VERSION 3.1 FINAL 07/11/07 APPENDIX X (Cont.) presentation and may include life-threatening hypotension and death. Subjects who Develop a hypersensitivity reaction must discontinue abacavir and must not be rechallenged with abacavir.
Presumed hypersensitivity reactions (HSR) must be reported as serious adverse events and should also be discussed with the study co-chair (PACTG sites) or the appropriate trial center (PENTA sites). Additionally, an e-mail notification to actg.penpact1@fstrf.org for any presumed HSR must be sent from the study site. In the event that ABC is permanently discontinued, it should be replaced by zidovudine (ZDV)

Information for Patients about ABC hypersensitivity:
Subjects must be informed of the risk of a hypersensitivity reaction to abacavir and provided with information to help them recognized the symptoms and signs associated with possible hypersensitivity reactions. Patients must be advised to contact their doctor immediately if they experience such symptoms.
Warning Card -All subjects receiving abacavir should receive a wallet-size warning card provided by GlaxoSmithKline. As each subject is enrolled, the study site must assure that: • The subject receives the warning card.
• The designated health care provider (e.g., physician, study nurse-coordinator, or pharmacist) reviews the signs and symptoms of hypersensitivity with the subject. • The subject verbalizes an understanding of the steps to take in the event of a suspected hypersensitivity, including contacting the study site.

Medical Management of a Possible ABC Hypersensitivity Reaction:
If a subject reports symptoms suggestive of hypersensitivity, s/he should be instructed not to take any additional doses and should be evaluated at the clinic. The evaluation should consist of a careful history and physical examination. Laboratory studies should be obtained as clinically indicated. There is no diagnostic test available to confirm the clinical diagnosis. If upon evaluation the subject does have a presentation consistent with hypersensitivity, therapy with abacavir must be permanently discontinued. In addition, the event "abacavir hypersensitivity" is to be reported as a serious adverse event on the SAE form and sent to the SAE office. The hematology, chemistry, signs and symptoms, diagnoses, event evaluation and serious event evaluation forms in the CRF should also be completed as indicated.
Symptoms usually start to resolve soon (within 24 hours) after stopping therapy. Symptomatic support, such as intravenous fluids for those who develop hypotension, is advised. There are no clinical data demonstrating the benefit of antihistamines or PENPACT 1 VERSION 3.1 FINAL 07/11/07 APPENDIX X (Cont.) corticosteroids in the management of hypersensitivity. Nevertheless, symptomatic and/or supportive treatment may be reasonable.
Patients who have had a hypersensitivity reaction must be advised that they should never take abacavir (or Ziagen) again as a life-threatening second hypersensitivity reaction can occur. Patients should be advised to return all unused abacavir at the time of discontinuation for return to the sponsor according to study procedures to reduce the risk of inadvertent rechallenge.

ABC Rash and Hypersensitivity:
Subjects receiving abacavir who develop rash of any grade should be evaluated for the possibility of hypersensitivity as outlined above. If there is no indication of any other organ system involvement and the subject has no systemic symptoms (fever, malaise, fatigue, headache), abacavir may be continued with the warning to discontinue immediately and permanently if other signs and/or symptoms consistent with hypersensitivity appear.

Fever and ABC Hypersensitivity
The onset of fever may also herald hypersensitivity. Subjects reporting fever should be evaluated as above. In the event of a clinical presentation consistent with hypersensitivity, abacavir should be discontinued permanently, and the steps taken as stated above.

Skin Rash/Cutaneous Dermatitis (other than ABC associated)
Rashes which meet the criteria for Grade 2 or higher AE (using the Supplemental Toxicity Table for grading severity of cutaneous/skin rash/dermatitis in Appendix VI) must be reported immediately to the PENPACT1 Team by e-mail at actg.penpact1@fstrf.org • Study drugs may be continued for Grade 2 (A or B) skin rash following consultation with the PENPACT1 team (Co-Chairs for PACTG sites trial center for PENTA sites).
• For children who develop cutaneous reactions > Grade 2 with any of the following signs/symptoms, antiretroviral therapy should be immediately discontinued. Sites should contact the study co-chair (PACTG sites) or the appropriate trial center (PENTA sites) to receive instructions on course of action: • • All study drugs must be permanently discontinued for any Grade 3 or 4 rash. Notify protocol team at actg.penpact1@fstrf.org.

Clinical Pancreatitis
If a subject develops nausea, vomiting , or abdominal pain of any grade associated with any elevation of serum fractionated pancreatic amylase or lipase, or develops a clinical syndrome that in the opinion of the subject's clinician is classified as pancreatitis, study medications should be permanently discontinued. Future consideration should be given to avoiding ddI or other drugs potentially affecting the pancreas. Notify protocol team at actg.penpact1@fstrf.org.

Hyperlipasemia
For elevations of lipase in blood, follow this algorithm: • For Grade 2 hyperlipasemia (>1.5 ULN), consider holding all study drugs, notify protocol team at actg.penpact1@fstrf.org immediately, schedule followup visits every two weeks if necessary until toxicity resolves to < Grade 1.
• For Grade 4 hyperlipasemia (>5.0 ULN), all study drugs should be held and may be permanently discontinued, do not restart until both lipase and amylase are < Grade 1.
Notify protocol team at actg.penpact1@frstf.org immediately to determine course of action. If hyperlipasemia recurs, discontinue all study drugs.

Hyperamylasemia
Management of this toxicity will be prompted for a Grade 3 or 4 hyperamylasemia.
Upon presentation of Grade 3 or 4, the amylase should be fractionated and the pancreatic fraction should then be used to determine the toxicity management.
Additionally, a lipase should also be obtained and the following algorithm applies: (Remember that this is done as secondary assay to a Grade 3 or 4 hyperamylasemia. Hyperlipasemia alone must be managed as described on the previous section) • If there is an elevation in lipase, hold all study drugs until both amylase and lipase are < Grade 1. Notify protocol team at actg.penpact1@fstrf.org immediately.
• Pending the results of the fractionated amylase evaluation if the lipase is normal, study medications may be continued. Notify protocol team at actg.penpact@frstf.org.
• Once available, fractionated pancreatic amylase elevations should be managed as per PENPACT 1 protocol Section 6.3 depending on the toxicity grade. The following algorithm for management of this toxicity should be observed: • For all Grade 2 LFT's, monitor subject every two weeks until values return to Grade 1.
• In general all Grade 2 LFT's or higher, should be reported to the team every other week.
• Elevations in LFT's should be managed as per Section 6.3 of the protocol depending on the toxicity grade.

CNS Symptoms
For grading CNS symptoms follow Appendix V "Division of AIDS Toxicity Table for Grading Severity of Pediatric (>3 months of age) Adverse Experiences." For management of CNS toxicities follow Section 6.3. Contact the protocol team via email at actg.penpact1@fstrf.org, if you have any doubts on how to proceed after observing specific CNS symptoms.

Hyperglycemia/glycosuria
If non-fasting blood glucose > 200 or urinary dipstick > 2+ positive, obtain fasting blood glucose. If the fasting blood glucose is > 150 mg/dl or greater, notify protocol team at actg.penpact1@fstrf.org immediately. Consult with an endocrinologist regarding possible new onset diabetes, and relay this information, and any followup information, to the protocol team.

Elevated Cholesterol or Triglycerides
Initiation of HAART with or without PIs and /or NNRTIs have been associated with elevations in cholesterol and triglyceride levels. These elevations should be managed as follows: • For cholesterol levels > 500 mg/dL, repeat a fasting cholesterol level.

Hematologic Toxicities
For hematologic toxicities, erythropoietin and/or G-CSF/GM-CSF may be administered as clinically indicated before considering dose reduction.
Only ABC, and d4T should be dose reduced. Only two (2) dose modification cycles are allowed. Following the second cycle, the full dose of the study drug can no longer be resumed.
For other hematologic toxicities where no dose reduction is allowed, follow Section 6.3 of the protocol. 11.0 Neutropenia and Anemia: These two toxicities are managed as illustrated in Figure 1.

Lactic Acidosis
Development of lactic acidosis is considered a toxicity endpoint. Lactic acidosis and a liver dysfunction syndrome have been associated with NRTI's mono-and combination therapies. In PENPACT 1 the possibility of the development of these conditions will be monitored. For subjects with ALT and AST values above 2.5 x ULN with no easily discernable etiology (e.g. acute hepatitis A, B, C, or chronic hepatitis B or C), a serum bicarbonate or lactate will be obtained. If persistent abnormal values are obtained by verified correct blood drawing techniques for the specimen, hold all study drugs and contact the protocol Co-chair (PACTG sites) or the appropriate Trials Center (PENTA sites). Also, send an e-mail to team log-on at actg.penpact1@fstrf.org notifying the protocol team. The protocol team will work with the subject's clinician to determine the best course of action for subjects in whom NRTI associated liver dysfunction syndrome and lactic acidosis are confirmed. * Children whose HIV infection status is not confirmed are classified by using the above grid with a letter E (for perinatally exposed) placed before the appropriate classification code (e.g., EN2).
** Both Category C and lymphoid interstitial pneumonitis in Category B are reportable to state and local health departments as acquired immunodeficiency syndrome.  (10), with the exception of LIP (Box 3).

Box 3. Conditions included in clinical Category C for children infected with human immunodeficiency virus (HIV)
CATEGORY C: SEVERELY SYMPTOMATIC* Serious bacterial infections, multiple or recurrent (i.e., any combination of at least two culture-confirmed infections within a 2-year period), of the following types: septicemia, pneumonia, meningitis, bone or joint infection, or abscess of an internal organ or body cavity (excluding otitis media, superficial skin or mucosal abscesses, and indwelling catheter-related infections) • Candidiasis, esophageal or pulmonary (bronch, trachea, lungs) • Coccidioidomycosis, disseminated (at site other than or in addition to lungs or cervical or hilar lymph nodes) • Cryptococcosis, extrapulmonary • Cryptosporidiosis or isosporiasis with diarrhea persisting > 1 month • Cytomegalovirus disease with onset of symptoms at age > 1 month (at a site other than liver, spleen, or lymph nodes) • Encephalopathy (at least one of the following progressive findings present for at least 2 months in the absence of a concurrent illness other than HIV infection that could explain the findings): a) failure to attain or loss of developmental milestones or loss of intellectual ability, verified by standard developmental scale or neuropsychological tests; b) impaired brain growth or acquired microcephaly demonstrated by head circumference measurements or brain atrophy demonstrated by computerized tomography or magnetic resonance imaging (serial imaging is required for children < 2 years of age); c) acquired symmetric motor deficit manifested by two or more of the following: paresis, pathologic reflexes, ataxia, or gait disturbance • Herpes simplex virus infection causing a mucocutaneous ulcer that persists for > 1 month; or bronchitis, pneumonitis, or esophagitis for any duration affecting a child > 1 month of age • Histoplasmosis, disseminated (at a site other than or in addition to lungs or cervical or hilar lymph nodes) • Kaposi's sarcoma • Lymphoma, primary, in brain • Lymphoma, small, noncleaved cell (Burkitt's), or immunoblastic or large cell lymphoma of B-cell or unknown immunologic phenotype • Mycobacterium tuberculosis, disseminated or extrapulmonary • Mycobacterium, other species or unidentified species, disseminated (at a site other than or in addition to lungs, skin, or cervical or hilar lymph nodes) • Mycobacterium avium complex or Mycobacterium kansasii, disseminated (at site other than or in addition to lungs, skin, or cervical or hilar lymph nodes) • Pneumocystis carinii pneumonia • Progressive multifocal leukoencephalopathy • Salmonella (nontyphoid) septicemia, recurrent • Toxoplasmosis of the brain with onset at > 1 month of age • Wasting syndrome in the absence of a concurrent illness other than HIV infection that could explain the following findings: a) persistent weight loss > 10% of baseline OR b) downward crossing of at least two of the following percentile lines on the weight-for-age chart (e.g., 95th, 75th, 50th, 25th, 5th) in a child > 1 year of age OR c) < 5th percentile on weight-for-height chart on two consecutive measurements, > 30 days apart PLUS a) chronic diarrhea (i.e., at least two loose stools per day for > 30 days) OR b) documented fever (for > 30 days, intermittent or constant)

Immunologic Categories
The three immunologic categories (Table 2) were established to categorize children by the severity of immunosuppression attributable to HIV infection. CD4+ T-lymphocyte depletion is a major consequence of HIV infection and is responsible for many of the severe manifestations of HIV infection in adults. For this reason, CD4+ counts are used in the adult HIV classification system (11). However, several findings complicate the use of CD4+ counts for assessing immunosuppression resulting from HIV infection in children. Normal CD4+ counts are higher in infants and young children than in adults and decline over the first few years of life (12)(13)(14)(15)(16) In addition, children may develop opportunistic infections at higher CD4+ levels than adults (17)(18)(19). Although insufficient data exist to correlate CD4+ levels with disease progression at all age groups, low age-specific CD4+ counts appear to correlate with conditions associated with immunosuppression in children (12,17,20,21). Therefore, despite these complications, classification based on age-specific CD4+ levels appears to be useful for describing the immunologic status of HIV-infected children.
Fewer data are available on age-specific values for CD4+ T-lymphocyte percent of total lymphocytes than for absolute counts. However, the CD4+ T-lymphocyte percent has less measurement variability than the absolute count (22). To establish the age-specific values of CD4+ percent that correlate with the CD4+ count thresholds, CDC compiled data from selected clinical projects in the United States and Europe. The data included > 9,000 CD4+ counts, with the corresponding CD4+ percent determinations, from both HIV-infected and uninfected children < 13 years of age. Nonparametric regression modeling was used to establish the CD4+ percent boundaries that best correlated with the CD4+ count boundaries in the classification system.
The immunologic category classification (Table 2) is based on either the CD4+ T-lymphocyte count or total lymphocytes. If both the CD4+ count and the CD4+ percent indicate different classification categories, the child should be classified into the more severe category. Repeated or followup CD4+ values that result in a change in classification should be confirmed by a second determination. Values thought to be in error should not be used. A child should not be reclassified to a less severe category regardless of subsequent CD4+ determinations.

Clinical Categories
Children infected with HIV or perinatally exposed to HIV may be classified into one of four mutually exclusive clinical categories based on signs, symptoms, or diagnoses related to HIV infection (Box 2). As with the immunologic categories, the clinical categories have been defined to provide a staging classification (e.g., the prognosis for children in the second category would be less favorable than for those in the first category).
Category N, not symptomatic, includes children with no signs or symptoms considered to be the result of HIV infection or with only one of the conditions listed in Category A, mildly symptomatic. Category N was separated from Category A partly because of the substantial amount of time that can elapse before a child manifests the signs or symptoms defined in Category B, moderately symptomatic. Also, more staging information can be obtained during this early stage of disease by separating Categories N and A. In addition, for children who have uncertain HIV-infection status (prefix E), Categories N and A may help to distinguish those children who are more likely to be infected with HIV (23) (i.e., children in Category EA may be more likely to be infected than children in Category EN Category A or C should be included in Category B. Anemia, thrombocytopenia, and lymphopenia have defined thresholds in the new classification system (23).
Category C includes all AIDS-defining conditions except lymphoid interstitial pneumonitis (LIP) (Box 3). Several reports indicate that the prognosis for children with LIP is substantially better than that for children who have other AIDS-defining conditions (21,24,25). Thus, LIP has been separated from the other AIDS-defining conditions in Category C and placed in Category B.
Signs and symptoms related to causes other than HIV infection (e.g., inflammatory or drug-related causes) should not be used to classify children. For example, a child with drug-related hepatitis or anemia should not be classified in Category B solely because these conditions may be associated with HIV infection. In contrast, a child with anemia or hepatitis should be classified in Category B when the condition related to HIV infection. The criteria for diagnosing some conditions and determining whether a child's signs, symptoms, or diagnoses are related to HIV infection may not be clear in all cases, and therefore may require judgment of the clinicians and researchers using the classification system.
Categories in the 1987 pediatric HIV classification system can be translated into categories in the 1994 system in most cases (Box 4). Class PO is now designated by the prefix "E", and Class P1 is now Class N. Children previously classified as P2A are now classified in more than one category, reflecting the different prognoses for children with different conditions included in the P2A category (e.g., children who have wasting syndrome have a worse prognosis than those who have lymphadenopathy).

RULES:
• Every child will be assessed with exactly the same instruments at baseline and follow-ups. •

Height
Once a subject is greater than 24 months of age and can stand upright, stature should be measured using a calibrated, wall-mounted stadiometer.
For best results, the subject is measured wearing a gown that allows the measurer to visualize the subject's body position. The subject stands with bare feet close together, body and legs straight, arms at sides, relaxed shoulders, and head, back, buttocks, and heels against the wall or shaft of the stadiomenter.
Instruct the subject to look straight ahead and stand tall, keeping heels on the ground.
Bring the headboard down to the top of the subject's head while at eye-to-eye level with the subject and record the height to the nearest 0.1 cm.

Length
Measure subject's recumbent length up to 24 months of age and, for those unable to stand, up to 36 months of age on a calibrated length board with a stable headboard and a sliding footboard.
Two people are required to perform an accurate length measurement. One person holds the subject's head in place while the other slides the footboard and takes the reading. The subject's foot should be flat against the footboard with toes pointing straight upward and legs straight at the time of measurement.
Subjects who are longer than standard length boards but cannot stand should be measured on a hospital bed as accurately as possible. Two measurers must be involved. One holds the subject's head in place while the other marks the bed paper where the top of the head meets the bed. The feet need to be flexed with toes pointing upward. Legs and torso need to be straight during the time of marking the bed at the heel. Using a ruler, draw a straight line from the marks to the edge of the bed paper. Measure between the lines without the subject's moving.

Weight
Use an electronic or beam scale with non-detachable weights. Weigh children who can stand on a beam scale, preferably one with "handle bars" for support. Calm children down and reduce their movement as much as possible for accurate measurements. Take a child's weight while he or she is wearing minimal clothing and no shoes.
For children who have disabilities that prevent them from standing on a beam scale but are large for an infant scale, use a bed scale. Alternatively, an adult may hold the child and stand on the scale with and without the child. The weight of the adult is subtracted from the combined adult-child weight to determine the child's weight. This method is only to be used for children who cannot stand alone and are too large for the infant scale.

Head Circumference
The tape is placed across the forehead with the lower border of the tape just above the eyebrows, around the head, above the ears and over the occipital prominence at the back of the head. Pull tape firmly to compress the hair and underlying soft tissues. Positioning of the tape over the forehead and occiput should be done to yield the maximum head circumference. Record head circumference in centimeters to the nearest 0.1 cm. No pubic hair. 2 Pubic hair is sparse, lightly pigmented, straight, medial border of labia. 3 Pubic hair is darker, beginning to curl, and increases in amount. 4 5 Pubic hair is coarse, curly, abundant but the amount is less that in an adult woman.
Pubic hair is that of an adult woman forming a triangle spread to medial surface of thighs. There are already at least 15 such drugs available for children, and new drugs are being developed. It is known that taking a combination of three drugs together works more effectively than using only one or two drugs. However it is not known which combination of drugs gives the most benefit over time with the least side effects in children.
After starting anti-HIV drugs it is expected that most children will have very low (undetectable) levels of HIV in the blood. However, after some time, the level of virus often starts to rise again, especially if the drugs are not taken very regularly. This may mean that the virus becomes resistant to the drugs. At the moment we still don't know when the best time is to switch therapy, if the drugs are changed too early that perhaps will mean that we quickly run out of suitable drugs for children. On the other hand, staying on the same drug combination may be more likely to increase resistance of HIV to the drugs. However, there is evidence the virus growing while on treatment with these drug combinations will not produce HIV-related disease as rapidly as when the virus grows in a person without drug treatment.

WHAT ARE THE AIMS OF THE TRIAL ?
The PENPACT 1 plans to include 256 HIV infected children from clinics in Europe and the USA who need to start treatment, (a decision made by your child's doctor). The study has 2 main aims: 1.
To compare different combinations of anti-HIV drugs to see which is the best to start with to slow the growth of the virus in the body and which has the least side-effects for children. The drugs are the same ones that your doctor would use even if you decide that you do not want your child to participate.

2.
To decide what to do if the HIV level rises again in the blood. We will look at whether it is better to change to a new set of anti-HIV drugs as soon as the virus becomes detectable or if it is better to wait until the amount of virus in the blood is a bit higher.
Children in the trial will be chosen at random by a computer to change their drugs when their viral load (level of the virus) goes over either 1 000 copies/ml or over 30 000 copies/ml. This will mean that some children may stay on the same therapy for a period of time with detectable viral load levels below 30 000 copies/ml. (In children on no treatment, the viral load is often greater than 100,000 copies/ml).

WHAT DRUGS WILL BE USED ?
It is important that your child takes anti-HIV medicine as prescribed by the doctor, whether they are in the trial or not.
Children will start treatment with 3 drugs: • two NRTIs and one NNRTI OR • two NRTIs and one Protease Inhibitor NRTIs -Nucleoside Reverse Transcriptase Inhibitors:-Your doctor will select 2 of the following drugs: • 3TC (also called Lamivudine or Epivir).
• ddI ( also called didanosine or Videx). This should be taken on an empty stomach.
• AZT (also called Zidovudine, Retrovir or ZDV) These drugs are all available as syrups or as tablets and should be taken twice a day, except for ddI which can be prescribed once or twice a day. (3TC can also be prescribed once a day in adolescents).
NNRTI -Non-Nucleoside Reverse Transcriptase Inhibitors or PI -Protease Inhibitors A computer will choose at random whether your child receives an NNRTI or a PI.
If your child is allocated to receive an NNRTI, your doctor will prescribe either : • Nevirapine (also known as Viramune) OR PENPACT 1 VERSION 3.1 FINAL 07/11/07 APPENDIX XVI (Cont.) • Efavirenz (also known as Sustiva).
If your child is allocated to receive a PI, your doctor will select ONE of the following drugs: • Nelfinavir (Viracept) Sometimes a small dose of Ritonavir is given as well to boost one of the other drugs in this group. The decision about which drug will be taken by your doctor.
When the time comes to change drugs, those children who started with a Protease inhibitor should change to an NNRTI and those children who started with an NNRTI drug should change to a Protease Inhibitor. The NRTIs will also be changed. However, if by the time your child needs to change drugs there are newer better drugs available, your doctor may discuss using different drugs.

HOW OFTEN WILL WE NEED TO ATTEND THE CLINIC?
Your child will be seen at the following times for blood tests and an examination: At the beginning of the trial to ensure that it is appropriate for your child to participate.
• 2 weeks later when the drugs will be started • 2 weeks after starting drugs • Every 4 weeks for the next 12 weeks • Then, once every 12 weeks until all children in the trial have been followed for 4 years.
We hope that you will agree for your doctor to continue to send information about your child, such as routine blood results and general medical progress for long term follow up after the trial period has ended. This information will continue to be confidential and will be used under the study number only.
The level of virus in the blood will be measured at each clinic visit. If it goes over the level allocated to your child (1,000 or 30,000 copies/ml) twice in a row, your doctor will prescribe new drugs for your child. At some clinic visits small quantities of blood may be stored to look at particular ways in which the virus behaves.
WHAT IF MY CHILD BECOMES ILL DURING THE TRIAL? If your child becomes ill at any time during the study, and your doctor feels that he or she would benefit from changing drugs, this will be discussed with you.

CONFIDENTIALITY
All information collected about your child during PENPACT 1 will be confidential. Names will not be used on any data collection forms. Your child will be identified by a study number only.
An independent group called the Data and Safety Monitoring Committee will meet regularly to oversee the progress of the trial. They will recommend whether the trial should continue as planned or should stop. Information from these meetings will be summarized in the PENTA Newsletter for families involved in PENTA studies.

PARTICIPATION
Participation in this study is entirely voluntary. If you decide that you do not wish your child to take part that is entirely your right. Your decision will in no way affect any present or future treatment for your child. You can withdraw your child from the trial at any time without giving a reason. This will not affect your child's medical care. We hope, however, that parents will give a reason why they wish to withdraw their child and will continue to allow follow-up.

WHAT ELSE DO I NEED TO KNOW?
The Ethics Committee of your hospital has given approval for this trial to be conducted at your clinic. PENTA, which is funded by the European Union, has made agreements for compensation should your child come to any harm during the trial. Your doctor will be able to tell you about this. SIDE-EFFECTS OF THE DRUGS PRESCRIBED Your child will be randomised to receive either a PI or an NNRTI. Your doctor will provide you with further information on the individual drugs. However some general points can be made: In general, the main side-effects of all Protease Inhibitor drugs are long-term and include concerns about the way the fats in the body are managed (high blood fat levels) and sometimes changes in fat distribution causing a thinning of the face, legs and arms and an increase in fat around the stomach (lipodystrophy). These body fat changes have also been observed with drugs from the NRTI group (especially d4T). The cause of these changes is not clear yet and it seems that not only drugs but other problems like a low CD4 count at start of therapy are also involved in the development of these body fat changes. The most common side-effect of the NNRTI drugs is rashes. Adverse effects to Efavirenz in the first days of therapy are often dizziness, insomnia, somnolence, abnormal dreams and hallucinations, and depression (nervous system symptoms). However these generally resolve after 2-4 weeks, although about 7% of patients may continue to have symptoms.
In addition to the PI or NNRTI drug your child will also receive 2 NRTIs. Occasional problems with the liver (hepatitis) or with the body's metabolism (lactic acidosis) or lipodystrophy have been reported with this type of drugs (NRTIs) The more significant side-effects of specific NRTIs are as follows: The main side-effect of Abacavir is flu-like symptoms, with or without a rash, up to 4 weeks after your child has started taking this drug. Your doctor or clinic nurse will give you more information about this. This side-effect is not very common, however if your child should develop these symptoms, you should inform your doctor immediately. If your doctor tells you to stop the Abacavir, your child should never start it again.
The most important side-effect of d4T is neuropathy (problems with the nervous system). This has been seen in adults but is rare in children. A sign of neuropathy can be pain or tingling of the feet to touch and your doctor will also check your child's reflexes at each visit.
A rare side-effect of ddI can be an inflammation of the pancreas (pancreatitis) which can be associated with vomiting, diarrhoea and abdominal tenderness and can be checked for with a blood test at clinic visits. It stops when the drug is stopped. ddI can also cause neuropathy. OTHER POSSIBLE RISKS It is possible that some combinations of antiretroviral drugs may harm an unborn child. If girls could become pregnant, they must have a pregnancy test before entering the trial and must use effective contraceptives including condoms or other barrier contraception if they are having sex. Any boys having sex must also use condoms.
Thank you for taking time to consider this trial for your child. Please ask any questions and let us know if there are things that you do not understand, or would like more information about. 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 allow your child/baby 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 will evaluate two different treatment combinations of anti-HIV drugs, and will use one of two plans for switching from one to the other treatment combinations. One plan will switch treatment combination when the viral load is 1,000 copies of HIV-1 per milliliter of blood in the bloodstream, and the other plan will switch treatment when the viral load is 30,000 copies of HIV-1 per milliliter of blood in the bloodstream. The study will evaluate if there is a difference in benefit for either of the two switching plans in a four-year treatment. These names are given based on their ways to lower HIV levels in your bloodstream. The use of different combinations of these kinds of drugs has been proven to be successful in decreasing the amount of HIV in the bloodstream.
This study will include the following drug combinations: 2 NRTIs + 1 PI 2 NRTIs + 1 NNRTI Although HIV resistance to these drugs and their combinations is expected when the amount of virus circulating in the blood is increasing (giving a higher viral load test), there is evidence the virus growing while on treatment with these drug combinations will not produce HIV-related disease as rapidly as when the virus grows in a person without drug treatment.
There will be a recommended switch from one treatment combination to the other when your/your child's initial treatment combination is not able to control the amount of HIV in the bloodstream. There will be two different viral load values for this switch, 1,000 copies/mL or 30,000 copies/mL. The study will evaluate if switching drugs when the amounts of HIV in the bloodstream are low (1,000 copies/mL) or when they are high (30,000 copies/mL), or starting with a PI or not, makes a difference in the power of the second treatment combination to fight HIV. The study will also evaluate how well you/your child tolerate(s) the drugs over at least a four-year treatment.
Although the study will recommend a second treatment combination switching from PI to non-PI, or vice-versa, your/your baby's/your child's clinician will choose the best available treatment combination, which could be different from the ones recommended by this protocol.
This study will also evaluate and compare the safety and how acceptable is each drug combination regimen used right after enrollment and after switching.

WHAT DO I HAVE TO DO IF I AM IN THIS STUDY?
You/your child/baby will be assigned at the entry visit to one of the drug combination regimens mentioned above. It is important that you/your child/baby take(s) all the drugs properly as prescribed by your doctor. A computer will choose at random whether you/your child/baby will receive 2NRTIs+1NNRTI or 2NRTIs+1PI. This is the best way to compare different drug PENPACT 1 VERSION 3.1 FINAL 07/11/07 APPENDIX XVII combinations. The computer will also assign the viral load value at which you/your child/baby should switch drugs.
The current anti-HIV drugs available for your/your child's/baby's doctor to be prescribed as part of this study, are as follows: (The choice will depend on what your doctor feels is most suitable for you/your child/baby, and if new drugs/treatment combinations become available. These new options will be discussed with you/your child when it is time for switching) PENPACT 1 VERSION 3.1 FINAL 07/11/07

APPENDIX XVII
The blood collected on this study visit will include routine laboratory tests as with any physical exam and the following specific laboratory tests: viral load (amount of HIV in bloodstream), and CD4+ cell counts (the number of cells in bloodstream that fight HIV).

Entry Visit
You/your child/baby will need to come for an entry visit, which will be on the day you/your child/baby are assigned to one of the treatment regimens. In this visit, about 2 teaspoons of blood will be drawn for similar laboratory tests as described previously. A urine sample will be collected on this visit. A pregnancy test will also be needed at this visit if you/your child are/is old enough to become pregnant.
On this visit, a neurologic exam will be performed. This exam evaluates the brain and nervous system functions, such as reflexes, hearing, sense of touch, vision, ability to move, and others.

U.S. Domestic Sites
Also on this visit a specialized doctor called neuropsychologist will perform an examination of your/your child's/baby's behavioral and learning development (this exam will include answering questions and doing some tasks).

On Study Visits
You/your child/baby will have a study visit at weeks 2, 4, 8, 12, 16, 24, and every 12 weeks thereafter until the week that your/your child's doctor determines that your/your child's drug regimen should be changed. Then you/your child/baby will come for a new re-entry visit and restart the schedule of visits for the new treatment combination.
On these visits blood (about 2 teaspoons) and urine samples will be collected for similar laboratory tests as previously described.
To help understand the effect that not taking the study drugs as per doctor's orders has on you/your child/your baby HIV infection, you/your child will be asked several questions at some of these on study visits. There will be two sets of questions: (1) to determine the amount the of study drugs actually taken within the previous 3 days, and (2) to determine your/your child's/your baby's special reasons for not taking each study drug.

U.S. Domestic Sites
At weeks 24, 48, and every 48 weeks thereafter, the neuropsychologist will perform an examination of your/your child's/baby's behavioral and learning development (this exam will include answering questions and doing some tasks). These visits may take 1-3 hours. The study doctor may need to take you/your child/baby off the study early without your permission if: • the study is cancelled by the U.S. Food and Drug Administration (FDA), National Institutes of Health (NIH), the drug companies supporting this study, or the site's Institutional Review Board (IRB). (An IRB is a committee that watches over the safety and rights of research subjects.) • a Data Safety Monitoring Board (DSMB) recommends that the study be stopped early (A DSMB is an outside group of experts who monitor the study.) • you are/your child/baby is not able to attend the study visits as required by the study The study doctor may also need to take you/your child/your baby off the study drug(s) without your permission if: • continuing the study drug(s) may be harmful to you/your child/baby • you/your child/baby need(s) a treatment that you/your child/baby may not take while on the study • you are/your child/baby is not able to take the study drug(s) as required by the study • you/your child become(s) pregnant If you/your child/baby must stop taking the study drug(s) before the study is over, the study doctor may ask you/your child/baby to continue to be part of the study and return for some study visits and procedures.

WHAT ARE THE RISKS OF THE STUDY?
Treatment combinations of anti-HIV drugs and other drugs may cause increase risk of side effects or death. There is the risk of serious and/or life threatening side effects when non-study medications are taken with study drugs. For your safety, you must tell your/you child's/your baby's clinician PENPACT 1 VERSION 3.1 FINAL 07/11/07 APPENDIX XVII and/or the study doctor or nurse about all medications you are taking before you start the study and also before starting any new medications while on the study. In addition, you must tell the study doctor or nurse before enrolling in any other clinical trials while on this study. Once your/your child's/baby's clinician has decided which antiretroviral drugs will prescribe as your regimen, he/she will inform you of risk and side effects observed for those medications.
Other side effects besides those listed and side effects from taking these drugs together may occur. If any unusual symptoms or changes happen, you should call your/your child's/baby's doctor immediately. It is also important that while participating in the study, you/your child/baby do(es) not take/receive any other prescription drugs or over-the-counter medications without first talking to your/your child's/baby's doctor or study nurse.
For the NRTI group of drugs Lactic acidosis (elevated lactic acid levels in the blood) and severe hepatomegaly (enlarged liver) with steatosis (fatty liver) that may result in liver failure, other complications or death have been reported with the use of antiretroviral nucleoside analogues alone or in combination. The liver complications and death have been seen more often in women on these drug regimens. Some nonspecific symptoms that might indicate lactic acidosis include: unexplained weight loss, stomach discomfort, nausea, vomiting, fatigue, cramps, muscle pain, weakness, dizziness, and shortness of breath.
For the NNRTI group of drugs Severe liver damage that can result in death may occur and is often associated with a rash. Being female or having a higher CD4 cell count, regardless of gender, increase the risk of developing liver damage. If you are developing liver damage, you may have one or more of the following: tiredness, general feeling of illness or flu-like feeling, loss of appetite, nausea, pale stools, dark urine, yellowing of the skin or whites of the eyes, liver tenderness, or abnormal liver function tests. Subjects with active Hepatitis B or C infection or abnormal liver function tests are at higher risk for worsening liver disease.
Rash is the most common side effect. Rash occurs more often in women. Most rashes occur early during treatment. The rash may be severe and rarely may cause death. One of the risk factors for developing serious skin reactions includes failure to take medications properly during the first 14 days of treatment.
Hypersensitivity reactions (allergic reaction) may occur. These reactions are rarely fatal. The symptoms that you may notice are rash, fever, tiredness, muscle or joint aches, flu-like feeling, blisters, mouth sores, facial swelling, red eyes and irritation of the eyes, general feeling of discomfort, and/or liver damage described above, kidney problems, and/or changes in white blood cell levels.

APPENDIX XVII
If you develop any of the side effects listed above, no matter how long you have been receiving nevirapine, you must contact your health care provider right away and before you take your next dose. Your health care provider will instruct you on what to do next. If you and your doctor then decide to stop your treatment because of liver damage, hypersensitivity, or severe skin reactions, you should never take nevirapine again.
The use of efavirenz during pregnancy and especially early pregnancy should be avoided. Efavirenz may cause fetal harm when taken during the first three months of pregnancy. Serious birth defects, including those of the central nervous system, have been seen in the offspring of animals and women on efavirenz.
A false-positive urine screening test for marijuana has been seen with one particular test brand and has not been seen when using other screening tests or with tests used to confirm results for marijuana.

For the PI group of drugs
The use of potent antiretroviral drug combinations (which commonly include a protease inhibitor) may be associated with an abnormal placement of body fat and wasting. Some of the body changes include: • Increase in fat around the waist and stomach area • Increase in fat on the back of the neck • Thinning of the face, legs, and arms • Breast enlargement The use of protease inhibitors may also be associated with the following: • Increases in the amount of triglycerides and/or cholesterol in the blood • Development of diabetes or the worsening of high blood sugar There have been reports of increased bleeding in HIV-infected persons with hemophilia (a bleeding disorder) who were treated with protease inhibitors. It is not known if protease inhibitors were the cause of these bleeding episodes Blood Drawing Risks Blood drawing may cause some discomfort, bleeding or bruising where the needle enters the body. A small blood clot may form at the site of venipuncture or there may be swelling in the area. There is a small risk of a minor infection at the blood draw site.

Risks of Switching Drug Regimens and Resistance
Every time you/your child/your baby switch(es) drug regimens because of increased HIV levels in the bloodstream, there is a possibility that new drug regimens may be difficult to find. Furthermore, the HIV in your/your child's/your baby's blood might change -or become resistant to -certain drugs. This means that certain drugs do not work well against your/your child's/your baby's HIV. Even new drugs from the same group of drugs as the current regimen may not work well against your/your child's/your baby's HIV. Your/your child's/your baby's clinician will explain the importance of taking all study drugs exactly the way and times they are prescribed to decrease the chance of developing drug resistance, and to keep HIV levels in the bloodstream low.

Neuropsychological Testing Risks (U.S. Domestic Sites)
The discomforts of neuropsychological testing are tiredness and difficulty concentrating.

ARE THERE RISKS RELATED TO PREGNANCY?
The drug or drug combinations in this study may be unsafe for unborn babies. The risks to unborn babies for each drug will be explained to you by your/your child's clinician once he/she has determined the antiretroviral drugs of your study regimen. If you are having sex that could lead to pregnancy, you must agree not to become pregnant or make a female pregnant Because of the risk involved, you and your partner must use two methods of birth control that you discuss with the study staff. You must continue to use both methods until three months after stopping study drugs. You may choose two of the birth control methods listed below: • Birth control drugs that prevent pregnancy given by pills, shots or placed under the skin • Male or female condoms with or without a cream or gel that kills sperm • Diaphragm or cervical cap with a cream or gel that kills sperm • Intrauterine device (IUD) If you are assigned to receive study drugs that do not require the use of two birth control methods, the study staff will discuss your options.
If you can become pregnant, you must have a pregnancy test before you enter this study. The test must show that you are not pregnant. If you think you may be pregnant at any time during the study, tell your study staff right away. The study staff will talk to you about your choices. If you/your child/baby take(s) part in this study, there may be a direct benefit to you/your child/baby, but no guarantee can be made. It is also possible that you/your child/baby may receive no benefit from being in this study. Information learned from this study may help others who have HIV.

WHAT OTHER CHOICES DO I/DOES MY CHILD/BABY HAVE BESIDES THIS STUDY?
Instead of being in this study you have the choice of: • treatment with prescription drugs, including some of the drugs used in this study as well as other drugs not prescribed in the study, are available to you/your child/baby • treatment with experimental drugs, if you/your child/baby qualify(ies) • no treatment Please talk to your doctor about these and other choices that may be available to you/your child/baby. Your doctor will explain the risks and benefits of these choices.

WHAT ABOUT CONFIDENTIALITY?
This study is part of a combined effort of two different organizations, the PACTG group and the PENTA group. The study teams from both organizations wrote one study called PENPACT 1, which includes actually two different studies, PACTG 390 (the one you/your child/your baby are/is enrolling) at U.S. and international sites connected with the PACTG, and PENTA 9 in Europe. PENPACT 1 will combine the information from these two studies, for a larger number of subjects.
To help us protect your privacy, we have obtained a Certificate of Confidentiality from the National Institutes of Health. With this Certificate, the researchers cannot be forced to disclose information that may identify you, even by a court subpoena, in any federal, state, or local civil, criminal, administrative, legislative, or other proceedings. The researchers will use the Certificate to resist any demands for information that would identify you, except as explained below. The Certificate cannot be used to resist a demand for information from personnel of the United States Government that is used for auditing or evaluation of federally funded projects or for information that must be disclosed in order to meet the requirements of the federal Food and Drug Administration (FDA). You should understand that a Certificate of Confidentiality does not prevent you or a member of your family from voluntarily releasing information about you or your participation in this research. If an insurer, employer, or other person obtains your written consent to receive research information, then the researchers may not use the Certificate of Confidentiality to withhold that information.
[The researchers should include language such as the following if they intend to make voluntary disclosure about things such as child abuse] The Certificate of Confidentiality does not prevent the researchers from disclosing voluntarily, without your consent, information that would identify you as a participant in the research project under the following circumstances. [The researchers should state here the conditions under which voluntary disclosure will be made] Your/your child's/baby's records may be reviewed by the U.S. Food and Drug Administration (FDA), (insert name of site) IRB, National Institutes of Health (NIH), PACTG (Pediatrics AIDS Clinical Trials Group) study staff, PENTA (Pediatric European Network for Treatment of AIDS) staff and study monitors.

WHAT ABOUT STORED SAMPLES?
Information for NIAID Sites: Some of your/your child's blood will be taken and stored (with usual protectors of identity) and used for testing that is required for this study (pharmacokinetic and genotypic) and future PACTG-approved, HIV-related research. Less than 1 teaspoon of your/your child's blood will be taken for this purpose.
Your/your child's samples will not be sold or directly used to produce commercial products. All proposed research studies using your/your child's samples will be reviewed by the National Institutes of Health (NIH). There is no time limit on how long your/your child's samples will be stored. The researchers do not plan to contact you or your/your child's regular doctor with the results of future studies done using your/your child's stored samples. This is because research studies are often done with experimental procedures, and results of such studies should not be used to make decisions about your/your child's medical care. If the researchers decide that the result of a certain study provides important information for your/your child's medical care, then your/your child's study doctor will be notified. If you would like to be contacted with this sort of information, you must notify the study staff of any changes in your/your child's address or phone number.

APPENDIX XVII
You may decide that you do not want your/your child's samples stored for future research studies. You/your child can still participate in this study even if you make this decision. You may withdraw your consent for the storage and use of your/your child's samples at any time. If you withdraw your consent, these stored samples will be destroyed.
Please read the following statement carefully and then mark your initials in the appropriate space provided. I agree to allow my/my child's blood samples to be stored for use in future PACTGapproved, HIV-related research studies.

__________ Yes __________ No __________ Initials __________ Date
Information for NICHD Sites: Some of your blood specimens collected as part of this study will be stored for testing at a later date as part of this study. There is a separate consent form to explain this and get your/your child's consent.

WHAT ARE THE COSTS TO ME?
Taking part in this study may lead to added costs to you and your insurance company. In some cases it is possible that your insurance company will not pay for these costs because you/your child/baby is/are taking part in a research study.
All the study medications prescribed by your/your child's doctor will not be covered by the study. You/your child and/or your/your child's health insurance will be responsible for purchasing the study medications.

WHAT HAPPENS IF I AM INJURED?
If you/your child/baby is/are injured as a result of being in this study, you/your child/baby will be given immediate treatment for your injuries. The cost for this treatment will be charged to you or your insurance company. There is no program for compensation either through this institution or the National Institutes of Health (NIH). You will not be giving up any of your legal rights by signing this consent form.

WHAT ARE MY RIGHTS AS A RESEARCH SUBJECT?
Taking part in this study is completely voluntary. You may choose not to take part/not to allow your child/baby to take part in this study or leave this study/take your child/baby out of the study at any time. You/your child/baby will be treated the same no matter what you decide.

APPENDIX XVII
We will tell you about new information from this or other studies that may affect your/your child's/baby's health, welfare or willingness to stay in this study. If you want 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: • name of the investigator or other study staff • telephone number of above For questions about your/your child's/baby's rights as a research subject, contact: • name or title of person on the Institutional Review Board (IRB) or other organization appropriate for the site • telephone number of above PARENT FACT SHEET When your child joins this NICHD sponsored Study, you will be asked to give permission for having some specimens that the doctor or nurse will take from your child's body saved in a repository. (A repository is a special laboratory with freezers where specimens like blood or tissue cells and body fluids that are taken from you during a study are kept. Your child's name will not be on these specimens, only a special study number. The people who run the repository laboratory will not know your child's name.) Why have a repository?
Researchers can learn a lot from a study but as time goes by the tests that they used get better or new tests appear, and there is a need to learn more. When study volunteers consent to put specimens in the repository and consent to the researchers doing new tests on the specimens later after their time in the study is ended, these questions can be answered and more can be learned. None of these future studies would happen unless the Institutional Review Board overseeing the repository examines the study and makes sure that your child's rights are being protected.
How will my child's privacy be protected?
The only record that your child participated in this NICHD sponsored study is at the clinic where it is kept separate from your child's health records and locked away.
Your child's specimens in the repository will not have your child's name on them. The specimens will have a special study code. It will be the same code that is on your child's information in the NICHD sponsored Study from your child's interviews and examinations.
Again, none of this information will have your child's name on it.
How would a researcher get to use the specimens in the repository?
If a researcher wants to do a test on specimens from the NICHD sponsored repository in the future, he or she will write up the idea and it will have to be approved by a committee to make sure the research is worthwhile. If the idea is approved, then coded specimens and coded information will be given to the researcher. The researcher will not know the names, addresses, or phone numbers of the people who gave the specimens to the repository. PENPACT 1 VERSION 3.1 FINAL 07/11/07 APPENDIX XVIII Why wouldn't I find out the results of the research using my child's specimens?
You will not receive the results of research done with your child's specimens. This is because research can take a long time and must use specimens from many people before results are known. Results from research using your child's specimens may not be ready for many years. Often when studies are first done, it is not always clear how to use the information from the study to change the health care that people receive. So none of these study results is likely to affect your child's care right now, but they may be helpful to people like your child in the future. Your child's specimens can last in the freezer for many years and there is no time limit to when studies could be done in the future.
Would I ever be contacted in the future about research using my child's specimens?
All of the studies to be done in the future on your child's specimens in the repository will be for the particular reasons that you agreed to. Every study that is planned to use specimens from your child and others from this NICHD sponsored Study has to be reviewed by a special committee of people known as an Institutional Review Board, who are not part of the Study. Their goal is to make sure that what is planned is the same kind of study that you had agreed to. If it is, then the research will go ahead since you would have agreed that these particular tests could be done without anyone contacting you to get your permission in the future.
If the study to be done is not like the kind of tests you agreed could be done, then the committee will decide if you need to be contacted to give permission for the new study.
I gave my permission to testing my child's specimens in the repository, but what if I change my mind?
People always have the right to stop participating in research. So if you decide that you do not want researchers to be able to use the specimens from your child in the repository, you can contact the clinic staff. They will tell the repository that the specimens with the study code number linked to your child's name in the clinic should not be studied. These specimens can be removed from the repository and destroyed if you tell us to do that.
What type of research will be done with my child's specimens?
Many different kinds of studies use specimens. Some researchers may develop new tests to find diseases. Others may develop new ways to treat or even cure diseases. In the future, some of the research may help to develop new products, such as tests and drugs. If this would happen and these tests or drugs make money, there are no plans to share that money with the people who gave the specimens. PENPACT 1 VERSION 3.1 FINAL 07/11/07 APPENDIX XVIII As part of this study (insert title), your child is being asked to have some (insert specimen source-blood, urine, tissue, genital fluid, saliva, etc.) taken. These specimens will go into the NICHD repository for research to be done at some time in the future so that more information can come from your child's time in this NICHD sponsored Study.
You do not have to agree to store your child's specimens for future tests for your child to take part in this study. Your child will not lose any benefits to which your child is entitled if you decide against storing your child's specimens.
You will also be asked to agree that these particular tests can be done without anyone contacting you to get your permission sometime in the future. No one doing these tests would know that these specimens came from your child and no one would contact you or your doctor or nurse with the results from these tests that might happen in the future.