Duration of Volunteer Participation

Deviations will be reported as required by IRBs. Annual continuing review reports at intervals designated by each participating investigator’s institutional review board, as well as a final study report, will be generated.

Every attempt will be made to follow the protocol, and to obtain and record all data requested for each subject at the specified times. However, ethical reasons may warrant the failure to obtain and record certain data, or to record data at the times specified. If this becomes necessary, the reasons for such must be clearly documented on the source document.
6. Methods
6.1 Recruitment of Study Volunteers
Clients who access HIV VCT services at the TRCAC will be given the information sheet with a brief description about the study and will be asked for their contact information by the clinic counselors and study nurses. Interested clients will be able to discuss the study in further detail with study nurses trained in HIV counseling and testing. There will also be posters and flyers (Appendix C) available in the clinic waiting area. These will also be distributed to hospitals and VCT centers in the Bangkok metropolitan area. Clients who are confirmed to have acute HIV infection will be asked to return and will be given a consent form which has a detailed description of this cohort study and additional consent forms for the optional procedures, genetic testing and tracking of and offering VCT to sexual contacts. Thai and English versions of the information sheets and consent forms will be used for Thai and English speaking non-Thai participants, respectively.
Clients who test HIV negative will receive post test counseling by TRCAC staff according to TRCAC procedures. The post test counseling will include risk reduction counseling. At-risk clients will be advised to return for HIV testing.
Standard of care in Thailand for newly determined HIV patients includes counseling, assessment of HIV clinical staging, screening for co-infections (e.g., hepatitis B) and vaccination or treatment as necessary, CD4 testing and determination of the need for opportunistic infection prophylaxis and antiretroviral treatment. Clients are generally followed every 2-3 months or more often if clinically indicated.

2. 
   Informed Consent Process
   

The investigator, or a person designated by the investigator, will give the clients an information sheet with a brief description of the study at the time of VCT. Clients will be asked for their contact information (name, address, telephone number) and their date of birth/place of birth. Clients whose testing confirms acute HIV infection will be contacted to return for counseling. The study staff will only notify the clients of their results if they are able to confirm correctly by phone their name, address, date of birth and place of birth. They will be asked to consent to enroll into this cohort study with a consent form that contains all pertinent aspects of the trial. The clients will also receive information about the optional procedures, genetic testing and tracking of and offering VCT to sexual contacts in separate consent forms. The written information sheet and consent form require approval by the IRB/IEC. The investigator or designee will ensure that before the volunteer decides to participate in the study, he/she understands its purpose, the procedure and any risks or benefits associated with the study. The volunteer will be given ample time to study the informed consent form and have the chance to ask questions about the study. He/she must understand that taking part in the study is his/her own choice. He/she may decide not to take part in the study or stop being in the study at any time without it making any difference to the medical care he/she receives now or in the future. The volunteer may choose to participate in the study without taking part in any or some of the optional procedures. A copy of the signed consent form(s) will be given to the volunteer to keep. The consenting process will be conducted in a private room. No study procedures will occur prior to the volunteer giving informed consent.

For the information sheet, clients are allowed to give a false name provided that the correct contact address and telephone numbers are given. Should clients be found to have an acute HIV infection, the clients will be asked to show their national identity card or passport which has their correct name and date of birth during the consent procedure. The purpose of the information sheet is to provide a brief overview of the study to a large number of clients (approximately 40,000) in order to be able to contact the very few clients with acute HIV infection (approximately 75).
6.3 HIV Counseling

Study personnel will provide the volunteers with HIV counseling consistent with TRCAC operating procedures and internationally accepted guidelines and accepted standards of practice for people with HIV infection. The counseling process will assist the volunteer with the following issues:

• 
  Where to obtain HIV care and treatment
  
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  Implications for sexual partners and family members
  
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  HIV risk reduction counseling
  
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  Psychological and social implications of HIV infection
  

Volunteers meeting all of the following criteria will be considered eligible for enrollment in the study:

1. 
   Age ≥ 18 years old
   
2. 
   Have protocol-defined acute HIV-1 infection (Tested 4th generation HIV EIA negative and NAT positive or tested 4th generation HIV EIA positive, negative by less sensitive EIA and NAT positive)
   
3. 
   Understand the study and sign informed consent form. Persons who cannot read will have the consent form read to them by a member of the study staff and may then give informed consent by using making a thumb print.
   
4. 
   Availability for follow-up for the duration of the planned study.
   

1. 
   Persons who have a history of a medical or psychiatric disorder by the investigator’s interview and physical examination according to standard practices, that in the judgment of the investigator(s), would interfere with or serve as a contraindication to adherence to the study protocol or ability to give informed consent.
   

The format of study identification will be a 4-digit number that will start with 0001, 0002 and continue until the last subject is enrolled. The study identification will not be placed on the informed consent document or any other data obtained from other sources. The link between study identification and participant personal identifying information will be the study coordinator.

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  Provide contact information including full name and nickname, address and telephone number, and date of birth/place of birth
  
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  Pre- and post-test HIV counseling including behavioral risk assessment and risk reduction counseling
  
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  Blood sample for HIV EIA (6ml EDTA). An additional blood sample for confirmatory testing according to TRCAC procedures (Appendix A) will be drawn (6 ml EDTA or equivalent) if their HIV EIA is positive. Remaining plasma will be archived. Part of the archived blood will be tested for acute HIV infection according to procedures in Section 6.5.3.2
  

Subjects who are found to have acute HIV infection will be contacted by the study physician and/or nurse by phone. Once their identity can be confirmed (see section 6.2), they will be counseled regarding their results (by stating that further discussion about their results is required without disclosing their HIV results over the phone) and ask to return to the TRCAC immediately for further discussion. They will be asked to consent to enrolment in the cohort study. Subjects who decline enrolment in the cohort study can continue to receive services at the TRCAC or they may be referred to local hospitals of their choice. There is no specific Thai law on disclosure of HIV results; however, the TRCAC maintains strict confidentiality.

• 
  Consenting for the acute HIV infection cohort study
  
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  HIV counseling including behavioral risk assessment and risk reduction counseling
  
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  Review and update contact information
  
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  History and physical examination by a TRCAC physician
  
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  Complete questionnaires on demographic information and HIV risk behavior
  

• 
  An abridged neuropsychological assessment by a certified nurse-psychometrist
  
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  Comprehensive neurological examination by a trained physician or a neurologist
  
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  Psychiatric questionnaires of anxiety, stress, depression and self-assessment of function (Appendix D)
  
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  An offer of hospitalization for the first 3-7 days. Observation or treatment for side effects of research procedures will be at Chulalongkorn University Hospital (if there are no beds, observation may be in other treatment units such as emergency room). However, if there are no beds at Chulalongkorn University Hospital and subjects wish to be hospitalized for non-medical or research indications, they may be accommodated at the Bangkok Christian Hospital which is a private hospital that is about 100 meters from Chulalongkorn University Hospital. No research procedures will be performed at Bangkok Christian Hospital.
  
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  Blood sample for HIV RNA (3ml), CBC (1ml), CD4 and CD8 cell counts (2ml), total/direct bilirubin, ALT, GGT (2ml), creatinine (1ml), triglyceride, cholesterol, high density lipoprotein, low density lipoprotein (2ml), RPR and TPHA, HCV antibody, HBsAg, and Anti HBs antibody (3ml)
  
• 
  Leukopheresis for lymphocyte studies and PBMC/plasma storage. This will allow collection of 5x10⁹ to 1x10¹⁰ of PBMC with minimal blood volume loss. The red blood cell loss from leukopheresis and some plasma that will be stored will be equivalent to about 50 ml blood loss. Subjects may choose not to have leukopheresis performed in which case 50ml will be drawn for PBMC and plasma storage.
  
• 
  Urinalysis and urine storage for assessment of novel HIV diagnostic algorithms and monitoring drug toxicity. Urine will be stored at AFRIMS for up to 10 years.
  
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  Urine pregnancy testing (for females)
  
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  Chest x-ray, EKG
  
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  Referral to an HIV clinic at the TRCARC or other clinics of the subjects’ choice for HIV care
  
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  Consenting of volunteers for other optional procedures
  
  • 
    Genital secretion collection including archiving of semen (male), cervicovaginal wash and vaginal swab (female) and anal wash and swab (MSM). Samples will be tested for HIV RNA and cytokines.
    
  • 
    Lumbar puncture for CSF collection which will be tested for CSF cell count, protein, glucose, HIV RNA and cytokines. Blood for glucose, protein and HIV RNA will be done at the same time as lumbar puncture.
    
  • 
    Brain MRI/MRS (without gadolinium)
    
  • 
    Colon biopsy for immunohistochemistry, flow cytometry and HIV RNA.
    
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  Consent volunteers for optional HLA testing (will be done on stored PBMC)
  
• 
  Consent volunteers for tracking/VCT of sexual contacts – during the first 12 weeks of enrollment
  

The procedures at week 0 may be performed on different days but preferably within 3 days.

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  History and physical examination by a TRCAC physician to monitor for adverse effects from procedures
  
• 
  Review and update contact information
  
• 
  Blood sample for CBC on day 7 (1ml)
  
• 
  Plasma and PBMC storage (20ml)
  
• 
  Urine storage
  
• 
  Genital secretion collection on days 3 and 7 (optional)
  
• 
  Other blood tests may be performed if clinically indicated
  

• 
  HIV counseling including behavioral risk assessment and risk reduction counseling
  
• 
  Review and update contact information
  
• 
  History and physical examination by a TRCAC physician
  
• 
  Blood sample for HIV RNA (3ml), CBC (1ml), CD4 and CD8 cell counts (2ml)
  

• 
  Completion of questionnaires on HIV risk behavior (weeks 24, 48, 72, 96, 144 and 192)
  
• 
  An abridged neuropsychological assessment by a certified nurse-psychometrist at weeks 12, 24, 96, 144 and 192
  
• 
  A comprehensive neurological examination by a by a trained physician or a neurologist at weeks 4, 12, 24, 96, 144 and 192
  
• 
  Psychiatric questionnaires of anxiety, stress, depression and self-assessment of function at weeks 4, 12, 24, 96, 144 and 192 (Appendix D)
  
• 
  Collection of blood samples for:
  
  • 
    Total/direct bilirubin, ALT, GGT (weeks 4, 12, 24, 48, 72 ,96, 120, 144, 168 and 192)
    
  • 
    Triglyceride, cholesterol, high density lipoprotein, low density lipoprotein (weeks 24, 48, 72, 96, 120, 144, 168 and 192)
    
  • 
    Creatinine (weeks 12, 24, 48, 72, 96, 120, 144, 168 and 192)
    
  • 
    Plasma and PBMC storage (40-45 ml at weeks 16, 20, 36, 60, 72, 84, 108, 120, 132, 144, 156, 168, 180 and 192)
    
• 
  Leukopheresis for lymphocyte studies and PBMC/plasma storage (weeks 2, 4, 8, 12, 24, 48 and 96). Subjects may choose not to have leukopheresis performed in which case 50ml will be drawn for PBMC and plasma storage.
  
• 
  Urine pregnancy testing (for females of child bearing age, weeks 12, 24, 36, 48, 60, 72, 84, 96, 108, 120, 132, 144, 156, 168, 180 and 192)
  
• 
  Urinalysis (weeks 12, 24, 48, 72, 96, 120, 144, 168 and 192)
  

• 
  MRI/MRS of brain without gadolinium unless clinically indicated (weeks 4, 12, 24 and 96)
  
• 
  Genital secretion collection including archiving of semen (male), cervicovaginal wash and vaginal swab (female) and anal wash and swab (MSM) at weeks 2, 4, 12, 24, 48, 72 and 96
  
• 
  Lumbar puncture for CSF collection which will be tested for CSF cell count, protein, glucose, HIV RNA. Blood for glucose, protein and HIV RNA will be done at the same time as lumbar puncture. Part of the samples will be archived for cytokines. These will be done at weeks 24 and 96
  
• 
  Colon biopsy for immunohistochemistry, flow cytometry, HIV RNA at weeks 24 and 96
  
• 
  Tracking/VCT of sexual contacts – during the first 12 weeks of enrollment
  

Leukopheresis will not be done in pregnant women. Brain MRI/MRS, genital secretion collection, lumbar puncture and colon biopsy will not be offered to pregnant women.

Positive samples will be confirmed by another NAT such as Bayer bDNA NAT and subsequently HIV DNA PCR. A standard HIV-1 p24 antigen assay (ABL Inc., Kensington, MD) without immune-complex dissociation will also be done on positive samples for Fiebig staging. Frequency of infection and attendant Fiebig stage will be tabulated.