Antiretroviral Localization in Gut-Associated Lymphoid Tissue and Lower Female Genital Tract Tissue of HIV+ Subjects

Study Design

This is an observational study of TFV, FTC, RAL, ATZ, EFV, and MVC localization within GALT
(terminal ileum & rectum), vaginal, and cervical tissues in the setting of undetectable
plasma HIV. Participants will be selected on the basis of receiving either TFV/FTC/RAL,
TFV/FTC/ATZ/r, TFV/FTC/EFV, or TFV/FTC/MVC as part of their ongoing HIV care. After
participant education, informed consent, and screening for study eligibility, participants
will be evaluated at baseline. All samples will be collected over the course of a 36 hour
inpatient visit as described below.

Study Sampling

1. Blood plasma will be collected after enrollment (approximately 2 hours after the start
of the inpatient visit) and before the start of bowel preparation (approximately 2-12
hours after the start of the inpatient visit).

2. Vaginal and cervical tissue will be collected after enrollment (approximately 2 hours
after the start of the inpatient visit) and before the start of bowel preparation
(approximately 2-12 hours after the start of the inpatient visit).

3. Rectal and terminal ileal tissue will be collected at approximately 18 hours after the
initiation of the bowel preparation.

Pharmacokinetic Analysis All blood, cervical, vaginal, ileal and rectal tissue samples will
be analyzed by the Clinical Pharmacology and Analytical Chemistry Laboratory (CPAC) at the
UNC School of Pharmacy, which is directed by the principal investigator, Angela Kashuba,
PharmD. To visualize ARV localization within a tissue, one biopsy from each tissue site will
be analyzed by IR-MALDESI using a previously established workflow for our laboratory.

HIV localization within tissues will be performed using in situ hybridization (ISH) in
collaboration with the Haase lab at the University of Minnesota. This group has substantial
experience in HIV RNA detection from human tissues, and preliminary studies have confirmed
our ability to detect HIV RNA from serial slices of tissues.

Localization within tissue slices will be evaluated by IR-MALDESI. Measurement of the
distribution of each ARV within pre-specified anatomical sub-regions across a tissue slice
will allow for identification of areas where drug is either concentrating or lacking. ISH and
IHC analysis of serial tissue slices will allow us to co-localize ARVs with HIV and HIV
target cells. Once these anatomical areas have been visually identified, imaging software
will be used to isolate and quantify the signal.

Inclusion Criteria:

1. Healthy HIV-positive female subjects between the ages of 18 and 65 years, inclusive on
the date of screening, with an intact gastrointestinal tract, uterus, and cervix.
Healthy is defined as no clinically relevant abnormalities that would interfere with
the interpretation of results, or pose unnecessary risk onto volunteers due to study
procedures.

2. All subjects must have an undetectable viral load at the time of screening or a
documented undetectable viral load within the preceding 3 months of screening.

3. All subjects must be receiving one of the study regimens as part of their regular HIV
care for at least 6 months preceding the date of enrollment.

4. Subjects must not have a history of GI disease (e.g. Crohn's disease, irritable bowel
syndrome, ulcerative colitis, diverticulitis, colon cancer) or have a history of GI
surgery.

5. All subjects (of childbearing potential) must have a negative serum pregnancy test at
screening and negative urine pregnancy tests on days of sampling and should be using
at least one of the following methods of contraception from the screening visit
through 72 hours prior to inpatient admission (at which time the women will be asked
to remain abstinent until after their follow-up visit):

1. Systemic hormonal contraceptive (oral, depot, transdermal or implant)

2. IUD placed at least 1 month prior to study enrollment

3. Bilateral tubal ligation (Sterilization)

4. Vasectomized male partners

5. Condom + Spermicide

6. Engaged in sexual activity with female only sex partners or abstinent for at
least 3 months prior with no intention of becoming sexually active during the
study period. Any history of recent or present concomitant male sex partners will
be addressed and ruled out in the context of screening participants for
eligibility for the protocol

6. Body Mass Index (BMI) of approximately 18 to 37 kg/m2; and a total body weight > 45 kg
(99 lbs).

7. Evidence of a personally signed and dated informed consent document indicating that
the subject has been informed of all pertinent aspects of the trial.

8. Willing and able to comply with scheduled visits, treatment plan, laboratory tests,
and other trial procedures.

9. Subject must have documentation of a normal pap smear within 36 months of the
screening visit, no procedures for abnormal cervical/vaginal pathology in the last six
months, at least one prior gynecological visit as part of subject's routine medical
history.

10. Not receiving any known CYP3A4 inducers (rifampin, carbamazepine, St. John's wort) or
inhibitors (ketoconazole, non-DHP calcium channel blockers, macrolide antibiotics)
other than those contained in their HIV regimen for at least 6 months prior to
enrollment.

11. Subject must be willing to abstain from sexual intercourse, douching, and all
intravaginal and intrarectal objects and products for at least 72 hours prior to
enrollment until study completion.

12. Subject must be Hepatitis B surface antigen negative as documented on screening labs
(or documented in their clinical record).

13. Subject must not be actively involved in the conception process.

14. Subject must be able to swallow pills and have no allergies to any component of the
study products (i.e. bowel preparation regimen)

Exclusion Criteria

1. Evidence or history of clinically significant hematological, renal, endocrine,
pulmonary, gastrointestinal, cardiovascular, hepatic, psychiatric, neurologic, or
allergic disease (including documented drug allergies, but excluding untreated,
asymptomatic, seasonal allergies at time of dosing).

2. Subjects with a history of hysterectomy or cervical resection that would preclude
obtaining a cervical biopsy.

3. Subjects who are pregnant, possibly pregnant or lactating.

4. Subjects with a presence of abnormal vaginal discharge bleeding at screening.

5. History of febrile illness within five days prior to enrollment.

6. A positive urine drug screen for illicit substances (e.g. cocaine, methamphetamines)
that would increase risk associated with sedation.

7. Active Hepatitis B infection

8. An untreated-positive test for syphilis, gonorrhea, Chlamydia, or trichomonas at
screening. Tests for these STIs will be performed on samples from both the vaginal and
rectal orifices.

9. Any clinically significant laboratory chemistry or hematology result Grade 3 or
greater according to the DAIDS Laboratory Grading Tables

10. Treatment with an investigational drug within 4 months preceding the first dose of
trial medication.

11. History of regular alcohol consumption exceeding 14 drinks (1 drink = 5 ounces (150
mL) of wine or 12 ounces (360 mL) of beer or 1.5 ounces (45 mL) of spirits) per week.

12. Participation in a clinical trial involving genital tract or rectal biopsies within 6
months preceding enrollment.

13. Blood donation of approximately 1 pint (500 mL) within 56 days prior to dosing.

14. History of sensitivity to heparin or heparin-induced thrombocytopenia.

15. Allergy to lidocaine or Monsel's solution.

16. Allergy to latex.

17. Abnormal pap smear in the past 36 months

18. Any degree of ectopy or abnormality evident during the pelvic exam at screening.

19. Any condition which, in the opinion of the investigator, is likely to interfere with
follow-up or ability to take the bowel preparation appropriately.

20. Unwilling or unable to comply with the dietary and concomitant drug restrictions in
regard to study drug administration as outlined in the study procedures and prohibited
medications sections.