Keywords: AIDS, HIV, AZT, DDI, DDC, 3TC, high mineral doses, lymph massage, lymphocyte, antigen, antibody tests, B2 microglobulin, PCR viral, DNA, pre-existing heart disease, T-cell, Pacemakers, spinal cordstimulators, bladder stimulator, cerebella stimulator, phrenic nerve stimulator, CD8+T Lymphocytes, p24 antibody title, B2 microglodulin, PCR tests, antigen-ICD.

F. PROTOCOL

1 Study Overview.

This will be a one year, controlled study on a total of 100 patients. These will include :

Group a) a control group of 20 patients that are HIV negative
Group b) a group of 20 patients that are HIV positive but who have CD4 cell counts >800, hence patients who have not yet developed AIDS. These will receive PAP IMI treatments exclusively and will not be receiving other therapies for their HIV.
Group c) a group of 20 patients that are HIV positive and who have CD4 cell counts <500, hence patients who do have AIDS. These will receive PAP IMI treatments exclusively and will not be receiving other therapies for their HIV.
Group d) a group of 20 patients that are HIV positive and who have CD4 cell counts <500, hence patients who do have AIDS. These will receive PAP IMI treatments along with other therapies for their HIV (e.g., AZT, DDI, DDC, 3TC, or alternative therapies such as high mineral doses or lymph massage).
Group e) a second control group of 20 patients that are HIV positive and who have CD4 cell counts <500, hence patients who do have AIDS. These will receive no PAP IMI treatments and will just be receiving other therapies for their HIV (e.g., AZT, DDI, DDC, 3TC, or alternative therapies).

These patients will be recruited for the study through AIDS centres and through newspaper advertisement. The treatment group, which will be made up of 80 patients, 20 from groups a) through d). They will receive active treatments with the PAP-IMI Model 600-P twice per week.

Initially, the patient will be screened for study entry by either his/her primary care physician or the AIDS treatment centre staff. The physician will complete a medical history, a general examination, and evaluate all prior and current therapies performed on the patient. An activity questionnaire (provided by the investigator) will be filled out by the patient for baseline quality of life assessment. Appropriate clinical diagnostic and treatment documentation, along with the baseline activity questionnaire, will be sent with the patient upon arrival at the research institution (-name to be announced-). Once at the study site, a psychological evaluation and a study entrance evaluation will occur. Urine samples will be collected and blood samples will be drawn for clinical, chemical analysis (including lymphocyte, antigen and antibody tests).

Vital signs will be monitored before and after each individual treatment. Adverse reactions will also be monitored after each individual treatment. Blood and urine samples will also be collected throughout the study. Standard hematology, clinical blood chemistry analysis, immunological panels (including CD4 and CD8 helper and suppressor T-lymphocytes) and HIV P24 antigen-ICD, as well as urinalysis will be conducted at the beginning of the study, and monthly until the study's completion. P24 antibody titre, B2 microglobulin, and PCR viral DNA analysis will be performed at the beginning and end of the study.

The patient's primary care physician will continue to care for, monitor and follow the occurrence and severity of the patient's opportunistic infections/diseases and will have the patient fill out an activity questionnaire on a hi-monthly basis as scheduled in Section I of this protocol.

2. Personnel and Institutions.

a) Principle Investigators:
.......................,.......................
......................... (institution)
........................., .........................
............................ (institution)
........................., .........................
............................ (institution)

b) Name and address of each sub-investigator working under the supervision of the investigator:
........................., .........................
......................... (address)

c) Name and address of the research facilities to be used:
............................ (institution)
...... ........................ (institution)

d) Names and addresses of institutional review board chairpersons
......................
......................
......................
......................
......................
......................
......................

3. Criteria for Patient Selection and for Exclusion of Patients and an Estimate of the Number of Patients to be Studied.

Patients diagnosed as being HIV positive according to the Centres of Disease Control and Prevention diagnostic criteria abut who have not yet developed symptoms of AIDS). Those patients who meet the inclusion criteria, and give informed consent will have a physical exam and medical history taken. Blood and urine samples will be collected and the patient will fill out an activity questionnaire. If opportunistic infections are evident or suspected, further tests will be performed on an individual basis for each patient.

a) Inclusion criteria for the HIV- group:

1. Male or Female patients.
2. Over 21 years of age.
3. Patient diagnosed as being HIV negative as defined by the criteria established by the Centres for Disease Control and Prevention.
4. Patients willing and able to give informed consent prior to the start of the study.
5. Patients must be willing to return for evaluations.

b) Inclusion criteria for the non AIDS HIV+ group :

1. Male or Female patients.
2. Over 21 years of age.
3. Patient diagnosed as being HIV positive as defined by the criteria established by the Centres for Disease Control and Prevention.29
4. Patients willing and able to give informed consent prior to the start of the study.
5. Patients must be willing to return for evaluations.
6. Patient must have an absolute T-cell count above 800.

c) Inclusion criteria for the AIDS HIV+ combination therapy group and AIDS HIV+ control:

1. Male or Female patients.
2. Over 21 years of age.
3. Patient diagnosed as being HIV positive as defined by the criteria established by the Centres for Disease Control and Prevention.
4. Patients willing and able to give informed consent prior to the start of the study.
5. Patients must be willing to return for evaluations.
6. Patient must have an absolute T-cell count between 200 and 500.
7. Patient must be taking other therapies for the treatment of AIDS.

d) Inclusion criteria for the AIDS HIV+ exclusive PAP IMI therapy group :

1. Male or Female patients.
2. Over 21 years of age.
3. Patient diagnosed as being HIV positive as defined by the criteria established by the Centres for Disease Control and Prevention.
4. Patients willing and able to give informed consent prior to the start of the study.
5. Patients must be willing to return for evaluations.
6. Patient must have an absolute T-cell count between 200 and 500.
7. Patient must not be taking other therapies for the treatment of AIDS and agrees not to take other therapies during the course of the study.

e) Exclusion criteria :

1. Inability to obtain informed consent from patient.
2. Pregnant or nursing females; prisoners; mentally retarded patients.
3. Medical contraindications including patients with pre-existing heart disease, or patients with implanted electrical stimulating devices such as cardiac pacemakers, spinal cord stimulators, bladder stimulators, cerebella stimulators and phrenic nerve stimulators.
4. Participation in any other clinical trial or study.
5. Required use of medical devices designed to relieve pain.
6. Failure to satisfactorily demonstrate psychological health as determined during the psychological evaluation.

f) Number of patients included :

Patients that meet the inclusion criteria and agree to enter the study by signing the informed consent form, may be entered into the study. The trial is designed to consist of a total of 100 patients, 20 patients from each of the five groups listed under F-1 (above). This includes 20 patients from control group a) 20 patients from control group e). Except for the HIV+AIDS control group patients (Group (e)), the other four groups will receive PAP-IMI-600 treatments two times per week for twelve months.

g) Outcome variables :

The primary efficacy outcome variables will be significant improvement over time in immunological status as measured by CD4+ and CD8+ T-lymphocyte helper cell count and helper/suppressor cell ratio. Additional tests will include P24 HIV antigen-ICD test. Other tests that may be included are P24 antibody titre, B2 microglobulin and PCR tests.

The secondary efficacy outcome variable will be .................. .

Safety will be assessed by clinical observations related to vital signs and general patient health as well as standard clinical analyses which will be performed on the blood and urine samples collected at designated intervals.

h) Study termination :

The following will result in a patient being terminated from the study:

1. Physician decision on clinical basis.
2. Patient request.
3. Violation of the protocol.
4. Satisfactory completion of the protocol (when a total of (108) treatments is reached).
5. Patient drop-outs (defined below in l).
6. Treatment failure (defined below in j).
7. Patient death.

i) Drop-outs :

Failure to return to clinic for all follow-up evaluations.

j) Treatment failure :

Failure of the active treatment therapy to measurably increase (or prevent a previous decreasing trend in) the CD4+ T-lymphocyte helper cells within the 12 month study period.

k) Concomitant therapies :

All concomitant medications and dose levels used by Group-(d) and Group-(e) during the study will be recorded, including AZT, DDI, DDC, and 3TC.

4. Patient Confidentiality.

Upon entry into the study, each patient will be assigned a study identification number. These identification numbers, along with the clinic's patient number, and the patient's initials, will be used exclusively on the Case Report Forms to preserve patient confidentiality. The Investigator will keep a master file that relates the identification numbers to the patients should any subsequent patient follow-up be required. The Investigator will keep such information available in his files for a period of five years.

5. Informed Consent.

An Informed Consent, employed and acceptable to the institution, will be obtained by the Principal Investigator or his designee in accordance with institutional policy and regulations set down by the Investigational Review Board. The Consent Form is appended (Appendix I).

6. Investigational Review Board.

The Principal Investigator will obtain written evidence that the protocol has been reviewed and approved by the Investigational or Institutional Review Board.

7. Methodology.

a) Study entry :

The patient's primary care physician will refer the AIDS diagnosed patient to the ........................ (institution) for study enrollment and PAP- IMI-600 treatment. The Investigator will be responsible for informing the Study Coordinator that a patient has been assigned to the Study. The Coordinator will provide the Investigator with the appropriate identification number. The Coordinator will also assign the patient to the appropriate treatment mode group.

b) Documentation on case report form :

The patient's primary physician will be responsible for completion of all Case Report Forms related to the ongoing monitoring of the physical health of the patient including the activity questionnaire. the Investigator will be responsible for those data collected at the time of treatment (vital signs, adverse reactions, dosage and length of PAP-IMI-600 treatment, etc.). Periodic monitoring of the Study will be undertaken by an independent consulting firm to confirm the validity of transcription of data to the appropriate Case Report Forms and the completion of the clinical evaluations that are required.

c) Discharge from study :

Patients will be discharged from the study when any of the criteria in Section F, 3-h, 3-l, or 3-j are reached. The reason for the discharge will be entered on the appropriate form and signed by the investigator.

Patient participation in the study can discontinue at any time, at the option of either the patient or the investigator.

An investigator may ask the patient to leave the study if the patient is noncompliant or if the patient develops any other medical problem which may interfere with this study. Patients will be encouraged by the Investigator to remain in the study so as not to bias any results.

If the patient drops out before completion of the therapy, the data will not be used as part of the study. If any patient drops out after completing the therapy, the data from that patient will be used to the fullest extent consistent with the principles of the study. All patients who drop out after completing the study will be contacted by the ........................... (institution) and asked why they dropped out.

d) Adverse reactions :

In the event that an adverse reaction occurs, the Adverse Reaction Form will be completed by the Investigator or primary care physician and signed. An adverse reaction is considered to be either an occurrence or degree of severity of a reaction that is beyond the usual clinical experience of patients undergoing such therapy.

While no adverse reactions have been observed or are expected, possible skin sensitivities, central nervous system manifestations and cardiovascular reactions will be specifically monitored.

In the event of severe adverse reactions regardless of relationship to the test article, appropriate diagnostic and therapeutic measures should be instituted. It will be left to the Investigator's or primary care physician's discretion as to whether the subject should continue or withdraw from the study. the Principal Investigator and Monitor must be notified within 24 hours of such an occurrence.

The Medical Monitor is :
.........................................
.........................................

e) Responsibilities :

Of the investigator :

1. Submit the Protocol to the Investigational Review Board and obtain its written approval to proceed.
2. Each Investigator will receive the investigational plan and be made aware of the responsibilities and the requirements of being an Investigator prior to beginning the study.
3. Appropriate data collection documents will be given to each Investigator.
4. Select qualified physicians to serve as a source of patient recruitment and to continue to treat and monitor the general physical health of the patient, as well as collect and record appropriate study data.
5. Obtain signed Consent Forms.
6. Select patients in accordance with the selection and exclusion criteria.
7. Assure that the procedures outlined in the protocol are followed.
8. Treat each patient as outlined in the protocol until the patient is discharged from the study and the study termination form has been completed.
9. Assure that all Case Report Forms are accurately and thoroughly completed in conjunction with the primary care physician.
10. Cooperate with the periodic monitoring visit by the independent Monitor.
11. Maintain a master Subject Log listing all patients by their names, the clinical assigned patient identification number, and the study identification number provided by the Coordinator.
12. Maintain regular communication with the primary care physician regarding the patient status and insure that the physician evaluates the patient at the regular intervals as scheduled in Section I of this protocol (approximately every two weeks).

Of the primary care physician :

1. Assess patient's clinical status and determine the need for study entry.
2. Refer patient to the ................................... (institution).
3. Prepare clinical diagnosis and treatment documentation, for the investigator's use, to accompany the patient upon arrival at the study site. This should include a completed baseline activity questionnaire filled out by the patient.
4. Continue to provide clinical care for and monitor the physical health status including opportunistic infections/diseases and the quality of life (the activity questionnaire) on days scheduled in Section I of this protocol (approximately every 2 weeks).
5. Maintain regular communication with the Investigator regarding the patient's status

Of the study coordinator :

The Principle Investigator will select another member of his/her staff to be the Study Coordinator. The Study Coordinator will be responsible for providing the identification number to the patient and for assigning the patient to the appropriate treatment mode group. The Study Coordinator will assist the Investigator in performance of the protocol study and completion and accuracy of all the necessary documentation.

Additionally, the primary care physician may select a member of his/her staff to assist in the ongoing monitoring of the patient and the data collection for the study.

Concerning case report forms :

As patients are discharged from the study, completed Case Report Forms containing all the clinical will be submitted to the Clinical Monitor who will review the forms for accuracy and completeness.

Concerning study monitoring:...................(company), will be responsible for monitoring this study. .................(company) personnel will conduct initial and termination site visits as well as periodic visits, and call the Investigators as needed. All aspects of study management will be reviewed with the Investigators prior to study initiation. Any questions should be directed to:

a.........................
b. ........................

f) Method of Determining the Doses to be Administered, the planned Maximum Dosage and the Duration of Individual Patient Exposure to the Device :

Each patient in Groups (a) - (d) will receive two treatments per week for twelve months for a total of 108 treatments. Treatment is administered by holding the PAP IMI probe in a parallel position close to the patient's body. The patients will receive 25 minutes of continuous treatment. The power scale of the machine will be set at the maximum setting. The vernier setting (rate of the pulses) will be set to produce approximately 2 pulses per second. the average output will be 12-18 volts across a 15 cm loop.

Each group will be broken into the following two subsets that will receive PAP IMI treatments in a different manner :

Subset 1 will treat the thymus area for 10 minutes and six principal lymphatic system sites for a total of 15 minutes (each site for 2-1/2 minutes: under each arm, on each side of the neck, and on each side of the abdomen).

Subset 2 will treat the thymus area but for just 5 minutes, only the upper four lymphatic sites for a total of 10 minutes (each site for 2-1/2 minutes: under each arm and on each side of the neck), and will also treat the spleen for 10 minutes.

g) Description of the observations and measurements to be made to fulfill the objectives of the study :

Patient will be referred to the research institution (-name to be announced-) by the patient's primary care physician. Upon arrival at CMC, the patient should bring with him/her all appropriate clinical, diagnostic, and treatment documentation.

The primary care physician should schedule regular appointments with the patient for monitoring of general physical health, occurrence and severity of any opportunistic infections and / or diseases, to have the patient complete an activity questionnaire, and any other relevant monitoring as scheduled below. These visits should take place bimonthly (24 times during the course of the study); between treatments 4 and 5, 8 and 9, 12 and 13, 16 and 17, ... and after treatment 108 (the last treatment).

h) Statistical analysis :

Analysis of improvement in immunological status (CD4+ T-lymphocytes) will be performed by a one-way ANOVA plus a multiple comparison of means test (Fischer's Least Significant Difference). Analysis of other tests may include P24 antigen and/or antibody analyses, B2 microglobulin and PCR tests.

i) Description of clinical procedures, laboratory tests, or other measures to be taken to monitor the effects of the device in human subjects and to minimize risk.

Initially the patient will be screened for study entry by his/her primary care physician. The physician should complete a medical history, a general examination and evaluate all prior and current therapies performed. An activity questionnaire (provided by the Investigator) should be filled out by the patient for baseline quality of life assessment. Appropriate clinical diagnostic and treatment documentation, along with the baseline Activity Questionnaire, should be sent with the patient to his/her first visit at ........................(institution).

Once at the study site, a psychological and a study entrance evaluation will occur. At both the initiation and end of the study, urine will be collected for standard urinalysis (8 components), and blood will be drawn for standard clinical chemical analysis (19 components). Other analyses to be performed on drawn blood, at these times, will include standard immune response profile (CBC with auto differential, platelet count and manual differential lymphocyte panel), HIV P24 antigen, HIV P24 antigen-ICD, B2 microglobulin, P24 antibody and PCR tests.

On a monthly basis standard urinalysis will be performed on urine samples and standard clinical chemical analysis will be performed on drawn blood. Immune response profile tests, including CBC with auto differential and platelet count and manual differential lymphocyte panel, and a P24 antigen-ICD will also be analysed monthly.

At the time of each PAP-IMI-600 treatment, the patient's vital signs will be measured before and after each treatment. The patient will be observed following each treatment for any adverse reactions that may occur.

Additionally, every 2 weeks during the study period the patient will visit his/her primary care physician for continued care. The physician will monitor the patient and collect data on the occurrence and severity of any opportunistic infections or diseases. At the time of this office visit, the patient will fill out an Activity Questionnaire to assess the quality of life.

j) Schedule:

1. Treatment 1:

Time: Pre-study

a. Baseline Data

Review of medical history, prior treatment, and baseline activity questionnaire.
Pre treatment Evaluation Study Entrance Form
Vital Signs - Blood pressure, pulse and body temperature

b. Psychological Evaluation

c. Blood sample including immunological panel, P24 antibody titre, HIV P24 antigen, HIV P24 antigen-ICD, B2 microglobulin and PCR tests.

d. Urine sample

Time: 0

Administration of PAP-IMI-600 treatment

Time: 10 minutes after treatment

a. Blood pressure, pulse/heart rate, body temperature
b. Observations and measurement of any adverse reactions. Questioning of patient regarding any other adverse reactions. If measurements are not possible, the Investigator is to use descriptive terms, such as slight/mild, moderate or severe. Information to be documented on the Adverse Reaction Report Form.

2. Treatments 2 - 4:

Time: Pre-treatment

Blood Pressure, pulse and body temperature

Time: 0

Administration of PAP-IMI-600 treatment

Time: 10 minutes after treatment

a. Blood pressure, pulse/heart rate, body temperature
b. Observations and measurement of any adverse reactions. Questioning of patient regarding any other adverse reactions. If measurements are not possible, the Investigator is to use descriptive terms, such as slight/mild, moderate or severe. Information to be documented on the Adverse Reaction Report Form.

Remind patient he/she is to see their primary care physician between the 6th and 7th treatments, and instruct patient to bring a completed activity questionnaire on the 7th day.

3. Treatment 5:

Time: Pre-treatment

a. Assure that patient has seen primary care physician since last treatment. Review patient's activity questionnaire.
b. Blood Pressure, pulse and body temperature

Time: 0

a. Blood pressure, pulse/heart rate, body temperature
b. Observations and measurement of any adverse reactions. Questioning of patient regarding any other adverse reactions. If measurements are not possible, the Investigator is to use descriptive terms, such as slight/mild, moderate or severe. Information to be documented on the Adverse Reaction Report Form.

4. Treatments 6 - 8:

Same as Treatments 2 - 4

Remind patient he/she is to see their primary care physician between the 8th and 9th treatments, and instruct patient to bring a completed activity questionnaire on the 9th treatment day.

5. Treatment 9:

a. Assure that patient has seen primary care physician since last treatment. Review patient activity questionnaire.
b. Same as Treatment 5.
c. Blood analysis also to include immunological panel and P24 antigen-ICD.

6. Treatments 10 - 12:

Same as treatments 2-4

Remind patient he/she is to see their primary care physician between the 12th and 13th treatments, and instruct patient to bring a completed activity questionnaire on the 19th treatment day.

7. Treatment 13:

a. Assure that patient has seen primary care physician since last treatment. Review patient activity questionnaire.
b. Same as treatment 5

8. Treatments 14 - 16:

Same as Treatments 2 - 4

Remind patient he/she is to see their primary care physician between the 17th and 18th treatments, and instruct patient to bring a completed activity questionnaire on the 18th treatment day.

(and so on)

9. Last treatment:

On the last treatment day, blood analysis should also include immunological panel, HIV P24 antigen, HIV P24 antigen-ICD, P24 antibody titre, B2 microglobulin and PCR tests.