Protocol. This trial protocol has been provided by the authors to give readers additional information about their work.

Transcription

1 Protocol This trial protocol has been provided by the authors to give readers additional information about their work. Protocol for: Giuliano AR, Palefsky JM, Goldstone S, et al. Efficacy of quadrivalent HPV vaccine against HPV infection and disease in males. N Engl J Med 2011;364:

2 PROTOCOL 020 A. OBJECTIVES Primary Safety Objective: To demonstrate that a 3-dose regimen of qhpv vaccine, when administered at 0, 2, and 6 months, is generally well tolerated in young men. Primary Efficacy Objective: To demonstrate that qhpv vaccine, when given in a 3-dose regimen, reduces the incidence of HPV 6-, 11-, 16- or 18-related external genital warts, penile/perianal/perineal intraepithelial neoplasia (PIN), penile, perianal or perineal cancer in young men who are naïve to the relevant HPV type, compared with placebo. MSM Substudy Efficacy Objective: To investigate the impact of administration of a 3- dose regimen of qhpv vaccine on the combined incidence of HPV 6-, 11-, 16-, or 18- related anal intraepithelial neoplasia (AIN) or Anal Cancer in MSM subjects who are naïve to the relevant HPV type. Secondary Efficacy Objectives: (1) To demonstrate that qhpv vaccine, when given in a 3-dose regimen, reduces the incidence of persistent HPV 6, 11, 16, or 18 infection in young men who are naïve to the relevant HPV type, compared with placebo (refer to Section I.F.1. for the definition of persistent infection). (2) To demonstrate that qhpv vaccine, when given in a 3-dose regimen, reduces the incidence of HPV 6, 11, 16, or 18 detection at one or more visits, in young men who are naïve to the relevant HPV type, compared with placebo. Immunogenicity Objective: To evaluate the vaccine-induced serum anti-hpv 6, anti- HPV 11, anti-hpv 16, and anti-hpv 18 responses in young men. B. HYPOTHESES Primary Safety Hypothesis: qhpv vaccine is generally well tolerated in young men. Primary Efficacy Hypothesis: Administration of a 3-dose regimen of qhpv vaccine reduces the combined incidence of HPV 6-, 11-, 16-, 18-related external genital warts, penile/perianal/perineal intraepithelial neoplasia (PIN), penile, perianal or perineal cancer in young men who are seronegative at Day 1 and PCR negative from Day 1 through Month 7 to the relevant HPV type, compared to placebo recipients. (It is anticipated that qhpv vaccine will reduce the combined incidence of HPV 6-, 11-, 16-, or 18-related external genital warts, penile/perianal/perineal intraepithelial neoplasia (PIN), penile, perianal or perineal cancer by 80% compared to placebo. The statistical criterion for 1

3 success requires that the lower bound of the confidence interval for the vaccine efficacy exclude 20 %.) MSM Substudy Efficacy Hypothesis: (1) Administration of a 3-dose regimen of qhpv vaccine reduces the combined incidence of HPV 6-, 11-, 16-, and 18 related AIN or anal cancer in MSM who are seronegative at Day 1 and PCR negative from Day 1 through Month 7 to the relevant HPV type, compared to placebo recipients. (It is anticipated that qhpv vaccine will reduce the combined incidence of HPV 6-, 11-, 16-, and 18-related AIN or anal cancer by 85% compared to placebo. The statistical criterion for success requires that the lower bound of the confidence interval for the vaccine efficacy exclude 0 %.) Secondary Efficacy Hypotheses: (1) Administration of a 3-dose regimen of qhpv vaccine reduces the incidence of persistent HPV 6, 11, 16, or 18 infection in young men who are seronegative at Day 1 and PCR negative from Day 1 through Month 7 to the relevant HPV type, compared to placebo recipients. (It is anticipated that qhpv vaccine will reduce the incidence of persistent HPV 6, 11, 16, 18 infection by 80% compared to placebo. The statistical criterion for success requires that the lower bound of the confidence interval for the vaccine efficacy exclude 20%. This hypothesis will only be tested if success is declared for the primary efficacy hypothesis.) (2) Administration of a 3-dose regimen of qhpv vaccine reduces the incidence of HPV 6, 11, 16, 18 DNA detection at one or more visits, in young men who are seronegative at Day 1 and PCR negative from Day 1 through Month 7 to the relevant HPV type, compared to placebo recipients. (It is anticipated that qhpv vaccine will reduce the incidence of HPV 6, 11, 16, 18 detection by 80% compared to placebo. The statistical criterion for success requires that the lower bound of the confidence interval for the vaccine efficacy exclude 20%. This hypothesis will only be tested if success is declared for the primary efficacy hypothesis.) C. DEFINITION 1. Inclusion Criteria Candidate subjects must meet ALL of the following: a. For HM: healthy, males between the ages 16 years and 0 days and 23 years and 364 days. 2

4 a.1 For MSM: healthy, males between the ages 16 years and 0 days and 26 years and 364 days. b. No clinical evidence of gross genital lesion suggesting sexually-transmitted disease, and no clinically present anogenital warts. c. No temperature 100 F or 37.8 C (oral) within 24 hours prior to vaccinations (vaccinations can be scheduled at a later date when the temperature falls into normal range). d. Must agree to refrain from sexual activity (including vaginal and anal penetration and any genital contact) for 2 calendar days prior to any scheduled visit that includes sample collection, to avoid detection of viral DNA which has been deposited in the male genital area during sexual intercourse and is not the result of ongoing infection. e. HM who have experienced sexual debut but have had no more than 5 lifetime sexual partners. For protocol purposes, a female sexual partner is defined as a woman with whom the subject has engaged in vaginal intercourse. For protocol purposes, a male sexual partner is defined as a man with whom the subject engaged in insertive or receptive anal intercourse. e.1 MSM subjects may have fewer than one lifetime sexual partner but no greater than 5 lifetime sexual partners. For MSM subjects with fewer than one lifetime sexual partner, they must identify themselves as a man who has sex with men and must have engaged in oral sex with another man within the past year. For protocol purposes, a female sexual partner is defined as a woman with whom the subject has engaged in vaginal intercourse. For protocol purposes, a male sexual partner is defined as a man with whom the subject engaged in insertive or receptive anal intercourse. f. Must agree to provide study personnel with a primary telephone number as well as an alternate telephone number for follow-up purposes. In FINLAND only, an alternate telephone number is not necessary as the national population register provides a second safety net for contact information. g.1. Additional inclusion criteria for heterosexual male subjects 3

5 Subjects must be a heterosexual male, who has had exclusively female sexual partners. g.2. Additional inclusion criteria for MSM subjects Subjects must identify themselves as a man who has sex with men and must have engaged in either insertive or receptive anal intercourse or oral sex with another male sexual partner within the past year. 2. Exclusion Criteria Candidate subjects who manifest ANY of the following exclusion criteria at the time of randomization will NOT be eligible for the study: a. Individuals concurrently enrolled in clinical studies of investigational agents or studies involving collection of genital specimens. b. History of known prior vaccination with an HPV vaccine. c. Receipt of inactivated vaccines within 14 days prior to enrollment or receipt of live virus vaccines within 21 days prior to enrollment. d. Individuals who have history of anogenital warts, or who have clinically present anogenital warts at Day 1. e. History of severe allergic reaction (e.g., swelling of the mouth and throat, difficulty breathing, hypotension or shock) that required medical intervention. f. Individuals allergic to any vaccine component, including aluminum, yeast, or BENZONASE (nuclease, Nycomed [used to remove residual nucleic acids from this and other vaccines]). g. Individuals who have received any immune globulin or blood derived products within the 6 months prior to the first injection, or plan to receive any through Month 7 of the study. h. Individuals with history of splenectomy, known immune disorders (e.g., systemic lupus erythematosus, rheumatoid arthritis), or receiving immunosuppressives (e.g., substances or treatments known to diminish the immune response such as radiation therapy, administration of antimetabolites, 4

6 antilymphocytic sera, systemic corticosteroids). Individuals who have received periodic treatments with immunosuppressives, defined as at least 3 courses of oral corticosteroids each lasting at least 1 week in duration for the year prior to enrollment, will be excluded. Subjects using topical steroids (i.e., inhaled or nasal) will be eligible for vaccination. i. Individuals who are immunocompromised or have been diagnosed as having Human Immunodeficiency Virus (HIV) infection. j. Individuals with known thrombocytopenia or any coagulation disorder that would contraindicate intramuscular injections. k. History of recent (within the last 12 months) or ongoing alcohol or drug abuse. Alcohol and drug abusers are defined as those who drink or use drugs despite recurrent social, interpersonal, and legal problems as results of alcohol or drug use. l. Any condition which in the opinion of the investigator might interfere with the evaluation of the study objectives. m. Any plan to permanently relocate from the area prior to the completion of the study or to leave for an extended period of time when study visits would need to be scheduled. n. HM with fewer than one or greater than 5 lifetime sexual partners. n.1 MSM subjects with greater than 5 lifetime sexual partners. o. Inability to give informed consent/assent. In Finland ONLY: local regulations concerning clinical conduct and subject s own right to decide of his/her participation in a clinical study, give the right to decide oneself at the age of 15. However, before the subject s 18 th birthday it is obligatory to inform the guardian of his/her child s decision in writing. This needs to be done before Visit 1 and is typically done by a study coordinator after giving an appointment to the subject. In these cases, no assent form will be signed. The Consent form will be signed by the study participant. In all other countries, local regulations will govern the age of consent. 5

7 D. STUDY DESIGN 1. Summary of Study Design For All Study Subjects This is a randomized, double-blind (with in-house blinding procedures), placebocontrolled, multicenter, international study. A total of approximately 4040 young men will be randomized in a 1:1 ratio to receive either qhpv vaccine or placebo at Day 1, Month 2, and Month 6. These 4040 men will include: Approximately 3450 heterosexual male (HM) subjects age 16 to 23 years; Approximately 590 men who have sex with men (MSM) age 16 to 26 years; these subjects will be enrolled at selected sites to participate in the Intensive Intra-anal Evaluation in MSM substudy. All subjects enrolled will undergo external anogenital lesion inspection and anogenital sampling for HPV detection at Day 1 and Months 7, 12, 18, 24, 30, and 36. If a lesion observed at Day 1 is judged by the investigator to be possibly, probably or definitely HPV-related (e.g. suspected or definite condyloma acuminata, or lesions in which HPV-related disease is part of the differential diagnosis), or of unknown etiology, then the subject should be excluded from the study. If the investigator feels further evaluation, treatment, or biopsy is necessary, it would be performed outside of the study. For every new lesion, a clinical impression will be rendered. All new genital lesions judged by the investigator to be possibly, probably or definitely HPV-related, or any lesion whose etiology is unknown will be biopsied. All biopsies will be processed at a central pathology laboratory designated by the SPONSOR. Slides from these biopsies will be read by pathologists at this central laboratory for purpose of medical management. In addition, all slides will be reviewed by a blinded pathology panel composed of up to 5 experts in HPV pathology for the purpose of endpoint determination. Sections from each biopsy will be prepared by the study s central laboratory and analyzed for up to 20 HPV types using Thinsection PCR at a laboratory selected by the SPONSOR. 6

8 Additional Procedures for Subjects Enrolled in South Africa Only Subjects participating in South Africa will undergo mandatory HIV testing at Day 1, Months 12, 24, and 36 visits. In addition, any subject from any other country who is found to be HIV infected will not be discontinued from the trial and will be referred for appropriate counseling and treatment and may participate in all study procedures. Additional Procedures for MSM Subjects Only Approximately 590 subjects participating in the substudy will undergo anal cytology at Day 1, Months 7, 12, 18, 24, 30, and 36 visits. Subjects will be triaged to high resolution anoscopy (HRA) on the basis of these tests using a protocol-specified algorithm. A high resolution anoscopy (HRA) is the examination of the anal canal using a colposcope and clear anoscope. In addition, subjects will also undergo HRA if lesions that are possibly, probably or definitely HPV-related are noted upon visual examination of the anal canal with simple anoscopy, or if external genital lesions are noted in the perianal region and these are histologically confirmed to be HPV-related. When an abnormal anal cytology result is obtained or HPV-related lesions are observed in the anal canal or a histologically confirmed HPV-related lesion is noted in the perianal region, the subject should be referred to HRA as soon as possible, and if necessary through an unscheduled visit. At the Month 36 visit, all MSM subjects will receive mandatory HRA evaluation after acetic acid administration All areas of abnormalities observed on HRA should be biopsied. To avoid contamination between lesions, separate forceps should be used to biopsy each area of abnormality. Biopsy specimens thus obtained should be placed in separate formalin containers and evaluated separately at the central laboratory. Study Duration The study employs a fixed event design. There will be a single primary analysis of efficacy after at least 32 cases of the primary efficacy endpoint have been observed, of which 23 must have occurred outside of the MSM substudy. Subjects enrolled in the main study and the MSM substudy will contribute to the primary analysis. For each subject enrolled, the duration of the study will be ~3 years. Month 36 follow-up will be obtained in all subjects even if it is possible to perform the primary analysis at an earlier time (i.e., as soon as 32 primary cases have been observed). Since this study is designed to assess the efficacy of the qhpv vaccine in preventing HPVrelated lesions and infection, the enrollment will target HPV-naïve subjects. Subjects will be enrolled in community health centers, college campuses and at their primary 7

9 health care providers. Enrollment of high-risk subjects such as those who attend Sexually Transmitted Disease (STD) Clinics should be avoided. 2. Treatment Participants will receive a total of 3 intramuscular injections of qhpv vaccine or placebo at Day 1, Month 2 (±3 weeks), and Month 6 (±4 weeks). Approximately 4040 subjects will be randomized (1:1) to receive the vaccine formulation (HPV 6 L1 VLP-20 µg, HPV 11 L1 VLP-40 µg, HPV 16 L1 VLP-40 µg and HPV 18 L1 VLP-20 µg) or matching placebo. Each subject will receive 1 injection at each vaccination visit (Day 1, Month 2, and Month 6). The vaccine and placebo formulations contain 225 µg of aluminum adjuvant per dose. Study vaccine/placebo will be given as a 0.5 ml intramuscular injection, preferably in the nondominant arm. The deltoid muscle is the preferred site for intramuscular injection in adults. Data suggest that injections given in the buttocks frequently are given in fatty tissue instead of into the muscle. Such injections have resulted in a lower seroconversion rate in studies evaluating certain vaccines (no such study has been conducted for the HPV vaccine). Thus, the vaccine/placebo should not be administered in the buttocks area. A needle long enough to ensure intramuscular injection deposition of vaccine should be used for the injections. Vaccine or placebo should be administered using a 1.0-mL syringe with the following needle length and gauge specifications: 1-inch needle, 22 to 23 gauge, for men weighing <200 pounds (90.9 kg), 1½-inch needle, 22 to 23 gauge for men weighing 200 pounds (90.9 kg). If the injection is given in the thigh, a 1½-inch needle, 22 to 23 gauge, should be used. In Finland ONLY: For I. M. injections, a 2.0 ml syringe is recommended for vaccinations. The 2.0 ml syringe suffices for the exact measurement of 0.5 ml of volume. 3. Study Procedures for All Subjects The procedures in this section should be performed on all subjects enrolled in the study (Refer to additional procedures required for MSM subjects). 8

10 a. Consent Written consent must be obtained from each subject or if the subject is a minor, from the subject s legal guardian, prior to the subject being entered into the study. Assent must also be obtained from minors. A copy of the signed consent form will be given to each subject for his records. Verification of the subject s identity and age is to be determined prior to obtaining written consent. b. Subject Discontinuation/Withdrawal Subjects may withdraw at any time or be dropped from the study at the discretion of the investigator should any untoward effects occur. In addition, a subject may be withdrawn by the investigator or the SPONSOR if he/she violates the study plan or for administrative and/or other safety reasons. The investigator or study coordinator must notify the SPONSOR immediately when a subject has been discontinued/withdrawn due to an adverse experience (telephone or FAX). When a subject discontinues/withdraws prior to study completion, all applicable activities scheduled for the final study visit should be performed at the time of discontinuation. Any adverse experiences which are present at the time of discontinuation/withdrawal should be followed in accordance with the safety requirements. A single subject cannot be assigned more than one allocation number. c. Study Visit Schedule Subjects will undergo scheduled visits at Day 1, and Months 2, 6, 7, 12, 18, 24, 30, and 36. In addition, subjects may undergo unscheduled visits for purpose of addressing health complaints, performance of biopsy for suspected HPV-related external anogenital lesions and administration of therapy for confirmed HPVrelated lesions. The study flow-chart is provided as Table 1 for subjects enrolled within the main study. Table 1 Study Procedures for Heterosexual Male Subjects Visit Months Event/Test D Obtain informed consent + Allocation number assigned + Genitourinary/medical history Sexual history Physical examination + + Procedures/specimen collection (in serial order) 9

11 Genitourinary examination of for external genital lesions Photograph of external genital lesion (if indicated) Penile/glans penis file and wetted swab for HPV PCR Scrotal file and wetted swab for HPV PCR Perianal examination for external genital lesions Perineal/perianal file and wetted swab for HPV PCR External genital lesion biopsy (if indicated) Treatment for external genital lesions (if indicated) Serum for HPV (6, 11, 16, 18) antibody measurements Serum for hepatitis B (if indicated) Serum for hepatitis C (if indicated) Serum for syphilis (if indicated) Serum for HIV (if indicated), Urine for gonorrhea PCR or LCR or SDA (if indicated) Urine for chlamydia PCR or LCR or SDA (if indicated) Swab for HSV culture (if indicated) Vaccination Clinical follow-up for safety Clinical contact visit documentation # Note: Any test may be repeated if medically indicated. The Month 2 visit can be performed within ±3 weeks. The Month 6 visit and all scheduled visits from Month 12 through Month 36 can be performed ±4 weeks. The interval between the Month 6 and Month 7 visits should be a minimum of 3 weeks and a maximum of 7 weeks from the Month 6 vaccination. Allocation number assignment should only occur AFTER the subject has been examined for the presence of HPV-related genital lesions. If a lesion is found, the subjects should not be allocated, and should be excluded from the study. Although complete review of the subject s genitourinary/medical history will not be scheduled for the Month 2 and Month 6 visits, their history will be updated as needed at these visits and at unscheduled visits. Processed and analyzed at Central Laboratory. In South Africa only, HIV testing is mandatory and will occur at Day 1, Months 12, 24, and 36 visits. In addition, an subject from any other country that is found to be HIV infected will not be discontinued from the trial and will be referred fro appropriate counseling and treatment and may participate in all study procedures. # Temperature will be measured prior to each injection. Contact visit documentation will be required every 3 months between study visits after Month 6 (Month 9, 12, 15, 18, 21, 24, 27, 30, and 33). This information can be obtained via telephone or electronic mail contact. For the Month 12, 18, 24, and Month 30 contacts, the information can be obtained during the visit. Testing to be performed by the local laboratory affiliated with the Investigative Site. Chronic, non HPV-related lesions (e.g. hemorrhoids, nevus, skin tag) present at Day 1 do not require photographs. At Day 1, only acute, non HPV-related lesions (e.g. molluscum contagiosum, folliculitis) are to be photographed. 10

12 1) Day 1 Procedures After the subject signs the informed consent form, he should undergo a medical history. The medical history should focus on an assessment of medical conditions that existed prior to enrollment in the study. Subjects should also be questioned about their lifetime number of female and/or male sexual partners, age of first sexual intercourse, any history of anogenital warts, any history of sexually transmitted diseases, and alcohol/tobacco consumption. The subject should also be questioned about their use of condoms. If the subject reports that he has engaged in sexual intercourse within 2 calendar days of the study visit, then the visit should be deferred until the 2- day requirement is fulfilled. After the completion of the medical history, a physical exam will be performed. In addition to vital signs (height, weight, sitting blood pressure, sitting pulse, and respirations), a general physical exam is recommended, including examination of skin, lymph node, head/eyes/ears/nose/mouth/ neck, chest, heart, abdomen, muscles/skeleton, peripheral vascular and neurology. When scheduling Day 1 visits (and subsequent specimen collection visits), subjects should be advised to refrain from shaving their genital region (and / or applying any post-shave lotions or lubricants) a minimum of 1 day prior to the visit, as this may interfere with the collection of skin cells. After the general physical examination, a complete genitourinary and perianal exam will be conducted. If a subject presents with an external genital lesion that is possibly, probably, or definitely HPV-related (e.g., suspected or definite condyloma acuminata, or lesions in which HPV-related disease is part of the differential diagnosis), or of unknown etiology, then the subject should be excluded from the study. If the investigator feels further evaluation, treatment, or biopsy is necessary, it would be performed outside of the study. If a subject presents with an external genital lesion that is definitely not HPV-related, and the subject meets all of the inclusion criteria, and the subject does not meet any of the exclusion criteria, that subject may be enrolled into the study. After the completion of this examination, specimens from the penile shaft, scrotum, perineal, and perianal region will be collected for HPV PCR. 11

13 After the completion of collection of anogenital specimens, subjects will undergo phlebotomy to obtain a specimen for measuring serum anti-hpv levels. If, after these procedures, the subject meets all the inclusion criteria, but not any exclusion criteria, he will be randomized and assigned an allocation number. Thereafter, prevaccination procedures will be performed. If not already performed as part of the physical examination, the subject s temperature (oral), weight, sitting blood pressure, sitting pulse, and respirations should be measured. If the subject has a temperature of 100 F or 37.8 C (oral) within 24 hours prior to an injection, the injection will be postponed until the subject s fever resolves. If the subject has received a course of systemic corticosteroids or other immunosuppressive agent, vaccination should be postponed for at least 2 weeks after completion of the medication regimen. After administration of the vaccine, the subject should be observed for 30 minutes. The observation period must be documented in the subject s medical chart. If the 30-minute observation period is uneventful, the subject should be given a Vaccine Report Card (VRC) and a thermometer. Subjects must undergo instruction in the completion of the VRC and the use of the thermometer. At any time during the study, a test for gonorrhea, chlamydia, herpes simplex, syphilis, hepatitis B serology, hepatitis C serology, and/or HIV test may be obtained if risk factors or clinical exams warrant such testing. At the Day 1 visit, if a subject presents with an active sexually transmitted disease, that subject should be treated for the disease, and should have enrollment deferred until the disease is resolved. Subjects who test positive to HIV should be referred for appropriate counseling and treatment but may continue in the study. They will not be included in the primary efficacy analysis. Subjects who test positive for gonorrhea, chlamydia, syphilis, hepatitis B (hepatitis B surface antigen [HBsAg]) or hepatitis C (hepatitis C antibody [HCAb]) may remain in the study. Subjects who test positive for these diseases should be referred for appropriate counseling and treatment. Ongoing education is to be provided to the subjects which may include written materials (e.g., IRB/ERC-approved pamphlets from the clinical site) to 12

14 increase the subject s knowledge base regarding HPV, sexually transmitted diseases and other health-related issues. The visit should end with retention activities, including ensuring that the study site has the subject s address, at least 2 telephone numbers, , and other contact information. The study staff should positively affirm the importance of the visit and the subject s participation in the study. Additional Procedures for Subjects Enrolled in South Africa Only Subjects participating in South Africa will undergo mandatory HIV testing at the Day 1 visit. Subjects who test positive for HIV at Day 1 will not be discontinued from the trial. Subjects should be referred for appropriate counseling and treatment and may participate in all study procedures. 2) Month 2 and 6 Visits Each visit should start and end with retention activities, including ensuring that the study site has the subject s updated address, at least 2 contact telephone numbers, , and other contact information. The site staff should positively affirm the importance of the visit and the subject s participation in the study, and thank the subject for his participation. The study coordinator or investigator will review the subject s vaccine report card with the subject. In addition, an interim medical history will be obtained, regarding any new medical history since the previous visit, and any new sexual partners. Thereafter, the subject s temperature (oral), sitting blood pressure, sitting pulse, and respirations will be measured. If the subject has a temperature of 100 F or 37.8 C (oral) within 24 hours prior to an injection, the injection will be postponed. If the subject has an elevated temperature at these visits, no procedure is to be performed. The subject is to be rescheduled. If the subject has received a course of systemic corticosteroids or other immunosuppressive agent before a vaccination is due, vaccination should be postponed for at least 2 weeks after completion of the medication regimen. After administration of the vaccine, the subject should be observed for 30 minutes. The observation period must be documented in the subject s medical chart. If the 30-minute observation period is uneventful, the subject 13

15 should be given a Vaccine Report Card (VRC) and a thermometer. Subjects must undergo instruction in the completion of the VRC and the thermometer. Subjects who do not complete the series of 3 vaccinations will be allowed to continue participation in the follow-up phase of study. 3) Month 7 Visit The visit should start and end with retention activities, including ensuring that the study site has the subject s updated address, at least 2 contact telephone numbers, , and other contact information. The site staff should positively affirm the importance of the visit and the subject s participation in the study, and thank the subject for his participation. The study staff will review the subject s vaccine report card with the subject. In addition, interim medical history will be obtained regarding any new medical history since the previous visit. If the subject reports that he has engaged in sexual intercourse within 2 calendar days of the study visit, then the visit should be deferred until the 2- day requirement is fulfilled. Subjects should also be questioned about their interim medical history and sexual activity, including the number of new females and/or males with which the subject engaged in sexual intercourse (for females, insertive vaginal intercourse; for males insertive or receptive anal intercourse), as well as their use of condoms. When scheduling the Month 7 visit (and subsequent specimen collection visits), subjects should be advised to refrain from shaving their genital region (and / or applying any post-shave lotions or lubricants) a minimum of 1 day prior to the visit, as this may interfere with the collection of skin cells. After the medical and sexual history, a complete genitourinary and perianal exam will be conducted All new lesions detected during the anogenital examination, that are possibly, probably or definitely HPV-related (e.g., suspected or definite condyloma acuminata, or lesions in which HPV-related disease is part of the differential diagnosis), or whose clinical diagnosis is unknown (lesions of unknown etiology), must be noted on the appropriate worksheets. 14

16 After the completion of this examination, specimens from the penile shaft, scrotum, perineal, and perianal region will be collected for HPV. All new lesions that are possibly, probably or definitely HPV-related (e.g., suspected or definite condyloma acuminata, or lesions in which HPVrelated disease is part of the differential diagnosis), or whose clinical diagnosis is unknown (lesions of unknown etiology) will be biopsied for confirmatory pathologic diagnosis. Lesions that are assessed to be definitely not HPVrelated need not be biopsied or excised. If a suspect lesion(s) is identified, a biopsy specimen is to be obtained and submitted to the central laboratory for analysis. The interval between genital wart/lesion biopsy and the next study visit that includes a complete genitourinary examination (Month 7, 12, 18, 24, 30, and 36) must be 2 months. After the completion of collection of anogenital specimens, subjects will undergo phlebotomy to obtain a specimen for measuring serum anti-hpv levels. At any time during the study, a test for gonorrhea, chlamydia, herpes simplex, syphilis, hepatitis B serology, hepatitis C serology, and/or HIV test may be obtained if risk factors or clinical exams warrant such testing. Subjects testing positive to HIV should be referred for appropriate counseling and treatment but may continue in the study. They will not be included in the primary efficacy analysis. Subjects who test positive for gonorrhea, chlamydia, syphilis, hepatitis B (hepatitis B surface antigen [HBsAg]) or hepatitis C (hepatitis C antibody [HCAb]) may remain in the study. Subjects who test positive for these diseases should be referred for appropriate counseling and treatment. If the participant presents with chlamydia or gonorrhea or any other active infection, the subject is to be treated for the infection and brought back for the visit after the infection has resolved. 4) Months 12, 18, 24, 30, and 36 Visits Each visit should start and end with retention activities, including ensuring that the study site has the subject s updated address, at least 2 contact telephone numbers, , and other contact information. The site staff should positively affirm the importance of the visit and the subject s participation in the study, and thank the subject for his participation. 15

17 The study staff should obtain an interim medical history at each visit. Subjects should also be questioned about their interim sexual activity at each visit, including the number of new females and/or males with which the subject engaged in sexual intercourse (for females, insertive vaginal intercourse; for males insertive or receptive anal intercourse), as well as their use of condoms. At the Month 36 visit, after the completion of the medical history, subjects should undergo a full physical examination. In addition to vital signs (height, weight, sitting blood pressure, sitting pulse, and respirations), a general physical exam is recommended, including examination of skin, lymph node, head/eyes/ears/nose/mouth/neck, chest, heart, abdomen, muscles/skeleton, peripheral vascular and neurology. If the subject reports that he has engaged in sexual intercourse within 2 calendar days of the study visit, then the visit should be deferred until the 2- day requirement is fulfilled. After the medical and sexual history, a complete genitourinary and perianal exam will be conducted All new lesions detected during the anogenital examination, that are possibly, probably or definitely HPV-related (e.g., suspected or definite condyloma acuminata, or lesions in which HPV-related disease is part of the differential diagnosis), or whose clinical diagnosis is unknown (lesions of unknown etiology), must be noted on the appropriate worksheets. When scheduling the Month 12, 18, 24, 30, and 36 visits, subjects should be advised to refrain from shaving their genital region (and / or applying any post-shave lotions or lubricants) a minimum of 1 day prior to the visit, as this may interfere with the collection of skin cells. After the completion of this examination, specimens from the penile shaft, scrotum, perineal, and perianal region will be collected for HPV PCR. All new lesions that are possibly, probably or definitely HPV-related (e.g., suspected or definitely condyloma acuminata, or lesions in which HPVrelated disease is part of the differential diagnosis), or whose clinical diagnosis is unknown (lesions of unknown etiology) will be biopsied for confirmatory pathologic diagnosis. Lesions that are assessed to be definitely not HPVrelated need not be biopsied or excised. If a suspect lesion(s) is identified, a biopsy specimen is to be obtained and submitted to the central laboratory for 16

18 analysis. The interval between anogenital wart/lesion biopsy and the next study visit that includes a complete anogenitourinary examination (Month 7, 12, 18, 24, 30, and 36) must be 2 months. At the Month 24 and 36 visits, subjects will undergo phlebotomy to obtain a specimen for measuring serum anti-hpv. At any time during the study, a test for gonorrhea, chlamydia, herpes, simplex, syphilis, hepatitis B serology, hepatitis C serology, and/or HIV test may be obtained if risk factors or clinical exams warrant such testing. Subjects testing positive to HIV should be referred for appropriate counseling and treatment but may continue in the study. They will not be included in the primary efficacy analysis. Subjects who test positive for gonorrhea, chlamydia, syphilis, hepatitis B (hepatitis B surface antigen [HBsAg]) or hepatitis C (hepatitis C antibody [HCAb]) may remain in the study. Subjects testing positive for these diseases should be referred for appropriate counseling and treatment. If the participant presents with chlamydia or gonorrhea or any other active infection, the subject is to be treated for the infection and brought back for the visit after the infection has resolved. Additional Procedures for Subjects Enrolled in South Africa Only Subjects participating in South Africa will undergo mandatory HIV testing at the Month 12, 24, and 36 visits. 5) Retention Visits In order to optimize subject retention, a contact visit will be performed. Contact visit documentation will be required every 3 months between study visits after Month 6 (Month 9, 12, 15, 18, 21, 24, 27, 30, and 33). This information can be obtained via telephone or electronic mail contact. For the Month 12, 18, 24, and Month 30 contacts, the information can be obtained during the visit. d. Unscheduled Visit An unscheduled visit may occur if subjects are symptomatic (e.g., anogenital pruritus, discomfort, presence of lumps or bumps). All new lesions that are possibly, probably or definitely HPV-related (e.g., suspected or definite condyloma acuminata, or lesions in which HPV-related disease is part of the 17

19 differential diagnosis), or whose clinical diagnosis is unknown (lesions of unknown etiology) will be biopsied for confirmatory pathologic diagnosis. Lesions that are assessed to be definitely not HPV-related need not be biopsied or excised. If a suspect lesion(s) is identified, a biopsy specimen is to be obtained and submitted to the central laboratory for analysis. Any other diagnostic procedure (e.g., testing for sexually transmitted diseases) may be performed at the investigator s discretion, but no other study specimens need to be obtained. At the unscheduled visit, a thorough genital wart inspection should be performed along with a biopsy for any identified lesions. The interval between genital wart/lesion biopsy and the next study visit that includes a complete anogenitourinary examination (Month 7, 12, 18, 24, 30, and 36) must be 2 months. At any time during the study, a test for gonorrhea, chlamydia, herpes simplex, syphilis, hepatitis B serology, hepatitis C serology, and/or HIV test may be obtained if risk factors or clinical exams warrant such testing. Subjects who have tested positive to HIV should be referred for appropriate counseling and treatment but may continue in the study. They will not be included in the primary efficacy analysis. Subjects who test positive for gonorrhea, chlamydia, syphilis, hepatitis B (hepatitis B surface antigen [HBsAg]) or hepatitis C (hepatitis C antibody [HCAb]) may remain in the study. Subjects testing positive for these diseases should be referred for appropriate counseling and treatment. If the participant presents with chlamydia or gonorrhea or any other active infection, the subject is to be treated for the infection and brought back for the visit after the infection has resolved. At each unscheduled visit, participants should be asked about their interim genitourinary history. e. Study Visit Requirements Subjects and study personnel should adhere to the following procedures: If necessary, any scheduled study visit may be rescheduled within the allowed time range of ±3 weeks (Month 2) or ±4 weeks (Month 6 and Month 12 through Month 36). The interval between the Month 6 and Month 7 visits should be a minimum of 3 weeks and a maximum of 7 weeks from the vaccination visit. For study visits that include a genitourinary exam, study personnel should verify by verbal history that: 1) Subjects have refrained from any sexual activity (including vaginal and anal intercourse; manual/oral genital contact; or genital/genital contact, whether 18

20 same sex or opposite sex) for 2 calendar days prior to any scheduled visit which includes a genitourinary exam. If the subject has not refrained from sexual activity for 2 calendar days prior to the scheduled visit, the exam and specimen collection will be postponed until this criterion has been met. 2) Subjects have not had a temperature of 100ºF or 37.8ºC (oral) within 24 hours prior to each injection. If a subject has a temperature of 100ºF or 37.8ºC (oral) within 24 hours prior to each injection, the injection will be postponed. (Note: This requirement is for vaccination visits only). 3) Subjects must not have received a course of systemic corticosteroids or any other immunosuppressives agent prior to vaccination. If systemic corticosteroid or any other immunosuppressive treatment has been received, vaccination should be postponed for at least 2 weeks after completion of the medication regimen. f. Collection and Handling of Specimens Procedures should be conducted in the order listed in Table 1, the Study Flow Chart. There is no need to change gloves during specimen collection unless contamination occurs. Use a no-touch technique to keep all swab tips and swab shafts (portion that will be placed in a collection/transport tube) untouched. g. Assignment of Allocation Number and Vaccine Randomization For study randomization, an allocation schedule will be generated by the Clinical Biostatistics department of the SPONSOR. Throughout this study and across all study sites, there will be no repetition of an allocation number. Subjects will be assigned an allocation number at the time of randomization on Day 1. This department will also generate schedules for the component identification numbers that will be used to identify the vaccine/placebo vials or pre-filled syringes that correspond to the subject s treatment group for the purpose described below. The allocation number will never change and will always remain the number that was assigned at the first vaccination visit. Once assigned, an allocation number cannot be reused for any reason. Allocation numbers for subjects who discontinue or withdraw may not be reassigned. 19

21 h. Vaccine/Placebo Administration 1) Preparation for Administration Both vaccines and placebo should be used as supplied. No dilution is required before administration. Prior to withdrawing and use, mix the contents of the vial/pre-filled syringe thoroughly by rolling the vial/pre-filled syringe between the palms of both hands. The 0.5-mL dose for the qhpv vaccine vaccine/placebo should be withdrawn from the vial containing 0.75 ml of injectable material. The pre-filled syringe will contain 0.62 ml. The qhpv vaccine and the placebo are whitish, semi-translucent suspensions when thoroughly mixed. The preferred site for the intramuscular injections is in the deltoid muscle. A needle long enough to ensure intramuscular deposition of vaccine should be used for the injections. 2) Guidelines for Vaccinations The 0.5-mL injection of vaccine or placebo will be administered intramuscularly at Day 1 and at Months 2 and 6. Injections should be administered at a 90º angle into the deltoid muscle of the nondominant arm using a 1.0-mL syringe with the following needle length and gauge specifications: 1-inch needle, 22 to 23 gauge, for men weighing <200 pounds (90.9 kg), 1½-inch needle, 22 to 23 gauge for men weighing 200 pounds (90.9 kg). If the injection is given in the thigh, a 1½-inch needle, 22 to 23 gauge, should be used. The vaccination may be given in the thigh if this is the subject s preference. Subjects who do not complete the series of 3 vaccinations will be allowed to continue participation in the study. i. Clinical Follow-Up All subjects will be observed for at least 30 minutes. This period of observation should be documented after each vaccination for any immediate reaction with particular attention to any evidence of allergic phenomena. All subjects will be followed for the reporting of serious adverse experiences from the time the consent is signed through 14 days following the first vaccination and from the time of any subsequent vaccination(s) through 14 days (total of 15 days of follow up). Additionally, any serious adverse experience brought to the attention of the investigator at any time outside the 14 day reporting period must 20

22 be reported if the event is either a death which resulted in the subject discontinuing the study, a SAE that is considered to be vaccine related or a SAE that is considered to be related to a study procedure. The VRC should be reviewed for completeness by the study site personnel at the Month 2, 6 and the Month 7 visit or by phone if the VRC was mailed back to the site and no timely visit is scheduled. All comments are to be reviewed by the study personnel and discussed with the participant for clarification if necessary. The information on the VRC should be generated only by the subject and is to be signed and dated by the subject to confirm the accuracy of the recorded information. Original information recorded by the participant should never be altered by study personnel. Any information gained by telephone contact with the subject should be clearly documented, initialed and dated on the subject work booklet of source documentation, other than the VRC. Discrepancies between information obtained during the telephone contact and the VRC need to be resolved; however, information on the VRC will be accepted over the telephone contact in the event that discrepancies cannot be resolved. j. Laboratory Measurements A 10-mL blood specimen will be obtained from each study participant at Day 1 and Months 7, 24, and 36, and all samples will be tested by clia for serum anti- HPV 6, 11, 16, and 18 (at MRL) at all time points stated. Subjects participating in the MSM substudy will have their serum tested for HIV by the ELISA test and their serum tested for syphilis using VDRL or RPR test at Day 1, Month 12, Month 24, and Month 36. This test will be performed at the local laboratory affiliated with the Investigative Site. A serum retention vial containing 1.5 ml of serum should be retained at the site during the duration of the study. If a serum specimen is to be sent for optional testing during the study (hepatitis B, hepatitis C, HIV, syphilis), then draw additional blood as per requirements of investigative site. If clinically indicated, urine specimens may be obtained for all subjects, to be tested for gonorrhea and chlamydia PCR or LCR or SDA. This test will be performed at the local laboratory affiliated with the Investigative Site. Genital swabs obtained from the penis/scrotal and perianal areas will be tested for HPV PCR by the SPONSOR or SPONSOR designated laboratory. All subjects 21

23 who are enrolled in the study will have these samples tested for the presence of HPV DNA using multiplex PCR or duplex PCR. All biopsy samples will also be analyzed by Thinsection HPV PCR regardless of whether an HPV-related histologic diagnosis is made, for the purpose of determining the causal HPV type in the lesion. HPV typing will be performed using either multiplex or duplex HPV PCR assay to detect vaccine and nonvaccine, high-risk HPV types on all samples. 4. Study Procedures for MSM Subjects a. Study Visit Schedule Subjects enrolled in the MSM Substudy will undergo scheduled visits at Day 1, and Months 2, 6, 7, 12, 18, 24, 30, and 36, the same as those subjects enrolled in the main study. In addition, subjects may undergo unscheduled visits for purpose of addressing health complaints, performance of biopsy for suspected HPV-related external genital lesions and administration of therapy for confirmed HPV-related lesions. Subjects enrolled in the MSM substudy will have an intra-anal swab collected for HPV PCR collected at all anogenital examination visits, as well as anal cytology testing. The study flow-chart is provided as Table 2 below for subjects enrolled within the Intensive Intra-anal Evaluation in MSM substudy. 22

24 Table 2 Study Procedures for MSM Subjects Visit Months Event/Test D Obtain informed consent + Allocation number assigned + Genitourinary/medical history Sexual history Physical examination + + Procedures/specimen collection (in serial order) Genitourinary examination of for external genital lesions Photograph of external genital lesion Penile/glans penis file and wetted swab for HPV PCR Scrotal file and wetted swab for HPV PCR Perianal examination for external genital lesions Perineal/perianal file and wetted swab for HPV PCR Anal cytology using ThinPrep methodology, Intra-anal wetted swab for HPV PCR Rectal swab for gonorrhea culture Rectal swab for chlamydia culture Rectal Exam Anoscopy (if indicated) External genital lesion biopsy (if indicated) Treatment for external genital lesions (if indicated) High resolution anoscopy and anal biopsy (if indicated) Serum for HPV (6,11, 16, 18) antibody measurements Serum for hepatitis B (if indicated) Serum for hepatitis C (if indicated) Serum for syphilis #, Serum for HIV #, Swab for HSV culture (if indicated) Urine for gonorrhea PCR or LCR or SDA (if indicated) Urine for chlamydia PCR or LCR or SDA (if indicated) Vaccination Clinical follow-up for safety Clinical contact visit documentation Note: Any test may be repeated if medically indicated. The Month 2 visit can be performed within 3 weeks. The Month 6 visit and all scheduled visits from Month 12 through Month 36 can be performed ±4 weeks. The interval between the Month 6 and Month 7 visits should be a minimum of 3 weeks and a maximum of 7 weeks from the Month 6 vaccination. Allocation number assignment should only occur AFTER the subject has been examined for the presence of HPV-related genital lesions. If a lesion is found, the subjects should not be allocated, and should be excluded. Although complete review of the subject s genitourinary/medical history will not be scheduled for the Month 2 and Month 6 visits, their history will be updated as needed at these visits and at unscheduled visits. # Processed and analyzed at Central Laboratory. High resolution anoscopy will be performed, if the subjects receive an anal cytology result of ASC-US, ASC-H, AGC, LSIL, HSIL or Cancer. A diagnosis of an HPV-related perianal lesion (e.g., perianal condyloma), as confirmed by the SPONSOR central laboratory ALSO constitutes a reason for referral to HRA. If a histologically confirmed HPV-related perianal lesion is diagnosed as a consequence of a simple anoscopy, then the subject does not require another referral to anoscopy. High resolution anoscopy will be performed on all subjects enrolled in the MSM substudy at the Month 36 visit. Serum for HIV and Syphilis to be performed at Day 1 and Month 12, 24, 36, and at any time point throughout the study if clinically indicated. Temperature will be measured prior to each injection. Contact visit documentation will be required every 3 months between study visits after Month 6 (Month 9, 12, 15, 18, 21, 24, 27, 30, 33). This information can be obtained via telephone or electronic mail contact. For the Month 12, 18, 24 and Month 30 contacts, the information can be obtained during the visit. If lesions are noted on the rectal exam, a simple anoscopy may be performed to visualize the intra-anal region. Testing to be performed by the local laboratory affiliated with the Investigative Site. Urine testing for gonorrhea and chlamydia does not replace rectal swab testing for gonorrhea and chlamydia. Chronic, non HPV-related lesions (e.g. hemorrhoids, nevus, skin tag) present at Day 1 do not require photographs. At Day 1, only acute, non HPV-related lesions (e.g. molluscum contagiosum, folliculitis) are to be photographed. 23