February 18, 2016!

FINAL

A Bridging study to Evaluate the Effects of LODONAL as an Immune-System

Regulating Agent in Subjects in which Immune System is Compromised: LODONALIN
THE TREATMENT OF SUBJECTS WITH HUMAN IMMUNODEFICIENCY VIRUS
(HIV)

Dr. Abayomi Oni1, Mr. John Babafemi Aiyegbo RN1, Dr. Femi Aina1, Dr. Olanrewaju Ibigbami1,
Mr.Damilola Tugbobo1, Noreen Griffin3, Dr. Jill Smith2, Dr. Nicholas P. Plotnikoff3, Professor
Fengping Shan4, Dr. Gloria B. Herndon3,5,6,
Dr. Estelle-Marie Heussen5, Dr. Richards Afonja6

1State Specialist Hospital Asubiaro, Osogbo, Osun State, Nigeria

2Georgetown University, College of Medicine, Washington DC, USA

3Immune Therapeutics, Inc, Orlando, Florida, USA

4Department of Immunology, China Medical University,

No.77, Puhe Road, Shenyang, China

Washington DC, USA
6American Hospital and Resorts [AHAR] Pharma, Lekki Lagos, Nigeria
5GB Pharma Holdings,

On June 11, 2014, approval was received from the National Agency for Food and Drug Administration
and Control [NAFDAC] for AHAR Pharma to conduct a 90-Day bridging clinical trial to evaluate the
effects of Low Dose Naltrexone (LodonalTM) as an Immune-System Regulating Agent in Subjects in
which Immune System is Compromised and to demonstrate the efficacy and safety of LodonalTM in the
local population. Conditional to NAFDAC approval of Lodonal as an over the counter immune
booster, to be marketed and sold in Nigeria, are results that demonstrate a positive trend leading to an
increase or halting the reduction of CD4 count. Therefore, the primary objective of this clinical trial was
to confirm that LodonalTM has a beneficial effect on the immune system of HIV+ patients in Nigeria and
to also prove its safety. This was determined by assessing mean changes in CD4 levels from baseline
[Day-1] to Days 30, 60 and 90. This was a Phase 3, single center, open labeled, randomized, bridging
study. A total of one hundred and fifty [150] patients of both gender between the ages of 18-60 were
recruited.
Results showed that LodonalTM has a positive effect in increasing CD4% in comparison to the Placebo
group. The mean % change between Day 1 and Days 30, 60, 90 was 44% for the Treatment group and
11% for the Placebo group, which was further reflected in the difference between Day-1 and Day 90
mean absolute CD4 count increase of 168 for the Treatment group compared to 50 in the Placebo group.
This increase was sustained over the 90-Day period.
Considering the robust results of the study it is recommended that given LodonalsTM tolerability and
efficacy it should be considered as a first line treatment because of its medical impact, significant
increase in quality of life and subsequent economic impact in developing countries. LodonalTM price of
about $1/day could drastically reduce first line treatment costs so that financial resources may be
diverted to reaching more patients and disease management.

!Aims: Primary objective of this clinical trial is to confirm that Lodonal

TM has beneficial effects on the

immune system of patients in Nigeria with compromised immune system. This was determined by
stabilization or increase in the CD4 count and or CD4% and stabilization of T cells (lymphocyte) count
from baseline to Day 30, 60 and 90.
Secondary objectives include:
1. To confirm stabilization or increase of haemoglobin levels from baseline to Day 30,60 and 90
2. Evaluation of subjects weight from baseline to Day 30, 60 and 90
3. To monitor interferon alpha levels from baseline to Day 30,60 and 90
4. To evaluate the safety of LodonalTM in adult participants with compromised immune system
using standard measure of safety (physical examination, vital signs, clinical laboratory
parameters (chemistry and hematology) and adverse event(s) reporting).

!Key Words: HIV, LDN, CD4 Count, Low Dose Naltrexone, Lodonal
Immune Therapy, immune balance.
!

TM,

Page 1/27

immune-enhancement, ART,

February 18, 2016!

FINAL

1.0 Introduction

Immune Therapeutics, American Hospitals and Resorts Pharma [AHAR Pharma], Lekki, Lagos,
State Specialist Hospital, Asubiaro, Osogbo and GB Pharma Holdings collaboratively engaged in
a 90-Day Bridging trial within a population of HIV+ patients. The study was conducted at one of
Nigerias leading HIV/AIDS clinics in order to assess the benefits and safety of Low Dose
Naltrexone [LDN, marketed as LodonalTM] in HIV+ patients. Naltrexone is an opioid antagonist
that was approved by FDA in 1984 [50mg] for the primary use in the management of alcohol
and opioid dependence. However, there is accumulating evidence to suggest that in its low dose
form [3.0-4.5mg] can promote health by supporting immune modulation, which reduces various
oncogenic inflammatory autoimmune processes and immune compromised states such as in HIV
and non-HIV states1. Other positive effects of LDN has been observed in cancer patients, such as
the reduction of nausea and vomiting associated with chemotherapy, which enables increased
quality of life for cancer sufferer and therefore promotes effectiveness of the chemotherapy.
There are some tolerable side effects that have been discovered mostly to do with sleep
disturbances, such as early wakefulness and vivid dreams; however, nothing that warrants
discontinuation given its positive effects. When the 4.5mg cannot be tolerated, the 3.0mg is
suggested and both have shown to be equally effective.

The value of Naltrexone as an immune correcting and balancing modulator was recognized by
Dr. Ian Zagon at the Pennsylvania State University2,3and the late Dr. Bernard Bihari, a
Neuropsychiatrist from New York, USA (who passed away on May 16th, 2010) who began
treating his (HIV/AIDS) patients in the late 1980s4,5 with low dose of the drug. Since their
pioneering work, many doctors throughout the United States have been prescribing LDN for a
number of indications including Multiple Sclerosis (MS), Parkinsons disease, and Crohns
disease, HIV/AIDS, cancer and other autoimmune and inflammatory diseases. In regards to LDN
immunotherapies, a number of research and clinical trials have been completed and undergone
with phase I and phase II Clinical Trials successfully run at a number of universities in the
United States and Europe, including Pennsylvania State University Medical School at Hershey;
University of Chicago; State University of New York; SUNY Upstate Medical University;
London Health Sciences Centre - University Hospital; Alpert Medical School of Brown
University; Department of Neurology, San Raffaele Scientific Institute; Division of
Rheumatology, St. Louis College of Pharmacy; Department of Internal Medicine, University of
Utah; Jondi-Shapoor University of Medical Sciences; Department of Psychiatry & Behavioral
Sciences, Duke University Medical Center; and Multiple Sclerosis Center at UCSF6. Leading
immunologists Dr. Nicholas Plotnikoff, Dr. Ronald Herberman, Dr. Bernard Bihari, Dr. Angus
Dalgleish, Dr. Ian S. Zagon, Dr. Jill Smith, Dr. McLaughlin, Dr. Jacqueline McCandless, and
Moshe Rogosnitzky, among others, pioneered these efforts. The combination of its proven safety
and efficacy in the United States necessitated approval of patents in the United States.

In reference to Africa, studies have been conducted in Mali by Dr. Jacqueline McCandless that
resulted in two papers published in the Journal of AIDS and HIV Research (JAHR) late in 2011,
which describe the two phases of the Mali Project initiated five years earlier. The first paper:
Page 2/27

February 18, 2016!

FINAL

Single cohort study of the effect of Low Dose Naltrexone on the evolution of immunological,
virological and clinical state of HIV+ adults in Mali describes the results of giving LDN to a
group of 57 HIV positive adults, all of whose CD4 count fell between 350 and 600 cell/mm3 and
who showed no symptoms of AIDS. The second paper: Impact of Low Dose Naltrexone (LDN)
on antiretroviral therapy (ART) treated HIV+ adults in Mali: A single blind randomized clinical
trial describes the results of comparing the health of two groups of 57 adults each, all of whom
were HIV positive, had a CD4 count below 350 cells/mm3 and were receiving standard ARV
medications. One group was also given a 3.0 mg dose of LDN and the other a placebo. The
purpose of this phase of the study was to see if LDN improved the standard ARV treatment in a
significant way. In the first study her team found that LDN significantly helped HIV positive
individuals to maintain their CD4% over a nine-month period. Although the same was not true
for the absolute CD4 count, the increase in that measure was less than for a similar population of
untreated patients. Since the CD4% is increasingly being seen as a more stable and indicative
measure of immune system health, they found the results encouraging. In the second study
involving a population in ARV treatment, LDN improved the CD4 count significantly relative to
the control group after six months and marginally after nine months. Taken together, the
conclusion from the two studies strongly suggests that LDN has a promising role to play in
treating HIV/AIDS. Between the 3.0 and 4.5mg daily dose is what is known to produce positive
attributes listed including CD4 elevation and reduction of opportunistic infections.

The mechanism and action of naltrexone, in autoimmune diseases and cancer, is still being
researched, but there are theories as to the mechanism of action that both explain why LDN
works on both autoimmune diseases, cancers, as well as in inflammatory and infectious diseases.
According to Mark J. Donahues paper on LDN that uses interviews from Dr. David Gluck, Dr.
Jacquelyn McCandless, Dr. Jarred Younger, and Dr. Ian Zagon: LDN is an opioid antagonist
that not only blocks the reception of opiates, but also the bodys own endogenous opioids
endorphins. However, because LDN is administered in such a 'low dose' it is believed that LDN
only briefly (for 3-4 hours) obstructs the effects of endorphins. Sensing an endorphin deficit, the
hypothalamus signals for increased production of endorphins in what is called 'the rebound
effect. The rebound effect results in three things happening that promote overall immune
balance and correcting:
Opioid receptor production increases in order to try and capture more endorphins.
Opioid receptor sensitivity increases, also in order to try and capture more endorphins.
Production of endorphins is increased in order to compensate for the perceived shortage.
Once LDN is metabolized by the liver and eliminated from the body (after 3-4 hours), the
elevated levels of endorphins produced, as a result of the rebound effect, can now interact and
bind with the more sensitive and more plentiful opioid receptors. These opioid receptors, are
found throughout the body, including virtually every cell of the bodys immune system. The
elevated levels of endorphins will usually last around 18-20 hours. During this time the elevated
endorphins act by up-regulating vital elements of the bodys immune cells. By doing so clinical
trials have shown the following:
Down regulating inflammatory cytokines
Reducing inflammation and oxidative stress
Page 3/27

February 18, 2016!

FINAL

Facilitating tissue repair and wound healing

Restoring T-helper/CD4 levels
Restoring the balance between Th1 & Th2 lymphocytes
Increasing cytotoxic T cells and natural killer (NK) cells
Regulating cell growth & inhibiting tumor growth
Reducing excitotoxicity and microglial activation
Reducing apoptosis of the myelin-producing oligo-dendrocytes
Stimulating mucosal healing (lining of bowel)7
Research, consistently over many countries, diseases and disorders, supports that LDN can serve
as an adjunct treatment for improving general health and prognosis in HIV+ patients as well as
assist in the decrease of opportunistic infections, which is an important result for HIV+ patients.
According to the recently published UNAIDS 2015 aggregated report on HIV/AIDS, of the 35
million people living with HIV in the world, 19 million do not know their HIV-positive status.
Although the number of people who are newly infected with HIV is continuing to decline in
most parts of the world, there were 2.1 million [1.9 million2.4 million] new HIV infections in
2013a decline of 38% from 2001. Some 86% of people living with HIV who know their status
in sub-Saharan Africa are receiving antiretroviral therapy, and nearly 76% of them have achieved
viral suppression but in many cases are still immune compromised. There are an estimated 24.7
million [23.526.1 million] people living with HIV in sub-Saharan Africa, nearly 71% of the
global total. Ten countriesEthiopia, Kenya, Malawi, Mozambique, Nigeria, South Africa,
Uganda, the United Republic of Tanzania, Zambia and Zimbabweaccount for 81% of all
people living with HIV in the region and half of those are in only two countriesNigeria and
South Africa. There are also more women living with HIV in sub-Saharan Africa than HIVpositive men: women account for 58% of the total number of people living with HIV. Fifteen
countries accounted for more than 75% of the 2.1 million new HIV infections that occurred in
2013.Nigeria being one of the 15 at second place with 10% of the population of newly affected
people, lead only by South Africa with 16%. HIV treatment coverage is only 20% in Nigeria.

Of all AIDS-related deaths in the sub-Saharan Africa region, 19% occur in Nigeria. Additionally
Nigeria is not noted for significant decrease in AIDS deaths compared to the decreases as seen in
South Africa (76%), Eritrea (67%), Botswana (58%), Burkina Faso (58%), Ethiopia (63%),
Kenya (60%), Zimbabwe (57%), Malawi (51%) and the United Republic of Tanzania
(44%).Moreover, more than 75% of all estimated HIV incident tuberculosis people live in just 10
countries, nine of them in sub-Saharan Africa. These include Ethiopia, Kenya, Mozambique,
Nigeria, South Africa, United Republic of Tanzania, Uganda, Zambia and Zimbabwe. Research
has shown that an HIV+ has a 66% chance of developing tuberculosis but is able to reduce their
risk of death by 50% when receiving ART. However, ART medications are costly and at times
complex to administer, particularly for children (Cross Continents Collaboration for Kids, 2008).
Moreover, the great diversity of HIV strains and the emergence of resistant hybrids limit this
therapeutic arsenal (Bennett et al., 2008). As a consequence, new therapeutic approaches are
being explored, including immune-regulatory molecules that may have the potential to delay or
prevent the onset of AIDS symptoms in HIV positive individuals (Gekker et al., 2001; Steele et
al., 2003, Zagon 2011). LDN has shown the capacity for immune-enhancement in HIV infected
Page 4/27

February 18, 2016!

FINAL

subjects with no significant side effects, thus preventing or delaying the progression of the
disease (Bihari et al., 1988; Mathews et al., 1983; Puente et al., 1991).

!
!
!

Page 5/27

February 18, 2016!

FINAL

!
2.0 Methodology
!

2.1 Study Objective

To confirm that LodonalTM has a beneficial effect on the immune system of patients in Nigeria
with a compromised immune system (refer to Inclusion/Exclusion Criteria). This will be
determined by the primary objectives of demonstrating:
The number of subjects with CD4 counts stabilization (less than 10% changes from
baseline mean values) or 25% increase in CD4 counts on LodonalTM compared to
observation group from baseline to Days 30, 60 and 90.
The CD4 percent stabilization or increase from baseline to Days 30, 60 and 90.
To evaluate the safety of LodonalTM in adult subjects with a compromised immune
system, using standard measures of safety [physical examinations, vital signs, clinical
laboratory parameters (chemistry & hematology), and AE reporting].

2.2 Design
In order to evaluate the efficacy of Low Dose Naltrexone [marketing name LodonalTM when
used in conjunction with ART medication for Human Immunodeficiency Virus positive (HIV+)
adults in Nigeria, one-hundred and fifty [150] subjects with active HIV disease were enrolled in
the study. With the approval of the National Agency for Food and Drug Administration and
Control (NAFDAC) to conduct the trial and having registered same in the Nigeria Clinical Trial
Registry (NCTR), the study was conducted as a Phase 3, open labeled, randomized two-group
clinical trial during the period of May 2015 through December 2015. The control group received
the standard ART medication plus a placebo, while the treatment group received 4.5 mg of
LodonalTM [daily at bedtime] in addition to the standard ART medications. Informed consent was
obtained from the participants after the study protocol had been well explained and understood
by them. All these were done before any study procedures including screening and pre-dose
baseline evaluations were conducted on the participants. All the participants were covered with
health insurance during the study period as required by NAFDAC and Osun State Ministry of
Health Ethics Committee.

The sample size of 150 (75 for each group) was established using available best estimates of
expected dropout rates and the variability of CD 4 count measurements. Participants were
randomized between the two groups. The patients were enrolled in a staggered fashion, starting
in May of 2015. The last few patients who were enrolled in September of 2015 completed their
ninety-day clinical evaluation in December of 2015. Testing was conducted for all subjects
starting with the first day in the program (baseline) and then on the 30th day of the first month,
second and third months. The impact of Lodonal +ART was evaluated in BMI, Triglycerides,
Cholesterol, Hemoglobin, Electrolytes, Creatinine, BUN and CD4 count.

Onset of AIDS symptoms or pregnancy was conditions requiring removal of the subject from the
clinical study (with treatment initiated as appropriate). Since this population was very small, no
survival analysis (OS) was performed on these patients. Future large studies to document the
Page 6/27

February 18, 2016!

FINAL

overall effect on survivors could be conducted, but for this study only safety and efficacy were
the focus.

2.3 Study Site

Recruitment, drug dispensing, sample collection and evaluations were conducted at one site:
State Specialist Hospital Asubiaro, Osogbo, Osun State, Nigeria. The site is one of the primary
treatment centers for HIV/AIDS and infectious diseases in Nigeria. The hospital specializes in
infectious diseases and the skin diseases that are common in HIV/AIDS.

2.4 Patient Selection

Eligible persons were invited and were given detailed information about the drug trial. The
process of recruiting patients based on exclusion criteria took some time as patients were located
in municipalities outside of the city and in villages. Subjects were recruited from a population of
HIV+ male and female adults between the ages of 18 and 60.
Exclusion criteria included:
Women of childbearing potential unless surgically sterile or using adequate contraception
(either IUD, oral or depot contraceptive, or barrier plus spermicide), and willing and able
to continue the same contraception during the study and for at least 3 months after the
completion of the study;
Women who are pregnant or breast-feeding; Elevated (i.e. >3x ULN) liver enzymes at
screening visit; Chronic kidney disease (CKD) as defined by GFR <60 mL/min/1.73m2 ;
Any disease, concomitant injury, or condition that interferes with the performance or
interpretation of protocol-specified assessments;
Unlikely to be available for follow-up as specified in the protocol;
Participated in a previous clinical study and received another investigational product
within 30 days of screening;
Allergy to naltrexone HCl or any of its excipients;
Patients taking high-dose opioid-based narcotics, unless they discontinued for at least 2
weeks prior to study initiation;
Active infection or neoplastic process; Evidence of active hepatitis C infection
determined by HCV Ab/RNA test.
Active drug or alcohol abuse;
Concurrent illness that in the opinion of the principal Investigator(s) may interfere with
trial completion;
Any issue which, in the opinion of the Investigator(s), will make the patient unsuitable
for study participation ;

Once patients were selected, consents forms were presented to all willing to participate in the
trial. After signing the Informed Consent Form (ICF), participants were grouped into 2 - the first
75 were selected as the "treated group" (Group A - labeled as LDN Group in the analysis) and
were placed on LodonalTM (Naltrexone 4.5mg) alongside their regular Highly Active
Antiretroviral Therapy (HAART) drugs. The remaining 75 were selected as the "delayedtreatment group" (Group B - controls - labeled as Placebo in the analysis) as they continued
Page 7/27

February 18, 2016!

FINAL

their HAART drugs only and were only to receive LodonalTM after the 90-day trial, so that they
too may receive the benefits of LodonalTM. Also, upon selection, patients medical records, blood
and urine samples necessary for the study were collected and compiled for all 150 patients. The
blood and urine samples were collected from all 150 participants under standard conditions.
Samples were transferred to the laboratory for examination and donors were dismissed with
instructions regarding when they were next required to come back. Tracking of the participants
was done via telephone, which means all reminders, dismissals or inquiry as to the nature of an
absence was conducted via telephone. We attempted to align their Clinical trial follow-up with
their regular check-up. During the 30, 60 and 90-day mark, following the normal clinic flow
chart, the patients would submit their appointment cards and from there they were led to the
nurses station where the vital signs such as blood pressure, weight, height ,BMI and temperature
would be recorded. The patients were then led to see the clinician in turn to discuss their
qualitative status [complaints/improvements or difficulties], and all points of the discussion were
recorded in the patients file. Thereafter they were given a laboratory request form that they
presented to the laboratory technicians. Prior to drawing blood, the patient was always made to
feel comfortable always and received an explanation of why and how of the study at the
phlebotomy unit. The phlebotomist carefully wrote the bio-data of the patients on the 3 sample
bottles (hematology, chemistry and urinalysis bottles). Injection site for each patient was cleaned
with methylated spirit after breaching the blood flow. The heamatology bottles were gently rolled
to mix with anticoagulant to avoid clotting and the serum separation bottle left serum above the
clotted sample. The heamatology sample was divided into two parts. The first part was used for
CD4 where they were processed, fixed and read in the BD- Facs count machine and the second
part for CBC with differentials. The serum was also collected and read in the Pro-Selectra
machine. The urinalysis kits were used to read the urine samples. All sample results were
recorded in the laboratory register. From the laboratory, the patient proceeded to the adherence
unit and finally to the pharmacy unit where drugs were dispensed and the next appointment date
was given. Two weeks prior to the next appointment date, patients were already being tracked
through calling and visitation.

2.5 Laboratory Analysis

The following analyses were conducted:
Chemistry
Pro-Selectra/ion Selective Electrode
HAEMATOLOGY
BD FACS COUNT (CD4)
SYSMEX/ABACUS

These laboratory analyses were conducted by trained, certified and experienced laboratory technicians.
Quality Assurance (QA) was conducted on a daily basis, equipment was calibrated as required by the set
QA standard and the analytic process through defined Quality Control procedures. It was important to use
these laboratory techniques in order to measure not only CD4 count but also other important organ
function and levels so as to ascertain drug safety in regards to liver function, bone marrow suppression,
electrolytes, kidney function and other systemic dysfunction.
Page 8/27

February 18, 2016!

FINAL

2.6 Test Results Entry

Results of the test were received from the laboratory and was sorted, collated, and imputed into
the electronic data spreadsheet. Two weeks after the initial stage, participants were being tracked
(follow-up) to return for day-30 evaluations. During the course of the follow-up, a brief physical
examination was performed to determine their eligibility to continue their participation in the
trial. On day 30, the participants were received again at the testing site and laboratory
examination processes were carried out. The results were collated and recorded. The same
collection methods and laboratory examination processes were repeated for day 60 and day 90
respectively. QA was assured at four levels, from the bottom upwards:
1.Laboratory Technician,
2-Head of the Laboratory,
3-Data Entry Technician and
4- Principal Investigators.

2.7 Statistical Analysis [Based on Clinical Protocol Document submitted to NAFDAC)

The main time point of interest is Day 90, but treatment comparisons over all visits, when
available, will be conducted.

The primary endpoints for the study are:

The number of subjects with CD4 [T cell] count stabilization (less than 10% change from
base line mean values) or 25% increase in CD4 counts on LodonalTM compared to
observation group from baseline to Days 30, 60 and 90.
CD4% stabilization or increase from baseline to Days 30, 60 and 90.

The secondary endpoints for this study are:

Hemoglobin stabilization or increase

Body weight stabilization or increase

Interferon alpha levels stabilization

The safety endpoints for this study:

Physical examinations, vital signs and clinical laboratory testing (chemistry, hematology,
and urinalysis)will be performed at baseline and every 4 weeks until the final clinical trial
visit (or early termination visit if applicable).
Adverse events and concomitant medications.

2.7.1 Sample Size Considerations

The sample size is based on previous experience with comparable bridging studies and practical
considerations to determine safety and efficacy of LodonalTM in the Nigerian population.

2.7.2 Actual Analyses

Page 9/27

February 18, 2016!

FINAL

One hundred fifty (150) enrolled subjects entered into the open-label study. It was anticipated
that premature withdrawal rate by Day 90 will be no more than 30 subjects yielding 120
evaluable subjects. Given the nature of the study, there was no imputation of missing data and
there were no formal statistical criteria; rather, the change in laboratory values from baseline was
evaluated to determine if the change in values at Days 30, 60 and 90 are statistically significant.

2.7.3 Statistical Methods

Summary statistics for discrete variables included number of subjects, counts, and percentages
for each category. Descriptive statistics for continuous variables included means, standard
deviations, medians, minima, and maxima calculated for CD4 measurements at the baseline visit
and at Days 30, 60 and 90, for both the those subjects initially randomized to LodonalTM
compared to those randomized to observation.
As hemoglobin levels [part of the safety indices] were within normal limits, further analysis was
not conducted. Analysis of IFN- levels was not possible as data collection was hampered by a
lack of technical capabilities and mechanism to assure sample integrity if shipped overseas for
analysis. Comparisons between treatment groups and changes from baseline values were
calculated and tested for statistical significance with two samples and paired t- tests, respectively.
The proportion of those achieving a response with a CD4 count of 200 at each time point and
those achieving a CD4 count of >500 was compared between LodonalTM and observation
subjects using the Fishers exact test. Analysis was performed with the intent-to-treat criteria.
Clinical significance was accepted if the difference meets 95% Confidence (p<0.05). It was
anticipated that outcomes exhibiting a skewed distribution would be analyzed with Wilcoxon
Signed-Rank and MannWhitney tests, but this was not necessary.

2.7.4 Analysis Sets

The Intent-to-Treat (ITT) analysis set consists of all subjects who were enrolled into the study.
This was considered the primary analysis set for efficacy analysis. Subjects were analyzed under
the same treatment plan. The Safety Population analysis set was the set of ITT subjects who
received at least one dose of study drug. Subjects were analyzed according to the treatment
received.

2.7.5 Safety:

Analyses of all safety data was performed on the Safety Population and was presented by the
treatment received. The occurrence of TEAEs and serious TEAEs was presented by treatment
group overall and within each MedDRA system organ class and preferred term.
Adverse event severity (within each system organ class and preferred term, subjects with more
than one incidence was categorized into the maximum severity experienced) and relationship to
study drug (subjects categorized into the most-related relationship) was provided.
Use of prior and concomitant medications was summarized. Descriptive statistics of laboratory
variables at each visit and on the change from baseline to each visit was presented on mean
change from baseline using analysis of covariance at each visit adjusting for baseline. Summary
of abnormalities using shift tables was presented for safety laboratory tests. Similar analyses
were carried out for vital signs. Notable physical findings were also identified.
Page 10/27

February 18, 2016!

FINAL

!2.7.6 Efficacy:
As mentioned above the descriptive statistics of laboratory variables for CD4 count, CD4%, at
each visit and on the change from baseline to each visit was presented on mean change from
baseline using analysis of covariance at each visit adjusting for baseline. Summary statistics for
continuous variables included means, standard deviations, medians, minima, and maxima. Full
specifications regarding all designated analyses were provided in the Statistical Analysis Plan for
safety and efficacy.!

!
!

Page 11/27

February 18, 2016!

FINAL

!
3.0 Results:
!

3.1 Descriptive Statistics

Of the 150 patients originally enrolled, seven Treatment patients and zero Placebo patients were
excluded from the study [See Table 1]. Of the seven treatment patients excluded, two dropped because of
relocation, one did get pregnant, two went on vacation, one was removed due to severe depression due to
bereavement (loss of mother) and one dropped without a trace. Subsequent reduction in patient
participation was due to the pending holiday season when most people travel to their home of origin.
Table 1: Patient Dropout during study

Enrollment (time=0)
n1 (Treatment) = 75,
n2 (Placebo) = 75
Tested Day One

Dropped from study/

missed appointment
n1=68, n2=75

Tested Month 1 (30-Days)

Dropped from study/

missed appointment
n1=67, n2=62

Tested Month 2 (60-Days)

Dropped from study/

missed appointment
n1=64, n2=53

Tested Month 3 (90-Days)

Dropped from study/

missed appointment
n1=53 n2=52

!
!
!
!
!
!
Page 12/27

February 18, 2016!

FINAL

Table 2: Descriptive Analysis Overview

Mean

Day-1

Day-30

Day-60

Day-90

LDN

366

514

537

534

Placebo

463

526

506

517

LDN

185

281

300

300

Placebo

269

334.21

266

277

LDN

305

505

502

534

Placebo

435

427.5

477

459

LDN

21

27

14

13

Placebo

24

10

11

29

880

1,422

1,394

1,366

1,222

1,829

1,322

1,378

STD

Median

Minimum

Maximum
LDN
Placebo

Although we went below the anticipated total number of subjects [120] for the study by day, results were
robust early enough in the study and maintained to suggest that they were not by chance. Looking at the
means between groups for each day, it is clear to see that Day-1 differences between the groups might
suggest a significant difference whilst the other test days do not. To check these differences we conducted
unpaired t-test analysis between the groups for each of the test days to determined statistical significance. As
assumed, only the first day showed a significance between the groups which was purely by chance as
patients were randomly assigned to each of the groups [Table 3]. This result is of no consequence to the
primary objective, which is to show change in CD4 count overtime time within a group. All values were
rounded off to the nearest whole number.
Table 3: Unpaired t-test comparison of means between groups for each test day
Day-0

Treatment

Placebo

Page 13/27

t-test results
Day-0

The t-value is
366 -2.50737. The
p-value is .
013298. The
result is
463 significant at p
< .05.

Day-30

t-test results
Day-30

t-value is
514 -0.22364. The
p-value is
.
823394. The
result is not
526 significant at p
< .05.

Day-60

t-test results
Day-60

The t-value is
537 0.59449. The pvalue is .
553354. The
result is not
506 significant at p <
.05.

Day-90

t-test results
Day-90

The t-value is
534 0.15431. The
p-value is .
877672. The
result is not
517 significant at
p < .05.

February 18, 2016!

FINAL

3.2 CD4 Count Analysis

The selection of patients between the Treatment and Placebo group was random, however the measurement
at Day-1 shows that the Treatment group started the study with a lower absolute mean CD4 count [366 vs.
463], which makes their increase to catch-up with the Placebo group at Day-30 even more dramatic
[Chart 1]. The change between Day 1 and Days 30, 60 & 90 for the Treatment group was above the 25%
increase we aimed to demonstrate in this study, whereas the Placebo group maintained an average increase
of about 11% which we had pre-determined would be considered a no-change effect, [Table 4].
Chart 1 - Absolute Mean CD4 (cell/mm3) Count Over 90 Days
Treatment

Placebo Group

600

Absolute Mean CD4 Count

540

480

420

360

300
Day-1

!
!
!
!
!
!
Page 14/27

Day-30

Day-60

Day-90

February 18, 2016!

FINAL

Table 4: Percentage Change Between each test day

T

Day-1
N
Mean

68
366

Day-30
75

Day-60

67

62

463 513(+40%)**

526(+14%)**

64
537(+5%)**

P
Day-90

53

53

506(-4%)** 534(-.01%)**

52
517(+1%)**

N= Number of patients Mean = Absolute Mean CD4 (cell/mm3 ) Count; T = Treatment Group; P = Placebo Group;
** Percentage Change in between test days

Although there is an impressive increase in absolute mean CD4 count from Day-1 compared to the other
evaluation points at Day 30, 60 and 90, the increases between the days were negligible, Table 5.

!
!
!

Table 5: Percentage Change Between Day1 and Days 30, 60 and 90.

Day 1 Vs. Day 30

Day 1 vs. Day 60

Mean % Change
from Day 1 to 30,
60 & 90

Day 1 vs. Day 90

Treatment

40%

47%

46%

44%

Placebo

14%

9%

11%

11%

We conducted paired t-tests with only the patients with complete data sets between each of the days within
each group. As a paired t-test can only be conducted with associated values only 50 patients from the
Treatment group and 40 from the Placebo group were part of the analysis, however their means were within
range of the total group [Table 6] so the analysis results were still demonstrated valid results.
Table 6: Percentage Change Between test days paired t-test
Day-1 vs. Day 30
% change and t-test

Treatment

40% The value of t is

5.014338. The value of
p is < 0.00001. The
result is significant at p
0.05. [Mean diff =
203]

Placebo

14% The value of t is

Page 15/27

3.162597. The value

of p is 0.003025. The
result is significant at
p 0.05.

!
!

Day-1 vs. Day 60

% change and t-test

47% The value of t is

4.357167. The value
of p is 6.7E-05. The
result is significant at
p 0.05. [mean diff =
190]
9% The value of t is

1.619905. The value

of p is 0.113312. The
result is not
significant at p
0.05.

Day-1 vs. Day 90

% change and t-test

44% The value of t is

4.042417. The value
of p is 0.000186.
The result is
significant at p
0.05. [mean diff=
177.8]
11% The value of t is
1.547536. The value
of p is 0.129811.
The result is not
significant at p
0.05.

February 18, 2016!

FINAL

Table 7: Means of sub-group of patients for paired t-test

Day-1

Day-30

Day-60

Day-90

Treament [N=50]

352

555

542

529

Placebo [40]

486

569

521

520

Because of the severe attrition towards the end of the study it is difficult to make inferences in regards to
patterns exhibited by patients with more than 200cell/mm3 or 500cell/mm3 between the groups over time.
Even with a Fishers exact test the N would have been too low, not paired and somewhat scattered. The
objective of showing the more than 25% increase CD4 count and percentage in the Treatment group
between Day-1 and Day-90 was demonstrated, whilst the Placebo group only demonstrated an average of
11% increase.

3.3 Side Effects/Quality of Life

There were no reported side effects. There were no reported opportunistic infections and no toxicity levels
uncovered. Liver function remained normal and there wasnt any negative impact on other systems based
on blood results. The patients were able to go about their daily routine unhindered. No significant sleep
disturbance or vivid dreams were present enough to justify trial discontinuation. No significant adverse
CNS, renal, cardiac, hepatic, musculoskeletal, hematopoietic side effects were present.

Page 16/27

February 18, 2016!

FINAL

3.4 Meetings

!
Pre-Trial Meeting in Osogbo (September 11, 2015):
!

Present: The full team comprised of Dr. Richards Afonja, Dr.Olanrewaju Ibigbami, John B.
Aiyegbo, Dr. Abayomi Oni, Pharm Babatunde Alaka, Olagunoye Adekola Gafar, Omotosho
Bukola R., Kolawole L. I., Joy Anokam, Dr Aina Oluwafemi, Damilola Tugbobo, Pharm
Akinrinmade D. B., Isamot I. A., Ogunbode O. J., Adewole M. O., Dr Ajibade Adewunmi.,
Ogunjenyo A. A., Mr Alabi (represented), Mrs Omoloye K. S., Mrs Odebiyi F. O., Mrs Oyedotun
Y. M.
The meeting began at exactly 10.15am with opening remarks said by the Principal Investigator
(PI) Dr. Abayomi Oni. He welcomed all, acknowledging the presence of the clinical and nonclinical members of the clinical trial team. He reiterated the fact that the approval of the
NAFDAC and the protocol for the Trial will be strictly adhered to. He stated the fact that all will
be done to ensure that the trial subjects are given the best consideration with regards to meeting
international ethical standards. He subsequently introduced the Sponsor Representative and CoInvestigator Dr. Afonja.
The Sponsor Representative, Dr. Afonja also welcomed all. He stated that the investigative
product (LodonalTM) has been shipped in and the packages verified hence, all is set to commence
the clinical trial as scheduled.The protocol for the study was then briefly presented and reviewed
by all present. He thereafter requested for clarifications on the protocol.
Dr. Aina the Project Manager itemized the issues that needed to be clarified to facilitate the
smooth running of the trial in regards to power supply to the laboratory, and the need to ensure
that there is adequate backup for the Laboratory staff to smoothly run the laboratory tests.
Dr. Oni stated that all the staff who will be involved in the trail will be favorably motivated by
the sponsors and further vouched to ensure that all who carry out extra duties as a result of the
trial will be duly compensated.
Dr. Afonja further emphasized the need to adhere strictly to the study protocol and ensure the
principles of Good Clinical Practice are maintained. Further on this point, the trial design was
reviewed in great detail to be sure that everyone was clear on all procedures.
The issue of the safety and accountability of the investigative product was also discussed and it
was agreed that the drugs be kept in Dr. Onis Office and the drug dispensed by the Pharmacist
with an inventory kept for proper monitoring.The PI thanked all for their presence and
contributions. The meeting ended at 1:05 pm.

!
!
Pre-Trial Meeting in Osogbo (September 21, 2015):
!

Present: Dr. Abayomi Oni& Dr. and Dr. Femi Aina from State Specialist Hospital Asubiaro; Dr.
Richards Afonja, Mr. John Aiyegbo, Ms. Joy Anokam and Mr. Damilola Tugbobo from AHAR;
Dr. Ibigbami from the Osun State Ethics committe. Four other support staff also joined

Page 17/27

February 18, 2016!

FINAL

Dr. Oni opened the meeting as usual exactly at 10:33am, stating that in seven days the treatment
group will be receiving their first round of LodonalTM. There is great anticipation and as such
several issues and challenges were discussed in order to decide a resolution. These included the
following:

Power issue - Reinforcing the generator infrastructure became a vital part of the study. The risk
of samples not being properly refrigerated and analyzed at the designated time frame would
negate the whole studys design and compromise the data.

Communication Issue- In order to curb attrition it was decided that all patients will be checked
through telephone on a fairly regular basis [at least twice between testing days]. Investigative
team members that had any cultural connections were paired with those patients in order to
reduce language and other disparities. It was also decided that each team member who was
tracking patients be given a phone card, logged locally and given access to transportation in the
event that a visit was necessary.

Transportation- A designated car for the study was at hand a few days prior to the 30, 60 & 90
day mark in order to facilitate any logistical requirements in so far as patients, reagents etc.

Day 0 (zero) was marked as Monday September 28, 2015. On this day the treatment group of 75
patients would receive 4.5mg LodonalTM [Low Dose Naltrexone] and the control group will
receive a placebo.

Actions still do be attended to are:

To print the remaining informed consent forms

Include names of AHAR staff members

Damilola will convert data from Monitoring and Evaluation [M&E] into a

spreadsheet
The operational staff for the study will be designated as follows:
M&E Unit - three people

Pharmacy - two people

Counseling - one person

Doctors - two people

Laboratory technicians - 5 people

Dr Ibigbami and Dr Oni have oversight at all times, which means 15 people altogether to be paid
monthly for the extra hours that they would be accruing as a result of the study.
*Names of all staff members to be provided by Dr. Aina
Meeting ended at 1:46pm.

!
!
!
!

Page 18/27

February 18, 2016!

FINAL

Trial Meeting in Osogbo (October 26, 2015):

Present: Dr. Abayomi Oni& Dr. and Dr. Femi Aina from State Specialist Hospital Asubiaro; Dr.
Richards Afonja, Mr. John Aiyegbo, Ms. Joy Anokam and Mr. Damilola Tugbobo from AHAR;
and support staff members

Dr. Oni opened the meeting as usual exactly at 9:10am, stating that the trial has commenced and
that we were off to an excellent start despite some issues with a number of patients, all of whom
coincidentally were in the treatment group. Patients in this group were not treated in any way
differently than the placebo group, nor were they aware of which group they were assigned.
Day-0 (zero) blood was drawn from 150 patients however, leading up to Day-30 we already
know that seven treatment patients will not be present due to the following reasons:
- One patient was overcome by their HIV/AIDS illness and died, two days after blood was
drawn
- One patient was declared pregnant
- One patient opted out due to bereavement [loss of parents]
- Two patients went on vacation.
- Two patients relocated
Given this attrition, it made clear that follow-up is paramount and patients must be contacted
close to 30-day marks but also in-between. This will add an extra burden on the budget of the
trial but it is very necessary in order to reduce significant reduction of patients. It was also
realized that leading up to the holiday season it will be paramount to keep in contact via
telephone and home visit with patients. Patients must be reminded of their trial protocol and
with traveling we know that many things seen as optional may not be adhered. It was agreed
that the aim is not to drop lower than 50 patients per experiment group by Day-90.
All procedures where further reviewed and no issues where found. At the end of the week the
Day-30 milestone will be reached and a very good turn out of patients is anticipated.
Dr. Oni dismissed the meeting at 11:35 and reminded everyone that only after Day-90 there will
be a committee meeting, which will be in the new year given the holiday season. Between now
and the end of the trial any operational issues will be dealt with immediately.

!!
Post-Trial Meeting in Osogbo (January 06 2016 ):
!

Present: TDr. Abayomi Oni& Dr. and Dr. Femi Aina from State Specialist Hospital Asubiaro, Mr.
John Aiyegbo, Ms. Joy Anokam and Mr. Damilola Tugbobo from AHAR; and support staff
members

!Dr. Oni opened the meeting at exactly 10:00am. The spirit was positive and everyone congratulated each

other on the new year and conclusion of the bridging trial. Dr. Oni acknowledged that getting patients for
the 90-Day testing was definitely the toughest round, but was very pleased with the turn out almost 110
patients from the original 150. Logistics was certainly the most challenging aspect of the trial and there
was agreement to reflect upon the trial so that the institution can better serve another clinical trial in this
area or others. Dr. Oni expressed his pride and respect for the team. He mentioned that they worked
Page 19/27

February 18, 2016!

FINAL

under harsh circumstances and yet in unison, which was critical to achieving complete data collection
according to the defined protocol. Several staff members became ill and still had to continue. Dr. Afonja
sent a note to express his gratitude for a job well done and took note of the fact that all were committed to
quality, which was the corner stone of success. M&E mentioned that the last set of data is yet to be logged
and would be completed some time within the next week. Dr. Oni thanked everyone and dismissed the
meeting at exactly 11:05am.

Page 20/27

February 18, 2016!

FINAL

4.0 Discussion

In line with other studies that showed a positive effect of LodonalTM in HIV+ patients, this 90day trial once again solidifies the therapeutic role LodonalTM can have on HIV+ patients.The
shorter duration of this study demonstrated that even within limited time frame, LodonalTMs
effects can be felt qualitatively and observed clinically. The lack of abnormal liver function
means that the drug was well tolerated in the local population and the positive effects of
LodonalTM in the first 30 days sustained after 30 days. Our results also seem to indicate that
patients with lower CD4 count may fair better with LodonalTM than patients with values above
500. An increase in CD4 count would have a stabilizing effect on the immune system, thus
reducing the chances of opportunistic infections and prolong life in patients with HIV. Dr. Cyril
A. Allen, former Director of United Medical Center Washington DC and leading specialist in
immune therapy, stated that the results of the study showed extremely good consistency with
previous studies and it is important to note that this drug as an opiate antagonist has been used in
studies since the 1970s. Moreover, the immunomodulatory effects of this drug have been well
described in previous studies.

As more people are retained on HIV treatment over the long term, dealing with co-morbidities is
becoming increasingly important. In particular, TB was responsible for 31% of the estimated 1.2
million HIV-related deaths globally in 2014. The African Region accounted for about three
quarters (73%) of the people dying from HIV- and TB-associated causes globally in 2014.

Alongside communicable diseases, people living with HIV are at increased risk of developing a
range of noncommunicable diseases as a consequence of their HIV infection or of side effects of
their treatment. These noncommunicable diseases include cardiovascular disease, diabetes, liver
and pulmonary disease, hypertension and a range of non-AIDS-associated malignancies, notably
cancer. Because of greater access to effective ART, people with HIV are living longer and
experiencing the noncommunicable diseases associated with aging, which is posing new
challenges to health-care systems. For non-communicable diseases related to depressed
immunity such as cancer, LodonalTM can serve as a preventative therapy, alleviating treatment
requirements that cannot be met due to a lack of medical infrastructure in oncological treatment.

Lastly, based on several clinical studies, one can extrapolate that LodonalTM could be an effective
mechanism for stabilizing patients experiencing ART resistance. Although the occurrence of HIV
+ status has been dramatically reduced by 38% within the past decade, it is apparent that alongside ART treatment which has significantly decreased morbidity also within the past decade, the
emergence of HIV drug resistance has to be minimized to preserve the long-term populationlevel effectiveness of ART. Drug resistance has been modest, but there are signs that it has been
rising in some countries and regions in recent years [ref WHO report].

Given these robust results, LodonalTM should be considered as an adjunct immune therapy given
its proven potential to maintain or increase CD4 count levels, which suggest an increase or
stabilization of patients immunity that can potentially prevent opportunistic infections,
Page 21/27

February 18, 2016!

FINAL

tolerability and efficacy. LodonalTMs affordability [at about $1/day], effective immune
balancing and correcting attribute, safety, ease in administration and storage makes it a
formidable adjunct therapy that needs to be considered for all HIV+ patients. Dr. Allen further
mentions that the compelling evidence to date is consistent with this study and while further indepth studies may provide further insights, it would be a shame to deprive patients of this
medication any further.

4.1 Trial Challenges and Mitigation Strategies:

Conducting the clinical trial had several mitigating factors that contributed to the start of trial,
drop out or removal of patients and processing of collected samples such as the following:
Suspicion and trust issues amongst some patients. Patients were use to receiving their
HAART medication and that process already has issues of trust associated with it.
Convincing a less educated segment of the patient population of participating in a clinical
drug trial was not something they were familiar with and were afraid of how it would
negatively affect their current medications.
The lesser educated patients were a challenge, however they were much easier to convince as you
could have then read some literature. The non-literate patients caused the most difficulty in
communication. More time was required over a period of time [repeated conversations] with them
to explain drug trials, side effects, potential benefits and consent signing. As with the patients
described above, translators were used and repeated conversations were put in place and within a
group of like minded individuals. Constantly being reiterated was the potential benefit of
LodonalTM as far as the increased CD4 count and protection from opportunistic infections are
concerned.
We also know that all patients whether recipients of placebo or LodonalTM where at times
Non-compliant with taking drugs, which could be related to - memory impairment
secondary to HIV and also family pressure. It was one thing to convince the patients, but
the patients sometimes had a difficult time explaining further to their families, which
would lead to uncertainty with our trial patients. The team took its time to explain the
potential benefit of LodonalTM as far as the increased CD4 count and protection from
opportunistic infections are concerned.
Non-compliance with follow-up at the clinic for blood work, side effect/complication
monitoring and evaluation mostly due to the cost of transportation to and from the
clinic.The HIV Clinic at Asubiaro is a regional clinic that draws patients from far and
near. Most patients outside the town incur so much cost coming back and forth for the
trial that we facilitated their presence at the hospital.
Samples were threatened by the lack and loss of electricity, however the hospital
generator was refurbished, backup generator was put in place and there was always
sufficient fuel on-site to run the generator for at least 24 hours
Although most patients had telephone access, there were a few for whom at home visits
were necessary because they either lacked access to a cell phone or preferred not to use
one. For these patients transportation or gas was provided for M&E team, physician,

Page 22/27

February 18, 2016!

FINAL

pharmacist and phlebotomist for home visits for patients who could not afford to come to
the clinic or for whom telephone access was challenging.
At times there were challenges with internet connection in order to facilitate real time
reporting of results. When these outages lasted longer than a day, staff travelled to the
next major city to communicate the situation and connect via an internet cafe.
Some American Hospital staff permanently situated in Osogbo for the 90-day duration of
the trial contracted Malaria and Salmonella Typhoid food poisoning and had to be
hospitalized and treated. The hardship on the trial staff was anticipated, therefore there
was sufficient backup of staff to continue with study requirements when there was
hospitalization. No one suffered any lasting health consequences and all treatments were
successful.
Difficulty choosing staff from the hospital to work in the trial (budget!) which meant the
other staff felt sidelined.

Page 23/27

February 18, 2016!

FINAL

Acknowledgements
The authors acknowledge members of the support team in Nigeria led by Ms. Joy Anokam and
the individuals who supported the program through their fiscal sponsorship, those who acted as
medical advisers, program coordinator and support to the principal investigators, the medical
team and other staff [Dr Olanrewaju Aina, Babatunde Alaka, Temitayo Petra Akintaro, Ademola
Gafari Olagunoye, Bukola Omotosho, Toyin Irigho, Idayat Ajoke Isamot, Lydia labo kolawole,
Monsurat Olubunmi Adewole, Oluseyi Joel Ogunbode, Olukemi Olukunle].Furthermore, the
authors are grateful to the Nigerian Ministry of Health, NAFDAC and the Osogbo Ministry of
Health Ethics Committee whose guidance insured that the trial was conducted according to the
quality, safety and protocol parameters set out by the Nigerian government.

Finally, the authors want to express their deep admiration and gratitude to the late Dr. Bernard
Bihari, the late Dr. Ronald Herberman andJacqueline McCandless whose pioneering work with
LodonalTM for the treatment of HIV/AIDS guided the design of the Nigeria Trials. In addition to
the above we wish to acknowledge Dr. Terry Grossman, Dr. Jay Ellenby, Dr. Jack Zimmerman,
Ms. Jaquelyn Young.

Conflict of interest
Immune Therapeutics have intellectual property rights and have a patent for the use of Lodonal
(Low Dose Naltrexone) in Human Immunodeficiency Virus (HIV), cancer, MS, Crohns
Disease, adjunct to chemotherapy, Parkinson Disease, IBS and have filed pending applications
for malaria, TB, Sickle Cell, myasthenia gravis. This disclosure was provided to all study
participants. The statistical analysis of the entire data sets pertaining to efficacy (specifically
primary and major secondary efficacy endpoints) and safety (specifically, serious adverse events
as defined in federal guidelines) have been independently confirmed by a biostatistician who has
no conflict of interest.

!
!
!

Page 24/27

February 18, 2016!

!
References
!

FINAL

1. Bennett DE, Bertagnolio S, Sutherland D, Gilks CF (2008). The World Health Organizations
global strategy for prevention and assessment of HIV drug resistance. Antivir Ther.,
13, Supplement 2: 113.
2. Bihari B, Ottomanelli GA, Drury F, Ragone VP. T-cell subsets and treatment response in
AIDS. AIDS Res. 1986;2(4):263-266.
3. Bihari B, Drury F, Ragone V (1988). (Poster Presentation) Low Dose Naltrexone in the
Treatment of Acquired Immune Deficiency Syndrome, 1988 International AIDS
Conference, Stockholm, Sweden.
4. Bihari B, Finvola DM, Ragone VP, Ottomanelli GA, Buimovici-klein E. Low Dose
Naltrexone in th Treatment of Acquired Immune Deficiency Syndrome. 1988;(June).
clinicalTrials.gov. https://clinicaltrials.gov/ct2/results?term=low+dose
+naltrexone&Search=Search.
5. Brown N, Panksepp J. Low-dose naltrexone for disease prevention and quality of life. Med
Hypotheses. 2009;72:333-337. doi:10.1016/j.mehy.2008.06.048.
6. Duvignac J, Anglaret X, Kpozehouen A, Inwoley A, Seyler C, Toure S, Gourvellec G,
Messou R, Gabillard F, Thibaut R (2008). CD4+ T-Lymphocytes Natural Decrease
in HAART- Nave HIV- Infected Adults in Abidjan. HIV Clin. Trials, 9(1): 26-35.
7. Fahey J, Taylor J, Detels R (1990). The prognostic value of cellular and serologic markers in
infection with human immunodeficiency virus type 1. N. Engl. J. Med., 322: 166-72.
Gekker G, Lokensgard JR, Peterson PK (2001). Naltrexone potentiates anti-HIV-1
activity antiretroviral drugs in CD4+ lymphocyte cultures:
Drug Alcohol Depend,
64(3): 257- 258.
8. Faith RE, Liang HJ, Murgo AJ, Plotnikoff NP. Neuroimmunomodulation with enkephalins:
enhancement of human natural killer (NK) cell activity in vitro. Clin Immunol
Immunopathol. 1984 Jun;31(3):412-8. PMID: 6713744
9. Hulgan T, Raffanti S, Kheshti A (2005). HIV+AIDS Comparison CD4+ Count VS
Percentage J. Infect. Dis., 192: 950-957.
10. Kamphuis S, Eriksson F, Kavelaars A, et al. Role of endogenous pro-enkephalin A-derived
peptides in human T cell proliferation and monocyte IL-6 production. J
Neuroimmunol. 1998; 84:5360. [PubMed: 9600708]
11. Meng J, Meng Y, Plotnikoff NP, Youkilis G, Griffin N, Shan F. -Low dose naltrexone (LDN)
enhances maturation of bone marrow dendritic cells (BMDCs). Int
Immunopharmacol. 2013 Dec;17(4):1084
12. Plotnikoff NP, Faith RE, Murgo A: Neuroimmunomodulation with Enkephaiins: Effects on
Thymus and Spleen Weights in Mice Clinical Immunology and Immunopathology
32,52,56 (1984)
13. Plotnikoff NP, Bihari B, Herberman R, Good R: Methionine Enkephalin in the treatment of
ARC (AIDS) Patients Memrias do Instituto Oswaldo Cruz (Impact Factor: 1.59).
01/1987; 82. DOI: 10.1590/S0074-02761987000600011

Page 25/27

February 18, 2016!

FINAL

14. Plotnikoff NP, Wybran J: Methionine-enkephalin shows promise in reducing HIV in blood.
Ann N Y Acad Sci. 1987;496:108-14. PMID: 3496822
15. Plotnikoff N, Wybran ; Methionine Enkephalin: a new lymphokine for the Treatment of
ARC patients Am Fam Physician. 1989 Sep;40(3):234.
16. Plotnikoff NP, Bihari B, Herberman R and Novak R; Methionine Enkephalin: Sustained
Increase of Cytotoxic T Cells in HIV + Patients Clin Immunol Immunopathol. 1997
Feb;82(2):93-101. Review.
17. Plotnikoff NP, Faith RE, Murgo A, Ronald Herberman R,Good R: Methionine Enkephalin: A
New CytokineHuman Studies Clin Immunol Immunopathol. 1997 Feb;82(2):
93-101.
18. Pirzada Y, Khuder S, Donabedian H (2006). Predicting AIDS-related events using CD4
percentage or CD4 absolute counts: AIDS Res Ther 2006, 3:20doi:
10.1186/1742-6405-3-20.
19. Puente J, Maturana P, Miranda D, Navarro C, Wolf ME, Mosnaim AD (1992). Enhancement
of natural cytotoxicity by beta-endorphin, Brain Behav. Immun., 6(1): 32-39.
20. Roy S, Loh HH (1996): Effects of opioids on the immune system. Neurochem Res.
Department of Pharmacology, Univ. Minnesota, MI 55455 USA, 21(11): 1375-86.
21. Smith JP, Stock H, Bingaman S, Mauger D, Rogosnitzky M, Zagon IS. Low-dose naltrexone
therapy improves active Crohns disease. Am J Gastroenterol. 2007;102:820-828.
doi:10.1111/j 1572-0241.2007.01045.x.
22. Songok EM, Bwibo RE, Oogo SA, Libondo D, Gichogo A, Tukei PM, (1993). The impact of
marital status on HIV seropositivity in Nairobi: a cross-sectional serological survey
on referred patients. Int. Conf. AIDS. 1993 Jun 6-11; 9: 930.
23. Steele AD, Henderson EE, Rogers TJ, (2003): Mu-opioid modulation of HIV-1 coreceptor
expression and HIV-1 replication. Virology, 309(1): 99-107. (UNAIDS) Joint United
Nations Programme on HIV/AIDS and World Health Organization (WHO) (2010).
AIDS Epidemic Update 2010.
24. Specter, S, Plotnikoff NP, Bradley WG, Goodfellow D: Methionine enkephalin combined
with AZT therapy reduce murine retrovirus-induced disease International Journal of
Immunopharmacology Volume 16, Issue 11, November 1994, Pages 911917.
25. Traore AK, Thiero O, Dao S, Kounde FFC, Faye O, Cisse M, McCandless JB, Zimmerman
JM: Impact of low dose naltrexone (LDN) on antiretroviral therapy (ART) treated
HIV+ adults in Mali: A single blind randomized clinical trial Journal of AIDS and
HIV Research Vol. 3(10), pp. 189-198, September 2011 ISSN 2141-2359 2011
Academic Journals
26. Traore AK, Thiero O, Dao S, Kounde FFC, Faye O, Cisse M, McCandless JB, Zimmerman
JM:Single cohort study of the effect of low dose naltrexone on the evolution of
immunological, virological and clinical state of HIV+ adults in Mali.
27. World Health Organization, Progress Resport, Global Health Sector Response to HIV,
2000-2015. Focus on Innovations in Africa, 2015
28. Zagon IS, Donahue RN, Bonneau
RH,
McLaughlin PJ
(2011): B Lymphocyte
Proliferation is Suppressed by the Opioid Growth Factor - Opioid Growth Factor
Receptor Axis: Implication for the Treatment of Autoimmune Diseases:
Page 26/27

February 18, 2016!

FINAL

29. Zagon IS, McLaughlin PJ. Opioid growth factor and the treatment of human pancreatic
cancer: a review. World J Gastroenterol. 2014;20:2218-2223. doi:10.3748/
wjg.v20.i9.2218.
30. UNAIDS, The Gap Report 2014, Joint United Nations Programme on HIV/AIDS

Page 27/27