*3.1. Study Participants*

Between September 2021–February 2022, 10 PLWH were enrolled. The initial enrollment target was 26 participants, but the study was closed prematurely due to rupture of cannabinoid capsules stock, the impossibility of renewing the stock of capsules with the same manufacturing criteria and enrolment challenges. Baseline characteristics are summarized in Table 2. Median age was 57.5 years (IQR: 54.75–61.75) and most were male (80%). Based on the CUDIT-R results, 7 out of the 10 participants (70%) reported having consumed cannabis during the past 6 months. Study group allocation is depicted in Figure 2.

**Table 2.** Demographic and biological characteristics of study participants at inclusion (*n* = 10).



**Figure 2.** Allocation of participants enrolled in the study (*n* = 10). Distribution of study participants randomized to arm 1 (TN-TC11M2; THC:CBD) or arm 2 (TN-C200M2; CBD-only), to the study.

#### *3.2. Safety and Tolerability*

Dosing completion and Adverse Events (AE): Dosing based on participant self-titration is depicted in Figure 3. The majority of participants experienced AEs that were mild or moderate in severity. Eight out of 10 participants completed 12 weeks of treatment. Two participants were withdrawn from the CBD-only arm at 6 weeks for safety concerns. In one case, the 33-year-old female had grade 2 anemia (Hg 83 g/L) at screening, which failed to improve with oral iron supplementation. With frequent phlebotomy, the anemia progressed to grade 3 (lowest Hg 76 g/L) over the course of the study. She was withdrawn to prevent aggravation of her anemia. She also had moderate transaminitis at week 6 which normalized within 1 week following CBD cessation (Figure 4). The second participant withdrawn was a 62-year-old male who developed acute hepatitis at 6 weeks (Figure 4), deemed to be an unexpected, life-threatening serious adverse events (SAE), possibly related to cannabinoid treatment and requiring permanent CBD discontinuation and hepatology evaluation. Imaging revealed a pancreatic head mass, confirmed by pathology as pancreatic adenocarcinoma. Other potential contributors rendering the participant at risk for hepatitis included diabetes type 2, mild hepatic steatosis (diagnosed by abdominal ultrasound), alcohol binging, and possible interaction with ART resulting in increased CBD levels. Due to these two episodes of hepatitis, the protocol was amended and the maximum allowed dose for the CBD-only arm was reduced to 400 mg daily. However, this new protocol amendment only affected one individual.

Eight out the 10 study participants (80%) reported at least one AE, including 4 out of 5 individuals in each arm. The most commonly reported AE was somnolence (50%), followed by diarrhea (20%), difficulty concentrating (20%), transaminitis (20%) and worsened diabetes type 2 (20%). Only somnolence, difficulty concentrating, cognitive impairment and increase appetite were considered definitively related to cannabinoids and resolved with dose reduction. Apart from the SAE, the majority of AEs were of mild-moderate severity. Other AEs, as listed in Table 3, were reported only once and were considered possibly, probably or not related to treatment (10%).

**Figure 3.** Daily dosage of CBD-only and THC/CBD combination during the 12 weeks of treatment. (**A**) THC/CBD arm: In arm 1 (THC/CBD), two participants were able to reach the maximum daily dose of the study drugs (15 mg THC/15 mg CBD), but only one remained at this dose until the end of the treatment, the other participant reduced his dosing to 10 mg THC/10 mg CBD per day because of the occurrence of AEs (somnolence). Two other participants from arm 1 reached the daily dose 10 mg THC/10 mg CBD, but after 3 weeks of treatment, they reduced their dosing because of the occurrence of AEs, one participant experienced cognitive impairment (#102109), while the other had somnolence, fatigue, difficulty concentrating, nightmares and paranoid thoughts (#102101). One remained at 5 mg THC/5 mg CBD per day and the other one who had multiple AEs reduced his daily dose to 2.5 mg THC/2.5 mg CBD after 5 weeks of treatment. A participant (#102110) from arm 1 who first reduced his daily dosing from 5 mg THC/5 mg CBD after 3 weeks of treatment to 2.5 mg THC:2.5 mg CBD, finally increased his dosing from 2.5 mg THC/2.5 mg CBD per day to reach 7.5 mg THC/7.5 mg CBD per day until the end of treatment. (**B**) CBD arm: 3 participants reached the maximum daily dose of 800 mg CBD after 4 weeks of treatment, but two of them experienced AEs (transient transaminitis for #102107) and SAE (hepatitis with persistent elevated transaminases and worsened diabetes type 2, for #102108) and the treatment was permanently discontinued 1 and 2 weeks after, and they were withdrawn from the study. The other participant who reached the maximum daily dose of 800 mg remained on this daily dose until the end of the study. Finally, two participants from arm 2 gradually increased their daily dosing to reach dose of 400 mg of CBD per day and remained in this range until the end of the study medication.

**Figure 4.** Dynamics of liver enzymes of participant #102107 and #102108 from arm 2 (TN-C200M2: CBD only), during cannabinoid uptake. Evolution of liver enzyme blood levels in (**A**). participant #102107 and (**B**). participant #102108 during the up-titration of CBD dose from the starting of CBD medication to the cessation of the treatment.


**Table 3.** List of adverse events (AEs) experienced by the participants during the study.


\* Life threatening, serious adverse event.

#### *3.3. Hematology, Biochemistry, and HIV Immunology and Virology*

As previously indicated, one participant (CBD-only arm) who started the study with a known anemia (83 G/L) of grade 2, progressed to anemia of grade 3 at visit 5 and 6 (Supplementary Table S3). Two diabetic participants developed worsened glucose control. One participant, from the THC/CBD arm, had a glucose which progressively reached, at the end of treatment (Visit 9), a WHO toxicity grade 3 (Supplementary Table S4). The other diabetic was the participant who experienced the SAE. His ALT rise progressed to WHO toxicity grade 4 by Week 6. His blood glucose was of WHO toxicity grade 3 at Weeks 4 and 6 (Figure 4 and Supplemental Table S4). Apart from these diabetic participants, we did not observe any significant changes in glucose control (Table 4). Moreover, cannabinoids did not affect CD4 and CD8 count, nor HIV viral load (Supplementary Table S5). Therefore, in the overall study, 7 out of 10 individuals (70%) did not experience any significant toxicity (Grades 0–2 scores on the WHO toxicity scale).

**Table 4.** Liver enzyme and kidney function profiles.


**Table 4.** *Cont.*


\$μmol/L: Micromolar per liter; € U/L: Units per liter; \* while statistically significant, this was not deemed to be clinically significant. £ mmol/L: Millimolar per liter.

#### *3.4. Quality of Life and Mood Assessment*

EQ-5D. Supplementary Figure S1 depicts the distribution of responses to the EQ-5D questionnaire at Baseline 2 (prior to treatment), Visit 6 (during treatment) and Visit 9 (end of treatment). Overall, cannabinoids did not significantly affect QOL.

WHOQOL-HIV BREF. Similar to what was observed with the EQ-5D questionnaire, at baseline and throughout cannabinoid treatment, the majority of participants reported moderate to very good quality of life (100%) and general health (80%, 90% and 100%, at Baseline 2, Visit 6 and Visit 9, respectively) (Supplementary Figure S2). Variations in scores across visits were not significant (Supplementary Figure S2).

POMS. Five out of ten participants (50%) showed a reduction in total mood disturbance (TMD) score over time. Three participants showed a slight increase in their TMD over time, including one in the THC/CBD arm, and 2 in the CBD-only arm who were withdrawn from the study. Variations in scores across visits were not significant (Supplementary Figure S3).
