Basics of HIV Management 2010

Dr. Dennis Sifris

LifeSense Disease Management

Basics of HIV Management 2010

1. When to start ARV therapy

2. Recommended ARV regimens

3. Monitoring progress and adherence

4. When to change to second regimen

5. Adverse events

6. TB/HIV, non-HIV-related morbidity, PEP, MTCT

Module 1

New WHO Guidelines 2010

• It promotes earlier treatment, recommending starting HIV treatment at 350 cells or below.

• It recommends moving to more patient-friendly and less toxic regimens, phasing out stavudine (d4T), which is more toxic than initially thought.

• It recommends starting co-infected people with TB (or hepatitis B if it requires treatment) on ART earlier, regardless of the CD4 count.

• It acknowledges the prevention benefits of treatment (i.e. HAART is prevention).

2010 Universal Shift

EARLY INITIATION OF ARVs

Benefits of Early ARV Treatment

• Earlier suppression of viral replication

• Lower risk of detrimental viral evolution

• Lower risk of virologic failure

• Preservation of immune function

• Prolongation of disease-free survival

• Decrease in the risk of HIV transmission

• Decrease of non-HIV related morbidity

Case for Earlier Initiation of Therapy

• Availability of more potent, easier, and less toxic regimens

• Cohort studies showing benefit with earlier therapy

• Better response to therapy

• Decreased transmission of HIV

• Preserve R5-tropic virus

• Cost efficacy

Early vs. Late Cost efficacy

Starting HAART: When to take the first step

Data backing up early initiation

1. START Study

2. CASCADE Study

3. CHARTER Study

4. CHER Study (paediatrics)

START Study

• 3 arms by CD4 stratification – <350

– 350- 500

– >500

• Significant advantage in arms 1 and 2 but no real advantage in arm 3 (>500)

• Ongoing

CASCADE-1

AIDS 2010: THLBB201

CASCADE-2

AIDS 2010: THLBB201

Data supporting Early Initiation

CHER STUDY

• Ongoing South African paediatric study

• Huge benefit of immediate starting of HAART in children vs. delayed treatment

• Better clinical outcome, as well as cost efficacy

When to Start ART: CHER Analysis

Data supporting Early Initiation

CAMELIA STUDY (Cambodia)

• With TB co-infection when is the best time to start ARVS

• Starting ARVs within 2 weeks of TB Rx decreased death from TB by a third

• 72% of TBs did not know their status

When to Start ART- The CAMELIA Trial (TB)

Conclusion HIV/TB Co-infection

• Treat TB immediately

• Introduce ARVs as soon as the patient has settled on the TB Rx and can tolerate the ARVs

• 2 weeks is optimal period irrespective of CD4 count

Data supporting Early Initiation

CHARTER STUDY • Higher incidence of neuro-cognitive disorders with

very low CD4 (nadir of < 50)

• Even after treatment with HAART, irreversible damage persists

Starting ARVs by CD4 count

• < 350 Start HAART • 350-500 Consider if patient ready and willing • > 500 Defer HAART With following exceptions: • TB Start HAART at any CD4 count • Pregnancy <350 lifelong HAART >350 MTCT Start ARVs on presentation

The Big Question:

Why are so many South Africans still reluctant to start HAART?

Obstacles High rates of “lost to follow-up” Major reasons include

• Advanced disease (late presentation) • Culture of denial still exists post-Mbeki • 51% of Americans still consider HIV a terminal illness • Co-payment for services • Hidden costs (e.g. 50% costs for transportation to

and from clinics) • Shortages in ARVs at clinics • Poor healthcare infrastructure • Traditional healers

In Summary • Encourage patients to start ARVs early • “Patient readiness” is often overemphasized • Delay of ARVs will cause future problems • Explain benefits of early intervention • Newer ARVs have are less toxic and more tolerable • More treatment options now available • Normal life expectancy is possible • HAART as prevention