Antiretroviral drugs and initiation of therapy

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Antiretroviral drugs and initiation of therapy

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Antiretroviral Agents NRTI
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Antiretroviral Agents NRTI
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Antiretroviral Agents NRTI
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Antiretroviral Agents NRTI
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Antiretroviral Agents NRTI
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Antiretroviral Agents NRTI
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Antiretroviral Agents NRTI
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Antiretroviral Agents NNRTI
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Antiretroviral Agents NNRTI
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Antiretroviral Agents PI
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Antiretroviral Agents PI
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Antiretroviral Agents PI
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Antiretroviral Agents PI
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Antiretroviral Agents PI
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Antiretroviral Agents PI
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When to Start
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CD4 Equipoise
Consider reasons to treat
Consider reasons not to treat
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HIV RNA Equipoise
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When to start therapy
Probability of progression to AIDS/death
according to baseline CD4 cell counts
0.50

• Prospective observational cohort study from
  Barcelona
• Starting ART 1/97 to 12/00
• n573
• Mean age 38 years
• 76 male
• CD4 243 cells/mm3
• HIV RNA 4.8 log10 c/mL
• By multivariate analysis, starting therapy with
  CD4 201-349 was associated with a higher risk of
  disease progression vs CD4 gt350

0.40
0.30
Probability of AIDS or death
plt0.001
lt200 cells/mm3
0.20
lt201-350 cells/mm3
0.10
gt350 cells/mm3
0
60
48
36
24
12
0
CD4 lt200 253 220 174 114 69 23 201-350 127 113
90 61 44 16 gt350 189 182 161 116 73 21
Months
Ferrer E, et al. 10th CROI, Boston 2003, 910
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Effect of baseline HIV RNA on survival

• Is poor prognosis for patients with high HIV RNA
  confounded by poor adherence?
• Vancouver cohort (n1422)
• Adherence refill rates (gt/lt95)
• Adjusting for adherence, HIV RNA gt100,000
  associated with HIV-related mortality (ARH 1.81,
  95 CI 1.15-2.84)
• Conclusion
• Even when controlling for adherence, VL gt100,000
  confers a worse prognosis

Time to HIV RNA suppression(lt500 c/mL)
100
90
lt95 ADHERENT
80
70
60
Probability of remaining detectable ()
50
40
30
gt95 ADHERENT
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All plt0.05
10
0
0
1
2
3
4
5
6
Time from the start of ARTs (months)
Wood E, et al. 10th CROI, Boston 2003, 182
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Effect of durable viral suppression on outcome

• Prior studies have shown that achieving durable
  viral suppression could compensate for poor
  prognosis of starting ART with low CD4
• Further follow up of Hopkins cohort (n1,173)
  suggests that even among those with suppressed
  HIV RNA, starting therapy with CD4 gt200 is
  associated with longer survival than starting
  after CD4 is lt200
• Results emphasize importance of starting at gt200

Sterling T, et al. 10th CROI, Boston 2003, 570
p-values noted
are all compared to CD4lt200
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Brithish HIV Assocaition Guidelines, July 2001
Initiation of ART in the HIV-Infected Patient

• Clinical Category Surrogate markers
  Recommendation
• Primary HIV infection
  If treatment considered,
  start as soon as (B III)
  possible, certainly within 6
  months of
  
  contracting HIV
• Established asym HIV CD4 gt350 /mm3
  Defer treatment any viral load (B II)
• 
  200-350/mm3 (B III) Start treatment within
  this range, taking into
  account the rate of CD4 decline, symptoms,
  patients wishes and viral
  load
• 
  lt200/mm3 Treat any viral
  load (A I)
• Serious/recurrent
  Treat
  HIV related illness or AIDS (A I)

http//www.bhiva.org
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Updated DHHS Guidelines, July 2003 Initiationof
ART in the Chronically HIV-Infected Patient

• Clinical Category CD4 count Plasma
  HIV-RNA Recommendation
• Symptomatic Any Any Treat(AIDS, severe symptoms)
• Asymptomatic AIDS lt200/mm3 Any Treat
• Asymptomatic AIDS 200-350/mm3 Any Treatment
  should be offered, although controversial
• Asymptomatic AIDS gt350 gt55,000 Experts
  recommendations differ, many treat
• Asymptomatic AIDS gt350 lt55,000 Most experts
  defer therapy and observe

http//AIDSinfo.nih.gov
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When to start treating HIV-infected Patients

• Parameter U.S. HHS BHIVA Thai Feb 2002 Mar
  2001 July 2003
• Symptomatic HIV treat treat treat
• CD4 counts lt200-350a lt200 lt200
• Plasma VL gt55,000b gt30,000c gt100,000c

a200-350 offer HAART to the patient bbDNA assay
v3.0 or RT-PCR cconsider individually and close
FU
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How to start
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Baseline Evaluation 1

• History illness, social, psychological,
  occupation, income, family, etc.
• Physical examination
• vital signs
• oral mucosa
• perianal area
• eye ground
• pelvic exam and pap smear

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Baseline Evaluation 2

• CBC, UA
• CXR
• Stool exam, Stool AFB stain
• BUN, Cr, FBS, uric acid, lipids, LFT
• VDRL, FTA-ABS (TPHA)
• CD4, HIV-RNA
• HBsAg, HBsAb
• Anti HCV
• Toxoplasma Ab-IgG (Optional)

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HIV-RNA
Monotherapy
- 0.5 log
Dual nucleoside
- 1.5 log
Potent Combination Therapy
Below detection
time
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Initiation of Therapy Regimens 1
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Initiation of Therapy Regimens 2
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Initiation of Therapy Regimens 3
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Initiation of Therapy Regimens 4
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DHHS July 2003Recommended NNRTI-based Regimen
http//www.aidsinfo.nih.gov/guidelines/adult/
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DHHS July 2003Recommended PI-based Regimen
http//www.aidsinfo.nih.gov/guidelines/adult/
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DHHS July 2003Recommended NRTI-based Regimen
http//www.aidsinfo.nih.gov/guidelines/adult/
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Results from Comparable TrialsITT analysis of
VL lt 400 c/mL at Week 48
Dupont 006 IDV AZT 3TC
Start I IDV AZT 3TC
Start I IDV d4T 3TC
Dupont 006 EFV IDV
Atlantic NVP d4T ddI
Atlantic 3TC d4T ddI
Agouron 542 Nelfinavir TID d4T 3TC
Atlantic IDV d4T ddI
Agouron 542 Nelfinavir BID d4T 3TC
M98-863 Nelfinavir d4T 3TC
Dupont 006 EFV AZT 3TC
M98-863 Kaletra d4T 3TC
0
10
20
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40
50
60
70
80
Randomized comparative trials with gt 100
subjects/arm