Современное лечение ВИЧ:АРТ у пациентов с сопутствующими заболеваниями.//Contemporary Management of HIV. Managing ART in HIV-Infected Patients With Common Comorbidities. 2016 In this downloadable slideset, David A. Wohl, MD, and Program Director Eric S. Daar, MD, review key data and optimal approaches for managing ART in the context of common comorbidities. Format: Microsoft PowerPoint (.ppt) File size: 3.51 MB

1. Contemporary Management of HIV:
Managing ART in HIV-Infected
Patients With Common Comorbidities
This program is supported by an independent educational grant from
ViiV Healthcare.

2. Slide credit: clinicaloptions.com
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3. Program Director and Core Faculty
Program Chair
Eric S. Daar, MD
Chief, Division of HIV Medicine
Harbor-UCLA Medical Center
Professor of Medicine
David Geffen School of
Medicine at UCLA
Los Angeles, California
David A. Wohl, MD
Associate Professor of
Medicine
School of Medicine
Site Leader, AIDS Clinical
Trials Unit-Chapel Hill
University of North Carolina at
Chapel Hill
Director, North Carolina AIDS
Training and Education Center
Chapel Hill, North Carolina
Co-Director for HIV Services
North Carolina Department of
Correction
Raleigh, North Carolina

4. Faculty Disclosure Information
Eric S. Daar, MD, has disclosed that he has received
consulting fees from AbbVie, Bristol-Myers Squibb, Gilead
Sciences, Janssen, Merck, Teva, and ViiV and funds for
research support from Bristol-Myers Squibb, Gilead
Sciences, Merck, and ViiV.
David A. Wohl, MD, has disclosed that he has received
consulting fees from Gilead Sciences and Janssen and funds
for research support from Gilead Sciences and Merck.

5. Case 1: Patient With CVD Risk
and Substance Abuse

6. Case 1: Pt With CVD Risk and Substance
Abuse
 LH is a 56-yr-old black woman diagnosed with HIV
infection 4 yrs ago
 She fell out of care 2.5 yrs ago and stopped ART
 2 mos ago, she was admitted to the hospital with angina,
and her workup revealed the following:
– MI ruled out
– Toxicology screen positive for cocaine
 Since discharge from the hospital, she has been in an
outpatient substance abuse treatment program and has
been receiving enalapril for hypertension
 Smokes 1 pack cigarettes per day for > 30 yrs
Slide credit: clinicaloptions.com

7. Case 1: HIV/ART History
 Laboratory values at the time of HIV diagnosis
– CD4+ cell count: 458 cells/mm3
– HIV-1 RNA: 11,000 copies/mL
 Started on EFV/TDF/FTC
– HIV-1 RNA was suppressed except for occasional blips
 Prior to falling out of care, her last CD4+ cell count was
762 cells/mm3
and HIV-1 RNA was 430 copies/mL
 Stopped ART when she started using cocaine more
frequently
Slide credit: clinicaloptions.com

8. Case 1: Recent History and Current
Presentation
 Returned to care 1 mo ago
– HIV-1 RNA: 24,000
copies/mL
– CD4+ count: 376 cells/mm3
– HCV negative; HBV immune
– Serum creatinine: 1.08
mg/dL (MDRD: > 60
mL/min/1.73m2
)
– HIV genotype: wild-type
virus
 Current presentation today
– BP: 142/88 mm Hg
– BMI: 29 kg/m2
– Urinalysis: trace protein
– Toxicology screen: negative
– HLA-B*5701 negative
– TC: 207 mg/dL; HDL:
42 mg/dL; LDL: 130 mg/dL;
TG: 176 mg/dL
Slide credit: clinicaloptions.com

9. Case 1: Issues for Discussion
 Should LH be prescribed a statin?
 What ART should LH be prescribed?
 What else can be done to reduce LH’s risk for new or
worsening comorbidities?
Slide credit: clinicaloptions.com
 56-yr-old black woman diagnosed with HIV and initiated ART 4 yrs ago
 Fell out of care and discontinued ART 2.5 yrs ago, now returned to care
 HIV-1 RNA: 24,000 copies/mL; CD4+ cell count: 376 cells/mm3
 HIV GT WT, but was viremic on EFV/TDF/FTC 2.5 yrs ago
 HBV immune, HCV negative, HLA-B*5701 negative
 Serum creatinine: 1.08 mg/dL (MDRD > 60 mL/min/1.73m2
); dyslipidemia
 Recovering from substance abuse (cocaine); receiving enalapril for HTN

10. Case 1: Issues for Discussion
 Should LH be prescribed a statin?
 What ART should LH be prescribed?
 What else can be done to reduce LH’s risk for new or
worsening comorbidities?
Slide credit: clinicaloptions.com
 56-yr-old black woman diagnosed with HIV and initiated ART 4 yrs ago
 Fell out of care and discontinued ART 2.5 yrs ago, now returned to care
 HIV-1 RNA: 24,000 copies/mL; CD4+ cell count: 376 cells/mm3
 HIV GT WT, but was viremic on EFV/TDF/FTC 2.5 yrs ago
 HBV immune, HCV negative, HLA-B*5701 negative
 Serum creatinine: 1.08 mg/dL (MDRD > 60 mL/min/1.73m2
); dyslipidemia
 Recovering from substance abuse (cocaine); receiving enalapril for HTN

11. CVD Deaths in Era of Modern ART: D:A:D
Smith C, et al. Lancet. 2014:384:241-248.
Most Common Causes of Death, 1999-2011
AIDS related
CVD related
Other
100
80
60
40
20
0
AllDeaths(%)
Total
(N = 3909)
1999-2000
(n = 256)
2001-02
(n = 788)
2003-04
(n = 862)
2005-06
(n = 718)
2007-08
(n = 658)
2009-11
(n = 627)
Liver related
Non-AIDS cancer
Unknown
Slide credit: clinicaloptions.com

12. Declines in MI, Stroke in United States:
Kaiser Permanente CA Cohort
After adjusting for stroke risk factors:
No increased risk in HIV+ with recent
CD4+ count ≥ 500 cells/mm3
or recent
HIV-1 RNA
< 500 c/mL
Increased risk in HIV+ with recent CD4+
count < 500 cells/mm3
or recent HIV-1
RNA ≥ 500 c/mL
Recent reduced MI rates for HIV+
likely due to:
CVD risk reduction, lipid-friendly ART,
reduced immunodeficiency
1. Klein DB, et al. CROI 2014. Abstract 737.
2. Klein DB, et al. Clin Infect Dis. 2015;60:1278-1280.
3. Marcus JL, et al. CROI 2014. Abstract 741.
4. Marcus JL, et al. AIDS. 2014;28:1911-1919.
200
150
100
50
1996-1999
2000-2003
2004-2007
2008-2009
2010-2011
250
0
Stroke Rates by HIV Status and Yr[3,4]
Cases/100,000PYs
400
MIs/100,000PYs
300
200
100
0
1996-99
2000-03
2004-07
2008-09
2010-11
HIV+
HIV-
MI Rates Over Time by HIV Status[1,2]
HIV+
HIV-
Slide credit: clinicaloptions.com

13. Guesses?
http://tools.acc.org/ASCVD-Risk-Estimator/
Case 1: ASCVD Risk Estimator
Any
Slide credit: clinicaloptions.com

14. http://tools.acc.org/ASCVD-Risk-Estimator/
Case 1: ASCVD Risk Estimator
Slide credit: clinicaloptions.com

15. http://tools.acc.org/ASCVD-Risk-Estimator/
ASCVD Risk Estimator:
Recommendations
Adults 40-75 yrs of age with LDL-C 70-189 mg/dL with no diabetes and estimated 10-yr
ASCVD risk ≥ 7.5% should be treated with moderate- to high-intensity statin therapy (I A)
Slide credit: clinicaloptions.com

16.  CVD risk scores calculated with data from 2006-2009 for pts in Partners HealthCare
System Cohort[1]
 An outpatient study cohort (n = 2392)had similar findings of underestimated CVD risk
[2]
1. Regan S, et al. CROI 2015. Abstract 751.
2. Thompson-Paul A, et al. CROI 2015. Abstract 747.
5-Yr Predicted Rate (%)
Framingham Risk Score[1]
5-YrEventRate(%)
5-YrEventRate(%)
ACC/AHACVD Risk Calculator[1]
5-Yr Predicted Rate (%)
Observed
Predicted
Observed
Predicted
CVD Outcomes Underestimated in HIV-
Positive Pts by Risk Calculators
n = 2270 n = 2152
25
20
15
10
5
0
< 2.5 2.5-4.9 5.0-7.4 7.5-9.9
25
20
15
10
5
0
< 2.5 2.5-4.9 5.0-7.4 7.5-9.9
Slide credit: clinicaloptions.com

17. Case 1: Issues for Discussion
 Should LH be prescribed a statin?
 What ART should LH be prescribed?
 What else can be done to reduce LH’s risk for new or
worsening comorbidities?
 56-yr-old black woman diagnosed with HIV and initiated ART 4 yrs ago
 Fell out of care and discontinued ART 2.5 yrs ago; now returned to care
 HIV-1 RNA: 24,000 copies/mL; CD4+ cell count: 376 cells/mm3
 HIV GT WT, but was viremic on EFV/TDF/FTC 2.5 yrs ago
 HBV immune, HCV negative, HLA-B*5701 negative
 Serum creatinine: 1.08 mg/dL (MDRD: > 60 mL/min/1.73m2
); dyslipidemia
 ASCVD 10-yr risk: 18%
Slide credit: clinicaloptions.com

18. Case 1 Question: Assuming LH is now
committed to adhering to ART, which of the
following regimens would you prescribe?
A. Restart EFV/TDF/FTC
B. RPV/TDF/FTC
C. Boosted PI + TDF/FTC
D. DTG + TDF/FTC
E. DTG/ABC/3TC
F. RAL + TDF/FTC
G. EVG/COBI/TDF/FTC
H. EVG/COBI/TAF/FTC
I. Something else
 HIV-1 RNA: 24,000 copies/mL; CD4+ cell count: 376 cells/mm3
 HIV GT WT, but was viremic on EFV/TDF/FTC 2.5 yrs ago
 HBV immune, HCV negative, HLA-B*5701 negative
 Serum creatinine: 1.08 mg/dL (MDRD: > 60 mL/min/1.73m2
); dyslipidemia
 ASCVD 10-yr risk: 18%
Slide credit: clinicaloptions.com

19. ART and Effects on Lipids
TDF ABCRAL
DTG
ATV/RTV or ATV/COBI
DRV/RTV or DRV/COBI
EVG/COBI
EFVRPV
ETV
Slide credit: clinicaloptions.com

20. Studies 104 and 111: Wk 48 Combined
Analysis of Fasting Lipids
Total
Cholesterol
LDL HDL Triglycerides TC:HDL Ratio
MedianValues(mg/dL)
Sax PE, et al. Lancet. 2015;385:2606-2615.
189
177
115 109
51 48
108
3.7
114
3.7
E/C/F/TAF
Baseline
Wk 48
E/C/F/TDF
Baseline
Wk 48P < .001
P < .001
P < .001
P = .027
P = .84
Slide credit: clinicaloptions.com
200
150
100
50
0
160
101
44
95
163
104
44
100
5
4
3
2
0
1
3.6 3.6

21. Case 1: Issues for Discussion
 Should LH be prescribed a statin?
 What ART should LH be prescribed?
– What if LH’s serum creatinine was 1.9 mg/dL and
MDRD was 42 mL/min/1.73m2
?
 What else can be done to reduce LH’s risk for new or
worsening comorbidities?
 HIV-1 RNA: 24,000 copies/mL; CD4+ cell count: 376 cells/mm3
 HIV GT WT, but was viremic on EFV/TDF/FTC 2.5 yrs ago
 HBV immune, HCV negative, HLA-B*5701 negative
 Serum creatinine: 1.9 mg/dL (MDRD: 42 mL/min/1.73m2
); dyslipidemia
 ASCVD 10-yr risk: 18%
Slide credit: clinicaloptions.com

22. Case 1 Question: Would you prescribe an
ABC-based regimen?
A. Yes
B. No
Slide credit: clinicaloptions.com
 HIV-1 RNA: 24,000 copies/mL; CD4+ cell count: 376 cells/mm3
 HIV GT WT, but was viremic on EFV/TDF/FTC 2.5 yrs ago
 HBV immune, HCV negative, HLA-B*5701 negative
 Serum creatinine: 1.9 mg/dL (MDRD: 42 mL/min/1.73m2
); dyslipidemia
 ASCVD 10-yr risk: 18%

23. Summary of Key Analyses Showing ABC
Associated With Risk of MI
Study
Study
Design
Age, Yrs
(Range)
Event
(n)
Pts,
N
ABC
CV Effect
Time on
ABC, Mos
Risk of MI
(95% CI)
D:A:D[1]
Cohort
40
(35-47)
MI, validated
(387)
22,625 Yes ≥ 6
2.04
(1.66-2.51)
D:A:D 2015[2]
Cohort
39
(33-46)
MI
(493)
32,663 Yes Current
1.47
(1.26-1.71)
SMART[3]
RCT
45
(39-51)
MI, validated
(19)
2752 Yes Current
4.3
(1.4-13.0)
STEAL[4]
RCT
45.7
±8.8
MI
(4)
357 Yes 96
2.79*
(1.76-4.43)
QPHID[5]
CC
47
(22-67)
MI
(125)
7053 Yes Any
1.79
(1.16-2.76)
Danish[6]
Cohort
39
(33-47)
MI
(67)
2952
Yes > 6
2.00
(1.07-3.76)
VA (Choi)[7]
Cohort 46
CVD event
(501)
10,931 Yes Recent
1.64
(0.88-3.08)
Swiss[8]
Cohort Not given
CVD event
(365)
11,856 Yes Recent
4.06†
(2.24-7.34)
MAGNIFICENT[9]
CC
50
(22-85.5)
CVD event
(571)
1875 Yes Current
1.56
(1.17-2.07)
NA-ACCORD[10]
Cohort
MI, validated
(301)
16,733 Yes Recent 1.33
References in slidenotes Slide credit: clinicaloptions.com
*Risk for serious non-AIDS events (most common was CVD, including MI); HR for CVD with TDF vs
ABC: 0.12 (95% CI: 0.02-0.98; P = .048).
†
Risk for CVD event, including MI, invasive CV procedure, or CV-related death.

24. Summary of Key Analyses Showing ABC
NOT Associated With Risk of MI
References in slidenotes
Study Study
Design
Age, Yrs
(Range)
Event
(n)
Pts,
N
ABC
CV
Effect
Time on
ABC,
Mos
Adj Risk of
MI
(95% CI)
FHDH[1]
CC
47
(41-54)
MI
(289)
74,958 No
< 12/
recent
1.27*
(0.64-2.49)
ALLRT/
ACTG[2] Cohort
37
(26-51)
MI
(36)
5056 No 72
0.6
(0.3 -1.4)
VA[3]
Cohort 46
MI
(278)
19,424 No Per 12
1.18
(0.92-1.50)
FDA[4]
Meta-
analysis of
RCTs
36-42
MI
(46)
9868 No 19
1.02
(0.56-1.84)
NA-
ACCORD[5] Cohort
MI,
validated
(301)
16,733 No Recent 1.33
*Without adjustment for cocaine use OR: 2.01 (1.11-3.64).
Slide credit: clinicaloptions.com

25. TAF in Pts With Renal Insufficiency
 Open-label trial of 242 virologically suppressed pts with stable eGFRCG
30-69 mL/min switched from TDF and non-TDF regimens to E/C/F/TAF
Pozniak A, CROI 2015. Abstract 795. Slide credit: clinicaloptions.com
15
10
5
0
-5
-10
Median(Q1,Q3)
eGFRChange
FromBaseline
(mL/min)
Change in eGFR (Cockcroft-Gault)
0 4 8 12 16 24 36 48 Baseline eGFR
< 50 mL/min
≥ 50 mL/min
Primary Endpoint
0.6
-1.4
15
10
5
0
-5
-10
Median(Q1,Q3)
eGFRChange
FromBaseline
(mL/min/1.73m2
)
Change in eGFR (CKD-EPI, Cystatin C)
0 4 8 12 16 24 36 48
Primary Endpoint
1.8
1.1
Wks
Wks

26. Novel TDF- and ABC-Sparing ART
Strategies Under Investigation
1. Cahn P, et al. EACS 2015. Abstract 961.
2. Raffi F, et al. Lancet. 2014;384:1942-1951.
3. Figueroa MI, et al. EACS 2015. Abstract 1066.
4. Perez-Molina JA, et al. Lancet Infect Dis. 2015;15:775-784.
5. Di Giambenedetto S, et al. EACS 2015. Abstract 867.
6. Arribas JR, et al. Lancet Infect Dis. 2015;15:785-792.
7. Casado JL, et al. J Antimicrob Chemother. 2015;70:630-632.
8. Margolis DA, et al. Lancet Infect Dis. 2015;15:1145-1155. Slide credit: clinicaloptions.com
Study
Initial or Switch
From Suppr. ART
N Regimen Results
GARDEL[1]
Initial 426 LPV/RTV + 3TC Similar efficacy as LPV/RTV + 2 NRTIs
PADDLE[2]
Initial 20 DTG + 3TC Small study; encouraging efficacy
NEAT001/
ANRS143[3] Initial 805 DRV/RTV + RAL Similar efficacy as DRV/RTV + TDF/FTC
SALT[4]
Switch 286 ATV/RTV + 3TC Similar efficacy as ATV/RTV + 2 NRTIs
ATLAS-M[5]
Switch 266 ATV/RTV + 3TC
Similar (improved in post hoc analysis)
efficacy vs ATV/RTV + 2 NRTIs
OLE[6]
Switch 250 LPV/RTV + 3TC
Similar efficacy as continued standard
ART
NA[7]
Switch 48 DRV/RTV + 3TC Small study; encouraging efficacy
LATTE[8]
Switch 243 CAB + RPV
Similar efficacy as continued standard
ART

27. CrCl Cutoffs for Single-Tablet Regimens
1. EVG/COBI/TDF/FTC [package insert].
2. EFV/TDF/FTC [package insert].
3. RPV/TDF/FTC [package insert].
4. DTG/ABC/3TC [package insert.
5. EVG/COBI/TAF/FTC [package insert].
Single-Tablet Regimen FDA Approved for Pts With CrCl,
mL/min
EVG/COBI/TDF/FTC[1]
≥ 70
EFV/TDF/FTC[2]
≥ 50
RPV/TDF/FTC[3]
≥ 50
DTG/ABC/3TC[4]
≥ 50
EVG/COBI/TAF/FTC[5]
≥ 30
Slide credit: clinicaloptions.com

28. Drug–Drug Interactions With First-line
ART and Lipid-Lowering Therapy
Antiretroviral Contraindicated Titrate Dose No Dose Adjustment
EFV Atorvastatin
Simvastatin
Pravastatin
Rosuvastatin
Pitavastatin
RPV Atorvastatin
Pitavastatin
ATV/RTV
ATV/COBI
Lovastatin
Simvastatin
Atorvastatin
Rosuvastatin
Pitavastatin
DRV/RTV
DRV/COBI
Lovastatin
Simvastatin
Atorvastatin
Pravastatin
Rosuvastatin
Pitavastatin
EVG/COBI/TAF/FTC Lovastatin
Simvastatin
Atorvastatin
EVG/COBI/TDF/FTC Lovastatin
Simvastatin
Atorvastatin
Rosuvastatin
DTG All
RAL All
DHHS Adult Guidelines. April 2015. US Food and Drug Administration. Slide credit: clinicaloptions.com

29. Case 1: Issues for Discussion
 Should LH be prescribed a statin?
 What ART should LH be prescribed?
 What else can be done to reduce LH’s risk for new or
worsening comorbidities?
 56-yr-old black woman diagnosed with HIV and initiated ART 4 yrs ago
 Fell out of care and discontinued ART 2.5 yrs ago; now returned to care
 HIV-1 RNA: 24,000 copies/mL; CD4+ cell count: 376 cells/mm3
 HIV GT WT, but was viremic on EFV/TDF/FTC 2.5 yrs ago
 HBV immune, HCV negative, HLA-B*5701 negative
 Serum creatinine: 1.08 mg/dL (MDRD: > 60 mL/min/1.73m2
); dyslipidemia
 Recovering from substance abuse (cocaine); receiving enalapril for HTN
Slide credit: clinicaloptions.com

30. Case 1: Additional Considerations
 Is aspirin indicated?
 Is LH’s blood pressure adequately controlled?
 Should you order a chest CT?
 Avoiding future comorbidities[1]
– Colonoscopy
– PAP smear
– Mammogram
– DXA
– Vaccinations
– STI screening
1. Aberg JA, et al. Clin Infect Dis. 2014;58:1-10. Slide credit: clinicaloptions.com

31. Case 1: Take-Home Points
 CVD is prevalent among HIV-infected individuals,
many of whom have major CVD risk factors
 The ASCVD risk calculator replaces the Framingham
estimation and has established a threshold for statin
initiation as a 7.5% 10-year risk
 Different antiretroviral agents have varying affects on
lipids and drug interactions with medications used to
treat CVD
 The potential impact of antiretroviral agents on CVD
risk must be considered when selecting HIV therapy
Slide credit: clinicaloptions.com

32. Case 2: Patient on Long-term
Suppressive ART With Low BMD
Identified After Fracture

33. Case 2: Pt on Long-term ART With Low
BMD Identified After Fracture
 RB is a 60-yr-old HIV-infected man with suppressed
HIV-1 RNA for > 8 yrs
– Nadir CD4+ cell count: 110 cells/mm3
– Baseline HIV genotype: wild-type
– Initial and current ART: ATV/RTV + TDF/FTC, initiated
during a clinical trial that has since ended
– HCV negative and HBV immune
– HLA-B*5701: negative
Slide credit: clinicaloptions.com

34. Case 2: Medical History and Current
Medications
 Past medical history and current medications
– Depression, citalopram
– Alcohol abuse
– Sober for 2 yrs
– COPD
 Former smoker
Slide credit: clinicaloptions.com

35. Case 2: Current Presentation
 At routine visit 3 wks ago, presented in orthopedic boot s/p
recent ankle fracture sustained when stepping out of his
high pickup truck
– HIV-1 RNA: < 20 copies/mL
– CD4+ cell count: 438 cells/mm3
– Serum creatinine: 1.2 mg/dL (MDRD: > 60 mL/min/1.73m2
)
– Urinalysis: trace protein
– ASCVD 10-yr risk: < 7.5%
– Vitamin D (25OH): 19 ng/mL
– DXA T-scores: L-spine: -2.6; femoral neck: -2.7; hip: -2.6
Slide credit: clinicaloptions.com

36. Case 2: Issues for Discussion
 Should RB’s ART be modified?
 Is any further assessment or intervention needed for
RB?
 60-yr-old HIV-infected man with suppressed HIV-1 RNA for > 8 yrs
 Initial and current ART: ATV/RTV + TDF/FTC
 HIV baseline GT WT, HBV immune, HCV negative, HLA-B*5701 negative
 Recent fracture
 DXA T-scores: L-spine: -2.6; femoral neck: -2.7; hip: -2.6
 Depression; former smoker; previous heavy alcohol use (sober 2 yrs)
 COPD
 Serum creatinine: 1.2 mg/dL (MDRD: > 60 mL/min/1.73m2
)
Slide credit: clinicaloptions.com

37. Case 2: Issues for Discussion
 Should RB’s ART be modified?
 Is any further assessment or intervention needed for
RB?
 60-yr-old HIV-infected man with suppressed HIV-1 RNA for > 8 yrs
 Initial and current ART: ATV/RTV + TDF/FTC
 HIV baseline GT WT, HBV immune, HCV negative, HLA-B*5701 negative
 Recent fracture
 DXA T-scores: L-spine: -2.6; femoral neck: -2.7; hip: -2.6
 Depression; former smoker; previous heavy alcohol use (sober 2 yrs)
 COPD
 Serum creatinine: 1.2 mg/dL (MDRD: > 60 mL/min/1.73m2
)
Slide credit: clinicaloptions.com

38. Case 2 Question: How would you manage
RB’s low BMD?
A. Continue ATV/RTV + TDF/FTC and start calcium/vitamin D ±
bisphosphonate
B. Continue ATV/RTV, but switch TDF/FTC to ABC/3TC
C. Continue TDF/FTC, but switch ATV/RTV to boosted DRV or an INSTI
or RPV
D. Switch to EVG/COBI/TAF/FTC
E. Switch to DTG + RPV
F. Something else
 60-yr-old HIV-infected man with suppressed HIV-1 RNA for > 8 yrs; initial/current ART:
ATV/RTV + TDF/FTC; HIV baseline GT WT, HBV immune, HCV negative, HLA-B*5701
negative; low BMD and recent fracture; treated depression; former smoker; previous
heavy alcohol use (sober 2 yrs); COPD; serum Cr: 1.2 mg/dL (MDRD: > 60
mL/min/1.73m2
)
Slide credit: clinicaloptions.com

39. Do HIV-Positive Pts Have Increased Risk
of Bone Loss and Fractures?
 Meta-analysis: HIV-positive pts had 6.4-fold increased risk of low BMD
and 3.7-fold increased risk of osteoporosis[1]
 8525 HIV-infected pts compared with 2,208,792 uninfected pts in
Partners HealthCare System, 1996-2008[2]
Women Men
1. Brown TT, et al. AIDS. 2006;20:2165-2174.
2. Triant V, et al. J Clin Endocrinol Metab. 2008;93:3499-3504.
Age (Yrs)
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0
FracturePrevalence/
100Persons
30-39 40-49 50-59 60-69 70-79
P = .002
(overall comparison)
HIV
Non-HIV
HIV
Non-HIV
Age (Yrs)
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0
FracturePrevalence/
100Persons
20-29 30-39 40-49 50-59 60-69
P < .0001
(overall comparison)
Slide credit: clinicaloptions.com

40. ART Associated With ~ 2% to 6% Loss in
BMD During First 1-2 Yrs After Initiation
1. Gallant JE, et al. JAMA. 2004;292:191-201.
2. Brown TT, et al. JAIDS. 2009;51:554-561.
3. Duvivier C, et al. AIDS. 2009;23:817-824.
4. van Vonderen MG, et al. AIDS. 2009;23:1367-1376.
5. Stellbrink HJ, et al. CID. 2010;51:963-972.
6. McComsey GA, et al. JID. 2011;203:1791-1801.
Study Pts,
N
Duration,
Wks
ART Change in BMD, %
Spine Hip Total
Gallant 2004[1]
602 144 EFV + TDF/3TC
EFV + D4T/3TC
-2.2
-1.0
-2.8
-2.4
-
-
Brown 2009[2]
106 96
LPV/RTV + ZDV/3TC
EFV + ZDV/3TC
-
-
-
-
-2.5
-2.3
Duvivier 2009[3]
71 48
PI
Non-PI
-4.4 to -5.8
-1.5
-2.4 to -3.7
-2.7
-
-
van Vonderen
2009[4] 50 104
LPV/RTV + ZDV/3TC
LPV/RTV + NPV
-5.1
-2.6
-6.3
-2.3
-
-
Stellbrink
2010[5] 385 48
EFV + TDF/FTC
EFV + ABC/3TC
-3.6
-1.9
-2.4
-1.6
-
-
McComsey
2011[6] 269 96
TDF/FTC
ABC/3TC
ATV/RTV
EFV
-3.3
-1.3
-3.1
-1.7
-4.0
-2.6
-3.4
-3.1
-
-
-
-
Slide credit: clinicaloptions.com

41. START: Immediate vs Deferred ART
 START: International, randomized phase IV study involving 215 sites
in 35 countries
 Study stopped by DSMB following results of interim analysis
– Overall HR: 0.43 (P < .001)
– HR for serious AIDS-related events: 0.28 (P < .001)
– HR for non-AIDS–related events: 0.61 (P = .04)
Serious AIDS and
Non-AIDS Events, n
42
96
Lundgren JD, et al. N Engl J Med. 2015;373:795-807.
Immediate ART
Delayed ART
(until CD4+ ≤ 350 cells/mm³)
Treatment-naive
pts with CD4+ count
> 500 cells/mm³
(N = 4685)
Slide credit: clinicaloptions.com

42. START Substudy: BMD Changes With
Immediate vs Deferred ART Over 3 Yrs
 Substudy included 193 pts in
early ART arm and 204 pts in
deferred ART arm with f/u
 Greater BMD loss in hip and
spine with immediate vs
deferred ART
– Estimated mean difference for
hip: -1.5% (95% CI: -2.3% to
-0.8%; P < .001)
– Estimated mean difference for
spine: -1.6% (95% CI: -2.2% to
-1.0%; P < .001)
 Osteoporosis incidence similar
between arms (P = .27)
Hoy JF, et al. EACS 2015. Abstract ADRLH-62.
ChangeFromBL(%)ChangeFromBL(%)
Total Hip BMD
0
-1
-2
-3
-4
-5
0 12 24 36
Immediate ART
Deferred ART
Total Spine BMD
0
-1
-2
-3
-4
-5
0 12 24 36
Mos From Randomization
Slide credit: clinicaloptions.com

43. A5224s: Mean Percent Change in Hip and
Spine BMD
 Substudy of A5202:
TDF/FTC vs ABC/3TC
with either ATV/RTV vs
EFV
 N = 269
– 85% male, 47% white,
median age: 38 yrs
 Significantly greater
spine and hip BMD loss
with TDF/FTC vs
ABC/3TC
 Significantly greater
BMD loss in spine but
not hip with ATV/RTV vs
EFV
McComsey GA, et al. J Infect Dis. 2011;203:1791-1801.
Wk
Wk
P = .004
P = .024
P = .61
Slide credit: clinicaloptions.com
SpineBMD%
ChangeFromWk0
0
-1
-2
-3
-4
-5
0
1
NRTI Component:
1° Analysis
24 48 96 144 192
TDF/FTC
ABC/3TC
HipBMD%
ChangeFromWk0
0
-1
-2
-3
-4
-5
0
1
24 48 96 144 192
TDF/FTC
ABC/3TC
0
-1
-2
-3
-4
-5
0
1
NNRTI/PI Component:
2° Analysis
24 48 96 144 192
EFV
ATV/RTV
P = .035
0
-1
-2
-3
-4
-5
0
1
24 48 96 144 192
EFV
ATV/RTV

44. A5260s Substudy of ACTG 5257: BMD
Loss With RAL vs Boosted PIs
 A5257: Phase III trial in which
treatment-naive pts with HIV-1
RNA ≥ 1000 copies/mL were
randomized to:
– RAL + TDF/FTC (n = 603)
– ATV/RTV + TDF/FTC (n = 605)
– DRV/RTV + TDF/FTC (n = 601)
 In A5260s metabolic substudy (N =
328), all arms associated with
significant loss of BMD through Wk
96 (P < .001)
 At hip and spine, similar loss of
BMD in the PI arms
– Significantly greater loss in
combined PI arms than in RAL arm
ATV/RTV + TDF/FTC
DRV/RTV + TDF/FTC
Combined PI arms
RAL + TDF/FTC
-5
-4
0
-3
-2
-1
-3.9
-3.4
-3.7
-2.4
-1.8
-4.0
-3.8
-3.6
P = .36
Total Hip Lumbar Spine
P = .005
P = .42
P < .001
Brown TT, et al. J Infect Dis. 2015;212:1241-1249. Slide credit: clinicaloptions.com

45. TAF vs TDF in Studies 104/111: BMD
Changes by Age in Treatment-Naive Pts
Difference
E/C/F/TAF
E/C/F/TDF
Mean%ChangeinBMDFromBaseline
DifferenceinLSM(%)
HipSpine
18-25 Yrs of Age
All Ages All Ages
Wohl D, et al. EACS 2015. Abstract 1091. Slide credit: clinicaloptions.com
0
-1
-2
-3
-4 0
2
1
3
4
0
-1
-2
-3
-4 0
2
1
3
4
0 24 48 72 96
0
-1
-2
-3
-4 0
2
1
3
4
18-25 Yrs of Age0
-1
-2
-3
-4 0
2
1
3
4
0 24 48 72 96
Wk Wk

46. Switch From TDF to ABC or From TDF to
RAL in Pts With Low BMD
Negredo E, et al. J Antimicrob Chemother. 2014;69:3368-3371.
Bloch M, et al. HIV Med. 2014;15:373-380.
Switch From TDF to ABC Switch From TDF to RAL
Slide credit: clinicaloptions.com
Tenofovir Abacavir Raltegravir
3.5
2.5
1.5
0.5
0
-0.5
-1.5
-2.5
-3.5
ChangeinBMDOver48Wks(%)
Femoral
Neck
Lumbar
Spine
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0
Total
Hip
Lumbar
Spine
2.1
-0.7
0.7
-1.2
3.0
2.5

47. Study 109: Switch From E/C/F/TDF to
E/C/F/TAF in Suppressed Pts
 Randomized, active-controlled, open-label study
– Primary endpoint: HIV-1 RNA < 50 c/mL at Wk 48
Thompson M, et al. IDWeek 2015. Abstract 725.
Pts with HIV-1 RNA
< 50 copies/mL (≥ 48 wks)
on stable TDF-based
regimen and eGFR
≥ 50 mL/min
(N = 1436)
Switch to EVG/COBI/FTC/TAF QD
(n = 959)
Continue Previous TDF-Based Regimen*
(n = 477)
Primary Endpoint
Wk 48
*Previous TDF-based regimens: EVG/COBI/FTC/TDF (n = 459), EFV/TDF/FTC (n = 376), ATV/COBI
or ATV/RTV + TDF/FTC (n = 601).
Continue
through
Wk 96
Slide credit: clinicaloptions.com

48. Study 109: Bone Outcomes in Pts
Receiving EVG/COBI/FTC/TDF at BL
Thompson M, et al. IDWeek 2015. Abstract 725.
Spine
Hip
3
2
1
0
-1
-2
-3
3
2
1
0
-1
-2
-3
BL Wk 48Wk 24
BL Wk 48Wk 24
1.33 (3.6)
-0.50 (3.4)
1.15 (2.7)
-0.24 (2.7)
E/C/F/TAF
E/C/F/TDF
E/C/F/TAF
E/C/F/TDF
Mean%ChangeinBMD
(SD)
Mean%ChangeinBMD
(SD)
P<.001P<.001
Slide credit: clinicaloptions.com

49. Case 2: Issues for Discussion
 Should RB’s ART be modified?
 Is any further assessment or intervention needed for
RB?
 60-yr-old HIV-infected man with suppressed HIV-1 RNA for > 8 yrs
 Initial and current ART: ATV/RTV + TDF/FTC
 HIV baseline GT WT, HBV immune, HCV negative, HLA-B*5701 negative
 Recent fracture
 DXA T-scores: L-spine: -2.6; femoral neck: -2.7; hip: -2.6
 Depression; former smoker; previous heavy alcohol use (sober 2 yrs)
 COPD
Slide credit: clinicaloptions.com

50. Slide credit: clinicaloptions.comNational Osteoporosis Foundation.
http://nof.org/files/nof/public/content/file/2791/upload/919.pdf

51. Brown TT, et al. Clin Infect Dis. 2015;60:1242-1251. Slide credit: clinicaloptions.com
Recommendations for Evaluation of Bone
Disease in HIV

52. Calculating Fracture Risk: FRAX Tool
 Developed by WHO to evaluate fracture risk, based on cohort
study data from North America, Europe, Asia, Australia
 Integrates clinical risk factors (smoking status, alcohol
consumption, rheumatoid arthritis) as well as BMD at the
femoral neck, age, and sex
 Provides 10-yr probability of hip fracture and 10-yr probability of
major osteoporotic fracture (clinical fracture in spine, forearm,
hip, or shoulder)
 Online risk calculators and paper charts for white, black,
Hispanic, and Asian populations in the United States and for
other countries available at: http://www.shef.ac.uk/FRAX/
FRAX tool. http://www.shef.ac.uk/FRAX/ Slide credit: clinicaloptions.com

53. Slide credit: clinicaloptions.com
National Osteoporosis Foundation.
http://nof.org/files/nof/public/content/file/2791/upload/919.pdf

54. VA Study: FRAX Underestimated Fracture
Risk in HIV-Positive Men
 97% of HIV-positive men
with an actual fracture
would not have been
flagged for treatment
based on their FRAX
score
 Adding HIV infection as a
“secondary” cause of
osteoporosis increased
the accuracy of the score
Yin M, et al. CROI 2015. Abstract 141.
10-YrFractureIncidence(%)
Major
Osteopor. Fracture
HIV infected HIV uninfected
Observed
Estimated by
Modified FRAX
Hip
Fracture
Major
Osteopor. Fracture
Hip
Fracture
P < .0001
P < .0001
P < .0001
P = .0008
5
4
2
0
1
3
Slide credit: clinicaloptions.com

55. Secondary Causes of Low BMD
Conditions Lab Test
Vitamin D deficiency 25-hydroxyvitamin D
Hyperparathyroidism iPTH, Ca, PO4
Renal phosphate wasting in pts on
TDF
Fractional excretion of phosphate
Subclinical hyperthyroidism TSH
Hypogonadism Morning free testosterone,
menstrual history, FSH
Idiopathic hypercalciuria 24-hr urinary calcium
National Osteoporosis Foundation.
http://nof.org/files/nof/public/content/file/2791/upload/919.pdf
Slide credit: clinicaloptions.com

56. Case 2: Additional Management
 Calcium and vitamin D supplementation
 Weight-bearing exercise
 Fall risk assessment
 Bisphosphonate?
Slide credit: clinicaloptions.com

57. Case 2: Take-Home Points
 Low bone density is common in patients living with
HIV
 Traditional and HIV-related factors, including
antiretroviral therapy, can lead to bone density loss
 There are recommendations for bone density
screening for HIV-infected men and women
 DXA scanning and the FRAX calculator can be used
to assess bone health
 Secondary causes of low BMD should be sought and,
if found, addressed
Slide credit: clinicaloptions.com

58. Case 3: Patient With HIV/GT1a
HCV Coinfection

59. Case 3: Pt With HIV/GT1a HCV Coinfection
 SC is a 42-yr-old woman diagnosed with HIV and HCV
coinfection 8 mos ago
– Active IDU (oxymorphone, heroin)
– Current medications: ranitidine for GERD
 She was screened for HIV when a small HIV outbreak was
detected among IDU in her community
Slide credit: clinicaloptions.com
 HCV parameters at
diagnosis
– HCV genotype: 1a
– HCV RNA: 1.2 million IU/mL
 HIV parameters at
diagnosis
– HIV-1 RNA: 38,000
copies/mL
– CD4+ cell count: 592
cells/mm3
– HIV genotype: WT only virus

60. Case 3: Additional Laboratory Values
 Serum creatinine: 0.9 mg/dL (MDRD: > 60
mL/min/1.73m2
)
 AST: 98 IU/L; ALT: 123 IU/L; total bilirubin: 0.7 mg/dL
 Hct: 48%; platelets: 143,000/mm3
 Albumin: 3.7 g/dL
 HBsAb positive, HAV Ab positive
 FibroSure prediction: F3 fibrosis
Slide credit: clinicaloptions.com

61. Case 3: Current Presentation
 She has been receiving DRV/COBI + TDF/FTC for
6 mos
– HIV-1 RNA: < 40 copies/mL
– CD4+ cell count: 658 cells/mm3
 She is injecting less and only uses clean needles
provided by a local advocacy group. After counseling,
she is also now using condoms with her boyfriend
 She wants to start HCV therapy
Slide credit: clinicaloptions.com

62. Case 3: Issues for Discussion
 How best to manage SC’s HIV and HCV coinfection
‒ What HCV therapy should be prescribed?
‒ Does SC’s ART need to be modified?
 42-yr-old HIV/GT1a HCV–coinfected woman with suppressed HIV-1 RNA on
DRV/COBI + TDF/FTC
 F3 liver fibrosis
 HIV baseline GT WT, HBV immune
 HCV RNA: 1.2 million IU/mL
 Serum creatinine: 0.9 mg/dL (MDRD: > 60 mL/min/1.73m2
)
 Current substance abuse (heroin)
 Receiving ranitidine for GERD
Slide credit: clinicaloptions.com

63. NA-ACCORD (1996-2010): ESLD and
Modern ART in HIV/HCV Coinfection
 Risk for ESLD* in modern
ART era (adjusted IR [ref:
HIV monoinfection])
– HIV/HCV: 6.9
– HIV/HBV: 5.9
– HIV/HCV/HBV: 17.9
 No clear reduction in
ESLD risk over the 3 ART
eras
ESLD Incidence Rates
HIV
Incidence(per1000Person-Yrs)
HIV/HCV HIV/HBV HIV/HCV/
HBV
Early ART era (1996-2000, n = 10,395)
Middle ART era (2001-2005, n = 21,188)
Modern ART era (2006-2010, n = 22,472)
Klein MB, et al. CROI 2015. Abstract 638.
Infection
*ESLD as indicated by events such as ascites,
spontaneous bacterial peritonitis, bleeding varices,
encephalopathy, hepatoma
Slide credit: clinicaloptions.com
25
20
15
10
5
0

64. Trials of HCV Therapy in HIV/HCV-
Coinfected Patients
1. Naggie S, et al. N Engl J Med. 2015;373:705-713. 2. Sulkowski
MS, et al. JAMA. 2015;313:1223-1231. 3. Wyles DL, et al. N Engl J
Med. 2015;373:714-725. 4. Molina JM, et al. Lancet. 2015;385:1098-
1106. 5. Osinusi A, et al. JAMA. 2015;313:1232-1239.
Study Population HCV Regimens
SVR12,
%
ION-4[1]
N = 335; GT1 (98%) or 4 LDV/SOF 12 wks 96
TURQUOISE-I[2]
N = 63; GT1
OBV/PTV/RTV + DSV + RBV
12 wks
OBV/PTV/RTV + DSV + RBV
24 wks
94
91
ALLY-2[3] N = 151; GT1 (83%), 2, 3,
or 4
Tx-naive:
SOF + DCV 12 wks
SOF + DCV 8 wks
Tx-expd: SOF + DCV 12 wks
97
76
98
PHOTON-2[4]
N = 275; GT1, 2, 3, or 4 SOF + RBV 24 wks
GT1: 85
GT2: 88
GT3: 89
GT4: 84
NIH[5]
N = 50; GT1 LDV/SOF 12 wks 98
Slide credit: clinicaloptions.com

65. SMV + SOF SOF LDV/SOF DCV + SOF
OBV/PTV/RTV
+ DSV
Atazanavir + RTV Χ √ ≈ ≈ √
Darunavir + RTV Χ √ ≈ √ Χ
Lopinavir/RTV Χ √ ≈ √ Χ
Tipranavir + RTV Χ Χ Χ Χ Χ
Efavirenz Χ √ ≈ ≈ Χ
Rilpivirine √ √ √ √ Χ
Etravirine ≈ √ √ ≈ ≈
Raltegravir √ √ √ √ √
Elvitegravir + COBI Χ ≈ ≈ ≈ ≈
Dolutegravir √ √ √ √ √
Maraviroc √ √ √ √ ≈
Tenofovir DF √ √ ≈ √ √
AASLD/IDSA. HCV guidelines. December 2015.
No clinically significant
interaction expected
Potential interaction may require adjustment to
dosage, timing of administration, or monitoring
Do not coadminister
Slide credit: clinicaloptions.com
AASLD Guidance on HIV/HCV DDIs

66. Case 3: HCV Therapy Selection
 Given potential drug–drug interactions between HCV
and HIV therapies, you prescribe ledipasvir/sofosbuvir
 However, the state Medicaid board lists ombitasvir/
paritaprevir/ritonavir + dasabuvir + RBV as the
preferred regimen for GT1a HCV infection and denies
your request
Slide credit: clinicaloptions.com

67. Case 3 Management Question: If you decide not to appeal, how
would you manage SC’s ART regimen (DRV/COBI + TDF/FTC)
when treating her HCV infection with OBV/PTV/RTV + DSV +
RBV?
A. Stay on current regimen
B. Switch to EVG/COBI/TAF/FTC
C. Switch to DTG/ABC/3TC or DTG + TDF/FTC
D. Switch to DRV/COBI + ABC/3TC
E. Switch to RAL + TDF/FTC
F. Switch to RPV/TDF/FTC
G. Something else
Slide credit: clinicaloptions.com

68. Case 3 Management Question: If you appeal and win approval
for LDV/SOF, how would you manage SC’s ART regimen
(DRV/COBI + TDF/FTC) when treating her HCV infection with
LDV/SOF?
A. Stay on current regimen
B. Switch to EVG/COBI/TAF/FTC
C. Switch to DTG/ABC/3TC or DTG + TDF/FTC
D. Switch to DRV/COBI + ABC/3TC
E. Switch to RAL + TDF/FTC
F. Switch to RPV/TDF/FTC
G. Something else
Slide credit: clinicaloptions.com

69. AASLD Guidance on HCV/HIV DDIs:
LDV/SOF
 LDV increases TFV levels in patients receiving TDF
and increase is highest when LDV and TDF are used
in combination with RTV-boosted PIs
 Avoid combination of LDV and TDF if CrCl
< 60 mL/min or if receiving TDF with a boosted PI
 TFV levels increased with efavirenz, rilpivirine, or
dolutegravir when administered with LDV/SOF and
TDF
 When LDV/SOF is coadministered with TDF-
containing ART, monitor closely for nephrotoxicity
AASLD/IDSA. HCV guidelines. December 2015. Slide credit: clinicaloptions.com

70. No Relevant DDIs Between LDV/SOF and
E/C/F/TAF or R/F/TAF*
 2 multiple-dose phase I DDI studies in healthy volunteers
Custodio JM, et al. IDWeek 2015. Abstract 727.
GMR for AUC
(90% CI)
E/C/F/TAF +
LDV/SOF vs
E/C/F/TAF
R/F/TAF +
LDV/SOF vs
R/F/TAF
E/C/F/TAF +
LDV/SOF vs
LDV/SOF
R/F/TAF +
LDV/SOF vs
LDV/SOF
TAF 0.86 (0.78-0.95) 1.32 (1.25-1.40) NA NA
TDF 1.27 (1.23-1.31) 1.75 (1.69-1.81) NA NA
EVG 1.1 (1.0-1.2) NA NA NA
COBI 1.5 (1.5-1.6) NA NA NA
RPV NA 0.95 (0.91-0.98) NA NA
FTC 0.97 (0.93-1.00) 1.00 (0.98-1.02) NA NA
LDV NA NA 1.79 (1.63-1.96) 1.02 (0.97-1.06)
SOF NA NA 1.47 (1.35-1.59) 1.05 (1.01-1.09)
GS-331007 NA NA 1.48 (1.44-1.53) 1.08 (1.06-1.10)
Slide credit: clinicaloptions.com
*Note that RPV/FTC/TAF is not currently approved by the US FDA.

71. Other Important Drug–Drug Interactions:
Ledipasvir
 Acid-reducing agents: increased gastric pH
decreases concentration of ledipasvir
– Separate antacids (eg, aluminum and magnesium
hydroxide) by 4 hrs
– H2 blockers can be given at same time or 12 hrs apart
at doses equivalent to famotidine 40 mg BID or lower
– PPIs at doses equivalent to omeprazole 20 mg/day or
lower can be given simultaneously under fasted
conditions
LDV/SOF prescribing information, 2015. Slide credit: clinicaloptions.com

72. Ombitasvir/Paritaprevir/RTV + Dasabuvir:
Contraindicated Drugs
 Anticonvulsants:
carbamazepine,
phenytoin, phenobarbital
 Alfuzosin
 Gemfibrozil
 Rifampin
 Ergot derivatives
 Ethinyl estradiol–
containing products
 St John’s wort
 Lovastatin, simvastatin
 Pimozide
 Sildenafil (at PAH
doses)
 Triazolam
OBV/PTV/RTV + DSV [package insert]. Slide credit: clinicaloptions.com

73. 1. Sulkowski M, et al. JAMA. 2015;313:1223-1231. 2. DHHS Guidelines. April 2015.
3. AASLD/IDSA. HCV guidelines. December 2015.
Guidance on HCV/HIV DDIs:
OBV/PTV/RTV + DSV
 Phase III study of OBV/PTV/RTV + DSV + RBV in HCV/HIV
coinfection included pts with ATV or RAL only, pts with DRV
being evaluated in ongoing part 1b[1]
 Do not coadminister OBV/PTV/RTV with:[2]
– DRV (DRV Cmin decreases 43% to 48%)
– LPV (PTV AUC increases 117%)
– ATV/COBI, DRV/COBI, FPV, SQV, TPV, EFV, EVG (no data)
– RPV (RPV AUC increases 150% to 225%)
– ETR, NPV (DAA decrease possible)
 Adjust/withhold RTV if receiving a boosted PI with
OBV/PTV/RTV + DSV[3]
Slide credit: clinicaloptions.com

74. Case 3: Take-Home Points
 There has been an increase in injecting drug use in
the United States and with it transmission of HCV
 New direct-acting antiviral regimens for treating HCV
infection are potent but differ in their potential for
drug-drug interactions with antiretroviral agents and
other medications
 Treatment of HIV/HCV coinfection may require
consideration for the modification of HIV therapy
during HCV treatment
Slide credit: clinicaloptions.com

75. Go Online for More CCO
Coverage of HIV!
Additional slidesets on contemporary management of HIV with expert
faculty commentary
Postconference Clinical Updates available following CROI, the
International AIDS Conference, and IDWeek
clinicaloptions.com/hiv