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  • Currently Available Antiretroviral Medications There are three classes of antiretroviral drugs available; two of them—the NRTIs and the NNRTIs—target HIV’s reverse transcriptase enzyme; the third—the PIs—target the protease enzyme.
  • The decision to begin therapy for the asymptomatic patient is complex and must be made in the setting of careful patient counseling and education. Considerations of initiating antiretroviral therapy should be primarily based on the prognosis of disease-free survival as determined by baseline CD4 + T cell count [27-29] ( Figure A ; and Table 3a, 3b ) . Also important are baseline viral load [27-29] , readiness of the patient to begin therapy; and assessment of potential benefits and risks of initiating therapy for asymptomatic persons, including short-and long-term adverse drug effects; the likelihood, after counseling and education, of adherence to the prescribed treatment regimen. Recommendations vary according to the CD4 count and viral load of the patient, as follows. <200 CD4 + T cell count, with AIDS-defining illness, or symptomatic. Randomized clinical trials provide strong evidence of improved survival and reduced disease progression by treating symptomatic patients and patients with <200 CD4 + T cells/mm 3 [30-33]. Observational cohorts indicate a strong relationship between lower CD4 + T cell counts and higher plasma HIV RNA levels in terms of risk for progression to AIDS for untreated persons and antiretroviral naïve patients beginning treatment. These data provide strong support for the conclusion that therapy should be initiated in patients with CD4 + T cell count <200 cells/mm 3 ( Figures A and Table 3a ) (AI) [27, 28]. 200-350 CD4 + T cell count, patient asymptomatic. The optimal time to initiate antiretroviral therapy among asymptomatic patients with CD4 + T cell counts >200 cells/mm 3 is unknown. For these patients, the strength of the recommendation for therapy must balance other considerations, such as patient readiness for treatment and potential drug toxicities. After considering available data in terms of the relative risk for progression to AIDS at certain CD4 + T cell counts and viral loads, and the potential risks and benefits associated with initiating therapy, most specialists in this area believe that the evidence supports initiating therapy in asymptomatic HIV-infected persons with a CD4 + T cell count of 200-350 cells/mm 3 (BII) . There is a paucity of data from randomized, controlled trials concerning clinical endpoints (e.g., the development of AIDS-defining illnesses or death) for asymptomatic persons with >200 CD4 + T cells/mm 3 to guide decisions on when to initiate therapy. Observational data from cohorts of HIV-infected persons provide some guidance to assist in risk assessment for disease progression. … . While there are clear strengths to these observational data, there are also important limitations. Uncontrolled confounding factors could impact estimates in both studies. Furthermore, neither study provides direct evidence on the optimum CD4 + T cell count to begin therapy. Such data will have to come from studies that follow patients who start therapy at different CD4 + T-cell counts above 200 cells/mm 3 and compare them with a similar group of patients (e.g., with similar CD4 + T cell count and HIV RNA level) who defer treatment. To completely balance the benefits and risks of therapy, follow-up will have to examine progression to AIDS, major toxicities, and death. >350 CD4 + T cell count, patient asymptomatic. There is little evidence on the benefit of initiating therapy in asymptomatic patients with CD4 + T cell count > 350 cells/mm 3 . Most clinicians would defer therapy. • The deferred treatment approach is based on the recognition that robust immune reconstitution still occurs in the majority of patients who initiate treatment while CD4 + T cell counts are in the 200–350 cells/mm 3 range. Also, toxicity risks and adherence challenges generally outweigh the benefits of initiating therapy at CD4 + T cell counts >350 cells/mm 3 . In the deferred treatment approach, increased levels of plasma HIV RNA (i.e., >100,000 copies/mL) are an indication for monitoring of CD4 + T cell counts and plasma HIV RNA levels at least every three months, but not necessarily for initiation of therapy. For patients with HIV RNA <100,000 copies/mL, therapy should be deferred (DII) . • In the early treatment approach, asymptomatic patients with CD4 + T cell counts >350 cells/mm 3 and levels of plasma HIV RNA >100,000 copies/mL would be treated because of the risk for immunologic deterioration and disease progression (CII) . An estimate of the short term risk of AIDS progression may be useful in guiding clinicians and patients as they weigh the risks and benefits of initiating versus deferring therapy in this CD4 cell range. As cited above, Table 3b provides an analysis of data from the CASCADE Collaboration, demonstrating the risk of AIDS progression within 6 months for different strata of CD4 + T cell count, viral load, and age. As seen in Table 3b , a 55 year old with a CD4 + T cell count of 350 and a HIV viral load of 300,000 copies/ml has a 5% chance of progression in 6 months, compared with a 1.2% chance for a similar patient with a viral load of 3000 copies/mL.
  • Antiretroviral Regimens Not Recommended Monotherapy (EII). Single antiretroviral drug therapy does not demonstrate potent and sustained antiviral activity and should not be used. The rare exception, though controversial, is the use of zidovudine monotherapy to prevent perinatal HIV-1 transmission in a woman who does not meet clinical, immunologic, or virologic criteria for initiation of therapy and who has an HIV RNA <1,000 copies/mL [96, 97] (DIII) . Most clinicians, however, prefer to use a combination regimen in the pregnant woman for the management of both the mother’s HIV infection and in the prevention of perinatal transmission. Dual nucleoside regimens (DII). These regimens are not recommended because they have not demonstrated potent and sustained antiviral activity as compared to three-drug combination regimens [98]. For patients previously initiated on this treatment who have achieved sustained viral suppression, it is reasonable to continue on this therapy or to add a PI or NNRTI to this regimen (DIII) . If the patient is to stay on a 2-NRTI regimen, the plan should be to change to a three or more drug combination if viral rebound occurs. (See Managing the Treatment Experienced Patient: Assessment of Antiretroviral Treatment Failure and Changing Therapy .) 3-NRTI regimen of abacavir + tenofovir + lamivudine (EII). In a randomized trial for treatment naïve patients, those randomized to a regimen consisting of abacavir + tenofovir + lamivudine had a significantly higher rate of “early virologic nonresponse” when compared to patients treated with efavirenz + abacavir + lamivudine [55] . This combination should not be used as a 3-NRTI regimen in any patient. 3-NRTI regimen of didanosine + tenofovir + lamivudine (EII). In a small pilot study, a high rate (91%) of virologic failure (defined as <2 log reduction of HIV-RNA by week 12) was seen in treatment-naïve patients initiated on this 3-NRTI regimen [84]. This combination should not be used as a 3-NRTI regimen in any patient. The Panel DOES NOT RECOMMEND the use of the following 3-NRTI regimens as sole antiretroviral combination at any time: • abacavir + tenofovir + lamivudine (EII) • didanosine + tenofovir + lamivudine (EII)
  • Didanosine + stavudine (EII). The combined use of didanosine and stavudine as a 2-NRTI backbone can result in a high incidence of toxicities, particularly peripheral neuropathy, pancreatitis, and lactic acidosis [50, 87, 99] .This combination has been implicated in several deaths in HIV-1 infected pregnant women secondary to severe lactic acidosis with or without hepatic steatosis and pancreatitis [100] . In general, a combination containing didanosine and stavudine should be avoided unless other 2-NRTI combinations have failed or have caused unacceptable toxicities, and where potential benefits outweigh the risks of toxicities (DIII) . Stavudine + zidovudine (EII). Combination regimens containing these two NRTIs should be avoided due to the demonstration of antagonism in vitro [103] and in vivo [104] . Emtricitabine + lamivudine (EIII). Both of these drugs have similar resistance profiles and have minimal additive antiviral activity. Didanosine + zalcitabine or stavudine + zalcitabine (EII). These combinations are contraindicated due to increased rates and severity of peripheral neuropathy [101, 102] . Lamivudine + zalcitabine (EII). In vitro data showed that these two agents may inhibit intracellular phosphorylation of one another, resulting in decreased triphosphate concentration and antiretroviral activities.
  • Efavirenz in first trimester of pregnancy and women with significant childbearing potential (EIII). Efavirenz use was associated with significant teratogenic effects in primates at drug exposures similar to those representing human exposure. Several cases of congenital anomalies have been reported after early human gestational exposure to efavirenz [57, 58] . Efavirenz should be avoided in pregnancy, particularly during the first trimester, and in women who are trying to conceive or who are not using effective and consistent contraception. If no other antiretroviral options are available in the woman who is pregnant or at risk for becoming pregnant, consultation should be obtained with a clinician who has expertise in both HIV and pregnancy. Nevirapine . Higher incidence of hepatotoxicity than with other NNRTIs, including serious and even fatal cases of hepatic necrosis • Female patients and patients with high pre-NVP CD4+ T cell counts (>250 cells/mm3 in females & >400 cells/mm3 in males) are at a higher risk of symptomatic hepatic events. NVP is not recommended in these patients unless the benefit clearly outweighs the risk.
  • Abacavir hypersensitivity reaction can be fatal-fever, rash, nausea, vomiting, malaise or fatigue and loss of appetite. Abacavir should be stopped immediately if hypersensitivity reaction is suspected. Abacavir should ot be re-started, because more severe symptoms will recur within hours and may include life-threatening hypotension and death. Cases of abacavir hypersensitivity syyndrome should be reported to the Abacavir Hypersensity Registry at 1-800-270-0425. Cases of fatal and nonfatal pancreatitis have occurred in treatment-naïve and treatment-experienced patients during therapy with ddI or in combination with other drugs, particularly d4T or d4T + hydroxyurea.
  • In clinical trials, NNRTIs were discontinued because of rash in 7% of patients taking nevirapine, 4.3% of patients taking delavirdine, and 1.7% of patients taking efavirenz. Rare cases of Stevens-Johnson Syndrome have been reported with the use of all three NNRTIs. CNS symptoms may include dizziness, somnolence, insomnia, abnormal dreams, confusion, abnormal thinking, impaired concentration, amnesia, agitation, depersonalization, hallucinations, and euphoria, The overall frequency of any of these symptoms associated with the use of efavirenz was 52% compared with 26% in controls. 2.6% of those on efavirenz discontinued the drug due to these symptoms.
  • Cases of worsening glycemic control in patients with pre-existing diabetes, and cases for new-onset diabetes including diabetic ketoacidosis have been reported with the use of all protease inhibitors. Fat redistribution and lipid abnormalities have been increasingly recognized with the use of protease inhibitors. Discontinuation of PIs may be required to reverse fat redistribution. Patients with hypertriglyceridemia or hypercholesterolemia should be evaluated for risks for cardiovascular events and pancreatitis. Possible interventions include dietary modification, lipid lowering agents, or discontinuation of PIs.
  • AIDS PPT. www.medicotesting.com

    1. 1. A Wanchu, MD, DM, MAMS Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh Antiretroviral Therapy: Current Status
    2. 2. Course of HIV infection
    3. 3. Aim of Antiretroviral Therapy
    4. 4. Potential targets RT Provirus Proteins RNA DNA RNA DNA DNA RT Viral regulatory proteins Viral protease Reverse transcriptase Viral integrase RNA RNA Binding, fusion and entry DNA DNA DNA
    5. 5. Currently Available Antiretroviral Medications <ul><li>Abacavir (ABC) </li></ul><ul><li>Didanosine (ddI) </li></ul><ul><li>Lamivudine (3TC) </li></ul><ul><li>Stavudine (d4T) </li></ul><ul><li>Zalcitabine (ddC) </li></ul><ul><li>Zidovudine (ZDV) </li></ul><ul><li>Emtricitabine (FTC) </li></ul><ul><li>Tenofovir (TDF) </li></ul>Delavirdine (DLV) Efavirenz (EFV) Nevirapine(NVP) Indinavir (IDV) Enfuvirtide (T-20) Nelfinavir (NFV) Ritonavir (RTV) Saquinavir (SQV) Amprenavir (APV) Lopinavir/ritonavir (LPVr) Atazanavir (ATV) FOS APV (FAPV) NNRTIs PIs Entry Inh NRTIs
    6. 6. When To Begin - Consensus? <ul><li>Patient committed and ready, and one or more.. </li></ul><ul><li>High viral load -- increasingly controversial </li></ul><ul><li>CD4 < 350 cells/mm 3 -- increasing consensus </li></ul><ul><li>Symptomatic HIV disease </li></ul><ul><li>Acute and very early HIV infection - duration of therapy unclear, however </li></ul><ul><li>Pregnancy </li></ul>
    7. 7. When Not To Begin <ul><li>Patient not committed </li></ul><ul><li>Patient unable to adhere to any regimen </li></ul><ul><ul><li>Cost of medication; access to refills; lifestyle barriers; psychosocial issues; side effects </li></ul></ul><ul><li>? During acute OI </li></ul><ul><li>Antiretroviral therapy is a LONG TERM commitment. Do not start it in a hospitalized patient unless there is commitment from the patient about future supplies </li></ul>
    8. 8. How to evaluate and start CD4< 200 CD4> 200 Follow up only Absolute lymphocyte count (or CD4) > 1200 (or CD4>200) < 1200 (or CD4<200) Start ARV Start ARV Follow up only All HIV positive patients Symptomatic Asymptomatic CD4 available CD4 not available WHO stage IV WHO stage II, III
    9. 9. WHO recommendations <ul><li>In resource restricted settings, adults and adolescents satisfying any of the following criteria can be offered therapy </li></ul><ul><ul><li>WHO stage IV (clinical AIDS), irrespective of CD4 </li></ul></ul><ul><ul><li>WHO stage I, II or III, if the CD4 is less than 200 </li></ul></ul><ul><ul><li>WHO stage II or III and an absolute lymphocyte count of less than 1200 </li></ul></ul>
    10. 10. WHO’s recommended second line regimens in adults and adolescents for treatment failure on first line ARV regimen (WHO 2003) TDF or ABC + ddI + LVP/r or SQV/r D4T or ZDV + 3TC + NVP or EV Second-line regimen First-line regimen
    11. 11. Indications for Initiation of Therapy: Chronic Infection Treatment should be offered, with consideration of pros and cons Any value >200 cells/µL but <350 cells/µL Asymptomatic Treat Any value <200 cells/µL Asymptomatic, AIDS Treat Any value Any value Symptomatic (AIDS, severe symptoms) Recommendation Plasma HIV RNA CD4 + T Cell Count Clinical Category
    12. 12. Indications for Initiation of Therapy: Chronic Infection Defer therapy <100,000 copies/mL CD4 + T cells >350 cells/µL Asymptomatic Most clinicians recommend deferring therapy; some will treat >100,000 copies/mL >350 cells/µL Asymptomatic Recommendation Plasma HIV RNA CD4 + T Cell Count Clinical Category
    13. 13. Antiretroviral Medications: Should not be offered at any time <ul><li>Regimens not recommended: </li></ul><ul><ul><li>Monotherapy (except possibly in prevention of perinatal HIV transmission) </li></ul></ul><ul><ul><li>Dual NRTI therapy </li></ul></ul><ul><ul><li>3-NRTI regimen of abacavir + tenofovir + lamivudine </li></ul></ul><ul><ul><li>3-NRTI regimen of didanosine + tenofovir + lamivudine </li></ul></ul>
    14. 14. Antiretroviral Medications: Not offered at any time <ul><li>Antiretroviral components not recommended: </li></ul><ul><ul><li>Didanosine + stavudine </li></ul></ul><ul><ul><li>Stavudine + zidovudine </li></ul></ul><ul><ul><li>Emtricitabine + lamivudine </li></ul></ul><ul><ul><li>Zalcitabine + stavudine; zalcitabine + didanosine; zalcitabine + lamivudine </li></ul></ul>
    15. 15. Antiretroviral Medications: Not offered at any time <ul><li>Antiretroviral components not recommended: </li></ul><ul><ul><li>Efavirenz in pregnancy and in women with high potential for pregnancy* </li></ul></ul><ul><ul><li>Nevirapine initiation in women with CD4 >250 cells/mm3 or men with CD4 >400 cells/mm3 </li></ul></ul>* Women with high pregnancy potential are those who are trying to conceive or who are not using effective and consistent contraception.
    16. 16. Characteristics of Nucleoside Reverse Transcriptase Inhibitors (NRTI’s)- I Zidovudine (AZT)   Didanosine (ddI)   Zalcitabine (ddC)   Dose 200 mg tid or 300 mg bid or with 3TC, 1 bid >60kg: 200 mg bid; 60kg: 125mg bid 0.75 mg tid Food No effect Levels No effect Adverse Events BM suppression: Anemia and/or neutropenia GI upset, headache, insomnia, asthenia   Pancreatitis Peripheral neuropathy nausea diarrhea   Peripheral neuropathy Stomatitis  
    17. 17. Characteristics of Nucleoside Reverse Transcriptase Inhibitors (NRTI’s)- I Zidovudine (AZT)   Didanosine (ddI)   Zalcitabine (ddC)   Dose 200 mg tid or 300 mg bid or with 3TC, 1 bid >60kg: 200 mg bid; 60kg: 125mg bid 0.75 mg tid Food No effect Levels No effect Adverse Events BM suppression: Anemia and/or neutropenia GI upset, headache, insomnia, asthenia   Pancreatitis Peripheral neuropathy nausea diarrhea   Peripheral neuropathy Stomatitis  
    18. 18. Characteristics of NRTI’s – II Stavudine (d4T)   Lamivudine (3TC)   Abacavir (ABC)   Dose >60 kg: 40 mg bid; < 60 kg: 30 mg bid 150 mg bid or with ZDV bid 300mg bid or with ZDV + 3TC bid Food No effect No effect No effect Adverse Events Pancreatitis Peripheral neuropathy   Minimal   Hypersensitivity (can be fatal);fever, rash, nausea, vomit, malaise/fatigue, loss of appetite Resp. symp. (sore throat, cough, SOB)
    19. 19. Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)   Nevirapine   Delavirdine   Efavirenz   Dosing 200 mg po qd x 14 days, then 200 mg po bid 400 mg po tid or four 100 mg tab in > 3 oz water Separate dosing with ddI or antacids by 1 hr 600 mg po HS Food Effects No regards to meals No regards to meals Avoid after high fat meals Adverse Events Rash Rash Rash CNS symptoms
    20. 20. Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)   Nevirapine   Delavirdine   Efavirenz   Dosing 200 mg po qd x 14 days, then 200 mg po bid 400 mg po tid or four 100 mg tab in > 3 oz water Separate dosing with ddI or antacids by 1 hr 600 mg po HS Food Effects No regards to meals No regards to meals Avoid after high fat meals Adverse Events Rash Rash Rash CNS symptoms
    21. 21. Protease Inhibitors - I Fat redistribution, lipid abnormalities and hyperglycemia are common to all   Name Indinavir Ritonavir Nelfinavir Dose 800 mg q8h. Separate dosing with ddI by 1 hr 600 mg q 12h. Separate dosing with ddI by 2 hrs 750 mg tid or 1250 mg bid Food Levels  77%. Take 1 hr before or 2 hrs after meals with skim milk/ low fat meal Levels  15%. Take with food if possible, may improve tolerability Levels  2-3 fold. With meal/ snack Side Effects Nephrolithiasis GI intolerance, nausea  indirect bilirubinemia Headache, asthenia, blurred vision, dizziness, rash, metallic taste, thrombocytopenia.   GI intolerance, nausea, vomiting, diarrhea Paresthesias - circumoral, extremities. Hepatitis. Pancreatitis. Asthenia. Taste perversion.  CPK & uric acid. transaminases  , Triglycerides  >200%. Diarrhea    
    22. 22. Protease Inhibitors - II GI intolerance, fat redistribution, lipid abnormalities & hyperglycemia are common Name Saquinavir Amprenavir Lopinavir + Ritonavir Dosing 1200 mg TID >50 kg: 1200 mg bid. <50 kg: 20mg/kg bid. Max. 2400 mg d 400 mg lopinavir + 100 mg ritnonavir bid Food Effect Levels  6-fold with large meal High fat meal  AUC 21%; with or without food Mod. fat meal  AUC by 48%. Take with food. Side Effects Nausea, diarrhea, abd. pain, dyspepsia Headache  transaminases Nausea, vomiting, diarrhea. Rash Oral paresthesias.  liver function tests Nausea, vomiting, diarrhea. Asthenia  transaminases    
    23. 23. Protease Inhibitors - II GI intolerance, fat redistribution, lipid abnormalities & hyperglycemia are common Name Saquinavir Amprenavir Lopinavir + Ritonavir Dosing 1200 mg TID >50 kg: 1200 mg bid. <50 kg: 20mg/kg bid. Max. 2400 mg d 400 mg lopinavir + 100 mg ritnonavir bid Food Effect Levels  6-fold with large meal High fat meal  AUC 21%; with or without food Mod. fat meal  AUC by 48%. Take with food. Side Effects Nausea, diarrhea, abd. pain, dyspepsia Headache  transaminases Nausea, vomiting, diarrhea. Rash Oral paresthesias.  liver function tests Nausea, vomiting, diarrhea. Asthenia  transaminases    
    24. 24. Adverse Effects: NRTIs <ul><li>Abacavir - hypersensitivity reaction, lactic acidosis (LA) </li></ul><ul><li>Didanosine - GI intolerance, pancreatitis, peripheral neuropathy (PN), LA </li></ul><ul><li>Stavudine - PN, LA, pancreatitis </li></ul><ul><li>Tenofovir - HA, GI </li></ul><ul><li>Zalcitabine - PN, LA </li></ul><ul><li>Zidovudine - HA, GI, LA, bone marrow suppression </li></ul><ul><li>Pregnant women may be at increased risk for lactic acidosis and liver damage when treated with the combination of stavudine and didanosine. This combination should be used in pregnant women only when the potential benefit clearly outweighs the potential risk. </li></ul>
    25. 25. Adverse Effects: NNRTIs <ul><li>Nevirapine - rash, hepatitis </li></ul><ul><li>Efavirenz – rash, CNS, teratogenic in primates </li></ul>
    26. 26. Adverse Effects: PIs <ul><li>Indinavir – nephrolithiasis, GI intolerance </li></ul><ul><li>Ritonavir - GI intolerance, hepatitis </li></ul><ul><li>Nelfinavir - diarrhea </li></ul><ul><li>Amprenavir - GI intolerance </li></ul><ul><li>Lopinavir + Ritonavir – GI intolerance </li></ul><ul><li>All PIs: </li></ul><ul><ul><li>Insulin resistance and diabetes </li></ul></ul><ul><ul><li>Fat redistribution </li></ul></ul><ul><ul><li>Hyperlipidemia </li></ul></ul>
    27. 27. ADR at PGIMER <ul><li>300 </li></ul><ul><li>37.6 + 8.3 yrs </li></ul><ul><li>211:89 </li></ul><ul><li>8 months </li></ul><ul><li>187 </li></ul><ul><li>59 </li></ul><ul><li>112 </li></ul><ul><li>127 </li></ul><ul><li>3 </li></ul><ul><li>Number </li></ul><ul><li>Age </li></ul><ul><li>Sex (males: females) </li></ul><ul><li>Median follow up </li></ul><ul><li>Past OI’s </li></ul><ul><li>WHO Class </li></ul><ul><ul><li>I </li></ul></ul><ul><ul><li>II </li></ul></ul><ul><ul><li>III </li></ul></ul><ul><ul><li>IV </li></ul></ul>
    28. 28. ADR at PGIMER <ul><li>Median CD4 count </li></ul><ul><li>Mean Hb </li></ul><ul><li>Mean ESR </li></ul><ul><li>Nevirapine based regimen </li></ul><ul><li>Efavirenz based therapy </li></ul><ul><li>141/ul </li></ul><ul><li>12.2 + 2.3 g/dl </li></ul><ul><li>38 + 22.2 mm 1 st hr </li></ul><ul><li>235 </li></ul><ul><li>65 </li></ul>
    29. 29. ADR at PGIMER <ul><li>Change > 1drug from the previous regimen </li></ul><ul><ul><li>47 (15.5%) </li></ul></ul><ul><li>Causes </li></ul><ul><ul><li>Lipodystrophy 15 </li></ul></ul><ul><ul><li>Skin rash 10 (one SJS) </li></ul></ul><ul><ul><li>Anemia 7 </li></ul></ul><ul><ul><li>Peripheral neuropathy 6 </li></ul></ul><ul><ul><li>TB soon after starting Rx 3 </li></ul></ul><ul><ul><li>Severe dizziness 2 </li></ul></ul><ul><ul><li>Severe headache 2 </li></ul></ul><ul><ul><li>Excessive vomiting 1 </li></ul></ul>
    30. 30. ADR at PGIMER <ul><li>Nevirapine based </li></ul><ul><ul><li>Rash 15 </li></ul></ul><ul><ul><li>Peripheral neuropathy 6 </li></ul></ul><ul><ul><li>Muscle pains 5 </li></ul></ul><ul><li>Efavirenz based </li></ul><ul><ul><li>Headache 5 </li></ul></ul><ul><ul><li>Skin & nail pigmentation 6 </li></ul></ul><ul><ul><li>Mild deranged LFT 1 </li></ul></ul>Current ADR (12.6%)
    31. 31. HAART - Long Term Concerns <ul><li>Long term risk of toxicity </li></ul><ul><ul><li>described </li></ul></ul><ul><ul><li>not yet described </li></ul></ul><ul><li>Durability of suppression unknown </li></ul><ul><li>Current options are limited </li></ul><ul><li>Future options uncertain </li></ul><ul><li>Adverse effects difficult to predict </li></ul><ul><li>Adherence difficult to predict </li></ul><ul><li>Response in any individual difficult to predict </li></ul><ul><li>Criteria for when to change, how to sequence ARV Rx inadequately characterized </li></ul>
    32. 32. Treatment Failure and Drug Resistance CD4 Count Viral Load Virologic failure Immunologic failure Clinical failure Drug Resistance
    33. 33. When to Switch: First HAART <ul><li>There are few data that provide the optimal point (e.g., any detectable viral load, > 500 copies/mL, > 1000 copies/mL) at which therapy should be changed . . . . the major short-term risk of any level of viral replication in the presence of antiretroviral therapy is emergence of resistance. </li></ul>
    34. 34. Treatment-Experienced Patients: Treatment Regimen Failure <ul><li>Virologic failure: </li></ul><ul><ul><li>HIV RNA >400 copies/mL after 24 wks, >50 after 48 wks, or >400 after viral suppression </li></ul></ul><ul><li>Immunologic failure: </li></ul><ul><ul><li>CD4 increase of less than 25-50 cells/mm 3 in first year of therapy </li></ul></ul><ul><li>Clinical failure: </li></ul><ul><ul><li>occurrence of HIV-related events (after >3 months on therapy; excludes immune reconstitution syndromes) </li></ul></ul>
    35. 35. Changing Therapy: Considerations for Toxicity <ul><li>For toxicity known to be due to single agent, single agent substitution </li></ul><ul><li>For toxicity that can’t be ascribed to single drug that is severe enough to warrant discontinuation, all agents should be stopped; introduce new regimen after resolution of toxicity </li></ul><ul><ul><li>Staggered discontinuation of drugs with different half-lives should be considered to avert resistance; but clinical relevance unknown </li></ul></ul>
    36. 36. Changing Therapy: Considerations for Toxicity (cont’d) <ul><li>For PI-associated lipid abnormalities, manage abnormalities if benefit of maintaining PI outweighs risk of changing </li></ul><ul><ul><li>If drug-susceptible virus at baseline, switch to NNRTI can be considered </li></ul></ul><ul><li>For fat maldistribution syndromes, early switching of responsible drug(s) is recommended if drug options exist </li></ul>
    37. 37. Changing Therapy: Considerations for Treatment Failure—First Regimen Failure <ul><li>Adherence, adherence, adherence </li></ul><ul><li>First regimen failure </li></ul><ul><ul><li>Resistance testing for plasma viral load >500 to 1000 HIV RNA copies/mL </li></ul></ul><ul><ul><li>Alter regimen if resistance is documented </li></ul></ul><ul><ul><li>Target for new therapy is <50 copies/mL (below detection) </li></ul></ul>
    38. 38. Adherence in the Chandigarh Cohort Characteristics of patients totally adherent & those who missed > 1at least one dose in the preceding 4 wks AIDS and Behavior (in press) Men Women Number who missed >1 dose 147 53 Age, yrs 40.4 + 8.1 36.6 + 6.6 Regimen Nevirapine based 39 43 Efavirenz based 104 10 Source of funding Self 73 31 State 74 22
    39. 39. Adherence in the Chandigarh Cohort Reasons for non-adherence among 53 patients AIDS and Behavior (in press) 2 (12.5%) 3 (8.1%) Too toxic 3 (18.8%) 2 (5.4%) Too many pills 0 (0%) 6 (16.2%) Away from home 1 (6.3%) 7 (18.9%) Ran out of drugs 3 (18.8%) 9 (24.3%) Forgot 7 (43.7%) 10 (27.0%) Financial constraints Women (16) Men (37) Reason
    40. 40. Conclusions: Multiple HAART Failure <ul><li>Disease progression is delayed in presence of MDR vs. wild-type HIV </li></ul><ul><ul><li>Mechanism not clear </li></ul></ul><ul><li>Strategies that select for viruses with reduced “fitness” may result in lower viral loads and delayed progression </li></ul><ul><ul><li>3TC, tenofovir, most protease inhibitors </li></ul></ul><ul><li>Fitness and “pathogenicity” are unique phenomena </li></ul><ul><ul><li>Are protease inhibitors required to achieve durable clinical benefit if face of MDR? </li></ul></ul><ul><ul><li>Will disease stage/co-infections impact on this? </li></ul></ul>
    41. 41. Monitoring Antiretroviral Therapy <ul><li>“ Blips” in viral load are not a reason to change drugs </li></ul><ul><li>If adverse effect on effective suppressing regimen, may change only one drug to address effect. </li></ul><ul><li>If change regimens due to failure, use at least 2 new drugs. </li></ul><ul><li>If need to stop, stop all drugs </li></ul><ul><li>Assure access to refills, communication so don’t interrupt therapy -- adherence/compliance is key </li></ul>
    42. 42. Problems with therapy <ul><li>Optimum duration? </li></ul><ul><li>Regimens are complex & may involve intake of more than 10 pills/day </li></ul><ul><li>Cost of currently available drugs + cost of lab tests </li></ul><ul><li>IRIS </li></ul><ul><li>Drug resistance </li></ul>
    43. 43. 3X5 31st Dec ‘05 60 centers & 21,318 patients on ART 0 50K 100K 150K 200K 250K 300K 350K 400K 450K 500K South Africa India Nigeria Zimbabwe Brazil Tanzania Ethiopia Kenya Mozambique Republic of Congo Zambia Malawi Thailand Uganda Côte d'Ivoire Cameroon Russian Federation Botswana China Sudan 20 countries with the highest ARV need As of June 2004 June to December 2004 January to June 2005 People still needing treatment to reach &quot;3 by 5&quot; target People receiving ARV therapy TARGET MET TARGET MET TARGET MET
    44. 44. Conclusions <ul><li>ART remains a rapidly evolving and challenging area of medicine </li></ul><ul><li>The field will continue to evolve with additional insights into pathogenesis and new drug development </li></ul><ul><li>New agents in existing classes and in new classes (eg, CCR5 inhibitors, integrase inhibitors, maturation inhibitors) that have reached clinical testing provide hope that new treatment options will be available in the next few years </li></ul>

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