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HIV and AIDS management in Italy: critical issues

HIV and AIDS management in Italy: critical issues . 1. Late and AIDS presenters 2. Costs-effectiveness management 3. Antiretroviral long term toxicties 4. HCV- and HBV-coinfections 5. Non AIDS-defining malignancies. 1. Late and AIDS presenters in Italy.

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HIV and AIDS management in Italy: critical issues

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  1. HIV and AIDS management in Italy:critical issues • 1. Late and AIDS presenters • 2. Costs-effectiveness management • 3. Antiretroviral long term toxicties • 4. HCV- and HBV-coinfections • 5. Non AIDS-defining malignancies

  2. 1. Late and AIDS presenters in Italy • According to recent surveys, more or less one third of HIV diagnosis involve subjects with CD4 cell counts lower than 200 cells/mL • 20% of HIV diagnosis are performed in the setting of an opportunistic infection • Age, male gender and not Caucasian ethnicity are often associated with a later presentation of HIV infection Borghi V, J Acquir Immune DeficSyndr 2008

  3. AIDS presenters: clinicaloutcome • Possible normalization of CD4 cell count still with low baseline counts (Mocroft, Lancet, 2007) • Slower immunoreconstitution if low baseline counts (Kaufmann, Clin Infect Dis 2005) • Among AIDS presenter idividuals mortality rate are significant also in the HAART era Mussini C, Manzardo C, Johnson M, et al. Patients presenting with AIDS in the HAART era: a collaborative cohort analysis. AIDS 2008; 22: 2461-2469

  4. 2. Costs-effectivenessmanagement in Italy E.G.: Lumbardy region “Piano diagnostico-terapeutico” “If there are several ARV regimens which are expected to have similar outcomes, choose the cheapest one” “Changes to more expensive regimens are advisable only in case of severe toxicities”

  5. Case presentation (November2010) • Male patient, 61 years-old; hypertension in therapy; good health until three weeks before Access toEmergencyDepartmentfor: fever and a progressive alteration of consciousness • Notanydeficit at the phisicalexamination (noteven rigor nucalis) • Increase of C reactive protein and of the eritrocite sedimentation rate with a slight anaemia • HIV-ELISA positive, a tuberculin intra-dermal reaction positive (5 UI, 48 hours) • CD4+71 cells/mL, HIV-RNA 418,130 copies/mL (homosexualriskfactor) • Lumbar puncture: 20 white blood cells (lymphocytes), low glucose and high protein • Ziehl-Neelsen coloration for mycobacteria and other opportunistic agents were negative A therapy for a Tuberculosis meningitis was begun PCR for Mycobacterium tuberculosis resulted to be positive

  6. Therapy and immuno-virologicaloutcome ETHAMBUTOL 800 6 PYRAZINAMIDE ISONIAZIDE RIFAMPICIN 700 5 600 L) 500 4 HIV-RNA (Log copies/mL) CD4 (cells/m 400 3 300 200 2 100 AZT TDF + FTC + EFV ABC + 3TC + RAL 0 1 nov-10 jan-11 feb-11 apr-11 jun-11 ago-11 oct-11 feb-11 jun-11 oct-11 CD4 HIV-RNA 935 euros/month 919 euros/month 653 euros/month

  7. During the followup… (November2012) PresentationofRECURRENT SCOTOMA • Normal physical examination and blood analysis • Normal funduscopic examination and visual acuity • Normal blood pressure Several frontal lesions with hypercaptation of contrast significant for perilesional oedema Cerebral biopsy: granulomatousgyganto-cellular meningo-encephalitis with necrosis, probable IRIS/TB: anti-TB tretment reintroduced, stillongoing

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