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DHHS Revised Adult and Adolescent Guidelines 1/29/2008. Swati Modi, M.D.
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Swati Modi, M.D.
Faculty, Florida/Caribbean AETCAssistant Professor, University of Florida Center for HIV/AIDS Research, Education and Service (UF CARES), Pediatric Infectious Disease and Immunology, University of Florida College of Medicine, Jacksonville, Florida.
This speaker has no significant financial relationships with commercial entities to disclose.
This slide set has been peer-reviewed to ensure that there areno conflicts of interest represented in the presentation.
As a result of attending this 1 hour course on HIV/AIDS, the participant will be able to:
Recognize current recommendation of when to start HIV therapy
Recognize current DHHS guidelines regarding preferred and alternative Anti-retroviral therapy and be familiar with antiretrovirals which are not recommended
Recognize when an HIV regimen is failing
Identify indications for drug resistance testing
Be familiar with implications of treatment interruption in HIV therapy and identify acute HIV syndrome
Identify and locate the latest Department of Health and Human Service adult and adolescent guidelines to treat HIV
Decrease risk of HIV-associated complications
eg, TB, NHL, KS, peripheral neuropathy, HPV-associated malignancies, HIV-associated cognitive impairment
Decrease risk of nonopportunistic conditions and non-AIDS-associated conditions
eg, CV, renal, and liver disease; malignancies; infections
Decrease risk of HIV transmissionPotential Benefits of Early Therapy(CD4 count >350 cells/µL)
Drug resistance (attributable to ART failure)
Inadequate time to learn about HIV, treatment,and adherence
Increase in total time on ART; greater chance oftreatment fatigue
Current ART may be less effective or more toxicthan future therapies
Transmission of ARV-resistant virus, if incompletevirologic suppressionPotential Risks of Early Therapy(CD4 count >350 cells/µL)
Treat all (regardless of CD4 count):
Less metabolic toxicity (dyslipidemia, insulin resistance) than with some PIs
PI options preserved for future use
Low genetic barrier to resistance - single mutation
Cross-resistance among most NNRTIs
Rash, hepatotoxicity, neuropsychiatric side effects
Potential drug interactions (CYP450)Antiretroviral Components in Initial Therapy: NNRTIs
Higher genetic barrier to resistance
PI resistance uncommon with failure (boosted PI)
NNRTI options preserved for future use
Metabolic complications (fat maldistribution, dyslipidemia, insulin resistance)
Potential for drug interactions (CYP450), especially with ritonavirAntiretroviral Components in Initial Therapy: PIs
Established backbone of combination therapy
Minimal drug interactions
PI and NNRTI preserved for future use
Lactic acidosis and hepatic steatosis reported with most NRTIs (rare)
Triple NRTI regimens show inferior virologic response compared with efavirenz- and indinavir-based regimens*ARV Components in Initial Therapy: NRTIs
* Triple NRTI regimen of abacavir + lamivudine + zidovudine to be used only when a preferred or alternative NNRTI- or PI-based regimen cannot or should not be used as first-line therapy.
*Should not be given to pregnant women
Antiretroviral Regimens or Components That ShouldNot Be Offered At Any Time
When constructing an antiretroviral regimen for an HIV-infected pregnant woman, please consult “Public Health Service Task Force Recommendations for the Use of Antiretroviral Drugs in Pregnant HIV-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States” in http://www.aidsinfo.nih.gov/guidelines/.
When considering an antiretroviral regimen to use in post-exposure prophylaxis, please consult “Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis” in CDC MMWR Recommendations and Reports. September 30, 2005/54 (RR 09); 1–17 and “Management of Possible Sexual, Injection-Drug-Use, or Other Non-occupational Exposure to HIV, Including Considerations Related to Antiretroviral Therapy” in CDC MMWR Recommendations and Reports. January 21, 2005/54 (RR 02); 1–19.
Discontinuation of emtricitabine, lamivudine, or
tenofovir in patients with hepatitis B:
Myalgia or arthralgia
Nausea and vomiting
Neurological symptomsAcute Retroviral Syndrome: Common Signs and Symptoms
Decrease the severity of acute disease
Alter the viral “set point”
Reduce the rate of mutation by suppressing viral replication
Preserve immune function
Reduce risk of viral transmission
Earlier emergence of drug resistance
Limitation of future treatment options
Potential need for indefinite treatment
Adverse effects on quality of lifeAcute HIV Infection: Treatment