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A Look Back at the International AIDS Conference Meeting Lessons from IAC 2010 A Clinical Context Report. Jointly Sponsored by: and MedPage Today. A Look Back at the International AIDS Conference Meeting—Lessons from IAC 2010.

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  1. A Look Back at the International AIDS Conference MeetingLessons from IAC 2010A Clinical Context Report

  2. Jointly Sponsored by: and MedPage Today A Look Back at the International AIDS Conference Meeting—Lessons from IAC 2010

  3. A Look Back at the International AIDS Conference Meeting—Lessons from IAC 2010 Supported in part by an educational grant fromBristol-Myers Squibb

  4. Clinical Context SeriesTarget Audience The goal of this program is to provide HIV/AIDS specialists, virologists, infectious disease specialists, experts in the care of patients with HIV/AIDS, physician assistants and nurse practitioners with up-to-date information and multiple perspectives on the pathogenesis, symptoms, risk factors, and complications of HIV/AIDS as well as current and emerging treatments and best practices in the management of HIV/AIDS.

  5. Activity Learning Objectives Upon successful completion of this educational program, participants should be able to: • Discuss the results of this report from IAC • Review the relevance and significance of the report in the broader context of clinical care

  6. CME Information: Physicians • Statement of Accreditation This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through joint sponsorship of Albert Einstein College of Medicine and MedPage Today.  Albert Einstein College of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

  7. CME Information • Credit Designation Albert Einstein College of Medicine designates this educational activity for a maximum of 0.25 AMA PRA Category 1 Credits.™ Physicians should only claim credit commensurate with the extent of their participation in the activity.

  8. CME Information: Nurses • Statement of Accreditation • Projects In Knowledge, Inc. (PIK) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. • Projects In Knowledge is also an approved provider by the California Board of Registered Nursing, Provider Number CEP-15227. • This activity is approved for 0.58 nursing contact hours. DISCLAIMER: Accreditation refers to educational content only and does not imply ANCC, CBRN, or PIK endorsement of any commercial product or service.

  9. CME Information: Pharmacists • Projects In Knowledge® is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education. This program has been planned and implemented in accordance with the ACPE Criteria for Quality and Interpretive Guidelines. This symposium is worth up to 0.25 contact hours (0.025 CEUs). The ACPE Universal Activity Number assigned to this knowledge-type activity is 0052-0000-10-1649-H01-P.

  10. Discussant Barry S. Zingman, MD Medical Director AIDS Center Montefiore Medical Center Professor of Clinical Medicine Albert Einstein College of Medicine Bronx, NY

  11. Disclosure Information Barry S. Zingman, MD, has disclosed that he has no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

  12. Disclosure Information Dori F. Zaleznik, MD, Associate Clinical Professor of Medicine, Harvard Medical School, Boston; Michael Smith and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner, have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity. The staff of Albert Einstein College of Medicine, MedPage Today, and Projects In Knowledgehave no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

  13. Disclaimer The moderators/authors have attempted to provide the most current and accurate clinical information according to accepted medical practice standards at the time of publication. The information should not be considered to be completely error-free or to include all relevant information; nor should it be used as an exclusive basis for decision-making. Neither Albert Einstein College of Medicine, Montefiore Medical Center, MedPage Today nor Bristol-Myers Squibb, the authors or any other party involved in the preparation of this work and the presentations contained herein warrant that the information is accurate or complete and are not responsible for any errors or omissions or for the results obtained from the use of such information. You are encouraged to consult other sources and confirm the information contained herein. Use of the information is strictly voluntary and at the user's sole risk. If misleading or otherwise inappropriate information is brought to our attention, a reasonable effort will be made to correct or delete it. Such concerns or any other questions or problems about the information should be sent to cme@montefiore.org.

  14. Summary • The most recent guidelines suggest that HIV therapy should start at a CD4 count of at least 500 • The treatments of choice to start therapy are now, increasingly, fixed dose combination pills • A vaginal microbicide that includes an antiretroviral drug, tenofovir, has shown efficacy in preventing HIV acquisition in a randomized controlled trial • The product has also appeared to lower the risk of acquiring herpes simplex virus 2, a known risk factor for HIV

  15. Recommendations for Initiating Antiretroviral Therapy (ART) in Treatment-Naïve Adults with HIV-1 Infection Who Are Ready to Begin Therapy • ART is recommended regardless of CD4 cell count for persons with symptomatic HIV disease, pregnancy, active HBV or HCV co-infection, or those at high risk for secondary HIV transmission • ART is recommended for asymptomatic adults with CD4 cell counts  500/μL • ART should be considered in patients who are asymptomatic with CD4 cell counts > 500/μL, unless the patient is an elite controller (HIV-RNA <50 copies/mL) or has a stable CD4 count and low-level viremia in the absence of ART

  16. Why Start ART Earlier • NA-ACCORD study demonstrated that there was lower mortality, as well as significantly lower non-age defining events, if people were started on ART before their T-cell count dropped to 500 • If therapy is not started until the patient’s CD4 count is <500, there is a lower chance that CD4 count will become normal on therapy • Several studies have demonstrated that HIV transmission between serodiscordant couples and in injection drug users is decreased with ART

  17. CASCADE Cohort • 9,455 HIV recent seroconverters, avg. age 30 • 812 (8.6%) developed AIDS • 544 (5.8%) died • Relative effects: AIDS/Death • CD4 count 0-49 – Incidence Rate per 1000 person years 193.3 Defer ART, 55.0 Initiate – adjusted HR 0.32 (95% CI 0.17,0.59) • CD4 50-199 – IR 56.6 Defer, 22.0 Initiate aHR 0.48 (0.31, 0.74 • CD4 200-349 – IR 29.4 Defer, 18.7 Initiate aHR 0.59 (0.43, 0.81) • CD4 350-499 – IR 20.8 Defer, 17.2 Initiate aHR 0.75 (0.49,1.14) • CD4 500-799 – IR 18.5 Defer, 14.9 Initiate aHR 1.10 (0.67, 1.79)

  18. CASCADE Caveats • Retrospective study of patients who had recently seroconverted • Significantly smaller than the 20,000 to 50,000 patients followed over years in NA-ACCORD and HIV-CAUSAL • Looked only at death not • AIDS-related cancers • Cardiovascular disease • CD4 counts • Prevention of kidney disease

  19. New Treatment Recommendations, ISA-USA • The committee came out in favor of fixed-dose combinations • Tenofovir/emtricitabine number one recommended NRTI combination • Abacavir/lamivudine secondary NRTI • Third component should be either • Efavirenz • A ritonavir-boosted protease inhibitor such as darunavir/ritonavir or atazanavir/ritonavir • Integrase inhibitor raltegravir • Lopinavir/ritonavir moved to 2nd line because of toxicity

  20. Modified from Karim, et al. Effectiveness and Safety of Tenofovir Gel, an Antiretroviral Microbicide, for the Prevention of HIV Infection in Women. Science. Published Online July 19, 2010 at: http://www.sciencemag.org/cgi/rapidpdf/science.1193748.pdf. Reprinted with permission from AAAS.

  21. Impact of Tenofovir Gel on HSV-2 Incidence Results of the CAPRISA 004 Trial. Presented by Salim Abdool Karim, July 20, at the XVIII International AIDS Conference, Vienna, Austria. Oral Abstract TUSS0504.

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