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Antiretroviral Treatment M onitoring: A Canadian Ca se Example. Robert Hogg, PhD BC Centre for Excellence in HIV/AIDS Dept. of Health Care and Epidemiology University of British Columbia. British Columbia HIV/AIDS Drug Treatment Program.

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antiretroviral treatment m onitoring a canadian ca se example
Antiretroviral Treatment Monitoring: A Canadian Case Example

Robert Hogg, PhD

BC Centre for Excellence in HIV/AIDS

Dept. of Health Care and Epidemiology

University of British Columbia

british columbia hiv aids drug treatment program
British ColumbiaHIV/AIDS Drug Treatment Program
  • In BC antiretrovirals have been centrally distributed free of charge to eligible HIV+ individuals since 1986
  • In October 1992, the HIV/AIDS Drug Treatment Program became the responsibility of the BC Centre for Excellence
  • Ever enrolled over 6,500 and 2,800 currently on therapy
monitoring and evaluation
Monitoring and Evaluation
  • Patient, Physician and geographical characteristics
  • Antiretroviral therapy dispensing information
  • Sociodemographic and adherence-related data
  • Clinical and laboratory data, including CD4 and plasma viral load
  • Morbidity and mortality data updated through linkages
  • Antiretroviral resistance
  • Adherence measures
percent frequency distribution of initial antiretroviral regimens in british columbia 1993 2001

Frequency Distribution (%)

N

614

317

398

764

456

397

291

284

963

Therapy Start Time (year)

Percent frequency distribution of initial antiretroviral regimens in British Columbia (1993-2001)
progression to aids death
Progression to AIDS/Death

No therapy

Mono-therapy

Dual-therapy

% of patients progressing

Triple therapy

Months

JAMA 1998 & CMAJ 1999

slide12

Drug Costs

Cost: 1992/93: $500,000 US

2003/3004: $30,000,000 US

haart observational medical evaluation and research homer study
HAART Observational Medical Evaluation and Research (HOMER) Study
  • Population-based study of HIV+ men and women in the Drug Treatment Program
  • Aged 18 years and over
  • Antiretroviral naive
  • First prescribed triple therapy (2 NRTIs and either a PI or an NNRTI) between August 1, 1996 and September 30, 1999

HOMER

slide15

When to start therapy in 2002

Recommendations

> 30 K

5 to 30 K

< 5 K

Cells/mm3

Recommend

< 350

Symptomatic

Disease Type

Recommend

350 to 500

 200 cells/mm3

Based on CD4 decline, high viral load, patient interest, adherence potential, and risk of side effects

> 200 cells/mm3

> 500

IAS-USA, JAMA, July 2002

combined cd4 hiv rna groups hogg et al jama 2001
Combined CD4 & HIV-RNA groupsHogg et al JAMA, 2001

Probablity of Survival (%)

Time from Start of ARVs (mths)

slide17

CD4 groups stratified by adherence

> 75% Adherent

< 75% Adherent

Probability of Survival (%)

Probability of Survival (%)

Time Since Start of ARVs

Time Since Start of ARVs

Wood et al. AIDS, 2003

slide19

NNRTI vs. PI: Time to Death

Log-rank

Probability of Survival (%)

p = 0.252

Initial Regimen

NNRTI

PI

Time from Start of ARVs (months)

Hogg et al., IAS, 2002

time to switching therapy
Time to Switching Therapy

log rank p<0.001

Probability of Adding/Switching ARV (%)

Time from Start of ARVs (months)

time to first simultaneous resistance to antiretrovirals
Time to First Simultaneous Resistance to Antiretrovirals

Probability of Detecting Resistance (%)

Time from Start of Antiretrovirals(months)

>=1C

1219

N=

873

743

621

488

N=

1219

>=2C

932

822

702

559

954

>=3C

N=

1219

861

752

602

4C

959

873

772

623

N=

1219

Harrigan et al., IAS, 2003

time to first detection of resistance to each class of antiretrovirals
Time to First Detection of Resistance to Each Class of Antiretrovirals

Probability of Detecting Resistance (%)

Time from Start of Antiretrovirals(months)

N=

1219

(Lamiv)

899

783

662

528

(NNRTI)

N=

712

1219

937

826

570

(NRTI)

730

N=

1219

935

839

580

(PI)

N=

1219

741

947

848

591

Harrigan et al., IAS, 2003

slide23

Donald RumsfeldClarifying US Policy on the war on terrorNewsweek, March 10, 2003

“There are known knows. These are things we know that we know. There are known unknowns. That is to say, there are things that we know we don’t know. But these are also unknown unknowns. There are things we don’t know we don’t know.”

slide25

Impact of Various ART Strategies in South Africa

50

49

48

47

46

1999

2000

2001

2002

2003

2004

2005

Based on E Wood and P Braitstein et al. Lancet 2000 June 17;vol 355:2095-2100

25% Antiretroviral Therapy Use

Life Expectancy at Birth

No Therapy

Year

acknowledgements
Acknowledgements

Michael O’Shaughnessy

Paula Braitstein

Richard Harrigan

Nada Gataric

Julio Montaner

Benita Yip

Keith Chan

Evan Wood

Michael Smith Foundation for Health Research

The Canadian Institutes of Health Research

BC Centre for Excellence in HIV/AIDS