Posts filed under ‘HIV/SDA en Seniles’

Compromised CD4:CD8 ratio recovery in people living with HIV aged over 50 years: an observational study.

HIV Med. February 2020 V.21 N.2 P.109-118.

Francis-Morris A1, Mackie NE2, Eliahoo J3, Ramzan F2, Fidler S1,4, Pollock KM1,2,4.

Abstract

OBJECTIVES:

Persistent CD4:CD8 ratio inversion (< 1) is associated with mortality in older people. We investigated the interaction of the effects of baseline CD8 count and age at HIV diagnosis on CD4:CD8 ratio recovery with antiretroviral therapy (ART).

METHODS:

An observational study (1 January 2007 to 31 December 2016) was carried out using routinely collected data from the HIV outpatient services at Imperial College Healthcare NHS Trust, London, UK. CD4 and CD8 counts, prior to and during ART, treatment during primary HIV infection (PHI) and HIV-1 viral load were included in univariate and multivariate analyses using Cox proportional hazard regression.

RESULTS:

Data were included for 876 patients starting ART, where HIV suppression was achieved. Of these patients, 741 of 876 (84.6%) were male and 507 of 876 (57.9%) were Caucasian. The median time on ART was 38 [interquartile range (IQR) 17-66] months. CD8 count change on ART was bidirectional; low CD8 counts (≤ 600 cells/μL) increased and high CD8 counts (> 900 cells/μL) decreased. The median pre-ART CD4:CD8 ratio was 0.41 (IQR 0.24-0.63), and recovery (≥ 1) occurred in 274 of 876 patients (31.3%). Pre- and post-ART CD4:CD8 ratios were lower in those aged > 50 years compared with young adults aged 18-30 years (P < 0.001 and P = 0.002, respectively). After adjustment, younger age at HIV diagnosis (P < 0.001) and treatment during PHI (P < 0.001) were favourable for CD4:CD8 ratio normalization.

CONCLUSIONS:

Older age (> 50 years) at HIV diagnosis was associated with persistent CD4:CD8 ratio inversion, whereas treatment of PHI was protective. These findings confirm the need for testing and early treatment of people aged > 50 years, and could be used in a risk management algorithm for enhanced surveillance.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7003811/pdf/HIV-21-109.pdf

March 4, 2020 at 3:38 pm

2020-01 Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV 378 pag DHHS

Developed by the DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents – A Working Group of the Office of AIDS Research Advisory Council (OARAC)

What’s New in the Guidelines? (Last updated December 18, 2019 and last reviewed December 18, 2019)

* Antiretroviral Therapy to Prevent Sexual Transmission of HIV (Treatment as Prevention)

* Dolutegravir Recommendations for Individuals of Childbearing Potential

* Laboratory Testing for Initial Assessment and Monitoring of People with HIV Receiving Antiretroviral   Therapy

* Initiation of Antiretroviral Therapy

* What to Start

* Optimizing Antiretroviral Therapy in the Setting of Virologic Suppression

* Acute and Recent (Early) HIV Infection

* HIV and the Older Person

* Tuberculosis/HIV Coinfection

* Cost Considerations and Antiretroviral Therapy

* Table Updates

PDF

https://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf

January 10, 2020 at 7:32 am

A New Perspective on HIV Diagnostics: Reinterpretation in the Age of Early Treatment

Clin. Microbiol. October 2019 V.57 N.10

Commentary

Early treatment of HIV infection with antiretroviral therapy in recently identified HIV-infected individuals reduces viral replication and decreases the risk of transmission.

The screening and supplemental, confirmatory assays used to identify infection are influenced by early treatment and may obscure a clear diagnosis of HIV infection.

In this issue of the Journal of Clinical Microbiology, Manak et al. demonstrate the impact of antiretroviral therapy on the evolution of biomarkers that have traditionally been used for identifying HIV infection

abstract

https://jcm.asm.org/content/57/10/e00978-19.abstract?etoc

PDF

https://jcm.asm.org/content/jcm/early/2019/07/26/JCM.00978-19.full.pdf

September 24, 2019 at 3:18 pm

2017-10 European AIDS Clinical Society (EACS). European guidelines for clinical management and treatment of HIV-1-infected adults in Europe 102 pag

Welcome to the EACS Guidelines!

These Guidelines were developed by the European AIDS Clinical Society (EACS), a not-for-profit organisation, whose mission is to promote excellence in standards of care, research and education in HIV infection and related co-infections, and to actively engage in the formulation of public health policy, with the aim of reducing HIV disease burden across Europe.

The EACS Guidelines were first published in 2005, and are currently available in print, online, and as a free App for both iOS and Android devices. The Guidelines are translated to a number of different languages, and are formally revised at least annually for the electronic version and biennially for the printed version. The electronic version can, however, be updated at any given moment if the panels consider it necessary.

The aim of the EACS Guidelines is to provide easily accessible and comprehensive recommendations to clinicians centrally involved in the care of HIV-positive persons.

The EACS Guidelines are covering a relatively large and diverse area geographically, with different national levels of access to care. As a natural consequence, the Guidelines aim to cover a relatively wide range of recommendations as opposed to the often more uniform national guidelines.

The Guidelines consist of five main sections, including a general overview table of all major issues in HIV infection, as well as detailed recommendations on antiretroviral treatment, diagnosis, monitoring and treatment of co-morbidities, co-infections and opportunistic diseases.

Each respective section of the Guidelines is managed by a panel of experienced European HIV experts, and additional experts, where needed. All recommendations are evidence-based whenever possible, and based on expert opinions in the rare instances where adequate evidence is unavailable. It was decided not to provide formal grades of evidence in the Guidelines. The panels make decisions by consensus or by vote when necessary. Yet, it was decided not to publish results of the votes or discrepancies if any.

A list of the main references used to produce the Guidelines is provided as a separate section. Please reference the EACS Guidelines as follows: EACS Guidelines version 9.0, October 2017. Video links to the EACS online course on Clinical Management of HIV are provided throughout the Guidelines, see Video links.

The diagnosis and management of HIV infection and related co-infections, opportunistic diseases and co-morbidities continue to require a multidisciplinary effort for which we hope the 2017 version of the EACS Guidelines will provide you with an easily accessible and updated overview.

All comments to the Guidelines are welcome and can be directed to guidelines@eacsociety.org

We wish to warmly thank all panellists, external experts, linguists, translators, the EACS Secretariat, the Sanford team and everyone else who helped to build up and to publish the EACS Guidelines for their dedicated work.

 

Enjoy!

Manuel Battegay and Lene Ryom – October 2017

PDF

http://www.eacsociety.org/files/guidelines_9.0-english.pdf

March 19, 2019 at 4:00 pm

Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV 332 pag – Department of Health and Human Services – OCTOBER 2018

What’s New in the Guidelines?

(Last updated October 25, 2018; last reviewed October 25, 2018)

Resistance Testing

New information has been added regarding the use of HIV-1 proviral DNA genotypic resistance tests to identify drug resistance mutations, especially in the setting of low-level viremia or when plasma HIV RNA is below the limit of detection. The section now includes a discussion on the benefits and limitations of these tests.

Co-Receptor Tropism Testing

For patients who have undetectable HIV RNA, the Panel now recommends using a proviral DNA tropism assay to assess co-receptor usage before maraviroc is initiated as part of a new regimen.

Dolutegravir and Association with Neural Tube Defects

Preliminary data from Botswana suggest that there is an increased risk of neural tube defects in infants born to women who were receiving dolutegravir (DTG) at the time of conception. In response to these preliminary data, several sections in the Adult and Adolescent Guidelines have been updated to provide guidance for clinicians who are considering the use of DTG or other integrase strand transfer inhibitors (INSTIs) in individuals who are pregnant, or in those of childbearing potential who plan to get pregnant or who are sexually active and not using effective contraception.

The sections that have been updated with this new information include:

  • What to Start
  • Virologic Failure
  • Optimizing Antiretroviral Therapy in the Setting of Viral Suppression (formerly Regimen Switching in the

Setting of   Virologic Suppression)

  • Acute and Recent (Early) HIV-1 Infection
  • Adolescents and Young Adults with HIV
  • Women with HIV

 

What to Start

The following changes have been made to the recommendations for initial antiretroviral (ARV) regimens:

  • Bictegravir/Tenofovir Alafenamide/Emtricitabine (BIC/TAF/FTC): BIC is a new INSTI that is approved by the Food and Drug Administration (FDA) as part of a single-tablet regimen (STR) that also includes TAF and FTC. This regimen is now classified as a Recommended Initial Regimen for Most People with HIV.
  • Elvitegravir/Cobicistat/Emtricitabine with Tenofovir Alafenamide or Tenofovir Disoproxil Fumarate (EVG/c/FTC/TAF or EVG/c/FTC/TDF): These regimens have been moved to the category of Recommended Initial Regimens in Certain Clinical Situations. This change was made because these combinations include cobicistat, a pharmaco-enhancer that inhibits cytochrome P450 3A4 and increases the likelihood of drug-drug interactions. EVG also has a lower barrier to resistance than DTG and BIC.
  • Doravirine (DOR): DOR, a new non-nucleoside reverse transcriptase inhibitor, was recently approved by the FDA and is available as a single-drug tablet and as part of an STR that also includes TDF and lamivudine (3TC). DOR/TDF/3TC and DOR plus TAF/FTC have been added to the category of Recommended Initial Regimens in Certain Clinical Situations.
  • Dolutegravir plus Lamivudine (DTG plus 3TC): This two-drug regimen is now one of the regimens to consider when abacavir, TAF, or TDF cannot be used or are not optimal.
  • A new table, Table 6b, has been added to provide guidance to clinicians who are considering the use of DTG or other INSTIs in those who are pregnant and in those of childbearing potential.
  • Several new tables (Tables 8a–8d) have been added to the sections for the individual drug classes. These tables compare the characteristics of the different drugs within the classes.
  • Updates have been made throughout the section with new safety and clinical trial data.

 

Virologic Failure

  • This section was updated to include newly reported data and new language on recently published clinical trial data for first- line ARV treatment failure.
  • The Panel notes that, in some persons with multidrug-resistant HIV, DTG may be the only treatment option, or one of few treatment options. Accordingly, the language on the use of DTG in those of childbearing potential has been updated. The section now emphasizes that clinicians and patients should discuss the risk of neural tube defects if pregnancy occurs while the patient is taking DTG, as well as the risk of persistent viremia in the patient and the risk of HIV transmission to the fetus if pregnancy occurs while the patient is not on effective ARV therapy. The decision of whether to initiate or continue DTG should be made after carefully considering these risks.
  • Ibalizumab (IBA), a CD4 post-attachment inhibitor, was recently approved for use in persons with multidrug-resistant HIV. A review of the results of a clinical trial on IBA use in this setting has been added to the section.

 

Optimizing Antiretroviral Therapy in the Setting of Viral Suppression

  • The title of this section has been changed from Regimen Switching in the Setting of Virologic Suppression to Optimizing Antiretroviral Therapy in the Setting of Viral Suppression to better reflect the rationale for regimen changes in this setting.

 

  • The Panel emphasizes the importance of reviewing all available resistance test results when constructing a new regimen.
  • The role of HIV-1 proviral DNA genotypic resistance testing in detecting archived drug resistance mutations in the setting of viral suppression is discussed.
  • The Panel recommends performing pregnancy testing for those of childbearing potential before a regimen switch and provides recommendations for INSTI use in these patients.
  • Clinical trial data on the use of several ARV combinations in switch studies are updated and discussed in this section.

 

Exposure-Response Relationship and Therapeutic Drug Monitoring Section

  • This section has been removed from the guidelines.
  • The subsection regarding the role of therapeutic drug monitoring in managing drug-drug interactions has been moved to the Drug-Drug Interactions section of the guidelines.

 

Additional Updates

Various tables in the guidelines have been updated with new data, as well as information related to BIC and DOR.

 

  • Hepatitis C Virus/HIV Coinfection
  • Adverse Effects of Antiretroviral Agents
  • Monthly Average Prices of Commonly Used Antiretroviral Drugs
  • Drug-Drug Interactions
  • Appendix B Tables: Characteristics of Antiretroviral Drugs and Antiretroviral Dosing Recommendations in

Patients with   Renal and Hepatic Insufficiency

 

PDF

https://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf

 

March 19, 2019 at 3:47 pm

2016 BHIVA GUIDELINES for the treatment of HIV-1-positive Adults with antiretroviral therapy

The British HIV Association

Writing Group

Laura Waters (Chair)

N Ahmed, B Angus, M Boffito, M Bower, D Churchill, D Dunn, S Edwards, C Emerson, S Fidler, †M Fisher, R Horne, S Khoo, C Leen, N Mackie, N Marshall, F Monteiro, M Nelson, C Orkin, A Palfreeman, S Pett, A Phillips, F Post, A Pozniak, I Reeves, C Sabin, R Trevelion, J Walsh, E Wilkins, I Williams, A Winston

†Professor Martin Fisher died in April 2015 – he made a significant contribution to these, many other guidelines and our speciality as a whole – he is greatly missed.

Introduction

The overall purpose of these guidelines is to provide guidance on best clinical practice in the treatment and management of adults with HIV infection on antiretroviral therapy (ART).

The scope includes: (i) guidance on the initiation of ART in those previously naïve to therapy; (ii) support of people living with HIV (PLWH) on treatment; (iii) management of individuals experiencing virological failure; and (iv) recommendations in specific populations where other factors need to be taken into consideration.

The guidelines are aimed at clinical professionals directly involved with and responsible for the care of adults with HIV infection, and at community advocates responsible for promoting the best interests and care of HIV-positive adults. They should be read in conjunction with other published BHIVA guidelines.

The 2016 interim update to the 2015 BHIVA antiretroviral guidelines has been published online to include tenofovir-alafenamide/emtricitabine as a preferred NRTI backbone for first-line therapy. Changes were based on new data and the consensus opinion of the writing committee. All changes to the guideline are highlighted and include updates to the chronic kidney disease and bone disease sections of special populations and some small changes to managing virological failure. The next formal update to the guidelines in anticipated in 2017.

PDF

http://www.bhiva.org/documents/Guidelines/Treatment/2016/treatment-guidelines-2016-interim-update.pdf

December 3, 2016 at 9:33 am

2016-07-14 Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents

Key Updates

What to Start: Initial Combination Regimens for the Antiretroviral-Naive Patient

The approval of 3 fixed-dose combination products containing tenofovir alafenamide (an oral prodrug of tenofovir) and emtricitabine (TAF/FTC) prompted several changes in the What to Start section. The key changes are highlighted below:

– TAF/FTC was added as a 2-NRTI option in several Recommended and Alternative regimens, as noted in Table 6 of the guidelines. The addition of TAF/FTC to these recommendations is based on data from comparative trials demonstrating that TAF-containing regimens are as effective in achieving or maintaining virologic suppression as tenofovir disoproxil fumarate (TDF)-containing regimens and with more favorable effects on markers of bone and renal health.

– In the What to Start section, the evidence quality rating “II” was expanded to include “relative bioavailability/bioequivalence studies or regimen comparisons from randomized switch studies.” This evidence rating was broadened because not all recommended regimens were evaluated in randomized, controlled trials in antiretroviral therapy (ART)-naive patients. The Panel on Antiretroviral Guidelines for Adults and Adolescents (the Panel) based their recommendations for some regimens on either data from bioequivalence or relative bioavailability studies, or by extrapolating results from randomized “switch” studies that evaluated a drug’s or regimen’s ability to maintain virologic suppression in patients whose HIV was suppressed on a previous regimen. Guidance for clinicians on choosing between abacavir (ABC)-, TAF-, and TDF-containing regimens was added to What to Start.

– The lopinavir/ritonavir (LPV/r) plus 2-NRTI regimen was removed from the list of Other regimens because regimens containing this protease inhibitor (PI) combination have a larger pill burden and greater toxicity than other currently available options.

Regimen Switching

– Based on the most current data, this section was simplified to focus on switch strategies for virologically suppressed patients. The strategies are categorized as Strategies with Good Supporting Evidence, Strategies Under Evaluation, and Strategies Not Recommended.

HIV-Infected Women

– The Panel emphasizes that ART is recommended for all HIV-infected patients, including all HIV-infected women.

– The Panel also stresses the importance of early treatment for HIV-infected women during pregnancy and continuation of ART after pregnancy.

– This section was updated to include new data on interactions between antiretroviral (ARV) drugs and hormonal contraceptives.

Hepatitis B Virus (HBV)/HIV Coinfection

– This section was updated to include TAF/FTC as a treatment option for patients with HBV/HIV coinfection. Data on the virologic efficacy of TAF for the treatment of HBV in persons without HIV infection and TAF/FTC in persons with HBV/HIV coinfection are discussed.

– The Panel no longer recommends adefovir or telbivudine as options for HBV/HIV coinfected patients, as there is limited safety and efficacy data on their use in this population. In addition, these agents have a higher incidence of toxicities than other recommended treatments.

Hepatitis C Virus (HCV)/HIV Coinfection

– The text and Table 12 in this section were updated with information regarding the potential pharmacokinetic (PK) interactions between different ARV drugs and the recently approved hepatitis C drugs daclatasvir and the fixed-dose combination product of elbasvir and grazoprevir.

– Peginterferon alfa and ribavirin were removed from Table 12, as these agents do not have significant PK interactions with ARV drugs.

Tuberculosis (TB)/HIV Coinfection

– This section was updated to include a discussion on the treatment of latent tuberculosis infection (LTBI) in HIV-infected persons. The added discussion notes that a 12-week course of once-weekly rifapentine and isoniazid is an option for patients receiving either an efavirenz (EFV)- or a raltegravir (RAL)-based regimen.

– This section addresses the data from the TEMPRANO and START studies demonstrating a potential role of ART in reducing TB disease.

The recommendations and discussion regarding when to initiate ART in patients with active TB were simplified.

– As rifamycins are potent inducers of P-glycoprotein (P-gp), and TAF is a P-gp substrate, coadministration of TAF and rifamycins is not recommended.

Additional Updates

Minor revisions were made to the following sections:

– Laboratory Testing for Initial Assessment and Monitoring of HIV-Infected Patients on Antiretroviral Therapy

– Drug Resistance Testing

– Adverse Effects of Antiretroviral Agents and Tables 14 and 15

– Monthly Average Wholesale Price of Commonly Used Antiretroviral Drugs (Table 16)

– Drug Interaction Tables 18, 19a-e, and 20b

– Drug Characteristics Tables (Appendix B, Tables 1–7)

PDF

https://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf

 

July 25, 2016 at 2:17 pm

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