Posts filed under ‘HIV/SDA en Seniles’

Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2016 Recommendations of the International Antiviral Society–USA Panel

JAMA July 12, 2016 V.316 N.2 P.191-210

Special Communication

Huldrych F. Günthard, MD; Michael S. Saag, MD; Constance A. Benson, MD; Carlos del Rio, MD; Joseph J. Eron, MD; Joel E. Gallant, MD, MPH; Jennifer F. Hoy, MBBS, FRACP; Michael J. Mugavero, MD, MHSc; Paul E. Sax, MD; Melanie A. Thompson, MD; Rajesh T. Gandhi, MD; Raphael J. Landovitz, MD; Davey M. Smith, MD; Donna M. Jacobsen, BS; Paul A. Volberding, MD

1University Hospital Zurich and Institute of Medical Virology, University of Zurich, Zurich, Switzerland

2University of Alabama at Birmingham, Birmingham

3University of California San Diego School of Medicine, San Diego

4Emory University Rollins School of Public Health and School of Medicine, Atlanta, Georgia

5University of North Carolina at Chapel Hill School of Medicine, Chapel Hill

6Southwest CARE Center, Santa Fe, New Mexico

7Alfred Hospital and Monash University, Melbourne, Australia

8Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts

9AIDS Research Consortium of Atlanta, Atlanta, Georgia

10Massachusetts General Hospital and Harvard Medical School, Boston

11University of California Los Angeles

12University of California San Diego, La Jolla

13International Antiviral Society–USA, San Francisco, California

14University of California San Francisco

Importance 

New data and therapeutic options warrant updated recommendations for the use of antiretroviral drugs (ARVs) to treat or to prevent HIV infection in adults.

Objective 

To provide updated recommendations for the use of antiretroviral therapy in adults (aged ≥18 years) with established HIV infection, including when to start treatment, initial regimens, and changing regimens, along with recommendations for using ARVs for preventing HIV among those at risk, including preexposure and postexposure prophylaxis.

Evidence

Review  A panel of experts in HIV research and patient care convened by the International Antiviral Society–USA reviewed data published in peer-reviewed journals, presented by regulatory agencies, or presented as conference abstracts at peer-reviewed scientific conferences since the 2014 report, for new data or evidence that would change previous recommendations or their ratings. Comprehensive literature searches were conducted in the PubMed and EMBASE databases through April 2016. Recommendations were by consensus, and each recommendation was rated by strength and quality of the evidence.

Findings 

Newer data support the widely accepted recommendation that antiretroviral therapy should be started in all individuals with HIV infection with detectable viremia regardless of CD4 cell count. Recommended optimal initial regimens for most patients are 2 nucleoside reverse transcriptase inhibitors (NRTIs) plus an integrase strand transfer inhibitor (InSTI). Other effective regimens include nonnucleoside reverse transcriptase inhibitors or boosted protease inhibitors with 2 NRTIs. Recommendations for special populations and in the settings of opportunistic infections and concomitant conditions are provided. Reasons for switching therapy include convenience, tolerability, simplification, anticipation of potential new drug interactions, pregnancy or plans for pregnancy, elimination of food restrictions, virologic failure, or drug toxicities. Laboratory assessments are recommended before treatment, and monitoring during treatment is recommended to assess response, adverse effects, and adherence. Approaches are recommended to improve linkage to and retention in care are provided. Daily tenofovir disoproxil fumarate/emtricitabine is recommended for use as preexposure prophylaxis to prevent HIV infection in persons at high risk. When indicated, postexposure prophylaxis should be started as soon as possible after exposure.

Conclusions and Relevance 

Antiretroviral agents remain the cornerstone of HIV treatment and prevention. All HIV-infected individuals with detectable plasma virus should receive treatment with recommended initial regimens consisting of an InSTI plus 2 NRTIs. Preexposure prophylaxis should be considered as part of an HIV prevention strategy for at-risk individuals. When used effectively, currently available ARVs can sustain HIV suppression and can prevent new HIV infection. With these treatment regimens, survival rates among HIV-infected adults who are retained in care can approach those of uninfected adults.

FULL TEXT

http://jama.jamanetwork.com/article.aspx?articleid=2533073

July 17, 2016 at 4:30 pm

GeSIDA/National AIDS Plan: Consensus document on antiretroviral therapy in adults infected by the human immunodeficiency virus (Updated January 2014).

Enferm Infecc Microbiol Clin. 2014 Aug-Sep;32(7):446.e1-42.

Article in Spanish

Panel de expertos de GeSIDA; Plan Nacional sobre el Sida.

Abstract

OBJECTIVE:

This consensus document is an update of combined antiretroviral therapy (cART) guidelines for HIV-1 infected adult patients.

METHODS:

To formulate these recommendations a panel composed of members of the Grupo de Estudio de Sida and the Plan Nacional sobre el Sida reviewed the efficacy and safety advances in clinical trials, cohort and pharmacokinetic studies published in medical journals (PubMed and Embase) or presented in medical scientific meetings. Recommendations strength and the evidence in which they are supported are based on modified criteria of the Infectious Diseases Society of America.

RESULTS:

In this update, antiretroviral therapy (ART) is recommended for all patients infected by type 1 human immunodeficiency virus (HIV-1). The strength and grade of the recommendation varies with the clinical circumstances: CDC stage B or C disease (A-I), asymptomatic patients (depending on the CD4+ T-lymphocyte count: <350cells/μL, A-I; 350-500 cells/μL, A-II, and >500 cells/μL, B-III), comorbid conditions (HIV nephropathy, chronic hepatitis caused by HBV or HCV, age >55years, high cardiovascular risk, neurocognitive disorders, and cancer, A-II), and prevention of transmission of HIV (mother-to-child or heterosexual, A-I; men who have sex with men, A-III). The objective of ART is to achieve an undetectable plasma viral load. Initial ART should always comprise a combination of 3 drugs, including 2 nucleoside reverse transcriptase inhibitors and a third drug from a different family (non-nucleoside reverse transcriptase inhibitor, protease inhibitor, or integrase inhibitor). Some of the possible initial regimens have been considered alternatives. This update presents the causes and criteria for switching ART in patients with undetectable plasma viral load and in cases of virological failure where rescue ART should comprise 2 or 3 drugs that are fully active against the virus. An update is also provided for the specific criteria for ART in special situations (acute infection, HIV-2 infection, and pregnancy) and with comorbid conditions (tuberculosis or other opportunistic infections, kidney disease, liver disease, and cancer).

CONCLUSIONS:

These new guidelines updates previous recommendations related to cART (when to begin and what drugs should be used), how to monitor and what to do in case of viral failure or drug adverse reactions. cART specific criteria in comorbid patients and special situations are equally updated.

PDF

http://apps.elsevier.es/watermark/ctl_servlet?_f=10&pident_articulo=90340091&pident_usuario=0&pcontactid=&pident_revista=28&ty=107&accion=L&origen=zonadelectura&web=www.elsevier.es&lan=es&fichero=28v32n07a90340091pdf001.pdf

June 13, 2015 at 10:40 am

Late diagnosis among our ageing HIV population: a cohort study.

J Int AIDS Soc. 2014 Nov 2;17(4 Suppl 3):19692.

Mensforth S1, Goodall L1, Bodasing N2, Coultas J3.

1Stoke and Staffordshire Partnership Trust, Cobridge Sexual Health, Stoke-on-Trent, UK.

2Infectious Diseases, University Hospital of North Staffordshire, Stoke-on-Trent, UK.

3University Hospital of North Staffordshire, Keele University School of Medicine, Stoke-on-Trent, UK.

Abstract

INTRODUCTION:

With the advent of combined antiretroviral therapy (cART), more people infected with HIV are living into older age; 22% of adults receiving care in the UK are aged over 50 years [1]. Age influences HIV infection; the likelihood of seroconversion illness, mean CD4 count and time from infection to development of AIDs defining illnesses decreases with increasing age. A UK study estimates that half of HIV infections in persons over 50 years are acquired at an age over 50 [2]. Studies exploring sexual practices in older persons have repeatedly shown that we cannot assume there is no risk of STI and HIV infection [3,4]. Physicians should be alert to risk of HIV even in the older cohort, where nearly half diagnoses are made late [2]. Local audit has demonstrated poor testing rates in the over 50’s on the Acute Medical Unit. Late diagnosis (CD4<350) results in poorer outcomes and age confounds further; older late presenters are 2.4 times more likely to die within the first year of diagnosis than younger counterparts [2].

MATERIALS AND METHODS:

A retrospective case notes review was conducted of all patients aged 60 years and over attending HIV clinic in the last 2 years. Outcomes audited included features around diagnosis; age, presentation, missed testing opportunities and CD4 count at diagnosis.

RESULTS:

Of the current cohort of 442 patients, 34 were over 60 years old (8%). Age at diagnosis in this group ranged from 36 to 80 years, mean 56.6 years. Presentation triggers included opportunistic infections or malignancies (n=10), constitutional symptoms (n=6), diagnosis of another STI (n=4), seroconversion illness (n=2), partner status (n=3). Eight patients were diagnosed through asymptomatic screening at Sexual Health. We identified missed opportunities in five patients who were not tested despite diagnoses or symptoms defined as clinical indicators for HIV. Half of older patients had a CD4 count of <200 at diagnosis.

CONCLUSIONS:

It is imperative that general medical physicians and geriatricians are alert to enquiring about risk and testing for HIV where clinical indicators are present, irrespective of age. The oldest patient in the cohort was diagnosed with HIV aged 80 years. All patients with missed opportunities for testing were over 47 years old.

 

PDF

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4225407/pdf/JIAS-17-19692.pdf

 

June 8, 2015 at 1:37 pm

2015-04 Guidelines for the Use of ARVs Agents in HIV-1-Infected Adults and Adolescents DHHS

2015-04 Guidelines for the Use of ARVs Agents in HIV-1-Infected Adults and Adolescents 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 April 8, 2015; last reviewed April 8, 2015)

Revisions to the May 1, 2014, version of the guidelines include key updates to several existing sections and the addition of two new tables. Significant updates are highlighted throughout the document.

Key Updates

The following are key updates to existing sections of the guidelines.

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

Since the last version of these guidelines, data from clinical trials and cohort studies, as well as experience in clinical practice, have prompted significant changes to the list of Recommended, Alternative, and Other regimens for treatment-naive patients (Table 6). Additionally, a new table, titled “Antiretroviral (ARV)

Regimen Considerations as Initial Therapy Based on Specific Clinical Scenarios,” has been created to guide clinicians on the selection of an initial ARV regimen based on specific clinical scenarios and ARV-related considerations (Table 7).

 

  • There are now five Recommended regimens for antiretroviral therapy (ART)-naive patients—four integrase strand transfer inhibitor (INSTI)-based regimens and one ritonavir-boosted protease inhibitor (PI/r)-based regimen, as listed below:

 

  INSTI-Based Regimens:

  • Dolutegravir/abacavir/lamivudine (DTG/ABC/3TC)—only for patients who are HLA-B*5701 negative (AI)
  • DTG plus tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) (AI)
  • Elvitegravir/cobicistat/TDF/FTC (EVG/c/TDF/FTC)—only for patients with pre-ART CrCl >70 mL/min (AI)
  • Raltegravir (RAL) plus TDF/FTC (AI)

 

PI/r-Based Regimen:

  • Darunavir/ritonavir (DRV/r) plus TDF/FTC (AI)

 

  • Two regimens previously classified as Recommended regimens have been moved to the Alternative regimens category, with the rationale stated below:

 

  • Atazanavir/ritonavir (ATV/r) plus TDF/FTC (BI)—Based on the results of a large comparative clinical trial showing a greater rate of discontinuation with ATV/r plus TDF/FTC because of toxicities when compared to (DRV/r or RAL) plus TDF/FTC

 

  • Efavirenz/TDF/FTC (EFV/TDF/FTC) (BI)—Based on concerns about the tolerability of EFV in clinical trials and practice, especially the high rate of central nervous system (CNS)-related toxicities and a possible association with suicidality

 

  • Three regimens (ATV/r plus ABC/3TC, EFV plus ABC/3TC, and rilpivirine/TDF/FTC) that were previously listed as Recommended regimens for baseline HIV RNA <100,000 copies/mL or CD4 T lymphocyte (CD4) count >200 cells/mm3 are now in the Alternative or Other category, with the same caveat about limiting their use in these populations.

 

  • Two regimens that use fewer than two nucleoside reverse transcriptase inhibitors (DRV/r plus RAL and lopinavir/ritonavir plus 3TC) are now listed among the Other regimens, with the caveat that their use would be limited to those patients who cannot take either TDF or ABC.

 

  • Coformulations of atazanavir (ATV) and darunavir (DRV) with the pharmacokinetic (PK) enhancer cobicistat (COBI) have been added to the Alternative regimen options.

 

Virologic Failure

The following key updates have been made to this section:

 

  • The Management of Virologic Failure in Different Clinical Scenarios subsection has been expanded to provide guidance on the management of patients failing first and second ART regimens.

 

  • A new subsection on Isolated CNS Virologic Failure and New Onset Neurologic Symptoms has been added.

 

  • The Suboptimal Immunologic Response Despite Viral Suppression subsection has been moved from this section to become a stand-alone section (see below).

 

Poor CD4 Cell Recovery and Persistent Inflammation Despite Viral Suppression

  • This new section describes the role of persistently low CD4 cell count (<200 cells/mm3) and persistent inflammation/immune activation on the increased risk of AIDS- and non-AIDS-related morbidity.

 

  • The Panel emphasizes that currently no therapeutic intervention designed to improve CD4 cell recovery or immune activation has been proven to improve health.

 

Acute/Early HIV Infection

  • This section has been updated to include the 2014 Centers for Disease Control and Prevention’s recommendation for diagnosis of HIV infection, including in individuals with acute/early HIV infection.

 

HIV-2 Infection

  • This section has been updated with the most recent literature on ARV use in HIV-2-infected patients.

 

HIV/Hepatitis C Virus (HCV) Coinfection

  • The text and table (Table 12) in this section have been updated with information on the concomitant use of different ARV drugs with the new HCV drug combination of ombitasvir, paritaprevir, ritonavir, and dasabuvir.

 

Drug Interaction

  • The text of this section has been updated to focus on mechanisms of interaction of ARV drugs.

 

  • A new table, titled “Mechanisms of Antiretroviral Associated Drug Interactions,” has been developed to provide clinicians with information on clinically relevant mechanisms of PK-associated interactions for individual ARV drugs (Table 17).

 

  • All the Drug Interaction tables have been updated; in particular, interactions related to ATV/c, DRV/c, and EVG plus PI/r have been added to these tables (see Tables 19a–e, 20a, and 20b).

 

Additional Updates

Minor revisions have also been made to the following sections:

  • Discontinuation or Interruption of Antiretroviral Therapy
  • Exposure-Response Relationship and Therapeutic Drug Monitoring (TDM) for Antiretroviral Agents
  • Monthly Average Wholesale Price of Antiretroviral Drugs (Table 16)
  • Drug Characteristics tables (Appendix B, Tables 1–7)

 

PDF

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

– – –

April 14, 2015 at 12:38 pm

Documento de consenso de GeSIDA/Plan Nacional sobre el Sida respecto al tratamiento antirretroviral en adultos infectados por el virus de la inmunodeficiencia humana (Actualización enero 2014)

Enfermedades Infecciosas y Microbiología Clínica Agosto-Septiembre 2014 V.32 N.7

2014 – CONSENSO GeSIDA – TARV en adultos -Update

Documento de consenso de GeSIDA/Plan Nacional sobre el Sida respecto al tratamiento antirretroviral en adultos infectados por el virus de la inmunodeficiencia humana (Actualización enero 2014)

Panel de expertos de GeSIDA y Plan Nacional sobre el Sida

Objetivo

Actualizar las recomendaciones sobre el tratamiento antirretroviral (TAR) para adultos infectados por el VIH-1.

Métodos

Este documento ha sido consensuado por un panel de expertos de GESIDA y de la Secretaría del Plan Nacional sobre el Sida tras revisar los resultados de eficacia y seguridad de ensayos clínicos, estudios de cohortes y de farmacocinética publicados en revistas biomédicas (PubMed y Embase) o presentados en congresos. La fuerza de cada recomendación y la gradación de su evidencia se basan en una modificación de los criterios de la Infectious Diseases Society of America.

Resultados

Se recomienda el TAR en todos los pacientes infectados por el VIH-1. La fuerza y la gradación de la recomendación varían según la circunstancia clínica: enfermedades B o C de los CDC (A-I), pacientes asintomáticos según número de CD4+ (< 350, A-I; 350-500, A-II; > 500, B-III), comorbilidades (nefropatía por VIH, hepatitis crónica por VHB o VHC, edad superior a 55 años, riesgo cardiovascular elevado, trastornos neurocognitivos o neoplasias, A-II) y prevención de la transmisión del VIH (materno-fetal o heterosexual, A-I; homosexual entre hombres, A-III). El objetivo del TAR es lograr una carga viral plasmática (CVP) indetectable. El TAR de inicio debe ser siempre una combinación de 3 fármacos que incluya una asociación de 2 ITIAN y otro fármaco de distinta familia (ITINN, IP/r o InInt). De las posibles pautas de inicio se han considerado algunas como alternativa. Se exponen las causas y los criterios para cambiar un TAR estando con CVP indetectable, así como en el fracaso virológico en el que en el TAR de rescate se deben usar 3 o 2 fármacos plenamente activos frente al virus. Se actualizan igualmente los criterios específicos del TAR en situaciones especiales (infección aguda, infección por VIH-2, embarazo) o comorbilidades (tuberculosis u otra enfermedad oportunista, afectación renal, hepatopatías y neoplasias).

Conclusiones

Este nuevo documento actualiza las recomendaciones previas respecto a cuándo y con qué regímenes iniciar el TAR, cómo monitorizarlo y qué hacer cuando fracasa o desarrolla toxicidad. Se actualizan los criterios específicos del TAR en pacientes con comorbilidades y en situaciones especiales.

PDF

http://apps.elsevier.es/watermark/ctl_servlet?_f=10&pident_articulo=90340091&pident_usuario=0&pcontactid=&pident_revista=28&ty=107&accion=L&origen=zonadelectura&web=zl.elsevier.es&lan=es&fichero=28v32n07a90340091pdf001.pdf

 

August 30, 2014 at 8:35 pm

Sexually transmitted infections in older populations

Current Opinion in Infectious Diseases Feb 2013 V.26 N.1 P.80–85

Poynten, I. Marya; Grulich, Andrew E.a; Templeton, David J.a,b

aKirby Institute, University of New South Wales, Sydney

bRPA Sexual Health, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia

Correspondence to Dr Mary Poynten, Kirby Institute, The University of New South Wales, Sydney, NSW 2052, Australia. Tel: +61 2 93850937; fax: +61 2 93850920; e-mail: mpoynten@kirby.unsw.edu.au

Purpose of review

People are living longer and healthier lives. In recent years, there has been a focus on recognition of ongoing sexual activity among older adults and leading from this, the potential for an increase in diagnoses of sexually transmitted infections (STIs). Data on STI rates, sexual behaviour and factors affecting susceptibility to STIs are discussed.

Recent findings

There is limited published literature in this field and few recent longitudinal studies of STI acquisition in people older than 50 years. Although there is evidence of an increase in incidence, STIs remain rare in older compared with younger populations. Compared with their heterosexual counterparts, older men who have sex with men are at higher risk of incident HIV and some other STIs. The HIV epidemic is ageing as a result of increasing life span and acquisition of HIV at older ages. Improved longevity, evolving societal norms and physiological changes may place older people at risk of HIV and other STIs.

Summary

Routine STI screening is not warranted in all older people. Education and prevention strategies for all people at greater risk of HIV, regardless of age are required. Age-appropriate interventions designed to impart knowledge and provide the requisite skills needed to reduce STI risk in older age would be beneficial.

FULL TEXT

http://journals.lww.com/co-infectiousdiseases/Fulltext/2013/02000/Sexually_transmitted_infections_in_older.12.aspx

PDF (CLIC PDF)

 

August 18, 2014 at 4:27 pm

HIV / SIDA IV CONSENSO ARGENTINO de Tratamiento Antirretroviral 2012 – SADI

Sociedad Argentina de Infectología (SADI)

Buenos Aires, Noviembre 2012

 

https://dl.dropboxusercontent.com/u/42385022/SADIconsenso%202012.pdf

June 30, 2013 at 5:32 pm

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