Posts filed under ‘HIV/SIDA Trastornos Oseos’

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

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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

Human Immunodeficiency Virus and Total Joint Arthroplasty: The Risk for Infection Is Reduced

Journal of Arthroplasty October 2016 V.31 N.10 P.2146–2151

Mohammad Ali Enayatollahi, Dermot Murphy, Mitchell G. Maltenfort, Javad Parvizi

Background

Highly active antiretroviral therapy (HAART) has changed the face of human immunodeficiency virus (HIV) and allowed patients to live for many decades. HIV and HAART are known risk factors for osteonecrosis of bone, osteopenia, and osteoporosis. Therefore, the demand for total joint arthroplasty (TJA) in HIV-infected patients is on the rise. We attempted to determine whether modern treatments for HIV have impacted the rate of periprosthetic joint infection (PJI).

Methods

Conducting a systematic review, 25 studies with a total of 722 TJAs were identified. We extracted data on rates of PJI after primary TJA in HIV-infected patients with and without hemophilia and data on administration of HAART at the time of arthroplasty.

Results

Three hundred eighty-one TJAs were performed in 293 patients with HIV infection without hemophilia. The follow-up ranged between 1.5 months and 11 years. Nine patients developed PJI. In patients with both HIV and hemophilia, 341 primary TJAs were performed. Forty-five received treatment for PJI. Follow-up ranged between 1 year and 26 years. Rates of PJI were 2.28% and 10.98% for HIV-only patients and patients with HIV and hemophilia, respectively. This difference was statistically significant (P < .0001) with a 5.28 odds ratio for hemophilia. HAART was associated with fewer infections overall (odds ratio, 0.12).

Conclusion

The rates of PJI after TJA in HIV-only patients are lower than those in patients with both HIV and hemophilia. Treatment of patients with HAART and optimization of underlying comorbidities appears to lower the rate of PJI in this patient population.

abstract

http://www.arthroplastyjournal.org/article/S0883-5403(16)00206-0/fulltext

PDF

http://www.arthroplastyjournal.org/article/S0883-5403(16)00206-0/pdf

November 2, 2016 at 12:48 pm

Hepatitis C virus coinfection as a risk factor for osteoporosis and fracture

Current Opinion In HIV and AIDS May 2016 V.11 N.3 P.285–293

Bedimo, Roger; Maalouf, Naim M.; Re, Vincent Lo III

aInfectious Diseases Section, Medical Service, Veterans Affairs North Texas Healthcare System

bDivision of Infectious Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center

cEndocrine Section, Medical Service, Veterans Affairs North Texas Healthcare System

dDivision of Mineral Metabolism, Department of Internal Medicine, and the Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas

eDivision of Infectious Diseases, Department of Medicine

fDepartment of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA

Purpose of review

With increased survival of HIV-infected patients, osteoporotic fractures have developed as a major cause of morbidity in these patients, and chronic hepatitis C virus (HCV) coinfection has emerged as a significant contributor to this increased fracture risk. The present article reviews the epidemiologic and clinical evidence for osteoporosis and increased fracture risk among HIV/HCV coinfected patients, and potential mechanisms for these outcomes with HCV coinfection.

Recent findings

Epidemiologic studies suggest that HIV/HCV coinfected patients exhibit a three-fold increased fracture incidence compared with uninfected controls, and 1.2–2.4-fold increased fracture risk compared with HIV monoinfected patients. Recent reports suggest that chronic HCV coinfection is independently associated with reduced bone mineral density in HIV, but that it is not associated with significantly increased bone turnover. The deleterious impact of chronic HCV on BMD and fracture risk occurs even in the absence of advanced liver fibrosis or cirrhosis. New tools to assess bone quality, including the trabecular bone score, high-resolution peripheral quantitative computed tomography, and in-vivo microindentation, may help improve understanding of the mechanisms of HCV-associated skeletal fragility. The impact of approved antiosteoporosis medications and direct-acting antivirals for the treatment of chronic HCV infection on patients’ bone health remain to be studied.

Summary

Chronic HCV infection is an independent risk factor for osteoporosis and fractures among HIV-infected patients, even before the development of cirrhosis. The underlying mechanisms are being unraveled, but major questions persist regarding the optimal evaluation and management of bone health in HIV/HCV coinfected patients.

FULL TEXT

http://journals.lww.com/co-hivandaids/Fulltext/2016/05000/Hepatitis_C_virus_coinfection_as_a_risk_factor_for.7.aspx

PDF  (CLIC in PDF)

 

August 2, 2016 at 1:24 pm

The protease inhibitors and HIV-associated bone loss

Current Opinion In HIV and AIDS May 2016 V.11 N.3 P. 333–342

Moran, Caitlin A.; Weitzmann, M. Neale; Ofotokun, Ighovwerha

aDepartment of Medicine, Division of Infectious Diseases, Emory University School of Medicine

bGrady Healthcare System, Atlanta

cDepartment of Medicine, Division of Endocrinology, Metabolism & Lipids, Emory University School of Medicine, Atlanta

dAtlanta Department of Veterans Affairs Medical Center, Decatur, Georgia, USA

Purpose of review

HIV infection is an established risk factor for osteoporosis and bone fracture. Combination antiretroviral therapy (cART) increases bone resorption leading to an additional 2–6% bone mineral density (BMD) loss within the first 1–2 years of therapy. Although tenofovir disoproxil fumarate is often blamed for antiretroviral drug-associated bone loss, evidence abounds to suggest that other agents, including the protease inhibitors (PIs), have adverse bone effects. In the current review, we examine bone loss associated with protease inhibitor use, describing the relative magnitude of bone loss reported for individual protease inhibitors. We also review the potential mechanisms associated with protease inhibitor-induced bone loss.

Recent findings

As a class, protease inhibitors contribute to a greater degree of bone loss than other anchor drugs. HIV disease reversal and the associated immune reconstitution following cART initiation play an important role in protease inhibitor-mediated bone loss in addition to plausible direct effects of protease inhibitors on bone cells.

Summary

Protease inhibitors remain an important component of cART despite their adverse effects on bone. A better understanding of factors that drive HIV/cART-induced bone loss is needed to stem the rising rate of fracture in the HIV-infected population.

FULL TEXT

http://journals.lww.com/co-hivandaids/Fulltext/2016/05000/The_protease_inhibitors_and_HIV_associated_bone.12.aspx

PDF (CLIC in PDF)

August 2, 2016 at 8:22 am

Tenofovir and bone health

Current Opinion In HIV and AIDS May 2016 V.11 N.3 P.326–332

Grant, Philip M.; Cotter, Aoife G.

aDivision of Infectious Diseases; Department of Medicine; Stanford University, Palo Alto, CA, USA

bHIV Molecular Research Group, School of Medicine & Medical Science, University College Dublin

cDepartment of Infectious Diseases, Mater Misericordiae University Hospital, Dublin, Ireland

Purpose of review

With continued improvements to the antiviral efficacy and tolerability of antiretroviral therapy, long-term safety of antiretroviral therapy has become paramount. Low bone mineral density and fragility fractures are more common in HIV-infected individuals than in the general population. The aims of this review are to describe potential mechanisms underlying the adverse effects of tenofovir on bone, clinical studies of tenofovir disoproxil fumarate (TDF) and bone, and more recent bone data on tenofovir alafenamide.

Recent finding

Several studies have demonstrated an approximately 1–3% greater bone mineral density loss with TDF compared with other agents. Recent studies with tenofovir alafenamide have shown improved bone (and renal) safety with similar virologic efficacy when compared to TDF.

Summary

Given these findings, TDF-containing regimens may be gradually replaced with non-TDF containing regimens for the treatment of HIV infection, especially in those at higher risk for fragility fracture.

FULL TEXT

http://journals.lww.com/co-hivandaids/Fulltext/2016/05000/Tenofovir_and_bone_health.11.aspx

PDF (CLIC in PDF)

August 2, 2016 at 8:21 am

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