Embed Size (px)
Citation preview
Cardiovascular risk in HIV, ART and
recent clinical trials data
Benjamin Young
International Association of Providers of AIDS Care
Washington, DC, USA
Disclosures
• Speakers Bureau/ Consultant:
Bristol-Myers Squibb
Gilead Sciences
Merck & Co
ViiV Healthcare
• Research Funding
Gilead Sciences
ViiV Healthcare
Overview
• Aging and non-communicable diseases
– Cardiovascular disease
• Emerging treatment paradigms
• Clinical trials data
– STARTMRK
– ACTG 5257
NON-COMMUNICABLE DISEASES
AND HIV
DHHS, 2014
DHHS Recommendations
Schouten, XIX IAC, 2012
Schouten, XIX IAC, 2012
Lancet, 2014
CARDIOVASCULAR DISEASE AND
HIV
Lichtenstein, Clin Infect Dis 2010
Van Zoest, 16th Intl Workshop on Co-morbidities and Adverse Drug Reactions, 2014
Post, Ann Int Med, 2014
Coronary artery plaque is more prevalent (RR 0.14-0.35)
and extensive among HIV+ men, independent of CAD risk
factors.
Bavinger, PLOS One, 2013
• 27 study meta-analysis shows mixed evidence of
relationship
• Increase in MI risk recently exposed:
– abacavir (RR 1.92, 95% CI 1.5-2.4)
– protease inhibitors (RR 2.12, 95% CI 1.06-4.28)
• Increase risk with additional year of exposure:
– indinavir (RR 1.11, 95% CI 1.05-1.17)
– lopinavir (RR 1.22, 95% CI 1.01-1.47)
• Four published meta-analyses of randomized trials, found
no increased risk of CVD.
CVD AND HIV GUIDELINES
EVOLVING ART
CONSIDERATIONS
New combinations, superior tolerability
“…the available evidence renders the discussion on
when to start ART unnecessary and that, instead,
efforts should be aimed at offering treatment as
soon as possible.”
Sigaloff, Lange, Montaner, Clin Infect Dis 2014
Evolving ART Combinations
DHHS Panel, 2014
Evolving ART Combinations
EACS, 2014
Evolving ART Tolerability: SPRING-2
Raffi, et al., Lancet, 2013
Evolving first-line ART: Integrase Inhibitor-based Treatments
• DTG superior to EFV
– SINGLE (Walmsley, New Engl J Med, 2013)
• DTG superior to DRV/r
– FLAMINGO (Clotet, Lancet 2014)
• RAL superior to EFV
– STARTMRK 5 year analysis (Rockstroh, JAIDS 2013)
• RAL superior to DRV/r and ATV/r
– ACTG 5257 (Landovitz, CROI 2014)
CLINICAL TRIALS DATA
Focusing on raltegravir
STARTMRK (192 WEEK)
ACTG 5257
EVOLVING TARGETS
Ending epidemic AIDS
Evolving Targets
UNAIDS, 2014
Normal Life Expectancy?
Cardiovascular disease and HIV
• HIV populations are getting older
• Cardiovascular disease is a major cause of
morbidity and mortality in the HIV community
– Risk factors are common
– Association with ART debated
• Evidence-based guidelines for managing non-
communicable diseases
ART and Raltegravir
• Expanding treatment recommendations
• RAL-regimens on DHHS, EACS and BHIVA
guidelines
• RAL superior vs EFV year 4, 5 (STARTMRK)
• RAL superior vs ATV/r and DRV/r (ACTG 5257)
• Favorable:
– Tolerability
– Safety/toxicity profile
Summary
• Aging of HIV populations around the world
• Increasing importance of non-communicable diseases
• Cardiovascular disease significant cause of morbidity and
mortality
– Treatment guidelines recommend prevention/treatment
• Evolving antiretroviral treatment guidelines
– Many agencies now recommend treatment for all
• Increasing role of HIV integrase inhibitors
– Superior safety and efficacy profile, compared with previous
standards
• Ending AIDS is possible
