Christopher Mathews, M.D. Director, Owen Clinic University of California, San Diego What Every...
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Christopher Mathews, M.D. Christopher Mathews, M.D. Director, Owen Clinic Director, Owen Clinic University of California, San University of California, San Diego Diego What Every Internist Should Know About HAART in 2003
Christopher Mathews, M.D. Director, Owen Clinic University of California, San Diego What Every Internist Should Know About HAART in 2003
Christopher Mathews, M.D. Director, Owen Clinic University of
California, San Diego What Every Internist Should Know About HAART
in 2003
Slide 2
Outline Historical milestones in HIV treatment Current
treatment strategies Drug toxicities Resistance testing Drug
interactions Medication Adherence Immune Recovery Inflammatory
Diseases Resources for staying up to date
Slide 3
Milestones of Therapy Licensure of antiretroviral agents in the
United States Trends in virologic suppression among patients under
care Trends in mortality
Slide 4
Slide 5
Proportion 60,00020 - 60,000 6 - 20,000 1 - 5,000
Considerations in Initiating Therapy HIV Asymptomatic
Theoretical benefit No proven long-term clinical benefit for CD4
>200 cells/ml 3 Expert opinion advises initiation of therapy for
CD4 350 cells/ml 3 CD4+ T cell The downside of antiretroviral
regimens QOL Short- and long-term toxicities
Slide 12
Risks and Benefits of Delayed Initiation of Therapy Benefits of
delayed therapy Avoid negative effects on quality of life (e.g.
inconvenience) Avoid drug-related adverse events Delay in
development of drug resistance Preserve maximum number of available
and future drug options when HIV disease risk is greatest Risks of
delayed therapy Possible risk of irreversible immune system
depletion Possible greater difficulty in suppressing viral
replication Possible increase risk of HIV transmission
Slide 13
Risks and benefits of early initiation of therapy Benefits of
early therapy Control of viral replication easier to achieve and
maintain Delay or prevention of immune system compromise Lower risk
of resistance with complete viral suppression Possible decreased
risk of HIV transmission Risks of early therapy Drug-related
reduction in quality of life Greater cumulative drug-related
adverse events Earlier development of drug resistance, if viral
suppression is suboptimal Limitation of future antiretroviral
treatment options
Slide 14
Goals of Therapy Maximal and durable suppression of viral load
Restoration and/or preservation of immunologic function Improvement
of quality of life Reduction of HIV-related morbidity and
mortality
Slide 15
Tools to Achieve Goals of Therapy Maximize adherence to the
antiretroviral regimen Rational sequencing of drugs Preservation of
future treatment options Use of resistance testing in selected
clinical settings
Slide 16
Considerations in Initiating Therapy HIV Asymptomatic
Willingness of patient to begin and the likelihood of adherence
Degree of immunodeficiency Plasma HIV RNA Risk of disease
progression Potential risks and benefits
Slide 17
Indications for ART in the Chronically HIV-Infected Patient
TREAT ALL (regardless of viral load) Symptomatic (AIDS, severe
symptoms) Asymptomatic, CD4+ 200/mm 3 but 200/mm 3 but
Slide 18
Indications for ART in the Chronically HIV-Infected Patient
TREATAsymptomatic, CD4+ >350/mm 3 and HIV RNA>55,000(RT-PCR
or bDNA)* * Some experts would recommend initiating therapy,
recognizing that the 3 year risk of developing AIDS in untreated
patients is >30%. In the absence of very high levels of plasma
HIV RNA, some would defer therapy and monitor the CD4+ and level of
plasma HIV RNA more frequently. Clinical outcomes data after
initiating therapy are lacking.
Slide 19
Indications for ART in the Chronically HIV-Infected Patient
DEFER TREATMENT Asymptomatic CD4+ cells > 350/mm 3 HIV RNA