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A Look Back at the International AIDS Conference Meeting Lessons from IAC 2010 A Clinical Context Report.

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Presentation on theme: "A Look Back at the International AIDS Conference Meeting Lessons from IAC 2010 A Clinical Context Report."— Presentation transcript:

1 A Look Back at the International AIDS Conference Meeting Lessons from IAC 2010 A Clinical Context Report

2 Jointly Sponsored by: and MedPage Today A Look Back at the International AIDS Conference Meeting—Lessons from IAC 2010

3 Supported in part by an educational grant from Bristol-Myers Squibb A Look Back at the International AIDS Conference Meeting—Lessons from IAC 2010

4 Clinical Context Series Target Audience The goal of this program is to provide HIV/AIDS specialists, virologists, infectious disease specialists, experts in the care of patients with HIV/AIDS, physician assistants and nurse practitioners with up-to-date information and multiple perspectives on the pathogenesis, symptoms, risk factors, and complications of HIV/AIDS as well as current and emerging treatments and best practices in the management of HIV/AIDS.

5 Activity Learning Objectives Discuss the results of this report from IAC Discuss the results of this report from IAC

6 CME Information: Physicians Statement of Accreditation Statement of Accreditation This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through joint sponsorship of Albert Einstein College of Medicine and MedPage Today. Albert Einstein College of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

7 CME Information Credit Designation Credit Designation Albert Einstein College of Medicine designates this educational activity for a maximum of 0.25 AMA PRA Category 1 Credits.™ Physicians should only claim credit commensurate with the extent of their participation in the activity.

8 CME Information: Nurses Statement of Accreditation Statement of Accreditation –Projects In Knowledge, Inc. (PIK) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. –Projects In Knowledge is also an approved provider by the California Board of Registered Nursing, Provider Number CEP-15227. –This activity is approved for 0.58 nursing contact hours. DISCLAIMER: Accreditation refers to educational content only and does not imply ANCC, CBRN, or PIK endorsement of any commercial product or service.

9 CME Information: Pharmacists Projects In Knowledge ® is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education. This program has been planned and implemented in accordance with the ACPE Criteria for Quality and Interpretive Guidelines. This symposium is worth up to 0.25 contact hours (0.025 CEUs). The ACPE Universal Activity Number assigned to this knowledge-type activity is 0052-0000-10-1649-H01-P. Projects In Knowledge ® is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education. This program has been planned and implemented in accordance with the ACPE Criteria for Quality and Interpretive Guidelines. This symposium is worth up to 0.25 contact hours (0.025 CEUs). The ACPE Universal Activity Number assigned to this knowledge-type activity is 0052-0000-10-1649-H01-P.

10 Barry S. Zingman, MD Medical Director AIDS Center Montefiore Medical Center Professor of Clinical Medicine Albert Einstein College of Medicine Bronx, NY Discussant

11 Disclosure Information Barry S. Zingman, MD, has disclosed that he has no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

12 Disclosure Information have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity. Dori F. Zaleznik, MD, Associate Clinical Professor of Medicine, Harvard Medical School, Boston; Michael Smith and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner, have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity. have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity. The staff of Albert Einstein College of Medicine, MedPage Today, and Projects In Knowledge have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

13 Disclaimer The moderators/authors have attempted to provide the most current and accurate clinical information according to accepted medical practice standards at the time of publication. The information should not be considered to be completely error-free or to include all relevant information; nor should it be used as an exclusive basis for decision- making. Neither Albert Einstein College of Medicine, Montefiore Medical Center, MedPage Today nor Bristol-Myers Squibb, the authors or any other party involved in the preparation of this work and the presentations contained herein warrant that the information is accurate or complete and are not responsible for any errors or omissions or for the results obtained from the use of such information. You are encouraged to consult other sources and confirm the information contained herein. Use of the information is strictly voluntary and at the user's sole risk. If misleading or otherwise inappropriate information is brought to our attention, a reasonable effort will be made to correct or delete it. Such concerns or any other questions or problems about the information should be sent to cme@montefiore.org.

14 Summary The most recent guidelines suggest that HIV therapy should start at a CD4 count of at least 500 The most recent guidelines suggest that HIV therapy should start at a CD4 count of at least 500 The treatments of choice to start therapy are now, increasingly, fixed dose combination pills The treatments of choice to start therapy are now, increasingly, fixed dose combination pills A vaginal microbicide that includes an antiretroviral drug, tenofovir, has shown efficacy in preventing HIV acquisition in a randomized controlled trial A vaginal microbicide that includes an antiretroviral drug, tenofovir, has shown efficacy in preventing HIV acquisition in a randomized controlled trial The product has also appeared to lower the risk of acquiring herpes simplex virus 2, a known risk factor for HIV The product has also appeared to lower the risk of acquiring herpes simplex virus 2, a known risk factor for HIV

15 Recommendations for Initiating Antiretroviral Therapy (ART) in Treatment-Naïve Adults with HIV-1 Infection Who Are Ready to Begin Therapy ART is recommended regardless of CD4 cell count for persons with symptomatic HIV disease, pregnancy, active HBV or HCV co-infection, or those at high risk for secondary HIV transmission ART is recommended for asymptomatic adults with CD4 cell counts  500/μL ART should be considered in patients who are asymptomatic with CD4 cell counts > 500/μL, unless the patient is an elite controller (HIV-RNA <50 copies/mL) or has a stable CD4 count and low-level viremia in the absence of ART

16 Why Start ART Earlier NA-ACCORD study demonstrated that there was lower mortality, as well as significantly lower non-age defining events, if people were started on ART before their T-cell count dropped to 500 If therapy is not started until the patient’s CD4 count is <500, there is a lower chance that CD4 count will become normal on therapy Several studies have demonstrated that HIV transmission between serodiscordant couples and in injection drug users is decreased with ART

17 CASCADE Cohort 9,455 HIV recent seroconverters, avg. age 30 812 (8.6%) developed AIDS 544 (5.8%) died Relative effects: AIDS/Death CD4 count 0-49 – Incidence Rate per 1000 person years 193.3 Defer ART, 55.0 Initiate – adjusted HR 0.32 (95% CI 0.17,0.59) CD4 50-199 – IR 56.6 Defer, 22.0 Initiate aHR 0.48 (0.31, 0.74 CD4 200-349 – IR 29.4 Defer, 18.7 Initiate aHR 0.59 (0.43, 0.81) CD4 350-499 – IR 20.8 Defer, 17.2 Initiate aHR 0.75 (0.49,1.14) CD4 500-799 – IR 18.5 Defer, 14.9 Initiate aHR 1.10 (0.67, 1.79)

18 CASCADE Caveats Retrospective study of patients who had recently seroconverted Significantly smaller than the 20,000 to 50,000 patients followed over years in NA-ACCORD and HIV- CAUSAL Looked only at death not AIDS-related cancers Cardiovascular disease CD4 counts Prevention of kidney disease

19 New Treatment Recommendations, ISA-USA The committee came out in favor of fixed-dose combinations Tenofovir/emtricitabine number one recommended NRTI combination Abacavir/lamivudine secondary NRTI Third component should be either Efavirenz A ritonavir-boosted protease inhibitor such as darunavir/ritonavir or atazanavir/ritonavir Integrase inhibitor raltegravir Lopinavir/ritonavir moved to 2 nd line because of toxicity

20 # HIV infections/ women years HIV incidence Incidence Rate Ratio P Value Tenofovir Placebo Tenofovir gel Placebo gel Overall effectiveness of tenofovir gel HIV endpoints 38 / 680.6 60 / 660.7 5.6 9.1 0.61 0.017 HIV endpoints by levels of adherence High adherers (>80% gel adherence) 11 / 259.2 25 / 269.4 4.2 9.3 0.46 0.025 Intermediate adherers (50-80% adherence) 10 / 159.8 10 / 99.7 6.3 10 0.62 0.343 Low adherers (<50% gel adherence) 16 / 258.5 25 / 290.6 6.2 8.6 0.72 0.303 Modified from Karim, et al. Effectiveness and Safety of Tenofovir Gel, an Antiretroviral Microbicide, for the Prevention of HIV Infection in Women. Science. Published Online July 19, 2010 at: http://www.sciencemag.org/cgi/rapidpdf/science.1193748.pdf. Reprinted with permission from AAAS.

21 Impact of Tenofovir Gel on HSV-2 Incidence Tenofovir gel n=202 Placebo gel n=224 # HSV-2 infections2958 Women-years (wy) of follow-up292.3287.3 HSV-2 incidence per 100wy (95% CI) 9.9 (6.6, 14.2) 20.2 (15.3, 26.1) IRR = 0.49 (CI:0.30, 0.78); P = 0.003 51% protection against HSV-2 by tenofovir gel (CI: 22%70%) Results of the CAPRISA 004 Trial. Presented by Salim Abdool Karim, July 20, at the XVIII International AIDS Conference, Vienna, Austria. Oral Abstract TUSS0504.


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