Download art_initiation_in_re.. - University of Washington

NORTHWEST AIDS EDUCATION AND TRAINING CENTER
ART Initiation in Resource-Limited Settings
Susan M. Graham
Assistant Professor, Medicine and Global Health
Adjunct Assistant Professor, Epidemiology
Presentation prepared by:
Susan M. Graham
Last Updated: October 22, 2014
NORTHWEST AIDS EDUCATION AND TRAINING CENTER
ART Initiation in Resource-Limited Settings
Susan M. Graham, MD MPH PhD
Dr. Graham is a member of the Kenya Research Group at the University of Washington. She began
working with the University of Nairobi/UW Mombasa Field Site in 2003 as an Infectious Diseases
Fellow, and developed the ART program offered at the UW research clinic here and another site north
of Mombasa. Her research interests focus on access to and engagement in care for most at-risk
populations in Kenya, including female sex workers and men who have sex with men. Dr. Graham
holds a medical degree from McGill University, an MPH from Boston University, and a PhD in clinical
epidemiology from the University of Toronto.
Outline
• ART Scale-up and Its Effects
• HIV Care in RLS
-
Treatment eligibility
Care cascade
Diagnostic testing
TB/HIV co-infection
Initial treatment regimens
• Prognosis following immigration to US
ART Scale-up Continues
UNAIDS Global Report 2013
Decreasing Mortality
The number of AIDS deaths is declining with 1.6 (1.4–1.9) million
in 2012, down from 2.3 (2.1–2.6) million in 2005
UNAIDS Global Report 2013
WHO Treatment Eligibility
Target population
2006
2010
2013
HIV+ asymptomatic
ARV-naive individuals
CD4 ≤200
CD4 ≤350
CD4 count < 500, irrespective of
WHO clinical stage
HIV+ symptomatic
ARV-naive individuals
• WHO stage 2 or 3 and CD4 ≤200
• WHO stage 3 if CD4 200-350 or
not available
• WHO stage 4, irrespective of
CD4 count
• WHO clinical stage 2 if CD4
≤350
• WHO clinical stage 3 or 4,
irrespective of CD4 count
WHO Stage 3 or 4, irrespective of
CD4 count
HIV+ pregnant women
• WHO stage 1 or 2 and CD4 ≤200
• WHO stage 3 and CD4 ≤350
• WHO stage 4, irrespective of
CD4 count
• CD4 ≤350, irrespective of
clinical symptoms
• WHO clinical stage 3 or 4,
irrespective of CD4 count
Pregnant or breastfeeding
women, irrespective of CD4 count
or clinical stage
HIV/TB co-infection
ARV-naive individuals
Active TB disease and CD4 ≤350
Active TB disease, irrespective
of CD4 cell count
Active TB disease, irrespective of
CD4 cell count
HIV/HBV co-infection
ARV-naive individuals
No specific
recommendation
Individuals who require
treatment for their HBV
infection, irrespective of
CD4 cell count
Individuals who require
treatment for their HBV
infection, irrespective of
CD4 cell count
HIV+ individuals with
in serodiscordant
relationships
No specific
recommendation
No specific
recommendation
Provide ART to all partners
infected with HIV
regardless of CD4 cell count (to
reduce the risk of
HIV transmission to the negative
partner)
World Health Organization treatment guidelines
Late Presentation
• Median CD4 count at ART initiation, although increasing,
has been far lower than 350 in almost all settings
• Late presentation associated with high early mortality rates
and poor retention in care
• HIV stigma is a huge barrier in many areas, and may be
worse for men in general
• Additional stigma and criminalization are important barriers
for many high-risk groups including
- men who have sex with men
- persons who use drugs
- sex workers
Koller JAIDS 2014, WHO ART Guidelines 2013
Care Cascade
• Increasing knowledge of HIV status, linkage to care if
positive, and optimal retention and adherence remain
significant challenges
• Currently, about half the people living with HIV globally do
not know their HIV status.
• In a systematic review of programs for HIV+ patients in subSaharan Africa, median estimates were:
- 59% (35%–88%) staged clinically or receiving a CD4 count,
- 46% (31%–95%) initially ineligible retained until eligibility,
- 68% (14%–84%) eligible for treatment initiated ART
Rosen PLoS Med 2011
Recommended Baseline Diagnostic Testing
Purpose
2006
2010
2013
Monitoring
treatment
CD4 count
CD4 count
CD4 count
Monitoring for
toxicities
Hemoglobin if AZT
CBC with differential
Hemoglobin if AZT
Desirable/targeted:
• Hemoglobin if AZT
• ALT if NVP
• Creatinine clearance and urine dipstick for
glycosuria if TDF
Desirable/targeted:
• ALT if NVP
• Creatinine clearance if TDF
Choice of regimen
Pregnancy test if EFZ
Co-infections and
comorbidities
Screen for TB
Screen for malaria
WHO Treatment Guidelines
Desirable:
Pregnancy test
Screen for TB
Screen for TB
Desirable:
• HBV (HBsAg) serology
Desirable:
• Blood pressure measurement
• HBV (HBsAg) serology
• HCV serology
• Cryptococcus antigen if CD4 count ≤100
• STD screening
• “Assessment for major noncommunicable chronic
diseases and comorbidities” (CVD, DM)
TB/HIV co-infection
• Since 2004, TB-related
deaths among people
living with HIV have
declined by 36%
worldwide
• The decline is slightly
less in Africa, home to
75% of all people living
with TB and HIV
• TB incidence highest in
countries with highest
HIV prevalence
(Swaziland, Lesotho,
South Africa)
UNAIDS Global Report 2013, WHO Global Tuberculosis Report 2014
Initial Treatment Regimens
Population
2006
2010
HIV+ ARV-naive
adults and
adolescents
AZT or d4T + 3TC (or FTC) + EFV or
NVP
AZT or TDF + 3TC (or FTC) + EFV or
NVP
TDF possible as substitute for AZT,
but not widely available
Phase out d4T as feasible
AZT + 3TC + NVP
AZT or TDF + 3TC (or FTC) + EFV or
NVP
HIV+ pregnant
women
AZT preferred over TDF
EFV included as option (but not
during first trimester)
HIV/TB
coinfection
HIV/HBV
coinfection
AZT or d4T + 3TC (or FTC) + EFV
AZT or TDF + 3TC (or FTC) + EFV
AZT + 3TC + ABC
Initiated as soon as possible in all
patients with active TB (within 8 wks
after TB treatment)
TDF + 3TC (or FTC) + EFV
NNRTI regimens that contain both
TDF + 3TC
(or FTC) are required
WHO Treatment Guidelines
2013
TDF + 3TC (or FTC) + EFV
preferred
Alternatives:
AZT + 3TC + EFV
AZT + 3TC + NVP
TDF + 3TC (or FTC) + NVP
Discontinue d4T
Prognosis Following Immigration
• In CA, foreign-born TB patients more likely than U.S.-born
patients to have new HIV diagnoses
- greater immunosuppression at TB diagnosis
- ART or treatment for latent TB infection could have prevented TB
• In Antiretroviral Therapy Cohort Collaboration, TB common
- During first year of ART, HIV-positive migrants had higher rates of AIDSdefining events than nonmigrants
• TB most common ADE among migrants
• In NY State from 2001 to 2009
- New HIV diagnoses among FB increased from 17% to 28% of total
- Compared with NFB, FB persons were significantly more likely to be
diagnosed concurrently with AIDS and had lower median CD4 count
- FB persons less likely to have insurance, and 13% needed language
interpretation services
Kong Public Health Rep 2014, ART-CC AIDS 2013, Wiewel STI 2013