Susan M Graham Assistant Professor Medicine and Global Health Adjunct Assistant Professor Epidemiology Presentation prepared by Susan M Graham Last Updated October 22 2014 Susan M Graham MD MPH PhD ID: 546475
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Slide1
ART Initiation in Resource-Limited Settings
Susan M. Graham Assistant Professor, Medicine and Global HealthAdjunct Assistant Professor, Epidemiology
Presentation prepared by:
Susan M. Graham
Last Updated:
October 22, 2014Slide2
Susan M. Graham, MD MPH PhD
ART Initiation in Resource-Limited SettingsDr. 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.Slide3
Outline
ART Scale-up and Its EffectsHIV Care in RLSTreatment eligibilityCare cascadeDiagnostic testingTB/HIV co-infectionInitial treatment regimensPrognosis following immigration to USSlide4
UNAIDS Global Report 2013
ART Scale-up ContinuesSlide5
UNAIDS Global Report 2013
Decreasing MortalityThe 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 2005Slide6
WHO Treatment Eligibility
World Health Organization treatment guidelinesTarget population200620102013
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)Slide7
Late Presentation
Median CD4 count at ART initiation, although increasing, has been far lower than 350 in almost all settingsLate presentation associated with high early mortality rates and poor retention in careHIV stigma is a huge barrier in many areas, and may be worse for men in generalAdditional stigma and criminalization are important barriers for many high-risk groups includingmen who have sex with menpersons who use drugssex workersKoller
JAIDS 2014, WHO ART Guidelines 2013Slide8
Care Cascade
Increasing knowledge of HIV status, linkage to care if positive, and optimal retention and adherence remain significant challengesCurrently, about half the people living with HIV globally do not know their HIV status.In a systematic review of programs for HIV+ patients in sub-Saharan 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 2011Slide9
Recommended Baseline Diagnostic Testing
Purpose200620102013Monitoring treatmentCD4 countCD4 count
CD4 count
Monitoring for toxicities
Hemoglobin if AZT
CBC with differential
Hemoglobin if AZT
Desirable/targeted:
ALT if
NVP
Creatinine clearance if TDF
Desirable/targeted:
Hemoglobin if AZT
ALT if
NVP
Creatinine clearance and urine dipstick for glycosuria if TDF
Choice of regimen
Pregnancy test if EFZ
Desirable:
Pregnancy
test
Co-infections
and comorbidities
Screen for TB
Screen for malaria
Screen for TBDesirable:HBV (HBsAg) serologyScreen for TBDesirable:Blood pressure measurementHBV (HBsAg) serologyHCV serologyCryptococcus antigen if CD4 count ≤100STD screening “Assessment for major noncommunicable chronic diseases and comorbidities” (CVD, DM)
WHO Treatment GuidelinesSlide10
TB/HIV co-infection
Since 2004, TB-related deaths among people living with HIV have declined by 36% worldwideThe decline is slightly less in Africa, home to 75% of all people living with TB and HIVTB incidence highest in countries with highest HIV prevalence (Swaziland, Lesotho, South Africa)UNAIDS Global Report 2013, WHO Global Tuberculosis Report 2014Slide11
Initial Treatment Regimens
Population20062010
2013
HIV+ ARV-naive
adults and
adolescents
AZT or d4T + 3TC (or FTC) + EFV or NVP
TDF possible as substitute for AZT, but not widely available
AZT or TDF + 3TC (or FTC) + EFV or NVP
Phase out d4T as feasible
TDF + 3TC (or FTC) + EFV preferred
Alternatives:
AZT + 3TC + EFV
AZT + 3TC + NVP
TDF + 3TC (or FTC) + NVP
Discontinue d4T
HIV+ pregnant
women
AZT + 3TC + NVP
AZT or TDF + 3TC (or FTC) + EFV or NVP
AZT preferred over TDF
EFV included as option (but not during first trimester)
HIV/TB
coinfection
AZT or d4T + 3TC (or FTC) + EFV
AZT + 3TC + ABCAZT or TDF + 3TC (or FTC) + EFVInitiated as soon as possible in all patients with active TB (within 8 wks after TB treatment)HIV/HBVcoinfection
TDF + 3TC (or FTC) + EFV
NNRTI regimens that contain both TDF + 3TC
(or FTC) are required
WHO Treatment GuidelinesSlide12
Prognosis Following Immigration
In CA, foreign-born TB patients more likely than U.S.-born patients to have new HIV diagnosesgreater immunosuppression at TB diagnosisART or treatment for latent TB infection could have prevented TBIn Antiretroviral Therapy Cohort Collaboration, TB commonDuring first year of ART, HIV-positive migrants had higher rates of AIDS-defining events than nonmigrantsTB most common ADE among migrantsIn 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