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ART Initiation in Resource-Limited Settings ART Initiation in Resource-Limited Settings

ART Initiation in Resource-Limited Settings - PowerPoint Presentation

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ART Initiation in Resource-Limited Settings - PPT Presentation

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