LONG TERM MANAGEMENT OF HIV PATIENTS

1
LONG TERM MANAGEMENT OF HIV PATIENTS

• S DE WIT
• Brussels

Montpellier, september 2007
2
Durability of Clinical Effect of HAART Incidence
of AIDS and Death 1994-2000
EuroSIDA
EuroSIDA November 2000
3
Reduction in AIDS-Related Mortality Western
European Countries (1998-2002)
Spain
Italy
Number of Deaths
France
Portugal
United Kingdom
Germany
1998 1999 2000
2001 2002 2003
2004
UNAIDS Surveillance in Europe 2004. End-of-year
report. Available at http//www.eurohiv.org/repor
ts/report_71/pdf/report_eurohiv_71.pdf.
4
Causes of death in DAD 2000-2004 percentage /
year
Total deaths 1248
CVD

Weber et al, CROI, 2005
5
Risk of disease progression andcurrent CD4
lymphocyte cell count
300 250 200
150 100 50 0

EuroSIDA
6
Immunosuppression increases risk of non-HIV
related death (DAD Study)
RR of death according to immune function and
specific cause

• Cohort study of gt23,000 patients in Europe,
  Australia, and the USA
• 1,248 (5.3) deaths 20002004(1.6/100
  person-years)
• Of these, 82 on ART
• Leading causes of death were AIDS (30), liver
  disease (14, of which 79 associated with viral
  hepatitis),heart disease 9, and malignancy (8)
• Both HIV- and nonHIV-related mortality were
  associated with CD4 cell count depletion,
  suggesting role for immunosuppression in causes
  of death typically considered not HIV-related

Liver-related Chronic viral hepatitis, liver
failure (other) Malignancy-related Malignancy,
non-AIDS hepatitis Heart-related MI, other CVD,
other heart disease
Weber R, et al. Arch Int Med 2006
7
CD4 cell recovery with well-controlled HIV-1
infection
Battegay M, et al. Lancet Infect Dis 2006
628087
8
Prognosis From Starting HAART
50-99
Egger M, et al. Lancet. 2002360119-129.
9
Reasons for AIDS-related deaths in populations
with unlimited access to ART

• Opportunistic diseases while ART is restoring
  immune function
• Immune reconsitution syndrome
• Ongoing infection when ART is initiated
  associated with low CD4 count
• Develops within first 3-4 months of starting ART
• New disease due to continued immunodeficiency
• Opportunistic diseases at un-usual high CD4
  counts
• Eg. TB, focal infections with eg. MAC/CMV, NHL
• Associated with low nadir CD4 count (Miller et
  al, AIM 1999) and risk of exposure (eg. TB)
• Opportunistic infections associated with
  virological and subsequent immunological failure
  of ART

10
Reasons for AIDS-related deaths in populations
with unlimited access to ART
Management strategy

• Opportunistic diseases while ART is restoring
  immune function
• Immune reconsitution syndrome
• Ongoing infection when ART is initiated
  associated with low CD4 count
• Develops within first 3-4 months of starting ART
• New disease due to continued immunodeficiency
• Opportunistic diseases at un-usual high CD4
  counts
• Eg. TB, focal infections with eg. MAC/CMV, NHL
• Associated with low nadir CD4 count (Miller et
  al, AIM 1999) and risk of exposure (eg. TB)
• Opportunistic infections associated with
  virological and subsequent immunological failure
  of ART

Start ART earlier in the course of the chronic
HIV infection
Virological management
11
CD4 count at start of ART, 20035

• Review of data from 42 countries, 176 sites
  n33,008
• Since 2000, CD4 cell count at initiation has
  increased in Sub-Saharan Africafrom 50 to 100
  cells/mm3 in developed countries it has remained
  stable at150200 cells/mm3

Egger M, et al. 14th CROI, Los Angeles 2007, 62
12
The Brussels Saint Pierre Cohort Biological
characteristics of naive patients starting
treatment by year
13
CD4 cell recovery and different degrees of
suppression of plasma HIV-1 RNA
Battegay M, et al. Lancet Infect Dis 2006
628087
14
The Brussels Saint Pierre Cohort Viral load
response to first line therapy for treatment
started in 2006 (On treatment)
15
Declining Incidence of Initial HAART Failure
During 1st Year of Treatment

• Data from 5 observational cohorts from Europe and
  North America on patients starting HAART
  1996-2002 (n 4143)
• Incidence of virologic failure (VL gt 500 c/mL
  6-12 months after initiating HAART) evaluated by
  calendar year
• VL failure declined significantly from 1996 to
  2002 (P lt .001)
• Risk of VL failure was lower with
• Older age
• Homosexual exposure to HIV
• Lower baseline VL
• Absence of AIDS diagnosis at time of HAART
  initiation

Patients With Virologic Failure by Year of
Starting HAART
50
42
40
39
40
34
31
30
30
25
Patients ()
20
10
0
1996
1997
1998
1999
2000
2001
2002
Lampe F, et al. CROI 2005. Abstract 593.
16
Anti VIH drugs 2007
Reverse transcriptase inhibitors Protease
inhibitors nucleosides analogues -
zidovudine (AZT, ZDV) - saquinavir (SQV) -
didanosine (ddl) - ritonavir (RTV) -
lamivudine (3TC) - indinavir (IDV) -
stavudine (d4T) - nelfinavir (NFV) - abacavir
(ABC) - fosamprenavir (FAPV) - emtricitabine
(FTC) - lopinavir/r (LPV/r) nucleotide analogue
- atazanavir (ATV) - tenofovir (TFV) -
tipranavir (TPV) - darunavir (TMC
114) non-nucleosides Fusion inhibitors -
nevirapine (NVP) -enfuvirtide (T20) - efavirenz
(EFV) - etravirine (TMC 125)
17
Anti VIH drugs 2007
Reverse transcriptase inhibitors Protease
inhibitors nucleosides analogues -
zidovudine (AZT, ZDV) - saquinavir (SQV) -
didanosine (ddl) - ritonavir (RTV) -
lamivudine (3TC) - indinavir (IDV) -
stavudine (d4T) - nelfinavir (NFV) - abacavir
(ABC) - fosamprenavir (FAPV) - emtricitabine
(FTC) - lopinavir/r (LPV/r) nucleotide analogue
- atazanavir (ATV) - tenofovir (TFV) -
tipranavir (TPV) - darunavir (TMC
114) non-nucleosides Fusion inhibitors -
nevirapine (NVP) -enfuvirtide (T20) - efavirenz
(EFV) - etravirine (TMC 125)
18
Anti VIH drugs 2007
Reverse transcriptase inhibitors Protease
inhibitors nucleosides analogues -
zidovudine (AZT, ZDV) - saquinavir (SQV) -
didanosine (ddl) - ritonavir (RTV) -
lamivudine (3TC) - indinavir (IDV) -
stavudine (d4T) - nelfinavir (NFV) - abacavir
(ABC) - fosamprenavir (FAPV) - emtricitabine
(FTC) - lopinavir/r (LPV/r) nucleotide analogue
- atazanavir (ATV) - tenofovir (TFV) -
tipranavir (TPV) - darunavir (TMC
114) non-nucleosides Fusion inhibitors -
nevirapine (NVP) -enfuvirtide (T20) - efavirenz
(EFV) - etravirine (TMC 125)
19
Anti VIH drugs 2007
Reverse transcriptase inhibitors Protease
inhibitors nucleosides analogues -
zidovudine (AZT, ZDV) - saquinavir (SQV) -
didanosine (ddl) - ritonavir (RTV) -
lamivudine (3TC) - indinavir (IDV) -
stavudine (d4T) - nelfinavir (NFV) - abacavir
(ABC) - fosamprenavir (FAPV) - emtricitabine
(FTC) - lopinavir/r (LPV/r) nucleotide analogue
- atazanavir (ATV) - tenofovir (TFV) -
tipranavir (TPV) - darunavir (TMC
114) non-nucleosides Fusion inhibitors -
nevirapine (NVP) -enfuvirtide (T20) - efavirenz
(EFV) - etravirine (TMC 125)
20
Novel Antiretrovirals in Development
21
Novel Antiretrovirals in Development
22
Sequencing Therapy in 2007

• One plausible scenario
• 2 NRTIs 1 NNRTI
• 3 NRTIs 1 PI/RTV
• 1 PI/RTV CCR5 inhibitor NRTIs
• Integrase inhibitor ENF other CCR5 inhibitor
  PI/RTV
• Maturation inhibitor other entry inhibitor(s)
  ?

• Problems
• People who fail initial therapy may have been
  nonadherent to the simplest of regimens
• The first shot may always be the best shot
• Infection with resistant virus can eliminate many
  initial regimens

23
Treatment opportunities in multi-experienced
patients

• Several new antiretroviral agents from existing
  and novel drug classes have demonstrated
  virologic efficacy in multidrug-resistant
  patients
• With the availability of new agents, the goal of
  treatment is complete viral suppression
  regardless of treatment experience
• New agents are most effective when combined with
  at least 1 other active agent
• Effective use of new agents in treatment-experienc
  ed patients requires strategic planning

24
Treatment Goals for Treatment-Experienced Patients

• Patients with access to 2 active agents
• Completely suppress viral load
• Now applies to an increasing number of salvage
  patients
• Patients with access to lt 2 active agents
• Reduce viral load by 1 log10 Stabilize CD4
  cell count
• Avoid monotherapy of new drug Minimize drug
  toxicity
• Prevent clinical progression and death
• Avoid emergence of new resistance mutations that
  could eliminate future options

25
Interleukin-2

• Questions
• Clinical impact on disease progression?
• Impact on reservoirs and resting T cells?
• Trials are underway

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29
Antiretroviral Therapy Challenges in the Last
Decade

• Pill burden/dose frequency
• Adherence
• Pill fatigue
• Management of toxicities
• Fatigue, gastrointestinal symptoms, CNS events
• Alteration in blood counts, abnormal LFTs,
  dyslipidemia
• Long-term complications
• Metabolic complications, mitochondrial-associated
  toxicity
• Lipodystrophic syndromes

30
Categorizing Antiretroviral Toxicities

• Immediately life threatening
• Potentially fatal
• Acute or short term
• Occur within first few months of beginning
  therapy
• Can affect adherence
• Chronic or long term
• Can occur at any time
• Anticipate in patients on long-term therapy

31
Physical and Metabolic Complications of
Antiretroviral Therapy
32
Incidence of myocardial infarction and duration
of antiretroviral therapy (DAD)
Relative rate per additional year of exposure to
cART 1.17 (95 CI 1.08-1.26)
Incidence / 1000 PY/ 95 CI
cART Exposure (yrs)
None lt1 1-2
2-3 3-4 4-5
5-6 gt6
MI
14 16 22
34 56 55
39 41 277
PYFU
10,103 6,324 8,165
10,846 13,060 12,254 9,073
6,751 76,577
Adjusted for conventional risk factors not
influenced by cART
El-Sadr et al, CROI 2005 (N-186)
33
The outcome X is an adverse event caused by drug
A although both drug A and B also reduced the
risk (as compared with not using them). Other
nonpharmacological factors also influence the
risk of X.
Non-drug factors


Drug(s) A
-
Risk of outcome X
-
Drug(s) B
-
Non-drug factors
34
Absolute versus relative riskimplication for
management

• Absolute risk incidence of disease
• Relative risk difference in incidence between
  two groups of patients (e.g. treated with two
  different medications)
• Certain drugs may cause toxicities
• but the clinical implications hereof is
  determined by the absolute risk of the outcome
  in each individual patient

35
HAART and the Risk of Myocardial Infarction
Updated Data From DAD

• Exposure to elements of HAART
• NNRTI 6.3 years (range 3.8-8.3)
• PI 3.0 years (range 0.5-5.4)
• NNRTI 0.9 years (range 0-3.2)
• Peak RR of MI in 2001 falling since
• Adjustment for lipids largely explains decline in
  MI
• PI exposure associated with similar increased
  risk as HAART exposure
• NNRTI exposure not associated with increased risk
  of MI
• Adjustment for NRTI exposure did not change risk
• Suggests that increased risk previously reported
  with HAART largely driven by PIs

RR of MI by ART Exposure
1.8
1.6
1.4
1.2
1.0
RR of MI
0.8
0.6
0.4
0.2
0
PI
NNRTI
ART
Adjusted for NNRTI exposure. Adjusted for PI
exposure.
Friis-Møller N, et al. CROI 2006. Abstract 144.
36
Contribution of Dyslipidemia to Myocardial
Infarction Risk
0.60 (0.42-0.88) P .008 1.64 (0.98-2.74) P
.06 1.15 (1.06-1.25) P .001 1.10
(1.01-1.19) P .03
HDL cholesterol (per mmol/L)
Triglycerides (per log2 mmol/L higher)
Total cholesterol (per mmol/L)
CART exposure (per additional year)
1
10
0.1
Relative Rate of Myocardial Infarction (95 CI)
Adjusted for conventional risk factors (age,
sex, prior/family history of CVD, smoking) not
influenced by CART.
El-Sadr W, et al. CROI 2005. Abstract 745.
37
Relative Rate of MI according to Calendar Year
of Follow-up
Univariable Model
Total 345 94,469 3.7 / 1000 PY
Events
47 94 67
72 65
PYFU
14666 21554 20655
19617 17978
Incidence
38
Relative Rate of MI according to Calendar Year
of Follow-up
Model adjusted for sex, age, cohort,
prior CVD, family CVD history, smoking,
BMI, cART exposure
Total 345 94,469 3.7 / 1000 PY
Events
47 94 67
72 65
PYFU
14666 21554 20655
19617 17978
Incidence
39
Relative Rate of MI according to Calendar Year
of Follow-up
Model adjusted for sex, age, cohort,
prior CVD, family CVD history, smoking,
BMI, cART exposure, and serum-lipids
(total cholesterol, HDL and
triglycerides)
Total 345 94,469 3.7 / 1000 PY
Events
47 94 67
72 65
PYFU
14666 21554 20655
19617 17978
Incidence
40
Studies of Treatment Interventions for
Dyslipidemia
1. Fisac C, et al. IAC 2002. Abstract ThPe7354.
2. Gatell J, et al. IAC 2006. Abstract THPE0123.
3. Hollowell S, et al. ICAAC 2005. Abstract
H-338. 4. Calza L, et al. AIDS. 2005191051-1058.
41
Treatment Interventions for Lipoatrophy
1. Carr A, et al. JAMA. 2002288207-215. 2.
Martin A, et al. AIDS. 2004181029-1036. 3.
McComsey G, et al. Clin Infect Dis.
200438263-270. 4. Moyle G, et al. CROI 2005.
Abstract 44LB. 5. Milinkovic A, et al. CROI 2005.
Abstract 857. 6. Murphy R, et al. CROI 2005.
Abstract 45LB. 7. Tebas P, et al. CROI 2005.
Abstract 40. 8. Sutinen J , et al. 7th Lipo
Workshop. Abstract. 9. Mallon P, et al. AIDS. In
press. 10. Sutinen J, et al. Antiviral Ther.
20038199-207. 11. Carr A, et al. Lancet.
2004363429-438. 12. Hadigen C, et al. Ann
Intern Med. 2004140786-794. 13. Cavalcanti R,
et al. CROI 2005. Abstract 854.
42
Treatment Interventions for Lipoatrophy
1. Carr A, et al. JAMA. 2002288207-215. 2.
Martin A, et al. AIDS. 2004181029-1036. 3.
McComsey G, et al. Clin Infect Dis.
200438263-270. 4. Moyle G, et al. CROI 2005.
Abstract 44LB. 5. Milinkovic A, et al. CROI 2005.
Abstract 857. 6. Murphy R, et al. CROI 2005.
Abstract 45LB. 7. Tebas P, et al. CROI 2005.
Abstract 40. 8. Sutinen J , et al. 7th Lipo
Workshop. Abstract. 9. Mallon P, et al. AIDS. In
press. 10. Sutinen J, et al. Antiviral Ther.
20038199-207. 11. Carr A, et al. Lancet.
2004363429-438. 12. Hadigen C, et al. Ann
Intern Med. 2004140786-794. 13. Cavalcanti R,
et al. CROI 2005. Abstract 854.
43
Treatment Interventions for Lipoatrophy
1. Carr A, et al. JAMA. 2002288207-215. 2.
Martin A, et al. AIDS. 2004181029-1036. 3.
McComsey G, et al. Clin Infect Dis.
200438263-270. 4. Moyle G, et al. CROI 2005.
Abstract 44LB. 5. Milinkovic A, et al. CROI 2005.
Abstract 857. 6. Murphy R, et al. CROI 2005.
Abstract 45LB. 7. Tebas P, et al. CROI 2005.
Abstract 40. 8. Sutinen J , et al. 7th Lipo
Workshop. Abstract. 9. Mallon P, et al. AIDS. In
press. 10. Sutinen J, et al. Antiviral Ther.
20038199-207. 11. Carr A, et al. Lancet.
2004363429-438. 12. Hadigen C, et al. Ann
Intern Med. 2004140786-794. 13. Cavalcanti R,
et al. CROI 2005. Abstract 854.
44
Treatment Interventions for Lipoatrophy
1. Carr A, et al. JAMA. 2002288207-215. 2.
Martin A, et al. AIDS. 2004181029-1036. 3.
McComsey G, et al. Clin Infect Dis.
200438263-270. 4. Moyle G, et al. CROI 2005.
Abstract 44LB. 5. Milinkovic A, et al. CROI 2005.
Abstract 857. 6. Murphy R, et al. CROI 2005.
Abstract 45LB. 7. Tebas P, et al. CROI 2005.
Abstract 40. 8. Sutinen J , et al. 7th Lipo
Workshop. Abstract. 9. Mallon P, et al. AIDS. In
press. 10. Sutinen J, et al. Antiviral Ther.
20038199-207. 11. Carr A, et al. Lancet.
2004363429-438. 12. Hadigen C, et al. Ann
Intern Med. 2004140786-794. 13. Cavalcanti R,
et al. CROI 2005. Abstract 854.
45
Use and Outcomes of Lipid-Lowering Therapy in
HIV-Infected Patients

• Kaiser Permanente1
• Retrospective analysis of Northern California
  database
• HIV pts monitored more frequently and treated
  more often but lower lipid reductions vs HIV-
  pts after 1 year of LLT
• HIV pts less likely to attain ATP-III goals for
  TC, LDL, and TG
• Ezetimibe study (N 50)3
• Mean 12 ? LDL-C vs 3 ? with placebo at Wk 6 (P
  .02)
• No effect on TG or HDL-C

• DAD substudy on LLT utilization2
• Patients (N 974) with first diabetes diagnosis
  or first CV event
• Overall 45 used LLT
• Increased from lt 20 in 1999 to 70 in 2006
• More common after MI (55) or invasive procedure
  (45) than stroke (30) or diabetes (lt 20)
• Other interventions (ACE inhibitors, anti-HTN)
  more common

1. Silverberg M, et al. CROI 2007. Abstract 814.
2. Sabin C, et al. CROI 2007. Abstract 816. 3.
Wohl D, et al. CROI 2007. Abstract 39.
46
Incidence of DM and exposure to CART
Incidence DM ( per 1000 PYFU)
Exposure to CART

• Unadjusted relative rate per year of exposure to
  cART
• 1.06 ?95 CI 1.03-1.09?, p 0.0001

47
Relationships between exposure to individuals
drugs and incidence of DM

• Adjusted for age, sex, BMI, race, smoking status
  , calendar year and cohort.

48
Relationships between exposure to individuals
drugs and incidence of DM

• Adjusted for age, sex, BMI, race, smoking status
  calendar year and cohort.

49
Relationships between exposure to individuals
drugs and incidence of DM

• Adjusted for age, sex, BMI, race, smoking status
  calendar year and cohort.

50
SMART HIV disease progression and severe
complications
No. of Patients With Events
Subgroups
Relative Risk (95 CI)
2.5
All Patients
164
Sex
2.3
Male
118
3.4
Risk of Disease Progression or Death
Female
46
Race
3.6
Black
71
2.0
Nonblack
93
1.5
Severe Complications
114
1.4
CVD, liver, or renal deaths
31
1.5
Risk of Complications
Nonfatal CVD events
63
1.4
Nonfatal hepatic events
14
2.5
Nonfatal renal events
7
1.0
10.0
0.1
Favors TI
Favors CT
El-Sadr W, et al. CROI 2006. Abstract 106 LB.
51
Traditional Factors Are the Biggest Contributor
to CHD in HIV Population
HIV infection
HAART
Emerging factorsLp (a), CRP, IMT, and
endothelial function
Diabetes
Metabolic syndrome. Precise contribution
unclear.
52
Cardiovascular Assessment

• Estimate overall cardiac risk
• Fasting assessments prior to ART initiation or
  switching, 3 to 6 mos later, and annually during
  stable ART
• Total, HDL-C, and LDL-C, TG, and glucose
• Oral glucose tolerance test in those at risk of
  type 2 diabetes or with severe lipodystrophy
• Assess ALL other modifiable cardiac risk factors
• Blood pressure
• Smoking

Schambelan M, et al. J Acquir Immune Defic Syndr
. 200231257-275.Dube M, et al. Clin Infect Dis
. 200337613-627.Grinspoon S, et al. N Engl J
Med. 200535248-62.
53
Sequencing or Combinations of Lipid Management
Strategies
TREATMENT
PREVENTION
Switch
Pharmacotherapy
LDL-C or TC
TG
If ineffective
Medical Intervention
Lifestyle Modifications
54
Kaplan-Meier Estimates of the Cumulative
Prevalence of Types of HPV DNA in 220
HIV-Seropositive Women and 231 HIV-Seronegative
Women
Sun, X.-W. et al. N Engl J Med 19973371343-1349
55
Anal Cancer Incidence

• Incidence and risk of invasive anal cancer
• Higher in HIV-infected vs age- and gender-matched
  general population (P lt .001)
• 60/100,000 PYs (95 CI, 40-89) vs 0.52/100,000
  PYs (95 CI, 0.27-0.78)
• Nonsignificant difference in pre-HAART and
  post-HAART era for HIV-positive individuals (P gt
  .05)
• 35/100,000 PYs (95 CI, 15-72) vs 92/100,000 PYs
  (95 CI, 52-149)
• Higher relative risk of anal cancer vs general
  population in post-HAART era
• Pre-HAART era, 67 Post-HAART era, 176

Bower M, et al. J Acquir Immune Defic Syndr.
2004371563-1565.
56
Non-AIDS defining malignancy-related
death according to latest CD4 count
CD4 count Rate ratio 95 CI p-value lt50
23.49 (9.41-58.65) 0.0001 50- 15.41
(6.56-36.21) 0.0001 100- 11.36
(6.05-21.35) 0.0001 200- 3.65
(1.92-6.93) 0.0001 350- 1.01
(0.43-2.40) 0.98 500- 1.00
Adjusted for HIV RNA, age, cohort, race and
smoking status.
57
Deaths in DADMultivariable relationships with
death rate Latest CD4 count
Latest CD4 count
lt50
50-99
100-199
All-cause mortality
200-349
350-499
gt500
lt50
50-99
100-199
Liver-related mortality
200-349
350-499
gt500
58
Liver disease mortality in HIV/HBV coinfected
patients
Thio CL et al., 9th CROI, Seattle 2002, 656
59
Viral hepatitis and HIV co-infection Influence of
HIV on HBV-related cirrhosis
100
90
HIV negative
80
lt 200/mm3
HIV positive, CD4
gt 200/mm3
HIV positive, CD4
70
60
of cirrhosis
50
40
p0.005
30
20
10
0
0
1
2
3
4
5
6
7
8
9
10
Follow-up (years)
Di Martino V et al. Gastroenterology 2002
60
Viral hepatitis and HIV co-infection Influence of
HIV on HBV-related cirrhosis
100
90
HIV negative
80
lt 200/mm3
HIV positive, CD4
gt 200/mm3
HIV positive, CD4
70
60
of cirrhosis
50
40
p0.005
30
20
10
0
0
1
2
3
4
5
6
7
8
9
10
Follow-up (years)
Di Martino V et al. Gastroenterology 2002
61
Clinical Efficacy of HBV Vaccine in HIV-Infected
Cohort

• Tri-Service AIDS Clinical Consortium
• N 873 HIV-positive, HBV-negative subjects
  monitored longitudinally
• Rate of HBV infection compared between vaccinated
  (n 430) and unvaccinated (n 443) subjects
• 64 cases in unvaccinated group (34 cases/1000 PY)
• 24 cases in vaccinated group (8.4 cases/1000 PY)
  (P lt .001)
• 23 of these not on HAART at time of vaccine
  failure
• Receipt of 1 dose of vaccine associated with
  decreased incidence of HBV infection (OR 0.294
  P lt .001)
• Factors related to vaccine failure
• Not receiving HAART at time of failure (OR 8.19
  P .046)
• Coinfection with HCV (OR 7.75 P .001)

Landrum M, et al. CROI 2006. Abstract 840.
62
Incidence rate ratios of death according to
hepatitis C status
Univariate
Multivariate (no VL)
IRR
95 CI
P
IRR
95 CI
P
New AIDS/ any death
HCV-neg
1.00
-
-
1.00
-
-
HCV-pos
1.32
1.17-1.50
lt0.0001
0.92
0.79-1.07
0.27
Liver related deaths
HCV-neg
1.00
-
-
1.00
-
-
HCV-pos
8.85
4.45-17.61
lt0.0001
3.18
1.23-6.18
0.014
adjustment for CD4-count, age, prior AIDS,
wether pat. had started HAART or not,
recruitment date, hepatitis B status, gender,
ethnic gender, region of Europe, risk group
63
Progression to HCC in HCV/HIV-Coinfected Patients

• HCV/HIV-coinfected patients progress more rapidly
  to HCC than HCV-monoinfected patients
• Coinfected pts also younger at HCC diagnosis,
  have higher AFP levels, receive HCC treatment
  more often

Bräu N, et al. IAS 2005. Abstract TuPe1.1C17.
64
Low Numbers of HCV/HIV Patients Achieve SVR in an
Urban HIV Clinic

• Retrospective analysis of Johns Hopkins HIV Clinic

n 277 referred (33)
n 845 with HCV
n 125 entered evaluation for treatment
n 29 initiated treatment

• n 6 (21) of these attained SVR
• This represents 2.1 of those referred, or 0.7
  of those with HCV

Mehta S, et al. CROI 2006. Abstract 884.
65
Access to anti HCV treatment

• Only a limited number of patients considered
  eligible for treatment actually receive therapy,
  mainly due to physicians lack of conviction and
  patient refusal
• There are wide variations in eligibility criteria
  among physicians
• Patient perception of HCV and HCV therapy are key
  factors influencing a patients decision to
  initiate treatment

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HIV Transplant Outcomes Not Inferior to Outcomes
in Uninfected Historical Controls

• Observational study of transplants in HIV
  recipients at 4 centers
• Outcomes comparable to HIV-negative historical
  controls
• Rejection associated with mean CD4 decreases

Roland M, et al. Abstract 953.
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Thank you for your attention
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