Quand dbuter les antirtroviraux Recommandations internationales

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Quand débuter les antirétroviraux?Recommandations
internationales

• Formation à lusage des antirétroviraux
• Pr Willy Rozenbaum

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(No Transcript)
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Potential Benefits of Early Therapy

• Earlier suppression of viral replication
• Preservation of immune function
• Prolongation of disease-free survival
• Lower risk of virologic failure?
• Lower risk of detrimental viral evolution
• Possible decrease in the risk of HIV transmission

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CD4 Cell Count Response Based on Baseline CD4
Cell Count
Johns Hopkins HIV Clinical Cohort
ATHENA National Cohort
1000
1000
800
800
600
600
Mean CD4 Cell Count (cells/mm3)
400
400
BL CD4
BL CD4
gt 500
201-350
gt 350
200
200
351-500
51-200
201-350
lt 200
lt 50
0
0
0
0
48
96
144
192
240
288
336
1
2
3
4
5
Years on HAART
Weeks From Starting HAART
Keruly J, et at. CROI 2006. Abstract 529. Gras
L, et al. CROI 2006. Abstract 530.
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HAART and Survival Based on Initial CD4 Cell
Count

• Modeled data from ART Cohort Collaborative
• 10,855 patients included
• 934 progressed to AIDS or died
• IDUs censored from model

Cumulative Probability of AIDS/Death According
to CD4 Cell Count at Initiation of HAART
0.14
101-200 cells/mm3201-350 cells/mm3351-500
cells/mm3
0.12
0.10
0.08
Probability of AIDS or Death
0.06
0.04
0.02
0.00
1
2
3
4
5
0
Years Since Initiation of HAART
DArminio Monforte A, et al. CROI 2006. Abstract
525.
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Time to Virologic Failure Stratified by Baseline
CD4 Cell Count
100
80
60
Patients Responding ()
Baseline CD4 cell count (cells/mm3)
40
lt 200 (n 331)
? 200 to lt 350 (n 345)
20
? 350 to lt 500 (n 302)
? 500 (n 236)
0
0
12
24
36
48
60
72
84
96
Time Since Start of Treatment (Weeks)
Levy RS, et al. CROI 2001. Poster 325.
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Increasing Prevalence of X4- or R5/X4-Tropic
Virus at Lower CD4 Cell Counts

• CCR5
• Patients with early-stage HIV disease tend to
  have pure R5-tropic virus
• CXCR4
• With advanced disease, X4- or dual-tropic virus
  emerges
• Associated with more rapid clinical and
  immunologic progression
• Could CCR5 inhibition select for more virulent
  X4-tropic virus?

100
80
60
Prevalence of X4 or R5/X4 ()
41.9
40.0
40
16.0
16.0
20
14.8
0
gt 300 248
201-300 104
101-200 81
51-100 31
lt 50 50
CD4 Cell Count (cells/mm3)
n
Moyle G, et al. ICAAC 2004. Abstract 1135.
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Prise en charge médicale des personnes
infectées par le VIH Rapport 2006 Traitement
antirétroviral (1)

• Quand débuter un traitement antirétroviral ?

• L'instauration d'un traitement ARV doit
  toujours être préparée
• Travail multidisciplinaire pour optimiser
  ladhésion au traitementet aux soins

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DHHS Guidelines When To Start 2008