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1、Antiretroviral therapy and Primary Care,Chris Boyle, MD 9/8/2011,Case,56 yo man tests positive for HIV after you initiate routine HIV testing during your first clinic visit. He feels well. He has a PMH of hyperlipidemia, GERD and seasonal allergies. He is highly motivated to initiate ARVs. Do you a)
2、 Refer him to a HIV specialist b) Take care of him yourself.,Katz, MH. Human Immunodeficiency Virus Is (Once Again) a Primary Care Disease. Arch Intern Med. 2011;171(8):719-720.,HIV Screening and Access to Care: Health Care System Capacity for Increased HIV Testing and Provision of Care (2011) “Incr
3、eased use of strategies such as task shifting, comanagement, and care coordination can help to maximize the ability of the current health care workforce to accommodate an increased number of HIV-positive individuals. In addition, these strategies may result in improved patient care and increased pro
4、vider satisfaction, which, in turn, may increase the retention of HIV/AIDS care providers in the field.” “.the emergence of HIV as a chronic medical condition.infectious disease specialists and primary care providers who are HIV experts due to substantial patient care experiences, formal training, o
5、r both, are generally better-prepared to manage HIV disease than are primary care generalistsHowever, most HIV-positive patients can benefit greatly from the broader skills of primary care providers in addressing their other health care needs.”,Committee on HIV Screening and Access to Care; Institut
6、e of Medicine. “HIV Screening and Access to Care: Health Care System Capacity for Increased HIV Testing and Provision of Care.” The National Academies Press, 2011.,Case,56 yo man tests positive for HIV after you initiate routine HIV testing during your first clinic visit. He feels well. He has a PMH
7、 of hyperlipidemia, GERD and seasonal allergies. He is highly motivated to initiate ARVs. You keep him!,Case,56 yo man tests positive for HIV after you initiate routine HIV testing during your first clinic visit. He feels well. He has a PMH of hyperlipidemia, GERD and seasonal allergies. He is highl
8、y motivated to initiate ARVs. You check HIV intake labs, including a CD4, viral load and resistance panel. Labs are significant for a CD4=496 and VL=6500, with wild type virus.,When to Start,56 yo man tests positive for HIV after you initiate routine HIV testing during your first clinic visit. He fe
9、els well. He has a PMH of hyperlipidemia, GERD and seasonal allergies. He is highly motivated to initiate ARVs. You check HIV intake labs, including a CD4, viral load and resistance panel. Labs are significant for a CD4=496 and VL=6500, with wild type virus. a) Initiate ARVs - everyone should be on
10、treatment b) Initiate ARVs - His CD4 count is 500 c) Do not initiate ARVs until his CD4 is 350 d) Do not initiate ARVs until his CD4 count is 200 e) Do not initiate ARVs until he has an opportunistic infection,When to Start,There are two major organizations that periodically make updates regarding w
11、hen and what to start. The Department of Health and Human Services (DHHS) - last updated in 01/2011 and The International Antiviral Society - USA (IAS-USA) - last updated in 07/2010,When to Start,Historical Perspective 1996 - treat for a CD4500, consider treatment in all Mantra “Hit Early, Hit Hard”
12、(N Engl J Med. 1995;333(7):450.) however drugs had multiple side effects, difficult to adhere to regimens, which led to. 2001 - treat for a CD4200 and consider treatment if 200-350 however regimens became better tolerated, easier to administer and there was increasing evidence that treating earlier
13、improved mortality, which led to. 2007 - treat for a CD4350, several caveats of when to treat earlier 2009 - treat for a CD4500, consider treatment in all.,When to Start - 2011,Cohort study from 1996-2004 using a large data registry with 3,851 HIV and 1,044,589 non-HIV patients at Brigham and Womens
14、 Hospital (BWH) or Massachusetts General Hospital (MGH) The primary outcome was myocardial infarction, identified by International Classification of Diseases coding criteria,J Clin Endocrinol Metab. 2007 Jul;92(7):2506-12,When to Start - 2011,J Clin Endocrinol Metab. 2007 Jul;92(7):2506-12,A, Myocar
15、dial infarction rates and corresponding adjusted RR.,HIV,Non-HIV,When to Start - 2011,Patel P, et al. Incidence of Types of Cancer among HIV Infected Persons Compared with the General Population in the United States, 19922003. Ann Intern Med. 2008;148:728-736.,When to Start - 2011,Randomized control
16、led study evaluating continuous use of antiretroviral therapy vs scheduled drug interruptions in management of HIV 5472 participants with 2720 assigned to drug conservation (scheduled interruptions) and 2752 to viral suppression arms (continuous therapy) Medial CD4 count at entry was 597. The primary end point was the development of an opportunistic disease or death from any cause. The secondary end point was major cardiovascular, renal, or hepatic disease.,SMART,El-Sadr WM, et al. CD4+
