Académique Documents
Professionnel Documents
Culture Documents
Acute HIV
Morbilliform Rash
86
74
59 57 55 52 44
50 60 70 80 90 100
N =160
Patients %
From: Vanhems P, et al. AIDS. 2000;14:375-81.
100
10 1 0 5 10 15 20
25
30
35
40
45
50
Antibody Titer
0
10
15
20
25
30
35
40
45
50
1,000,000
10,000 20 1,000
100
10 1 0 5 10 15 20 25 30 35 40 45 50
15
10
Antibody Titer
100,000
25
Transmission of HIV
HIV
Transmission of HIV
Chronic HIV infection Quasispecies HIV-Negative
+ -
Case History
A 28-year-old man was diagnosed with HIV about 18 months ago. She is seen in the clinic for follow up. His CD4 counts have been 770, 710, 640, and 610 cells/mm3. He has no active medical, mental health, or substance abuse issues. He is sexually active with other men and uses condoms most of the time. Would you recommend starting antiretroviral therapy?
800
500
400
200
Initiating Antiretroviral Therapy in Treatment-Nave Patients Change in CD4 Threshold in HHS Guidelines
1000
800
2012
600
500
400
2009 2007
350
200
200
2003
Earlier Therapy
Later Therapy
400
200
AIDS
0
0
Year 1
4 5 6 Years
9 10 11 12 13 14 15
400
200
0
0
1 0 0 Year 0 0 (expanded)
4 5 6 Years
9 10 11 12 13 14 15
ANTIRETROVIRAL THERAPY
Attributable Risk Factors Associated with Cardiovascular Disease Events HOPS Study, January 2002September 2009
Cox Proportional Hazards: Relationship of Baseline CD4 and Risk of Subsequent Cardiovascular Events
N = 2,005
1.58
1.29
Attributable Risk Factors Associated with Cardiovascular Disease Events HOPS Study, January 2002September 2009
Baseline Factor Associated with Incident Cardiovascular Disease Events
Diabetes Male gender HDL < 40 male HLD < 50 female LDL/nonHDL > goal CD4 < 500 cells/l Tobacco Smoking Hypertension Age 42 years (median)
N = 2,005
49.2 0 10 20 30 40 50 60
n = 872
n = 853
n = 37
n=1
800
600
250
200
P < 0.001
27
10
15
20
25
30
Linked Transmissions
NNRTI-Based Efavirenz-Tenofovir-Emtricitabine
INSTI-Based
Raltegravir + Tenofovir-Emtricitabine
NNRTI-Based Efavirenz-Tenofovir-Emtricitabine
$2860
$2925
INSTI-Based
Raltegravir + Tenofovir-Emtricitabine
$2562
2011: New FDA-Approved HIV Medications (or New Preparations of Older Medications)
Nevirapine XR (Viramune XR): 400 mg tablet
Case History
A 30-year-old woman with asymptomatic HIV infection is seen for follow-up in the clinic to discuss starting antiretroviral therapy. She states she really wants to take the the one pill a day regimen. She has no other medical problems.
Most recent labs show a CD4 cell count of 375 cells/mm3 and CD4% = 16. Most recent HIV RNA is 65,300 copies/ml. A baseline genotype shows no mutations. Which one pill once a day regimen to give her?
Tenofovir-Emtricitabine-Efavirenz
NRTI NRTI NNRTI
Tenofovir-Emtricitabine-Rilpivirine
NRTI NRTI NNRTI
Rilpivirine vs. Efavirenz in ARV-Naive ECHO and THRIVE Pooled Data: Study Design
Study Features
Protocol - Randomized, double-blind trial - Phase 3 - N = 690 (ECHO) and 678 (THRIVE) - Age > 18 - ARV-nave - HIV RNA > 5,000 copies/ml - No baseline NNRTI mutations - Randomized to one of 2 arms - All given 2 NRTIs* Rilpivirine: 25 mg qd + TDF/FTC (n = 346)
ECHO
1x
THRIVE
1x
*2 NRTIs: ECHO: Tenofovir + Emtricitabine (TDF/FTC) THRIVE: Tenofovir + Emtricitabine; Zidovudine + Lamivudine;
Abacavir + Lamivudine
Rilpivirine vs. Efavirenz in ARV-Naive ECHO and THRIVE Pooled Data: Week 48 Results
Virologic Response ( ITT-TLOVR) over 48 Weeks
100 Patients with Virologic Response
80
2NRTIs+ Rilpivirine (n = 686)
84% 82%
2NRTIs+ Efavirenz (n = 682)
60
40
20
0 0 2 4 8 12 16 24 32 40 48
Time (weeks)
Source: Cohen C, et al. JAIDS. 2012:Feb 16 [Epub ahead of print].
Rilpivirine vs. Efavirenz in ARV-Naive ECHO and THRIVE: Virologic Failure Results
Virologic Failure 48 Week Data
20
Virologic Failure 15 10 5 0 Rilpivirine: 25 mg Efavirenz: 600 mg 17
10
6
7
5 5
All
100K
> 100K
Cutaneous Manifestations
CLINICAL MANIFESTATIONS
Case History
CLINICAL MANIFESTATIONS
Case History
CLINICAL MANIFESTATIONS
Case History
CLINICAL MANIFESTATIONS
Case History
CLINICAL MANIFESTATIONS
Case History
CLINICAL MANIFESTATIONS
Case History
CLINICAL MANIFESTATIONS
Case History
CLINICAL MANIFESTATIONS
Case History
Oral Manifestations
CLINICAL MANIFESTATIONS
Case History
OPPORTUNISTIC INFECTIONS
Case History
CLINICAL MANIFESTATIONS
Case History
CLINICAL MANIFESTATIONS
Case History
CLINICAL MANIFESTATIONS
Case History
Postexposure Prophylaxis
Question
What is the risk of acquiring HIV from a needlestick injury when all following are present: - HIV-infected source patient not on antiretroviral therapy - Needlestick involved venipuncture needle - Skin on hand punctured - No antiretroviral postexposure prophylaxis given
60 50 40 30 30 20 10 50
Seroconversion (%)
0.3
HIV
2
Hepatitis C HBsAg+ HBeAg-
0
HBsAg+ HBeAg-
Source: CDC and Prevention. MMWR Morb Mortal Weekly Rep. 2001;50(RR-11):1-42.
Case History
Logistic-Regression Analysis of Risk Factors for HIV Transmission after Percutaneous Exposure to HIV-Infected Blood
Risk Factors for HIV Seroconversion in Health Care Workers Risk Factor Deep Injury Visible Blood on Device Terminal Illness in Source Patient Needle in Source Vein/Artery PEP with Zidovudine (AZT) Adjusted Odds Ratio 15.0 6.2 5.6
4.3
0.19
Recommended HIV PEP after Percutaneous Exposure Known Source HIV Status
Percutaneous Exposure Type
Source Infection Status HIV+ Class 1* Recommend Basic 2-drug PEP Recommend Expanded 3-drug PEP HIV+ Class 2^ Recommend Expanded > 3-drug PEP Recommend Expanded > 3-drug PEP
Less Severe
More Severe#
Less Severe: e.g., solid needle or superficial injury # More Severe: e.g., large-bore hollow needle, deep puncture, visible blood on device, or needle used in patients artery or vein *HV+ Class 1: Asymptomatic HIV infection or low viral load (e.g., <1,500 copies/mL) ^HIV+ Class 2: Symptomatic HIV, AIDS, acute seroconversion, or known high viral load
Source: CDC and Prevention. MMWR Morb Mortal Weekly Rep. 2005;54(RR-9):1-17.
Recommended HIV PEP after Percutaneous Exposure Known Source HIV Status
Percutaneous Exposure Type
Source Infection Status HIV+ Class 1* Recommend Basic 2-drug PEP Recommend Expanded 3-drug PEP HIV+ Class 2^ Recommend Expanded > 3-drug PEP Recommend Expanded > 3-drug PEP
Less Severe
More Severe#
Less Severe: e.g., solid needle or superficial injury # More Severe: e.g., large-bore hollow needle, deep puncture, visible blood on device, or needle used in patients artery or vein *HV+ Class 1: Asymptomatic HIV infection or low viral load (e.g., <1,500 copies/mL) ^HIV+ Class 2: Symptomatic HIV, AIDS, acute seroconversion, or known high viral load
Source: CDC and Prevention. MMWR Morb Mortal Weekly Rep. 2005;54(RR-9):1-17.
2005 Recommended PEP Antiretroviral Therapy Preferred Basic and Expanded Regimens
Drugs for Basic Regimens (28 days) Preferred Regimens Zidovudine-Lamivudine (Combivir) Lopinavir-Ritonavir (Kaletra) Tenofovir + Emtricitabine (Truvada) Alternative Regimens Stavudine (Zerit) + Lamivudine (Epivir) Atazanavir (Reyataz) + Ritonavir (Norvir) Drugs for Expanded Regimen (28 days) Basic Regimen Plus:
Questions?