BHIVA When to start treatment Flashcards
When do you start ART in established infection
- All PLW HIV should be on ART
- Should have opportunity to start within 2-4 weeks of diagnosis
What is the rational for immediate ART initiation?
Multiple RCT evidence of of benefit in terms of both HIV-related and non-HIV-related morbidity and mortality
In START what was the percentage risk of serious illness ,over 3 year years, in the immediate vs deferred treatment arms ( CD4 count >350)
Immediate 1.5%
Deferred 4.1%
When is same-day ART recommended
- Primary HIV
- When the person wants to and has no contra-indications
Rational for ‘Same day ART’
Reduced mortality in low- and middle- income countries at 12 months was demonstrated in a meta-analysis of four same day ART trials.
However a Cochrane review of seven studies with >18 000 patients showed no clear reduction in mortality
It is unclear if same day ART should be recommended in the UK and more evidence is required, may not suit every patient
Initiating ART in patients presenting with AIDS or a Major Infection
We recommend that most individuals presenting with an AIDS defining infection or with a serious bacterial infection and CD4 count <200 start ART within 2 weeks of initiation of specific antimicrobial chemotherapy
Rational for starting ART in AIDS or serious bacterial infection within 2 weeks of treatment
ACTG 5164 study
1. Fewer deaths and more cost effective to start ART at 14D compared with 45D
- those with TB were excluded and most patients had PCP. All patients were well enough to take oral medicines so might not apply to ITU setting
In which illnesses should you avoid early initiation of ART and why?
TB and cryptococcal meningitis
COAT study showed those with acellular CSF or decreased consciousness had a higher risk of death with early ART.
What is the definition of primary HIV infection
HIV infection within a maximum of 6 months from the estimated time of HIV acquisition.
What criteria are associated with morbidity or very rapid disease progression in individuals with primary HIV
- Neurological involvement
- Any AIDS-defining illness
- CD4 <350
- PHI within 12 weeks of a previous negative test
List 6 advantages of starting ART in Primary HIV
- Enhanced probability of immunological recovery
- Patient may feel comforted knowing on treatment
- Reduced risk of onwards transmission
- Reduced morbidity and rapid disease progression associated with high viraemia
- Clinical benefit shown in trials start, Temprano and HPTN052 of starting regardless of CD4 count
- Limited viral reservoir
List 3 disadvantages of starting ART in Primary HIV
- Emotionally challenging time for patient May lead to poor adherence
- In emotionally vulnerable state and ill prepared to commit to long term treatment
- Side effects of ARt may overlap with symptoms of primary HIV
What are the recommendations for monitoring viral controllers off ART?
6-12 monthly viral load
6 monthly CD4 and CD4:CD8 ratio
6 monthly assessment for CVD, malignancy, comorbidity, pregnancy and hepatitis co-infection
Definition of viral controllers
Confirmed HIV (antibody)or RNA or DNA AND not taking ART but have an undetectable viral load <50 on more than one occasion AND CD4 normal or CD4:CD8 ratio >1
Why is CD4 count-guided intermittent therapy not recommended?
It is associated with a significantly higher rate of opportunistic disease and all-cause mortality and a higher rate of major CVD or renal or hepatic disease. This was seen at all CD4 cell count levels
Therefor interruptions should only be considered in exceptional circumstances (toxicity, psychological distress, major organ dysfunction or clinical trial)
