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A Look Back at the International A Look Back at the International AIDS Conference MeetingAIDS Conference Meeting
Lessons from IAC 2010Lessons from IAC 2010
A Clinical Context ReportA Clinical Context Report
Jointly Sponsored by:Jointly Sponsored by:
and MedPage Todayand MedPage Today
A Look Back at the International AIDS A Look Back at the International AIDS Conference Meeting—Lessons from IAC 2010Conference Meeting—Lessons from IAC 2010
Supported in part by an Supported in part by an educational grant fromeducational grant fromBristol-Myers SquibbBristol-Myers Squibb
A Look Back at the International AIDS A Look Back at the International AIDS Conference Meeting—Lessons from IAC 2010Conference Meeting—Lessons from IAC 2010
Clinical Context SeriesClinical Context SeriesTarget AudienceTarget Audience
The goal of this program is to provide HIV/AIDS The goal of this program is to provide HIV/AIDS specialists, virologists, infectious disease specialists, virologists, infectious disease specialists, experts in the care of patients with specialists, experts in the care of patients with HIV/AIDS, physician assistants and nurse HIV/AIDS, physician assistants and nurse practitioners with up-to-date informationpractitioners with up-to-date informationand multiple perspectives on the pathogenesis, and multiple perspectives on the pathogenesis, symptoms, risk factors, and complications of symptoms, risk factors, and complications of HIV/AIDS as well as current and emerging HIV/AIDS as well as current and emerging treatments and best practices in the management treatments and best practices in the management of HIV/AIDS.of HIV/AIDS.
Activity Activity Learning ObjectivesLearning Objectives
Upon successful completion of this Upon successful completion of this educational program, participants should educational program, participants should be able to:be able to:
Discuss the results of this report from IACDiscuss the results of this report from IAC Review the relevance and significance of the Review the relevance and significance of the
report in the broader context of clinical carereport in the broader context of clinical care
CME Information: PhysiciansCME Information: Physicians Statement of AccreditationStatement of Accreditation
This activity has been planned and This activity has been planned and implemented in accordance with the Essential implemented in accordance with the Essential Areas and Policies of the Accreditation Council Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) for Continuing Medical Education (ACCME) through joint sponsorship of Albert Einstein through joint sponsorship of Albert Einstein College of Medicine and MedPage Today. College of Medicine and MedPage Today. Albert Einstein College of Medicine is Albert Einstein College of Medicine is accredited by the ACCME to provide continuing accredited by the ACCME to provide continuing medical education for physicians.medical education for physicians.
CME InformationCME Information
Credit DesignationCredit DesignationAlbert Einstein College of Medicine Albert Einstein College of Medicine designates this educational activity for a designates this educational activity for a maximum of 0.25 maximum of 0.25 AMA PRA Category 1 AMA PRA Category 1 Credits.™ Credits.™ Physicians should only claim Physicians should only claim credit commensurate with the extent of credit commensurate with the extent of their participation in the activity.their participation in the activity.
CME Information: NursesCME Information: Nurses Statement of AccreditationStatement of Accreditation
– Projects In Knowledge, Inc. (PIK) is accredited Projects In Knowledge, Inc. (PIK) is accredited as a provider of continuing nursing education as a provider of continuing nursing education by the American Nurses Credentialing Center’s by the American Nurses Credentialing Center’s Commission on Accreditation.Commission on Accreditation.
– Projects In Knowledge is also an approved Projects In Knowledge is also an approved provider by the California Board of Registered provider by the California Board of Registered Nursing, Provider Number CEP-15227.Nursing, Provider Number CEP-15227.
– This activity is approved for 0.58 nursing This activity is approved for 0.58 nursing contact hours. contact hours.
DISCLAIMER: Accreditation refers to educational content only and does not imply ANCC, CBRN, or PIK endorsement of any commercial product or service.
CME Information: PharmacistsCME Information: Pharmacists
Projects In KnowledgeProjects In Knowledge®® is accredited by the is accredited by the Accreditation Council for Pharmacy Education Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy (ACPE) as a provider of continuing pharmacy education. This program has been planned and education. This program has been planned and implemented in accordance with the ACPE implemented in accordance with the ACPE Criteria for Quality and Interpretive Guidelines. Criteria for Quality and Interpretive Guidelines. This symposium is worth up to 0.25 contact This symposium is worth up to 0.25 contact hours (0.025 CEUs). The ACPE Universal Activity hours (0.025 CEUs). The ACPE Universal Activity Number assigned to this knowledge-type activity Number assigned to this knowledge-type activity is 0052-0000-10-1649-H01-P.is 0052-0000-10-1649-H01-P.
Barry S. Zingman, MD Medical Director
AIDS CenterMontefiore Medical Center
Professor of Clinical Medicine Albert Einstein College of Medicine
Bronx, NY
DiscussantDiscussant
Disclosure InformationDisclosure Information
Barry S. Zingman, MD,has disclosed that he has no relevant financial has disclosed that he has no relevant financial
relationships or conflicts of interest with commercial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational interests related directly or indirectly to this educational
activity.activity.
Disclosure InformationDisclosure InformationDori F. Zaleznik, MD, Associate Clinical Professor of Medicine, Harvard Medical School, Boston; Michael Smith and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner, have disclosed that they have no relevant financial have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.related directly or indirectly to this educational activity.
The staff of Albert Einstein College of Medicine, MedPage Today, and Projects In Knowledge have no relevant have no relevant financial relationships or conflicts of interest with commercial financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational interests related directly or indirectly to this educational activity.activity.
DisclaimerDisclaimerThe moderators/authors have attempted to provide the most current and The moderators/authors have attempted to provide the most current and accurate clinical information according to accepted medical practice accurate clinical information according to accepted medical practice standards at the time of publication. The information should not be standards at the time of publication. The information should not be considered to be completely error-free or to include all relevant considered to be completely error-free or to include all relevant information; nor should it be used as an exclusive basis for decision-information; nor should it be used as an exclusive basis for decision-making. Neither Albert Einstein College of Medicine, Montefiore Medical making. Neither Albert Einstein College of Medicine, Montefiore Medical Center, MedPage Today nor Bristol-Myers Squibb, the authors or any other Center, MedPage Today nor Bristol-Myers Squibb, the authors or any other party involved in the preparation of this work and the presentations party involved in the preparation of this work and the presentations contained herein warrant that the information is accurate or complete and contained herein warrant that the information is accurate or complete and are not responsible for any errors or omissions or for the results obtained are not responsible for any errors or omissions or for the results obtained from the use of such information. You are encouraged to consult other from the use of such information. You are encouraged to consult other sources and confirm the information contained herein. Use of the sources and confirm the information contained herein. Use of the information is strictly voluntary and at the user's sole risk. If misleading or information is strictly voluntary and at the user's sole risk. If misleading or otherwise inappropriate information is brought to our attention, a otherwise inappropriate information is brought to our attention, a reasonable effort will be made to correct or delete it. Such concerns or any reasonable effort will be made to correct or delete it. Such concerns or any other questions or problems about the information should be sent toother questions or problems about the information should be sent to cme@montefiore.orgcme@montefiore.org. .
SummarySummary
The most recent guidelines suggest that HIV therapy The most recent guidelines suggest that HIV therapy should start at a CD4 count of at least 500should start at a CD4 count of at least 500
The treatments of choice to start therapy are now, The treatments of choice to start therapy are now, increasingly, fixed dose combination pillsincreasingly, fixed dose combination pills
A vaginal microbicide that includes an antiretroviral A vaginal microbicide that includes an antiretroviral drug, tenofovir, has shown efficacy in preventing HIV drug, tenofovir, has shown efficacy in preventing HIV acquisition in a randomized controlled trialacquisition in a randomized controlled trial
The product has also appeared to lower the risk of The product has also appeared to lower the risk of acquiring herpes simplex virus 2, a known risk factor acquiring herpes simplex virus 2, a known risk factor for HIVfor HIV
Recommendations for Initiating Antiretroviral Therapy (ART) in Treatment-Naïve Adults with HIV-1 Infection Who Are Ready to Begin Therapy
• ART is recommended regardless of CD4 cell count for persons with symptomatic HIV disease, pregnancy, active HBV or HCV co-infection, or those at high risk for secondary HIV transmission
• ART is recommended for asymptomatic adults with CD4 cell counts 500/μL
• ART should be considered in patients who are asymptomatic with CD4 cell counts > 500/μL, unless the patient is an elite controller (HIV-RNA <50 copies/mL) or has a stable CD4 count and low-level viremia in the absence of ART
Why Start ART Earlier
• NA-ACCORD study demonstrated that there was lower mortality, as well as significantly lower non-age defining events, if people were started on ART before their T-cell count dropped to 500
• If therapy is not started until the patient’s CD4 count is <500, there is a lower chance that CD4 count will become normal on therapy
• Several studies have demonstrated that HIV transmission between serodiscordant couples and in injection drug users is decreased with ART
CASCADE Cohort
• 9,455 HIV recent seroconverters, avg. age 30• 812 (8.6%) developed AIDS• 544 (5.8%) died• Relative effects: AIDS/Death
• CD4 count 0-49 – Incidence Rate per 1000 person years 193.3 Defer ART, 55.0 Initiate – adjusted HR 0.32 (95% CI 0.17,0.59)
• CD4 50-199 – IR 56.6 Defer, 22.0 Initiate aHR 0.48 (0.31, 0.74• CD4 200-349 – IR 29.4 Defer, 18.7 Initiate aHR 0.59 (0.43, 0.81)• CD4 350-499 – IR 20.8 Defer, 17.2 Initiate aHR 0.75 (0.49,1.14)• CD4 500-799 – IR 18.5 Defer, 14.9 Initiate aHR 1.10 (0.67, 1.79)
CASCADE Caveats
• Retrospective study of patients who had recently seroconverted
• Significantly smaller than the 20,000 to 50,000 patients followed over years in NA-ACCORD and HIV-CAUSAL
• Looked only at death not• AIDS-related cancers• Cardiovascular disease• CD4 counts• Prevention of kidney disease
New Treatment Recommendations, ISA-USA
• The committee came out in favor of fixed-dose combinations
• Tenofovir/emtricitabine number one recommended NRTI combination
• Abacavir/lamivudine secondary NRTI• Third component should be either
• Efavirenz• A ritonavir-boosted protease inhibitor such as
darunavir/ritonavir or atazanavir/ritonavir• Integrase inhibitor raltegravir
• Lopinavir/ritonavir moved to 2nd line because of toxicity
# HIV infections/ women years HIV incidence Incidence
Rate Ratio P Value
Tenofovir Placebo Tenofovir
gel Placebo gel
Overall effectiveness of tenofovir gel
HIV endpoints 38 / 680.6 60 / 660.7 5.6 9.1 0.61 0.017
HIV endpoints by levels of adherence
High adherers (>80% gel adherence)
11 / 259.2 25 / 269.4 4.2 9.3 0.46 0.025
Intermediate adherers(50-80% adherence)
10 / 159.8 10 / 99.7 6.3 10 0.62 0.343
Low adherers(<50% gel adherence)
16 / 258.5 25 / 290.6 6.2 8.6 0.72 0.303
Modified from Karim, et al. Effectiveness and Safety of Tenofovir Gel, an Antiretroviral Microbicide, for the Prevention of HIV Infection in Women. Science. Published Online July 19, 2010 at: http://www.sciencemag.org/cgi/rapidpdf/science.1193748.pdf. Reprinted with permission from AAAS.
Impact of Tenofovir Gel on HSV-2 Incidence
Tenofovir geln=202
Placebo geln=224
# HSV-2 infections 29 58
Women-years (wy) of follow-up 292.3 287.3
HSV-2 incidence per 100wy (95% CI)
9.9(6.6, 14.2)
20.2(15.3, 26.1)
IRR = 0.49 (CI:0.30, 0.78); P = 0.003
51% protection against HSV-2 by tenofovir gel (CI: 22%70%)
Results of the CAPRISA 004 Trial. Presented by Salim Abdool Karim, July 20, at the XVIII International AIDS Conference, Vienna, Austria. Oral Abstract TUSS0504.
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