HIV Treatment Update 2013:
What’s new?
Christopher Vinnard, MD MPH MSCEAssistant Professor of MedicineDivision of Infectious Diseases & HIV MedicineDrexel University College of Medicine
A new report of a cure...
Functional HIV Cure after Very Early ART of an Infected Infant Infant exposure to HIV was confirmed through
review of maternal HIV antibody and plasma viral load testing
Infant infection was documented by plasma viral load testing
ART (Combivir + Nevirapine) initiated in the infant at 30 hours of age
Persistence of HIV following treatment discontinuation was assessed using plasma viral load, proviral DNA, and HIV antibody testing
Ultrasensitive assays done at age 24 and 26 months
CROI 2013
Results
Infant infection was confirmed by positive HIV DNA and RNA testing on 2 separate blood samples obtained on 2nd day of life
3 additional plasma viral load tests on day 7, 12, and 20 were positive, before reaching undetectable levels at age 29 days
Plasma HIV RNA remained undetectable between months 1 through 26, despite discontinuation of ART at age 18 months
A “functional cure”
Ultrasensitive methods found a single copy of HIV RNA in plasma at age 24 months
Replication-competent virus was not detected following co-culture of 22 million purified resting CD4+ T cells
Plasma viral load, PBMC DNA, and HIV-specific antibodies remained undetectable with standard clinical assays
Why did this approach work?
What about the first patient cured of HIV infection?
New approaches to treatment: Targeting the CCR5 Receptor
HIV binds to the CCR5 receptor to enter immune cells
“When to start treatment?”
New recommendations
Understanding the alphabet soup of recommendations
When to start: Overall
What are the reasons for this new recommendation? Benefit to the patient
AIDS defining events Cancers All cause mortality
Benefit to the patient’s partner ART was 96% effective in reducing
transmission between discordant couples
Prevention of HIV-1 Infection with Early Antiretroviral Therapy
When to start: Specific conditions
When to start: Opportunistic infections
A new one-pill-once-daily regimen
Percentage of patients with undetectable viral loads
Mean change of CD4 from baseline
Change in kidney function
A new indication for antiretroviral therapy
Take home message
From 2 years ago...
Why not 100% protection? Adherence
http://www.cdc.gov/hiv/prep/
What is a REMS?
Risk Evaluation and Mitigation Strategy
Manage known or potential serious risks with a drug or biological product
FDA sometimes determines that a REMS is needed in order for the benefits to outweigh the risks of an approved drug
REMS may include: Medication Guide, Patient Package Insert, communication plan, and other elements to assure safe use
https://www.truvadapreprems.com/#
New treatments (and new drug-drug interactions) for hepatitis C co-infection
HIV and Hepatitis C
~30% if HIV-infected individuals in the U.S. are co-infected with hepatitis C
Chronic hepatitis C infection is a leading cause of liver disease and mortality in HIV-infected patients
HIV/hepatitis C co-infected patients are at greater risk for liver disease and death, compared with hepatitis C patients without HIV infection
Improved sustained virologic response with the new treatments in HIV/hepatitis C co-infected patients
Telaprevir + PegIFN/Ribavirin
PegIFN/Ribavirin
Boceprevir + PegIFN/Ribavirin
PegIFN/Ribavirin
Beware drug-drug interactions!
For now, three options
Telaprevir NRTI backbone plus either raltegravir,
efavirenz, atazanavir/ritonavir, etravirine, or riplivirine
With efavirenz, increase dose of telaprevir
Boceprevir NRTI backbone plus raltegravir
Wait... New treatments on the horizon for 2014
So what’s new in 2013?
New report of a cured patient New research towards a “functional cure” New guidelines for “when to start” therapy
in different patient populations New one-pill-once-daily treatment regimen New indication for antiretroviral therapy
Pre-exposure prophylaxis New hepatitis C treatments, and new drug-
drug interactions with antiretroviral therapy
Newest member of the Vinnard family
Thank you!