HIV Medicine - part 3 pptx

Euro-group receiving AZT+ddC+saquinavir hard gel, compared to the Euro-groups on dualtherapy Stellbrink 2000.Table 4.3: Patient case female, 41 years illustrating the success of HAART* C

im-2001, Teixera im-2001, Viard 2001) Patients who are intravenous drug users also haverelatively poor increases in CD4+ T-cells compared to other patients (Dragstedt2004).

Other possible causes for a lack of immunological response despite good viral pression may be immuno- or myelosuppressive concomitant therapies

sup-Conversely, HAART may be extremely effective immunologically and induce nificant increases in the CD4+ T-cell count, while viral load remains detectable.This can sometimes be observed in children and adolescents (see “Pediatrics”chapter) The frequencies of such discordant responses in adults are outlined in thetable below

sig-Table 4.1: Prospective cohort studies, treatment response*

n = 42

Grabar 2000

n = 2236

* Immunological response: rise in CD4+ T-cells > 100/µl after 30 months (Piketty 2001) or

> 50/µl after 6 months (Grabar 2000) Virological response: continually at least 1 log below baseline or < 500 copies/ml (Piketty 2001) or < 1,000 copies/ml (Grabar 2000).

Practical considerations in dealing with viral load and CD4 T-cell count

! Viral load is the most important parameter in treatment monitoring

! If possible, use only one type of assay (in the same lab) – bear in mind thatthere is considerable methodological variability (up to half a log)!

! Virological success should be monitored one month after initiation or cation of HAART

modifi-! Viral load should be below 50 copies/ml after 3-4 months (with high initialviral load, after 6 months at the latest) – if it is not, look for a cause!

! The greater the decrease in viral load, the more durable the response to ment

treat-! Transient, low-level increases in viral load (blips) are usually insignificant –but VL should be monitored at short intervals (e.g 2-4 weeks after such blips)

! The older the patient, the likelier a discordant response (low viral load with nosignificant increase in CD4 count)

! In contrast to viral load, increase in CD4+ T-cells, i.e immunological success,

is difficult to influence CD4+ T-cells are probably more predictive of the vidual risk for AIDS

indi-! Once CD4 count is good, it requires less frequent monitoring Remember thatwith higher CD4 counts, values may vary considerably from one measurement

to the next (which may mislead the patient to either a false sense of euphoria orunnecessary concern)

Clinical treatment success and failure

Clinical treatment success is dependent on virological and immunological peutic success (see Table 4.2) In individual patients, clinical response is not alwayseasy to assess After all, there is no way to show what might have occurred if treat-ment had not been started As an asymptomatic patient cannot feel any better, itmay be difficult to find good arguments to continue treatment in the presence ofside effects, which, at least temporarily, may affect the quality of life

thera-Clinical success is almost always evaluated via clinical endpoints (AIDS-definingillnesses, death), although the improvement on HAART in a patient with consider-able constitutional symptoms should also be seen as clinical success With regard torisk of disease progression, the immunological response is at least as important asthe virological response

However, the extent of virological success is of great significance: in the Swiss hort, out of those with a constantly undetectable viral load, the proportion of pa-tients developing AIDS or dying was 6.6 % after 30 months In contrast, this pro-portion was 9.0 % in patients with viral rebound and even 20.1 % if the viral loadwas never suppressed to undetectable levels (Ledergerber 1999) The importance ofcomplete and sustained virological treatment success for clinical benefit has alsobeen reported from other cohorts (Salzberger 1999, Thiebaud 2000)

Co-Table 4.2: Risk of progression, as defined by immunological and virological treatment sponse See previous table caption for definitions 95 % confidence interval in parentheses.

re-Grabar 2000 Piketty 2001

Relative risk Relative risk

Immunological response only 1.6 (1.0-2.5) 6.5 (1.2-35.8)

Clinical failure is usually defined as the development of an AIDS-associated tion or even death However, illness is not always indicative of clinical treatmentfailure This is particularly true for the immune reconstitution inflammatory syn-drome (IRIS), where a pre-existing, subclinical infection becomes apparent duringthe first weeks following initiation of antiretroviral therapy (see “AIDS” chapter)

condi-On the other hand, if a patient develops serious side effects or even dies, this shouldclearly be regarded as treatment failure Luckily, this is rare It should be noted thatthere might also be other causes Many severe, life-threatening events that affectHIV infected patients on HAART today are associated neither with HAART norAIDS (Reisler 2003)

What can be achieved today?

Every HIV clinician sees the remarkable strides made possible by HAART flected in his or her own patients (see example below) In many areas, the incidence

re-of AIDS has been reduced to less than a tenth (Mocrre-oft 2000) Some illnesses thatoccur only with severe immunodeficiencies are rarely seen today CMV retinitis orMAC disease have become unusual AIDS cases in Western countries occur mainly

in patients who are not being treated with antiretroviral therapy – usually becausethey are unaware of their infection or do not want to acknowledge it These so-called “late presenters” now make up a large proportion of AIDS cases In patientswho are continuously followed in specialized centers, AIDS has become a rare oc-currence

The mortality rate has continued to decline over time (Mocroft 2002) In the SIDA Cohort, the risk of suffering or dying from AIDS in the years 1998-2002 washalf that of 1996-1997 (Mocroft 2003) The Swiss cohort also showed that the ef-fect of HAART increases over time – after more than two years on HAART, therisk of disease progression was only 4 % of the risk without HAART (Sterne 2005).Data from prospective, controlled studies on this dramatic change is still limited, asthere have been few randomized trials with clinical endpoints (Hammer 1997,Cameron 1998, Stellbrink 2000) The results seen in these studies, due to their de-sign, led to licensing of the PIs In a multi-center trial, 1,090 clinically advancedpatients received ritonavir liquid formulation or placebo in addition to their ongoingtreatment The probability of AIDS and death with a follow-up of 29 weeks was21.9 % in the ritonavir arm and nearly double (37.5 %) in the placebo arm (Cam-eron 1998) In the SV14604 Study, the largest study of its kind to date, involving3,485 patients, the frequency of AIDS and death was reduced by about 50 % in the

Euro-group receiving AZT+ddC+saquinavir hard gel, compared to the Euro-groups on dualtherapy (Stellbrink 2000).

Table 4.3: Patient case (female, 41 years) illustrating the success of HAART*

CD4 + T-cells Viral load

AIDS-Studies of mono- or dual therapy are no longer ethically justifiable and the number

of clinical endpoints that occur is fortunately now extremely low As a result, theduration of any contemporary study to prove clinical benefit of one combinationover another would have to be extended over long periods Unrealistically largestudy populations would also now be required given the extremely low probability

of progression – only rarely will such investigations be undertaken in the future(Raffi 2001)

Table 4.4: Decline in morbidity and mortality in large cohorts

Where? (n) Patients (Period) Mortality

(/100 PY)

Morbidity (/100 PY)

1999

Switzerland

(2410)

6 months before versus

3 months after HAART

* MAC, PCP, CMV Mortality/Morbidity each per 100 py = patient years

This is why data from large cohorts such as Euro-SIDA, the Swiss Cohort andAmerican HOPS Cohort is usually used (see Table 4.4) According to a more recentinvestigation, the effect on the individual AIDS diseases appears to be different: the

most obvious is the decline in the incidence of viral OIs, although this is not so nounced for fungal infections (D’Arminio 2005).

pro-With regard to opportunistic infections and malignancies, the effect of HAART isequally as apparent on their clinical course as it is on their incidence Illnesses such

as cryptosporidiosis or PML can be cured, while Kaposi’s sarcoma can resolvecompletely without specific therapy Prophylaxis of pneumocystis pneumonia,toxoplasmic encephalitis, CMV, or MAC infection can usually be safely with-drawn These effects are discussed in more detail in the corresponding chapters

References on therapy success and failure

1 Buchacz K, Patel P, Taylor M, et al Syphilis increases HIV viral load and decreases CD4 cell counts

in HIV-infected patients with new syphilis infections AIDS 2004, 18:2075-2079.

6 Deeks SG Determinants of virological response to antiretroviral therapy: implications for long-term strategies Clin Infect Dis 2000, 30 Suppl 2: S177-84 http://amedeo.com/lit.php?id=10860903

7 DeJesus E, McCarty D, Farthing CF, et al Once-daily versus twice-daily lamivudine, in combination with zidovudine and efavirenz, for the treatment of antiretroviral-naive adults with HIV infection: a randomized equivalence trial Clin Infect Dis 2004, 39:411-8 http://amedeo.com/lit.php?id=15307010

8 Di Mascio M, Markowitz M, Louie M, et al Dynamics of intermittent viremia during highly active antiretroviral therapy in patients who initiate therapy during chronic versus acute and early HIV type 1 infection J Virol 2004, 78:10566-73 http://amedeo.com/lit.php?id=15367623

9 Di Mascio M, Markowitz M, Louie M, et al Viral blip dynamics during highly active antiretroviral apy J Virol 2003; 77:12165-72 http://amedeo.com/lit.php?id=14581553

ther-10 Dragsted UB, Mocroft A, Vella S, et al predictors of immunological failure after initial response to highly active antiretroviral therapy in HIV-1-infected adults: A EuroSIDA study J Infect Dis 2004, 190:148-55 http://amedeo.com/p2.php?id=15195254&s=hiv

11 Easterbrook PJ, Ives N, Waters A, et al The natural history and clinical significance of intermittent viraemia in patients with initial viral suppression to < 400 copies/ml AIDS 2002; 16:1521-7 http://amedeo.com/lit.php?id=12131190

12 Florence E, Lundgren J, Dreezen C, et al Factors associated with a reduced CD4 lymphocyte count response to HAART despite full viral suppression in the EuroSIDA study HIV Med 2003;4:255-62 http://amedeo.com/lit.php?id=12859325

13 Goetz MB, Boscardin WJ, Wiley D, Alkasspooles S Decreased recovery of CD4 lymphocytes in older HIV-infected patients beginning HAART AIDS 2001, 15:1576-9.

http://amedeo.com/lit.php?id=11504992

14 Grabar S, Kousignian I, Sobel A, et al Immunologic and clinical responses to highly active ral therapy over 50 years of age Results from the French Hospital Database on HIV AIDS 2004, 18:2029-2038 http://amedeo.com/p2.php?id=15577624&s=hiv

antiretrovi-15 Grabar S, Le Moing V, Goujard C, et al Clinical outcome of patients with HIV-1 infection according to immunologic and virologic response after 6 months of HAART Ann Intern Med 2000, 133: 401-10 http://amedeo.com/lit.php?id=10975957

16 Gulick RM, da Silva B, McMillan F, et al Lopinavir/ritonavir (LPV/r)-based therapy in antiretroviral (ARV)-nạve, HIV-infected patients: 6-year follow-up of study 720 Abstract P28, 7th Int Congress Drug Ther HIV Inf 2004, Glasgow.

17 Gulick RM, Meibohm A, Havlir D, et al Six-year follow-up of HIV-1-infected adults in a clinical trial of antiretroviral therapy with indinavir, zidovudine, and lamivudine AIDS 2003; 17:2345-2349 http://amedeo.com/lit.php?id=14571186

18 Gunthard HF, Wong JK, Ignacio CC, et al Human immunodeficiency virus replication and genotypic resistance in blood and lymph nodes after a year of potent antiretroviral therapy J Virol 1998, 72:2422-8 http://amedeo.com/lit.php?id=9499103

19 Hammer SM, Squires KE, Hughes MD, et al A controlled trial of two nucleoside analogues plus indinavir in persons with HIV infection and CD4 cell counts of 200 per cubic millimeter or less ACTG

320 Study Team N Engl J Med 1997, 337:725-33 http://amedeo.com/lit.php?id=9287227

20 Havlir DV, Bassett R, Levitan D, et al Prevalence and predictive value of intermittent viremia with combination HIV therapy JAMA 2001, 286:171-9 http://amedeo.com/lit.php?id=11448280

21 Kaufmann D, Pantaleo G, Sudre P, Telenti A CD4-cell count in HIV-1-infected individuals remaining viraemic with HAART Swiss HIV Cohort Study Lancet 1998, 351:723-4.

22 Kaufmann GR, Perrin L, Pantaleo G, et al CD4 T-lymphocyte recovery in individuals with advanced HIV-1 infection receiving potent antiretroviral therapy for 4 years: the Swiss HIV Cohort Study Arch Intern Med 2003; 163:2187-95 http://amedeo.com/lit.php?id=14557216

23 Kaufmann GR, Furrer H, Ledergerber B, et al Characteristics, determinants, and clinical relevance of CD4 T cell recovery to <500 cells/microL in HIV type 1-infected individuals receiving potent antiretro- viral therapy Clin Infect Dis 2005;41:361-72 http://amedeo.com/lit.php?id=16007534

24 Kempf DJ, Rode RA, Xu Y, et al The duration of viral suppression during protease inhibitor therapy for HIV-1 infection is predicted by plasma HIV-1 RNA at the nadir AIDS 1998, 12: F9-14.

28 Ledergerber B, Egger M, Erard V, et al AIDS-related opportunistic illnesses occurring after initiation

of potent antiretroviral therapy: the Swiss HIV Cohort Study JAMA 1999, 282: 2220-6.

31 Lederman MM, McKinnis R, Kelleher D, et al Cellular restoration in HIV infected persons treated with abacavir and a protease inhibitor: age inversely predicts naive CD4 cell count increase AIDS 2000, 14: 2635-42 http://amedeo.com/lit.php?id=11125881

32 Maggiolo F, Migliorino M, Pirali A Duration of viral suppression in patients on stable therapy for HIV-1 infection is predicted by plasma HIV RNA level after 1 month of treatment J AIDS 2000, 25:36-43 http://amedeo.com/lit.php?id=11064502

33 Marimoutou C, Chene G, Mercie P, et al Prognostic factors of combined viral load and CD4+ cell count responses under triple antiretroviral therapy, Aquitaine cohort, 1996-1998 JAIDS 2001, 27:161-7 http://amedeo.com/lit.php?id=11404538

34 Martinez V, Marcelin AG, Morini JP, et al HIV-1 intermittent viraemia in patients treated by nucleoside reverse transcriptase inhibitor-based regimen AIDS 2005;19:1065-1069.

non-http://amedeo.com/lit.php?id=15958838

35 Mezzaroma I, Carlesimo M, Pinter E, et al Clinical and immunologic response without decrease in virus load in patients with AIDS after 24 months of HAART Clin Infect Dis 1999, 29:1423-30 http://amedeo.com/lit.php?id=10585790

36 Miller LG, Golin CE, Liu H, et al No evidence of an association between transient HIV viremia ("Blips") and lower adherence to the antiretroviral medication regimen J Infect Dis 2004, 189:1487-

96 http://amedeo.com/lit.php?id=15073687

37 Mira JA, Macias J, Nogales C, et al Transient rebounds of low-level viraemia among HIV-infected patients under HAART are not associated with virological or immunological failure Antivir Ther 2002, 7:251-6 http://amedeo.com/lit.php?id=12553479

38 Mocroft A, Brettle R, Kirk O, et al Changes in the cause of death among HIV positive subjects across Europe: results from the EuroSIDA study AIDS 2002, 16:1663-71 http://amedeo.com/lit.php?id= 12172088

39 Mocroft A, Katlama C, Johnson AM, et al AIDS across Europe, 1994-98: the EuroSIDA study Lancet

59 Smith K, Aga E, Bosch RJ, Valdez H, et al Long-term changes in circulating CD4 T lymphocytes in virologically suppressed patients after 6 years of highly active antiretroviral therapy AIDS 2004, 18:1953-6 http://amedeo.com/lit.php?id=15353982

60 Stellbrink HJ, Hawkins DA, Clumeck N, et al Randomised, multicentre phase III study of saquinavir plus zidovudine plus zalcitabine in previously untreated or minimally pretreated HIV-infected patients Clin Drug Invest 2000, 20:295-307.

61 Sterne JA, Hernan MA, Ledergerber B, et al Long-term effectiveness of potent antiretroviral therapy

in preventing AIDS and death: a prospective cohort study Lancet 2005, 366:378-84.

http://amedeo.com/lit.php?id=16054937

62 Sungkanuparph S, Overton ET, Seyfried W, et al Intermittent episodes of detectable HIV viremia in patients receiving nonnucleoside reverse-transcriptase inhibitor-based or protease inhibitor-based highly active antiretroviral therapy regimens are equivalent in incidence and prognosis Clin Infect Dis, 41:1326-32 http://amedeo.com/lit.php?id=16206110

63 Teixeira L, Valdez H, McCune JM, et al Poor CD4 T cell restoration after suppression of HIV-1 cation may reflect lower thymic function AIDS 2001, 15:1749-56.

repli-http://amedeo.com/lit.php?id=11579235

64 Thiebaut R, Morlat P, Jacqmin-Gadda H, et al Clinical progression of HIV-1 infection according to the viral response during the first year of antiretroviral treatment Groupe d'Epidemiologie du SIDA en Aquitaine (GECSA) AIDS 2000, 14:971-8 http://amedeo.com/lit.php?id=10853978

65 Valdez H, Connick E, Smith KY, et al Limited immune restoration after 3 years' suppression of HIV-1 replication in patients with moderately advanced disease AIDS 2002, 16:1859-66.

Eradication – Is it feasible?

At this point in time, eradication of HIV in the sense of a cure is still unrealistic.Although as late as 1997, many still dreamt of eradication, leading researchers arenow inclined to be pessimistic The main problem lies in the pool of latently HIV-infected cells, which probably comprise a lifelong reservoir (review: Saksena2003) Even after years of sufficient viral suppression to below 20-50 copies/ml,cellular viral transcription still takes place (Finzi 1999, Furtado 1999, Zhang 1999,Sharkey 2000) This is particularly true for blood cells, but also applies to lymphnodes and sperm (Lafeuillade 2001, Nunnari 2002)

In a more recent study, a half-life of 44.2 months was calculated for the latentlyinfected reservoir in 62 patients, whose viral load had been successfully suppressed

on HAART for seven years (Siciliano 2003) The calculated time to eradication ofthese reservoirs was 73.4 years Even in a highly selected group of patients, withouteven a single viral blip measured during a minimum of three years of stableHAART, and with an overall trend for a slightly more rapid decrease in infectedcells, the time to eradication was 51.2 years

Latently infected reservoirs consist of very heterogeneous cell populations, the bility of which is probably even independent of residual viral replication Therefore,even complete inhibition of viral replication would be insufficient to eradicate HIV(Strain 2004)

sta-Different methods have been used in the last few years to attempt to flush out theselatent reservoirs (IL-2, hydroxyurea, OKT), but all have failed (Kulkosky 2002,Pomerantz 2002) In summer 2005, a research team from Dallas (Lehrman 2005,Routy 2005) caused a stir with a novel approach using an old medication: they dis-covered that valproinic acid, an antiepileptic treatment used worldwide, is an in-hibitor of histon deacetylase-1 (HDAC1) This enzyme mediates chromatin remod-

eling, the inhibition of viral gene expression and the production of virions ploratory work has shown that the blockade of HDAC1 results in HIV beingwashed out of dormant T cells This small pilot study investigated four HIV-infected patients, in whom the virus had been suppressed using HAART for at leasttwo years The patients received valproinic acid for three months, in relatively lowdoses compared to standard anti-epileptic treatment In order to intensify HAARTand to catch the virus set free by valproinic acid, the entry inhibitor T-20 was added

Ex-to the treatment regimen for three weeks prior Ex-to and during the administration ofvalproinic acid The number of latently infected CD4+ T-cells was measured beforeand during treatment using a very complicated method Result: although the levelremained constant under conventional HAART, on valproinic acid it decreased sig-nificantly in three of the four patients, to the extent of 68 %, 72 % and more than

84 % In addition, the half-life of the latent infected cells sank to 2-3 months, incomparison to other studies, which have reported 44.2 months under classicalHAART (Siciliano 2004) and 10 months under intensive HAART (Ramratnam2004)

So, what do these results tell us? First of all, the euphoria has to be restrained As sooften happens, more new questions are posed than answered The most importantquestions are: Is the virological effect really due to valproinic acid? Is this effect,from just three patients, actually reproducible? Does it also apply to other cell com-partments apart from blood? Why was the effect only measurable in three of thefour patients? All these points can only be speculated on at the moment

In other words: based on the currently available medication, eradication is still notpossible Latent infected cells differ from non-infected cells through a minute de-tail, which can hardly be detected using modern methods that are also unspecific.Washing out the reservoirs, or simply eliminating all infected memory cells is eitherunsuccessful, too toxic or much too dangerous It remains to be seen whether val-proinic acid or other immune therapies given in addition to HAART, will provide aperspective Due to the complexity of the immune system, which is only graduallybeginning to be understood, a solution seems to be a long way off

Other important aspects of HAART

Besides the goals described above – virological, immunological and clinical ment success – several other aspects need to be considered Although not the pri-mary aim of HAART, they are nevertheless important Cost reduction, prevention,and improving compliance remain a constant challenge for every HIV clinician

treat-Reduction of costs

Antiretroviral treatment is expensive It is important for clinicians to be informedabout the price of drugs they prescribe, and to rationalize in any way that would becost beneficial to patients and health services For example, in Germany individualdrugs cost between 270 Euro (Epivir™) and 2,000 Euro (Fuzeon™) per month.Even within drug classes, astonishing differences exist In some countries, Crix-ivan™, at 325 Euro per month, is relatively cheap, while Aptivus™, at 1,100 Europer month, is the most expensive PI A combination regimen with Trizivir™andKaletra™ adds up to at least 1,700 Euro per month in some countries As a

healthcare provider, it is therefore important to have an idea of costs On the otherhand, one should not be put under pressure by health insurances Hopefully, theirattempt to disqualify antiretroviral drugs as “me-too” preparations, through themodernization law to the legal insurance scheme, will not be successful.

The pricing policy of the pharmaceutical industry is, however, sometimes veryquestionable For example, in some countries Combivir™ costs slightly less thanthe individual drugs AZT and 3TC, but Trizivir™ costs significantly more thanAZT and 3TC or Combivir™plus abacavir The reason why directly concurrentpreparations (nevirapine and efavirenz or 3TC and FTC) cost almost exactly thesame, whilst other substances from the same drug class are over 300 % more ex-pensive, cannot be explained through development costs alone

Despite all criticism, the positive effect of HAART remains unquestioned andshould not be forgotten despite the discussion of its cost Reliable estimates assume

an expenditure of between $13,000 and $23,000 per additional QUALY adjusted year of life; Freedberg 2001) – relatively cheap in comparison to manyother therapies HAART reduces the cost of expensive treatment of opportunisticinfections, inpatient and outpatient care In one German study, between 1997 and

(quality-2001, total annual outgoings per patient decreased from 35,865 Euro to 24,482 Euro(Stoll 2002) Many patients are able to work again, resulting in an overall economicgain for society (Sendi 1999)

Nevertheless, the fact remains, that HAART is expensive in Western countries It istherefore reasonable to expect that patients use up remaining stores and packets ofdrugs, if the reason for changing medication is to reduce the pill burden or because

of doubts about long-term toxicity Patients should also be made aware of the cost

of medication – not so that they feel guilty, or to blame the inaccessibility of thehealthcare system on them, but to provide an awareness of the value of the therapy

It is important that initially only one packet is prescribed, even if the standard dose

of Retrovir™ 250 mg it is still just enough for 20 days – almost 20 years after itsintroduction! In this way, one avoids sitting on a mountain of drugs if intolerabilityoccurs Prescription of more than three months supply of medication should also beavoided Since the reform of the health system in 2004 and the subsequent addi-tional payment obligation, many patients refuse it anyway

In any case, it is important to be informed about the costs of HAART It is not onlythe patent on AZT that will be lifted, the patents on ddI (US patent until October2006), 3TC, d4T and abacavir will also be removed within the next decade It isinteresting to see how the company policies will develop However, it will take alittle longer until the end of the patent on the first PI: saquinavir will be freed in2010

60 %, based on the probability of transmission per couple (Porco 2004) HAART isthus an important component of prevention, which is often underestimated (Hos-seinipur 2002).

Most patients are interested in knowing: “Do I still need to use a condom?” Theanswer is: “Yes!” Studies have shown that the decrease of viral load in plasma andseminal fluid is roughly parallel and that a decrease of several logs in plasma afterseveral months may also be seen in semen (Liuzzi 1999) Although the same seems

to be true for the vaginal and anorectal mucosa, individual risk remains difficult toestimate (Cu-Uvin 2000) Furthermore, viral load levels in blood and other bodyfluids do not always correlate with one another

In addition, HIV-infected patients are not protected from superinfection with newviral strains Dual infections with several subtypes are often associated with accel-erated disease progression (Gottlieb 2004) Transmission of resistant strains is alsopossible (Yang 2005)

There has also been concern that the preventive effects of HAART lead to an crease in risk behavior Calculations have shown that an increase in risk behavior ofonly 10 % would offset the effects of HAART (Blower 2001, Law 2001) However,one meta-analysis concluded that HAART does not increase risk behavior of pa-tients, even if viral load is undetectable (Crepaz 2004) The gladly circulated sce-nario of the irresponsible HIV patient, who sets his desires loose again in the age ofHAART, putting innocent people at risk, is just a rumor

in-On the other hand, with the steadily decreasing interest in AIDS in the media andpolitics, a reduced awareness of the risks can also be observed This is supported bythe news that the sale of condoms in Germany in 2001 went down for the first timesince 1998 (by 4.4 %) In the French PRIMO Cohort, so-called risk contacts of pa-tients increased from 5 to 21 % between 1998 and 2001 (Desquilbet 2002) Smallsyphilis endemics among HIV-infected individuals are now being reported in everymajor city in the US and Europe Of equal concern is the increasing data on trans-mission of multiresistant viruses A case, such as that of the New York patient, whobecame infected with a multidrug-resistant virus and underwent rapid progressionwithin a few months (Markowitz 2005), as controversial as it was, at least showedhow important protection still is In Germany, the rate of new infections in homo-sexual men increased by 20 % in 2005 - an all time high

Adherence as a goal of therapy

Adherence is the Achilles heel of antiretroviral therapy Non-adherence is a main, ifnot the most important factor in treatment failure (review: Turner 2002) Insuffi-cient plasma drug levels and partial suppression of viral load are the conditions un-der which resistance can develop There is no question that HAART has to be takenregularly All or nothing: with regard to resistance, it is still better not to take anydrugs at all Taking more than 90 % or less than 69 % of drugs were both associatedwith a lower risk for resistance (Sethi 2003) Compliance is defined as consent andacceptance of a treatment regimen by the patient In the mid-90s a newer, more po-litically correct term was adopted – “adherence” This term describes both clinicianand patient working together to achieve a treatment concept acceptable for both,and emphasizes, that not only the patient may be responsible for treatment failure

Adherence includes all factors that influence staying on a regimen, in terms of ceptability” Whichever term is used, three facts remain:

“ac-1 If only 5 % of pills are not taken, treatment success is put at risk

2 Clinicians usually overestimate the compliance of their patients

3 The more complex the therapy, the worse the compliance

“Risk patients” for noncompliance include individuals with substance or alcoholabuse or those experiencing side effects Many studies have, however, also identi-fied patients with depression, living alone, or of a younger age, as being particularly

at risk (Murri 2001, Frank 2002, Glass 2006) Positive factors are physician ence, confidence of the patient in the positive effects of HAART, and social sup-port Race, sex or stage of disease does not seem to be relevant The individual’sview of disease and health, acceptance of modern medicine and fear of side effectsare further considerations However, all of these factors vary greatly, and in the end,compliance is difficult to predict in individual cases (Lerner 1998)

experi-The importance of taking drugs regularly has been demonstrated in numerous ies in recent years In one study of 99 patients, in which compliance was evaluated

stud-by way of an electronic monitoring system, the rate of treatment failure was only

22 % in patients with a level of compliance of at least 95 % (95 % of doses taken).Failure rates in patients with 80-94 % or < 80 % compliance were 61 % and 80 %,respectively (Paterson 2000) However, it must be taken into consideration that thismuch cited study is now relatively old Newer drugs with longer half-lives, higherresistance barriers and better overall pharmacokinetics may be more forgiving ofnoncompliance

In the aforementioned study, with regard to compliance, 41 % of patients weremisjudged by their treating clinicians Nurses seemed to have a better understanding

of their patients, judging incorrectly in only 30 % of cases (Paterson 2000) Theimportance of compliance is also demonstrated by the successes reported in patientswith directly observed therapy (DOT) In Florida’s correctional facilities 100 % ofparticipants in a DOT study had a viral load below 400 copies/ml at 48 weeks,compared with 81 % in an unmonitored control group in the general population(Fischl 2001)

Poor adherence not only leads to virological failure It also has immunological sequences In an analysis of two prospective studies, patients with a compliance of

con-100 %, 80-99 % and 0-79 % experienced reductions in viral load by 2.77, 2.33 and0.67 logs after one year At the same time, the CD4 cell count rose by 179, 159 and

53 cells/µl, respectively (Mannheimer 2002) Furthermore, noncompliance also hasclinical effects beyond the surrogate markers In a Spanish study, patients who didnot take more than 10 % of their drugs had a four-fold increase in mortality risk(Garcia 2002) This data has been confirmed in other studies (Maher 1999, Hogg

2000, Wood 2004) Hospital stays are also less frequent in patients with high pliance (Paterson 2000) In addition, it should be considered that noncompliant pa-tients increase the risk of transmission of resistant viruses

com-The basic mechanisms for development of resistance should be explained to tients One must emphasize that, in contrast with other chronic illnesses, resistancemutations do not disappear once they have developed Diabetes and hypertensionmake effective examples: whereas these diseases may “tolerate” forgetting the oc-

pa-casional tablet (blood glucose or blood pressure levels can easily be lowered againthe next day), HIV is different Even short-term lapses can have irreversible conse-quences And every new occurrence of resistance makes therapy more complicatedand more difficult Patients have to be made aware of this unusual feature of HIVdisease These conversations should be repeated from time to time and become astandard component of routine care Cooperation with special treatment discussiongroups offered by various support organizations can be useful The table belowprovides additional suggestions.

In addition, a number of very different strategies have been investigated in order toimprove compliance They range from the employment of additional nurses to tele-phoning patients regularly A large recent ACTG study showed that at least theregular telephone reminders do not appear to have any influence on compliance(Collier 2005)

Twelve steps to improve adherence

1 Every patient should receive a written (legible!) treatment plan, which should

be reviewed at the end of the visit It should include a telephone number to call

in case of problems or questions

2 Patient and clinician should agree on the treatment plan The patient’s concerns

or critical questions should be discussed

3 The patient should have the impression that the treatment regimen was not domly chosen, but tailored to his/her individual needs

ran-4 The explanation of a new or modified treatment plan takes time, and should not

be rushed – all questions should be answered

5 The reasons why adherence is so important should be explained It makes sense

to repeat such conversations – they should not only take place when initiating

or modifying treatment, but should be part of routine care

6 Possible side effects should be explained, as well as what can be done to ate them

allevi-7 Support groups and other types of assistance should be utilized and offered

8 It is important to tell the patient to come back if any problems are encounteredwith HAART – it is better to solve them together than have the patient try todeal with them alone at home

9 The patient should know that the treatment regimen must be taken in its tirety (“Last month I left out the big tablets”)

en-10 Prescriptions should be documented, in order to get a rough idea of adherence.Irregularities should be addressed openly

11 During the early phases of therapy, the patient should be informed of treatmentsuccess as seen by reduction of viral load and rise in CD4 count

12 Ensure clinical vigilance to detect the early signs of depression and treat propriately

ap-If compliance remains low

Despite all efforts, some patients will not be able to improve their compliance sicians and other healthcare providers are advised not to take this personally or tofeel offended should a patient not want to participate in the advances of medicine.Although it may be difficult to accept others’ views on life, disease and treatment,tolerance and acceptance should remain fundamental to the interactions of allhealthcare providers with their patients Some providers, especially those who treatselective patient populations in university settings, sometimes forget the reality ofroutine medical practice Rigidly upholding the principles of modern medicine usu-ally doesn’t help here, and putting patients under pressure achieves even less It isimportant to clearly outline and explain one’s own position

Phy-The question of whether noncompliant patients should continue to be treated withantiretroviral therapy is not always easy to address On the one hand, there are pa-tients who benefit even from suboptimal therapy; on the other hand, drugs are ex-pensive and should not be prescribed too readily When resources are limited, avail-able drugs should be used prudently If poor compliance is suspected in the initialconsultation, restraint should be applied

One also needs to be aware of criminal intentions – there have repeatedly been ports of patients who have done deals with pharmacists (black sheep occur every-where!) for other medication (methadone, etc.) or money Therefore, written pre-scriptions should be endorsed where possible If in doubt about the compliance orhonesty of the patient, plasma levels can be measured (preferably without priorwarning)

re-Duesbergians – a sect of HIV medicine

The patients that refuse antiviral treatment on principal form a special case Thesepatients are frequently under treatment from (shockingly misdirected) doctors, whocall themselves “Duesbergians” (after the US virologist and AIDS dissident PeterDuesberg, who denied any association between AIDS and illness) Here, it can bevery difficult to watch patients go to their fate with open eyes Informative consul-tations should be as detailed as possible and preferably documented in writing Be-low is an actual example:

An approximately 40-year old patient with a long history of untreated HIV, 30CD4+ T-cells/µl and cerebral toxoplasmosis, which improved significantly after 4weeks of acute treatment (the last MRI still showed scattered lesions) presented atthe HIV outpatients department Clinically, he was relatively well and fully ori-ented, and due for discharge that day In a conversation, the patient categoricallyrefused to start the urgently recommended antiretroviral therapy (“one can die fromAZT, and the other drugs are not much better”) as well as antibiotics Therefore hecould also not continue to take the toxoplasmosis maintenance therapy, which hadcaused him from the first day in hospital to suffer from diarrhea (NB, probablycryptosporidiosis), skin problems (seborrheic dermatitis, thrush), and an extremeloss of weight (MAC?) It was most important for him to have a break from every-thing

In cases such as these, we make sure the patients sign the information sheets Everypatient is allowed to and should decide for himself (if fully oriented) – but he mustknow and be fully informed about what he is doing It is important to give the pa-

tient control: if he changes his mind (and of course, being sarcastic about the abovecase: if the toxoplasmosis relapses), he can return! Arguing with medical Duesber-gians does not achieve anything in our experience The view of the world that thissect has is closed A discussion about the prayer-wheel-like repeated old argumentsjust uses up time and wastes energy.

Fortunately, these cases have become more seldom The initial widespread cism about HAART has decreased significantly, due to its overwhelming success inthe last few years And: where Peter Duesberg is concerned (thankfully), it has alsobecome quieter, at least as far as his HIV activities goes The sect is in decline

3 Crepaz N, Hart TA, Marks G Highly active antiretroviral therapy and sexual risk behavior: a analytic review JAMA 2004, 292:224-36 http://amedeo.com/p2.php?id=15249572

meta-4 Cu-Uvin S, Caliendo AM, Reinert S, et al Effect of HAART on cervicovaginal HIV-1 RNA AIDS 2000, 14: 415-21 http://amedeo.com/lit.php?id=10770544

5 Desquilbet L, Deveau C, Goujard C, et al Increase in at-risk sexual behaviour among HIV-1-infected patients followed in the French PRIMO cohort AIDS 2002, 16:2329-33.

12 Garcia de Olalla P, Knobel H, Carmona A, et al Impact of adherence and HAART on survival in infected patients J Acquir Imm Defic Syndr 2002, 30:105-10 http://amedeo.com/lit.php?id=12048370

HIV-13 Glass TR, De Geest S, Weber R, et al Correlates of Self-Reported Nonadherence to Antiretroviral Therapy in HIV-Infected Patients: The Swiss HIV Cohort Study J AIDS 2006, 41:385-392.

2000, Durban, South Africa.

16 Hosseinipour M, Cohen MS, Vernazza PL, Kashuba AD Can antiretroviral therapy be used to prevent sexual transmission of HIV type 1? Clin Infect Dis 2002, 34:1391-5.

http://amedeo.com/lit.php?id=11981736

17 Kulkosky J, Nunnari G, Otero M, et al Intensification and stimulation therapy for HIV type 1 reservoirs

in infected persons receiving virally suppressive HAART J Infect Dis 2002, 186:1403-11.

http://amedeo.com/lit.php?id=12404155

18 Lafeuillade A, Khiri H, Chadapaud S, Hittinger G, Halfon P Persistence of HIV-1 resistance in lymph node mononuclear cell RNA despite effective HAART AIDS 2001, 15:1965-9.

22 Liuzzi G, Chirianni A, Bagnarelli P, Clementi M, Piazza M A combination of nucleoside analogues and

a protease inhibitor reduces HIV-1 RNA levels in semen: implications for sexual transmission of HIV infection Antivir Ther.1999, 4:95-9 http://amedeo.com/lit.php?id=10682154

23 Maher K, Klimas N, Fletcher MA Disease progression, adherence, and response to protease inhibitor therapy for HIV infection in an Urban Veterans Affairs Medical Center J Acquir Immune Defic Syndr

1999, 22:358-63 http://amedeo.com/lit.php?id= 10634197

24 Mannheimer S, Friedland G, Matts J, et al The consistency of adherence to antiretroviral therapy predicts biologic outcomes for HIV-infected persons in clinical trials Clin Infect Dis 2002, 34: 1115-21 http://amedeo.com/lit.php?id=11915001

25 Markowitz M, Boden D Multidrug-resistant, dual-tropic HIV-1 and rapid progression Lancet 2005, 365:1924 http://amedeo.com/lit.php?id=15936415

26 Murri R, Ammassari A, De Luca A, et al Self-reported nonadherence with antiretroviral drugs predicts persistent condition HIV Clin Trials 2001, 2:323-9 http://amedeo.com/lit.php?id=11590535

27 Nunnari G, Otero M, Dornadula G, et al Residual HIV-1 disease in seminal cells of HIV-1-infected men

on suppressive HAART: latency without on-going cellular infections AIDS 2002, 16:39-45.

33 Routy JP Valproid acid: a potential role in treating latent HIV infection Lancet 2005, 366: 523-524.

34 Saksena NK, Potter SJ Reservoirs of HIV-1 in vivo: implications for antiretroviral therapy AIDS Rev 2003; 5:3-18 http://amedeo.com/lit.php?id=12875103

35 Schwarze S Getretener Quark wird breit, nicht stark: Was man von den "AIDS-Skeptikern" wirklich lernen kann http://hiv.net/2010/news2001/n1219.htm

36 Sendi PP, Bucher HC, Harr T, et al Cost effectiveness of HAART in HIV-infected patients Swiss HIV Cohort Study AIDS 1999, 13:1115-22 http://amedeo.com/lit.php?id=10397543

37 Sethi AK, Celentano DD, Gange SJ, Moore RD, Gallant JE Association between adherence to roviral therapy and HIV drug resistance Clin Infect Dis 2003;37:1112-8.

42 Tovanabutra S, Robison V, Wongtrakul J, et al Male viral load and heterosexual transmission of HIV-1 subtype E in northern Thailand J Acquir Immune Defic Syndr 2002 29:275-83.

http://amedeo.com/lit.php?id=11873077

43 Turner BJ Adherence to antiretroviral therapy by HIV-infected patients J Infect Dis 2002; 185 Suppl 2: S143-51 Abstract: http://amedeo.com/lit.php?id=12001036

44 Wood E, Hogg RS, Yip B, et al The impact of adherence on CD4 cell count responses among infected patients J Acquir Immune Defic Syndr 2004, 35:261-8.

5 When to start HAART

Christian Hoffmann, Fiona Mulcahy

"It’s the most important question in HIV therapy" (A Fauci)

The indication for antiretroviral therapy is based on the clinical assessment, CD4+T-cell count, and viral load These three important factors determine whether ther-apy should be started or if it can still be deferred At first glance, it appears straight-forward: the lower the CD4+ T-cell count and the higher the viral load, the higherthe risk of AIDS (Mellors 1997, Lyles 2000), and the more urgent the indication fortreatment

But, how high is the individual risk really? The following table lists the (selected)risks of developing AIDS within six months, as identified in 3,326 patients from thepre-HAART era (Phillips 2004) The range of individual risk of progression varieswidely – from 0 to almost 50 % For a 55 year-old patient with a CD4+ T-cell count

of 50/µl and a viral load of 300,000 copies/ml, the risk of progressing to AIDSwithin the next 6 months was 44.8 % In a 25 year-old patient with 500 CD4+ T-cells/µl and a viral load of 3,000 copies/ml, the risk was only 0.3 % This demon-strates the importance of these parameters for estimating the individual risk andindication for treatment (some other examples of possible constellations and theirrespective risks are shown in Table 5.1) Surprisingly, the age of the patients, whichaccording to these data significantly increases the risk of progression, has so far notbeen included in any of the guidelines

Table 5.1: Predicted six-month percentage risk of developing AIDS, according to age, viral load and CD4+ T-cell count (data from the pre-HAART era)

VL = Viral load (From: Phillips A, CASCADE Collaboration Short-term risk of AIDS according

to current CD4+ T-cell count and viral load in antiretroviral drug-naive individuals and those treated in the monotherapy era AIDS 2004, 18:51-8 http://amedeo.com/lit.php?id=15090829)

Nevertheless, the best time for initiation of therapy remains the subject of versial debate The risk of AIDS must be weighed against the risks of long-termtoxicity and viral resistance These risks and the realization that eradication cannot

contro-be achieved at present have led to less rigid guidelines in many countries in recentyears The initial “hit hard and early” dogma of 1996, which recommended therapyfrom the earliest stages of infection, has since been discarded Similarly, it is now

no longer common practice to treat every patient with a viral load above 10,000copies/ml, independent of the CD4+ T-cell count, as was still generally recom-mended in the 1997 US guidelines (Carpenter 1997).

Table 5.2: Recommendations from various guidelines on when to initiate therapy

Clinical CD4 cells/µl Initiation of HAART is

CDC B+C All values “recommended” (DHHS, GA, GB)

CDC A < 200 “recommended” (DHHS, GA, GB)

CDC A 200-350 “should be offered” (DHSS)

“generally advisable, independent of viral load” (GA)

“recommended for most patients, but should depend on vidual factors”* (GB)

indi-CDC A 350-500 “most experts recommend deferring with VL > 100,000, some

clinicians will treat; defer with VL < 100,000” (DHHS)

“recommended by some experts with VL 50,000–100,000; most were hesitant to treat with VL of 50,000” (GA)

“to be deferred” (GB) CDC A > 500 “deferral recommended by most experienced clinicians and

treatment recommended only by some for VL > 100,000; defer with VL < 100,000”** (DHHS)

“to be deferred”** (GB)

“most experts hesitant to treat” (GA)

VL = viral load *The individual factors include symptoms, patient wishes, expected adherence, potential toxicity, decline in CD4+ T-cells, level of viral load and age **No distinction is made between 350-500 and > 500 CD4+ T-cells

DHHS: Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and cents, Department of Health and Human Services (DHHS), 06 October 2005.

200 CD4+ T-cells/µl should be treated However, for patients with more than

200 CD4+ T-cells/µl, the situation becomes more confusing Lack of randomizedstudies forces all guidelines to rely on cohort studies, meta-analyses and evaluation

of larger databases Such data is problematic, however, as important aspects such ascompliance or prior treatment regimens are not captured, and very heterogeneouspatient populations are included As a result, a range of interpretations is possible

In Table 5.2, the current guidelines from the USA, Europe, Britain and Germany onstarting therapy are summarized

Guidelines merely provide points of reference and are not set in stone Decisionsmust be made on a case-by-case basis, even if some health insurance providers tend

to ignore this and use such guidelines to their advantage In some situations, therapymay be started earlier than recommended in the guidelines; in other cases, therapymight (or even should) be deferred The following chapter discusses relevant stud-ies on initiation of therapy in chronic HIV infection (the special case of acute HIVinfection is discussed in a separate chapter).

Experiences from practice

Even if the indication for HAART seems obvious, it should be clarified whether thepatient is indeed prepared to start treatment The problem is not the initiation ofHAART, but the continuity The decision to initiate treatment is often made pre-maturely It is usually unwise to prescribe antiretroviral medication to a patient inthe first consultation One should first attain an overall picture of the patient, and try

to get to know something about his lifestyle and motives – why he has come to see

a doctor, and what he expects

In some cases, patients put themselves under pressure unnecessarily, or let others do

so A single lower CD4 count, a prolonged case of flu seeming to indicate a ened immune system (“I never had anything like that before”), springtime lethargy,new study results, a promising new drug in the newspaper (“I’ve heard a lot aboutT-20”), a partner who has started therapy – none of these are therapeutic indica-tions It is often particularly difficult to inform people from other cultures that notevery person with an HIV infection needs immediate therapy

weak-As a rule, as much time as is needed should be taken for the decision to start apy This is usually possible A well-informed patient complies better with treat-ment! We recommend that patients come for several consultations to prepare thememotionally for treatment There are two exceptions: acute HIV infection, and se-vere immunodeficiency However, even in the presence of most AIDS-definingconditions, the acute disease should often be treated first before initiating ART, asthe potential for complications with PCP, toxoplasmosis or CMV therapies unnec-essarily jeopardize treatment options Not a single study to date has shown a benefit

ther-of commencing HAART simultaneously with OI therapy

If a long vacation is planned, it is better to delay therapy so that treatment responseand side effects can be adequately monitored On the other hand, patients maysometimes find one reason after another (stress at work, exams, change of job, etc.)

to delay initiation of treatment Many patients are afraid of AIDS, but often just asafraid of HAART (“the pills are the beginning of the end!”) They may have irra-tional or simply false expectations of HAART and its consequences – starting ther-apy does not mean that one will be subjected to daily infusions and no longer able

to work!

Therapy should be explained to every patient from the outset It is also useful todefine individual threshold values for the commencement of therapy with patientsearly on, so that therapy is started only when these levels are reached In our expe-rience, patients are more motivated by this approach

We also tend to start HAART earlier in older patients (above 50 years) Althoughthe regenerative capacity of the immune system in older patients is significantlyreduced (Ledermann 2002, Grabar 2004), this has not been acknowledged in anyguidelines to date More importantly, the risk of developing opportunistic infections

also depends on age (Phillips 2004) Another example from the CASCADE Study(Table 5.1) exemplifies this: a 25 year-old patient with 100 CD4+ T-cells/µl and aviral load of 100,000 copies/ml has a risk of approximately 10 % for developingAIDS within six months – for a 55 year-old, this level of risk is reached at

150 CD4+ T-cells/µl and a viral load of 30,000 copies/ml!

It is also important that not only the absolute CD4+ T-cell count is considered, butthe percentage value too In particular, when the CD4 count is high and the immunestatus appears good, the CD4 percentage is the most important parameter for pre-dicting the risk of developing AIDS In one study, the risk of progression for pa-tients with more than 350 CD4+ T-cells/µl was increased approximately four fold,

if the percentage of CD4+ T-cells was below 17 % (Hulgan 2005)

Finally, it should not be forgotten, that the whole discussion is based on bare ures, as the CD4+ T-cells are actually surrogate markers As a “surrogate”, they areconceived as a replacement for clinical endpoints Therefore, they are only a roughexpression of the clinical reality Although they usually do this supremely, and eventhough the CD4+ T-cell count is one of the best surrogate markers in medicine, it isnot everything The patient also has to be examined!

fig-Symptomatic patients

There is currently consensus that every symptomatic patient should receive roviral therapy This is, of course, mainly true for patients in WHO Stage C (withAIDS), but also for all patients in Stage B Although this should be correct in mostcases, it may be advisable to consider the situation more closely in individual cases

antiret-To avoid misunderstanding: all opportunistic infections indicative of severe nodeficiency, such as CMV, MAC, toxoplasmosis or PCP, and also AIDS malig-nancies (including the non-AIDS-defining Hodgkin’s Disease), should thereforeprompt rapid initiation of therapy, especially if there is no specific treatment avail-able, as in the case of PML In such cases, rapid initiation of maximally suppressiveHAART is the only treatment option available

immu-However: Herpes zoster (Stage B) may occur even with a slight immune defect anddoes not necessarily indicate immunological deterioration Thrombocytopenia orconstitutional symptoms may also have other causes A further example: tuberculo-sis, which is an AIDS-defining illness and therefore an “urgent” indication for ther-apy, is a facultative opportunistic infection It may occur without or with only mod-erate immunodeficiency In our experience, one is justified in waiting with HAART

in a TB patient with good CD4+ T-cells (see example in Table 5.3) The Britishguidelines (http://www.bhiva.org) specifically mention pulmonary tuberculosis asbeing a possible exception in which treatment may be deferred

On the other hand, typical illnesses that may be relatively harmless in comparison,such as oral candida or oral hairy leukoplakia, are also unerring indications of animpaired immune system They may often precede far more serious illnesses Insuch cases, it is advisable to offer the patient therapy, even if the CD4+ T-cell count

is relatively stable The same applies to constitutional or cognitive disturbances Apatient who develops concentration deficits within a short period of time, or whocomplains of forgetfulness, could – if other causes have been ruled out – have de-veloped the first cognitive deficiency associated with HIV Neuropsychologicalchanges are seen early in the course of infection and sometimes are observed in

otherwise asymptomatic patients (Review: McArthur 2005) – initiation of therapyshould be seriously considered in such situations.

Table 5.3: Case study, in which HIV treatment, if it had been given in accordance to the guidelines, could have led to almost ten years of over-treatment NA = not available

CD4 (%) Viral load

Feb 96 End of tuberculosis treatment

Patient refuses (urgently recommended) HAART

Oct 97 Patient refuses (urgently recommended) HAART 402 (33) 29,500 Oct 99 Patient refuses (urgently recommended) HAART 393 (29) 13,500 Oct 00 Patient refuses (recommended) HAART 520 (30) 12,500 Jun 02 Doctor does not want to start HAART 521 (29) 7,440

Mar 06 Nothing new Will it change again? 408 (25) 8,500

On the other hand, if after a detailed discussion, a patient wants to begin treatment,even though the results justify waiting, HAART should not be withheld For manypatients, treatment can be a psychological support Not everybody can sleep peace-fully at night knowing that inside his/her body a hundred million new viruses arebeing produced every day and a huge number of helper cells are being destroyed

Asymptomatic patients – below 200 CD4+ T-cells/µl

It is agreed, that there is a clear indication for initiation of therapy in asymptomaticpatients with less than 200 CD4+ T-cells/µl 200 CD4+ T-cells/µl is the cut-off, andone should not wait for values to drop below this level, as the risk for severe com-plications increases significantly with increasing duration (Mellors 1997, Egger2002) For patients with CD4+ T-cells of 200/µl and a high viral load, the six-month risk for AIDS is sometimes greater than 10 % (Phillips 2004) It is thereforeadvisable not to let this happen: the first manifestation of AIDS may not be an eas-ily treatable infection such as PCP or esophageal thrush If PML, CMV, or toxo-plasmic encephalitis occurs instead, the result is often permanently damaging.However, such considerations are redundant for many of the patients presenting forthe first time in outpatient clinics and private practices today At least one thirdhave a CD4+ T-cell count below 200/µl Nevertheless, even here the point is not tostart therapy within a matter of days, but rather to prepare patients for initiation ofHAART Is the patient going to return at all? We have now made it our practice tostart PCP prophylaxis in such patients The first two weeks are used for diagnosticprocedures (fundoscopy! thoracic x-ray, ultrasound) to provide informative coun-seling – as well as explaining whether the patient is eligible to enter a study - and toidentify patients with psychosocial issues Requirements with respect to pill burdenand dosing schedules need to be raised HAART is started only when these issueshave been addressed

The risk of AIDS remains elevated in these patients even after initiation ofHAART This is logical – severe immunodeficiency requires a longer time to re-

constitute, and patients therefore remain at risk during the initial months A pletely destroyed immune system cannot recover so quickly However, this risk isrelatively low: in an analysis of treatment-nạve patients with less than

com-200 CD4+ T-cells/µl at the beginning of therapy, 8.3 new AIDS-defining illnessesper 100 patient years were observed - in patients with at least 350 CD4+ T-cells/µlthis value was 1.8/100 patient years Similarly, mortality was slightly elevated at2.9 versus 0.7/100 patient years (Phillips 2001)

Asymptomatic patients – 200-350 CD4+ T-cells/µl

Even in these patients, most guidelines more or less urgently recommend startingtreatment, although the risk of developing AIDS is still low In the MACS Cohort,frozen blood samples obtained in the years 1985-1988 were analyzed and correlatedwith the clinical course of disease in these patients (Phair 2002) Results showedthat not a single patient with more than 200 CD4+ T-cells/µl and a viral load below20,000 copies/ml had developed AIDS within the following year The authors con-cluded that it is possible to wait in cases of low viral load in such patients It is nev-ertheless advisable to consider individual factors in this CD4+ T-cell category Isthe patient willing and able to take therapy? If there are doubts, it is better to wait.How rapid is the CD4+ T-cell decline? What are the percentage values? If there is

no clear trend, it may also be appropriate to wait See below for results of cohortstudies

Asymptomatic patients – above 350 CD4+ T-cells/µl

The cut-off level of 350 CD4+ T-cells/µl is important in many guidelines Above

350 CD4+ T-cells/µl, it is usually recommended to defer therapy In the MACSCohort, not a single patient with more than 350 CD4+ T-cells/µl and a viral loadbelow 60,000 copies/ml developed an AIDS illness within a year (Phair 2002) Forpatients with more than 350 CD4+ T-cells/µl, the 2004 recommendations from the

US and Germany have been slightly revised At a viral load below50,000 copies/ml, both guidelines recommend deferring treatment – but it should beconsidered with a high viral load, although it is no longer strongly recommended.Only the British guidelines, even in the latest edition, recommend deferring initia-tion of treatment

It is now more widely recognized that only a few studies have so far been able toshow the advantage of beginning with HAART at these CD4+ T-cell counts; allothers have not found any such advantage for the patient Proponents of early ini-tiation of therapy often cite a matched-pair analysis from Switzerland, which indi-cated a small, though statistically significant clinical benefit if HAART was startedwith CD4+ T-cells above this level (Opravil 2002) 283 patients, who were started

on HAART with a count above 350 CD4+ T-cells/µl, were matched by age, sex,CD4+ T-cell count, viral load and risk group for HIV infection with control patientswho had been untreated for at least 12 months At follow up around three yearslater, the AIDS risk was more than twice as high in the untreated group However,besides considerable methodological problems due to the design of this study, thesmall print also has to be looked at more closely The 52 illnesses (10 AIDS cases),which occurred additionally in the untreated group, have to be compared to the sideeffects of HAART Certain are: OHL (8 cases), oral thrush (10), herpes zoster (9),

thrombocytopenia (9), and a few cases of tuberculosis, pneumonia and Candidaesophagitis worse than the side effects of antiretroviral therapy? Over one third(35 %) of treated patients discontinued HAART, 51 due to gastrointestinal com-plaints, 25 due to CNS, renal problems, or lipodystrophy Is there really clinicalbenefit in starting treatment early? If one takes into account the toxicity of the drugsand the associated reduction in the quality of life, this benefit seems to come atquite a high price.

Another study came to the conclusion, that there is a survival benefit if ral therapy is started in patients with more than 350 CD4+ T-cells/µl (Palella 2003)

antiretrovi-In this highly complicated analysis based on data from the American HOPS Cohort,patients were assigned to groups based on the first (baseline) CD4+ T-cell count.Patients of the same group, who had either started ART immediately or waited untilthey had “dropped” into a lower group, were compared This design eliminated aproblem encountered in most cohort studies, in that a patient’s risk is usually onlydetermined at the time when therapy is started In the HOPS Study, the clock wastheoretically started at the same time point for all patients However, even this studyraises many questions when analyzed more closely For example, the overall analy-sis also included patients that had started treatment with ART (i.e mono or dualtherapy) The first patients included in the analysis were from 1994 Therefore it ispossible to argue that no difference would have been seen with the highly effectivecombinations available today Adherence was not considered in this analysis Pa-tients who started therapy later were more frequently black substance abusers with

no health insurance Nevertheless, the risk of mortality was low in the end In thegroup of patients that actually started HAART at levels above 350 CD4 cells/µl, themortality risk was 6.9/1,000 patient years, compared to 10.0/1,000 patient years inpatients with 200-350 CD4+ T-cells/µl at the beginning of treatment

According to expert commentaries, this data cannot be used to swing the pendulumback in favor of starting treatment early (Mocroft 2004)

Why has no randomized study been performed to address this question? An rial on the cohort described above provided some calculations (Lane 2003): in order

edito-to design a randomized study with 80 % power on starting treatment above or low 250 CD4+ T-cells/µl, about 650 events would be required to detect a 20 % dif-ference in mortality With an estimated probability for progression of 1 % per pa-tient year, around 65,000 patients would have to be followed for one year, or 6,500patients for 10 years – an impossible venture

be-In summary: as many different cohorts have not shown any difference betweengroups of patients with 200-350 and above 350 CD4+ T-cells/µl (see also Table5.5), the available data is unconvincing

Consequences for the further course of disease

In addition to the risk of death and disease progression, the controversy over theoptimal time for starting therapy also raises other questions Large cohorts repeat-edly attempt to prove that the starting time point influences virological or immuno-logical treatment success But, do the so-called late presenters, the patients that pre-sent late in the course of their illness, really have a worse prognosis? The following

is a summary of the data based on this discussion

Is virological response less durable with a low CD4+ T-cell count and a high viral load?

At first glance, many cohort studies have clearly demonstrated that virological sponse is poorer if the CD4+ T-cell count at initiation of treatment was low and theviral load high (Casado 1998, Mocroft 1998 and 2000, Miller 1999, Wit 1999,Deeks 1999, Chaisson 2000, Grabar 2000, Le Moing 2002, Yamashita 2001, Palella

re-2003, Wood 2005) In a meta-analysis of 30 prospective studies, baseline CD4+ cell count was important for viral load decline on treatment (Skowron 2001) Itmight appear straightforward: the higher the viral load and the lower the CD4+ T-cell count, the less the virological success of HAART Defenders of an early initia-tion of HAART, who often cite this data, forget three important points:

T-First, this is not true for the two large cohorts in which only nạve patients were studied (Cozzi-Lepri 2001, Phillips 2001) These confirm ourobservations that even a treatment-nạve patient with a high viral load and a lowCD4+ T-cell count has good chances of sufficient and long-term suppression ofviral load Under these circumstances, the initial values are less important – if thepatient is compliant! Even in the French APROCO Cohort, in which greater differ-entiation existed between treatment-nạve and treatment-experienced patients (LeMoing 2002), treatment-nạve patients with a high viral load at baseline showed atmost an insignificant negative trend That viral load and CD4+ T-cell count havepredictive values in all cohort studies in which most (up to 91 %) patients includedwere usually pre-treated with NRTIs, indicates one thing above all: virological suc-cess of HAART may be compromised in patients with prolonged mono or dualtherapy Previous nucleoside analog therapy has been a risk factor for virologicaltreatment failure in many cohorts (Casado 1998, Deeks 1999, Chaisson 2000, Gra-bar 2000, Le Moing 2002) In the HOPS Cohort, lack of prior therapy was decisiveparticularly for long-term treatment success (Holmberg 2003) As there are fortu-nately hardly any patients on mono or dual therapy nowadays, it is justified to con-centrate on treatment-nạve patients

treatment-Secondly, the relative risk of virological failure was often only increased inpatients with substantial immunosuppression (below 50 CD4+ T-cells/µl) or veryhigh viral load (above 100,000 copies/ml) At levels above 200 CD4+ T-cells/µl or

a viral load of less than 100,000 copies/ml, differences could generally not be tected (see below)

de-Thirdly, only a few of these studies considered compliance A patient whostarts HAART under emergency conditions at 30 CD4+ T-cells/µl (and who went tothe physician only shortly before or even after clinical manifestation of AIDS) mayhave a different view on sickness and health, and may be less adherent than some-one who seeks medical advice with a good CD4+ T-cell count and begins HAARTafter thorough reflection It seems clear that the benefit of HAART differs for suchpatients Adherence was an important and even decisive predictor in the few studies

in which it has been investigated (Le Moing 2002, Wood 2003+2004)

If these aspects are considered, the issue of whether virological response is reallypoorer with less favorable baseline values becomes less clear-cut Even a patientwith high viral load and a very low CD4+ T-cell count can potentially control in-fection quite successfully! The prerequisite for this is that the drugs are taken regu-larly – and the regimen administered must be a potent one: data from prospective

studies such as SOLO or M98-863, in which nelfinavir (a relatively weak PI) wastested against lopinavir or fosamprenavir showed poorer responses in highly vire-mic patients on nelfinavir.

Is immunological response less with unfavorable initial values?

Multiple factors influence the increase in CD4+ T-cells: duration of pression, age, thymus size or extent of thymus degeneration (see chapter “Goals andPrinciples of Therapy”) Do these include values at initiation of therapy? Astonish-ingly, several cohorts found no association (Yamashita 2001, Pezzotto 2001, Cozzi-Lepri 2001) However, these studies all showed that the rise in CD4+ T-cells issimilar, although levels remained lower if the CD4 count was initially low Fur-thermore, in our experience immune reconstitution is rarely complete if values werelow initially; the more damaged the immune system, the less likely a complete re-covery in the long run (Garcia 2004) In the Swiss Cohort, having a low CD4+ T-cell count at baseline was a clear risk factor for not attaining 500 CD4+ T-cells/µlafter four years (Kaufmann 2002+2005) There is also concern over the 10-15 % ofpatients with a discordant response where HAART is virologically extremely suc-cessful, but CD4+ T-cell count remains low (Piketty 1998, Renaud 1999)

immunosup-Another consequence of starting therapy later can be that antigen-specific immunereconstitution remains impaired, both against HIV and other pathogens Numerousstudies suggest that qualitative immune reconstitution does not initially occur at thesame pace as quantitative reconstitution (Gochorov 1998, Tortatjada 2000, Leder-man 2001, Lange 2002) One can make the analogy with a patch of desert whereweeds will grow before flowers So, what are the clinical consequences of these labdata? Why does the risk of AIDS decrease so impressively and rapidly with a risingCD4+ T-cell count? The weed does not appear to be so bad after all Why can evenseverely immunodeficient patients discontinue their prophylaxis quite safely, oncetheir CD4+ T-cell count has risen to above 200/µl? These clinical observations – atleast in the short term – seem to contradict our knowledge of the currently observedimmune reconstitution

Does the risk of clinical progression remain high even after starting HAART with a low CD4+ T-cell count and a high viral load?

Most studies have found a clear correlation between CD4+ T-cell count at initiation

of HAART and rates of both AIDS and death (Hogg 2000, Grabar 2000, Lepri 2001, Kaplan 2001, Phillips 2001, Egger 2002, Kaplan 2003, Palella 2003,Sterling 2003) Above all, if the CD4+ T-cell count is below 50/µl when startingtherapy, the risk for developing AIDS remains permanently high (Hogg 2003) Inother cohorts, the risk remained elevated even below a CD4+ T-cell count of 200/µl(Phillips 2001, Sterling 2001, Kaplan 2003)

Cozzi-The largest study to date was published in 2002 by the ART Cohort Collaboration(Egger 2002), in which almost 13,000 patients on HAART were analyzed The dataseems clear-cut The CD4+ T-cell count at the start of treatment correlated highlywith the probability later in the course of the illness of AIDS or death In compari-son to the patients who started HAART with less than 50 CD4+ T-cells/µl, the riskswith higher levels of helper cells were significantly less (see Table 5.4)

Table 5.4: Risk of progression in the ART Cohort Collaboration (Egger 2002)

Baseline CD4+ T-cells/µl Relative risk

T-Are there any differences between 200-350 and >350 CD4+ T-cells/µl?

In the above-mentioned meta-analysis, the difference was minimal (Egger 2002).The AIDS rate was 2.3 versus 1.8; the mortality rate 1.0 versus 0.7 per 100 patientyears This means one more case of AIDS in 200 patient years! Vast randomizedstudies would probably be necessary to detect a difference between the two patientgroups Other cohort studies have also posed the question of whether there is a dif-ference if patients first start at a CD4+ T-cell count of 200-350 cells or earlier Sofar, most have not been able to detect an advantage for starting treatment early (Ta-ble 5.5) However, the observation periods were usually relatively short It is possi-ble that differences will be found in the long term

Table 5.5: The influence of CD4+ T-cell count on treatment success Comparison between 200-350 CD4+ T-cells/µl and > 350 CD4+ T-cells/µl at initiation of HAART.

fewer deaths?

More nounced in- crease in CD4+ T-cells?

pro-Improved rological re- sponse?

A problem of many cohort studies is that they do not consider the success ofHAART on the individual level A very complex analysis on almost 10,000 pa-tients, which considered the baseline values as well as the values after six months(Chene 2003), produced a very clear result: the success of HAART is key for thefurther risk of suffering AIDS and/or dying Baseline values were irrelevant Inother words – if HAART is successful, the initial status does not matter.

All in all, the available results, despite their limitations, do support the current trend

of deferring initiation of therapy at levels above 200 CD4+ T-cells/µl

This risk assessment will probably change again as soon as treatment regimens withbetter long-term tolerability become available The less worries there are aboutlong-term side effects, the more likely they are to be used The current criteriatherefore have a preliminary character and have to be continuously re-evaluated.Some experts are already propagating an earlier start for anti-retroviral therapy(Holmberg 2004, Schechter 2004) However, better treatment options could alsomean that it would actually be possible to start later

Practical tips for starting therapy in asymptomatic patients

! Below 200 CD4+ T-cells/µl treatment should be started as soon as possible

! “As soon as possible” does not mean “immediately”: one should still take thetime to get acquainted with the patient, give proper counseling, start prophy-laxis in advance, and undergo diagnostic procedures (fundoscopy!) – it’s notusually a question of having to start within a few days!

! Above 200 CD4+ T-cells/µl, there is even more time – the individual course ofthe CD4+ T-cell count is important Beware the percentage values!

! A decrease of more than 80-100 CD4+ T-cells/µl per year is too much! Don’tdelay too long in such patients!

! Because of considerable variability a single CD4+ T-cell count (especiallywhen in the range of 200-350/µl) should be repeated before starting therapy

! Above 350 CD4+ T-cells/µl: wait, but continue to monitor at least every threemonths

! The higher the viral load, the more frequent checks of CD4+ T-cell counts arenecessary: > 100,000 copies/ml, testing should be performed at least every twomonths

! Initiation of treatment may be justified at levels above 350 CD4+ T-cells/µl – ifviral load is very high, CD4+ T-cell count is decreasing rapidly or the patientrequests it (after careful counseling)

! Check ahead of time whether a patient may be suitable for enrolment in a cal trial!

clini-Finding the optimal time to start treatment is one of the most difficult decisions ofHIV therapy To conclude, here are a few typical arguments about the pros and cons

of starting therapy

Arguments for and against an EARLY start

“The lower the CD4 count, the longer the

patient will remain at risk later.”

„This statement applies mainly to patients with substantial immunosuppression in whom initiation

of therapy should not be debated The earlier one starts, the more long-term toxicities will occur!”

“A lower CD4 count often implies that

only moderate immunological-virological

treatment success is possible – at some

stage, the destruction of the immune

system is irreversible.”

„This is mainly true for patients with substantial immunosuppression However, the virological response does not seem to be reduced in treat- ment-nạve patients.”

“The longer one waits, the fitter the virus

becomes via generation of quasispecies

and immune escape variants, and the

more difficult it is to treat.”

“Interesting laboratory hypothesis But, where’s the relevant clinical data?”

“The worse the condition of the patient,

the worse the tolerability of HAART.”

“Ancient, proven medical wisdom But, does it apply here, where we are referring to asympto- matic patients.”

“HIV should be treated as early as

pos-sible, as should any other infectious

disease.”

„HIV is not akin to any other infectious disease HIV cannot be cured like many bacterial infections Herpes viruses, for which there is no cure, are also treated only as needed.”

“It has been proven that patients are less

infectious on treatment.”

„And may be more prone to risk behavior In tion, the risk of transmission of primary resistance mutations increases.”

addi-Arguments for and against a LATE start

“The earlier one starts, the sooner and

more certain the side effects.”

„This may be true The question is: does one more year without therapy, but with an increasing risk of AIDS, really make a difference?”

“The earlier one starts, the higher the

risk for resistance in the long term.”

„OK, but… compliant patients, who have sufficient suppression of viral load, have good chances of not developing resistance, even over many years.”

“Even a bad immune system can

regen-erate; after all, prophylaxis can be safely

stopped after a rise in CD4 count.”

„This may be true for some patients, but not for all There are indications that the qualitative response remains impaired.”

“It is never too late to start therapy at

200 CD4 cells.”

„Who can be so sure? Some AIDS diseases may rarely occur even in this scenario; there is no cer- tainty that PML or lymphoma might not develop – and if should they, good advice is hard to find.”

References on starting therapy

1 Ahdieh-Grant L, Yamashita TE, Phair JP, et al When to initiate highly active antiretroviral therapy: a cohort approach Am J Epidemiol 2003, 157:738-46.

2 Carpenter CC, Fischl MA, Hammer SM, et al Antiretroviral therapy for HIV infection in 1997 Updated recommendations of the International AIDS Society-USA panel JAMA 1997;277:1962-9.

3 Casado JL, Perez-Elias MJ, Antela A, et al Predictors of long-term respones to protease inhibitor therapy in a cohort of HIV-infected patients AIDS 1998; 12:F131-F135.

http://amedeo.com/lit.php?id=9708403

4 Chaisson RE, Keruly JC, Moore RD Association of initial CD4 cell count and viral load with response

to HAART JAMA 2000; 284:3128–29 Originalarbeit: http://hiv.net/link.php?id=204

5 Chene G, Sterne JA, May M, et al Prognostic importance of initial response in HIV-1 infected patients starting potent antiretroviral therapy: analysis of prospective studies Lancet 2003; 362: 679-686 http://hiv.net/link.php?id=12957089

6 Cozzi-Lepri A, Phillips AN, d'Arminio Monforte A, et al When to start HAART in chronically infected patients: evidence from the ICONA study AIDS 2001; 15:983-90.

HIV-http://amedeo.com/lit.php?id=11399980

7 Deeks SG, Hecht FM, Swanson M, et al HIV RNA and CD4 cell count response to protease inhibitor therapy in an urban AIDS clinic: response to both initial and salvage therapy AIDS 1999, 13:F35-43 http://amedeo.com/lit.php?id=10397555

8 Egger M, May M, Chene G, et al Prognosis of HIV-1-infected patients starting HAART: a collaborative analysis of prospective studies Lancet 2002; 360:119-29 http://amedeo.com/lit.php?id=12126821

9 Garcia F, De Lazzari E, Plana M, et al Long-Term CD4+ T-Cell Response to Highly Active ral Therapy According to Baseline CD4+ T-Cell Count J AIDS 2004, 36:702-713.

12 Grabar S, Kousignian I, Sobel A, et al Immunologic and clinical responses to highly active ral therapy over 50 years of age Results from the French Hospital Database on HIV AIDS 2004, 18:2029-2038 http://amedeo.com/lit.php?id=15577624

antiretrovi-13 Grabar S, Pradier C, Le Corfec E, et al Factors associated with clinical and virological failure in tients receiving a triple therapy including a protease inhibitor AIDS 2000, 14:141-9.

19 Kaplan JE, Hanson DL, Cohn DL, et al When to begin HAART? Evidence supporting initiation of apy at CD4+ lymphocyte counts <350 cells/uL Clin Infect Dis 2003; 37:951-8.

9 th CROI 2002, Seattle, USA http://www.retroconference.org//2002/Abstract/14064.htm

22 Kaufmann GR, Furrer H, Ledergerber B, et al Characteristics, determinants, and clinical relevance of CD4 T cell recovery to <500 cells/uL in HIV type 1-infected individuals receiving potent antiretroviral therapy CID 2005, 41:361-72 http://amedeo.com/lit.php?id=16007534

23 Lane HC, Neaton JD When to start therapy for HIV infection: a swinging pendulum in search of data Ann Intern Med 2003;138:680-1.

24 Lange CG, Valdez H, Medvik K, Asaad R, Lederman MM CD4+ T-lymphocyte nadir and the effect of highly active antiretroviral therapy on phenotypic and functional immune restoration in HIV-1 infection Clin Immunol 2002, 102:154-61 http://amedeo.com/lit.php?id=11846457

25 Le Moing V, Chene G, Carrieri MP, et al Predictors of virological rebound in HIV-1-infected patients initiating a protease inhibitor-containing regimen AIDS 2002, 16:21-9.

http://amedeo.com/lit.php?id=11741159

26 Ledergerber B, Egger M, Opravil M, et al Clinical progression and virological failure on highly active antiretroviral therapy in HIV-1 patients: a prospective cohort study Swiss HIV Cohort Study Lancet

1999, 353:863-8 http://amedeo.com/lit.php?id=10093977

27 Lederman MM, McKinnis R, Kelleher D, et al Cellular restoration in HIV infected persons treated with abacavir and a protease inhibitor: age inversely predicts naive CD4 cell count increase AIDS 2000, 14: 2635-42 http://amedeo.com/lit.php?id=11125881

28 Lederman MM Immune restoration and CD4+ T-cell function with antiretroviral therapies AIDS 2001, Suppl 2:S11-5 http://amedeo.com/lit.php?id=11424971

29 Lyles RH, Munoz A, Yamashita TE, et al Natural history of HIV type 1 viremia after seroconversion and proximal to AIDS in a large cohort of homosexual men J Infect Dis 2000, 181:872-880.

34 Mocroft A, Gill MJ, Davidson W, Phillips AN Predictors of a viral response and subsequent virological treatment failure in patients with HIV starting a protease inhibitor AIDS 1998, 12:2161-2167.

35 Mocroft A, Phillips AN, Lundgren JD HIV survival benefit associated with earlier antiviral therapy Ann Intern Med 2004, 140:578-9 http://amedeo.com/lit.php?id=15068990

36 Opravil M, Ledergerber B, Furrer H, et al Clinical efficacy of early initiation of HAART in patients with asymptomatic HIV infection and CD4 cell count > 350 x 10(6)/l AIDS 2002, 16:1371-81.

41 Phillips AN, Staszewski S, Weber R, et al HIV viral load response to ART according to the baseline CD4 cell count and viral load JAMA 2001, 286:2560-7 http://amedeo.com/lit.php?id=11722270

42 Piketty C, Castiel P, Belec L, et al Discrepant responses to triple combination antiretroviral therapy in advanced HIV disease AIDS 1998, 12:745-50 http://amedeo.com/lit.php?id=9619806

43 Powderly WG, Saag MS, Chapman S, Yu G, Quart B, Clendeninn NJ Predictors of optimal virological response to potent antiretroviral therapy AIDS 1999,13:1873-1880.

48 Staszewski S, Morales-Ramirez J, Tashima KT, et al Efavirenz plus zidovudine and lamivudine, renz plus indinavir, and indinavir plus zidovudine and lamivudine in the treatment of HIV-1 infection in adults N Engl J Med 1999, 341:1865-1873 http://amedeo.com/lit.php?id=10601505

efavi-49 Sterling TR, Chaisson RE, Moore RD HIV-1 RNA, CD4 T-lymphocytes, and clinical response to HAART AIDS 2001, 15:2251-7 http://amedeo.com/p2.php?id=12627368&s=hiv

50 Chaisson RE, Moore RD Initiation of HAART at CD4+ T lymphocyte counts of > 350 cells/mm3: ease progression, treatment durability, and drug toxicity Clin Infect Dis 2003; 36: 812-5.

dis-http://amedeo.com/lit.php?id=11698698

51 Tortajada C, Garcia F, Plana M, Gallart T, Maleno MJ, Miro JM et al Comparison of T-cell subsets' reconstitution after 12 months of highly active antiretroviral therapy initiated during early versus ad- vanced states of HIV disease J Acquir Immune Defic Syndr 2000, 25: 296-305.

54 Wood E, Hogg RS, Yip B, et al The impact of adherence on CD4 cell count responses among infected patients J Acquir Immune Defic Syndr 2004, 35:261-8.

Mul-6 Which HAART to start with?

pref-Recommended initial regimens at a glance

Combinations that we currently recommend for first-line therapy (as of January2006) are shown in Table 6.1 Of note, there is no order of preference Moreover,many other combinations are possible These combinations may be acceptable inindividual cases or in investigational studies, but general recommendations for theiruse cannot be given Problematic drugs or combinations, that are not advisable foruse, are listed at the end of this chapter

Table 6.1: Combinations suitable for initial HIV therapy (not in order of preference!)

NRTI combinations recommended for initial regimens (left upper column) may also be

combined with alternative NNRTIs/PIs (right lower column) and vice versa.

* Convincing data only on combination with efavirenz.

** Beware hepatotoxicity when CD4+ T-cells are high (women > 250, men > 400/µl)

*** May be problematic with nevirapine due to possible allergies, therefore use only with PIs if possible.

**** In some special circumstances, when NNRTIs or PIs are not suitable.

Practical approach to the first regimen – important rules

All current initial regimens consist of two nucleoside analogs, combined with either

a boosted PI, an NNRTI or – with distinct restrictions - a third nucleoside analog

No single combination has clearly been shown to be superior to another (Olsen2005) There is no gold standard

Practical tips for first-line therapy:

! The first regimen offers the patient the best chance This means that the ral load must decrease to below detection levels within 3-6 months!

vi-! Don’t rush – the patient must be ready for HAART, no half-hearted startvi-!

If in doubt, wait and continue to monitor the levels

! If possible, don’t prescribe medication in the first consultation with a newpatient who brings along his results Do you know the patient well enough?

Is he really motivated? Will he ever come back again?

! For every patient, only prescribe the ART he is able to take! Don’t insist ontheoretically superior combinations

! The pros and cons (side effects) of different combinations should be cussed – there is usually enough time for this

dis-! The initial regimen should be taken no more then twice daily Once-dailytreatment should be considered if it is important for the patient

! The toxicity profiles should not overlap, if possible – never use several lergenic drugs simultaneously

al-! Ask about other medication (and drug consumption) – are relevant tions to be expected?

interac-! Concomitant illnesses should also be checked – what about the liver(hepatitis), kidneys?

! All drugs are started on the same day – no lead-in mono- or dual therapy!

! Be sure to check whether the patient would be eligible for a clinical study!All patients, especially if treatment-nạve, should be encouraged to partici-pate in clinical trials!

When choosing primary therapy, many factors are involved, besides the antiviralpotency and tolerability Individual situations, such as compliance, concurrent ill-nesses and concomitant medications, and the needs of the patient should be in-cluded in the decision One should be aware that primary therapy is of great signifi-cance and needs to be well prepared It is at this time that the chance of viral sup-pression is greatest

What should be clarified beforehand?

Dosing issues

Can the patient really take drugs several times a day? Is this realistic with regard tohis individual, professional or social situation? If in doubt, a simpler regimen ispreferable to one that is presumed to be more effective For example, it is often not

realistic to expect intravenous drug users to take ten or more tablets a day according

to a strict protocol However, junkies also need treatment, and there have been cessful attempts at once-daily regimens for drug addicts (Staszewski 2001), whichare also suitable for DOT (Directly Observed Therapy) together with the substitu-tion

suc-For many patients, the numbers of pills or requirements for food intake are tant The range of licensed and recommended initial regimens varies from 2 to 13pills per day Some find it unacceptable to have to take pills at certain times duringthe day with fatty foods Patients today are more demanding than earlier – justifia-bly so There are now alternatives Even the size or consistency of tablets can be a

impor-problem Such issues must be discussed before initiating therapy.

Concurrent illnesses

Before starting treatment, possible concurrent illnesses must be identified oughly questioning and examination) The knowledge of their presence is important

(thor-to proceed further (see Table 6.2) For example, a patient with diarrhea should not

be given nelfinavir or lopinavir ddI is contraindicated in patients with a history ofpancreatitis! Caution with tenofovir or indinavir in renal disease! Polyneuropathyrequires that any d-drugs (ddI, ddC, d4T) be avoided; they are only used as excep-tions in primary therapy Non-insulin-dependent diabetes can become insulin-dependent for the first time on PI treatment

Liver disease and chronic hepatitis must also be taken into account, because thenthe risk of developing severe hepatotoxicity on nevirapine or ritonavir is highest(Den Brinker 2000, Martinez 2001, Sulkowski 2000+2002) Caution is also re-quired with boosted PIs However, one study conducted in over 1,000 patientsfound no difference between lopinavir/ritonavir and an unboosted PI such as nelfi-navir in patients co-infected with hepatitis C (Sulkowski 2004) In co-infectionswith HBV, the good HBV-efficacy of 3TC or FTC (not simultaneously!) and pref-erably also tenofovir should be utilized

Table 6.2: Concurrent illnesses requiring caution with specific drugs There are no absolute contraindications.

Active hepatitis B Nevirapine, boosted PIs

(In contrast: 3TC, FTC, tenofovir are beneficial!) Active hepatitis C Nevirapine, boosted PIs

Active substance abuse, substitution NNRTIs, ritonavir

Arterial hypertension Indinavir

Chronic diarrhea, intestinal diseases Nelfinavir, lopinavir, other PIs

Diabetes mellitus PIs (especially if a NIDDM is at risk of becoming an

IDDM!)

Myocardial infarction PIs (potentially beneficial: nevirapine)

Psychoses, other CNS illnesses Efavirenz

Interactions with medications and drugs

Interactions are important in the choice of combination regimens Whereas tions between antiretroviral drugs are well known, interactions with other con-comitant medications are often less well characterized The urgent need for moreresearch was demonstrated in a study investigating the interactions betweenHAART and statins In healthy volunteers, the measurement of plasma levelsshowed that levels of simvastatin were elevated by 3.059 % after concurrent dosingwith ritonavir or saquinavir (Fichtenbaum 2002) One case of fatal rhabdomyolysis

interac-on simvastatin and nelfinavir has been described (Hare 2002)

Many drugs should be avoided in combination with particular antiretroviral drugs,

as incalculable interactions may occur These include certain contraceptives Evendrugs that seem unproblematic at first glance can have unfavorable effects: for ex-ample, the plasma levels of saquinavir can be reduced by half due to concurrentadministration of garlic capsules (Piscitelli 2002) Even a seemingly harmless sub-stance such as vitamin C can influence plasma levels A small study in healthy vol-unteers showed that 1 g of vitamin C can significantly lower (14 %) unboostedindinavir levels (Slain 2005)

Coumarin-derivative anticoagulants such as warfarin can also be a problem; vir can significantly lower plasma levels (Llibre 2002) Further typical “problemdrugs” include migraine remedies, prokinetic drugs and sedatives/hypnotics Onefatal case has been described with ergotamine and ritonavir (Pardo 2003) The si-multaneous administration of HAART and PDE-5 inhibitors (sildenafil, vardenafil,tadalafil) can also be problematic, see section on “Sexual Dysfunction”

ritona-Drugs or alcohol can also interact with HAART For those in substitution programs,the methadone requirement may be significantly increased by certain antiretroviraldrugs such as nevirapine and efavirenz (Clarke 2001) To a lesser extent, this is alsotrue for ritonavir and nelfinavir There is inconsistent data on lopinavir, but it may

also require dose adjustments (McCance-Katz 2003, Stevens 2003) Tenofovir doesnot seem to have significant interactions with methadone (Smith 2004).

Other interactions have even more dangerous consequences Several deaths havebeen reported after simultaneous dosing with ritonavir and amphetamines orMDMA/ecstasy, or the popular narcotic gamma hydroxybutyric acid (GHB, Sam-sonit™or “liquid ecstasy”; Henry 1998, Harrington 1999, Hales 2000) Ritonavir inparticular inhibits the metabolism of amphetamines (speed or MDMA/ecstasy),ketamines or LSD (review in: Antoniou 2002) Clinician and patient are well ad-vised to have an open conversation about drug use before starting therapy Mari-juana and THC appear to have a low potential for interactions (Kosel 2002) Am-phetamines seem to be particularly dangerous and neurotoxic in HIV patients(Langford 2003)

Not every substance can be discussed here Many are described in the respectivedrug chapters It is always recommended to check the package insert Initiation ofHAART provides a good opportunity to re-evaluate existing prescribed medica-tions

Additive toxicities

Several potential additive toxicities should be considered in the choice of therapy

If other myelotoxic drugs (valganciclovir!) are necessary, caution is required withAZT The same is true for hydroxyurea or dapsone When treating hepatitis C withinterferon and ribavirin, AZT must be avoided Ribavirine should also never becombined with ddI

Patients taking acyclovir have significantly more frequent renal problems on navir (Herman 2001) Tenofovir should also be avoided with renal problems or po-tentially nephrotoxic drugs

indi-Lastly, it is not advisable during the primary therapy to start with potential inducing substances if anti-infectious prophylaxis with co-trimoxazole or other sul-phonamides is necessary Included in this are nevirapine, efavirenz, and abacavir(and possibly fosamprenavir) In order not to disturb the prophylaxis, it is better toavoid these drugs Otherwise, it can be difficult to clearly identify the causativeagent for a drug-induced exanthema

allergy-Which drug classes are to be used?

All combinations currently used as initial regimens consist of two nucleoside logs plus either a PI, an NNRTI, or - with limitations - a third nucleoside analog.These three strategies reduce the risk of AIDS approximately equally (Olsen 2005)

ana-In contrast, all other combinations are experimental or not justified for use outsidethe framework of clinical studies Advantages and problems of these three strategiesare outlined in the Table 6.3

There are only a few studies comparing all three strategies The interest of thepharmaceutical industry in such large projects is limited Indeed, why determine,with huge financial commitments, that one’s own drug may be weaker? Such stud-ies are therefore usually performed independently of the industry, but also takelonger

Table 6.3: Combining drug classes: Advantages (") and disadvantages (#)

2 Nukes + PI 2 Nukes + NNRTI 2 Nukes + 3rd Nuke

" a lot of data, including

clinical endpoints and

se-verely immuno-compromised

patients

" equivalent, perhaps even better suppression of viral load than with Pis

" low pill burden, easy ing

dos-" long-term data available " low pill burden! once-daily

may be possible " leaves many options

" high genetic resistance

barrier

" leaves PI options " few interactions

# high pill burden (for the

older PIs), partly strict dosing

requirements, most

once-daily regimens not licensed

# clinical effect not proven (only surrogate marker studies)

# less potent, with higher viral load, and in particular tenofovir-containing triple nuke therapy

# frequent drug interactions # less data in severly

im-munocompromised patients # once-daily with AZT notpossible

# some PIs with

crossresi-stance, leaving limited

op-tions

# rapidly occurring plete cross-resistance

com-# No clinical endpoints, no long-term data

# long-term toxicity,

lipodys-trophy, dyslipidemia with

most PIs

# strict monitoring required initially (esp nevirapine), allergies frequent

# Possible raised drial toxicity

mitochon-In the Atlantic Study, 298 patients were openly randomized to received4T+ddI+3TC versus d4T+ddI+nevirapine versus d4T+ddI+indinavir (Van Leeu-wen 2003) After 48 weeks, 49 %, 49 % and 40 % of patients, respectively, attained

a viral load of less than 50 copies/ml in the intent-to-treat analysis (ITT) Thesedifferences were not significant However, several subanalyses (96 weeks, patientswith high viral load) did show differences: although indinavir and nevirapine wereboth quite comparable, they were significantly better than 3TC This study providedthe first arguments against triple-nuke therapy However, the combinations tested inthe Atlantic Study are now fairly outdated

In the CLASS Trial, the following three classes were tested with an ABC+3TCbackbone: amprenavir/ritonavir as a boosted PI regimen, efavirenz as an NNRTIoption and d4T as a third nucleoside analog (Bartlett 2004) As in the AtlanticStudy, the differences in the various arms after 48 weeks were not significant, based

on the normal viral load assay with a detection limit of 400 copies/ml Differencesonly became apparent with the ultrasensitive assay, where only the NNRTI arm had

an advantage This was also true for a subgroup of patients with a high viral load ofabove 100,000 copies/ml Interestingly, there was no difference between the othertwo arms (boosted PI regimen versus triple nuke!), although it did seem like thevirological failure rate in the triple nuke arm was relatively high However, some ofthe CLASS regimens are also no longer current

The different strategies are discussed here in more detail Options that will bly play a more important role in the future will also be considered, such as once-daily, nuke sparing, and so-called induction therapies These are effective and

proba-promising according to current data, but cannot, at least in part, be generally ommended yet Combinations that are problematic and better avoided will also bementioned.

rec-In the following, various strategies or primary therapies are discussed Theseinclude:

1 Two nucleoside analogs plus a protease inhibitor

2 Two nucleoside analogs plus a NNRTI

3 Three nucleoside analogs (“triple nuke”)

4 Once-daily combination

5 Experimental combinations (“nuke sparing”, intensive approaches)

6 Problematic primary therapies

When nucleoside analogs are mentioned below, the nucleotide analog tenofovir

is also included, but for simplicity it is not presented separately each time

1 Two Nucleoside Analogs Plus a PI

The combination of two nukes plus one protease inhibitor is the only HAART that

is supported by efficacy data from randomized studies with clinical endpoints(Hammer 1997, Cameron 1998, Stellbrink 2000) Most importantly, data is avail-able over longer periods than for other combinations Some studies have been on-going for over five or six years (Gulick 2003, Hicks 2003) Many experts still like

to use these combinations today, particularly in patients with AIDS or high viralload, as another advantage is the robustness of boosted PIs with respect to viral re-sistance However, it has not yet been proven whether this does actually have anadvantage in primary therapy Disadvantages of the PI-containing primary therapyare the, sometimes considerable, pill burden and relatively frequent side effects,which makes compliance difficult The following briefly describes the most com-mon combinations:

Two nukes plus lopinavir/r

These are categorized in many guidelines as a combination that should be used inpreference to other regimens Long-term efficacy seems to be good (Hicks 2003)

No resistance has been described for such primary therapy to date The combination

of d4T+3TC+lopinavir/r seemed to show better efficacy than d4T+3TC+nelfinavir

in the only comparative study described to date After week 48, 67 versus 52 % ofpatients had a viral load below 50 copies/ml (Walmsley 2002) Whether lopinavir/r

is really more effective for initial therapy than other boosted PIs remains uncertain

at the moment Many large studies are currently underway to compare otherboosted PIs with lopinavir (saquinavir, atazanavir, TMC-114) It is also not clearwhat treatment would be effective if lopinavir/r fails The nuke backbone used inmost studies is currently TDF+FTC (Molina 2004)

Two nukes plus saquinavir/r

The combination of AZT+ddC+saquinavir-HGC was the first PI-combination forwhich survival benefit was shown in a randomized study This was the largest ran-domized HIV study ever (Stellbrink 2000) Nevertheless, saquinavir is still given

with other nukes, rather than with AZT+ddC, and more importantly still, in itsboosted form alone (saquinavir/r) Without the booster effect of ritonavir, the bio-availability is too low Tolerability is probably better than for indinavir/r, which is

no longer recommended for first-line therapy (Dragstedt 2003) The boosted bination of 1,000 mg saquinavir with 100 mg ritonavir, both twice daily, has beenlicensed More data is available for the AZT-containing nuke backbones than forthose containing tenofovir

com-ABC+3TC plus fosamprenavir

With the end of the patent protection of the long-lasting phenomenon AZT loomingahead, GSK has set up a number of studies in recent years testing its other twonukes ABC+3TC as a backbone The fixed combination tablet Kivexa™ (US: Epzi-com™) has been available since 2005 and provides an additional once-daily option

In the NEAT and SOLO studies, ABC+3TC showed good efficacy in combinationwith fosamprenavir (Gathe 2004, Rodriguez-French 2004) As there is little dataavailable for other PI combinations, we would therefore recommend fosamprenavir

as the best option for combination with the ABC+3TC backbone Despite someencouraging data on efavirenz (DeJesus 2004), we do not recommend the combina-tion of ABC+3TC plus an NNRTI for first-line therapy, due to the difficult differ-ential diagnosis of an allergy (abacavir? NNRTI?) that can unnecessarily jeopardizefuture treatment options

Two nukes plus nelfinavir

Nelfinavir combinations were previously among the most frequently used ARTregimens The licensing studies tested nelfinavir mainly with AZT+3TC (Saag

2001, Gartland 2001) In the Combine Study, nelfinavir seemed slightly weakerthan nevirapine (Podczamzer 2002); in INITIO it was significantly weaker thanefavirenz (Cooper 2005) In direct comparison to boosted PIs such as lopinavir/r orfosamprenavir/r, nelfinavir is also less potent (Walmsley 2002, Gathe 2004, Rodri-guez-French 2004) Nelfinavir-containing combinations have a high pill burden andare associated with unpleasant diarrhea, so that we generally no longer recommend

it for first-line therapy Unfortunately, Roche has not managed to overcome theproduction problems of the new formulation (625 mg, less pills, better tolerability)for the European market This is in contrast to Pfizer, who distribute nelfinavir in-ternationally

2 Two Nucleoside Analogs Plus an NNRTI

NNRTIs have an equal, if not presumably even superior effect on surrogate markers

as PI combinations NNRTIs have done well in numerous randomized studies: virenz-based regimens in studies such as 006, ACTG 384, ACTG 5095 or CLASSwere superior to indinavir, nelfinavir, amprenavir/r or triple nuke (Staszewski 1999,Robbins 2003, Gulick 2004, Bartlett 2004) The nevirapine-containing regimens inCombine or Atlantic were at least equivalent to nelfinavir and indinavir, and betterthan triple nuke (Podzamczer 2002, van Leeuwen 2003) A direct comparison in the2NN Study showed no major differences between efavirenz and nevirapine (vanLeth 2004)