Transcript Case Presentations: When to Start ART

Pre-departure HIV Orientation
Session A: Pre-ART Considerations
23 January, 2007
Royce C. Lin, MD
Assistant Clinical Professor of Medicine
University of California, San Francisco
Director, AIDS Consult Service
San Francisco General Hospital
Deputy Director, ASPIRE
Positive Health Program, SFGH
GOALS
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Overview: Pre-ART considerations
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Medical indications
WHO guidelines
Kenyan national guidelines
US DHHS guidelines
WHO Staging system
Cotrimoxazole prophylaxis
Adherence issues
Pre-ART considerations: US
Initial Visit
Full HPI, PMH
Full Lab
Counseling (tx, support)
Establish relationship
Adjunct services (social, insurance)
Vaccinations
Problem list, Px, Rx
F/U Visit
Follow CD4 decline
Prep ART as CD4 <350
HAART
Choose regimen with pt input
Adherence counseling/support
F/U Visit
Monitor toxicity
Therapy switch as needed
Pre-ART considerations: RLS
Initial Visit
HPI, PMH (form/algorithm driven)
Select Labs (baseline + ?TB, preg)
WHO staging (triage ART)
Counseling (x 3. Peer groups support)
Adjunct services (nutrition, HBC)
Cotrimoxazole
Problem list, Px, Rx (algorithm-driven)
F/U visit
See CD4 result
With WHO, assess ART eligibility
Adherence counseling x 3 if ART
Cotrimoxazole, other prevention
HAART
All get Triomune, unless contraindication
Pregnancy? TB?
F/U Visit
Monitor toxicity (TB, preg, IRIS)
Therapy switch as needed
When to Start HAART?
When to Start Therapy in adults
Kenyan Guidelines
 All who have a CD4+ count ≤ 200 cells/mm3,
regardless of stage of illness
 All who are in WHO stage IV clinical criteria, regardless
of CD4+ cell count
 Consider those who are in WHO Stage III clinical
criteria and have CD4 cell counts ≤ 350/mm3
Note!
The patient must have expressed willingness
and be ready to start therapy
U.S. DHHS Guidelines Summary:
ART recommended for…
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All with history of AIDS-defining
illness, regardless of CD4 count
All with CD4<200
CD4 201-350 should be offered
therapy
CD4>350
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Most clinicians defer therapy regardless of
VL
Some offer therapy if VL>100,000
Confirmed HIV + Individual
Perform WHO
clinical staging
WHO Clinical
Stage 1
WHO Clinical
Stage 2
WHO Clinical
Stage 3
Perform CD4+ T cell count
CD4: >350
cells/mm3
Do NOT
initiative ART.
Monitor patient
regularly
CD4: 200-350
cells/mm3
Consider ART
ONLY if in
WHO clinical
stage III
WHO Clinical
Stage 4
Eligible for ART
regardless of
CD4 count
CD4: <200
cells/mm3
Eligible for ART
regardless WHO
Clinical stage
WHO Clinical Staging
Natural History of Untreated
HIV-1 Infection
1000
800
Early OIs
+
CD4
Cells
600
Late Opportunistic Infections
400
CD4 < 100
200
0
1
Infection
2
3
4
5
6
7
8
9
Time in Years
10 11 12 13 14
CD4 Decline and WHO Staging
WHO 1
WHO 2
WHO 3
WHO 4
WHO Clinical Staging System for Adults and Adolescents
WHO Clinical Staging System for Adults and Adolescents
Stage I
Asymptomatic
Stage II
Not yet AIDS, but getting sick
CD4 usually 200-350
Courtesy of Jackie Dolev, M.D.
Department of Dermatology
University of California, San Francisco
www.uptodate.com
www.uptodate.com
Prurigo
Herpes Zoster-Shingles
Stage III
Early AIDS
CD4 usually <200
Stage III
• Pulmonary TB
• Severe bacterial infections
• Bacterial pneumonia
• Pyomyositis
• Performance scale 3
• Bedridden <50% in past month
Stage IV
Late AIDS
CD4 usually < 50-100
Other Stage IV
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Extrapulmonary TB
Cryptococcal Meningitis
Toxoplasmosis
Esophoegeal candidiasis
MAC
CMV Retinitis
HSV in mucocutaneous site
Progressive Multifocal Leukoencephalopathy
AIDS Dementia Complex
Weight loss >10% and bedbound >50%
MEDICAL
Indications
PSYCHOSOCIAL
Contraindications
Who should get ART first?
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A. Female University Student
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B. Successful Businessman
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CD4 178. Thrush. Treated with clotrimazole
Family knows and is supportive
CD4 168. Very high VL (>500,000)
Diagnosed 1 week, anxious, demands
immediate ART. Reluctant to disclose to
spouse.
C. Disbelieving Rural Woman
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CD4 47. Bacterial pneumonia. Cutaneous KS
Skeptical about her AIDS diagnosis.
When to Start: PART II
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Medical consideration only half of the
equation
Patient readiness EQUALLY important
Therapy quickly FAILS if suboptimal
adherence
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>95% Adherence needed!
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Especially important with Triomune!
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Once first-line fails, second-line agents may
not be effective and are more toxic
BETTER TO WAIT AND START WHEN
PATIENT IS TRULY READY
Adherence
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A major determinant of degree and
duration of viral suppression
Poor adherence associated with
virologic failure
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Optimal suppression requires 9095% adherence
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What percentage adherence is most
strongly-associated with emergence of
viral resistance?
Even MORE important in resource-limited
settings given lack of access to resistance
testing, limited salvage options
Suboptimal adherence is common
Predictors of Inadequate Adherence
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Poor clinician-patient relationship
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Active drug use or alcoholism
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Unstable housing
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Mental illness (especially depression)
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Major life crises
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Lack of patient education
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Lack of patient access to medical care
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Medication adverse effects
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Fear of medication adverse effects
Predictors of Good Adherence
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Emotional and practical supports
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Family, friends, social support
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Importance of social work, CBOs
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Understanding the importance of adherence
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Belief in efficacy of medications
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Keeping clinic appointments
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Feeling comfortable taking medications in front
of others
Convenience of regimen
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Consideration of patient preferences in
constructing an antiretroviral regimen
Predictors of Inadequate Adherence
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Age, race, sex, educational level,
socioeconomic status, and a past history
of alcoholism or drug use do NOT reliably
predict suboptimal adherence.
Higher socioeconomic status and higher
education levels and lack of history of
drug use do NOT reliably predict optimal
adherence.
Practicum:
Case Discussions
Case scenario #1
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35 yo woman from Kisumu
Tested HIV+ recently
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Physically well, no symptoms
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Comes to you for first visit in clinic
Wants to know what she should do
Baseline weight 68kg. Now 66kg.
What WHO clinical stage is she?
What else do you want to know?
What do you want to do today?
Case scenario #1
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1 year later, pt presents to casualty with 1
month hx of dry, non-productive cough.
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Hx: Increasing shortness of breath
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Scant sputum. No hemoptysis
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Weight: 59kg RR 32
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CXR: diffuse, patchy bilateral infiltrates.
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Exam: Diffuse rales, L>R. Oral thrush
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Pt is admitted to the ward
Has his clinical stage changed?
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What stage do you guess him to be in now?
What do you want to do now?
Case Scenario #1
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Hospital course
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Sputum x 3: smear negative for AFB
Started empirically on amoxicillin without
improvement.
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TMP/SMX begun (for presumed PCP)
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5-days later: decreased SOB, cough
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Discharged. Complete Rx at home
5 days later (day#10 rx)
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Seen in clinic
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Still on PCP treatment. Finished amoxicillin
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CD4 comes back: 178
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Feeling much better, slight residual cough
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Weight 57kg. RR 18. Rales resolved.
When do you want to start ART?
Case Scenario #1
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Who wants to start ART today?
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Does he meet medical indications to start ART?
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By which criteria?
What are other considerations?
What would you do at this visit?
When is the optimal time to start ART?
Teaching points
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Wait until OI is treated
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Increased overlapping toxicity
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Increased risk of immune reconstitution syndrome
Prepare patient for ART
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Assess psychosocial readiness
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Establish relationship
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Involve entire care team
Good preparation =
Successful therapy
Summary
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Medical Indications
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Any AIDS-defining condition
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Any OI
WHO Stage IV
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CD4<200
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WHO, US guidelines agree
Psychosocial contraindications
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Factors of adherence
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Belief systems
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Role of social work, CBO, support
Balance between the two determines
when to start ART
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Careful consideration of both sides of equation leads
to optimal chance at successful suppression of HIV.