6. NACO GUIDELINES 2012
Classification of
HIV-associated
clinical disease
WHO STAGE
CD4 NOT
AVAILABLE
Asymptomatic
1
CD4 AVAILABLE
Do not treat
Treat if CD4 <350
Mild symptoms
2
Do not treat
Advanced
symptoms
3
Treat
Consider treatment
if CD4 <350
and initiate ART
before CD4
drops below 200
Severe/advanced
symptoms
4
Treat
Treat irrespective of
CD4 count
12. Antiretroviral switching
• Drug toxicity
• Drug drug interactions
• Simplification of regimens (change to once daily
regimens)
• Pregnancy (Efavirenz to Nevirapine)
• Cost
• Proactive
• Antiretroviral therapy failure
13. Antiretroviral drug toxicity
DRUG REGIMEN
OFFENDING DRUG
DRUG TOXICITY
DRUG SWITCH
Zidovudine + Lamivudine +
Nevirapine
Zidovudine
Anemia
Change to Stavudine
or Tenofovir
GI intolerance
Skin and nail
hyperpigmentation
Lactic acidosis
Tenofovir +
Emticitabine+Efavirenz
Tenofovir
Fanconi syndrome
Renal dysfunction
Change to Zidovudine
or Abacavir
Osteomalacia
Decreased BMD
Stavudine +
Lamivudine+Nevirapine
Stavudine
Lipoatrophy
Peripheral neuropathy
Pancreatitis
Lactic acidosis
DM, Dyslipidemia
Change to Tenofovir
14. Antiretroviral drug toxicity
DRUG REGIMEN
OFFENDING DRUG
DRUG TOXICITY
DRUG SWITCH
Zidovudine + Lamivudine +
Nevirapine
Nevirapine
Rash
Change to Efavirenz
Hepatitis
Stevens johnson
syndrome
Tenofovir +
Emticitabine+Efavirenz
Efavirenz
Rash, Hepatitis
Drowsiness, abnormal
dreams
Impaired concentration
Abacavir + Lamivudine +
Efavirenz
Abacavir
Hypersensitivity
Change to Nevirapine
in case of CNS
symptoms, change to
ATV/r in case of rash
Change to Tenofovir
if Creat clearance > 50
ml/min or else use
Zidovudine
15. Antiretroviral drug drug interactions
• Nevirapine to Efavirenz in patients with Tuberculosis due to
use of Rifampicin.
• HIV/HCV co infection : change to Tenofovir + Lamivudine +
Efavirenz
• HIV and cancer : avoid Zidovudine with chemotherapy due to
myelosuppressive side-effects of both.
• HIV and CMV : avoid co-administration of Zidovudine with
Valganciclovir
• HIV and cryptococcal meningitis : avoidance of Tenofovir with
Amphotericin B.
16. Antiretroviral drug drug interactions
• Antiretroviral regimens not recommended :
• Tenofovir + Lamivudine + Nevirapine : high
chance of virologic failure.
• Stavudine + Didanosine
• Stavudine + Zidovudine
• Tenofovir + Abacavir
• Tenofovir + Didanosine
17. Antiretroviral treatment failure
•
•
•
•
•
Virologic failure :
inability to achieve or maintain suppression of viral
replication to HIV-1 RNA levels < 50 copies/mL
2 consecutive tests indicating HIV-1 RNA > 400 copies/mL
after 24 weeks or > 50 copies/mL at 48 weeks
Immunologic failure
Inability of CD4 count to increase > 100 cells/mm3 in 1st year of
ART
Fall in CD4 count from peak level by > 50 %
Clinical failure
AIDS defining illness occurring more than 3-6 months after
starting antiretroviral therapy
18. Difference between viral rebound and viral blip
•
•
•
•
Viral blip :
defined as a single, low-level plasma HIV-1 RNA level
of 50-1000 copies/mL) that is immediately preceded
and followed by an undetectable HIV-1 RNA
false elevations of HIV-1 RNA related to erroneous
laboratory findings or to release of archived virus
from activated cells.
not associated with the development of resistance
mutations
temporally linked to nonadherence to therapy
19. Recommended methods for determining
virologic failure
• HIV-1 viral load measurements should be done by
any one of the following US FDA recommended
tests:
• Roche Cobas Amplicor
• Branched DNA method
• Nucleic acid sequence based assay (NASBA)
20. Causes of ARV Treatment Failure
Social/personal issues
Regimen issues
Poor potency
Wrong dose
Toxicities
Host genetics
Poor adherence
Poor absorption
Drug pharmacokinetics
Transmitted resistance
Insufficient drug level
Drug interactions
Viral replication in the
presence of drug
Resistant virus
ART resistance testing. AETC National Resource Center.
21. 1st line Antiretroviral therapy treatment failure
•
•
•
•
•
•
•
•
•
Should be confirmed by 2 plasma viral load reports (plasma viral load >
400 copies/ml) after 6 months on 1st line ART.
2nd line ART should not be started on immunologic (CD4)/clinical evidence
alone.
Genotypic resistance testing should ideally be recommended while
patient is on failing 1st line antiretroviral regimen.
Reason for 1st line ART failure and cost of 2nd line antiretroviral regimen
should be discussed in detail.
Adding at least two (preferably three) fully active agents to an optimized
background antiretroviral regimen can provide significant antiretroviral
activity
Boosted PI regimens well studied, expected to be effective
Backbone of 2 NRTI’s can be decided from resistance testing report
Goal of 2nd line ART is to re-suppress plasma viral load to undetectable
levels.
Highly drug resistant HIV
23. Genotypic resistance testing
• Identifies mutations within reverse transcriptase and
protease genes that have been associated with impaired
virologic response
• Readily available
• Quick turnaround time (1-2 weeks)
• Confers short-term virologic benefits
• Useful for mixtures of wild type and drug resistant virus
• Genotype testing is suitable for straightforward situations,
such as testing for drug-resistant virus in treatment-naive
subjects or evaluating resistance in a patient with viral
rebound after their first regimen
24. Common reverse transcriptase inhibitor resistance
(NRTI/NtRTI/NNRTI) mutations
TYPE OF DRUG
DRUGS INCLUDED
SIGNATURE MUTATIONS
THYMIDINE ANALOGS
ZIDOVUDINE
41L, 67N,70R,210W,215Y,219Q
(TAM’s)
STAVUDINE
41L, 67N,70R,210W,215Y,219Q
NON-THYMIDINE ANALOGS
TENOFOVIR
K65R
ABACAVIR
L74V,K65R
DIDANOSINE
L74V,K65R
NEVIRAPINE
K103N,Y181C
EFAVIRENZ
K103N,Y181C
LAMIVUDINE
M184V
NNRTI
NRTI
EMTRICITABINE
25. Dynamics of resistance development
DRUG
K103N,Y181C
LAMIVUDINE
M184V
ZIDOVUDINE
TAM’s
EFAVIRENZ
TRUSTIVA/VIRADAY
RESISTANCE MUTATION
NEVIRAPINE
ZIDOLAM N/ DUOVIR N
COMPONENTS
K103N,Y181C
EMTRICITABINE
M184V
TENOFOVIR
K65R
26. Higher Mortality and Disease Progression in
MDR HIV
• Drug-resistant virus associated with poorer prognosis
and higher mortality
• Factors correlating with increased risk of death
– Lower CD4+ cell count
― Higher viral load
– Treatment history with greater number of anti-HIV agents
– Earlier diagnosis of MDR HIV
Class-Wide Resistance Mutations
Parameter, %
0
1
2
3
P Value
All-cause death
8.9
11.7
13.4
27.1
.0286
AIDS-related death
6.1
9.9
13.4
21.5
.0299
New AIDS event or death
16.0
17.7
19.3
35.9
.0155
Zaccarelli M, et al. AIDS. 2005;19:1081-1089.
27. CASE 1
•
•
•
•
•
Mr A.B
Resident of Phaltan, married with two kids
Farmer by occupation
Occasional Smoker
Was diagnosed HIV-1 positive in March 2008 when
he suffered from disseminated TB
• Pt was put on 4 drug ATT, Septran and responded
well
• Investigations done were as follows :
28. INVESTIGATIONS
Haemoglobin
12.3 g/dl
T. Bil
1 mg/dl
TLC
6500 cells/mm3
D. Bil
0.3 mg/dl
Lymphocyte count
2500 cells/mm3
I.Bil
0.7 mg/dl
Platelet count
189,000
AST/ALT
34/34
BUN
20 mg/dl
CD4
132 cells/mm3
Creat
1 mg/dl
CD8
987 cells/mm3
HBsAg
Positive
XRC P/A
Lower zone infiltrates
VDRL
negative
USG Abdomen
Mesentric
lymphadenopathy
29. Further course
• Pt was started on Zidovudine/Lamivudine in July
2008 along with ATT
• Pt was shifted to
Zidovudine/Lamivudine/Nevirapine in October 2008
by his physician on completion of his ATT
• Pt took treatment extremely regularly over the next
6 months although he was having AZT induced
gastritis and myalgia
• He presented to Noble Hospital, Pune in April 2009
• His investigations revealed :
30. INVESTIGATIONS
Haemoglobin
10.1 g/dl
T. Bil
1.1 mg/dl
TLC
6500 cells/mm3
D. Bil
0.3 mg/dl
Lymphocyte count
1600 cells/mm3
I.Bil
0.8 mg/dl
Platelet count
549,000
AST/ALT
84/114
BUN
32 mg/dl
CD4
32 cells/mm3
Creat
1.2 mg/dl
PVL+
123,000 copies/ml
HBsAg
Positive
XRC P/A
WNL
VDRL
negative
USG Abdomen
WNL
31. QUESTIONS
• What will be your next step ?
• Pt has failed 1st line therapy change to second
line therapy immediately
• Continue same treatment
• Do a genotypic resistance testing pending
which shift the pt to 2nd line ART
• Refer the pt to a ID specialist
32. Further course
• Plasma viral load is reconfirmed and the value
is 125,000 copies/ml
• Pt was willing to submit his plasma sample for
Genotypic HIV-1 resistance testing
• Pt is counseled about need for second line
ART regimen and was willing for the same
33. QUESTIONS
• What are the precautions to be taken while
sending plasma sample of pt for genotypic
resistance testing ?
• Resistance testing should be done when pt is
on failing ART regimen or within 4 weeks of
discontinuation
• Might not detect resistance mutations when
viral load is very low i.e < 5000 copies/ml
• Might not detect minority variants
35. Common reverse transcriptase inhibitor resistance
(NRTI/NtRTI/NNRTI) mutations
TYPE OF DRUG
DRUGS INCLUDED
SIGNATURE MUTATIONS
THYMIDINE ANALOGS
ZIDOVUDINE
41L, 67N,70R,210W,215Y,219Q
(TAM’s)
STAVUDINE
41L, 67N,70R,210W,215Y,219Q
NON-THYMIDINE ANALOGS
TENOFOVIR
K65R
ABACAVIR
L74V,K65R
DIDANOSINE
L74V,K65R
NEVIRAPINE
K103N,Y181C
EFAVIRENZ
K103N,Y181C
LAMIVUDINE
M184V
NNRTI
NRTI
EMTRICITABINE
36. QUESTIONS
• Would you keep lamivudine/Emtricitabine in
second line ART regimen ?
• What would be the preferred second line ART
regimen in above pt ?
37. Further course
• Pt was started on
Tenofovir/Emtricitabine/Lopinavir/Ritonavir
as second line regimen
• He tolerated the regimen well and
investigations done in December 2009 were
as follows :
• CD4 count : 323 cells/mm3
• Plasma viral load < 400 copies/ml
• Serum Creatinine – 1.2 mg/dl
38. CASE 2
•
•
•
•
•
Mr X.Y
Resident of Pune, married with 3 kids
Police constable by occupation
Heavy drinker and chain smoker
Was diagnosed HIV-1 positive in May 2003 when he
went for routine health check
• Investigations done were as follows :
39. INVESTIGATIONS
Haemoglobin
9.3 g/dl
T. Bil
1.3 mg/dl
TLC
10500 cells/mm3
D. Bil
1 mg/dl
Lymphocyte count
3500 cells/mm3
I.Bil
0.6 mg/dl
Platelet count
413,000
AST/ALT
83/31
BUN
32 mg/dl
CD4
66 cells/mm3
Creat
0.6 mg/dl
CD8
432 cells/mm3
HBsAg
Negative
XRC P/A
WNL
VDRL
negative
USG Abdomen
WNL
40. Further course
• Pt was started on Zidovudine/Lamivudine/Nevirapine in May
2003
• Pt took treatment extremely regularly but developed AZT
induced anemia in November 2003
• Pt was shifted to Stavudine/Lamivudine/Nevirapine which he
continued to take till July 2010
• During episodes of binge drinking pt used to skip ART
• Pt also gave history of taking drugs once daily instead of twice
daily when on official duty
• His self reported adherence was around 75 %
• He presented to Ruby Hall Clinic, Pune in July 2010 with h/o
high grade fever,anorexia,wt. loss since 20 days
• His past investigations revealed :
44. QUESTIONS
• What will be the drugs to be included in
antitubercular regimen of this patient ?
• When will you initiate second line
antiretroviral therapy in this pt ?
• What dose of rifabutin is recommended to be
used with Lopinavir-Ritonavir ?
45. Timing of ART initiation in patients with
tuberculosis
CD4 count
< 50 cells /mm3
Time to initiate antiretroviral
therapy
within 2 weeks
50 – 200 cells/mm3 (low Karnofsky
2-4 weeks
score, body mass index, haemoglobin, or
albumin, organ system dysfunction)
50 – 200 cells/mm3 (no severe
markers)
200 – 500 cells/mm3
Within 8-12 weeks
> 500 cells/mm3
Within 8-12 weeks
Tubercular meningitis
irrespective of CD4 count
Delay ART till meningitis under
control
Within 8-12 weeks
46. Recommendations for Coadministering
Antiretroviral Drugs with RIFABUTIN
DRUG WITH WHICH RIFABUTIN IS
CO-ADMINISTERED
DOSE OF RIFABUTIN
EFAVIRENZ
450-600 mg/day
NEVIRAPINE
300 mg/day
RITONAVIR BOOSTED DARUNAVIR
150 mg daily
RITONAVIR BOOSTED ATAZANAVIR
150 mg daily
RITONAVIR BOOSTED LOPINAVIR
150 mg daily
50. QUESTIONS
• What are Thymidine analog mutation (TAM)
pathways and why are they important?
• 41L, 67N,70R,210W,215Y,219Q
• 41,210,215 pathway
• 67,70,219 pathway
51. QUESTIONS
• What will be the second line ART regimen
chosen for this pt ?
• What are the recommended PI regimens for
second line therapy ?
52. Further course
• Pt was started on
Tenofovir/Emtricitabine/Lopinavir/Ritonavir
as second line regimen
• He tolerated the regimen well and
investigations done in Jan 2011 were as
follows :
• CD4 count : 493 cells/mm3
• Plasma viral load < 400 copies/ml
• Serum Creatinine – 0.8 mg/dl
53. CASE 3
•
•
•
•
•
Mr G.B
Resident of Dhule, married
Businessman by occupation
Tobacco chewer
Was diagnosed HIV-1 positive in April 2009 when he
went to a dermatologist regarding recurrent penile
ulcers and oral apthous ulcers
• Investigations done were as follows :
54. INVESTIGATIONS
Haemoglobin
11.1 g/dl
T. Bil
0.5 mg/dl
TLC
4600 cells/mm3
D. Bil
0.2 mg/dl
Lymphocyte count
1600 cells/mm3
I.Bil
0.3 mg/dl
Platelet count
138,000
AST/ALT
84/34
BUN
27 mg/dl
CD4
132 cells/mm3
Creat
1.3 mg/dl
CD8
1148 cells/mm3
HBsAg
NEGATIVE
XRC P/A
WNL
VDRL
negative
USG Abdomen
WNL
55. Further course
•
•
•
•
•
•
•
Pt was started on Stavudine/Lamivudine/Nevirapine in January 2009
Pt developed severe itching and erythematous rash within 15 days of
starting treatment and took tablets alternate day for 20 days and then
stopped them altogether
Pt presented to local physician in April 2009 who shifted him to
Tenofovir/Emtricitabine/Efavirenz which he continued to take till
December 2009
Pt took the treatment extremely regularly and had no side-effects
His self reported adherence was around 95 %
He presented in January 2010 with h/o weight loss of 5 kgs over 1 month
His investigations revealed :
56. INVESTIGATIONS
Haemoglobin
8.7 g/dl
T. Bil
1.3 mg/dl
TLC
10300 cells/mm3
D. Bil
0.3 mg/dl
Lymphocyte count
5700 cells/mm3
I.Bil
1 mg/dl
Platelet count
143,000
AST/ALT
23/31
BUN
32 mg/dl
CD4
14 cells/mm3
Creat
0.6 mg/dl
Plasma viral load
141,000 copies/ml
HBsAg
Negative
Serum Cryptococcal
Antigen
negative
XRC P/A
WNL
USG Abdomen
WNL
HRCT chest
WNL
CT abdomen
WNL
60. QUESTIONS
• What will be the second line ART regimen
chosen for this pt ?
• What is the commonest side-effect of
Atazanavir- ritonavir ?
61. Further course
• Pt was started on
Zidovudine/Lamivudine/Tenofovir/Atazanavir/
Ritonavir as second line regimen
• He tolerated the regimen well and investigations
done in Sept 2010 were as follows :
• CD4 count : 189 cells/mm3
• Plasma viral load < 400 copies/ml
• Serum Creatinine – 0.6 mg/dl
• T.Bil – 4.3
• I.Bilirubin – 3.7
• SGPT/SGOT- 39/37
62. CASE 4
•
•
•
•
•
Mr S.J
Resident of Akluj, married
Farmer by occupation
Non- addict
Was diagnosed HIV-1 positive in June 2004 when he
was admitted for pile banding surgery at Solapur
• Investigations done were as follows :
63. INVESTIGATIONS
Haemoglobin
7.1g/dl
T. Bil
0.8 mg/dl
TLC
4500 cells/mm3
D. Bil
0.5 mg/dl
Lymphocyte count
2200 cells/mm3
I.Bil
0.3 mg/dl
Platelet count
643,000
AST/ALT
14/34
BUN
34 mg/dl
CD4
201 cells/mm3
Creat
0.7 mg/dl
CD8
1029 cells/mm3
HBsAg
negative
XRC P/A
WNL
VDRL
negative
USG Abdomen
WNL
64. Further course
•
•
•
•
•
•
•
•
•
•
•
•
Pt was started on Zidovudine/Lamivudine/Nevirapine in July 2004
Pt continued treatment till January 2008
His self reported adherence was around 80 %
He used to take multiple gaps in treatment especially during visits to other
villages for work
He was also unhappy with the gastritis and myalgia he developed on
consuming ART tablets.
Pt’s CD4 count done in January 2008 was 219 cells/mm 3
He was shifted to Tenofovir/Emtricitabine/Efavirenz by local physician in
January 2008
He took treatment extremely regularly till July 2008
His repeat CD4 count done was 159 cells/mm3
Pt was disappointed by falling CD4 count and stopped all drugs
He presented to Noble Hospital, Pune in May 2009
Pt was asymptomatic on presentation
65. INVESTIGATIONS
Haemoglobin
9.6g/dl
T. Bil
0.9 mg/dl
TLC
2300 cells/mm3
D. Bil
0.6 mg/dl
Lymphocyte count
1200 cells/mm3
I.Bil
0.3 mg/dl
Platelet count
419,000
AST/ALT
54/44
BUN
21 mg/dl
CD4
78 cells/mm3
Creat
0.5 mg/dl
CD8
1349 cells/mm3
HBsAg
negative
XRC P/A
WNL
Cryptococcal
Antigen
negative
USG Abdomen
WNL
66. QUESTIONS
• What will be your next step ?
• What will be the second line ART regimen
chosen for this pt ?
67. Further course
• Pt was started on
Stavudine/Lamivudine/Tenofovir/Atazanavir/
Ritonavir as second line regimen
• He tolerated the regimen well and investigations
done in Feb 2010 were as follows :
• CD4 count : 514 cells/mm3
• Plasma viral load < 400 copies/ml
• Serum Creatinine – 0.9 mg/dl
68. Take home message
•
•
•
•
•
Antiretroviral therapy switching occurs because of multiple reasons
Drug toxicity, ART resistance, cost reduction and ART simplification are
the major causes of drug switching in India.
Individual drug substitution to circumvent drug toxicity or reduce regimen
cost should be done only after confirming viral suppression.
Virologic failure needs to be identified early by doing at least yearly
plasma viral load in patients on ART. Non identification of failure can lead
to accumulation of drug resistance mutations and reduced capability of
second line regimens to suppress the virus.
Causes of virologic failure need to be scrupulously identified otherwise
second line regimens will also be compromised.
ARV, antiretroviral.
This slide reviews the causes for antiretroviral treatment failure. There are many factors that affect treatment failure and they are primarily associated with insufficient drug levels. If drug levels are not sufficient, viral replication occurs in the presence of the drug, thereby permitting emergence of resistant virus and subsequent treatment failure.
Poor adherence is one cause of insufficient drug levels, but poor adherence has a negative connotation that implies the patient has done something wrong. Frequently, there are social or personal issues that may be out of the patient’s control. For example, if their state of residence closes the AIDS Drug Assistance Program, patients may have difficulty obtaining their medication. There may also be regimen issues, including tolerability problems that do not reach the level of toxicity. In addition, toxicity issues involving serious adverse effects may interrupt therapy.
However, there are other reasons for insufficient drug levels. For example, the clinician may choose a regimen with low potency. Alternatively, the wrong dose may be prescribed or dispensed and even though the patient may be perfectly adherent, this suboptimal dose may be the cause for treatment failure. There might be differences in host genetics that affect drug metabolism. Likewise, there might be issues affecting drug absorption. We have also mentioned drug pharmacokinetics and drug-drug interactions.
Transmitted resistance is another factor affecting the ability to achieve sufficient drug level. If the patient is infected with an NNRTI-resistant virus, for example, any level of efavirenz will be insufficient. This results in viral replication in the presence of the drug and may lead to emergence of further drug resistance even to other classes of drugs. However, if the patient does not take his or her medication, he or she is unlikely to develop a resistant virus but treatment failure would still occur.
A study of 623 individuals who had genotype resistance testing during antiretroviral failure demonstrated a heightened risk of death with viral drug resistance. These highly experienced patients had a median 24 months of HAART before genotype testing, and a median of 3 failed regimens. Approximately half of these patients (50.9%) had at least 1 class-wide resistance mutation according to genotype results, and 24 (3.9%) had resistance to all 3 classes. Over 48 months of observation from the time of genotype resistance testing, 28 new AIDS events were documented and 38 deaths occurred, of which 29 were AIDS related. The incidence of death in patients with 0, 1, 2, or 3 class-wide resistance mutations was found to be 3.50, 2.79, 3.97, and 11.90 per 100 person-years of follow-up, respectively.
Multivariate statistical analysis correlated triple-class resistance with an increased risk of death (hazard ratio [HR], 5.34; 95% CI, 1.76- 16.24; P < .01); AIDS-related death (HR, 4.14; 95% CI, 1.17-14.68; P = .03); and new AIDS diagnosis or death (HR, 5.36; 95% CI, 2.16-13.32; P < .01). Other factors associated with increased morbidity and mortality were higher current HIV-1 RNA level and pregenotype AIDS diagnosis. Higher CD4+ cell count at the time of genotype resistance testing significantly reduced the risk of death.