Top 10 HIV/AIDS Stories of 2006
The year 2006 was one of milestones and advances in HIV/AIDS management. The
pandemic is over 25 years old and we now have new insights into treatment, life
expectancy, and cost effectiveness. It has also been an exciting year that adds
clarity of first-line treatments with some head-to-head studies of the most commonly
used antiretrovirals. Additionally, both the DHHS and the International AIDS
Society HIV/AIDS Treatment Guidelines were updated. Thus, from a treatment standpoint,
the future looks promising.
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1. Which is better Kaletra ® or Sustiva ®?
The answer
lies within adherence and which drug the patient will take most consistently.
It had been thought that patients with high viral loads would be better treated
with a protease inhibitor (PI) than a non-nucleoside reverse transcriptase inhibitor
(NNRTI). However, the De Luca study shows that there is no difference in clinical
outcomes with good adherence. So what does that mean? Based on this study population,
there is no clinical difference in treatment with Sustiva ® versus
Kaletra ®. However, non-adherent patients should benefit from being on a
protease inhibitor secondary to less resistance and a higher genetic barrier.
De Luca A, Cozzi-Lepri A, et al. Lopinavir/ritonavir or efavirenz plus two
nucleoside analogues as first-line antiretroviral therapy: a non-randomized comparison. Antivir
Ther. 2006;11(5):609-18.
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2. Which is better Truvada ® or Combivir ®?
Although
we do not have a study that directly compares the Truvada ® formulation
to the Combivir ® formulation we have a study that compares the components
of Truvada ® (tenofovir/emtricitabine) to Combivir ® (lamivudine/zidovudine).
Truvada ® has been plagued with questions regarding its potential to cause
renal toxicity and for promoting the development of the K65R mutation. In this
study, tenofovir and emtricitabine were shown to be superior in achieving and
maintaining an HIV RNA level <400 copies/mL (viral load), increase in CD4
cells (a marker of immune function) and maintaining limb fat. There was no emergence
of the K65R mutation and no statistically significant difference in renal toxicity
when compared to Combivir ®.
Gallant JE, DeJesus E, et al. Tenofovir DF, emtricitabine, and efavirenz
vs. zidovudine, lamivudine, and efavirenz for HIV. N Engl J Med. 2006
Jan 19;354(3):251-60.
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3. There is no place in therapy for structured treatment
interruptions
Patients
on antiretroviral therapy must maintain a very high rate of adherence – in
many cases in upwards of 95%. The thought of being on lifelong treatment (at
this rate of adherence) can be overwhelming. There have been many studies to
see whether uninterrupted therapy can induce a better immune response or if the
patient can benefit from temporarily stopping medications to give relief from
side effects. The newest evidence demonstrates interruptions in antiretroviral
treatment are not effective. The ‘SMART’ study looked at CD4+ count-guided
interruptions and found that this put the patient at greater risk of opportunistic
infections and even death. There was also no significant benefit from adverse
events related to medication interruption.
The Strategies for Management of Antiretroviral Therapy (SMART) Study Group
et al. CD4+ Count-Guided Interruption of Antiretroviral Treatment. N Engl
J Med. 2006 Nov 30;355(22):2283-96.
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4. What are the new treatment guidelines?
The biggest change
in the DHHS guidelines was the expansion of recommended first-line treatments
to included Kaletra ®, boosted-Reyataz ®, boosted-Lexiva ®,
or Sustiva ®, in combination with Truvada ® or Combivir ®. Previous
guidelines limited first-line recommendations to Sustiva ® with either Truvada ® or
Combivir ® and Kaletra ® with Combivir ® only. The International
AIDS Society has similar recommendations but has included boosted-Invirase ® as
a first-line treatment. Please refer to the links below and/or links provided
under the Clinical “Guidelines” section of this website.
DHHS Panel. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected
Adults and Adolescents. October 10, 2006 http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf PDF
- 2,500KB
SM, Saag MS, et al. Treatment for adult HIV infection: 2006 recommendations
of the International AIDS Society-USA panel. JAMA. 2006 Aug 16;296(7):827-43.
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5. Induction
and simplification to monotherapy
Interest was generated in starting
patients on a full 3-drug containing regimen and then simplifying to a monotherapy
regimen. This would be similar to what is done to treat tuberculosis. Although
some of the studies look promising, there is much skepticism on the durability
of PI-based monotherapy regimen. With the convenient dosing of Truvada ® and Combivir ®,
it is probably not worth the risk at this point in most patients.
Swindells S, DiRienzo et al. Regimen simplification to atazanavir-ritonavir
alone as maintenance antiretroviral therapy after sustained virologic suppression. JAMA.
2006 Aug 16;296(7):806-14.
Pierone G Jr, Mieras J, et al. A pilot study of switch to lopinavir/ritonavir
(LPV/r) monotherapy from nonnucleoside reverse transcriptase inhibitor-based
therapy. HIV Clin Trials. 2006 Sep-Oct;7(5):237-45.
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6. CDC Recommends more
routinized screening efforts
Release of these guidelines should represent
a positive step forward in HIV/AIDS mitigation efforts. The revisions have appropriately
stimulated discussion and revealed the challenges and barriers of implementation,
yet this gives us an opportunity to utilize them as a springboard for action.
In the spirit of the release and rationale, it may be critical that we do not
create unnecessary barriers to screening within our system. There will (appropriately)
be concerns surrounding specific recommendations such as ‘general consent’ or
the ‘guidelines
surrounding prevention counseling’ as well as the potential for stigma
and discrimination and conflicting state health regulations. The alternative
- not taking advantage of these revisions - could keep us locked into a pattern
that will not improve or protect the health of our people. These recommendations
are for streamlining general procedures and must be interpreted and applied with
cultural and disease specific competence.
CDC Releases Revised Recommendations for HIV Screening in Health-Care Settings.
An Opportunity for IHS? CCC Corner. October 2006: Retrieved 2/18/07 from: http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_AOM.cfm
Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant
Women in Health-Care Settings. MMWR Sept 22, 2006/55(RR14):1-17 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm
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7. Circumcision can prevent HIV infections
There has always been an association showing that circumcision can prevent
transmission of HIV. Now there is evidence-based research to confirm this association.
Data is being examined by the United Nations to provide public health recommendations
for countries that do not routinely use circumcision secondary to customs and
religious beliefs.
Kuehn BM. Routine male circumcision could prevent millions of HIV infections
in Africa. JAMA. 2006 Aug 16;296(7):755.
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8. What is the life expectancy
for HIV infected patients in the US?
Many providers are optimistic that with proper care and adherence to medications,
life expectancies for HIV patients may approach those of uninfected individuals.
We now have additional data to give our patients. New research shows that the
life expectancy after diagnosis is 24 years. With advances in treatment and care
this estimate will continue to improve.
Schackman BR, Geb o KA, et al. The lifetime cost of current human immunodeficiency
virus care in the United States. Med Care. 2006 Nov;44(11):990-7. Review.
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9. More
research evaluating traditional markers of disease progression and immune status
The
article by Pirzada et al reminds us of the importance and the stability of the
CD4% count. CD4% count has been known to be a good predictor for risk of PCP
pneumonia (<14%) – an opportunistic infection that occurs when
the immune status is compromised. This article leads additional evidence that
CD4% may be a better predictor of opportunistic infection risks for patients
with CD4 counts between 201 and 350.
Pirzada Y, Khuder S, and Donabedian H. Predicting AIDS-related events using
CD4 percentage or CD4 absolute counts. AIDS Research and Therapy 2006,
3:20 (17 August 2006).
The Cohen article below gives evidence that viral load is not a consistent
correlate between viral loads and immune function and cannot be used to predict
progression of disease.
Cohen J. Immunology. Study says HIV blood levels don't predict immune decline. Science. 2006
Sep 29;313(5795):1868.
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10. New Treatment Options
There was only one new drug approval
in 2006. Prezista ® (darunavir) is
a new protease inhibitor with expanded resistance profile that can be used in
treatment experienced patients.
Atripla ® made national news as the first one-pill once-a-day treatment
for HIV. However, Atripla ® does not represent a new medication only a combination
of existing medications (tenofovir/emtricitabine/efavirenz). The most exciting
medications news came from clinical trials. In addition to the expected new protease
inhibitor and non-nucleoside reverse transcriptase inhibitors, there are 2 new
drug classes that will make an appearance in 2007. The integrase inhibitors and
CCR5 inhibitors should provide needed drug therapy options for treatment experience
patients.
Sharp M. 13th Conference on Retrovirus and Opportunistic Infections. Update
on experimental HIV drugs. The newest, latest pipeline drugs from CROI.
Posit Aware. 2006 May-Jun;17(3):17-9.
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