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EACS guidelines in the context of the HIV epidemiology in Europe Jürgen Rockstroh

EACS guidelines in the context of the HIV epidemiology in Europe Jürgen Rockstroh Department of Medicine I, University of Bonn, Bonn, Germany. EACS guidelines.

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EACS guidelines in the context of the HIV epidemiology in Europe Jürgen Rockstroh

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  1. EACS guidelines in the context of the HIV epidemiology in Europe Jürgen Rockstroh Department of Medicine I, University of Bonn, Bonn, Germany

  2. EACS guidelines • EACS produces the European Guidelines for treatment of HIV infected adults in Europe. So far the treatment guidelines have been translated from English into 13 additional languages. • All diffferentversions in all languagesarefreedowloadablefromtheeacswebsite: • http://www.europeanaidsclinicalsociety.org

  3. Table ofcontents

  4. EACS guidelines: When to start • Initiation of ART • ART is always recommended if CD4 count <350 cells/mm3 • Serodiscordant couples: Early ART should be considered and actively discussed C, CONSIDER; D, DEFER; R, RECOMMENDED Adapted from EACS Guidelines. Version 6; Oct 2011. Available at: www.europeanaidsclinicalsociety.org. Accessed June 2012

  5. Type 2 diabetes: diagnosis and management Diagnostic criteria (i) i As defined by WHO and International Diabetes Federation (2005) ii An abnormal finding should be repeated before confirming the diagnosis iii Recommended in patients with fasting blood glucose 5.7–6.9 mmol/L (100–125 mg/dL) as it may identify patients with overt diabetes iv Do not use HbA1c in presence of haemoglobinopathies, increased erythrocyte turnover and sever liver or kidney dysfunction. Falsely high values are measures under supplementation with iron, vitamin C and E as well as older age (age >70: HbA1c +0.4%) Both IGT and IFG increase CV morbidity and mortality, and increase the risk of developing diabetes by 4–6 fold. These patients should be targeted for lifestyle intervention, and their CV risk factors must be evaluated and treated EACS guidelines 2011; 1:1–61.

  6. Interventions for Treatment of Diabetes If modification of lifestyle measures is insufficient • Sulfonylureas • May be considered for non-overweight if glucose is very high • No clinical trial in HIV +ve patients • Metformin • Always to be considered as the first oral agent (i) • Start dose (500–700 mg qd), increase to max tolerated dose of 2(-3) g/d in 4– weeks • (May worsen lipoatrophy) HbA1c > 6.5–7% Use a combination of 2 oral agents (i) (metformin/sulfonylurea/incretine/exenatide) HbA1c > 6.5–7% Refer to specialist use insulin • Management of patients with diabetes • Treatment goals: glucose control (Hb1Ac <6.5–7% without hypoglycaemia, fasting plasma glucose 4–6 mmol/L (73–110 mg/dL) • Normal blood lipids and blood pressure<130/80 mmHg (see p. 31 and p. 27) • Acetylsalicylic acid (75–150 mg/d) considered in diabetes with elevated underlying CVD risk (see p. 26) • Nephropathy, polynephropathy and retinopathy screening should be performed as in diabetic patients without HIV • Consultation with a speciality in diabetology is recommended • i Very limited data for incretines (e.g. liraglutide, saxagliptine, sitagliptine, vildagliptine) and exenatide in HIV patients; no clinically significant drug-to-drug interaction expected; clinical use of pioglitazone questioned by its side effects EACS guidelines 2011; 1:1–61.

  7. Prevalence of hepatitis C in the HIV population (1960/5957 patients = 33%) Regions: South Central North East North: 359 = 23.2 % East: 613 = 46.9 % Central: 293 = 19.6 % South: 695 = 41.4 % Rockstroh et al. J Inf Dis 2005;192:992–1002

  8. Acute HCV among HIV+ MSM Canada24: ~30 cases Prevalence chronic HCV/HIV25 19%: 11.200 Europe: 1068 cases Prevalence chronic HCV/HIV14,15 25%: 185.500 -UK3,4 552 -Germany5,18, 28 157 -France6,7 126 -Netherlands8,17 97 -Belgium20 69 -Swiss9 23 -Italy10 21 -Denmark21 13 -Spain27 ~8 USA1,2: 55 cases Prevalence chronic HCV/HIV12-14 15 – 30%: 180.000 – 360.000 Taiwan29: 30 cases Prevalence chronic HCV/HIV30 55%: 8.800 Lebanon22: 1 case Prevalence chronic HCV/HIV26 49%: 1.500 Australia11: 47 cases Prevalence chronic HCV/HIV16,19 < 1%: 1.000 1:Luetkemeyer JAIDS 2006; 2:Cox Gastroenterology 2008; 3:Giraudon Sex Transm Infect 2008; 4:Ruf Eurosurveill 2008; 5:Vogel CID 2009; 6:Gambotti Euro Surveill 2005; 7:Morin Eur J Gastro Hepat 2010; 8:Urbanus AIDS 2009; 9:Rauch CID 2005; 10:Gallotta 4th Works. HIV & Hep. Coinf. 2008; 11:Matthews CID 2009; 12:Sherman CID 2002; 13:Backus JAIDS 2005; 14:UNAIDS Report 2008; 15:Soriano JID 2008; 16:Matthews CID 2011; 17:Arends Neth J Med 2011; 18:Neukam HIV Med 2011; 19:Pfafferott PLoS One 2011; 20:Bottieau Euro Surveill 2010; 21:Barfod Scand JID 2011; 22:Dionne-Odom Lancet Infect Dis 2009; 23:Taylor Gastroenterology 2009; 24:Hull personal conversation 2011; 25:Remis 1st Canadian HCV Conference 2001; 26:UNGASS Country progress Report 2010; 27:Soriano personal conversation 2011; 28:Boesecke 18thCROI Boston 2011 abstract #113; 29:Sun Liver International 2011; 30:Lee J F Med Assoc 2008

  9. Algorithm for management of acute HCV in HIV-infected individuals EACS guidelines 2011; NEAT Acute Hepatitis C Infection Consensus Panel. AIDS 2011:25;399-409

  10. New Treatment Options for HIV/HCV Genotype 1 Patients: EACS Guidelines • EACS guidelines include the option to treat HIV/HCV GT 1 coinfected patients with telaprevir*[1] • Updated guidelines will also include option to treat with boceprevir as interim results became available *With efavirenz, telaprevir dose should be increased to 1150mg every 8 hours. Data on coadministration of telaprevir with raltegravir is anticipated, but clinicians are advised to check www.hep-druginteractions.com for further information. 1. EACS Guidelines, October 2011, Version 6.0.

  11. Management of newly diagnosed HIV-HCV coinfected genotype-1 patients Management of Newly Diagnosed HIV/HCV Coinfected Genotype 1 Patients Newly diagnosed chronic HCV GT 1 infection Perform transient elastography and/or serum marker and/or liver biopsy In general, treatment can be deferred. Consider treatment with Peg/RBV and an HCV protease inhibitor or Peg/RBV alone if low HCV viral load, IL28B CC genotype, absence of insulin resistance and high CD4+ cell count. Treatment with Peg/RBV and an HCV protease inhibitor if compensated disease. Treatment should be undergone in specialised centres. Treatment with Peg/RBV and an HCV protease inhibitor. F0F1a F4a F2F3a aMetavir fibrosis score: F0=no fibrosis; F1= portal fibrosis, no septae; F2= portal fibrosis, few septae, F3=bridging fibrosis, F4=cirrhosis. Ingiliz P, Rockstroh. J. Liver International 2012

  12. EACS guidelines • Reflect the different regulatory and economic treatment scenarios in Europe • Are based on “treatment has to benefit the individual” • Attempt to improve management of concomitant comorbidities • Provide guidance on management of viral hepatitis coinfection • http://www.europeanaidsclinicalsociety.org

  13. Comeandvisitthe EACS booth 116 in hall D

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