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ART: When to Start? – Case Discussion

ART: When to Start? – Case Discussion. Roy M. Gulick, MD, MPH Professor of Medicine Chief, Division of Infectious Diseases Weill Medical College of Cornell University New York City, USA. Case: NR. NR is a 32 year old accountant referred to to discuss HIV treatment options.

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ART: When to Start? – Case Discussion

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  1. ART:When to Start? – Case Discussion Roy M. Gulick, MD, MPH Professor of Medicine Chief, Division of Infectious Diseases Weill Medical College of Cornell University New York City, USA

  2. Case: NR • NR is a 32 year old accountant referred to to discuss HIV treatment options. • Past History: • gonorrhea 1 year ago that responded to rx • tested HIV negative “every year since 2000” • Meds: none • Social History: Sexually active gay man, not currently in a committed relationship; has health insurance through work.

  3. Case: NR (continued) • Physical Exam: normal • Labs: • CBC, chemistries, liver function tests normal • HIV antibody + • HIV RNA 47,000 • CD4 count 635/µL • He understands the requirements of ART and is willing to start if you recommend it.

  4. Question Asymptomatic, VL 47,000; CD4 635 Do you recommend ART now? • Yes • No • It depends

  5. When to Start? 3 YES

  6. ART for “Certain Patients” with CD4 >350 BHIVA Guidelines 2012: • AIDS (e.g., KS) • HIVAN • ITP • Neurocognitive • HBV • HCV (CD4 <500) • Non-AIDS malignancies requiring rx EACS Guidelines 2012: • AIDS, including TB • HIVAN • Neurocognitive • HBV • HCV (CD4 <500) • Hodgkin’s lymphoma • HPV-associated cancer

  7. Case NR (continued) • He says he’ll think about it and schedules an appointment for additional labs and a follow-up visit in 3 months. • At the 3 month visit: • Asymptomatic with normal physical exam • Hepatitis B surface Ag -, Ab +; Hep C Ab - • HIV RNA 53,000; CD4 642 • Met a new partner 2 months ago who is “the love of his life” and is HIV-negative. He knows “all about” safe sex but also wants to do “everything he can” to protect his partner.

  8. Question Asymptomatic, VL 53,000; CD4 642; HIV-negative partner Do you recommend ART now? • Yes • No • Maybe

  9. HPTN 052 • 1,763 discordant couples (97% heterosexual) in Africa, Asia, Americas with HIV+ with CD4 350-550 • HIV+ partner randomized to start cART immediately or deferred until CD4 <250 • DSMB Interim analysis: • 90% on ART had HIV RNA <400 • 40 incident cases of HIV • 29 linked genetically to partner • 96% reduction in transmission! New HIV infections (all) probability 28 cases 1 case years Cohen #MOAX0102 and NEJM 2011;365:493

  10. ART + Serodiscordant Couples • BHIVA Guidelines 2012: “…if a patient with a CD4 >350 wishes to start ART to reduce the risk of transmission to partners, this decision is respected and ART is started.” • EACS Guidelines 2012: “…should be strongly considered and actively discussed.”

  11. Case NR (continued) • He agrees to start ART. • He also understands he should continue to practice safe sex with his partner. • At his routine visit 3 months later, he has not missed an ART dose and is VL is 2,350. • He says he’s heard something about giving HIV- uninfected people HIV drugs to protect them and asks what you would recommend for his partner?

  12. Question • HIV+ MSM on ART • At 3 months, VL ↓ 2,350 cps/ml • HIV- partner • Do you recommend PrEP? • Yes • No • Maybe

  13. Question • HIV+ MSM on ART • At 6 months, VL <20 cps/ml • HIV- partner • Do you recommend PrEP? • Yes • No • Maybe

  14. Oral PrEP Studies

  15. Oral PrEP Studies

  16. When to start ART? 2013 DeCock and El-Sadr NEJM 2013;368:886

  17. Acknowledgments • Cornell HIV Clinical Trials Unit (CCTU) • Division of Infectious Diseases • Weill Medical College of Cornell University • AIDS Clinical Trials Group (ACTG) • Division of AIDS, NIAID, NIH • The patient volunteers!

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