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Cases from the Clinic( ians ): Case-based Panel Discussion

Explore the impact of delaying ART in HIV patients with CM in high-income settings through observational cohorts. Discover evidence on mortality rates and associations with early vs. deferred ART. Understand implications for treatment strategies in resource-rich environments.

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Cases from the Clinic( ians ): Case-based Panel Discussion

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  1. Cases from the Clinic(ians): Case-based Panel Discussion Michael S. Saag, MD Professor of Medicine Associate Dean for Global Health University of Alabama at Birmingham Birmingham, Alabama FORMATTED: 11/17/2015 New Orleans, Louisiana: December 15-17, 2015

  2. European AIDS Society Continues to Recommend ATP Initial Regimen for ART-Naïve Adult HIV-positive persons (11/14)

  3. Research Question: • Effect of delaying ART in naïve patients presenting with CM in high-income settings Methods: • Observational cohorts contributing to COHERE, NA-ACCORD and CNICS • Diagnosis of CM between 1998 and 2009. Follow-up 6 months. • Mimicking RCT comparing • Regime A: start ART within 14 days of CM diagnosis • Regime B : defer ART until 14 -56 days after CM diagnosis. • Marginal structural modelling to adjust for selection bias • Pooled logistic regression model, adjusted for clustering on patient IDs to estimate the association of regime with mortality. • adjusted for: age, gender, transmission risk group, year, country, AIDS (other than CM), CD4 and HIV viral load.

  4. Results: • 235 patients from 28 cohorts • 84% male, median age at CM 38 years. • Death rate at 6 months: 42/235 (18%) • Hazard Ratios (95% CI) for deferred vs early ART • Crude 1.29 (0.68-2.43) • Adjusted 1.30 (0.66-2.55) Conclusions: • Early ART does not seem to be associated with higher mortality in resource rich settings, in contrast to data from resource limited settings • Underpowered to provide robust evidence • Limitation: lack of data on CM treatment and disease management. We aim to obtain this in the future.

  5. ARV Interaction Score Card Slide courtesy of Jennifer Kiser * Decrease DCV dose to 30mg QD, Increase DCV dose to 90mg QD, ** PrOD + EFV led to premature study discontinuation due to toxicities

  6. Switch from TDF to E/C/F/TAF Pts CrCl 69-30 cc/ml CROI 2015: Pozniak, et al. Abst 795

  7. Switch from TDF to E/C/F/TAF Pts CrCl 69-30 cc/ml CROI 2015: Pozniak, et al. Abst 795

  8. Abacavir and Risk for Myocardial Infarction- NA-ACCORD Adjusted hazard ratios of select established CVD risk factors that remained significantly associated with MI●Restricted study population ● Full study population Recent ABC use Age <40 (vs. 50–59) years Age 40-49 (vs. 50–59) years Age ≥60 (vs. 50–59) years Hypertension Diabetes eGFR 30-59 (vs. ≥60) ml/min/1.73m2 eGFR <30 (vs. ≥60) ml/min/1.73m2 High (≥240 vs. <240 mg/dL) total cholesterol High (≥300 vs. <300 mg/dL) triglycerides Statin use Palella FJ et al, Abstract 749 CROI Seattle 2015

  9. Risk Factors for Non-AIDS Defining Cancers in NA-ACCORD • Smoking is a much higher risk for HIV-infected persons than other HIV-associated factors like low CD4 counts, detectable HIV RNA or clinical AIDS dx • Treating HIV should also help NADCs • Limitations: no BMI or alcohol use data Althoff K et al. CROI 2015 #726

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