A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

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A Guide to Primary Care of People with HIV/AIDS Chapter 5: Antiretroviral Therapy 5 Agents in HIV-Infected Adults and Adolescents (available at http://www.aidsinfo.nih.gov) the CD4 cell count range of 200-350/mm 3 is also an indication for ART, but the decision is tempered by the viral load, the rapidity of the CD4 cell count decline (CD4 cell slope), and patient readiness. The role of viral load in this decision is based on 2 observations: 1) the viral load is an independent predictor of progression and 2) the CD4 decline slope is directly correlated with viral load. The implication is that a high viral load imparts a risk for more rapid progression to AIDS and a more rapid decline in the CD4 cell count. The threshold that appears important in the CD4 cell strata of 200-350 is ≥20,000 copies of virus/mL (c/mL). Some authorities also treat patients with a viral load of 50,000-100,000 c/mL even when the CD4 cell count is >350/mm 3 , but there is no consensus here. It should be emphasized that multiple cohort studies involving thousands of patients clearly indicate that therapy is necessary when the CD4 cell count is 350/mm 3 and a viral load of 350/mm 3 Defer therapy Some authorities treat if viral load is >55,000 c/mL CD4 cell count of 200- 350/mm 3 Treat or defer therapy Influencing factors include • Patient readiness • CD4 slope (rate of decline) • Viral load (
A Guide to Primary Care of People with HIV/AIDS Chapter 5: Antiretroviral Therapy How do you decide on a specific regimen? The selection of a regimen is based on the experience with completed trials and idiosyncrasies of the specific patients. No single regimen is appropriate for all patients, but virtually all experienced AIDS treaters have a few favorites. Most start with a 3- or 4-drug regimen that includes 1) an NNRTI combined with 2 nucleosides, 2) a PI either alone or boosted with ritonavir (RTV) plus 2 nucleosides, or 3) a 3-nucleoside regimen that includes abacavir (ABC), lamivudine (3TC), and zidovudine (combined as Trizivir). This last regimen has been popular for patients who struggle with complicated medical regimens because it is only 1 pill twice a day; however, the regimen is considered suboptimal compared with the PI- or NNRTI-based regimens. Is once-a-day therapy possible? This is now feasible and clearly preferred by some patients. The following drugs may be given once a day: tenofovir (TDF), lamivudine (3TC), emtricitabine (FTC), didanosine (ddI), stavudine (d4T), efavirenz (EFV), atazanavir (ATV), and amprenavir plus ritonavir (APV/r). Table 5-3. Rationale for Changing Therapy Problem Definition Intervention Virologic failure Drug toxicity Failure to decrease viral load to 500 c/mL with at least 2 measurements Causes: non-adherence, resistance or pharmacologic issues (poor bioavailability, drug interaction, etc.) Consequences: viral replication with progression of immunodeficiency and accumulating resistance mutation Side effects that may be 1) annoying (GI intolerance, asthenia), 2) life-threatening (pancreatitis, lactic acidosis, hypersensitivity, hepatic necrosis), 3) cosmetic (fat redistribution), or 4) pose illdefined risks (hyperlipidemia) Change drugs, usually based on sensitivity tests Substitute a different drug 5 WHEN TO CHANGE THERAPY When do you change therapy because of virologic failure? The goal of therapy is to reduce the viral load to undetectable levels. The expectation is a reduction by 1 log 10 c/mL within 1-4 weeks, a viral load of
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