HIV/AIDS Treatment and Care : Clinical protocols for the European ...

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HIV/AIDS TREATMENT AND CARE CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION
3.4. Second-line HAART regimens
For second-line HAART, WHO recommends selecting three different drugs containing at least one
new pharmacological class.
• The best options are regimens with a boosted protease inhibitor (PI) as the key drug, together
with two nucleosides if a classical approach of 2 NRTIs + 1 NNRTI was the first-line treatment.
• In case of a simplified first choice with 3 NRTIs, the second-line should use a boosted PI + 1
NNRTI and/or 1 NRTI.
Among second-line NRTIs, those with better resistant profiles, such as ddI, ABC and TDF, should
be given preference.
• The combination d4T+ddI has to be avoided due to the risk of mitochondrial toxity, leading to
hepatic steatosis and potentially enhancing fibrosis (56).
• TDF/ddi is also contraindicated due to negative pharmacological interactions.
Table 8. treatment regimens for second-line HaaRt in HiV/HCV-coinfected patients
ARV drug classes HAART regimens
ABC + TDF LPV/r
or
Preferred second line 2 NRTIs + 1 boosted PI
or + SQV/r
or
ABC + ddIa ATZ/rb Alternative second line
1 NNRTI +/- 1 NRTI + 1 boosted PI
ABC Ó Ï LPV/r
EFV Ë SQV/r
TDF Ï Ó ATZ/r b
or
LPV/r + EFV
or
LPV/r + SQV
a A ddI dose in combination with TDF should be adjusted to less than 4.1 mg/kg per day so as not to compromise immune
recovery. It is contraindicated in patients with cirrhosis and under RBV treatment, and should be used with caution in
patients with less severe liver disease.
b Unboosted ATZ or NFV can be used in absence of a cold chain.
4. Coinfected patients requiring both HCV and HIV/AIDS treatment
Coinfected patients requiring both HCV and HIV/AIDS treatment meet the following criteria:
• CD4 count ≤350 cells/mm 3 in symptomatic patients or patients with viral load >100 000 copies/ml,
or CD4 count ≤200 cells/mm 3 irrespective of symptoms; and
• acute or chronic hepatitis C. 12
4.1. Strategy for initiation of treatment
See Table 9 below.
• If a coinfected patient has severe immunodeficiency (CD4 count 200 cells/mm 3 ) for a few months before starting HCV
treatment. HAART should be continued during HCV treatment but ddI, ZDV or d4T should be
changed for other drugs (ABC, TDF, etc.) before initiating RBV.
12 For patients with evidence of advanced liver fibrosis, HCV treatment should be a priority.
or
double PI