The important ARV guidelines session featured 4 speakers and a discussion/scenario panel
We STARTed (sorry) with the START study preliminary results by Jenny Hoy. Jenny discussed the data we've all been looking at since it was released in May. Essentially, we can now confidently recommend ARV for all people diagnosed with HIV, regardless of CD4. The study was ceased early due the strength of results in both AIDS and Non-AIDS complications in the immediate ARV arm. The benefits were maintained regardless of age, gender, race, world location and CD4 and VL at entry to study. Worldwide ARV recommendations have updated accordingly.
Next speaker was Julian Elliott who reminded us of other studies (TEMPRANO & CASCADE) which have shown similar data in terms of treatment benefit at higher CD4s. Understandably, the number needed to treat is greater with high CD4 counts.
As chair of the ASHM HIV guidelines, Julian re-iterated that the decision to start ARV, while recommended in all HIV infected patients, should be a patient & clinician collaboration.
Mark Boyd was then tasked with summarising why the integrase inhibitors (InSTIs) are now first-line drugs. Pivotal and open label studies over the last few years have left no doubt that raltegravir, and more recently dolutegravir, show non-inferior (and often superior) efficacy, with minimal side effect profiles and a fairly high barrier to resistance. The tolerability of the InSTIs really make them an appealing option for almost everyone.
James McMahon concluded the formal presentations running through the important changes based on the updated DHHS guidelines. In short, Efavirenz - gold standard for a decade - is on the out due to side effects (dreams, dizziness, rash). In actual fact, it's been on the out for a while and prescribers have been updating accordingly, however the official recommendations have now followed suit. James spoke about Darunavir, a PI worth considering, but not reimbursable on the PBS criteria as a first line agent.
The scenario based panel followed with the abacavir CV risk a main topic for discussion. The jury is still out. Most of us are not keen to prescribe abacavir, and thus Triumeq, if the CV Framingham risk is a concern.
Thanks for a good session!