ASHM Report Back

Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.

Manoji Gunathilake

Manoji Gunathilake

Dr Manoji Gunathilake (MBBS/Dip Ven/MD/DFSRH/FAChSHM)


Manoji Gunathilake is the sexual health physician at Sexual Health & Blood Borne Virus Unit of the Centre for Disease Control – Darwin, Northern Territory.

Speaker: Edouard Battegay from the Centre for Competence Multi-morbidity (MM) at University Hospital Zurich.

Between 20–30% of the population and about 90% of inpatients hospitalised in General Internal Medicine have multiple concurrent acute or chronic diseases.

 He spoke about most prevalent triads seen at their out patient clinics such as combination of hypertension, dyslipidaemia, with chronic back pain/ osteoarthritis/diabetes mellitus or coronary heart disease, in people living with HIV. 

There are limited evidence-based guidelines for MM, be it without or with HIV, even for more prevalent forms of MM and frequent interacting combinations. This leaves MM care heavily reliant upon clinical guidelines intended for the treatment of single diseases.

He informed the audience about the new version of EACS guidelines (released 3-4 days ago) with new additions on managing MM.

The link to new edition of EACS guidelines;

http://www.eacsociety.org/files/guidelines_8.1-english.pdf  

Speaker - Brian Pence from the University of North Carolina 

His talk addressed a very common barrier to HIV care and treatment - mental health concerns, discussing  previous publications in the early years of the epidemic about responding to psychological crisis of HIV/AIDS. It is still a challenge faced by many of us, more than 30 years later. He gave an overview of psychological trauma and the heavy burden of stressful life events of many people living with HIV leading to chronic mental health issues in addition to stressful risk behaviours, immune suppression and side effects of antiretroviral therapy.

He showed data on depression and mortality in modern ART era from the WIHS cohort (in press) as well as in the early ART era from HERS cohort (Ickovics et al.JAMA 2001) where chronic depressive symptoms were reported commonly in patients with CD4 <200. 

Barriers to addressing mental health concerns among people living with HIV;

  • Lack of mental health expertise in HIV care settings
  • Stigma around mental health services
  • Access to specialty metal health services
  • Fragmentation of care

The concept of depression care managers where a nurse, social workers or a medical assistant is trained to assess and help clients with depressive symptoms under the supervision of psychiatrists,helping the HIV care providers to deal with mental health concerns of patients was a highlight in his talk.

The ways to move forward - it is necessary to think of,

  • How best to integrate evidence-based mental health approaches into HIV care
  • How to engage patients in mental health services
  • How best to address multiple psychiatric co-morbidities
  • How best to integrate mental health treatment with other adherence/retention support strategies

 

96-week data from ATLAS – M trial – a multicenter, open labeled, randomized trial on simplification to atazanavir/ritonavir and lamivudine versus maintaining atazanavir/ritonavir with 2 NRTI (Triple therapy) in virologically suppressed HIV infected patients was presented by Roberta Gagliardini, Catholic University from Rome, Italy.

  • A total of 266 patients (78%males with a median CD4 of 603 cells, 79% of them had Tenofovir in their treatment regimen) were enrolled in this trial.
  • 96 week data were available for 254 (126 in dual therapy arm and 128 in triple therapy arm).

At 96 weeks, the proportion of patients free of treatment failure were 77.8% (95% CI  70.5 – 85.1) in the dual therapy arm compared to 65.6%  (95% CI  57.4 – 78.3) in the triple therapy arm.

Virological failure was observed in two patients (1.6%) randomized to dual therapy arm and eight (6.3%) patients in the triple therapy arm (p=0.056).

  • Data demonstrated non-inferiority of treatment simplification to dual therapy in virologically suppressed patients.
  • Additionally, switch was associated with improved renal function but with increased total cholesterol and bilirubin levels in dual therapy arm. 

ANRS 12286/MOBIDIP trial investigator Laura Ciaffi from France presented 96-week data to show that dual therapy with a boosted protease inhibitor plus lamivudine is an effective maintenance strategy in patients on second-line antiretroviral therapy in Africa. 

  • This randomised, open-label, clinical trial was conducted in Cameroon, Senegal and Burkina Faso.
  • Recruited HIV-1 positive patients on stable protease inhibitors plus NRTIs as second-line Antiretroviral therapy.
  • All patients had HIV viral load below 200 copies/mL, CD4 above 100 cells/mm3 and adherence was ≥90%.
  • Two arms of the trial compared monotherapy with the ongoing protease inhibitor/ritonavir(PI/r): darunavir (DRV/r) or lopinavir (LPV/r) with the same PI/r associated with lamivudine 300 mg in the dual therapy arm.
  • From March 2014 to January 2015, 265 patients were randomised (133 in mono-therapy arm and 132 in dual therapy arm).
  • Most patients were women (73%).
  • At failure of first line, 96% had the M184V mutation.

At 48 weeks, Data Safety Board instructed to stop mono therapy arm.

In the ITT analysis, 3.0% (95% CI 0.8–7.6) in the dual therapy arm and 22.6% (95% CI 15.8–30.6) in the mono- therapy arm had virological failure (p<0.001).

  • Median time to failure was 24 weeks.
  • All failing patients, except one, re-suppressed to less than 200 copies/mL in a median time of 12 weeks after reintroduction of the NRTI backbone.
  • Increase in CD4 was significantly higher in the dual therapy arm (48 vs 7 cells/mm3).
  • No differences in adverse events were observed.

Investigators concluded that

  1. after viral suppression with PI/r plus NRTIs in second-line therapy, maintenance with PI/r plus lamivudine is associated with a high rate of success despite the presence of M184V.
  2. PI/r mono therapy cannot be recommended.

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