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.
ART Guideline: Panel Discussion
Another interesting and interactive panel discussion featuring Professor Jennifer Hoy, Dr Julian Elliot, Dr Mark Boyd, Dr James McMahon, and Dr Mark Bloch. This discussion built on earlier plenary session presentations on Theme B: ARV Guidelines - When and What to Start.
Three interactive clinical scenario on starting ART were presented to the audience and the panellists. These cases reflected the daily practical challenges facing clinicians and patients in deciding the best regimen to start that will optimize treatment outcomes with minimal side effects. Dr Mark Bloch pointed out that the decision on what to start should be tailored to the patient, taking into consideration their presenting general health, medical history, concurrent medical conditions, life style, emotional and psychological wellbeing and socioeconomic status.
It was interesting to note from the panellists that while for patient simplicity of the treatment regimen and toxicity are most important issues to consider in starting and continuing with medications, for clinicians the decisions on what to start can be very challenging. Clinicians always find themselves in situations where the existing guidelines do not provide them evidence based recommendations on what to start or when and how to switch from one regimen to another, or from one drug to another.
The question of Abacavir and the risk of AMI for patients with or without background risk of cardiovascular disease was highlighted as the perfect example where the current evidence is still contentious. Mark Boyd also highlighted another challenge facing clinicians when they have to manage patients who are generally not represented in clinical trials. He gave example of patients with reduced kidney functions (measured by eGFR) and the lack of evidence from randomized trials for the use of petentially nephrotoxic drugs like Tenofovir (TDF) or drugs which have been shown to impact creatinine clearance(Dolutegravir and Cobicistat).
The take home message from this session is that clinicians need to carefully engage and comprehensively review their patients before starting or switching ART. They need to make sure that their patients understand existing guideline recommendations and options available, the potential adverse events and toxicity for each drug(s) they are going to take. It is also important for HIV clinicians to work collaboratively with non HIV clinicians, and allied health professionals in managing non-AIDS conditions. This will eventually optimize treatment outcome and minimize any drug–drug interactions and risk of non AIDS events.