NORTHWEST AIDS EDUCATION AND TRAINING CENTER Second-Line Therapy David Spach, MD Clinical Director, Northwest AETC Professor of Medicine, Division of Infectious Diseases University of Washington Presentation Prepared by: David Spach, MD Last Updated: May 14, 2012
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NORTHWEST AIDS EDUCATION AND TRAINING CENTER
Second-Line Therapy David Spach, MD Clinical Director, Northwest AETC Professor of Medicine, Division of Infectious Diseases University of Washington Presentation Prepared by: David Spach, MD Last Updated: May 14, 2012
Class Therapy Pill Burden
NNRTI-Based Efavirenz-Tenofovir-Emtricitabine
PI-Based
Ritonavir + Atazanavir + Tenofovir-Emtricitabine
Darunavir + Ritonavir + Tenofovir-Emtricitabine
INSTI-Based Raltegravir + Tenofovir-Emtricitabine
HHS Antiretroviral Therapy Guidelines: March 2012 Preferred Regimens for ARV-Naïve Patients: Pill Burden
Source: 2012 HHS Antiretroviral Therapy Guidelines. AIDS Info (www.aidsinfo.nih.gov)
2NRTIs + NNRTI
2 NRTIs + RTV-boosted PI
2 NRTIs + INSTI
or
or
Virologic Failure after Initial Therapy
?
?
?
Case History
• A 29-year-old woman with a baseline CD4 count of 285 cells/mm3 and HIV RNA 94,000 copies/ml starts on a regimen of tenofovir-emtricitabine-efavirenz (Atripla). After 4 months, she has an HIV RNA of less than 40 copies/ml and she does very well on this regimen for about 10 months. After missing two appointments, she comes in for follow-up visit and admits she had a relapse with her alcohol problem, but is now sober. Her HIV RNA drawn at this routine visit is 1120 copies/ml.
• What is the treatment goal of second-line therapy?
• What mutations would you expect on a genotype?
• What second-line regimen would you recommend (if needed)?
HHS Antiretroviral Therapy Guidelines: March 2012 Goal in Treatment-Experienced Patients
• Treatment Goal for Patients with Prior Drug Exposure & Drug Resistance: -Re-establish maximal virologic suppression (HIV-1 RNA < 50 copies/mL)
1Study 934: Gallant JE, et al. N Engl J Med. 2006;354:251-60. 2Study 5142. Riddler SA, et al. N Engl J Med. 2008;358;2095-106. 3STARTMRK. Lennox JL, et al. Lancet. 2009;374:796-806.