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clinicaloptions.com/hiv

Nuevos retos en gestión clínica en el manejo del paciente con VIH/SIDA

Dr. Jose R Arribas

UNIDAD VIH


Nuevos retos en gestión clínica en el

manejo del paciente con VIH/SIDA

El retraso diagnóstico





Cronificación

Survival from age 25 years (Non HCV)

Lohse N et al. Ann Intern Med. 2007;146:87-95.


SMR in 2435 HIV-infected adults, ANRS CO8

APROCO-COPILOTE, and ANRS CO3 AQUITAINE

cohorts, 1997 to 2005.

Lewden C et al. J Acquir Immune Defic Syndr 2007;46:72–77

Changes in causes of death over time

1999-2000

N=255

2009-2011

N=548





Cronificación/Envejecimiento

clinicaloptions.com/hiv Chronic liver disease

Cognitive disorders

Non-Aids cancers

Chronic renal disease

Osteoporosis CVD

Frailty

Depression

Diabetes mellitus






Modelo crónico de enfermedad

30

Evolution of HIV Care

Disease Care

Acute

Reactive

Focus on dx/rx

Customized care

Spiritual

MD role central

Health Care

Chronic

Proactive

Focus on behavior

Standardized care

Practical

Pt role central

Kathleen Clanon, MD 2007

1980 2010

31

Tyranny of the Urgent:

What doesn’t get done

when we do disease

care instead of

health care?

32

Tyranny of the Urgent: What

Doesn’t Get Done

Adherence counseling

Prevention counseling

Family planning

Nutrition

Stress reduction training

Mental health

Smoking cessation

Substance abuse treatment

Vaccinations

Cancer screening

HCV treatment

Cohorte anual

Retención: 84%


UNIDAD VIH DEL HOSPITAL LA PAZ

Aproximadamente 140 pacientes nuevos por año

4 Adjuntos

3 Enfermeras

1 Auxiliar de clínica







Tratamiento de hepatitis

Regions:

South

Central

North

East

South: 623 = 44.9 %

North: 346 = 24.5 %

Central: 280 = 22.9 %

East: 412 = 47.7 %

Rockstroh J et al.,

EACS 2003; F12/4

Prevalence of hepatitis co-infection (1685/4957 patients = 33.9%)

37

7175

57

68

1712 12 14

0

10

20

30

40

50

60

70

80

90

100

5/7 12/16 8/14 25/37 1/6 1/8 1/8 3/22

Pat

ien

ts

with

HC

V R

NA

Un

det

ecta

ble

(%

)

Telaprevir + PegIFN/RBV in

HIV/HCV co-infected patients at Week 12

Sulkowski LB. 18th CROI; 2011 Feb 27-Mar 2; Boston, MA, USA. Abstract 146LB

Telaprevir + PR

n/N =

PR

Total

Total

ATV/r + TDF + FTC/3TC

No ART

PR

► Pharmacokinetic interactions between telaprevir and ATV or EFV were not clinically

significant

Patients with HCV RNA undetectable at Week 12

EFV/TDF/FTC








Asistencia a inmigrantes









Prevención

Progress in HIV-1 Prevention Research

in the Last Decade

Randomized, Controlled Intervention

Trial of Male Circumcision for

Reduction of HIV Infection Risk: The

ANRS 1265 Trial.

Bertran Auvert, Dirk Taljaard, Emmanuel Lagarde, Joelle

Sobngwi-Tambekou, Remi Sitta, Adrian Puren.

PLoS Medicine, 2005 Nov;2(11):e298.

Male circumcision for HIV prevention

in men in Rakai, Uganda: a

randomised trial.

Ronald H Gray, Godfrey Kigozi, David Serwadda, Frederick

Makumbi, Stephen Watya, Fred Nalugoda, Noah Kiwanuka,

Lawrence H Moulton, Mohammad A Chaudhary, Michael Z Chen,

Nelson K Sewankambo, Fred Wabwire-Mangen, Melanie C

Bacon, Carolyn F M Williams, Pius Opendi, Steven J Reynolds,

Oliver Laeyendecker, Thomas C Quinn, Maria J Wawer.

Lancet, 2007;369:657–66.

Effectiveness and Safety of

Tenofovir Gel, an Antiretroviral

Microbicide, for the Prevention of

HIV Infection in Women.

Quarraisha Abdool Karim, Salim S. Abdool Karim, Janet A.

Frohlich, Anneke C. Grobler, Cheryl Baxter, Leila E.

Mansoor, Ayesha B. M. Kharsany, Sengeziwe Sibeko,

Koleka P. Mlisana, Zaheen Omar, Tanuja N. Gengiah, Silvia

Maarschalk, Natasha Arulappan, Mukelisiwe Mlotshwa,

Lynn Morris, Douglas Taylor, on behalf of the CAPRISA 004

Trial Group November 2000.

Science, 2010 Sep 3;329(5996):1168-74.

Preexposure Chemoprophylaxis

for HIV Prevention in Men Who Have

Sex with Men.

Robert M. Grant, M.D., M.P.H., Javier R. Lama, M.D., M.P.H., . .

. Ana I. Martinez, R.Ph., David N. Burns, M.D., M.P.H., and

David V. Glidden, Ph.D., for the iPrEx Study Team.

N Engl J Med., 2010 Dec 30;363(27):2587-99.

Prevention of HIV-1 Infection with

Early Antiretroviral Therapy

Myron S. Cohen, Y. Q. Chen, M. McCauley,T. Gamble, M. C.

Hosseinipour,N. Kumarasamy, J. G. Hakim,J. Kumwenda,

Beatriz Grinsztejn, Jose H.S. Pilotto,S. V. Godbole, S.

Mehendale, S. Chariyalertsak,B.R. Santos, K. H. Mayer, I. F.

Hoffman,S. H. Eshleman, E. Piwowar-Manning, L. Wang,J.

Makhema, L. A. Mills, G. de Bruyn,I. Sanne, J. Eron, J. Gallant,D.

Havlir, S. Swindells, H. Ribaudo,V. Elharrar, D. Burns, T. E.

Taha,K. Nielsen-Saines, D. Celentano, M. Essex and T. R.

Fleming, for the HPTN 052 Study Team.

N Engl J Med., 10.1056/NEJMoa1105243

Placebo 1248 1198 1157 1119 1030 932 786 638 528 433 344 239 106

FTC/TDF 1251 1190 1149 1109 1034 939 808 651 523 419 345 253 116

iPrEx: Updated Report on Effectiveness of PrEP

• 2,499 MSM randomized 1:1 to received TDF/FTC or placebo • F/U was continued for 8 weeks after stopping study drug

0

0,2

0,4

0,6

0,8

1

1,2

0 12 24 36 48 60 72 84 96 108 120 132 144

Cu

mu

lati

ve

Pro

ba

bil

ity o

f H

IV In

fec

tio

n

Weeks Since Randomization

Placebo

FTC/TDF P=0.002

N=

Grant R, et al. 18th CROI; Boston, MA; February 27-March 2, 2011. Abst. 92.

Reducción del 44%









Prevención

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