HIV/AIDS HIV/AIDS: Outline. Morbidity and Mortality Weekly Report (MMWR)
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1 HIV/AIDS: Outline HIV/AIDS 2013 Roy M. Gulick, MD, MPH Professor of Medicine Chief, Division of Infectious Diseases Weill Medical College of Cornell University New York City January 31, 2013 Epidemiology Virology Testing Transmission Pathogenesis Natural History AIDS-defining illnesses Antiretroviral therapy Prevention Morbidity and Mortality Weekly Report (MMWR) In 2011: New HIV infections: 2.5 million [2.2, 2.8] Deaths due to AIDS: 1.7 million [1.5, 1.9] Adult (aged 15-49) prevalence 0.8% UNAIDS World AIDS Day Report 2012 UNAIDS World AIDS Day Report 2011 UNAIDS Report 2010
2 Years 2008 Report on the Life expectancy at birth, selected regions, to US HIV/AIDS Western Europe Asia Southern Africa Western Africa Eastern Africa Central Africa Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: The 2006 Revision, global AIDS epidemic CDC MMWR 2011;60:689 U.S.: New HIV Infections / Year 50,000 Hall JAMA 2008;300:520
3 Early History of AIDS Later History of HIV/AIDS 1981: reports of gay men with PCP, KS, CD4 depletion then injection drug users, hemophiliacs, transfusion recipients blood-borne; sexually transmitted : isolation of HIV : HIV-1 antibody testing available 1986: isolation of HIV : first antiretroviral drug approved (AZT) 25,000 Americans dead 1994: AZT prophylaxis for perinatal transmission; 2-drug ART introduced into clinical practice 1996: 3-drug ART introduced into clinical practice 2000: Durban conference, move to bring ART to developing world gains momentum 2012: 6.6 million+ on ART in developing world HIV-1 Virions Gelderblom, Human Retroviruses and AIDS 1997 Human Immunodeficiency Virus formerly HTLV-III; isolated 1983 human retrovirus outer glycoprotein coat, inner protein coat and genetic material: RNA (2 strands) types: HIV-1 and HIV-2 subtypes (clades): B most common in North America and Europe target cell: CD4+ T-lymphocyte Origin of HIV Evidence for zoonosis similarity of genomes, phylogenetic relationships, prevalence in normal host, geographic coincidence, plausible route of transmission SIVsm (sooty mangabey) --- HIV-2 SIVcpz (chimpanzee) --- HIV-1 (~1920)? Skin/mucous membrane exposure to infected animals (pets, food) Hahn Science 2000;287:607 Sharp Philos Trans R Soc Lond B Biol Sci 2010;365: HIV Testing HIV antibody testing (indirect) Window period ~3 months Screening test: HIV antibody by ELISA If repeatedly positive, proceed to confirmatory test Confirmatory test: HIV antibody by Western Blot 20-minute oral test now available HIV viral testing (direct) p24 antigen viral culture HIV RNA (viral load)
4 Diagnosis: Rapid Tests Uni-Gold Recombigen Multispot HIV-1/HIV-2 Reveal G2 OraQuick Advance 9/06 HIV Transmission Routes Sexual transmission Low efficiency (~1% per contact) Injection drug use High efficiency (~ 10% per contact) Blood, blood products, tissue Very high efficiency (~ 90% per transfusion) Perinatal transmission (~25% per birth) Needlestick injury (~1/300 exposures) Life Cycle of HIV Budding HIV Virions DS dna COMPLEX
5 Viral Dynamics -- Summary Time Course of HIV Infection 10 billion new virions created and cleared daily 2 billion CD4 cells destroyed daily (twice the rate of replacement by the hematopoietic system) Grossman Nature Medicine 2006; 12: CDC Adult AIDS Case Definition 1982: AIDS -- list of diseases (definitive diagnosis) and disqualifying conditions 1985: HIV antibody testing added to definition 1987: presumptive diagnoses with a positive HIV antibody added 1993: CD4 <200 (without symptoms) and other diagnoses added Opportunistic Infection (OI): Definition Infection caused by an organism capable of causing disease only in a host whose resistance is lowered (by other diseases or by drugs) Examples of Common OIs/Malignancies Developed world Pneumocystis carinii (fungus) Cytomegalovirus (virus) Toxoplasma gondii (parasite) Mycobacterium avium complex (bacterium) Kaposi s sarcoma (malignancy) Developing world Mycobacterium tuberculosis (bacterium) Cryptococcus (fungus) Wasting disease
6 Survival: CASCADE Cohort 23 cohorts from Australia, Europe and Canada HIV+ pre-1996 HIV HIV Bhaskaran, JAMA 2008; 300: Haiti: Survival on ART Historically: 1-year survival without ART: 30% Severe, NEJM 2005;353: Leger NEJM 2009;361:828 UNAIDS Global Report 2011 When to start ART? US DHHS IAS-USA 2012 JAMA 2012;308:387 When to Start? AIDS/ symptom s CD4 <200 CD CD4 >350 YES YES YES YES YES YES YES YES UK 2012 HIV Med 2012;13 Sup 2:1-6 EACS rg/ WHO en YES YES YES certain patients YES YES YES certain patients YES YES YES NO
7 CIPRA HT001 Study Randomized 6 deaths study (N=816 patients with CD4 23 deaths ) Start immediately vs. wait until CD4 <200 or AIDS event DSMB stopped study early Mortality / TB Fitzgerald NEJM 2010;363:257 ART Easier, less toxic, and more potent therapy Antiretroviral Drug Approval: AZT EFV ABC LPV/r RTV NFV APV IDV DLV NVP 3TC SQV ddc d4t ddi TDF ETR ENF RAL ATV MVC FTC DRV FPV TPV EVG RPV Goal of Antiretroviral Therapy to suppress HIV RNA (viral load level) as low as possible, for as long as possible to preserve or enhance immune function to delay clinical progression of HIV disease fusion Life Cycle of HIV nucleosides non-nucleosides reverse transcriptase chemokine receptor HIV entry DS dna COMPLEX integrase protease Antiretroviral Drugs: 2013 nucleoside/tide RTIs (NRTIs) zidovudine (ZDV, AZT) didanosine (ddi) stavudine (d4t) lamivudine (3TC) abacavir (ABC) emtricitabine (FTC) tenofovir (TDF) NNRTIs nevirapine (NVP) delavirdine (DLV) efavirenz (EFV) etravirine (ETR) rilpivirine (RPV) protease (PIs) saquinavir (SQV) ritonavir (RTV) indinavir (IDV) nelfinavir (NFV) lopinavir/r (LPV/r) atazanavir (ATV) fosamprenavir (FPV) tipranavir (TPV) darunavir (DRV) entry (EIs) enfuvirtide (T-20, fusion inh) maraviroc (MVC, CCR5 inh) integrase (IIs) raltegravir (RAL) elvitegravir (EVG)
8 HIV RNA change (log 10 c/ml) Antiretroviral Activity: Durability of ART: 7 years : AZT Monotherapy 1994: 2-NRTI Therapy : HAART including 2-NRTI + PI 81% Study 903E: TDF+3TC+EFV week responses Fischl, NEJM, 1987 Eron, NEJM, 1995 Hammer, NEJM, Gulick, NEJM, 1997 Cameron, Lancet, Cassetti HIV Clin Trials 2007;8:164-72; IAS 2008 abstract #TuPE Drug Combination ART: AM 4PM 12 MID SIDE EFFECTS AZT + 3TC + IDV fasting (1 hour before/2 hours after meals) 1 liter of hydration/day Single Tablet Regimens TDF/FTC/EFV (2006) TDF/FTC/RPV (2011) TDF/FTC/EVG/c (2012) What to start? Preferred Regimens NNRTI-based tenofovir/emtricitabine + efavirenz PI-based tenofovir/emtricitabine + atazanavir/r tenofovir/emtricitabine + darunavir/r INSTI-based tenofovir/emtricitabine + raltegravir U.S. DHHS Guidelines 3/27/12
9 ART Responses in British Columbia % 87% ACTG 5095: 4-drugs? Study population: HIV+, treatment-naïve (N=765) ZDV/3TC/ABC + EFV (4 drugs) ZDV/3TC + EFV (3 drugs) Conclusion: 4-drug rx is no better than 3-drug rx Year N = Gill CID 2010;50:98 Gulick JAMA 2006;296:769 Antiretroviral Drug Approval: AZT EFV ABC LPV/r RTV NFV APV IDV DLV NVP 3TC SQV ddc d4t ddi TDF ETR ENF RAL ATV MVC FTC DRV FPV TPV EVG RPV HIV Prevention Strategies Abstain, Be faithful, Condoms, Counseling & testing ABC Adapted from Ramjee IAS Meeting 2006, #TUPL02
10 HIV Prevention Strategies Immunization I Buchbinder Lancet 2008 Rerks-Ngarm NEJM 2009 HSV-2 suppressive treatment H Celum NEJM 2010 Adapted from Ramjee IAS Meeting 2006, #TUPL02 Abstain, Be faithful, Condoms, Counseling & testing? ABC Genital tract infection control G Wawer Lancet 1999 F E Kamali Lancet 2003 Female-controlled Gregson PLoS Med 2007 microbicides Abdool Karim Science 2010 C Circumcision Auvert PLoS Med 2005 Bailey Lancet 2007 Gray Lancet 2007 D Diaphragms Padian Lancet 2007 Exposure prophylaxis (MTCT, PEP, PrEP) Connor NEJM 1994 Grant NEJM 2010 Baeten NEJM 2012 Thigpen NEJM 2012 HIV-1 RNA CD4 cell count HIV Cure (N=1) Hutter NEJM 2009;360:692 Conclusions HIV/AIDS is a worldwide pandemic. In the U.S., ~20% of HIV+ people don t know they are infected. Routine HIV testing should be offered to ALL patients. Antiretroviral therapy (ART) HIV RNA, CD4 cell counts, prevents disease progression, and prolongs survival. Current ART consists of 3-drug therapy and is increasingly available worldwide. Current life expectancy for HIV+ people on therapy approaches that of the general population. Prevention of HIV infection continues to be key. Acknowledgments Cornell HIV Clinical Trials Unit (CCTU) Division of Infectious Diseases Weill Medical College of Cornell University AIDS Clinical Trials Group (ACTG) Division of AIDS, NIAID, NIH The patient volunteers! Cornell HIV Clinical Trials Unit Todd Luis Glenn Sandra Felix Valery Marisol Christina Kirsis Veronica Joanne Kristie Marshall Trip Tim
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