A Look Back at the International
AIDS Conference Meeting
Lessons from IAC 2010
A Clinical Context Report
A Look Back at the International AIDS
Conference Meeting—Lessons from IAC 2010
Jointly Sponsored by:
and MedPage Today
A Look Back at the International AIDS
Conference Meeting—Lessons from IAC 2010
Supported in part by an
educational grant from
Bristol-Myers Squibb
Clinical Context Series
Target Audience
The goal of this program is to provide HIV/AIDS
specialists, virologists, infectious disease
specialists, experts in the care of patients with
HIV/AIDS, physician assistants and nurse
practitioners with up-to-date information
and multiple perspectives on the pathogenesis,
symptoms, risk factors, and complications of
HIV/AIDS as well as current and emerging
treatments and best practices in the management
of HIV/AIDS.
Activity Learning Objectives


Discuss the results of this report from IAC
Review the relevance and significance of the
CME Information: Physicians

Statement of Accreditation
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medical education for physicians.
CME Information

Credit Designation
Albert Einstein College of Medicine
designates this educational activity for a
maximum of 0.25 AMA PRA Category 1
Credits.™ Physicians should only claim
credit commensurate with the extent of
their participation in the activity.
CME Information: Nurses

Statement of Accreditation
– Projects In Knowledge, Inc. (PIK) is accredited
as a provider of continuing nursing education
by the American Nurses Credentialing
Center’s Commission on Accreditation.
– Projects In Knowledge is also an approved
provider by the California Board of Registered
Nursing, Provider Number CEP-15227.
– This activity is approved for 0.58 nursing
contact hours.
DISCLAIMER: Accreditation refers to educational content only and does not imply
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CME Information: Pharmacists
 Projects In Knowledge® is accredited by the
Accreditation Council for Pharmacy Education
(ACPE) as a provider of continuing pharmacy
education. This program has been planned and
implemented in accordance with the ACPE
Criteria for Quality and Interpretive Guidelines.
This symposium is worth up to 0.25 contact
hours (0.025 CEUs). The ACPE Universal Activity
Number assigned to this knowledge-type activity
is 0052-0000-10-1649-H01-P.
Discussant
Barry S. Zingman, MD
Medical Director
AIDS Center
Montefiore Medical Center
Professor of Clinical Medicine
Albert Einstein College of Medicine
Bronx, NY
Disclosure Information
Barry S. Zingman, MD,
has disclosed that he has no relevant financial
relationships or conflicts of interest with commercial
interests related directly or indirectly to this educational
activity.
Disclosure Information
Dori F. Zaleznik, MD, Associate Clinical Professor of
Medicine, Harvard Medical School, Boston; Michael Smith
and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse
Planner, have disclosed that they have no relevant financial
relationships or conflicts of interest with commercial interests
related directly or indirectly to this educational activity.
The staff of Albert Einstein College of Medicine, MedPage
Today, and Projects In Knowledge have no relevant
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Disclaimer
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and accurate clinical information according to accepted medical
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Summary

The most recent guidelines suggest that HIV
therapy should start at a CD4 count of at least 500

The treatments of choice to start therapy are now,
increasingly, fixed dose combination pills

A vaginal microbicide that includes an antiretroviral
drug, tenofovir, has shown efficacy in preventing
HIV acquisition in a randomized controlled trial

The product has also appeared to lower the risk of
acquiring herpes simplex virus 2, a known risk
factor for HIV
Recommendations for Initiating Antiretroviral
Therapy (ART) in Treatment-Naïve Adults with
HIV-1 Infection Who Are Ready to Begin Therapy
• ART is recommended regardless of CD4 cell count for
persons with symptomatic HIV disease, pregnancy,
active HBV or HCV co-infection, or those at high risk
for secondary HIV transmission
• ART is recommended for asymptomatic adults with
CD4 cell counts  500/μL
• ART should be considered in patients who are
asymptomatic with CD4 cell counts > 500/μL, unless
the patient is an elite controller (HIV-RNA <50
copies/mL) or has a stable CD4 count and low-level
viremia in the absence of ART
Why Start ART Earlier
• NA-ACCORD study demonstrated that there was
lower mortality, as well as significantly lower non-age
defining events, if people were started on ART before
their T-cell count dropped to 500
• If therapy is not started until the patient’s CD4 count
is <500, there is a lower chance that CD4 count will
become normal on therapy
• Several studies have demonstrated that HIV
transmission between serodiscordant couples and in
injection drug users is decreased with ART
CASCADE Cohort
• 9,455 HIV recent seroconverters, avg. age 30
• 812 (8.6%) developed AIDS
• 544 (5.8%) died
• Relative effects: AIDS/Death
•
•
•
•
•
CD4 count 0-49 – Incidence Rate per 1000 person years 193.3
Defer ART, 55.0 Initiate – adjusted HR 0.32 (95% CI 0.17,0.59)
CD4 50-199 – IR 56.6 Defer, 22.0 Initiate aHR 0.48 (0.31, 0.74
CD4 200-349 – IR 29.4 Defer, 18.7 Initiate aHR 0.59 (0.43, 0.81)
CD4 350-499 – IR 20.8 Defer, 17.2 Initiate aHR 0.75 (0.49,1.14)
CD4 500-799 – IR 18.5 Defer, 14.9 Initiate aHR 1.10 (0.67, 1.79)
CASCADE Caveats
• Retrospective study of patients who had recently
seroconverted
• Significantly smaller than the 20,000 to 50,000
patients followed over years in NA-ACCORD and HIVCAUSAL
• Looked only at death not
•
•
•
•
AIDS-related cancers
Cardiovascular disease
CD4 counts
Prevention of kidney disease
New Treatment Recommendations, ISA-USA
• The committee came out in favor of fixed-dose
combinations
• Tenofovir/emtricitabine number one recommended
NRTI combination
• Abacavir/lamivudine secondary NRTI
• Third component should be either
•
•
•
Efavirenz
A ritonavir-boosted protease inhibitor such as
darunavir/ritonavir or atazanavir/ritonavir
Integrase inhibitor raltegravir
• Lopinavir/ritonavir moved to 2nd line because of toxicity
# HIV infections/
women years
Tenofovir
Placebo
HIV incidence
Incidence
P Value
Rate Ratio
Tenofovir
gel
Placebo
gel
5.6
9.1
0.61
0.017
Overall effectiveness of tenofovir gel
HIV endpoints
38 / 680.6 60 / 660.7
HIV endpoints by levels of adherence
High adherers
(>80% gel adherence)
11 / 259.2 25 / 269.4
4.2
9.3
0.46
0.025
Intermediate adherers
(50-80% adherence)
10 / 159.8 10 / 99.7
6.3
10
0.62
0.343
Low adherers
(<50% gel adherence)
16 / 258.5 25 / 290.6
6.2
8.6
0.72
0.303
Modified from Karim, et al. Effectiveness and Safety of Tenofovir Gel, an Antiretroviral Microbicide, for
the Prevention of HIV Infection in Women. Science. Published Online July 19, 2010 at:
http://www.sciencemag.org/cgi/rapidpdf/science.1193748.pdf. Reprinted with permission from AAAS.
Impact of Tenofovir Gel on HSV-2 Incidence
# HSV-2 infections
Women-years (wy) of follow-up
HSV-2 incidence per 100wy
(95% CI)
Tenofovir gel
n=202
Placebo gel
n=224
29
58
292.3
287.3
9.9
20.2
(6.6, 14.2)
(15.3, 26.1)
IRR = 0.49 (CI:0.30, 0.78); P = 0.003
51% protection against HSV-2 by tenofovir gel (CI: 22%70%)
Results of the CAPRISA 004 Trial. Presented by Salim Abdool Karim, July 20, at the XVIII
International AIDS Conference, Vienna, Austria. Oral Abstract TUSS0504.