Cardiovascular risk in HIV, ART and recent clinical trials ... · Cardiovascular risk in HIV, ART...
Transcript of Cardiovascular risk in HIV, ART and recent clinical trials ... · Cardiovascular risk in HIV, ART...
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Cardiovascular risk in HIV, ART and
recent clinical trials data
Benjamin Young
International Association of Providers of AIDS Care
Washington, DC, USA
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Disclosures
• Speakers Bureau/ Consultant:
Bristol-Myers Squibb
Gilead Sciences
Merck & Co
ViiV Healthcare
• Research Funding
Gilead Sciences
ViiV Healthcare
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Overview
• Aging and non-communicable diseases
– Cardiovascular disease
• Emerging treatment paradigms
• Clinical trials data
– STARTMRK
– ACTG 5257
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NON-COMMUNICABLE DISEASES
AND HIV
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DHHS, 2014
DHHS Recommendations
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Schouten, XIX IAC, 2012
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Schouten, XIX IAC, 2012
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Lancet, 2014
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CARDIOVASCULAR DISEASE AND
HIV
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Lichtenstein, Clin Infect Dis 2010
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Van Zoest, 16th Intl Workshop on Co-morbidities and Adverse Drug Reactions, 2014
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Post, Ann Int Med, 2014
Coronary artery plaque is more prevalent (RR 0.14-0.35)
and extensive among HIV+ men, independent of CAD risk
factors.
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Bavinger, PLOS One, 2013
• 27 study meta-analysis shows mixed evidence of
relationship
• Increase in MI risk recently exposed:
– abacavir (RR 1.92, 95% CI 1.5-2.4)
– protease inhibitors (RR 2.12, 95% CI 1.06-4.28)
• Increase risk with additional year of exposure:
– indinavir (RR 1.11, 95% CI 1.05-1.17)
– lopinavir (RR 1.22, 95% CI 1.01-1.47)
• Four published meta-analyses of randomized trials, found
no increased risk of CVD.
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CVD AND HIV GUIDELINES
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EVOLVING ART
CONSIDERATIONS
New combinations, superior tolerability
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“…the available evidence renders the discussion on
when to start ART unnecessary and that, instead,
efforts should be aimed at offering treatment as
soon as possible.”
Sigaloff, Lange, Montaner, Clin Infect Dis 2014
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Evolving ART Combinations
DHHS Panel, 2014
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Evolving ART Combinations
EACS, 2014
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Evolving ART Tolerability: SPRING-2
Raffi, et al., Lancet, 2013
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Evolving first-line ART: Integrase Inhibitor-based Treatments
• DTG superior to EFV
– SINGLE (Walmsley, New Engl J Med, 2013)
• DTG superior to DRV/r
– FLAMINGO (Clotet, Lancet 2014)
• RAL superior to EFV
– STARTMRK 5 year analysis (Rockstroh, JAIDS 2013)
• RAL superior to DRV/r and ATV/r
– ACTG 5257 (Landovitz, CROI 2014)
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CLINICAL TRIALS DATA
Focusing on raltegravir
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STARTMRK (192 WEEK)
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ACTG 5257
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EVOLVING TARGETS
Ending epidemic AIDS
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Evolving Targets
UNAIDS, 2014
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Normal Life Expectancy?
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Cardiovascular disease and HIV
• HIV populations are getting older
• Cardiovascular disease is a major cause of
morbidity and mortality in the HIV community
– Risk factors are common
– Association with ART debated
• Evidence-based guidelines for managing non-
communicable diseases
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ART and Raltegravir
• Expanding treatment recommendations
• RAL-regimens on DHHS, EACS and BHIVA
guidelines
• RAL superior vs EFV year 4, 5 (STARTMRK)
• RAL superior vs ATV/r and DRV/r (ACTG 5257)
• Favorable:
– Tolerability
– Safety/toxicity profile
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Summary
• Aging of HIV populations around the world
• Increasing importance of non-communicable diseases
• Cardiovascular disease significant cause of morbidity and
mortality
– Treatment guidelines recommend prevention/treatment
• Evolving antiretroviral treatment guidelines
– Many agencies now recommend treatment for all
• Increasing role of HIV integrase inhibitors
– Superior safety and efficacy profile, compared with previous
standards
• Ending AIDS is possible