Managing second line failure in Sri Lanka

Page 1

Managing Second Line Failure in Sri Lanka Kulasiri Buddhakorale, MD, FRCP (Glasg)


Commencement of ART ď‚— December 2004 ď‚— No of patients commenced - 16


Treatment Options - 2004  AZT+3TC+NVP  AZT+3TC+EFV

 3TC+D4T+NVP  3TC+D4T+EFV


Treatment Options - 2004 ď‚— Indinavir/r


Treatment Options – 2006/07  TDF + FTC + EFV added to the protocol


Treatment Options - 2009  LPV/r added  Commenced phasing out D4T

 Indinavir/r was removed


Treatment Options - 2010  2010 – WHO treatment guidelines adopted

 CD 4+ < 350 – changed the eligibility criteria


Treatment Options - 2012  MARPS – Commenced treatment irrespective of the CD 4+ cells

 All pregnant women – (HIV +)

 Discordant couples


ART eligibility: 5 policy scenarios Estimated millions of people eligible for ART in LMIC in 2011

11

15

23

25

32

1

2

3

4

5

CD4 ≤ 200

CD4 ≤ 350

CD4 ≤ 500

All HIV+

Recommended

CD4 ≤ 350 + TasP Incremental

since 2010

approach 2012

Recommend ed

Since 2003

Ongoing systematic review of evidence (GRADE review)

ART regardless of CD4 count for: - Serodiscordant couples - Pregnant women - Key populations (SW, IDU, MSM)

“Test and treat”


Cohort analysis report (60 months) for patients who started ART in 2006

Name of the clinic: Total all 5 ART Centers_ Number of patients who started ART in 2006

Follow-up details of the cohort

Total number

Male

Female

<=15

15+

<=15

15+

a.

Original cohort started on ART in this clinic

33

0

18

1

14

b.

Transfers In

Add +

0

0

0

0

0

c.

Transfers Out

Sustract -

0

0

0

0

0

d.

Net current cohort(N)

33

0

18

1

14

Status of these patients after 60 months of starting ART

e.

On Original 1st line regimen

18

0

11

0

7

f.

On 2nd line regimen (Switched)

4

0

2

0

2

g.

Stopped (S)

0

0

0

0

0

h.

Died (D)

10

0

5

1

4

i.

Lost to follow-up (F)

1

0

0

0

1

j.

Number alive and on ART (A)[N-(S+D+F)]

22

0

13

0

9

k.

percent of cohort alive and on ART(A/N*100)

66.7

na

72.2

0

64.3


Cohort analysis report (12 months) for patients who started ART in 2010 Name of the clinic: Total all 5 ART Centers_ Number of patients who started ART in 2010

Follow-up details of the cohort

Total number

Male

Female

<=15

15+

<=15

15+

a. Original cohort started on ART in this clinic

72

1

47

2

22

b. Transfers In

Add +

1

0

1

0

0

c. Transfers Out

Sustract -

4

0

3

0

1

69

1

45

2

21

d. Net current cohort(N)

Status of these patients after 12 m onths of starting ART

e. On Original 1st line regimen

49

0

35

1

13

f. On 2nd line regimen (Switched)

1

0

0

1

0

g. Stopped (S)

3

1

0

0

2

h. Died (D)

9

0

8

0

1

i. Lost to follow-up (F)

3

0

2

0

1

j. Number alive and on ART (A)[N-(S+D+F)]

54

0

35

2

17

78.3

0

77.78

100

80.95

k. percent of cohort alive and on ART(A/N*100)


Cohort analysis report (24 months) for patients who started ART in 2010 Name of the clinic: Total all 5 ART Centers_ Number of patients who started ART in 2010

Follow-up details of the cohort a. Original cohort started on ART in this clinic

Total number

Male

Female

<=15

15+

<=15

15+

79

2

54

1

22

b. Transfers In

Add +

0

0

0

0

0

c. Transfers Out

Sustract -

0

0

0

0

0

79

2

54

1

22

d. Net current cohort(N)

Status of these patients after 24 m onths of starting ART

e. On Original 1st line regimen

55

2

35

0

18

f. On 2nd line regimen (Switched)

3

0

2

1

0

g. Stopped (S)

3

0

1

0

2

14

0

13

0

1

4

0

3

0

1

58

2

37

1

18

73.4

100

68.5

100

81.8

h. Died (D) i. Lost to follow-up (F) j. Number alive and on ART (A)[N-(S+D+F)] k. percent of cohort alive and on ART(A/N*100)


Cohort analysis report (12 months) for patients who started ART in 2011 Name of the clinic: Total all 5 ART Centers_ Number of patients who started ART in 2011

Follow-up details of the cohort

Total number

Male

Female

<=15

15+

<=15

15+

a. Original cohort started on ART in this clinic

80

0

45

1

34

b. Transfers In

Add +

0

0

0

0

0

c. Transfers Out

Sustract -

0

0

0

0

0

80

0

45

1

34

d. Net current cohort(N)

Status of these patients after 12 m onths of starting ART

e. On Original 1st line regimen

60

0

32

1

27

f. On 2nd line regimen (Switched)

1

0

0

0

1

g. Stopped (S)

1

0

1

0

0

h. Died (D)

8

0

5

0

3

i. Lost to follow-up (F)

10

0

7

0

3

j. Number alive and on ART (A)[N-(S+D+F)]

61

0

32

1

28

76.3

0

71.11

100

82.35

k. percent of cohort alive and on ART(A/N*100)


Treatment Options - 2013  WHO – introduced new treatment guidelines


ART eligibility: 5 policy scenarios Estimated millions of people eligible for ART in LMIC in 2011

11

15

23

25

32

1

2

3

4

5

CD4 ≤ 200

CD4 ≤ 350

CD4 ≤ 500

All HIV+

Recommended

CD4 ≤ 350 + TasP Incremental

since 2010

approach 2012

Recommend ed

Since 2003

Ongoing systematic review of evidence (GRADE review)

ART regardless of CD4 count for: - Serodiscordant couples - Pregnant women - Key populations (SW, IDU, MSM)

“Test and treat”


WHO – Treatment Guidelines  First line  Second line

 Third line


CDC – Guideline  Initiating antiretroviral therapy in treatment-naïve patients

 Management of treatmentexperienced patients


May-13

Mar-13

Jan-13

Nov-12

Sep-12

Jul-12

May-12

Mar-12

Jan-12

Nov-11

Sep-11

Jul-11

May-11

Mar-11

Jan-11

Nov-10

Sep-10

Jul-10

May-10

Mar-10

Jan-10

CD 4+

900

800

700

600

500

400 CD 4+

300

200

100

0


VIRAL LOAD  FEB 2012 – 419,749  MAR 2012 – 443,786

 MAY 2013 – 1,493,797


THIRD LINE DRUGS  ATAZANAZVIR/r  DARUNAVIR/r

 RALTEGRAVIR


THIRD LINE DRUGS ?  ABACAVIR  LAMIVUDINE



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