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