EACS guidelines in the context of
the HIV epidemiology in Europe
Jürgen Rockstroh
Department of Medicine I, University of
Bonn, Bonn, Germany
EACS guidelines
• EACS produces the European Guidelines for
treatment of HIV infected adults in Europe. So
far the treatment guidelines have been
translated from English into 13 additional
languages.
• All diffferent versions in all languages are free
dowloadable from the eacs website:
– http://www.europeanaidsclinicalsociety.org
Table of contents
EACS guidelines: When to start
• Initiation of ART
– ART is always recommended if CD4 count <350 cells/mm3
– Serodiscordant couples: Early ART should be considered and actively discussed
Condition
Current CD4 + lymphocyte count
350-500
>500
Asymptomatic HIV infection
C
D
Symptomatic HIV disease (CDC B or C conditions) incl. tuberculosis
R
R
Primary HIV infection
C
C
Pregnancy (before third trimester)
R
R
HIV-associated kidney disease
R
R
HIV-associated neurocognitive impairment
R
R
Hodgkin's lymphoma
R
R
HPV-associated cancers
R
R
Other non-AIDS-defining cancers requiring chemo- and/or radiotherapy
C
C
Autoimmune disease — otherwise unexplained
C
C
High risk for CVD (>20% estimated 10-yr risk) or history of CVD
C
C
R
R
C/R
D
HCV for which anti-HCV treatment is being considered or given
R
D
HCV for which anti-HCV treatment not feasible
R
C
Conditions (likely or possibly) associated with HIV, other than CDC stage B or C disease:
Chronic viral hepatitis
HBV requiring anti-HBV treatment
HBV not requiring anti-HBV treatment
C, CONSIDER; D, DEFER; R, RECOMMENDED
Adapted from EACS Guidelines. Version 6; Oct 2011. Available at: www.europeanaidsclinicalsociety.org. Accessed June 2012
Type 2 diabetes: diagnosis and management
Diagnostic criteria (i)
Fasting plasma
glucose mmol/L
(mg/dL) (ii)
Oral glucose
tolerance test
(OGTT) 2-h value
mmol/L (mg/dL) (iii)
HbA1c (iv)
≥7.0 (126) OR →
≥11.1 (200)
≥6.5%
Impaired
<7.0 (126) AND →
glucose
tolerance (IGT)
7.8–11.0 (140–199)
Prediabetes
5.7–6.4%
Impaired
5.7–6.9 (100–125)
fasting glucose
(IFG)
<7.8 (140)
Diabetes
i As defined by WHO and International Diabetes Federation (2005)
ii An abnormal finding should be repeated before confirming the diagnosis
iii Recommended in patients with fasting blood glucose 5.7–6.9 mmol/L (100–125 mg/dL) as it may identify patients with overt diabetes
iv Do not use HbA1c in presence of haemoglobinopathies, increased erythrocyte turnover and sever liver or kidney dysfunction. Falsely
high values are measures under supplementation with iron, vitamin C and E as well as older age (age >70: HbA1c +0.4%)
Both IGT and IFG increase CV morbidity and mortality, and increase the risk of developing diabetes by 4–6 fold. These patients should be
targeted for lifestyle intervention, and their CV risk factors must be evaluated and treated
EACS guidelines 2011; 1:1–61.
Interventions for Treatment of Diabetes
If modification of lifestyle measures is insufficient
•
•
•
Metformin
Always to be considered as the first oral agent (i)
Start dose (500–700 mg qd), increase to max
tolerated dose of 2(-3) g/d in 4– weeks
(May worsen lipoatrophy)
•
•
Sulfonylureas
May be considered for non-overweight if
glucose is very high
No clinical trial in HIV +ve patients
HbA1c > 6.5–7%
Use a combination of 2 oral agents (i)
(metformin/sulfonylurea/incretine/exenatide)
HbA1c > 6.5–7%
Refer to specialist use insulin
Management of patients with diabetes
Treatment goals: glucose control (Hb1Ac <6.5–7% without hypoglycaemia, fasting plasma glucose 4–6 mmol/L (73–110 mg/dL)
• Normal blood lipids and blood pressure<130/80 mmHg (see p. 31 and p. 27)
• Acetylsalicylic acid (75–150 mg/d) considered in diabetes with elevated underlying CVD risk (see p. 26)
• Nephropathy, polynephropathy and retinopathy screening should be performed as in diabetic patients without HIV
• Consultation with a speciality in diabetology is recommended
i Very limited data for incretines (e.g. liraglutide, saxagliptine, sitagliptine, vildagliptine) and exenatide in HIV patients; no clinically significant
drug-to-drug interaction expected; clinical use of pioglitazone questioned by its side effects
EACS guidelines 2011; 1:1–61.
Prevalence of hepatitis C in the HIV population
(1960/5957 patients = 33%)
North: 359 = 23.2 %
East: 613 = 46.9 %
Central: 293 = 19.6 %
South: 695 = 41.4 %
Rockstroh et al. J Inf Dis 2005;192:992–1002
Regions:
South
Central
North
East
Acute HCV among HIV+ MSM
Canada24: ~30 cases
Prevalence chronic HCV/HIV25
19%: 11.200
USA1,2: 55 cases
Europe: 1068 cases
Prevalence chronic HCV/HIV14,15
25%: 185.500
-UK3,4 552
Prevalence chronic
-Germany5,18, 28 157
15 – 30%: 180.000 – 360.000
-France6,7 126
22
Lebanon : 1 case
-Netherlands8,17 97
Prevalence chronic HCV/HIV26
-Belgium20 69
49%: 1.500
-Swiss9 23
-Italy10 21
-Denmark21 13
-Spain27 ~8
HCV/HIV12-14
Taiwan29: 30 cases
Prevalence chronic HCV/HIV30
55%: 8.800
Australia11: 47 cases
Prevalence chronic HCV/HIV16,19
< 1%: 1.000
1:Luetkemeyer JAIDS 2006; 2:Cox Gastroenterology 2008; 3:Giraudon Sex Transm Infect 2008; 4:Ruf Eurosurveill 2008; 5:Vogel CID 2009; 6:Gambotti Euro
Surveill 2005; 7:Morin Eur J Gastro Hepat 2010; 8:Urbanus AIDS 2009; 9:Rauch CID 2005; 10:Gallotta 4th Works. HIV & Hep. Coinf. 2008; 11:Matthews CID
2009; 12:Sherman CID 2002; 13:Backus JAIDS 2005; 14:UNAIDS Report 2008; 15:Soriano JID 2008; 16:Matthews CID 2011; 17:Arends Neth J Med 2011;
18:Neukam HIV Med 2011; 19:Pfafferott PLoS One 2011; 20:Bottieau Euro Surveill 2010; 21:Barfod Scand JID 2011; 22:Dionne-Odom Lancet Infect Dis 2009;
23:Taylor Gastroenterology 2009; 24:Hull personal conversation 2011; 25:Remis 1st Canadian HCV Conference 2001; 26:UNGASS Country progress Report
2010; 27:Soriano personal conversation 2011; 28:Boesecke 18thCROI Boston 2011 abstract #113; 29:Sun Liver International 2011; 30:Lee J F Med Assoc 2008
Algorithm for management of acute HCV in
HIV-infected individuals
EACS guidelines 2011; NEAT Acute Hepatitis C Infection Consensus Panel. AIDS 2011:25;399-409
New Treatment Options for HIV/HCV
Genotype 1 Patients: EACS Guidelines
• EACS guidelines include the option to treat
HIV/HCV GT 1 coinfected patients with
telaprevir*[1]
• Updated guidelines will also include option to
treat with boceprevir as interim results became
available
*With efavirenz, telaprevir dose should be increased to 1150mg every 8 hours. Data on
coadministration of telaprevir with raltegravir is anticipated, but clinicians are advised to check
www.hep-druginteractions.com for further information.
1. EACS Guidelines, October 2011, Version 6.0.
Management
of newly
diagnosed
HIV-HCVHIV/HCV
coinfected
Management
of Newly
Diagnosed
genotype-1 patients
Coinfected Genotype 1 Patients
Newly diagnosed chronic
HCV GT 1 infection
Perform transient elastography and/or
serum marker and/or liver biopsy
F0F1a
In general, treatment can be
deferred. Consider treatment
with Peg/RBV and an HCV
protease inhibitor or Peg/RBV
alone if low HCV viral load,
IL28B CC genotype, absence
of insulin resistance and high
CD4+ cell count.
F2F3a
Treatment with Peg/RBV and an
HCV protease inhibitor.
aMetavir
F4a
Treatment with Peg/RBV
and an HCV protease
inhibitor if compensated
disease.
Treatment should be
undergone in specialised
centres.
fibrosis score: F0=no fibrosis; F1= portal fibrosis, no septae;
F2= portal fibrosis, few septae, F3=bridging fibrosis, F4=cirrhosis.
Ingiliz P, Rockstroh. J. Liver International 2012
EACS guidelines
• Reflect the different regulatory and economic
treatment scenarios in Europe
• Are based on “treatment has to benefit the
individual”
• Attempt to improve management of
concomitant comorbidities
• Provide guidance on management of viral
hepatitis coinfection
– http://www.europeanaidsclinicalsociety.org
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