HIV and AIDS management in Italy: critical issues 1. Late and AIDS presenters 2. Costs-effectiveness management 3. Antiretroviral long term toxicties 4. HCV- and HBV-coinfections 5. Non AIDS-defining malignancies

1. Late and AIDS presenters in Italy According to recent surveys, more or less one third of HIV diagnosis involve subjects with CD4 cell counts lower than 200 cells/mL 20% of HIV diagnosis are performed in the setting of an opportunistic infection Age, male gender and not Caucasian ethnicity are often associated with a later presentation of HIV infection Borghi V, J Acquir Immune Defic Syndr 2008

AIDS presenters: clinical outcome Possible normalization of CD4 cell count still with low baseline counts (Mocroft, Lancet, 2007) Slower immunoreconstitution if low baseline counts (Kaufmann, Clin Infect Dis 2005) Among AIDS presenter idividuals mortality rate are significant also in the HAART era Mussini C, Manzardo C, Johnson M, et al. Patients presenting with AIDS in the HAART era: a collaborative cohort analysis. AIDS 2008; 22: 2461-2469

2. Costs-effectiveness management in Italy E.G.: Lumbardy region “Piano diagnostico-terapeutico” “If there are several ARV regimens which are expected to have similar outcomes, choose the cheapest one” “Changes to more expensive regimens are advisable only in case of severe toxicities”

Case presentation (November 2010) Male patient, 61 years-old; hypertension in therapy; good health until three weeks before Access to Emergency Department for: fever and a progressive alteration of consciousness Not any deficit at the phisical examination (not even rigor nucalis) Increase of C reactive protein and of the eritrocite sedimentation rate with a slight anaemia HIV-ELISA positive, a tuberculin intra-dermal reaction positive (5 UI, 48 hours) CD4+71 cells/mL, HIV-RNA 418,130 copies/mL (homosexual risk factor) Lumbar puncture: 20 white blood cells (lymphocytes), low glucose and high protein Ziehl-Neelsen coloration for mycobacteria and other opportunistic agents were negative A therapy for a Tuberculosis meningitis was begun PCR for Mycobacterium tuberculosis resulted to be positive

Therapy and immuno-virological outcome 100 200 300 400 500 600 700 800 nov-10 jan-11 feb-11 apr-11 jun-11 ago-11 oct-11 CD4 (cells/m L) 1 2 3 4 5 6 HIV-RNA (Log copies/mL) CD4 HIV-RNA ISONIAZIDE RIFAMPICIN ETHAMBUTOL PYRAZINAMIDE AZT ABC + 3TC + RAL TDF + FTC + EFV 935 euros/month 919 euros/month 653 euros/month

Presentation of RECURRENT SCOTOMA During the follow up… (November 2012) Presentation of RECURRENT SCOTOMA Normal physical examination and blood analysis Normal funduscopic examination and visual acuity Normal blood pressure Several frontal lesions with hypercaptation of contrast significant for perilesional oedema Cerebral biopsy: granulomatous gyganto-cellular meningo-encephalitis with necrosis, probable IRIS/TB: anti-TB tretment reintroduced, still ongoing