1. N ORTHWEST A IDS E DUCATION AND T RAINING C ENTER 2014 IAS-USA Treatment Guidelines Brian R. Wood, MD Medical Director, NW AETC ECHO Assistant Professor of Medicine, University of Washington Presentation prepared by: Presenter Last Updated: 10/16/14

2. International Antiviral Society-USA Guidelines Updated July 2014  Prevention Guidelines – Dr. Marrazzo will discuss 11/6/14  Treatment Guidelines

3. Rating Scale Strength of Recommendations: -A: Strong support -B: Moderate support -C: Limited support Quality of Evidence: -Ia: >1 RCTs published in peer-reviewed literature -Ib: >1 RCTs presented at peer-reviewed scientific meetings -IIa: non-RCT’s, cohort, or case-control studies published -IIb: non-RCT’s, cohort, or case-control studies presented -III: panel’s analysis of accumulated available evidence

4. When to Start ART is recommended regardless of CD4 count CD4 count <500: AIaCD4 count >500: BIII Pregnancy: AIa Chronic hepatitis B: AIIa HIV-associated nephropathy: AIIa

5. What to Start: Recommended Initial Regimens ^Single tablet regimen (STR) option

6. Additional Considerations Tenofovir: -Potential for renal and bone toxicity Abacavir: -Associated with cardiovascular events, though data conflicting -HLA-B*5701 must be negative Abacavir/lamivudine: -Less efficacious than tenofovir/emtricitabine when given with efavirenz or boosted atazanavir if baseline HIV RNA >100,000

7. What to Start: Alternatives

8. Estimated Patent Expiration Dates for Branded Antiretrovirals

9. Initiating ART in Special Circumstances “ART should be offered to all individuals with acute infection and should be started as early as possible to maximize benefit” (BIII) Benefits: reduction of proviral DNA and plasma viral load, lower viral set point, robust immune reconstitution Acute HIV: “The data for initiating ART in elite controllers is stronger than before but still insufficient to recommend routine therapy” Elite Controllers:

10. Initiating in Setting of an Acute OI or Tuberculosis Start within first 2 weeks of diagnosis (AIa) Includes other AIDS-defining illnesses likely lymphoma or HPV-related cancer (AIa-BIII) Timing less certain for crypto meningitis…(COAT trial) Acute OI: Within 2 weeks if CD4 count <50 (AIa) By 8-12 weeks if higher CD4 count (AIa) TB meningitis: optimal timing less certain, but likely should be started within 2-8 weeks (BIII) Tuberculosis:

11. ART Monitoring HIV RNA 4 weeks after ART initiation or change, then every 3 mo (AIa) Evaluate for cause of virological failure if HIV RNA >200 copies (AIIa) CD4 Once HIV RNA suppressed for >2 years and CD4 consistently >500, monitoring CD4 count is optional (CIII) “There are insufficient data to make general recommendations for the management of patients with sustained viremia of 50 to 200 copies/mL.”