The Body Covers: The 38th Annual Meeting of the Infectious Diseases Society of America
Meet the Professor Session: Post-Exposure and Other Prophylaxis: Late-Breaker Slides
September 9, 2000
IDSA-International AIDS Society USA Interactive SessionJonathan Shapiro from Stanford led the first case discussion focusing on resistance issues. The audience response in this whole session reflected a high level of knowledge and a growing conservatism about full-tilt aggressive treatment. A major take-home message from this session was that the technology of resistance testing has improved faster than our ability to optimally interpret the results.
Diane Havlir from UCSD then focused on salvage therapy. She pointed out from one large office-based study that fully 70% of patients on therapy have detectable viremia and are candidates for salvage therapy. A key point was that the further into salvage one gets the more the goal shifts to protecting the CD4 count, general health, and possibly future treatment options. The clinical value of treatment interruptions in late stage disease as a means to induce a shift to wild-type drug-sensitive virus has a clear clinical downside and can not be promoted as a general technique.
Steve Grinspoon from Harvard then took us through an extraordinarily complex case illustrating many of the metabolic issues we now face. The audience scored well on the questions which I felt reflected an increasing awareness about the importance of these issues. Finally, Mark Sulkowski from Johns Hopkins discussed the issue of hepatitis C in the context of HIV infection.
Meet the Professor Session: Post-Exposure and Other ProphylaxisFor the 3rd day in a row, I made it to this 7 AM session. The good news was that it was not raining, the bad news was that the humidity was thick. Julie Gerberding from the CDC and David Henderson from the NIH spent a lively hour answering questions from the audience. I will summarize a few pearls:
Late-Breaker SlidesThere was one HIV presentation and it was noteworthy. The MONTANA Study (# 648) was conducted in France and involved the use of a once-a-day regimen consisting of FTC, ddI (2 chewable tablets), and efavirenz taken together at bedtime. Forty treatment-naïve patients enrolled with an average CD4 count = 373 and viral level = 4.77 log. At 48 weeks, by intent-to-treat analysis (missing data = failure) 38/40 (95%) had levels < 400 copies/ml. Only two patients failed at 48 weeks. The study drugs were well tolerated with one switch from ddI to D4T and one switch from efavirenz to nevirapine. The CD4 cell increase was 200 cell/mm3 at 48 weeks. Given all the limitations of an open-label, single-arm trial, these are still impressive results and make the possibility of effective, simple, once-daily treatment (+/- directly observed therapy) within our grasp. The enteric ddI might make that regimen even more attractive but FTC is not available. I would be cautious trying to extrapolate any use of 3TC in place of FTC without more data.
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