Cardiovascular risk in HIV, ART and

recent clinical trials data

Benjamin Young

International Association of Providers of AIDS Care

Washington, DC, USA

Disclosures

• Speakers Bureau/ Consultant:

Bristol-Myers Squibb

Gilead Sciences

Merck & Co

ViiV Healthcare

• Research Funding

Gilead Sciences

ViiV Healthcare

Overview

• Aging and non-communicable diseases

– Cardiovascular disease

• Emerging treatment paradigms

• Clinical trials data

– STARTMRK

– ACTG 5257

NON-COMMUNICABLE DISEASES

AND HIV

DHHS, 2014

DHHS Recommendations

Schouten, XIX IAC, 2012

Schouten, XIX IAC, 2012

Lancet, 2014

CARDIOVASCULAR DISEASE AND

HIV

Lichtenstein, Clin Infect Dis 2010

Van Zoest, 16th Intl Workshop on Co-morbidities and Adverse Drug Reactions, 2014

Post, Ann Int Med, 2014

Coronary artery plaque is more prevalent (RR 0.14-0.35)

and extensive among HIV+ men, independent of CAD risk

factors.

Bavinger, PLOS One, 2013

• 27 study meta-analysis shows mixed evidence of

relationship

• Increase in MI risk recently exposed:

– abacavir (RR 1.92, 95% CI 1.5-2.4)

– protease inhibitors (RR 2.12, 95% CI 1.06-4.28)

• Increase risk with additional year of exposure:

– indinavir (RR 1.11, 95% CI 1.05-1.17)

– lopinavir (RR 1.22, 95% CI 1.01-1.47)

• Four published meta-analyses of randomized trials, found

no increased risk of CVD.

CVD AND HIV GUIDELINES

EVOLVING ART

CONSIDERATIONS

New combinations, superior tolerability

“…the available evidence renders the discussion on

when to start ART unnecessary and that, instead,

efforts should be aimed at offering treatment as

soon as possible.”

Sigaloff, Lange, Montaner, Clin Infect Dis 2014

Evolving ART Combinations

DHHS Panel, 2014

Evolving ART Combinations

EACS, 2014

Evolving ART Tolerability: SPRING-2

Raffi, et al., Lancet, 2013

Evolving first-line ART: Integrase Inhibitor-based Treatments

• DTG superior to EFV

– SINGLE (Walmsley, New Engl J Med, 2013)

• DTG superior to DRV/r

– FLAMINGO (Clotet, Lancet 2014)

• RAL superior to EFV

– STARTMRK 5 year analysis (Rockstroh, JAIDS 2013)

• RAL superior to DRV/r and ATV/r

– ACTG 5257 (Landovitz, CROI 2014)

CLINICAL TRIALS DATA

Focusing on raltegravir

STARTMRK (192 WEEK)

ACTG 5257

EVOLVING TARGETS

Ending epidemic AIDS

Evolving Targets

UNAIDS, 2014

Normal Life Expectancy?

Cardiovascular disease and HIV

• HIV populations are getting older

• Cardiovascular disease is a major cause of

morbidity and mortality in the HIV community

– Risk factors are common

– Association with ART debated

• Evidence-based guidelines for managing non-

communicable diseases

ART and Raltegravir

• Expanding treatment recommendations

• RAL-regimens on DHHS, EACS and BHIVA

guidelines

• RAL superior vs EFV year 4, 5 (STARTMRK)

• RAL superior vs ATV/r and DRV/r (ACTG 5257)

• Favorable:

– Tolerability

– Safety/toxicity profile

Summary

• Aging of HIV populations around the world

• Increasing importance of non-communicable diseases

• Cardiovascular disease significant cause of morbidity and

mortality

– Treatment guidelines recommend prevention/treatment

• Evolving antiretroviral treatment guidelines

– Many agencies now recommend treatment for all

• Increasing role of HIV integrase inhibitors

– Superior safety and efficacy profile, compared with previous

standards

• Ending AIDS is possible

Gracias!

byoung@iapac.org