Professional Documents
Culture Documents
and HIV
Weerawat Manosuthi, MD
Bamrasnaradura Infectious Diseases Institute
Ministry of Public Health
Bamrasnaradura Infectious Diseases Institute
Outlines
Update on “current HIV/TB epidemics”
Summary/update of the evidence of “treatment and prophylaxis of TB”
– 6 months vs. 9 months for TB treatment
– Rifampicin- vs. non-rifampicin containing anti-TB regimen
– Update drug development for drug-resistant TB
– INH prophylaxis
Summary/update of ART in co-infected HIV/TB patients
– Optimal timing to initiate ART
– Appropriate ART regimen to start with
– PK and clinical data regarding ARV and anti-TB drugs interactions
Bamrasnaradura Infectious Diseases Institute
HIV XDR TB
TB MDR TB
9.4 million
Bamrasnaradura Infectious Diseases Institute
Treatment of Tuberculosis
1.Duration of anti-TB regimen
2. Rifampicin- vs. non-rifampicin containing anti-TB
regimen in co-infected HIV/TB patients
3. New pipeline drugs and redeveloped drugs for
MDR and non-MDRTB
4. Izoniazid preventive therapy
Bamrasnaradura Infectious Diseases Institute
1. Rates of relapse and death were significantly higher among patients who
received a rifamycin for only 2 months.
2. Intermittent treatment during initial intensive phase was associated with
significantly higher rates of failure and relapse.
3. Receipt of ART was associated with non-significantly lower rates of failure
and relapse
Khan F, et al. Clin Infect Dis 2010; 50:1288–1299.
Bamrasnaradura Infectious Diseases Institute
Primary outcomes:
– Favorable responses at the end of treatment: (83% vs. 76%;
P>0.05)
– Bacteriological recurrences (15 vs. 7%;P<0.05)
Secondary outcome:
– Death by 36 months: (36% vs. 35%; P >0.05)
Ma Z, et al. Lancet2010;375:2100-09.
Bamrasnaradura Infectious Diseases Institute
Ma Z, et al. Lancet2010;375:2100-09.
Bamrasnaradura Infectious Diseases Institute
WHO/HTM/TB/2008.402
Bamrasnaradura Infectious Diseases Institute
.7
value
Reduces mortality and potential drug-drug Low potential drug-drug Mortality and morbidity
morbidity due to HIV interactions interactions due to HIV
HIV Infection with CD4 < 500 and sputum AFB smear positive & receiving standard
anti-TB therapy regimens
ART: Didanosine + Lamivudine + Efavirenz once daily
Significantly higher incidence of IRIS with early vs. late ART: 4.03 vs 1.44 per 100
person-months (p<0.001)
1.00
20.0
Plasma EFV level (mg/L)
0.75
17.5
p=0.632
15.0
0.50
12.5
0.25
10.0
7.5
0.00
5.0 0 16 24 36 48
analysis time
3.39 (median)
2.5 3.02
efv = 600 efv = 800
0.0
EFV 600 mg EFV 800 mg
Dose per day
20.0
17.5
Plasma NVP level (mg/L)
15.0
12.5
10.0
2.5 •3.4
0.0
NVP + RFP NVP NVP + RFP
we e k 8+12 we e k 8+12 we e k 60 (no RFP)
Treatment Group
ART regimens containing efavirenz (600 mg per day) were less compromised by
concomitant use of rifampicin than were those that contained nevirapine (400 mg per
day) in patients with concurrent HIV-1 infection and TB.
“Low drug exposure” and “low body weight” are important predictive factors for
treatment failure.
Manosuthi W, et al. Clin Infect Dis 2009, 48:1752-1759.
Bamrasnaradura Infectious Diseases Institute
24 (A) 24 (B)
22 22
20 20
18 18
Pearson’s correlation = -0.255 Pearson’s correlation = -0.239
16 16
P = 0.003
14 14 P = 0.001
12 12
10 10
8 8
6 6
4 4
2 2
0 0
-2 -2
-4 -4
30 35 40 45 50 55 60 65 70 75 80 85 90 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
•There appears to be a relationship between high body weight and low combined C12 efavirenz at week 6 and 12 (P=0.003,
r=-0.255).
•Conversely, plotting the regression line by defining C12 efavirenz as independent variable, C12 efavirenz at 1 mg/L
intercepted body weight at a mean of 57.5 (95% CI: 54.9-60.1) kilograms. The same trends were found at week 6 (P=0.033,
r=-0.257) and week 12 (P=0.058, r=-0.234); and also found in C12 efavirenz at week 6, week 12, and after rifampicin
discontinuation as shown in Figure 2B (P=0.001, r=-0.239).
Manosuthi W, et al. Antimicrob Agents Chemo 2009; 53:4545-8.
Bamrasnaradura Infectious Diseases Institute
Effect of PI Effect of
NNRTI Rifampicin Rifampicin
Nevirapine ↓ 37-58% Saquinavir ↓ 80%
Efavirenz ↓ 13-26% Ritonavir ↓ 35%
Indinavir ↓ 90%
Nelfinavir ↓ 82%
Amprenavir ↓ 81%
Lopinavir/rtv ↓ 75%
Bamrasnaradura Infectious Diseases Institute
Drug-drug Recommendation
Rifampicin + unboosted PI Do not use
Rifampicin + boosted PI Not recommended because of poor
pharmacokinetics and
high rates of hepatotoxicity in healthy
volunteers
Rifabutin + unboosted PI Reduce rifabutin to 150mg daily,
increase unboosted PI
Rifabutin + boosted PI Reduce rifabutin to 150mg three times
per week
Summary
HIV and TB are still the major public health threat and the leading
cause of death. In addition, MDR TB and XDR TB epidemics are
rapidly expanding.
– Further strategic management and collaborative treatment is needed.
Summary
Effective combined ART substantially reduce the risk of death.
– Early initiation of ART in severe immunosuppressive co-infected HIV/TB
patients is associated with improved survival but not for the TB meningitis.
– However, more clinical trials is still needed from the different medical
infrastructures.
Thank you