HIV/AIDS and diabetes in South Africa: role of antiretroviral therapiesZeena Nackerdien

Independent prevalence estimates of HIV/AIDS and diabetes in South AfricaHIV/AIDS

prevalence (2012)(1)

Diabetesprevalence (2013)(2)

• Number of HIV+-people: 6,100,000 [5,800,000 - 6,400,000]

• Adults (≥15-49 y): 17.9% [17.3% - 18.4%]

• Mean cost ART/patient ($US): 682 (3)

• Deaths due to AIDS: 240,000 [220,000 - 270,000]

• Number of diabetics: 2,600,000

• Adults (20-79y): 9.3% [17.3% - 18.4%]

• Mean diabetes-related costs/person ($US): 935

• Deaths related to diabetes: 83,114

ART, antii-retroviral therapy; y, years1. UNAIDS. HIV and AIDS (2012 estimates) 2012 [cited 2014 May]. Available from: http://www.unaids.org/en/regionscountries/countries/southafrica/2. International Diabetes Federation. IDF Diabetes Atlas, 6th edn. Brussels, Belgium: International Diabetes Federation, 2013: Regional overviews [cited 2014 May]. Available from: https://www.idf.org/sites/default/files/DA6_Regional_factsheets_0.pdf.3. Multi‐Country Analysis of Treatment Costs for HIV (MATCH) conducted by the Clinton Health Access Initiative (CHAI) in partnership with the Governments of Ethiopia, Malawi, Rwanda, South Africa and Zambia and the Center for Global Development. Preliminary findings for discussion at the International AIDS Economics Network Pre‐Conference Meeting, July 2012. Available from: http://www.iaen.org/library/Presentation_3_Elya_Tagar.pdf

SOC: Maximally suppressive ART; monitor drug interruptions & drug-

drug interactions

Pre-specified clinical indicators to start treatment e.g., low CD4 count, ongoing monitoring, indications for changing ART

Other considerations for special groups, co-infected patients (e.g., TB), & sero-discordant couples

Goals for ART in adults (SA guidelines)(4)• Maximally suppressive ART• Improve QoL• Reduce disabilities/deaths• Maximal & durable viral suppression• Restore & preserve immune function

ART, antiretroviral therapy, QoL, quality of life; SOC, standard of care, SA, South African; TB, tuberculosis(4) Meintjes G, Maartens G, Boulle A et al. Guidelines for Antiretroviral Therapy in Adults, September 2012. SAJHIVMED 2012;13:3.

Drug classes & targets of SA-based ARTs (5) EIs e.g.,

maraviroc & enfuvirtide

NRTIs , NNRTIs & NtRTIs e.g.,

ziduvidine, abacavir, nevirapine

INSTIs e.g., raltegravir

PIs e.g., lopinavir

Eis, entry inhibitors; INSTIs, integrase inhibitors; NRTs, NNRTIs & NtRTIs, nucleoside, non-nucleoside, and nucleotide reverse transcriptase inhibitors; Pis, protease inhibitors

(5) Management of HIV/AIDS: Wikipedia; [cited 2014 May]. Available from: http://en.wikipedia.org/wiki/Management_of_HIV/AIDS.

Mechanisms and some drug class AEs (4)

AEs, adverse events; Eis, entry inhibitors; InSTIs, Integrase inhibitors; NRTIs and NtRTIs, nucleoside and nucleotide reverse transcriptase inhibitors; NNRTIs, Non-nucleoside reverse transcriptase inhibitors; PIs, protease inhibitors(4) Meintjes G, Maartens G, Boulle A, et al. Guidelines for Antiretroviral Therapy in Adults, September 2012. SAJHIVMED 2012;13:3.

NRTIs and NtRTIs

Mechanism: Reverse

transcriptaseInhibition

AEs: Rash, hepatitis

Mechanism: Proteaseinhibition

AEs: Cardiac conduction abnormalities, dyslipidaemia, hyperglycemia

Mechanism: Reverse

transcriptaseInhibition

AEs: Rash, headache

NNRTIs

PIs

InSTIs

Mechanism: Entry inhibitors

AEs: colds, cough, fever

Mechanism: Reverse

transcriptaseInhibition

AEs: lipo-atrophy , myopathy, bone marrow

suppression

EIs

Management of diabetes in HIV/AIDS patients (6)

Prevention & management

• Screening for disease onset and associated complications, behavioral changes, appropriate glycemic control

Switching ARTs

• Reinforce lifestyle interventions• Consider discontinuing problematic

ARTs causing hyperglycemia if safe & effective alternatives are available

• Carefully consider effects of discontinuing ARTs on virologic control & potential AEs of new ARTs

• Antidiabetics may still be necessary after ART substitution, in some cases

• Regularly check HbA1c levels until goal is reached and then, periodically, as per recommended guidelines

6. US Department of Veterans Affairs. HIV/AIDS (Diabetes). April 2009; Last reviewed/updated: October 28, 2011 [cited 2014 May]. Available from: http://www.hiv.va.gov/provider/manual-primary-care/diabetes.asp#S4X.