IDCR - Infectious Diseases in Corrections Report

Raltegravir (Isentress, MK-0528): This agent is the first integrase inhibitor to receive FDA approval. Integrase inhibitors are a novel class of antiretrovirals. After the reverse transcription of HIV viral RNA into DNA is complete, integration of the HIV DNA into the host cell’s DNA occurs. Integrase inhibitors work by blocking this process. Raltegravir, combined with optimized background therapy (OBT), was shown to offer durable efficacy and safety in patients with multiple-drug-resistant HIV and a history of treatment failure.^1,2 Many incarcerated HIV patients have exhausted treatment options, and raltegravir offers an additional tool for creation of salvage therapy for patients who have developed extensive resistance.

Etravirine (Intelence, TMC 125): Etravirine is the first non-nucleoside reverse transcriptase inhibitor (NNRTI) to receive FDA approval in the last 10 years. In treatment-experienced patients with multi-drug resistance, a regimen of etravirine plus OBT demonstrated greater viral load (VL) reduction and increase in CD4 counts compared to placebo plus OBT.^3,4 Etravirine is approved for treatment-experienced patients who have HIV that is resistant to multiple antiretroviral drugs. The FDA has not approved etravirine for use in treatment naive patients.

Nevirapine: Once-daily dosing of 400mg of the NNRTI nevirapine (Viramune, NVP) was shown to be as effective as 200mg twice-daily. Further, investigators concluded that “[f]or patients with detectable HIV RNA who have been exposed to other antiretroviral drugs, and commence a regimen including NVP, NVP once-daily, is associated with better and, a faster, virological suppression, as well as a stronger immune restoration (as compared to twice daily).” ⁵ Once-daily NVP may help decrease costs associated with medication administration in the correctional setting.

Lopinavir/ritonavir (Kaletra): Data was presented that demonstrated comparable tolerability and efficacy between 4 tablets once-daily and two tablets twice-daily of Kaletra (lopinavir /ritonavir).⁶ The January 29, 2008, update of DHHS’s federal treatment guidelines suggests that twice-daily Kaletra may be more suitable for those patients with high (> 100,000 copies/mL) pre-treatment viral loads.⁷

HIV diagnosis and perceived transmission risk factors: During the symposium “Curbing the US Epidemic,” incarceration was cited as an important HIV transmission risk factor no less than six times, specifically in relation to the sexual network patterns and societal disparities of African-American women.⁸ By extrapolation, this seemingly speaks to the need for improved prison/jail prevention efforts. Perhaps eradicating behavioral risk group (BRG) labeling in HIV testing is a beginning toward that end. For example, many male inmates do not identify themselves as MSM, and therefore do not perceive themselves at risk for contracting HIV and then transmitting it to their post-release female sexual partners. In a blinded serostudy of New York City jail entrants, most HIV infected inmates did not report recognized HIV risk factors.⁹



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