Hiv primary care
This presentation is the property of its rightful owner.
Sponsored Links
1 / 50

HIV PRIMARY CARE PowerPoint PPT Presentation


  • 31 Views
  • Uploaded on
  • Presentation posted in: General

HIV PRIMARY CARE. Derrick Butler, MD, MPH Associate Medical Director T.H.E. Clinic, Inc Los Angeles, CA. Quiz. Magic Johnson tested positive for HIV in 1992 and is now cured of the virus. a) True, he is rich and can afford the best medicine.

Download Presentation

HIV PRIMARY CARE

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Hiv primary care

HIV PRIMARY CARE

Derrick Butler, MD, MPH

Associate Medical Director

T.H.E. Clinic, Inc

Los Angeles, CA


Hiv primary care

Quiz

  • Magic Johnson tested positive for HIV in 1992 and is now cured of the virus.

    a) True, he is rich and can afford the best medicine.

    b) False, he is still infected, but is controlled on medication.

    c) Don’t know, I don’t follow football.


We ve come a long way baby

We’ve Come a Long Way, Baby


Hiv primary care

Electron micrographic picture


T cell count 1 2

T-Cell Count1,2

500 cells/mm3 or more

Normal immune system

200-499 cells/mm3

Weakened immune system

Less than 200 cells/mm3

Severely weakened immune system (high risk for infection)

T-cell count shows how well someone’s immune system is working

References: 1. Centers for Disease Control and Prevention. 1993 revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR, December 18, 1992; 41(RR-17). Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/00018871.htm. Accessed June 12, 2008. 2. AIDSinfo: A Service of the U.S. Department of Health and Human Services. HIV and its treatment: what you should know. February 2008. Available at: http://www.aidsinfo.nih.gov/contentfiles/HIVandItsTreatment_cbrochure_en.pdf. Accessed June 12, 2008.

5


Viral load

Viral Load

High

>100,000 copies/mL

Low to Moderate

400-100,000 copies/mL

Undetectable

<400 copies/mL

or <50 copies/mL

Viral load = the amount of HIV in a sample of blood

6


How does hiv therapy work

How Does HIV Therapy Work?

PIs

(Protease Inhibitors)

Disable a protein that HIV needs to make more copies of itself.

Entry and Fusion

Inhibitors

Work by blocking

HIV from entering cells.

NRTIs

(Nucleoside Reverse Transcriptase Inhibitors)

Fake building blocks that stop HIV from making copies of itself.

Integrase Inhibitors

Disable a protein that HIV uses to put its genes into the T-cells’ genes.

  • HIV goes through a series of stages in order to multiply

  • Different classes of drugs block HIV at some of these different stages

NNRTIs

(Non-Nucleoside Reverse Transcriptase Inhibitors)

Bind to and disable a protein that HIV needs to make copies of itself.

Reference: AIDSinfo: A Service of the U.S. Department of Health and Human Services. HIV and its treatment: what you should know. February 2008. Available at: http://www.aidsinfo.nih.gov/contentfiles/HIVandItsTreatment_cbrochure_en.pdf. Accessed June 12, 2008.

7


Current arv medications

Current ARV Medications


Hiv primary care

HIV replication cycle and sites of drug activity

Protease

New HIV

particles

Capsid

proteins

and viral

RNA

CD4

Receptor

Viral RNA

Fusion Inhibitor

T-20 (Enfuvirtide, Fuzeon)

Integrase Inhibitor

Raltegravir (Isentress)

CCR5 Antagonist

Maraviroc (Celsentri)

Reverse

Transcription

Attachment

Translation

Uncoating

Integration

Transcription

  • Protease Inhibitors

  • Indinavir (Crixivan)

  • Ritonavir (Norvir)

  • Saquinavir (Fortovase)

  • Nelfinavir (Viracept)

  • Lopinavir/ritonavir (Kaletra)

  • Atazanavir (Reyataz)

  • Fos Amprenavir (Lexiva)

  • Tipranavir (Aptivus)

  • Darunavir (Prezista)

  • NNRTIs

  • Efavirenz (Sustiva)

  • Delavirdine (Rescriptor)

  • Nevirapine (Viramune)

  • Etravirine (Intelense)

  • NRTIs

  • AZT (Zidovudine-Retrovir)

  • ddI (Didanosine-Videx)

  • ddC (Zalcitabine-Hivid)

  • d4T (Stavudine-Zerit)

  • 3TC (Lamivudine-Epivir)

  • ABC(Abacavir-Ziagen)

  • FTC (Emtricitabine, Emtriva)

  • nRTI

  • Tenofovir DF

  • (Viread)

Cellular DNA

Nucleus

HIV Virions

Reverse

Transcriptase

Integrase

Unintegrated

double stranded

Viral DNA

gag-pol

polyprotein

Integrated

viral DNA

Viral

mRNA

6

5

1

3

4

2

Assembly and

Release


What is haart

What Is HAART?

  • HAART stands for Highly Active Antiretroviral Therapy

  • HAART combines drugs from different classes, slowing HIV replication down at different stages

  • HAART is also called combination therapy, a “cocktail,” or a “regimen”

NNRTI

Examples of HAART regimens:

NRTI

NRTI

+

or

PI

Reference: AIDSinfo: A Service of the U.S. Department of Health and Human Services. HIV and its treatment: what you should know. February 2008. Available at: http://www.aidsinfo.nih.gov/contentfiles/HIVandItsTreatment_cbrochure_en.pdf. Accessed June 12, 2008.

10


Therapy is easier more potent and less toxic in single tablet regimens

Therapy is Easier, More Potent, and Less Toxic in Single-Tablet Regimens


Mortality and haart over time

Mortality and HAART Over Time

8

90%

80%

7

70%

6

60%

5

50%

Deaths per 100 Person-Years

Patients on HAART

4

40%

3

30%

2

20%

1

% of patients on HAART

10%

Deaths per 100 person-years

0

0

1996

1997

1998

1999

2000

2001

2002

2003

2004

Time

Reference: Palella FJ Jr, Baker RK, Moorman AC, et al; and HIV Outpatient Study Investigators. Mortality in the highly active antiretroviral therapy era: changing causes of death and disease in the HIV outpatient study.

J Acquir Immune Defic Syndr. 2006;43:27-34.

12


Hiv patients baseline evaluation

HIV Patients:Baseline Evaluation

  • General history

  • HIV disease characteristics

  • Mental health history

  • Substance abuse history

  • Sexual history

  • Psychosocial assessment

  • Review of systems


Newly diagnosed patient recommended laboratory tests for initial visit

Newly Diagnosed Patient: Recommended Laboratory Tests for Initial Visit

DHHS. Available at: http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf.

Revision March 27, 2012.


Newly diagnosed patient recommended laboratory tests for initial visit1

Newly Diagnosed Patient: Recommended Laboratory Tests for Initial Visit

*Renal function determination: include estimation of creatinine clearance using Cockcroft & Gault equation

of glomerular filtration rate based on MDRD equation.

DHHS. Available at: http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf.

Revision March 27, 2012.


When to start treatment

When to Start Treatment

The IAS-USA guidelines also recommends initiating antiretroviral therapy in HIV-infected patients with active hepatitis C virus infection, active or high risk for cardiovascular disease, and symptomatic primary HIV infection.

DHHS. Available at: http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf.

Revision March 27, 2012; Thompson MA, et al. JAMA. 2012;308:387-402.


Dhhs treatment guidelines when to start

DHHS Treatment GuidelinesWhen to Start


Dhhs guidelines preferred regimens

DHHS Guidelines: Preferred Regimens

INSTI: Integrase strand transfer inhibitors.

1Efavirenz should not be used during the first trimester of pregnancy or in women trying to conceive or not using effective and

consistent contraception.

2Lamivudine may substitute for emtricitabine or visa versa.

3Tenofovir DF should be used with caution in patients with renal insufficiency.

4Atazanavir + RTV should not be used in patients who require >20 mg omeprazole equivalent/day.

DHHS. Available at: http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf.

Revision March 27, 2012.


Dhhs guidelines alternative regimens

DHHS Guidelines: Alternative Regimens

1Abacavir should not be used in patients who test positive for HLA-B*5701. Use abacavir with caution in patients with

high risk of cardiovascular disease or pretreatment HIV RNA >100,000 copies/mL.

2Lamivudine may substitute for emtricitabine or visa versa.

3Use rilpivirine with caution in patients with pretreatment HIV RNA >100,000 copies/mL.

4Once-daily lopinavir/r is not recommended in pregnant women.

5Patients with creatinine clearance >70 mL/min.

DHHS. Available at: http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. March 27, 2012;

and http://aidsinfo.nih.gov/contentfiles/AdultARVStatementOnEVG_COBI_TDF_FTC.pdf.


Recommended laboratory tests at haart initiation and follow up

Recommended Laboratory Tests at HAART Initiation and Follow-Up

*Every 6 to 12 months: on a suppressive regimen and CD4 counts well above the threshold for OI risk.

1Borderline or abnormal at last measurement; 2normal at last measurement.

DHHS. Available at: http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf.

Revision March 27, 2012.


Opportunistic infections o i

Opportunistic Infections (O.I.)

Candidiasis of bronchi, trachea, or lungs

Candidiasis esophageal

Cervical cancer (invasive)

Coccidioidomycosis, disseminated or extrapulmonary

Cryptococcosis, outside of the lungs

Cryptosporidiosis, chronic intestinal for longer than 1 month

Cytomegalovirus disease (other than liver, spleen or lymph nodes)

Encephalopathy (HIV-related)

Herpes simplex: chronic ulcer(s) (for more than 1 month); or bronchitis, pneumonitis, or esophagitis

Histoplasmosis, disseminated or outside the lung

Isosporiasis, chronic intestinal (for more than 1 month)

Kaposi's sarcoma (skin cancer –internal and external

Lymphoma (Burkitt's), immunoblastic or if primary location is the brain

Mycobacterium avium complex (MAC)

Mycobacterium, other species, disseminated or if found outside the lungs

Pneumocystis jiroveci pneumonia (formerly Pneumocystis carinii)

Pneumonia (recurring, persistent infections)

Progressive multifocal leukoencephalopathy (PML)

Salmonella septicemia (recurrent)

Toxoplasmosis of the brain

Tuberculosis, disseminated (widespread or outside the lung)

Wasting syndrome due to HIV


O i screening

O.I. Screening

  • At Baseline:

    -TB Screening (PPD, CXR, Quantiferon)

    - Toxoplasmosis

    - Cryptococcus

  • Yearly:

    - TB Screening


O i prophylaxis

O.I. Prophylaxis

  • CD4 count <200: PCP Prophylaxis

  • CD4 count <50: MAC Prophylaxis

    Toxo Prophylaxis

    CMV Screening


Immunizations

Immunizations

  • Tetanus/Diptheria ( Td, TDaP)

  • Pneumonia (Prevnar 13, Pneumovax)

  • Influenza

  • Hepatitis A

  • Hepatitis B


Haart long term complications

HAART:Long-Term Complications

Dyslipidemia/CHD

Abnormalities of Body Composition

Hepatotoxicity


Screening for coronary heart disease

Screening forCoronary Heart Disease

  • Complete clinical history

  • Physical examination

  • Risk assessment with the Framingham Risk Equation (or similar)

    • Every patient without ischemic heart disease

      • Before HAART initiation

      • Annually thereafter

  • 12-lead ECG

    • Men (>40 years) and women (>50 years of age)

      • Annually

Hsue PY, et al. Circulation. 2008;118:e41-e47.

Lundgren JD, et al. HIV Med. 2008;9:72-81.


Traditional factors are the biggest contributor to chd in hiv population

Traditional Factors Are the Biggest Contributor to CHD in HIV Population

Abdominal obesity*

Inactivity, diet

Age

Cigarette smoking

CHD risk

Hypertension*

Hyperglycemia

Family history

Sex

Lipids*

HIVinfection†

HAART†

Emerging factors:Lp(a), CRP, IMT, and endothelial function

Insulin resistance*

Diabetes

*Component of metabolic syndrome.

†Precise contribution unclear.


Impact of statins in routine clinical care of hiv infected patients

Impact of Statins in RoutineClinical Care of HIV-Infected Patients

Reductions on Lipid Parameters After 1 Year

Pravastatin (reference) (n=280)

Atorvastatin (n=303)

Rosuvastatin (n=95)

109ll

89

Change From Baseline (mg/dL)

54

49¶

43†

40*

40§

29*

28

26‡

25

14

Total

Cholesterol

LDL-C

HDL-C

Triglycerides

*P<0.001; †P=0.004; ‡P<0.01; §P=0.002; ¶P=0.0001; llP=0.04 versus pravastatin.

Singh S, et al. 48th ICAAC. Washington, DC, 2008. Abstract H-2303.


Cardiovascular risk

Cardiovascular Risk


Diabetes recommended laboratory tests

Diabetes:Recommended Laboratory Tests

  • Fasting serum glucose measurement

    • Before starting treatment

      • If normal, annually thereafter

    • 3 to 6 months after starting HAART if borderline or abnormal before starting treatment

      • If normal, repeat every 6 months

  • Oral glucose tolerance test

    • In patients with family history of diabetes, obesity or metabolic syndrome, on HAART

      • At the first visit

      • Repeat when there is a clinical suspicion of impaired glucose tolerance

DHHS. Available at: http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf.

Revision March 27, 2012.

Florescu D, et al. Antiviral Ther. 2007;12:149-162.


Hiv pathogenic mechanisms of insulin resistance

HIV:Pathogenic Mechanismsof Insulin Resistance

  • Similar in HIV and non-HIV patients

    • Genetic influences

    • Elevated circulating free fatty acids

    • Increased muscle and organ fat

    • Hormones

    • Comorbid diseases

    • Chronic inflammatory changes (cytokines)

  • Specific for HIV-infected patients

    • Lipodystrophy

    • HAART components, particularly PIs and some NRTIs (didanosine, stavudine)

Florescu D, et al. Antiviral Ther. 2007;12:149-162.


Malignancies in hiv changes in incidence over the past 10 years

Malignancies in HIV: Changes in Incidence Over the Past 10 Years

  • AIDS-related malignancies

    • Decreased

      • Kaposi sarcoma and CNS lymphoma

    • Increased

      • Non-Hodgkin lymphoma

  • Non-AIDS defining malignancies

    • Overall incidence increased by >3-fold

    • Greatest increases seen in liver, larynx, anal, and lung cancers

    • No increase in prostate and breast cancers

Mitsuyasu RT. Top HIV Med. 2008;16:117-121.

Engels EA, et al. Int J Cancer. 2008;123:187-194.

Patel P, et al. Ann Intern Med. 2008;148:728-736.


Cancer early detection and prevention

CANCER: Early Detection and Prevention

  • Yearly intervals

    • Cervical and anal Papanicolaou tests

    • Gynecologic examinations and high-resolution anoscopy

    • Breast examinations

    • Prostate examinations (including prostate-specific antigen)

  • Periodically

    • Liver function tests and alpha-fetoprotein in HBV and/or HCV coinfection

  • Sunscreen and avoidance of overexposure to sunlight

    • Endothelial and epithelial cells in HIV-infected patient may be more susceptible to carcinogenesis

Mitsuyasu RT. Top HIV Med. 2008;16:117-121.


Cancer prevention

Cancer: Prevention

  • Smoking cessation

  • Use of hepatitis and HPV vaccines in seronegative individuals

    • Immunogenicity studies for HPV underway in HIV-infected persons

  • Maintain a high suspicion for cancer in HIV-infected persons

Mitsuyasu RT. Top HIV Med. 2008;16:117-121.


Osteoporosis

Osteoporosis

  • Higher rates of osteoporosis in HIV populations

  • Long term effect of ART (Tenofovir)

  • Higher rates of Vitamin D deficiency in HIV populations

  • Higher rates of smoking, alcohol.

  • Bone Mineral Density Screening with DEXA Scan (Men >50, Postmenopausal women, any h/o fracture)

  • RX- Calcium/Vit D, Biphosphpnates


Screening strategies to detect asymptomatic stds first visit

Screening Strategies to Detect Asymptomatic STDs: First Visit

  • All patients

    • Serologic test for syphilis

      • RPR or VDRL, confirm positive test with FTA-Abs or TP-PA

    • Consider testing for gonorrhea, Chlamydia species, and herpes simplex based on patient sexual history

    • Serologic tests for hepatitis A, B, C at baseline

  • Female

    • Culture or DNA amplification test for gonorrhea

    • Urine sample examination for Trichomonas infection

    • Immunofluorescence or DNA amplification for chlamydia if:

      • Sexually active (<25 years of age)

      • At increased risk for particular situation (eg, commercial sex worker)

Aberg JA, et al. Clin Infect Dis. 2004;39:609-629.

New York State Department of Health. Available at:

http://www.hivguidelines.org/GuideLine.aspx?pageID=257&guideLineID=13.


Screening strategies to detect asymptomatic stds subsequent visits

Screening Strategies to Detect Asymptomatic STDs: Subsequent Visits

  • All sexually active patients

    • Screening tests for STDs should be repeated at least annually

  • More frequent periodic screening (at least 3 to 6 month intervals) for asymptomatic persons at higher risk

    • Multiple or anonymous sex partners

    • Past history of any STD

    • Behaviors associated with transmission of HIV or other STDs

    • Sexual or needle-sharing partners with any of the above risks

    • Changes in lifestyle/circumstances that are associated with increased risk behavior

    • High prevalence of STDs in the area or in the patient population

Aberg JA, et al. Clin Infect Dis. 2004;39:609-629.

New York State Department of Health. Available at:

http://www.hivguidelines.org/GuideLine.aspx?pageID=257&guideLineID=13.


Hiv hbv coinfection management begins with detection

HIV/HBV-Coinfection:Management Begins With Detection

  • All HIV-infected patients should be screened for HBV (anti-HBs and HBsAg)

  • Vaccination should be offered to anti-HBV-negative patients

  • Response to vaccine is influenced by CD4 count and HIV RNA level

    • Initiate HAART first if CD4 count is <200 cells/mm3 and there is ongoing HIV RNA replication

USPHS Guideline. Available at: http://www.cdc.gov/ncidod/diseases/hepatitis/b/Bserology.htm.

Lok AS, et al. Hepatology. 2009;50:661-662. Available at:

http://www.aasld.org/Pages/Default.aspx.

EASL. J Hepatol. 2009:50:227-242.


Hiv hbv coinfected patients

HIV/HBV-Coinfected Patients

  • Advise to abstain from alcohol

  • Should receive hepatitis A vaccine if found not to be immune at baseline

    • Absence of hepatitis A total or IgG antibody

  • Advise on methods to prevent HBV transmission (similar to those used to prevent HIV transmission)

  • Evaluate for the severity of HBV infection

DHHS. Available at: http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf.

Revision March 27, 2012.


Hbv treatment options in hiv hbv coinfected patients

HBV Treatment Options inHIV/HBV-Coinfected Patients

Lok AS, et al. Hepatology. 2009;50:661-662. Available at:

http://www.aasld.org/Pages/Default.aspx.

DHHS. Available at: http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf.

Revision March 27, 2012.


Dhhs and aasld recommendations prior to art hiv hcv coinfected patients

DHHS and AASLD RecommendationsPrior to ART: HIV/HCV-Coinfected Patients

  • HCV antibody (EIA)

    • Performed in all HIV-infected persons

  • HCV RNA testing

    • Performed to confirm HCV infection in HIV-infected persons who are positive for anti-HCV

    • Performed in those who are negative and have evidence of unexplained liver disease

  • Patients with HIV/HCV coinfection

    • Advise to avoid alcohol

    • Use appropriate precautions to avoid transmission of both viruses

    • Receive HAV and HBV vaccines if susceptible

DHHS. Available at: http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf.

Revision March 27, 2012.

Ghany MG, et al. Hepatology. 2009;49:1335-1374.


Recommended pre treatment assessments in hiv hcv coinfected patients

Recommended Pre-Treatment Assessments in HIV/HCV-Coinfected Patients

  • Liver disease status

    • HCV RNA, HCV genotype, AFP* and US for HCC, HBV status (HBsAg, anti-HBc), anti-HAV IgG, MELD calculation

  • HIV disease status

    • Presence or history of OIs, HIV-associated malignancy, CD4 cell count, HIV RNA, details of HAART

  • Factors precluding HCV therapy or requiring control prior to initiating HCV therapy

    • TSH; screen for depression or other psychiatric disease; CBC; blood sugar; history of significant cardiac, renal, or pulmonary disease; fundus examination; beta HCG (women of childbearing potential); social support; treatment adherence

*Most hepatologists recommend; not recommended by AASLD.

Singal AK, et al. World J Gastroenterol. 2009;15:3713-3724.


Hiv hcv coinfection who to treat

HIV/HCV Coinfection:Who to Treat

  • Consider comorbid conditions that limit life expectancy or increase the risks associated with HCV therapy

  • HIV disease should be stable with or without HAART

    • CD4 cell count <200 cells/mm3

      • Treat HIV and defer HCV

  • Interferon can exacerbate pre-existing mental illness

    • Evaluate patients with underlying psychiatric disease before initiating HCV treatment

  • Substance abuse

    • Active substance abuse is not a contraindication

    • Associated with high rates of treatment nonadherence and may compromise treatment outcomes

Sulkowski MS, et al. J Viral Hepatitis. 2007;14:371-386.


Mental health and hiv

Mental Health and HIV


Mental disorders and substance abuse

Mental Disorders and Substance Abuse


Depression and hiv

Depression and HIV


Depression and hiv1

Depression and HIV


Management issues in older hiv infected patients

Management Issues in Older HIV-Infected Patients

Choice of HAART

Early initiation of HAART to avoid immune decline and help maintain immune function as patients age

Avoidance of metabolic and other toxicities a key issue

Need for regular screening and health maintenance

Fasting lipids and glucose, renal function, bone disease

Cancer screening as would be performed in general population

Awareness of drug-drug interactions

Management of dyslipidemia

Increased likelihood of need for lipid-lowering therapy

Recognition that HIV-infected patients may not respond as well to lipid-lowering therapy


Effect of adherence on hiv

Effect of Adherence on HIV

Reference: Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in

HIV-1-Infected Adults and Adolescents. Department of Health and Human Services. January 29, 2008. Available at:http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed June 20, 2008.

  • It is important for people to take their meds

  • Taking meds as prescribed helps to fight the virus

    • Viral load may go down

    • When viral load is low, T-cell count can go up

49


Stigma

STIGMA

Church sign in Birmingham, Alabama


  • Login