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Management of the Newly Diagnosed HIV-infected Patient

Management of the Newly Diagnosed HIV-infected Patient. Sarah Lewis MHS, PA-C. Case Presentation. A 32 yo woman presents for care at your clinic, referred from a public health clinic after testing positive for HIV She presented for testing after discovering a past boyfriend of hers is HIV+

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Management of the Newly Diagnosed HIV-infected Patient

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  1. Management of the Newly Diagnosed HIV-infected Patient Sarah Lewis MHS, PA-C

  2. Case Presentation • A 32 yo woman presents for care at your clinic, referred from a public health clinic after testing positive for HIV • She presented for testing after discovering a past boyfriend of hers is HIV+ • What questions do you have for her?

  3. What does she know about HIV? • Human Immunodeficiency Virus • HIV is no longer a ‘death sentence’ • Diabetes mellitus can be a useful analogy • Chronic, incurable disease • Not immediately fatal • Eventually requires medications in most cases • Can usually be controlled with careful adherence, management, and follow-up • As with the care of persons with diabetes, working in a team and providing continuing education is essential throughout the course of the disease • Patients educated about HIV and the potential for resistance have better adherence to therapy1,2 1. Malow RW, et al. Alcohol Drug Abuse 1998;49:1021-4. 2. Tuldra A, et al. 39th Interscience Conference on Antimicrobial Agents and Chemotherapy; 1999; Abstract 595.

  4. HIV 101 for Patients

  5. History of HIV • retroviruses discovered in 1900 in animals only • HIV related to primate retroviruses, that may have crossed species into humans and undergone mutations that became HIV as early as 1675?? • established in Africa as an epidemiologic disease after 1930 • 1980 1st retroviruses found to affect T cells • Gallo, Essex, & Montagnier pioneers of the cause of AIDS

  6. History of HIV • 1981 1st descriptions of immunodeficiency disease in previously healthy person in medical literature • specific retrovirus, HIV-1 was not isolated until 1983 • HIV-2 (West Africa) is distinct from HIV-1 (Central Africa) by a longer clinical latency period • although syndrome of AIDS was not reported until 1981, isolated cases were clearly reported in 1950s & 1960s

  7. History of HIV • HIV antibodies found in blood sample from 1950s in Central Africa suggesting emergence in 1930s; • remained localized there until spreading to Africa and then Haiti in late 1970s • to US & Europe from Haiti & Africa • first suspect US case 1968 15 y/o BM St. Louis w/ Kaposi’s & disseminated Chlamydial; blood samples + for HIV • HIV blood transmission documented 1982 • HIV testing 1985 • HIV drug Rx approved 1987

  8. Primary HIV Infection (PHI)a/k/a Acute HIV Infection • Pathogenesis • Clinical Presentation • Diagnosis • Epidemiology • PHI and the Natural History of HIV Disease • Treatment Options • Conclusions & Recommendations

  9. Etiology: HIV Structure • RNA retrovirus • RNA into DNA an absolute must to multiply • core, nucleocapsid • double stranded RNA-genome at least nine genes • protein & enzymes • reverse transcriptase (RNA-to-DNA) • polymerase (DNA-to DNA) • ribonuclease (destroys old RNA) • integrase (splices viral DNA into host DNA, now permanent) • protease (molecular scissor) • spherical lipid bilayer viral envelope

  10. Life Cycle of HIV

  11. Sites of Action of antiretroviral Medications

  12. Exposure to HIV at mucosal surface (sex) Day 0 Virus collected by dendritic cells, carried to lymph node Day 0-2 HIV replicates in CD4 cells, released into blood Day 4-11 Day 11 on Virus spreads to other organs Kahn JO, Walker BD. N Engl J Med. 1998;339:33-39.

  13. Primary HIV Infection: Pathogenesis CD4 Cell Count (cells/mm³) Symptoms Plasma RNA Viral Load 1,000 CD4 Cell Count 500 4-8 Weeks Up to 12 Years 2-3 Years

  14. How often do people with PHI seek health care? Swiss cohort • 87% of seroconverters (20/23) in cohort study had symptoms • 95% of these patients had medical evaluation • PHI considered in only 5 of 19 patients PHI often leads to medical evaluation, but is under-diagnosed! Schacker T et al. Ann Int Med 1996;125:257-64.

  15. How does HIV cause AIDS? • HIV infects and destroys an important type of cell in the body’s immune system known as the T-helper (TH) cell, also known as the CD4 cell

  16. How does HIV cause AIDS? • CD4 cells direct and coordinate other cells in the immune system to battle infections • When CD4 cells are destroyed, the body loses its ability to fight off infections

  17. HIV Infection is characterized by a steady decline in the number of CD4 cells Acute Infection Asymptomatic HIV Infection AIDS CD4 Cell Count 1,000 CD4 Cells 500 200 4-8 Weeks Up to 12 Years 2-3 Years Time

  18. HIV Infection is characterized by a steady decline in the number of CD4 cells CD4 Cell Count (cells/mm³) Acute Infection Asymptomatic HIV Infection AIDS 1,000 CD4 cell count 500 200 high risk of opportunistic infections 4-8 Weeks Up to 12 Years 2-3 Years Time

  19. How does HIV cause AIDS? • Infections that develop as a result of HIV-inflicted damage to the immune system are called “opportunistic infections” or “OIs” • When someone with HIV develops an opportunistic infection, they are diagnosed with AIDS

  20. How does HIV cause AIDS? • In the past, virtually all patients diagnosed with AIDS died within a few years • Now, with treatment, many patients diagnosed with AIDS are surviving many years with the disease

  21. What is the “Viral Load”? • The HIV viral load is simply a measure of the quantity of HIV in a drop (mL) of a patient’s blood, and it is usually measured in copies/mL • In general, the higher the viral load, the faster CD4 cells are destroyed

  22. Clinical Approach to the Diagnosis of Primary HIV Infection • Exposure • Signs & Symptoms • Laboratory Testing

  23. Exposure Risks (average, per episode, involving HIV-infected source patient)

  24. Primary HIV Infection: Signs & Symptoms • 40-90% of patients will be symptomatic • A mononucleosis-like illness of non-specific signs and symptoms • Signs and symptoms typically begin 1-4 weeks post-exposure • High index of suspicion is critical Kahn JO, Walker BD. N Engl J Med. 1998;339:33-39. Schacker T, et al. Ann Intern Med. 1996;125:257-264.

  25. Primary HIV Infection: Common Signs & Symptoms N = 160 patients with PHI in Geneva, Seattle, and Sydney % of patients Vanhems P et al. AIDS 2000; 14:0375-0381. 

  26. Primary HIV Infection: Other Signs & Symptoms % of patients Kahn JO, Walker BD. N Engl J Med. 1998;339:33-39.

  27. Primary HIV Infection Rash Mucosal Lesions Trunk and face > limbs Small pink macules Oral ulcers, thrush (Kahn, NEJM, 1998)

  28. Oral Ulcers in Acute HIV Infection From: Walker, B. 40th IDSA, Chicago 2002.

  29. Genital Ulcer in Acute HIV Infection From: Walker, B. 40th IDSA, Chicago 2002.

  30. Diagnostic Testing for PHI 1 mil HIV RNA 100,000 + HIV RNA HIV-1 Antibodies _ 10,000 Ab P24 + 1,000 Exposure 100 Symptoms 10 0 20 30 40 50 Days

  31. Diagnostic Testing:Viral Load • More sensitive than HIV antibody or p24 Ag test3 • Positive one to three weeks before antibody test1 • Typically high level, e.g. greater than 50,000-100,000 copies/mL2,3 • False positives can occur • Most false positives are low level (<10,000 copies/mL) • HIV VL <10,000 copies/mL should probably be considered “indeterminate” 1. Busch MP, Satten GA. Am J Med 1997;102:Suppl 5B:117-24. 2. Kahn JO, Walker BD. N Engl J Med. 1998;339:33-39. 3. Daar ES et al. Ann Intern Med. 2001;134:25-29.

  32. Diagnostic Testing: HIV Antibody • The gold standard for diagnosis of HIV infection when used with confirmatory Western Blot • Antibody conversion typically 22-27 days following infection1 1. Kahn JO, Walker BD. N Engl J Med. 1998;339:33-39.

  33. Why do we Care about Diagnosing PHI? • Public Health: • Patients with PHI are likely to be highly infectious • Diagnosis of HIV infection may lead to safer sex • Personal Health • 40% of patients with HIV not diagnosed until they have AIDS • Antiretroviral therapy (ART) during PHI may alter the natural course of HIV disease

  34. HIV Rapid Tests

  35. Public Health Need for Rapid HIV Tests • High rates of non-return for test results • In 2000, 31% did not return for results of HIV-positive conventional tests at publicly funded sites • Need for immediate information or referral for treatment choices • Perinatal settings • Post-exposure treatment settings • Screening in high-volume, high-prevalence settings

  36. Multispot HIV-1/HIV-2 Uni-Gold Recombigen Reveal G2 OraQuick Advance

  37. Multispot HIV-1/HIV-2 Uni-Gold Recombigen Reveal G2 OraQuick Advance

  38. Four FDA-approved Rapid HIV Tests Sensitivity (95% C.I.) Specificity (95% C.I.) OraQuick Advance - whole blood - oral fluid - plasma 99.6 (98.5 - 99.9) 99.3(98.4 - 99.7) 99.6 (98.5 - 99.9) 100(99.7-100) 99.8(99.6 – 99.9) 99.9(99.6 – 99.9) Uni-Gold Recombigen - whole blood - serum/plasma 100(99.5 – 100) 100 (99.5 – 100) 99.7(99.0 – 100) 99.8 (99.3 – 100)

  39. Four FDA-approved Rapid HIV Tests Sensitivity (95% C.I.) Specificity (95% C.I.) Reveal G2 serum plasma 99.8(99.2 – 100) 99.8(99.0 – 100) 99.1 (98.8 – 99.4) 98.6 (98.4 – 98.8) Multispot serum/plasma HIV-2 100 (99.9 – 100) 100 (99.7 – 100) 99.9 (99.8 – 100)

  40. Additional Rapid Tests • FDA approved – May 2006 Sure Check Stat Pak

  41. Confirmatory Testing • Confirmatory test is essential (not just EIA) • For Western blot: • Venipuncture for whole blood • Oral fluid specimen • Follow-up testing of persons with negative or indeterminate Western blot results after 4 weeks

  42. The Berlin Patient • Treated soon after acute HIV infection with didanosine, indinavir, and hydroxyurea • Baseline VL 80,000-89,000 pre-treatment • Treatment briefly interrupted twice in first 4 months of treatment • Viral rebound during first interruption but not the second • VL remained undetectable after treatment was stopped a third time Lisziewicz J et al. NEJM 1999; 340: 1683-1684.

  43. Unplanned Treatment Interruptions of ART following Primary HIV Infection: “the Berlin Patient” ARV Rx Started Prior to HIV Seroconversion ddI + HU + IDV No ARV Rx Lisziewicz J et al. N Engl J Med 1999;340:1683.

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