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AIDS Rates per100,000 Population. Reported in1999. 6.3. 3.4. VT. 6.4. 1.5. 1.1. 6.8. 4.0. 3.8. NH. 2.0. 2.9. 42.3. 23.5. 2.2. MA. 6.6. RI. 10.8. 3.1. 17.9. 3.0. 16.4. CT. 4.0. 25.1. NJ. 13.4. 4.9. 6.1. 24.7. 12.8. DE. 7.3. 3.8. 29.5. MD. 7.9. 16.4. 13.7.

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  1. AIDS Rates per100,000 Population Reported in1999 6.3 3.4 VT 6.4 1.5 1.1 6.8 4.0 3.8 NH 2.0 2.9 42.3 23.5 2.2 MA 6.6 RI 10.8 3.1 17.9 3.0 16.4 CT 4.0 25.1 NJ 13.4 4.9 6.1 24.7 12.8 DE 7.3 3.8 29.5 MD 7.9 16.4 13.7 9.7 6.4 161.5 7.0 DC 10.4 13.8 18.4 4.4 5.3 7.6 24.7 21.5 10.9 15.2 15.9 Rate per 100,000 36.2 19.5 <5 2.4 5 - 14.9 8.4 15+ PR 32.1 VI 32.6

  2. Pediatric AIDS Cases Reported in 1999 N=263 0 0 0 1 0 1 1 1 7 0 MA 1 38 0 4 0 RI 2 0 CT 23 0 0 22 NJ 1 4 19 0 3 4 DE 0 1 12 10 MD 3 1 2 1 DC 3 3 1 13 0 0 0 4 1 11 3 13 1 Number of Cases 39 <5 0 5 -14 0 PR 5 15 VI 1

  3. Estimated Incidence of AIDS and Deaths of Adults with AIDS*, 1985 - June 1999, United States 25,000 1993 definition AIDS implementation Deaths 20,000 15,000 Number of Cases/Deaths 10,000 5,000 0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Quarter-Year of Diagnosis/Death *Adjusted for reporting delays

  4. Acute HIV Syndrome: 1-8 weeks Fever 96% Rash 70% Sore Throat 70% Adenopathy 74% Myalgias 54% Headache 32% Diarrhea, N-V, malaise, thrush, hepatosplenomegaly, neuro sx (meningitis/neuropathy, facial palsy) Oral/Genital Ulcers -- Specific

  5. Counseling and Testing Who and when to test Types of tests

  6. Exposures in the Occupational Setting Needlestick 0.03 percent Risk Stratification a. Deep injury b. Visible blood c. Device used in artery or vein d. Advanced disease

  7. Exposures in the Occupational Setting Treatment (PEP) reduced transmission 80% Zidovudine plus lamivudine +/- protease inhibitor Other regimens for exposures from source patients with documented or possible ARV drug resistance

  8. Routine Health Care Medical/Psychosocial/Family History Physical Examination Markers of HIV Disease Progression • CD4+ (T-helper) lymphocyte count • Viral load

  9. Labs (Routine) CD4+ Urinalysis (?) Viral load+ CXR CBC + Platelets + Sed rate Serum chemistries + LDH Syphilis serologies +Cryptococcal antigen Toxoplasmosis titre (?) + G6PD Lipid profile

  10. Other Immunizations, including influenza vaccine, pneumovax, measles, + hepatitis B No OPV in families with HIV positive person Pap smear: 6 mos x2; 12 mos PPD (5 mm) Anergy testing not recommended: assess risk Prophylaxis not indicated for PPD negatives with risk factors only

  11. Combination Antiretroviral Therapy Indications • CD4+ 350-200 cells/uL • Viral load > 55,000 copies • Symptomatic disease • Decision must be individualized

  12. Reverse transcriptase inhibitors (RTIs) • Zidovudine (AZT, ZVD, Retrovir) • Didanosine (ddI, Videx or Videx EC) • Zalcitabine (ddC, Hivid) • Stavudine (d4T, Zerit) • Lamivudine (3TC, Epivir) • Abacavir (Ziagen)

  13. Protease inhibitors (PIs) • Nelfinavir (Viracept) • Indinavir (Crixivan) • Saquinavir (Fortovase) • Ritonavir (Norvir) • Amprenavir (Agenerase) • "Boosted“ regimens: Ritonavir plus saquinavir, indinavir, nelfinavir, abacavir, or lopinavir 400 mg (Kaletra); nelfinavir plus indinavir or saquinavir.

  14. Non-nucleoside reverse transcriptase inhibitors (NNRTIs) • Efavirenz (Sustiva) • Nivarapine (Viramune) • Delavirdine (Rescriptor)

  15. Nucleotide reverse transcriptase inhibitor • Tenofovir (Viread)

  16. Indications of response to ARVs Viral load decrease CD4 count increase Some effect within 4-6 weeks CD4+ increase within 2-4 months Ideal: undectectable by 4-6 months

  17. Treatment failure Adherence problems Drug interactions; inadequate drug delivery Resistance: de novo during treatment off treatment Resistance testing – genotypic, phenotypic

  18. Changing Therapy Viral load increase; CD4+ decrease Progressive disease Change 2 or more drugs Goals of therapy: suppression? non-detectable viral load?

  19. Complications of ARV therapy Lipodystrophy, lipid abnormalities Lactic acidosis Glucose intolerance Activation or reactivation of disease (immune reconstitution)

  20. Drug interactions • Among ARVs • Special considerations with anti-tuberculosis therapy, especially with rifampin

  21. Prophylaxis against OIs(Opportunistic Infections) Pneumocystis carinii < 200 CD4+ Toxoplasma gondii < 100 CD4+ M. avium complex (MAC) < 50 CD4+ M. tuberculosis Any CD4+

  22. Prophylaxis Not Required: • Fungal infections • HSV • CMV

  23. Discontinuation of primary prophylaxis with effective ARV therapy Pneumocystis carinii >200 for >3 months Toxoplasma gondii >100 for > 3 months M. avium complex (MAC) >100 for > 6 months following 12 months of therapy

  24. Candidal infections • Oral, vaginal, etc infections • Esophageal candidiasis • Systemic candidal infections

  25. Acute PCP Trimethoprim-Sulfamethoxazole 15 mg TMP/75 mg SMX per kg (Septra,TM BactrimTM) daily given in 3 - 4 doses po or as 1 - 2 hour IV infusion for patients with PaO2< 70 add: Methylprednisolone (IV) 40 mg bid for 5 days followed by or 40 mg q d for 5 days followed by Prednisone (po) 20 mg q d for 11 days (can also be tapered to zero over last 11 days)

  26. Hepatitis C Co-infection decisions: Whether to treat hepatitis C Which to treat first

  27. Sources of Information Guidelines: www.hivatis.org www.cdc.gov General Information, Links to Guidelines, and Other Websites: www.hivinsite.ucsf.edu www.hopkins-aids.edu www.ama-assn.org/special/hiv

  28. NATIONAL HIV/AIDS CLINICIANS' CONSULTATION CENTERwww.ucsf.edu/hivcntrNational HIV Telephone Consultation Service (Warmline)National Clinicians’ Post-Exposure Prophylaxis Hotline (PEPline)Health Resources and Services Administration (HRSA)AIDS Education and Training Centers (AIDS ETC)Centers for Disease Control and PreventionAmerican Academy of Family Physicians

  29. National HIV Telephone Consultation Service (Warmline)(800) 933-3413 For questions about HIV/AIDS, including antiretroviral therapy, clinical manifestations, laboratory evaluation, etc. Monday-Friday 6 am – 5 pm PST

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