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HIV Grand Round F2 Dr Sris Allan Consultant GU / HIV Physician Honorary Associate Professor.

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Presentation on theme: "HIV Grand Round F2 Dr Sris Allan Consultant GU / HIV Physician Honorary Associate Professor."— Presentation transcript:

1 HIV Grand Round F2 Dr Sris Allan Consultant GU / HIV Physician Honorary Associate Professor

2 June 2011 – 36 year old weighing 64.5Kg Black African Abnormal cervical smear Contraception discussed Case History – female

3 On examination Case study – female

4 DateCD4 cell countViral load cells /ml HAART – 26.5%<40Atripla – 20.1%<40Atripla – 20.0%<40Atripla – 17.0%<40Atripla – 15.0%<40Atripla – 11.1%<40Atripla – 8.0%<60Atripla – 8.5%3,401Atripla – 10.5%N/A Case study – female

5 June 2011 – 62 years Partner HIV positive SOB >4 years Cough ++ minimal sputum On home oxygen Recurrent chest infection – 2006 to 2011 Chronic obstructive airway disease oesophageal candidiasis – Case study – male

6 Stopped smoking 2 years ago (smoked 70 to 80 cigarettes per day for 45 years) Oxygen saturation 92% Case study – male

7 On examination Right sided R.R – 22/min Very poor air entry Ab = L = 5cm Spleen – J.P. Discussion Case study – male

8 Prescriptions Doxycycline Co-trimoxazole Tests performed FBC U&E LFT HIV – Viral load count CD4 count Case study – male

9 HAART Case study – male

10 July 2011 Feeling better Weight gain of 2kg in 3 weeks Cough better with Doxycycline Feels like a drunk when walking Sleep problems Erythematous rash Discuss side effects Case study – make

11 August 2011 Better No cough Oxygen saturation 98% Right side air entry – good Case study – male

12 October 2012 Knee replacement Discuss surgery in HIV Case study – male

13 January 2013 Erectile dysfunction Discuss treatments of erectile dysfunction Case study – male



16 DateCD4 countViral load cells /ml HAART – 21.4%52Atripla – 20.9%<40Atripla %<40Atripla – 19.0%62Atripla – 18.0%<40Atripla N/A383Atripla – 16.9%226Atripla – 18.2%7,786Atripla – 17.0%1,469,270Atripla Case study – male

17 Take Home messages The size of the problem CD4 count HIV-1 RNA plasma viral load Opportunistic Infections and AIDS Era of antiviral therapy New challenges Adherence, Toxicity, Resistance The continued spread of the epidemic Protected Sex

18 Course of HIV infection

19 Basic principles 4 As a rule of thumb The higher the viral load the faster the disease progression Values for people not on therapy < 40 copies per ml Undetectable <1000 copies per ml very low < 100,000 copies per ml low >100,000 copies per ml very high

20 Basic Principles 5 The clinical presentation of the patient will be related to the degree of the immune suppression. The CD4 count will gives an indication of the degree of immune suppression. Rule of thumb CD cells /mm 3 normal range CD4 > 500 cells /mm 3 minimal immune suppression CD4 ~350 cells /mm 3 moderate immune suppression CD4 <200 cells /mm 3 advanced immune suppression CD4 <50 cells /mm 3 severe immune suppression

21 Hepatitis B & C Epidemiology /Prevalence Transmission Acute infection Chronic infection Diagnosis Natural History Treatment consideration Treatment options

22 US CDC, 2006

23 Acute infection

24 Risk of Chronic HBV Depends on nature of immune response to initial infection Varies according to the age at which the infection is acquired Neonates – almost 100% Young children – about 50% Adults – about 2-10% Immunocompromised Males > Females

25 Diagnosis of chronic HBV Chronic Hepatitis B is defined as viraemia and hepatic inflammation that persists for > 6 months after acute infection with HBV. HBsAg positive Anti–HBc total positive, IgM positive (low titre) HBeAg positive or negative (indicator of viral replication) some variants do not express HBeAg HBV DNA positive

26 Serology of chronic carrier

27 TestResultsInterpretation HBsAg Anti-HBc Anti-HBs Negative Naïve, susceptible HBsAg Anti-HBc Anti-HBs Negative Positive Immune due to natural infection HBsAg Anti-HBc Anti-HBs Negative Positive Immune due to Hepatitis B vaccination HBsAg Anti-HBc IgM Anti-HBc Anti-HBs Positive Negative Acutely infected HBsAg Anti-HBc IgM Anti-HBc Anti-HBs Positive Positive or Negative Negative Chronically infected HBsAg Anti-HBc Anti-HBs Negative Positive Negative Four possibilities

28 Management consideration Patient Liver health Occupational health Baby health Partner/ close contact Prevention is better than (NO) cure Monitor & minimise viral activity

29 Long term agents Lamivudine Nucleoside reverse transcriptase inhibitor In HBeAg positive CHB - treatment is generally for one year or more with the aim to bring eAg seroconversion In HBeAg negative CHB - long term treatment is needed Resistance is the main problem with long term treatment, more than 60% develop resistance after 3 years of treatment.

30 Long term agents Adefovir dipivoxil Structurally related to purine base adenine. Inhibits synthesis of hepatitis B virus DNA through competition for the enzyme reverse transcriptase and incorporation into viral DNA Others: Entecavir Tenofovir Emtricitabine Telbivudine

31 Treatment Life long Monitoring for viral resistance a) genotypic e.g. A181V and N236T for ADV b) virologic a) + >1 log increase in DNA c) clinicala) + b) + ALT rise Regain viral suppression quicker, less clinical decompensation

32 Hepatitis C: The virus ~50 nm

33 Hepatitis C (HCV) Prevalence It is estimated that up to 250,000 people are infected with HCV in England and Wales 1 The number of adults diagnosed with CHC is projected to increase four-fold in the next 15 years in the USA and western Europe 2 The main population subgroups infected with HCV are: 1 Blood donors – 0.04% People attending antenatal clinics in London – 0.4% People attending genitourinary clinics – 1% Intravenous (IV) drug users – 50% 1.NICE technology appraisal guidance Albert A, et al. Dig Liver Dis 2004; 36: 646–654.


35 HCV Natural History infection chronic hepatitis cirrhosis liver failure liver cancer clearance 20% 20 years 30 years 1.4% pa 3.9% pa liver transplantation

36 Treatment consideration Goal: clear HCV Secondary aim: reduction in the rate of fibrosis progression? Assessment and progress markers HCV-RNA ALT Histology Treatment of finite duration Generally poorly tolerated compared to HBV oral agents

37 Predictors of Response to treatment HCV genotype 2 > 3 > 5 > 4 >1 HCV titre the lower the better Amount of liver fibrosis less is better Age younger is probably better Ethnicity inferior response in black patients

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