1. 26 th Annual PCOMS Winter Conference HIV Infection or Infestation Kerry Chamberlain D.O., FACOI Florida Cancer Specialists January 28, 2015

2. Objectives Historical perspective Update on the status of HIV in the world & our community and how it impacts us. Update on post exposure prophylaxis

3. Disclosure I have no financial relationship in regard to the content of this presentation Although I wish I did

5. The Revolution at the Corner Drugstore Wall Street Journal January 24, 2015 CVS is the largest supplier -25% of the $86 BILLION industry Expected growth 38% to 50% Fee for service is fading out CVS- becoming “integrated pharmacy-care organization. Our purpose, our goal is to help people on their path to better health”

6. The Revolution at the Corner Drugstore 960 walk in clinics in 31 states and growing “a shelf of academic research shows the quality of care at such clinics is the same or sometimes better than the ER” “Advanced pharmaceutical therapies, for diseases like multiple sclerosis and HIV, are often more complex than simply taking a pill” “adherence --- ensuring that patients take the medications' they are prescribed --- is one area where CVS can contribute”

7. The Revolution at the Corner Drugstore “manage the pharmacy patient, not just the administration of the drug”—Larry Merlo CEO of CVS

8. New England Journal of Medicine January 22, 2015 South Africa – 6.2 million infected with HIV---18% of all adults Highest rate among sexually active women 2.4 million HIV adults and 156,000 children are in active treatment Annual exams – goal is undetectable level of viral load Initial regimen is tenofvir, lamivudine, and emtricitabine as a single pill costs ~ $8/ month

9. New England Journal of Medicine January 22, 2015 In Africa 25% of patients who begin ART are lost to F/U by a year later 25% viral suppression is not achieved Annual viral load measurements should replace routine CD-4 testing for stable healthy ART recipients

11. Factoids on HIV in the US Southern states in the U.S. had the nations lowest 5 year survival rate – diagnosed with HIV or AIDS 2003-2004 Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Texas – Clinical Advisor January 14, 2015

12. Factoids of HIV Half life of HIV in serum is 1.2 days 24 hours intracellular 6 hours extracellular 30% of total body viral burden is turned over daily– this means that AIDS is a result of continuous high level HIV-1 replication and destruction of CD4 lymphocytes Unclear why 99.7% of occupational exposures DO NOT transmit the virus

13. Factoids of HIV US- more than 80% of current infections of HIV occur through heterosexual transmission Over 50% of all HIV infected people in the world are women Over 50 year old crowd is a growing population. Nine subtypes in worldwide circulation

14. Where did HIV Come From?

15. History & Perspective 1983 – discovered to be a retrovirus 1985 – discovered a serological test for diagnosis 1987- discovered the first antiviral drugs 1996 – introduction of HAART (highly active antiretroviral therapy) 1999- the mortality of AIDS diagnosis and hospitalizations fell 60-80%

16. Stages of HIV Infection Transmission Acute infection (primary HIV infection) Seroconversion Clinical latent period w/wo adenopathy Early symptomatic HIV infection AIDS (CD4 <200/ml & other criteria) Advanced AIDS (CD4 <50/ml)

17. Risk Factors for Transmission Viral load Circumcision- lowers risk by ~ 60% Sexual risk Ulcerative sexually transmitted diseases Nitrate inhalant use Host and genetic factors

19. National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention Division of HIV/AIDS Prevention Epidemiology of HIV Infection through 2012

20. Diagnoses of HIV Infection among Adults and Adolescents, by Sex, 2008–2012—United States and 6 Dependent Areas Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting.

21. Diagnoses of HIV Infection among Adults and Adolescents, by Transmission Category, 2008–2012—United States and 6 Dependent Areas Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays and missing transmission category, but not for incomplete reporting. a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection. b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.

22. Diagnoses of HIV Infection among Adults and Adolescents, by Transmission Category, 2012—United States and 6 Dependent Areas N = 48,651 Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays and missing transmission category, but not for incomplete reporting. a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection. b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.

23. Diagnoses of HIV Infection among Adults and Adolescents, by Sex and Transmission Category, 2012—United States and 6 Dependent Areas Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays and missing transmission category, but not for incomplete reporting. a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection. b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.

24. Diagnoses of HIV Infection among Adults and Adolescents, by Race/Ethnicity, 2008–2012—United States and 6 Dependent Areas Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting. a Hispanics/Latinos can be of any race.

25. Diagnoses of HIV Infection among Adults and Adolescents, by Sex and Race/Ethnicity, 2012—United States and 6 Dependent Areas Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting. a Hispanics/Latinos can be of any race.

26. Rates of Diagnoses of HIV Infection among Adults and Adolescents, 2012—United States and 6 Dependent Areas N = 48,651Total Rate = 18.4 Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting.

27. Rates of Diagnoses of HIV Infection among Adults and Adolescents, by Sex and Race/Ethnicity, 2012—United States Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting. Rates are per 100,000 population. a Hispanics/Latinos can be of any race.

28. Diagnoses of HIV Infection among Adult and Adolescent Males, by Race/Ethnicity, 2012—United States Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting. Rates are per 100,000 population. a Hispanics/Latinos can be of any race. b Because column totals for estimated numbers were calculated independently of the values for the subpopulations, the values in each column may not sum to the column total.

29. Diagnoses of HIV Infection among Adult and Adolescent Females, by Race/Ethnicity, 2012—United States Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting. Rates are per 100,000 population. a Hispanics/Latinos can be of any race. b Because column totals for estimated numbers were calculated independently of the values for the subpopulations, the values in each column may not sum to the column total.

30. Deaths of Persons with Diagnosed HIV Infection, by Race/Ethnicity, 2011—United States Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. Deaths of persons with a diagnosed HIV infection may be due to any cause. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting. Rates are per 100,000 population. a Includes Asian/Pacific Islander legacy cases. b Hispanics/Latinos can be of any race. c Includes persons of unknown race/ethnicity. Because column totals for estimated numbers were calculated independently of the values for the subpopulations, the values in each column may not sum to the column total.

31. Adults and Adolescents Living with Diagnosed HIV Infection, by Sex and Race/Ethnicity, Year-end 2011— United States and 6 Dependent Areas Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting. a Includes Asian/Pacific Islander legacy cases. b Hispanics/Latinos can be of any race.

32. Adults and Adolescents Living with Diagnosed HIV Infection, by Sex and Transmission Category, Year-end 2011— United States and 6 Dependent Areas Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays and missing transmission category, but not for incomplete reporting. a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection. b Includes hemophilia, blood transfusion, and risk factor not reported or not identified.

33. Rates of Adults and Adolescents Living with Diagnosed HIV Infection, Year-end 2011—United States and 6 Dependent Areas N = 896,621Total Rate = 342.1 Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting.

34. Stage 3 (AIDS) Classifications and Deaths of Persons with HIV Infection Ever Classified as Stage 3 (AIDS), among Adults and Adolescents, 1985–2011—United States and 6 Dependent Areas Note. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting. Deaths of persons with HIV infection, stage 3 (AIDS) may be due to any cause.

35. Stage 3 (AIDS) Classifications among Adults and Adolescents with HIV Infection, by Race/Ethnicity and Year of Diagnosis, 1985–2012— United States and 6 Dependent Areas Note. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting. a Hispanics/Latinos can be of any race. b Includes Asian/Pacific Islander legacy cases.

36. Percentages of Stage 3 (AIDS) Classifications among Adults and Adolescents with HIV Infection, by Race/Ethnicity and Year of Diagnosis, 1985–2012—United States and 6 Dependent Areas Note. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting. a Hispanics/Latinos can be of any race. b Includes Asian/Pacific Islander legacy cases.

37. Stage 3 (AIDS) Classifications among Adults and Adolescents with HIV Infection, by Transmission Category and Year of Diagnosis, 1985–2012— United States and 6 Dependent Areas Note. All displayed data have been statistically adjusted to account for reporting delays and missing transmission category, but not for incomplete reporting. a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection. b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.

38. Percentages of Stage 3 (AIDS) Classifications among Adults and Adolescents with HIV Infection, by Transmission Category and Year of Diagnosis, 1985–2012—United States and 6 Dependent Areas Note. All displayed data have been statistically adjusted to account for reporting delays and missing transmission category, but not for incomplete reporting. a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection. b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.

39. Stage 3 (AIDS) Classifications among Adults and Adolescents with HIV Infection, by Sex and Transmission Category, 2012— United States and 6 Dependent Areas Note. All displayed data have been statistically adjusted to account for reporting delays and missing transmission category, but not for incomplete reporting. a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection. b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.

40. Stage 3 (AIDS) Classifications among Adults and Adolescents with HIV Infection, by Race/Ethnicity, 2012—United States Note. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting. Rates are per 100,000 population. a Includes Asian/Pacific Islander legacy cases. b Hispanics/Latinos can be of any race. c Because column totals for estimated numbers were calculated independently of the values for the subpopulations, the values in each column may not sum to the column total.

41. Persons Living with Diagnosed HIV Infection Ever Classified as Stage 3 (AIDS), by Race/Ethnicity, 1993–2011—United States and 6 Dependent Areas Note. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting. a Hispanics/Latinos can be of any race. b Includes Asian/Pacific Islander legacy cases.

45. HIV Testing  Antibody detection  Window period of antibody development  Detectable antibodies in 2-8 weeks avg-25 days  97% will have antibodies in 3 months  Rare cases can take up to 6 months  All positive tests MUST be confirmed

46. Factoid The deferral of ART beyond 12 months of estimated Seroconversion reduces the likelihood of immunologic health in patients with HIV-1 Subjects with CD4 counts > 500 cells/ul at ART initiations had significantly higher CD4 normalization rates compared to those with CD4 counts less than 500

49. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings-I HIV screening for pt in all health-care setting after the pt is notified that testing will be performed unless the pt declines Persons at high risk for HIV should be screened at least annually Separate written consent for HIV testing should not be required

50. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings-II Prevention counseling should not be required with HIV diagnostic testing or a as part of HIV screening programs in health-care settings. HIV screening should be included In the routine panel of prenatal screening tests. HIV screening is recommended after the pt is notified that testing will be performed unless she opts out

51. HIV 2  1986 Isolated from AIDS patient in West Africa  Same mode of transmission  Immunodeficiency slowly develops/less infectious  Predominantly found in Africa  HIV 1 inhibited by HIV 2 –NEJM 2012

52. Modes of Transmission  Sharp object  Blood or tissue donation  Medical or dental practices  Eating pre-chewed food  Bitten  Broken skin  French kissing  Tattooing  Infants to mother via breastfeeding- Europe only

53. Mode of Transmission  Not by air or water or insects  Not by spitting  Not by shaking hands  Not by sharing dishes  Not by social kissing

54. Role of Primary Care in HIV ART has altered the natural history Infections less common Greater than 50% of deaths NOT related to HIV HIV and its treatment increase cardiac/renal/hepatic/malignancies

55. Background June 5, 2011 marked the 30 th year of the CDC identifying HIV/AIDS Initially 100% fatal now average life expectancy is more than 20 years Still not under control Success is possible – remember polio, chickenpox & smallpox No STD has ever been under control in a free democratic society except by vaccine

56. Initial Visit Document the HIV antibody –Chamberlain’s law: patients lie to you doctors lie to you! –Repeat the test! Unless it is right in front of you

57. Initial Visit- continued Gage the patients level of understanding Risk Factors past and present History of previous infections Quantitation of CD4/viral load Hepatitis studies of A/B/C Document TB-ppd

58. Initial Visit --Continued Cardiovascular Risk Factors Hypertension/DM/Dyslipidemia– will influence ART Protease inhibitors increase glucose intolerance and dyslipidemia

59. Initial Visit --Continued STD’s –Herpes simplex and anal or genital warts will require treatment

60. Initial Visit --Continued Cancer– higher incidence of malignancy

61. Initial Visit --Continued Psychiatric- as in any chronic diseases Medication history Immunization history Substance abuse Family History

62. Role of ART Prolong life Greater quality of life Restore an preserve immunological function Suppress HIV viral load

63. Health Maintence Immunizations CD4 greater than 200 give pneumococcal every 5 years influenza yearly-ok for yearly inactivated Hepatitis B vaccine Hepatitis A vaccine Cervical Cancer Screening every 6 – 12 months

64. Health Maintance Anal Cancer– both male and female STD’s Age appropriate screening –Breast –Prostate –Colon

65. General Considerations Avoid raw eggs/seafood Avoid colon cleansing Don’t drink where fish dogs cattle pee Fully cook your food Wear gloves when cleaning out litter box

66. Occupationally Acquired HIV Among Healthcare Workers Since 1999 only one confirmed case reported to the CDC (data from 58 confirmed and 150 possible cases 1985-2013) Post Exposure Management- 2013 Pre-Exposure Prophylaxis (PrEP)- 2014

67. Determining need for Prophylaxis

68. Postexposure Prophylaxis for HIV Infection NEJM October, 29, 2009 Vol. 361. NO. 18

69. Regimens for 28-Day Postexposure Prophylaxis for HIV Infection Landovitz R, Currier J. N Engl J Med 2009;361:1768-1775

70. Clinical Manifestations of the Acute HIV Infection Fever Lymphadenopathy Sore throat Rash Myalgia Headache Cough

71. Establishing the Diagnosis Continued Vague symptoms Financial burden on the physicians Physician bias Patients prefer the anonymous testing of “clinics” Patients don’t see themselves at high risk– remember “a alcoholic is someone who drinks more than his physician”

72. Conclusions  After rapidly increasing since the 1980s, the annual rate of death due to HIV infection peaked in 1994 or 1995 (depending on the demographic group), decreased rapidly through 1997, and continued to decrease much more slowly thereafter.  Persons dying of HIV infection increasingly consist of:  women (27% in 2010)  blacks/African Americans (54% in 2010)  residents of the South (52% in 2010)  persons 45 years of age or older (67% in 2010)  HIV infection remains as one the leading causes of death among persons 25 to 44 years old, particularly among blacks/African Americans.

73. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention

75. HIV Vaccine Status 16,000 volunteers in Thailand –Thai specific ALVAC-HIV & AIDSVAX in combination Prime the immune process and a booster for later immunity Decrease in contracting HIV by 31.2%

77. The End