Farinaz khan Dept of FCM HIV Care for PCPs Farinaz khan Dept of FCM

HIV in the U.S. 1.2 million people currently living with HIV 50,000 new cases each year ~20 to 25% do not know they are positive up to 70% are getting suboptimal care Untreated, generally has a 10-year progression until opportunistic infections and malignancies appear

HIV in New Mexico (in 2016) Prevalence: 3215 Incidence: 125 Mortality: 72 Rate of black vs white women is 10.6 times more; latina is 1.4 Rate of black vs white men is 2.7; latino is 1.2 Transmission Men  MSM Women  hetero sex

Initial Steps Take a good history Presence of thrush, ulcers/warts, lymphadenopathy, skin lesions Screening for adolescents and adults aged 15 to 65 years Very high risk: annually Higher than average risk: q 3-5 years Screen each pregnancy Patient comes up positive  what to do next?

Baseline & Follow Up Labs CD4 count Normal: 1000 +/- 200 Check 3 months after tx starts; then q 3-6 months q 12 months when CD4 > 300 Increase by 50 to 150 per year until steady state HIV genotype Viral load At tx start; then 2-8 weeks later q 4-8 weeks until VL < 200; then q 3-6 months Undetectable levels are typically achieved in eight to 24 weeks Check G6PD, HLA B5701, toxoplasma, hepatitis panel

Labs cont’d CBC with diff 3-6 months CMP 2-8 weeks after tx start, then 3-6 months Lipid panel 4-8 weeks after tx start, then annually UA annually Pap smear: q 6-12 months, then q 3 years if the initial three results are normal (+/- cotesting) abnormal, get colposcopy TST or IGRA annually based on risk >/= 5 mm is positive

What to start… Regimen consists of two nucleoside reverse transcriptase inhibitors (NRTIs) + third active drug from one of 3 drug classes: integrase strand transfer inhibitor (INSTI) non-nucleoside reverse transcriptase inhibitor (NNRTI) Protease inhibitor (PI) with a pharmacokinetic (PK) enhancer Get a pregnancy test

Initial Regimen Stribild Don’t use if Cr Cl < 70 Coformulated elvitegravir 150 mg; cobicistat 150 mg; emtricitabine 200 mg; tenofovir disoproxil fumarate 300 mg Don’t use if Cr Cl < 70 Tenofovir disoproxil has increased risk of nephrotoxicity, bone loss Cobicistat has potential for multiple drug interactions Risk of hepatitis B flare if stopped 1 pill, take with food, don’t take with Mg/Al/Ca antacids

Regimens cont’d Triumeq: Coformulated abacavir 600 mg; dolutegravir 50 mg; lamivudine 300 mg Don’t use if Cr Cl < 50 or HLA B5701 positive Dolutegravir is relatively well tolerated and lipid- and glucose-neutral Increase risk of cardiotoxicity, transaminitis Risk of hepatitis B or C flare if stopped 1 pill, don’t take with Mg/Al/Ca antacids

Regimens cont’d Genvoya Less favorable to lipids Coformul elvitegravir 150 mg; cobicistat 150 mg; emtricitabine 200 mg; tenofovir alafenamide 10 mg Less favorable to lipids Don’t use if Cr Cl < 30, renal dysfunction Cobicistat has potential for multiple drug interactions Risk of hepatitis B flare if stopped 1 pill, take with food, don’t take with Mg/Al/Ca antacids

Meeting patients where they’re at Start when patients are ready Emphasize adherence Biopsychosocial model Cost Stigma Preventing transmission PEP PrEP

PrEP Truvada Tenofovir disoproxil fumarate and emtricitabine Risk of getting HIV is up to 92% lower with consistent use Get negative HIV test, chem7, hep B vaccination status/titer F/u appt q 3 months, do HIV test Check BMP q 3-6 months Test for STIs q 6 months needle exchange, condoms, counseling

When to ask for help Cases of antiretroviral drug resistance, consideration of alternative regimens HIV/AIDS Management Hotline 1-800-933-3413 (Monday through Friday, 9 a.m. to 8 p.m. EST) Perinatal HIV Hotline 1-888-448-8765 (24 hours, 7 days a week)

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