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

2. 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

3. 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

5. 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?

6. Baseline & Follow Up Labs
CD4 count
Normal: /- 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

7. 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

8. 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

9. 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

10. 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

11. 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

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

14. 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

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

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