Presentation is loading. Please wait.

Presentation is loading. Please wait.

HIV Grand Round F2 Dr Sris Allan Consultant GU / HIV Physician

Similar presentations

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

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

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

3 Case study – female On examination

4 Case study – female Date CD4 cell count Viral load cells /ml HAART
400 – 26.5% <40 Atripla 310 – 20.1% 310 – 20.0% 340 – 17.0% 180 – 15.0% 200 – 11.1% 180 – 8.0% <60 220 – 8.5% 3,401 150 – 10.5% N/A

5 Case study – male 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 –

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

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

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

9 Case study – male HAART

10 Case study – make July 2011 Discuss side effects 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

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

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

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



16 Case study – male Date CD4 count Viral load cells /ml HAART 19.06.13
180 – 21.4% 52 Atripla 160 – 20.9% <40 % 160 – 19.0% 62 160 – 18.0% N/A 383 100 – 16.9% 226 140 – 18.2% 7,786 90 – 17.0% 1,469,270

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 /mm3  normal range CD4 > 500 cells /mm3  minimal immune suppression CD4 ~350 cells /mm3  moderate immune suppression CD4 <200 cells /mm3  advanced immune suppression CD4 <50 cells /mm3  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 Test Results Interpretation Naïve, susceptible
HBsAg Anti-HBc Anti-HBs Negative Naïve, susceptible Positive Immune due to natural infection Immune due to Hepatitis B vaccination IgM Anti-HBc Acutely infected Positive or Negative Chronically infected Four possibilities

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

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) clinical a) + 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 Wales1 The number of adults diagnosed with CHC is projected to increase four-fold in the next 15 years in the USA and western Europe2 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% NICE technology appraisal guidance 106 Albert A, et al. Dig Liver Dis 2004; 36: 646–654.


35 HCV Natural History infection clearance chronic hepatitis cirrhosis
20% clearance chronic hepatitis 20 years 30 years cirrhosis 3.9% pa 1.4% pa liver failure liver cancer 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 Defined as undetectable HCV-RNA in the serum for 6/12 after Tx stopped

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

Download ppt "HIV Grand Round F2 Dr Sris Allan Consultant GU / HIV Physician"

Similar presentations

Ads by Google