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HIV Update and State of the Art

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Presentation on theme: "HIV Update and State of the Art"— Presentation transcript:

1 HIV Update and State of the Art
April 21, 2017 HIV Update and State of the Art Christian Woods, MD

2 Disclosures Speaker Bureau for Cubist Pharmaceuticals April 21, 2017

3 Objectives Brief review of advances in HIV medicine
Brief review of the current epidemiology of HIV Brief review of advances in HIV prevention April 21, 2017

4 HIV Update and State of the Art
The basics April 21, 2017

5 April 21, 2017

6 April 21, 2017

7 Co-Receptor Inhibitors
April 21, 2017

8 Fusion Inhibitors April 21, 2017

9 Nucleoside Reverse Transcriptase Inhibitors
April 21, 2017

10 Non-Nucleoside Reverse Transcriptase Inhibitors
April 21, 2017

11 Integrase Inhibitors April 21, 2017

12 Protease Inhibitors April 21, 2017

13 April 21, 2017

14 April 21, 2017

15 Acute HIV Fever Fatigue and Myalgia Lymphadenopathy
Pharyngitis (nonexudative) Weight Loss Headache Nausea & Diarrhea Rash (erythematous, macular) Thrush Rarely Pneumocystis Aseptic Meningitis April 21, 2017

16 April 21, 2017

17 April 21, 2017

18 April 21, 2017

19 April 21, 2017

20 April 21, 2017

21 April 21, 2017

22 CDC HIV CLASSIFICATION SYSTEM
CD4 Criteria Symptom Criteria Stage 1: CD4 >500 Stage 2: CD Stage 3: CD4 <200 Stage A: Asymptomatic Stage B: B symptoms Stage C: AIDS Defining Conditions April 21, 2017

23 CDC HIV CLASSIFICATION SYSTEM
CD4 Criteria Symptom Criteria Stage 1: CD4 >500 Stage 2: CD Stage 3: CD4 <200 Stage A: Asymptomatic Stage B: B symptoms Stage C: AIDS Defining Conditions For example, a 21 year old man with CD4 150 and no complications other than Thrush is stage B3 April 21, 2017

24 Direct Viral Mediated End Organ Damage
HIV Associated Nephropathy Focal Segmental Glomerulonephritis with Nephrotic Range Proteinuria Rapid deterioration and progression to need for Kidney Replacement Therapy HIV Associated Cardiomyopathy Manifests like other viral cardiomyopathies Can progress to need for ventricular assist device or cardiac transplant April 21, 2017

25 Direct Viral Mediated End Organ Damage
HIV Associated Dementia Complex Cognitive abnormalities Can also manifest motor abnormalities Psychiatric disturbance is not uncommon Significant progressive functional impairment HIV Associated Minor Cognitive-Motor Disorder Minor impairments in attention, concentration, memory, movement, coordination, memory, personality change Often very slow to progress April 21, 2017

26 Direct Viral Mediated End Organ Damage
Hematologic Injury Idiopathic Thrombocytopenic Purpura Thrombotic Thrombocytopenic Pupura Anemia, mild thrombocytopenia, relative leukopenia not emergencies Nervous System Peripheral Neuropathy Vacuolar Myelopathy Musculoskeletal Myositis and Rhabdomyositis April 21, 2017

27 Direct Viral Mediated End Organ Damage
Suppression of HIV with Antiretroviral therapy can halt disease progression Only option in most (except ITP and TTP) Rapid initiation of antiretrovirals and suppression of viral load is imperative to prevent disease progression This is also true for the Opportunistic Infection Progressive Multifocal Leukoencephalopathy April 21, 2017

28 Primary Prophylaxis in HIV
VACCINES Opportunistic Infections Pneumovax Prevnar Influenza TDAP Hepatitis A Hepatitis B Zostavax (CD4>200) HPV Vaccine (age 13-26) Pneumocystis/Toxoplasma CD4 <200/100 Bactrim (DS/SS, QD/TIW) Dapsone 100 mg daily Atovaquone 1500 mg daily MAC (CD4 <50) Azithromycin 1200 mg Weekly/divided Twice Week April 21, 2017

29 Primary Prophylaxis in HIV
Special Cases Residing in an area endemic for Histoplasmosis and CD4<150: Itraconazole 200 mg daily Residing in an area endemic for Coccidioides and CD4<250: Fluconazole 400 mg daily Residing in an area endemic for Penicilliosis and CD4<100: Itraconazole 200 mg daily April 21, 2017

30 Endemic Areas for Coccidioidomycosis
April 21, 2017

31 Endemic Areas for Histoplasmosis
April 21, 2017

32 Endemic Areas for Penicilliosis
April 21, 2017

33 TAKE HOME MESSAGES Mono-like illness: Consider Acute HIV
Vaccinate: Prevnar, Pneumovax, Influenza Stage and Prophylax CD4 count < 200: Pneumocystis CD4 count <100: Toxoplasmosis CD4 count < 50: MAC End Organ Damage is an HIV Emergency HIVAN Dementia Cardiomyopathy April 21, 2017

34 HIV ELISA Antibody Test Oraquick HIV Antibody Test
A 28 year old African American man presents to your clinic with complaints of 2 days of fever, night sweats, and sore throat. He admits to accepting money from men in exchange for unprotected sex starting three months ago. Exam reveals thrush, swollen cervical and inguinal lymph nodes, a flat erythematous rash on his trunk. Which test is most likely to be diagnostic right now? HIV ELISA Antibody Test Oraquick HIV Antibody Test HIV Western Blot Test HIV 4th Generation Antigen/Antibody Test CD4 count April 21, 2017

35 HIV ELISA Antibody Test Oraquick HIV Antibody Test
A 28 year old African American man presents to your clinic with complaints of 2 days of fever, night sweats, and sore throat. He admits to accepting money from men in exchange for unprotected sex starting three months ago. Exam reveals thrush, swollen cervical and inguinal lymph nodes, a flat erythematous rash on his trunk. Which test is most likely to be diagnostic right now? HIV ELISA Antibody Test Oraquick HIV Antibody Test HIV Western Blot Test HIV 4th Generation Antigen/Antibody Test CD4 count April 21, 2017

36 April 21, 2017

37 Window Period April 21, 2017

38 HIV Update and State of the Art
HIV TESting April 21, 2017

39 CDC HIV Testing Recommendations: HIV screening is normal medical practice
HIV screening is recommended for patients in ALL health-care settings (opt-out screening) – particularly pregnant women High Risk Persons should be screened annually Separate written consent should not be required Repeat screening should occur for pregnant women in the 3rd trimester April 21, 2017

40 Terms High Risk (Expanded!!) IDU and their sex partners
Commercial sex workers Partners of HIV infected persons Men who have sex with men (MSM) Persons who have had more than 1 sex partner since their most recent HIV test (or their partners) April 21, 2017

41 Tests Available Antibody Tests (confirmatory WB required)
Laboratory Blood Tests Rapid Blood Tests (multiple) Home Access/Express HIV-1 Test System using fingersticks Home Rapid Tests (Oraquick, Orasure) using Saliva Western Blot (Confirmatory) Positive: 2 of the following – p24, gp41, gp120/160 Indeterminate: any positive bands Negative: no positive Bands 4th Generation HIV Antibody/Antigen Tests April 21, 2017

42 4th Generation Architect HIV-1/2/O/M Ag/Ab Combo (Lab)
Alere Determine HIV-1/2 Ag/Ab Combo (Rapid) Reflex testing Reflex to HIV1 and HIV 2 specific testing If either test is positive, then the patient has a positive test for either HIV1 or HIV2 and no Western Blot required If both negative then reflex to viral load testing If viral load test is positive, then patient has a positive test and no Western Blot is required April 21, 2017

43 April 21, 2017

44 TAKE HOME MESSAGES All adults (and sexually active adolescents) should be tested on entry into medical care Repeat annual testing in high risk groups (living in DC is a high risk group – see next section!) Rapid Tests and Home Tests still need confirmation 4th Gen Test will detect infection in the “Window Period” Otherwise, use Nucleic Acid test to detect infection in the “Window Period” April 21, 2017

45 Which of the following locations is estimated to have a higher prevalence of HIV than the others listed? Ethiopia Haiti Guinea-Bissau Washington, DC Sierra Leone April 21, 2017

46 Which of the following locations is estimated to have a higher prevalence of HIV than the others listed? Ethiopia (1.4 %) Haiti (1.8%) Guinea-Bissau (1.4%) Washington, DC (2.7%) Sierra Leone (1.6%) April 21, 2017

47 Which of the following locations is estimated to have a higher prevalence of HIV than the others listed? Washington, DC (2.7%) Swaziland (26%) Mozambique (11.3%) Botswana (23.4%) Malawi (10%) Lesotho (23.3%) Uganda (7.2%) South Africa (17.3%) Kenya (6.2%) Zimabwe (14.9%) Tanzania (5.8%) Nambia (13.4%) Gabon (5%) Zambia (12.5%) April 21, 2017

48 HIV Update and State of the Art
Epidemiology April 21, 2017

49 WHO Global summary of the AIDS epidemic 2011
Number of people living with HIV Total Adults Women Children (<15 years) 34.0 million [31.4–35.9 million] 30.7 million [28.2–32.3 million] 16.7 million [15.4–17.6 million] 3.3 million [3.1–3.8 million] 2.5 million [2.2–2.8 million] 2.2 million [1.9–2.4 million] [ – ] 1.7 million [1.5–1.9 million] 1.5 million [1.3–1.7 million] [ – ] People newly infected with HIV in 2011 AIDS deaths in 2011

50 Adults and children estimated to be living with HIV  2011
Western & Central Europe [ – 1.0 million] Eastern Europe & Central Asia 1.4 million [1.1 million – 1.8 million] North America 1.4 million [1.1 million – 2.0 million] East Asia [ – 1.2 million] Middle East & North Africa [ – ] Caribbean [ – ] South & South-East Asia 4.0 million [3.1 million – 5.2 million] Sub-Saharan Africa 23.5 million [22.1 million – 24.8 million] Latin America 1.4 million [1.1 million – 1.7 million] Oceania 53 000 [ – ] Total: 34.0 million [31.4 million – 35.9 million]

51 Estimated adult and child deaths from AIDS  2011
Western & Central Europe 7000 [6100 – 7500] Eastern Europe & Central Asia 92 000 [ – ] North America 21 000 [ – ] East Asia 59 000 [ – ] Middle East & North Africa 23 000 [ – ] Caribbean 10 000 [8200 – ] South & South-East Asia [ – ] Sub-Saharan Africa 1.2 million [1.1 million – 1.3 million] Latin America 54 000 [ – ] Oceania 1300 [<1000 – 1800] Total: 1.7 million [1.5 million – 1.9 million]

52 New HIV infections and AIDS-related deaths, 1990–2011
Globally new HIV infections peaked in 1997 People New HIV infections AIDS-related deaths

53 People living with HIV, 1990–2011
millions People living with HIV

54 Total number of people dying from AIDS-related causes in low- and middle-income countries, 1995–2011
2000 2005 2010

55 At the end of 2010, an estimated 888,921
At the end of 2010, an estimated 888,921* adults and adolescents were living with diagnosed HIV infection in the United States and 6 dependent areas. Among the 665,872* males living with diagnosed HIV infection, 38% were white, 37% were black/African American, and 21% were Hispanic/Latino. Approximately 2% were Asian and approximately 1% were males of multiple races. Less than 1% each were American Indian/Alaska Native and Native Hawaiian/other Pacific Islander. Among the 223,045* females living with diagnosed HIV infection, 60% were black/African American, 19% were white, and 18% were Hispanic/Latino. Approximately 2% were females of multiple races, 1% were Asian, and less than 1% each were American Indian/Alaska Native, and Native Hawaiian/other Pacific Islander. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not for incomplete reporting. The Asian category includes Asian/Pacific Islander legacy cases (cases that were diagnosed and reported under the pre-1997 Office of Management and Budget race/ethnicity classification system). Hispanics/Latinos can be of any race. * Persons living with diagnosed HIV infection by race/ethnicity are classified as adult or adolescent based on age at year-end Total number adults and adolescents living with HIV infection is inclusive of persons of unknown sex. Total males include 582 persons and total females include 180 persons with unknown race/ethnicity.

56 This slide presents the percentage distribution of adults and adolescents* living with diagnosed HIV infection by sex and transmission category at the end of 2010 in the United States and 6 dependent areas. Among male adults and adolescents living with diagnosed HIV infection at the end of 2010, 67% of infections were attributed to male-to-male sexual contact. An estimated 14% of infections were attributed to injection drug use, 11% to heterosexual contact, and 7% to male-to-male sexual contact and injection drug use. Approximately 1% of males had infection attributed to perinatal exposure, and less than 1% of males had infection attributed to other transmission categories. Among female adults and adolescents living with diagnosed HIV infection at the end of 2010, 72% of infections were attributed to heterosexual contact and 25% to injection drug use. Approximately 2% of females had infection attributed to perinatal exposure, and less than 1% of females had infection attributed to other transmission categories. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and missing transmission category, but not for incomplete reporting. Heterosexual contact is with a person known to have, or to be at high risk for, HIV infection. Perinatal exposure includes persons who were exposed to HIV perinatally and diagnosed after birth, but were aged 13 years and older at the end of 2010. Other transmission categories include hemophilia, blood transfusion, and risk factor not reported or not identified. * Persons living with diagnosed HIV infection by race/ethnicity are classified as adult or adolescent based on age at year-end 2010.

57 Estimated rates (per 100,000 population) of adults and adolescents living with diagnosed HIV infection at the end of 2010 in the United States and 6 dependent areas are shown in this slide. Areas with the highest estimated rates of persons living with diagnosed HIV infection at the end of 2010 were the District of Columbia (2,704.3), New York (810.0), the U.S. Virgin Islands (667.1), Maryland (632.9), Florida (592.7), Puerto Rico (584.3), New Jersey (488.2), Louisiana (451.7), and Georgia (428.8). The District of Columbia (i.e., Washington, DC) is a city; please use caution when comparing the rate of persons living with diagnosed HIV infection in DC with the rates in states. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not for incomplete reporting. Persons living with a diagnosis of HIV infection are classified as adult or adolescent based on age at year-end 2010.

58 District of Columbia Rate=2,704.3 people living with HIV per 100,000 population in DC at end 2011 >2.7% of DC population HIV positive in 2011 Caveats: DC is a city and statistics not muted by a non-urban populations as in the states However, DC still had the highest rate of any US city DC DOH recommends annual HIV testing for all residents regardless of stated sexual activity or risk group April 21, 2017

59 April 21, 2017

60 April 21, 2017

61 April 21, 2017

62 April 21, 2017

63 April 21, 2017

64 April 21, 2017

65 TAKE HOME POINTS MSM, African Americans still the hardest hit
Safe Sex, Needle Exchange, Education DC has an epidemic rate comparable to countries in Subsaharan Africa DC DOH recommends all residents aged be tested ANNUALLY for HIV In the US, HIV is not a death sentence – now a survivable and manageable chronic disease Money and work required to make this true in resource limited countries, like those in Subsaharan Africa April 21, 2017

66 Fluticasone nasal spray Inhaled Salmeterol Metoprolol
A 56 year old man with newly diagnosed HIV and baseline resistance on genotype to non-nucleoside reverse transcriptase drugs is recommended to start antiretrovirals. After discussing different regimens that are available to him, he settles on Truvada & Ritonavir boosted Atazanavir. Which of the following drugs can he continue to take? Omeprazole 40 mg daily Simvastatin 40 mg daily Fluticasone nasal spray Inhaled Salmeterol Metoprolol April 21, 2017

67 Fluticasone nasal spray Inhaled Salmeterol Metoprolol
A 56 year old man with newly diagnosed HIV and baseline resistance on genotype to non-nucleoside reverse transcriptase drugs is recommended to start antiretrovirals. After discussing different regimens that are available to him, he settles on Truvada & Ritonavir boosted Atazanavir. Which of the following drugs can he continue to take? Omeprazole 40 mg daily Simvastatin 40 mg daily Fluticasone nasal spray Inhaled Salmeterol Metoprolol April 21, 2017

68 Antiretroviral Therapy
HIV Update and State of the Art Antiretroviral Therapy April 21, 2017

69 Thinking about HIV 1982 – What is it?
1985 – Incurable virus – why know? 1987 – Toxic therapy – 1993 – false hope of Duotherapy 1996 – HAART!! (angel choirs and bolts of glory) 2000 – Toxicity – delay therapy? – Non-toxic therapies (Truvada, Atazanavir, Darunavir, Raltegravir) 2011 – HPTN 052 April 21, 2017

70 HPTN 052 April 21, 2017

71 Community Viral Load April 21, 2017

72 NIH/USHHS Guidelines on HIV Treatment
All HIV-infected patients are recommended to start Antiretrovirals to prevent disease progression CD4<350 (AI) CD (AII) CD4 >500 (BIII) And to prevent transmission of disease Perinatal Transmission (AI) Heterosexual Transmission (AI) All other Transmission groups (AIII) Therapy can be deferred by provider or patient based on clinical or social factors April 21, 2017

73 Co-Receptor Inhibitor Integrase Inhibitor
NRTI Zidovudine Lamivudine Zalcitabine Didanosine Stavudine Abacavir Tenofovir Emtricitabine NNRTI Delavirdine Nevirapine Efavirenz Etravirine Rilpivirine Fusion Inhibitor Fuzeon Protease Inhibitors Saquinavir Indinavir (Ritonavir)  boosting agent Nelfinavir Amprenavir  fos-Amprenavir Lopinavir Atazanavir Tipranavir Darunavir Co-Receptor Inhibitor Maraviroc Integrase Inhibitor Raltegravir Elvitegravir Dolutegravir April 21, 2017

74 Combination Pills Combivir (Zidovudine/Lamivudine)
Epzicom (Lamivudine/Abacavir) Trizivir (Zidovudine/Lamivudine/Abacavir) Truvada (Tenofovir/Emtricitabine) Atripla (Tenofovir/Emtricitabine/Efavirenz) Complera (Tenofovir/Emtricitabine/Rilpivirine) Kaletra (Ritonavir/Lopinavir) Stribild (Tenofovir/Emtricitabine/Cobicistat/ Elvitegravir) Triumeq (Dolutegravir/Abacavir/Lamivudine) April 21, 2017

75 Highly Active Antiretroviral Therapy (HAART)
1 agent insufficient to suppress viral replication Combination therapy potent enough 2NRTI “backbone” PLUS 1 potent agent (PI, NNRTI, Integrase Inhibitor) Resistance  Salvage regimens Also called Potent AntiRetroviral Therapy (PART), Combination AntiRetroviral Therapy (CART) April 21, 2017

76 Resistance Highly Error Prone Reverse Transcriptase
1 mutation produced per genome copied Viral Turnover rate: 1x109 particles/day Mutation Rate * Turnover Rate/# of basepairs Mutation at every genome position every day Drug resistance archived Fitness Cost=Reversion to wildtype Genotype testing unreliable absent selection pressure April 21, 2017

77 Resistance Risk Consequences: multi-drug resistance Lessons
Drug pressure (taking drugs) Viral Replication (poor adherence/poor drug selection) Consequences: multi-drug resistance Lessons Simplest regimen=better compliance=less resistance Close monitoring to ensure viral suppression Compliance to visits and education April 21, 2017

78 Starting Regimens Only start with referral to an expert
Never start without appropriate testing – HIV Genotype HBV Serologies (co-treatment) HLAB5701 Always assess potential side effects and fit regimen to patient profile – comorbidities, drug interactions, lifestyle preferences Always review adherence strategies with the patient April 21, 2017

79 Starting Regimens Atripla Complera Stribild Epzicom/Efavirenz
Truvada OR Epzicom + Ritonavir/Atazanavir Truvada OR Epzixom +Ritonavir/Darunavir Truvada Raltegravir Combivir or Truvada or Epzicom + Kaletra April 21, 2017

80 Important Side Effects
NRTIs: peripheral neuropathy, lipoatrophy Zidovudine – headache, asthenia, anemia Didanosine – pancreatitis, neuropathy Stavudine – lactic acidosis, neuropathy Tenofovir – Fanconi Syndrome NNRTIS: rash, TEN, Stevens Johnson Nevirapine – liver failure Efavirenz – drowsiness, vivid dreams, depression Rilpivirine -- depression April 21, 2017

81 Important Side Effects
Protease Inhibitors: Hyperlipidemia, lipodystrophy, hyperglycemia, diarrhea, nausea Atazanavir: nephrolithiasis, prolonged QT, benign asymptomatic hyperbilirubinemia Tipranavir: Intracerebral hemorrhage Integrase Inhibitors: myositis April 21, 2017

82 Some Interactions Oral contraceptives
HMG Co-A Reductase (least with rosuvastatin and atorvastain) Steroids (avoid fluticasone, beclomethasone preferred) Salmeterol Psychiatric medications Anticonvulsants Antifungals Proton Pump Inhibitors (Atazanavir, Rilpivirine) April 21, 2017

83 TAKE HOME POINTS All patients encouraged to start therapy to prevent opportunistic infections, malignancy, and to decrease community viral load Resistance is a problem – continuous monitoring necessary Do not refill HIV meds if patients are not making their follow ups with their HIV provider Look out for drug interactions April 21, 2017

84 Safe sex is the only prevention available
A 26 year old HIV negative man who is non-monogamously partnered with an HIV positive man on antiretroviral therapy asks you if there is a drug he can take to reduce his risk of getting HIV. What do you tell him? Safe sex is the only prevention available Truvada has had success but needs close monitoring and compliance The best option for him is abstinence Combivir and Kaletra has had success with close monitoring and compliance This therapy has only had success in IDU April 21, 2017

85 Safe sex is the only prevention available
A 26 year old man with male who is non-monogamously partnered with an HIV positive man on antiretroviral therapy asks you if there is a drug he can take to reduce his risk of getting HIV. What do you tell him? Safe sex is the only prevention available Truvada has had success but needs close monitoring and compliance The best option for him is abstinence Combivir and Kaletra has had success with close monitoring and compliance This therapy has only had success in IDU April 21, 2017

86 Pre and Post Exposure Prophylaxis
HIV Update and State of the Art Pre and Post Exposure Prophylaxis April 21, 2017

87 Occupational Exposures
Sep New guidelines from USDPHHS in Infection Control & Hospital Epidemiology Source: body fluids from infected or high risk patients (blood, semen, vaginal secretions, CSF, synovial, pleural, peritoneal, pericardial, amniotic) Excludes: feces, urine, saliva, emesis Exposures: Percutaneous injury, mucous membrane, non-intact skin Risk: 0.3% percutaneous blood, 0.09% mucous membrane April 21, 2017

88 PEP Regimens Timing: within 72 hours of exposure for 4 weeks
No 2 vs. 3 drug regimens based on risk – just 3 drugs! Preferred: Truvada Raltegravir Alternatives Fixed dose single agent: Stribild  OR Combine: Raltegravir, Ritonavir/Darunavir, Etravirine, Rilpivirine, Ritonavir/Atazanavir, Kaletra With: Truvada, Combivir, Others: only with expert ID consultation April 21, 2017

89 PEP Regimens Follow Up If 4th Generation HIV Test is used
BASELINE: HIV test, CBC, CMP, counseling 2 weeks: CBC, CMP, counseling 6 wks: HIV Test, counseling 3 months: HIV Test 6 months: HIV Test If 4th Generation HIV Test is used 4 months: HIV Test April 21, 2017

90 nPEP 2005 CDC initiated guidelines Criteria for nPEP
<72 hours from exposure Source patient HIV positive or unknown Substantial exposure risk Substance: Blood, Semen, Vaginal Secretions, Rectal Secretions, Breast Milk Exposure: Vagina, Rectum, Eye, Mouth, Other Mucous Membrane, Non-Intact Skin, Percutaneous Injury/Contact No Risk: urine, nasal secretions, saliva, sweat, tears Previous Recommendations PI based Now most moving to PEP drugs April 21, 2017

91 PrEP Pre-Exposure Prophylaxis Truvada approved by FDA for PrEP in 2012
Recommended by CDC in 2012 Evidence iPrEx (in HIV negative US MSM) Partners PrEP (in serodiscordant heterosexual couples in Kenya and Uganda) The Bangkok Tenofovir Study (in IDU) No significant adverse events Success predicated on close monitoring, risk reduction counseling, and compliance April 21, 2017

92 iPrEx April 21, 2017

93 Partners PrEP April 21, 2017

94 The Bangkok Tenofovir Study
April 21, 2017

95 PrEP Guidelines Eligibility: Baseline Testing Counseling
Baseline HIV negative High Risk MSM Multiple partners Commercial Sex Workers Not using condoms IDU Partner is HIV positive Discordant couple trying to conceive Baseline Testing Renal Function Hepatitis B status (if positive can treat as part of HBV therapy) Pregnancy Test Pregnant: counsel on lack of data Counseling Risk Reduction! Adherence! April 21, 2017

96 PrEP Guidelines Follow Up Discontinuation
No more than 90 day prescription and no automatic refills Every 2-3 months: HIV 4th gen test and pregnancy test, adherence education At 3 months then every 6 months thereafter: Renal Function, HBV screen, STD Screening Discontinuation Screen for pregnancy, HIV, HBV If positive, linkage to care for appropriate therapy April 21, 2017

97 TAKE HOME POINTS PEP now much more simple Truvada can be used for PrEP
Truvada Raltegravir is recommended regimen The sooner you start the better Truvada can be used for PrEP High risk populations (MSM, commercial sex workers, HIV negatives in serodiscordant couples, IVDU) Concomitant risk reduction counseling Close monitoring required for safety and success April 21, 2017

98 HIV Update and State of the Art
HIV Care at MWHC April 21, 2017

99 HIV Care at MWHC Section of Infectious Diseases
Glenn Wortmann, Section Chief, PD Maria Ruiz, Assistant Chief, IRB Chair Leon L. Lai, Ryan White Program Director, APD Christian Woods, (Pulm Crit Care), APD Dawn Fishbein, Viral Hepatitides Faria Farhat Joe Kovacs and Caryn Morse from the NIH 4 MWHC ID Fellows 2 NIH ID Fellows April 21, 2017

100 HIV Care at MWHC HRSA Ryan White Part C and D Supported
Jasmine Reid, RN, Program Coordinator Chizoba Anako, NP and Women’s Health Liaison Allison Daly, Case Manager and Medication Educator Antonio Pineda, Treatment Navigator Patricia Bauza, MD, Psychiatry Allen Zemon, PhD, Psychology April 21, 2017

101 HIV Care at MWHC Outpatient Services Inpatients with HIV
HIV and pregnancy April 21, 2017

102 TAKE HOME POINTS Call us if you have any questions! Outpatients –
Chris Woods, MD at Outpatients – Ryan White Intake: Appointments: Pregnancy and HIV is an emergency! Contact NP Anako at April 21, 2017

103 Selected References Baeten JM et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. NEJM (5): 399. Choopanya K et al. Antiretroviral prophylaxis for HIV ifnection in injecting drug users in Bangkok, Thailand (the Bangkok Tenofovir Study): a randomised, double-blind, placebo-controlled phase 3 trial. Lancet :2083. Cohen MS et al. Prevention of HIV-1 infection with early antiretroviral therapy. NEJM (6): 493. Das, M et al. Decreases in community viral load are accompanied by reductions in new HIV infections in San Francisco. PLoS One (6):e Grant RM et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. NEJM (27): Kuhar DT et al. Updated US Public Health Service guidelines for the management of occupational exposures to Human Immunodeficiency Virus and recommendations for post-exposure prophylaxis. Infection Control and Hospital Epidemiology, (9):875. Panel on the Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1 infected adults and adolescents. Department of Health and Human Services. February 12, Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. July 8, Smith DK et al. Update to interim guidance for preexposure prophylaxis for the prevention of HIV Infection. MMWR (23):463. Strategic Information System, HAHSTA, DC Department of Health. Annual Epidemiology and Surveillance Report, 2011. April 21, 2017

104 April 21, 2017

105 Post-Test Question 1 A 68 year old male resident of DC comes to you for care of his hypertension, hyperlipidemia, and diet controlled diabetes. He lives with his wife, daughter, and twin grandchildren. He says he is monogamous, is a prior smoker, and never used drugs. Which is not a routine part of his care? Flu shot HIV Test Abdominal Ultrasound Hemoglobin A1C PSA April 21, 2017

106 Post-Test Question 1 A 68 year old male resident of DC comes to you for care of his hypertension, hyperlipidemia, and diet controlled diabetes. He lives with his wife, daughter, and twin grandchildren. He says he is monogamous, is a prior smoker, and never used drugs. Which is not a routine part of his care? Flu shot HIV Test Abdominal Ultrasound Hemoglobin A1C PSA April 21, 2017

107 Post-Test Question 1 Flu shot – recommended yearly for patients over 65 years of age and with HIV HIV Test – recommended yearly in all DC residents Abdominal Ultrasound – recommended once in men over the age of 65 in all smokers or previous smokers Hemoglobin A1C – recommended every 6 months in patients with diabetes PSA – no longer recommended screening except in high risk men April 21, 2017

108 Post-Test Question 2 A 32 year old HIV negative old woman who is the partner of a 36 year old man with HIV well controlled for 10 years on antiretroviral therapy wishes to conceive. They cannot afford sperm washing. How do you advise her? They can use a turkey baster to decrease risk The risks of pregnancy are too high He is undetectable on his meds, so there is no risk She can take PrEP to reduce her risk They should use an HIV positive surrogacy program April 21, 2017

109 Post-Test Question 2 A 32 year old HIV negative old woman who is the partner of a 36 year old man with HIV well controlled for 10 years on antiretroviral therapy wishes to conceive. They cannot afford sperm washing. How do you advise her? They can use a turkey baster to decrease risk The risks of pregnancy are too high He is undetectable on his meds, so there is no risk She can take PrEP to reduce her risk They should use an HIV positive surrogacy program April 21, 2017

110 Post-Test Question 2 They can use a turkey baster to decrease risk –does not reduce risk from HIV infected semen The risks of pregnancy are too high – untrue – successful pregnancy in HIV is quite possible with appropriate care and counseling He is undetectable on his meds, so there is no risk – risk is greatly reduced but data is unclear if there is NO risk She can take PrEP to reduce her risk – true, and part of CDC PrEP guidelines They should use an HIV positive surrogacy program – this does not exist April 21, 2017

111 Post-Test Question 3 A 48 year old woman with HIV, seasonal allergies, asthma, hypertension, dyspepsia, and coronary artery disease comes to your clinic for a routine checkup. Her med list includes Truvada, Ritonavir, Atazanavir, Inhaled Beclomethasone, Advair (Fluticasone/ Salmeterol), Metoprolol, and Aspirin. Which is causing an interaction? Aspirin Advair Beclomethasone Metoprolol April 21, 2017

112 Post-Test Question 3 A 48 year old woman with HIV, seasonal allergies, asthma, hypertension, dyspepsia, and coronary artery disease comes to your clinic for a routine checkup. Her med list includes Truvada, Ritonavir, Atazanavir, Inhaled Beclomethasone, Advair (Fluticasone/ Salmeterol), Metoprolol, and Aspirin. Which is causing an interaction? Aspirin Advair Beclomethasone Metoprolol April 21, 2017

113 Post-Test Question 3 Aspirin - there is no interaction
Advair – both fluticasone and salmeterol, components of Advair, have significant interactions with protease inhibitors Beclomethasone – this is the preferred steroid to use in inhaled and intranasal preparations when a patient is on protease inhibitors Metoprolol - there is no interaction April 21, 2017

114 Post-Test Question 4 A 26 year old man with HIV returns to care after 18 months. His viral load was undetectable on Atripla but he says he has been off medicines for over a year. You obtain a genotype and there is no resistance. Which is true? He may still harbor hidden resistance Resistance to Atripla is rare Once a resistant virus reverts to wildtype, it becomes sensitive to drug again The resistance test needs to be repeated again before starting new medications April 21, 2017

115 Post-Test Question 4 A 26 year old man with HIV returns to care after 18 months. His viral load was undetectable on Atripla but he says he has been off medicines for over a year. You obtain a genotype and there is no resistance. Which is true? He may still harbor hidden resistance Resistance to Atripla is rare Once a resistant virus reverts to wildtype, it becomes sensitive to drug again The resistance test needs to be repeated again before starting new medications April 21, 2017

116 Post-Test Question 4 He may still harbor hidden resistance – Resistance is archived in memory T cells, but may not be the dominant virus in a patient absent drug pressure – thus genotypic testing off therapy can be unreliable Resistance to Atripla is rare – The most common mutations, M184V and K103N are induced by atripla Once a resistant virus reverts to wildtype, it becomes sensitive to drug again – false – the resistant mutant is archived and will re-emerge with sufficient drug pressure The resistance test needs to be repeated again before starting new medications – false, resistance test should be repeated after restarting HIV medications if there is an inappropriate response April 21, 2017

117 Post-Test Question 5 A 32 year old previously healthy man residing in New Orleans presents to his physician with a chancre. RPR is positive, HIV is positive, CD4 count is 18. He is treated for syphilis. Which of the following is not indicated? Bactrim DS daily Azithromycin 1200 mg weekly Fluconazole 200 mg daily Itraconazole 200 mg daily Pneumovax April 21, 2017

118 Post-Test Question 5 A 32 year old previously healthy man residing in New Orleans presents to his physician with a chancre. RPR is positive, HIV is positive, CD4 count is 18. He is treated for syphilis. Which of the following is not indicated? Bactrim DS daily Azithromycin 1200 mg weekly Fluconazole 200 mg daily Itraconazole 200 mg daily Pneumovax April 21, 2017

119 Post-Test Question 5 Bactrim DS daily – indicated for CD4 count <200 Azithromycin 1200 mg weekly – indicated for CD4 count <50 Fluconazole 200 mg daily – not indicated in a patient without persistent candidasis or at risk for Coccidioides imitis Itraconazole 200 mg daily – indicated for a patient with CD4 <150 residing in area endemic for Histoplasmosis (New Orleans) Pneumovax – indicated in all HIV patients April 21, 2017

120 Post-Test Question 6 You see a 36 year old woman with well controlled HIV on Truvada, Ritonavir, and Atazanavir. She is asymptomatic except for icterus. Viral Load is <20 copies/ml, CD4=565, and Total Bilirubin is Which of the following is true? Abdominal Ultrasound should be done Antiretrovirals should be held Antiretrovirals should continue unless the icterus is intolerable to her Cholecystectomy for acalculous cholecystitis is the next step April 21, 2017

121 Post-Test Question 6 You see a 36 year old woman with well controlled HIV on Truvada, Ritonavir, and Atazanavir. She is asymptomatic except for icterus. Viral Load is <20 copies/ml, CD4=565, and Total Bilirubin is Which of the following is true? Abdominal Ultrasound should be done Antiretrovirals should be held Antiretrovirals should continue unless the icterus is intolerable to her Cholecystectomy for acalculous cholecystitis is the next step April 21, 2017

122 Post-Test Question 6 Abdominal Ultrasound should be done –
Antiretrovirals should be held Antiretrovirals should continue unless the icterus is intolerable to her – Atazanavir induces a benign moderate hyperbilirubinemia that does not require cessation of therapy or any other intervention absent patient dissatisfaction with cosmetic effects of icterus. Severe hyperbilirubinemia warrants further workup and consideration for change in therapy Cholecystectomy for acalculous cholecystitis is the next step April 21, 2017


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