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HIV AND PRIMARY CARE IN MAINE PRESENTED BY MARY RAFTER, MSN MNPA 2013 CONFERENCE

HIV AND PRIMARY CARE IN MAINE PRESENTED BY MARY RAFTER, MSN MNPA 2013 CONFERENCE. HIV & ME. LET’S START AT THE VERY BEGINNING…. A GLOBAL PANDEMIC CONTINUES. 34 million people living with HIV/AIDS in 2010 (17% more than 2001) 2.7 million new cases of HIV diagnosed in 2010

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HIV AND PRIMARY CARE IN MAINE PRESENTED BY MARY RAFTER, MSN MNPA 2013 CONFERENCE

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  1. HIV AND PRIMARY CARE IN MAINEPRESENTED BY MARY RAFTER, MSNMNPA 2013 CONFERENCE HIV & ME

  2. LET’S START AT THE VERY BEGINNING…

  3. A GLOBAL PANDEMIC CONTINUES 34 million people living with HIV/AIDS in 2010 (17% more than 2001) 2.7 million new cases of HIV diagnosed in 2010 (15% less than 2001 and 21% less than peak of pandemic in 1997) 1.8 million deaths attributed to HIV/AIDS in 2010 (down from 2.2 million in the mid 2000s) Sub-Saharan Africa remains most heavily affected. 22.9 million people living with HIV/AIDS 12% of the global population comprises 68% of the HIV epidemic

  4. HIV/AIDS IN AMERICA TODAY 1.2 million people living with HIV in the United States today. Essentially stable from 2007 through 2010. 55,000 to 60,000 new HIV diagnoses annually Approximately one in five people with HIV, do not know their status

  5. DEMOGRAPHICS OF TRANSMISSION

  6. THE STATE OF HIV IN MAINE 1,600 people living with HIV in Maine 48 new HIV diagnoses in 2012 28 MSM (58%) 0 IDU 7 Heterosexual Contact with at-risk partners (15%) 8 Heterosexual, Not at-risk partners disclosed (17%) 4 No risk reported/identified (8%) 1 Perinatal (1%) Immigrated to US after birth 11 (23%) New HIV cases identified by Prevention Funded Programs

  7. RYAN WHITE “PART C” CLINICS IN MAINE

  8. THE SPECTRUM OF PREVENTION

  9. POST EXPOSURE PROPHYLAXSIS (P.E.P)

  10. POST EXPOSURE PROPHYLAXSIS (P.E.P) Antiretroviral Therapy Options: Occupational Exposure: • Combivir 300/150mg tab 1 PO QD • Truvada 300/200 mg tab 1 PO QD • Kaletra 200/50mg tab 2 PO QD Non-Occupational Exposure: • Atripla 600/200/300mg tab 1 PO QD • Truvada 300/200mg tab 1 PO QD P.E.P. 28 day regimen Monitoring: HIV antibody (Baseline, 4-6 weeks, 3 & 6 months) CBC & CMP (baseline & 2-4 weeks after initiation of PEP) STI screening Pregnancy Hepatitis B & C

  11. UNEXPOSED PATIENTS: WHO TO TEST CDC recommends voluntary opt-out testing for HIV for all patients No need for pre-test counseling or special consent Screening offered to all individuals 13-64 years Routine aspect of prenatal screening High risk patients should be screened annually • Clinical History • Flu-like illness, weight loss • Infections such as thrush, • pneumonia, shingles, TB • Hepatitis • Persistent generalized • lymphadenopathy • Children born to HIV + mothers • History of transfusion/transplant • Hemophilia or coagulation • disorders • Occupational exposure to human • blood, body fluids or tissue • Substance Abuse/Social History • Injection drug use • Drug-using sexual partners • Sharing drug paraphernalia • Alcohol dependence or detox • Psychiatric hospitilzations • History of incarceration • Homelessness • Sexual History • Unprotected sexual intercourse • (vaginal, anal, oral) • Sexual contact w/ an HIV infected • person or a person at risk for HIV • Multiple sex partners • Abnormal Pap • STI or related signs/symptoms

  12. SO YOU’VE DECIDED TO TEST… For a negative result: The validity of the negative Possible retesting if indicated; and Reinforcement of transmission reduction behaviors For a Positive result: • Review of the availability and effectiveness of treatment • Reinforcement of disclosure to spouse and/or sexual partners and/or drug partners • Reminder of transmission reduction behaviors; and • Assess any intent to harm self or others.

  13. TESTING AND THE WINDOW PERIOD

  14. NOTIFICATION OF POSITIVE PATIENTS Immediate Counsel Treatment Access to Care Emotional Support Risk Assessment Behavior Modification Partner Testing/Notification Questions Linkage to Care MaineCare Waiver ADAP Nearby ID/HIV specialist Case Management

  15. ENGAGEMENT IN HIV CARE Case Management Frannie Peabody Center (Portland) Horizons (Augusta) Eastern Maine AIDS Network (Bangor) Down East Aids Network (Ellsworth, Machias, Calais) HIV Specialty Care Positive Healthcare (Portland) Virology Treatment Center (Portland) Maine Centers for Healthcare (Westbrook) The Horizon Clinic (Gardiner) Central Maine Medical Center (Lewiston) Maine General Health (Augusta) Eastern Maine Medical Center (Bangor) Regional Medical Center (Lubec)

  16. THE INITIAL WORK-UPPHYSICAL EXAM

  17. THE INITIAL WORK-UPLABORATORY EVALUATION • Screening for Hepatitis • Co-Infection: • Heatitis A: Hep A Ab • Hepatitis B: HBsAB, HBsAg, HBcAb • Hepatitis C: Hep C Ab • Screening for OIs & • Other Infections: • TB screening • Screening for STIs • Syphilis screening • Toxoplasma serology The Basics: CBC w differential Complete Metabolic Panel Lipid profile & glucose screen Cervical/Anal pap smear Urinalysis HIV Specific Tests: CD4 T cell count (absolute & percentage) HIV Viral Load HIV genotype

  18. PROPHYLAXIS AGAINSTOPPORTUNISTIC INFECTIONS

  19. TO TREAT OR NOT TO TREAT Potential Benefits Reduce viral replications Reduce sx of acute infection Alter viral set point Reduce rate of viral mutations Reduce risk of transmission Reduce immunologic damage Potential Risks Drug toxicities Drug resistance Need for continuous therapy Adverse effect on quality of life

  20. BEGINNING ANTIRETROVIRAL THERAPY Interpreting the Genotype Stanford University HIV Drug Resistance Database hivdb.stanford.edu/ Johns Hopkins HIV Guide Patient Readiness Lifelong Therapy Stability Adherence Counseling Side Effects Choosing ART for a treatment naive patient Recommended First Line Regimes: Atripla Reyataz, Truvada & Norvir Darunavir, Truvada & Norvir Raltegravir & Truvada

  21. HOW ANTIRETROVIRALS WORK

  22. ATRIPLA(EFAVIRENZ 600MG, EMTRICITABINE200MG & TENOFOVIR 300MG) Single table regimen: NNRTI & NRTI combination The first single table regimen on the market 2006 Eligible for generic manufacturing in 2013 Advantages Once daily dosing improves adherence Single pill regimen decreases co-pays Generally well tolerated Common Side Effects Diarrhea/Nausea Fatigue/Depression Dizziness Headache Vivid dreams Transient Rash Insomnia Special Dosing Considerations Standard dose for pts > 12 yrs and 88 pounds Teratogenic effect: not used for female pts considering pregnancy (or 12 weeks after discontinuation) Special caution with decreased renal function (dosage not adjustable In single tablet form, but can be divided into components

  23. TRUVADA & NORVIR Truvada: (emtracitabine 200mg & tenofovir 300mg) Backbone of NRTI therapy Fixed dose tablet Norvir: (ritonovir) 100mg tablet Protease Inhibitor (used as a booster) Available as tablet or gel cap (needs regfigeration) Advantages: Better tolerated than other NRTI backbones Effective in co-management of Hepatits B infection Advantages: Low dose (100mg) well tolerated Among the original PI’s shown to treat HIV Common Side Effects: Diarrhea, nausea, depression, fatigue, insomnia, abnormal dreams & rash Common Side Effects: Weakness, upset stomach pain (N/V/D/C), tingling/numbness of mouth hands or feet taste disturbance, appetite/weight loss Dosing Considerations: Renal dosing needed with decreased GFR Long term bone density decreases Active Component of Atripla, Complera & Stribild Dosing Considerations: May be better tolerated with high fat intake Can increase LFT’s, cholesterol & GI symptoms

  24. REYATAZ(ATAZANAVIR SULFATE) Protease inhibitor with once daily administration (300 mg cap) Administered with Norvir 100mg and Truvada 200/300mg Adjustable dosing available for many variations of prescribing needs Advantages Once daily dosing increases adherence Generally well tolerated Approved for pts >6yrs old May be used during pregnancy More cholesterol friendly than other PIs Common Side Effects Mild elevation of bilirubin (may cause jaundice, rarely) Dizziness/lightheadedness Rash Kidney/Gallstones Elevated LFTs Special Dosing Considerations Requires low stomach pH for absorption (may be complex if pt has GERD) Should not be used with dialysis Levels are decreased with Truvada dosing Hence the need for Norvir boost

  25. PREZISTA(DARUNAVIR) Protease Inhibitor with once daily administration (800mg tab) Administered with 100mg Norvir and Truvada 200/300mg Advantages Approved in 2008, become recognized as one of the most effective & utilized PI’s Not dependent on stomach pH Lipid & insulin friendly New 800mg dosing (replacing 400mg tabs) reduces pill burden Common Side Effects Diarrhea Nausea/Vomiting Headache Rash Abdominal Pain Rare LFT elevation Dosing Considerations May decrease effectiveness of some birth control pills Not appropriate with severe liver function impairment Careful selection of lipid lowering agent for co-morbidity Contains a sulfa component

  26. ISENTRESS(RALTEGRAVIR) Integrase Inhibitor: 400mg tab BID with Truvada 200/300mg tab FDA approved in 2009: adding a new class of ARVs Advantages New class of ARVs may be more effective for patients with HIV resistant strains Effective & well tolerated Approved for patients Older than 2 yrs (dose adjust 2-11yrs) Common Side Effects: Diarrhea Insomnia Nausea Headache Fatigue Dosing Considerations Twice daily dosing may decrease adherence Short half life requires strict adherence to avoid mutation

  27. IMMEDIATE FOLLOW UP Recheck CD4 and Viral load 4-6 weeks after initiating ARVs Expect a one log decline in HIV VL CD4 count will increase gradually and plateau Monitor for IRIS Viral load should be undetectable in 6 months Monitoring CD4 and VL Q 3-6mo Virologic Failure = sustained VL > 200 copies/mL

  28. ADDITIONAL RESOURCES National Clinicians' Post-Exposure Prophylaxis Hotline (PEPline): 1-888-448-4911 National HIV Telephone Consultation Service: 1-800-933-3413 FDA: Report unusual or severe toxicity to Antiretroviral Agents: 1-800-332-1088 AIDS Info: www.aidsinfo.nih.gov The Body: www.thebody.com Medscape: www.medscape.com/hiv International AIDS Society: www.iasuasa.org HIV InSite: www.hivinsite.ucsf.edu AETC National Resource Center: www.aidsetc.org

  29. QUESTIONS???MARYR@PORTLANDMAINE.GOV207-756-8080

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