AIDS 101 Current status and History Challenges and issues

1. AIDS 101 Current status and History Challenges and issues

11. TRANSITION PERIOD FOR MANAGEMENT OF HIV/AIDS1995 David Ho – HIV Replication 10,000,000,000/day1996 John Mellors – Viral load1996 Introduction of PIs1997 Triple therapy

15. HIV PREVENTION: BEYOND ABC HSV – 2 Acyclovir prophylaxis TDF prophylaxis Partial efficacy – monkeys Microbicides Detergents or buffers Antivirals Diaphragm Protects cervix Circumcision ARNS – 65% reduction Early detection Counseling & treatment Depression Bupropion

17. Complications of HIV Infection 500 vaginal candidiasis skin disease fatigue bacterial pneumonia CD4 Count herpes zoster oral hairy leukoplakia, thrush, fever, diarrhea, weight loss 200 Kaposi’s sarcoma, non-Hodgkin’s lymphoma Pneumocystis carinii pneumonia 100 Toxoplasmosis, esophageal candidiasis, cryptococcosis 50 CMV, MAC, CNS lymphoma Time

18. STDs pregnancy tuberculosis recurrent pneumonia refractory/recurrent vaginal candidiasis generalized lymphadenopathy unexplained dementia, aseptic meningitis, or peripheral neuropathy B-cell lymphoma chronic, unexplained fever, diarrhea, or weight loss shingles (young adults) or generalized HSV unexplained cytopenias evidence of cellular immuno- deficiency hospitalized adults (if AIDS rate > 1/1000 discharges or seroprevalence > 1%) Indications for Voluntary HIV Testing …or upon request

19. Candidiasis Angular cheilitis Pseudomembranous candidiasis (“thrush”)

20. Universal HIV Testing of All Pregnant Women • 1998 Institute of Medicine recommended universal routine HIV testing with the right of refusal for all pregnant women in the US. • CDC plans to recommend a second test offered in third trimester. • ACOG recommends universal testing and third trimester testing in high risk women (Nov 2004)

21. Elizabeth: pregnant HIV+ • 19 year old Hispanic female, diagnosed with HIV when 17 yrs (April, 2003) in a family planning clinic when she presented with a discharge which was positive for Chlamydia. • She has been in your care since that time. She has not been on ART due to poor adherence with apts. • She presents with a complaint of delayed menses.

22. Timing of Transmission 1/3 Antepartum (in utero) 2/3 peripartum 1 2 3 Birth

23. Obstacles to Good Care for Women with HIV • Not going to clinic • Poverty (can’t afford, can’t get to clinic, other pressing priorities) • Forget to take medications • Poor support system • Depression • History of abuse • Chemical Dependency (current alcohol and drug use) • Housing instability • Distrust/ Lack of disclosure

24. Gender Issues and Adherence • Depression • Alcohol • Mental health Treatment • Low Educational Level • Unemployment • Absence of Social worker in Clinical center

25. Late Testing Results in Missed Opportunitiesfor Treatment and Prevention of HIV

26. Importance of HIV Diagnosis • Benefits to individual • Influencing the course of infection • Prevention of opportunistic infections • Prevention of morbidity • Prevention of mortality • Benefits to others • Prevention of transmission • Ability to care for others

27. Linkage to Care Proud Woman Letwin Mugavezi

28. Linking Person with HIV to Care • One third of individuals aware of their HIV infection are not receiving care • Possible reasons: • Fear, denial, stigma • Substance use, mental illness • Unaware of availability of care and treatment • Lack of care programs • Difficulty in access: e.g. financial barriers, distance

29. The Mosaic of Services HIV PrimaryCare Adults Children Mental Health Women’s Health Social Support & Counseling Research Harm Reduction Adherence Support Outreach Peer Program Nutrition

30. Epidemiology of HIV in U.S. •  marginalized populations • Blacks = 50% of all new HIV/AIDS cases in 2003 • AIDS cases 1999-2003 •  blacks,  Latinos,  whites •  15% women,  1% men • After AIDS dx, survival lowest in IDUs CDC

32. Rapid Spread of HIV among IDUs

33. Injection Drug Use and HIV in the US • 1.5 million injection drug users • 800,000 in need of drug treatment • 120,000 in treatment programs • 10-30% with HIV disease • ~355,000 IDUs with HIV/AIDS • 100,00 receiving HIV care • Second highest risk for incident HIV infections • 25% new HIV infections

34. HIV and injecting drug use (2003) (55) No IDU reported (22) IDU without HIV (114) IDU and HIV Source: WHO Programme on Substance Abuse 98036-E-29 – 15 July 1998

35. Principles of Harm Reduction • Minimize harmful effects of drugs • Success not necessarily abstinence • Low threshold services • Patient vs. provider agenda • Addressing “non-medical” issues • Redefine health, goals, and success/failure

36. Risk (Harm) Reduction in Drug Users The chronic and relapsing pattern of drug misuse, wide array of serious medical consequences and increased HIV transmission risk require realistic, flexible and sustainable preventive risk reduction strategies. Risk reduction does not promote injection or non-parenteral drug use, but seeks to decrease the frequency of adverse events related to this practice. Successful risk reduction strategies are based on the underlying principle that injection and non-injection drug misuse is a medical illness which may not be cured in the individual or eliminated from society but can be conducted in a way that minimizes harm to the user and others. While complete cessation of drug use remains a laudable goal, reduction in drug use frequency and safer injection and non-injection practices is more realistic for many drug users until abstinence can be achieved.

37. The Real World STDs Superinfection Tina - Not Turner transmitted resistance HIV Fatigue!

38. HIV Transmission Risk Behavior Among Active HIV+ IDU in Clinical Care (n=55)

39. STD in HIV+ Persons Incidence of STI in 1,350 STD clinic attendees followed after initial HIV diagnosis 1993-8 in Baltimore [Erbelding J AIDS 2003] Further: Primary HIV infection is common among STD clinic attendees in high HIV prevalence areas: 5% of 476 HIV antibody negative men in Malawi [Pilcher AIDS 2005] See also: Bachmann 2005, Taylor 2005

40. Changing Causes of Death in the Era of ART, 1996-2002(n=5561) • Death Rate-Total • 1996: 6.3/100 patient-years • 2002: 2.2/100 patient-years • Death Rate due to OIs • 1996: 23/100patient-years (54% of all deaths) • 2002: 6/100 patient-years (28% of all death) • CD4 Count Closest to Death • 1996: 65 cells • 2002: 148 cells • Causes of death in 2002 • Opportunistic: 28% • Non-Opportunistic 72% • Hepatic 36% • Cardiovascular 17% • Pulmonary 23% • Renal 10% Palella, HOPS DATA BASE, CROI 2004, #873

41. abacavir 15 Combivir 17 didanosine 12 emtricitabine 19 Emtriva 12 Epivir 11 Epzicom 22 Hivid 12 Kivexa 20 lamivudine 16 Retrovir 11 stavudine 13 tenofovir 15 Trizivir 20 Truvada 11 Videx 16 Viread 10 zalcitabine 24 Zerit 14 Ziagen 16 zidovudine 24 delavirdine 16 efavirenz 24 enfuvirtide 18 nevirapine 13 Rescriptor 14 Stocrin 9 Sustiva 10 Viramune 13 Agenerase 10 amprenavir 17 atazanavir 22 Crixivan 20 Fortovase 15 indinavir 13 Fuzeon 18 Invirase 11 Kaletra 11 Lexiva 16 lopinavir 14 nelfinavir 16 Norvir 9 Reyataz 19 ritonavir 12 saquinavir 22 Telzir 15 Viracept 15 Drug Names: Scrabble Scores

42. The Community Health Care Van DAART Specialist HIVPhysician Drug Treatment Coordinator Outreach Workers