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HIV Treatment in Saskatchewan

HIV Treatment in Saskatchewan. Kurt E. Williams MD FRCPC 2012/Feb/9 Saskatoon. Objectives. To review Saskatchewan epidemiology of HIV. To identify cofactors which affect the way we prescribe antiretrovirals in Saskatchewan.

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HIV Treatment in Saskatchewan

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  1. HIV Treatment in Saskatchewan Kurt E. Williams MD FRCPC 2012/Feb/9 Saskatoon

  2. Objectives • To review Saskatchewan epidemiology of HIV. • To identify cofactors which affect the way we prescribe antiretrovirals in Saskatchewan. • To illustrate with brief case studies, some of the issues in ARV access and use.

  3. HIV Epidemiology: Current HIV Epidemic • The number of new diagnoses of HIV positive people has increased 5 fold in the last few years. • The primary risk behavior is IDU. • Heterosexual sex is likely under-rated as a risk factor in this epidemic. • First Nations people are disproportionately affected.

  4. Fig. 3: Selected Risk Factors Among HIV Cases in Saskatchewan, 2000-2009 Insert risk factors here

  5. Fig 2: HIV cases reported by Age and Gender in Saskatchewan, 2010 (Preliminary) 40 35 30 25 Number of cases 20 15 10 5 0 15-19 20-29 30-39 40-49 50+ 1 22 34 28 22 male 4 24 24 10 1 female

  6. Proportion of HIV cases reported by Year & Health Jurisdictions

  7. Geographic Challenges in Saskatchewan • 60 - 40, rural – urban split. • Some Reserves are among the hardest hit areas so transportation is an issue.

  8. Dealing With Geography • Outreach clinics in Prince Albert, La Ronge and LaLoche. • Partnering with the TB program for transport. • Directed visits to Reserves to facilitate testing, provide medical care. • Visits involve a team (ID doc, ID nurse, pharmacist, social worker, MHO).

  9. Dealing With Geography: Goals of Rural Team Visits • To provide expert medical care. • To mentor local health care providers (peer to peer). • To provide subsequent backup by telephone, email etc for increased patient well being and decreased patient travel. • To enhance local capacity, decrease travel.

  10. Prescription of ARVs • Generally prescribed by sub-specialists in Infectious Diseases. • Generally prescribed according to published guidelines which are similar around North America. • Guidelines are specific enough that first regimens in the absence of viral resistance can be prescribed by non-ID specialists- some HIV-experienced Internists and Family Physicians.

  11. Peculiarities of the Saskatchewan Formulary • They allow appropriate latitude in prescribing practices for qualified prescribers. • ARVs are not (yet) provided free of charge for all HIV infected people in Saskatchewan. • Some ARVs remain free of charge: chronologically, all ‘old’ drugs are ‘free’ ie AZT, ddI, ddC, d4T, 3TC, saquinavir, ritonavir and indinavir. • The newer ARVs are all ‘co-pay’.

  12. Peculiarities of the Saskatchewan Formulary • Only ritonavir and 3TC are among the ARVs recommended as ‘preferred components’ in current guidelines. • Current first regimens still consist of two NRTIs plus either an NNRTI or a PI (Protease inhibitor) usually boosted with ritonavir. • Preferred NRTIs = tenofovir and emtricitabine. But abacavir and lamivudine may be equal.

  13. Peculiarities of the Saskatchewan Formulary • Preferred NNRTI = Efavirenz. • Preferred PIs = either Atazanavir or Darunavir, with ritonavir boost. • Preferred Integrase Inhibitor = Raltegravir.

  14. Why Embrace Early HIV Treatment in Saskatchewan? • The appearance of ‘Rapid Progressors’ in unusual numbers: AIDS develops after 1 -3 years after infection vs 50% by 10 years. • Reduced toxicity of current ARVs with less cumulative toxicity. • Could decrease chances of further spread: treatment as a public health measure. • Prolonged immune suppression, even with reconstitution, leads to more cancer.

  15. Frequent Patient Factors to Consider in Saskatchewan • Younger women account for more of our new cases than elsewhere. • Co-infection with HCV in 80% of new cases. • Co-infection with Mycobacterium tuberculosis provides well-recognized drug interactions and IRIS (Immune Reconstitution Syndrome). • PI side-effects can include elevated lipids and cholesterol = cardiovascular disease, in already vulnerable population (First Nations).

  16. Case #1 • 37 year old caucasian male with high school education, no other training. • HIV + 2001. • Escalating viral load (200,000), CD4 count 348 (23.2%) prompted initiation of ARVs. • Combivir (AZT/3TC) + Efavirenz fall 2002. • Viral load ‘not detected’, CD4 count > 1000 (37 – 50%) essentially normal immune system.

  17. Case #1 • 2011 April: viral load = 1001, CD4 = 725 (30.3%). • 2011 early June: viral load = 59,000, CD4 = 524 (23.3%). Claimed complete adherence. • 2012 January: acknowledged some physical problems and missing appointments. Taking ARVs one month on, one off, for most of 2011. • $200 co-pay for a minimum wage earner not able to work full time.

  18. Case #1: Illustrates 3 Issues • Working poor are especially vulnerable where co-payment is required. • Pharmacists rock but you must talk to them before they can help you with emergency support. • If you won’t talk to a pharmacist you’d better learn about pharmacokinetics and how the long half life of Efavirenz can be trouble.

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