Early Treatment: cases

Early Treatment:cases David Baker & Craig Rodgers East Sydney Doctors ASHM Clinical Advisors

Ron – 2011 • 34 year old gay male • HIV +ve 2011 • CD4 = 570, VL = 102 000 • One partner who is HIV +ve • Not wanting treatment • Otherwise well

Considerations for Ron • How hard do we “encourage” treatment • Don’t want to turn Ron away, he need to feel he can continue to come back even if he does not start treatment. People who keep attending clinic end-up on treatment • Work thru benefits and risks: • net harm, toxicities very low less than 1% per year • net benefit, individual benefit not great • prevention, does he have other partners?

Clinical note - Control • For some people with HIV the last area of control is in regard to treatment decisions (same as in other chronic conditions) • MSM may have higher trust issues, and are reported in some cases to have elevated experience of abuse • Irregularity in attendance is an indication of low trust, and associated with failing treatment, establishing trust important

Ron – 2014 • No regular follow-up • Herpes zoster • CD4 = 470 • Starting ARVs

Ron’s Follow-up • Ron returned as soon as he had what he identified as a symptom of HIV • He was then eager to go onto treatment • Ron has commenced treatment

Clinical note – call backs • In general practice clinic attendance is largely driven by the patient • Call back systems exist for some conditions, PAP smear registry, over 50’s health check etc • HIV prescribers can do clinical audit, RACGP accredited, and review patients • Could be timely to conduct call back with all HIV patients not on treatment or all gay men (testing)

Greg - 2013 • 57 year old gay male • HIV +ve 1997 • Long term HIV –ve partner • Reluctant patient – rarely attends • CD4 = 660 • VL undetectable

Considerations for Greg • Greg is an elite controller • Some evidence that virus may get into CNS, but no compulsion to treat to “save brain” • Is he sexually active? • Can you include partner, what does she think? • CVD risk and will be higher because of HIV? • Keep door open to Greg, he may be receptive to treatment if situation changes.

Clinical note – patient choice • There is a risk that Greg will abandon relationship with the clinic if he feels pressured to start treatment and if he starts reluctantly there is a risk of poor adherence • Greg needs to feel it is alright to change his mind at any time and commence treatment • His long-term partner is negative and while there is risk, it seems managed. • Watch and try and encourage regular visits

Jack- 2014 • 62 year old heterosexual male • Long term HIV – ve partner • Otherwise well • CD4 = 718 • VL = 7800

Considerations for Jack • Jack is interested in treatment, but not committed • Raise risk of transmission to partner, treatment will reduce risk of transmission • Older people have a poorer immune reconstitution so he does not want damage • Strongly encourage he start treatment

Clinical note – family situation • Many older people may have grand children and will often take treatment in order to maximise their role with or length of time to enjoy grand children

Jason • 32 year old gay male, single • HIV +ve 2 weeks ago • Has booked 5 month holiday starting in 3 weeks • CD4 = 521 • VL = 4500

Considerations for Jason • Jason really wants to start treatment • His holiday poses an issue: • Patient starting therapy needs to be monitored • Are there options for this, dependent on where he is going, you can seek assistance from ASHM • Some patients access treatment in Australia but reside overseas (PNG, Bali & other postings) • Starting >CD4 500 increases chance of normalising CD4

Clinical note – Time to undetectable • Getting a better handle on when Jason became infected may be useful, his results suggest he is over sero-conversion • Jason needs to understand that treatment will not deliver an immediate undetectable VL, but it is likely to happen relatively soon • Try and get a second CD4 and VL and percentage

Clinical note – Drugs and travel • People who regularly work for periods overseas and are stable on treatment can usually secure drugs for an extended period • There may be issues with dispensing 5 month’s supply to new patient • Depending on where he is going may have reciprocal arrangements • May be able to have drugs collected and sent if tolerable

Clinical note – Sex & holidays • People get HIV when travelling as a function of prevalence & perhaps freedom of being away • A two week gay cruise for singles may pose a different risk from a 5 month working holiday or job relocation • Jason may wanting treatment to facilitate condomless sex. He needs to be counselled to maintain condom use and discuss STI transmission and risks as well as any IDU risk

Peter • 33 year old gay male • HIV +ve 4 months ago in Melbourne • Moving to Sydney • Long term HIV –ve partner • CD4 = 789 • VL = 48000 • Wants trial of natural therapies

Considerations for Peter • Peter is a new patient to you, he may get lost if his views on natural therapies shunned • Has a negative partner so risk of transmission. Need to disucss need for ongoing condom use & no “prevention benefit” of natural therapy • Try and set parameters for monitoring NT • How will we know working • Try for a period of time • Monitor CD4, VL, % and feeling of wellness

Clinical note – involving partner • Involving partners can be useful for some patients • Partners can support treatment decisions

Clinical note: Cultural understandings • Some cultures more affinity with natural therapies • Some cultures have different constructions of health and wellness • Religion may also play a role in decision making, responsibility, pre-determination

Tim • 44 year old gay male • HIV +ve 2 years • Single, multiple partners • CD4 = 620 • VL = 89 000 • Weekend alcohol and crystal binges • Wants to sort out drug problem before

Considerations for Tim • Tim needs to understand obligations about not transmitting HIV • Crystal meth is used by 1 in 5 MSM at least once annually, not exclusionary for treatment • Regular or binge crystal use and/or alcohol will impact compliance for most people • Your knowledge of the patient will be the best determinate of his capacity to manage treatment

Clinical note: Controlling drug use • That Tim is motivated to modify drug use should be maximised • Caution that a cycle does not start, can’t start treatment because D & A not managed v have to stop D & A to have ART could be self- defeating conundrum • Support and possible referral as well as plan for ART commencement • Likely to have continued use in some form

Steve • 26 yr old male, FTE, stable accommodation, Brazilian with Australian residency • HIV positive Sept 2012 (HIV neg May 2012) • Admitted to SVH Aug 2012 with febrile illness but nil HIV test (? Sinusitis) • Possible rUPAI early Aug (2 x CMP in Ibeza) – states nil ejaculation “thought he was being careful”) • CD4 480, HIV VL 38,000

Considerations for Steve • Prevention is a big issue for Steve, he is making assumptions about what is risky • May be unaware of legal obligations and needs to understand that he has risk of transmitting the virus as well as contracting STI • Treatment will assist with this but he should also still be using condoms for sex

Steve • Repeat pathology Oct 2012 • CD4 556 (31%), VL 22,600 • Treatment options were actually discussed at this time but not interested as yet • Also not interested in further counselling / groups – worried about other people knowing about his diagnosis

Considerations for Steve • Steve’s numbers have improved but he needs to understand that these fluctuations are common • Discuss benefits of early treatment reducing immune system damage better reconstitution • He may be more conducive to one-on-one counselling or perhaps to see a psychiatrist if he wants to discuss concerns, this would be totally confidential

Steve • Repeat pathology March 2013 • CD4 535 (21%), VL 63,000 • Seborrhoiec dermatitis, rosacea (Dermatology review) • Rectal and pharyngeal gonococcal PCR positive (states ‘brief’ rUPAI) • Anxious about physical appearance • Concerned he might have lymphadenopathy • Worried that all physical symptoms linked to HIV • Requests to commence treatment

Considerations for Steve • He has acquired HIV relatively recently and that is why his numbers are fluctuating. Try and explain that a CD4 decline will ordinarily lag behind a viral load increase • Revisit risk of transmission and the prevention benefits of treatment also potential legal ramifications if he is having condomless sex, is not on treatment with a viral load and not informing partners of his status. Prudent to document this in his file.

Clinical note: Symptom trigger • For many people the existence of any symptom will be the trigger to commencing treatment. • While this opportunity should be maximised, it is still vital to explain the implications of treatment and the long-term nature of treatment. It can not be stopped with the symptom “goes away”

Stephen – Alternative to Steve • 26 yr old male, same results • Unemployed, Newstart • Currently ‘living with friends’ • Using $50 methamphetamine daily IV • Regular rUPAI

Clinical note: HIV as motivator • Stephen is in a bit of a mess. Can HIV be viewed as a motivator to try and get his life sorted out • His drug use is impacting him financially and he needs to understand that treatment will have costs associated with it as well • He may be accepting of counselling, social work or community support for assistance with housing & possible financial support etc

Clinical note: Prevention • Needs to be made aware of public health issues & vulnerable to legal remedies if: • not informing partners of his status • not using condoms, and • does not have an undetectable viral load • Clinician may be able to provide a reality check & options which may provide support • Referral options will differ by location community agencies may be able to assist

Early Treatment: cases