1 / 140

Comprehensive Care for Newly Diagnosed HIV Patients

A guide for healthcare professionals managing a newly diagnosed HIV patient, including history, treatment options, and patient education.

soyala
Download Presentation

Comprehensive Care for Newly Diagnosed HIV Patients

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Management of the Newly Diagnosed HIV-infected Patient Sarah Lewis MHS, PA-C

  2. Case Presentation • A 32 yo woman presents for care at your clinic, referred from a public health clinic after testing positive for HIV • She presented for testing after discovering a past boyfriend of hers is HIV+ • What questions do you have for her?

  3. What does she know about HIV? • Human Immunodeficiency Virus • HIV is no longer a ‘death sentence’ • Diabetes mellitus can be a useful analogy • Chronic, incurable disease • Not immediately fatal • Eventually requires medications in most cases • Can usually be controlled with careful adherence, management, and follow-up • As with the care of persons with diabetes, working in a team and providing continuing education is essential throughout the course of the disease • Patients educated about HIV and the potential for resistance have better adherence to therapy1,2 1. Malow RW, et al. Alcohol Drug Abuse 1998;49:1021-4. 2. Tuldra A, et al. 39th Interscience Conference on Antimicrobial Agents and Chemotherapy; 1999; Abstract 595.

  4. HIV 101 for Patients

  5. History of HIV • retroviruses discovered in 1900 in animals only • HIV related to primate retroviruses, that may have crossed species into humans and undergone mutations that became HIV as early as 1675?? • established in Africa as an epidemiologic disease after 1930 • 1980 1st retroviruses found to affect T cells • Gallo, Essex, & Montagnier pioneers of the cause of AIDS

  6. History of HIV • 1981 1st descriptions of immunodeficiency disease in previously healthy person in medical literature • specific retrovirus, HIV-1 was not isolated until 1983 • HIV-2 (West Africa) is distinct from HIV-1 (Central Africa) by a longer clinical latency period • although syndrome of AIDS was not reported until 1981, isolated cases were clearly reported in 1950s & 1960s

  7. History of HIV • HIV antibodies found in blood sample from 1950s in Central Africa suggesting emergence in 1930s; • remained localized there until spreading to Africa and then Haiti in late 1970s • to US & Europe from Haiti & Africa • first suspect US case 1968 15 y/o BM St. Louis w/ Kaposi’s & disseminated Chlamydial; blood samples + for HIV • HIV blood transmission documented 1982 • HIV testing 1985 • HIV drug Rx approved 1987

  8. Primary HIV Infection (PHI)a/k/a Acute HIV Infection • Pathogenesis • Clinical Presentation • Diagnosis • Epidemiology • PHI and the Natural History of HIV Disease • Treatment Options • Conclusions & Recommendations

  9. Etiology: HIV Structure • RNA retrovirus • RNA into DNA an absolute must to multiply • core, nucleocapsid • double stranded RNA-genome at least nine genes • protein & enzymes • reverse transcriptase (RNA-to-DNA) • polymerase (DNA-to DNA) • ribonuclease (destroys old RNA) • integrase (splices viral DNA into host DNA, now permanent) • protease (molecular scissor) • spherical lipid bilayer viral envelope

  10. Life Cycle of HIV

  11. Sites of Action of antiretroviral Medications

  12. Exposure to HIV at mucosal surface (sex) Day 0 Virus collected by dendritic cells, carried to lymph node Day 0-2 HIV replicates in CD4 cells, released into blood Day 4-11 Day 11 on Virus spreads to other organs Kahn JO, Walker BD. N Engl J Med. 1998;339:33-39.

  13. Primary HIV Infection: Pathogenesis CD4 Cell Count (cells/mm³) Symptoms Plasma RNA Viral Load 1,000 CD4 Cell Count 500 4-8 Weeks Up to 12 Years 2-3 Years

  14. How often do people with PHI seek health care? Swiss cohort • 87% of seroconverters (20/23) in cohort study had symptoms • 95% of these patients had medical evaluation • PHI considered in only 5 of 19 patients PHI often leads to medical evaluation, but is under-diagnosed! Schacker T et al. Ann Int Med 1996;125:257-64.

  15. How does HIV cause AIDS? • HIV infects and destroys an important type of cell in the body’s immune system known as the T-helper (TH) cell, also known as the CD4 cell

  16. How does HIV cause AIDS? • CD4 cells direct and coordinate other cells in the immune system to battle infections • When CD4 cells are destroyed, the body loses its ability to fight off infections

  17. HIV Infection is characterized by a steady decline in the number of CD4 cells Acute Infection Asymptomatic HIV Infection AIDS CD4 Cell Count 1,000 CD4 Cells 500 200 4-8 Weeks Up to 12 Years 2-3 Years Time

  18. HIV Infection is characterized by a steady decline in the number of CD4 cells CD4 Cell Count (cells/mm³) Acute Infection Asymptomatic HIV Infection AIDS 1,000 CD4 cell count 500 200 high risk of opportunistic infections 4-8 Weeks Up to 12 Years 2-3 Years Time

  19. How does HIV cause AIDS? • Infections that develop as a result of HIV-inflicted damage to the immune system are called “opportunistic infections” or “OIs” • When someone with HIV develops an opportunistic infection, they are diagnosed with AIDS

  20. How does HIV cause AIDS? • In the past, virtually all patients diagnosed with AIDS died within a few years • Now, with treatment, many patients diagnosed with AIDS are surviving many years with the disease

  21. What is the “Viral Load”? • The HIV viral load is simply a measure of the quantity of HIV in a drop (mL) of a patient’s blood, and it is usually measured in copies/mL • In general, the higher the viral load, the faster CD4 cells are destroyed

  22. Clinical Approach to the Diagnosis of Primary HIV Infection • Exposure • Signs & Symptoms • Laboratory Testing

  23. Exposure Risks (average, per episode, involving HIV-infected source patient)

  24. Primary HIV Infection: Signs & Symptoms • 40-90% of patients will be symptomatic • A mononucleosis-like illness of non-specific signs and symptoms • Signs and symptoms typically begin 1-4 weeks post-exposure • High index of suspicion is critical Kahn JO, Walker BD. N Engl J Med. 1998;339:33-39. Schacker T, et al. Ann Intern Med. 1996;125:257-264.

  25. Primary HIV Infection: Common Signs & Symptoms N = 160 patients with PHI in Geneva, Seattle, and Sydney % of patients Vanhems P et al. AIDS 2000; 14:0375-0381. 

  26. Primary HIV Infection: Other Signs & Symptoms % of patients Kahn JO, Walker BD. N Engl J Med. 1998;339:33-39.

  27. Primary HIV Infection Rash Mucosal Lesions Trunk and face > limbs Small pink macules Oral ulcers, thrush (Kahn, NEJM, 1998)

  28. Oral Ulcers in Acute HIV Infection From: Walker, B. 40th IDSA, Chicago 2002.

  29. Genital Ulcer in Acute HIV Infection From: Walker, B. 40th IDSA, Chicago 2002.

  30. Diagnostic Testing for PHI 1 mil HIV RNA 100,000 + HIV RNA HIV-1 Antibodies _ 10,000 Ab P24 + 1,000 Exposure 100 Symptoms 10 0 20 30 40 50 Days

  31. Diagnostic Testing:Viral Load • More sensitive than HIV antibody or p24 Ag test3 • Positive one to three weeks before antibody test1 • Typically high level, e.g. greater than 50,000-100,000 copies/mL2,3 • False positives can occur • Most false positives are low level (<10,000 copies/mL) • HIV VL <10,000 copies/mL should probably be considered “indeterminate” 1. Busch MP, Satten GA. Am J Med 1997;102:Suppl 5B:117-24. 2. Kahn JO, Walker BD. N Engl J Med. 1998;339:33-39. 3. Daar ES et al. Ann Intern Med. 2001;134:25-29.

  32. Diagnostic Testing: HIV Antibody • The gold standard for diagnosis of HIV infection when used with confirmatory Western Blot • Antibody conversion typically 22-27 days following infection1 1. Kahn JO, Walker BD. N Engl J Med. 1998;339:33-39.

  33. Why do we Care about Diagnosing PHI? • Public Health: • Patients with PHI are likely to be highly infectious • Diagnosis of HIV infection may lead to safer sex • Personal Health • 40% of patients with HIV not diagnosed until they have AIDS • Antiretroviral therapy (ART) during PHI may alter the natural course of HIV disease

  34. HIV Rapid Tests

  35. Public Health Need for Rapid HIV Tests • High rates of non-return for test results • In 2000, 31% did not return for results of HIV-positive conventional tests at publicly funded sites • Need for immediate information or referral for treatment choices • Perinatal settings • Post-exposure treatment settings • Screening in high-volume, high-prevalence settings

  36. Multispot HIV-1/HIV-2 Uni-Gold Recombigen Reveal G2 OraQuick Advance

  37. Multispot HIV-1/HIV-2 Uni-Gold Recombigen Reveal G2 OraQuick Advance

  38. Four FDA-approved Rapid HIV Tests Sensitivity (95% C.I.) Specificity (95% C.I.) OraQuick Advance - whole blood - oral fluid - plasma 99.6 (98.5 - 99.9) 99.3(98.4 - 99.7) 99.6 (98.5 - 99.9) 100(99.7-100) 99.8(99.6 – 99.9) 99.9(99.6 – 99.9) Uni-Gold Recombigen - whole blood - serum/plasma 100(99.5 – 100) 100 (99.5 – 100) 99.7(99.0 – 100) 99.8 (99.3 – 100)

  39. Four FDA-approved Rapid HIV Tests Sensitivity (95% C.I.) Specificity (95% C.I.) Reveal G2 serum plasma 99.8(99.2 – 100) 99.8(99.0 – 100) 99.1 (98.8 – 99.4) 98.6 (98.4 – 98.8) Multispot serum/plasma HIV-2 100 (99.9 – 100) 100 (99.7 – 100) 99.9 (99.8 – 100)

  40. Additional Rapid Tests • FDA approved – May 2006 Sure Check Stat Pak

  41. Confirmatory Testing • Confirmatory test is essential (not just EIA) • For Western blot: • Venipuncture for whole blood • Oral fluid specimen • Follow-up testing of persons with negative or indeterminate Western blot results after 4 weeks

  42. The Berlin Patient • Treated soon after acute HIV infection with didanosine, indinavir, and hydroxyurea • Baseline VL 80,000-89,000 pre-treatment • Treatment briefly interrupted twice in first 4 months of treatment • Viral rebound during first interruption but not the second • VL remained undetectable after treatment was stopped a third time Lisziewicz J et al. NEJM 1999; 340: 1683-1684.

  43. Unplanned Treatment Interruptions of ART following Primary HIV Infection: “the Berlin Patient” ARV Rx Started Prior to HIV Seroconversion ddI + HU + IDV No ARV Rx Lisziewicz J et al. N Engl J Med 1999;340:1683.

More Related