Updates in HIV

2. Updates in HIV Simha Reddy HMC Noon Conference June 6, 2012

3. LEARNING

4. Change Behavior

5. Topics • Testing • Treatment • Prevention • Being smart about STDs

6. Testing

7. Testing • Male pt turned 50 yesterday and here for a routine physical. No medical problems and no health complaints. No notable family history or bad habits. Eats well and exercises regularly. Exam is benign. What’s your next step? • “Happy Birthday! I got you a colonoscopy! • “Well, you don’t looklike you have colon cancer. I’ll see you in a couple years.”

8. Current HIV Screening Guidelines • 2006 CDC Guidelines • Unless prevalence is less than 1/1000, routine screening of all persons aged 13-64 in all health care settings • Screen again with STD screens, before TB therapy, before new relationship, if > 1 partner since last test, or on clinical judgment • Annually for high risk: IVDU, sex workers, partners of above or of HIV+ ? Did you know? All baby boomers (born 1945 – 1965) should be screened for Hepatitis C. (draft CDC recommendation on May 18,2012)

9. Testing • How would you provide HIV screening for that same 50 yo asymptomatic patient? • HIV antibody (EIA or enzyme immunoassay) • HIV RNA PCR • Western blot • HIV RNA PCR and antibody (EIA) Did you know? 17% of all HIV positive patients are over the age of 50 Curr. Infect. Dis. Reports 2009, 11:246-254

10. Testing • 29 yo MSM comes to clinic with several days of sore throat and fever. Had unprotected receptive anal sex two weeks ago. • HIV antibody (EIA) • HIV RNA PCR • Western blot • HIV RNA PCR and antibody (EIA) Did you know? Mono is “glandular fever” in England. In a recent study, 11 of 857 with mono-like sx had acute HIV. Only 3 caught on presentation. HIV Medicine, 2012 (online: doi: 10.1111/j.1468-1293.2012.01023.x)

11. Window period

12. To Review • Everyone should be tested • HIV ab for screening (serum, rapid swab) • If concerned about acute HIV: • HIV RNA + antibody • Repeat antibody testing in 3 months Coming soon $34.95

13. Treatment

14. Treatment • 28 yohealthy W comes to clinic with a new dx of HIV after routine testing. Last negative HIV test in 2010. CD4 of 740 and viral load of 6800. Your advice? • Begin HAART now • Wait until CD4 < 500 • Wait until CD4 < 350 • Wait until CD4 < 200

15. 2012 HHS Guidelines

16. Wait Treat Everyone History of ARV initiation

17. \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ Viral load 500 350 200 or 14% (AIDS) CD4 count

18. PJP Crypto Toxo KS Etc. HIV \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \

19. NA-ACCORD Kitahata et al. Effect of early versus deferred antiretroviral therapy for HIV on survival. NEJM, 2009; 360 (18): 1815-1826

20. So what are her options? • NRTI backbone emtricitabine/tenofovir = Truvada • Atripla = efavirenz (NNRTI) + Truvada • atazanavir(PI) + ritonavir (PI) + Truvada • darunavir(PI) + ritonavir (PI)+ Truvada • raltegravir(integrase inhibitor) + Truvada Did you know? Ritonavir used to decrease metabolism of other PI (boosting)

21. BID Atripla Pros - convenience Cons - CNS effects - teratogenic Atazanvir-r Pros - high barrier to resistance Cons - GI side effects - lipids - needs low pH - interactions (statins, rifampin fluticasone. . .) Darunavir-r Pros - high barrier to resistance Cons - GI side effects - lipids - interactions Raltegravir Pros - few side effects Cons - BID dosing - elevated CK

22. On the horizon • Complera • (rilpivirine/tenofovir/emtricitabine) • already here! • few CNS effects • caution if viral peak > 100,000 • Quad pill • (elvitegravir/tenofovir/emtricitabine/cobicistat) • Fewer side effects. Cobicistat is a booster.

23. Review • TREAT EVERYONE (think about adherence) • Chronic illness is exacerbated • Decide based on side effect profile • It will only get easier

24. Prevention

25. PrEP • Pre-exposure prophylaxis • Truvada, the OTHER “little blue pill”

26. PrEP • iPrEX • Multinational RCT with ~2500 men who have sex with men • Relative risk reduction of 44% with Truvada • NNT of 89, most of those infected in intervention were not actually taking the drug • Partners PrEP • 4758 serodiscordant heterosexual couples • Infected: 17 w/ TDF, 13 w/ FTC/TDF, 52 in control • RRR of 65 to 75%

27. Barriers to PrEP • Adherence • Resistance • Cost

28. Who is PrEP for? • CDC preliminary guidance • can be considered in high risk MSM patients • Need q3month HIV/STD testing • FDA committee • MSM • Serodiscordant • At risk due to sexual activity • STAY TUNED . . . final decision TOMORROW

29. Better news. . .txprevents spread • HPTN (HIV Prevention Trials Network) 052 • Multinational RCT • 1763 serodiscordant couples (97% heterosexual) • Control treated with HAART once <250 or AIDS • Experimental treated right away • 96% reduction in infection rate • Of 28 infections traced to partner, only one in treatment arm • Stopped early by DSMB last year

30. Review • PrEP can be considered in high risk MSM and serodiscordant couples. Find out more tomorrow • Better strategy: treat the people with HIV

31. STD TESTING UPDATE

32. STD Testing • 19 yo asymptomatic woman gets routine STD testing. Because you remembered to ask about anal sex, you got a rectal swab in addition to urine. NAAT has returned positive for gonorrhea, but not chlamydia. What is the best choice? • Cefixime 400 PO • Cefixime 400 PO + Azithromycin 1 gram PO • Ceftriaxone 250 IM • Ceftriaxone 250 IM + Azithromycin 1 gram PO

33. Gonorrhea resistance historically • sulfonamides • penicillin • tetracycline • ciprofloxacin • cephalosporins? • azithromycin?

34. Syphilis • The old way to screen or test RPR

35. Syphilis • The new, “improved” way Treponemal specific EIA TP-PA (treponemal) No syphilis RPR No syphilis syphilis still syphilis (late latent or treated)

36. REVIEW • Gonorrhea is smarter than you • Ceftriaxone IM + azithromycin (even if chlamydia negative) • Careful, syphilis testing is now annoying • Order a quant RPR if your pt has had syphilis • STD clinic is amazing. AMAZING. Call them about your pt

37. CONCLUSION • TEST EVERYONE • TREAT EVERYONE • Watch the news for PrEP • Ceftriaxone + azithro for gonorrhea • Think about quantitative RPRs

38. QUESTIONS