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Pre-departure HIV Orientation Session A: Pre-ART Considerations

Pre-departure HIV Orientation Session A: Pre-ART Considerations. 23 January, 2007. Royce C. Lin, MD Assistant Clinical Professor of Medicine University of California, San Francisco Director, AIDS Consult Service San Francisco General Hospital Deputy Director, ASPIRE

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Pre-departure HIV Orientation Session A: Pre-ART Considerations

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  1. Pre-departure HIV OrientationSession A: Pre-ART Considerations 23 January, 2007 Royce C. Lin, MD Assistant Clinical Professor of Medicine University of California, San Francisco Director, AIDS Consult Service San Francisco General Hospital Deputy Director, ASPIRE Positive Health Program, SFGH

  2. GOALS • Overview: Pre-ART considerations • Medical indications • WHO guidelines • Kenyan national guidelines • US DHHS guidelines • WHO Staging system • Cotrimoxazole prophylaxis • Adherence issues

  3. Pre-ART considerations: US Full HPI, PMH Full Lab Counseling (tx, support) Establish relationship Adjunct services (social, insurance) Vaccinations Problem list, Px, Rx Initial Visit F/U Visit Follow CD4 decline Prep ART as CD4 <350 HAART Choose regimen with pt input Adherence counseling/support F/U Visit Monitor toxicity Therapy switch as needed

  4. Pre-ART considerations: RLS HPI, PMH (form/algorithm driven) Select Labs (baseline + ?TB, preg) WHO staging (triage ART) Counseling (x 3. Peer groups support) Adjunct services (nutrition, HBC) Cotrimoxazole Problem list, Px, Rx (algorithm-driven) Initial Visit F/U visit See CD4 result With WHO, assess ART eligibility Adherence counseling x 3 if ART Cotrimoxazole, other prevention HAART All get Triomune, unless contraindication Pregnancy? TB? F/U Visit Monitor toxicity (TB, preg, IRIS) Therapy switch as needed

  5. When to Start HAART?

  6. When to Start Therapy in adultsKenyan Guidelines • All who have a CD4+ count ≤ 200 cells/mm3, regardless of stage of illness • All who are in WHO stage IVclinical criteria, regardless of CD4+ cell count • Consider those who are in WHO Stage III clinical criteriaand have CD4 cell counts ≤ 350/mm3 Note!The patient must have expressed willingness and be ready to start therapy

  7. U.S. DHHS Guidelines Summary: ART recommended for… • All with history of AIDS-defining illness, regardless of CD4 count • All with CD4<200 • CD4 201-350 should be offered therapy • CD4>350 • Most clinicians defer therapy regardless of VL • Some offer therapy if VL>100,000

  8. Confirmed HIV + Individual Perform WHO clinical staging Perform CD4+ T cell count WHO Clinical Stage 1 WHO Clinical Stage 2 WHO Clinical Stage 3 WHO Clinical Stage 4 Eligible for ART regardless of CD4 count CD4: >350 cells/mm3 CD4: 200-350 cells/mm3 CD4: <200 cells/mm3 Do NOT initiative ART. Monitor patient regularly Consider ART ONLY if in WHO clinical stage III Eligible for ART regardless WHO Clinical stage

  9. WHO Clinical Staging

  10. WHO Clinical Staging System for Adults and Adolescents

  11. WHO Clinical Staging System for Adults and Adolescents

  12. Stage I Asymptomatic

  13. Stage II Not yet AIDS, but getting sick CD4 usually 200-350

  14. Courtesy of Jackie Dolev, M.D. Department of Dermatology University of California, San Francisco

  15. www.uptodate.com

  16. www.uptodate.com

  17. Prurigo

  18. HerpesZoster-Shingles

  19. Stage III Early AIDS CD4 usually <200

  20. Stage III • Pulmonary TB • Severe bacterial infections • Bacterial pneumonia • Pyomyositis • Performance scale 3 • Bedridden <50% in past month

  21. Stage IV Late AIDS CD4 usually < 50-100

  22. Other Stage IV • Extrapulmonary TB • Cryptococcal Meningitis • Toxoplasmosis • Esophoegeal candidiasis • MAC • CMV Retinitis • HSV in mucocutaneous site • Progressive Multifocal Leukoencephalopathy • AIDS Dementia Complex • Weight loss >10% and bedbound >50%

  23. CD4 Substance abuse OI clinical signs Family and support? Adherence? MEDICAL Indications PSYCHOSOCIAL Contraindications

  24. Who should get ART first? • A. Female University Student • CD4 178. Thrush. Treated with clotrimazole • Family knows and is supportive • B. Successful Businessman • CD4 168. Very high VL (>500,000) • Diagnosed 1 week, anxious, demands immediate ART. Reluctant to disclose to spouse. • C. Disbelieving Rural Woman • CD4 47. Bacterial pneumonia. Cutaneous KS • Skeptical about her AIDS diagnosis.

  25. When to Start: PART II • Medical consideration only half of the equation • Patient readiness EQUALLY important • Therapy quickly FAILS if suboptimal adherence • >95% Adherence needed! • Especially important with Triomune! • Once first-line fails, second-line agents may not be effective and are more toxic • BETTER TO WAIT AND START WHEN PATIENT IS TRULY READY

  26. Adherence • A major determinant of degree and duration of viral suppression • Poor adherence associated with virologic failure • What percentage adherence is most strongly-associated with emergence of viral resistance? • Optimal suppression requires 90-95% adherence • Even MORE important in resource-limited settings given lack of access to resistance testing, limited salvage options • Suboptimal adherence is common

  27. Predictors of Inadequate Adherence • Poor clinician-patient relationship • Active drug use or alcoholism • Unstable housing • Mental illness (especially depression) • Major life crises • Lack of patient education • Lack of patient access to medical care • Medication adverse effects • Fear of medication adverse effects

  28. Predictors of Good Adherence • Emotional and practical supports • Family, friends, social support • Importance of social work, CBOs • Understanding the importance of adherence • Belief in efficacy of medications • Keeping clinic appointments • Feeling comfortable taking medications in front of others • Convenience of regimen • Consideration of patient preferences in constructing an antiretroviral regimen

  29. Predictors of Inadequate Adherence • Age, race, sex, educational level, socioeconomic status, and a past history of alcoholism or drug use do NOT reliably predict suboptimal adherence. • Higher socioeconomic status and higher education levels and lack of history of drug use do NOT reliably predict optimal adherence.

  30. Practicum: Case Discussions

  31. Case scenario #1 • 35 yo woman from Kisumu • Tested HIV+ recently • Comes to you for first visit in clinic • Wants to know what she should do • Physically well, no symptoms • Baseline weight 68kg. Now 66kg. • What WHO clinical stage is she? • What else do you want to know? • What do you want to do today?

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