HIV Principles in Primary Care and Triage of the HIV patient

1. HIV Principles in Primary Careand Triage of the HIV patient David Aymond, MD, AAHIVM

2. Disclaimer • All of this info comes from NIH guidelines, there are links to these guidelines on the Wiki. I recommend reading the summary’s and tables of these guidelines.

3. HIV in Primary Care • “Despite the complexity of managing HIV-infected patients, an observational cohort study suggests that family physicians with appropriate experience and expertise in HIV care can provide high-quality care to patients with this complex chronic illness” (Landon et al., 2005) • Experience is defined as 20 HIV patient visits a year

4. HIV in Primary CareLife Cycle and Treatment • Step 1: Fusion • Step 2: HIV reverse transcriptase converts Viral RNA to DNA. RTI are used to inhibit this step: NRTI’s are competitive inhibitors and NNRTI’s are non-competitive inhibitors. • Step 3: Integrase enzyme • Step 4: DNA is then turned in mRNA (viral proteins)=translation. Proteins are then spliced by protease enzymes into functional proteins. Protease inhibitors (PI) inhibit this step. (NOT IF HIV-2)

5. HIV in Primary CareDiagnosing? • Diagnosed with Elisa and Western Blot • Rapid HIV testing approved by FDA: 1. Oraquick (Both)=this is what RRMC uses 2. Reveal 3. Uni-Gold 4. Multispot HIV-1 and HIV-2

6. HIV in Primary CareWhen to Initiate HAART? • Current guidelines from the US DHHS, in collaboration with the CDC, NIH and IDSA, all recommend starting HAART when CD4 counts are <500 cells/mm (SOR A). Also, due to 2 studies that showed an increase in mortality when deferred above 500 cells/mm, ½ of the panel suggest starting HAART at any CD4 (SOR B) and the other ½ said only below 500 cells/mm. Therefore, any HIV + pt should be started on HAART, do not delay. • Also, all pregnant, HIV with Hep B, and HIV nephropathy patients should be treated.

7. HIV in Primary CareDrug Resistance/Genotype Testing Resistance testing must be done at admit or in clinic if this has never been done!! •HIV drug-resistance testing is recommended for persons with HIV infection when they enter into care regardless of whether antiretroviral therapy (ART) will be initiated immediately or deferred (AIII). •Genotypic testing is recommended as the preferred resistance testing to guide therapy in antiretroviral (ARV)-naive patients (AIII). -Standard genotypic drug-resistance testing in ARV-naive persons involves testing for mutations in the reverse transcriptase (RT) and protease (PR) genes.

8. HIV in Primary CareInitiating HAART in Treatment Naïve Patients The initiation of HAART is the same in all patients based on current CDC and IDSA guidelines. The caveat is that there must be genotype with resistance testing before initiating treatment. Also, weigh the side effect profiles, frequency of dosing, and co-morbiditys when considering a regimen. HAART has what is called a “backbone” meaning that regardless of the situation the pt is in, they should be on this backbone. The backbone of HAART is Nucleoside/tide Reverse Transcriptase Inhibitors (NRTI). They should be on 2 NRTI’s regardless of what is going on. Then 1 of the following 3 options should be added: a Non-Nucleotide Reverse Transcriptase Inhibitor (NNRTI), a Protease Inhibitor (PI), or an Integrase inhibitor* When you add the NRTI “backbone” there are only 2 that are first line and therefore must be used (unless resistance): Emtricitabine and Efavirenz If you decide to add a NNRTI to your backbone there is only 1 first line treatment: Efavirenz; Nevirapine can be used as an alternative If you decide to add a PI there are only 2 first line treatments: Darunavir and Atazanavir; now if a PI is added it must be boosted with Ritonavir. Ritonavir is a PI its-self that enhances the pharmacokinetics of the other PI’s but has no HIV killing activity by its-self. This is called boosting a PI or being on a Boosted PI regimen. Below are once daily, 1-2 tablet dosing regimens that are First Line treatment unless contraindication: • Atripla=Emtricitabine + Tenofovir + Efavirenz • Emtricitabine + Tenofovir + Ritonavir boosted Darunavir

9. OI’s • There are only 3: 1. PCP: CD4 <200=Bactrim 2. MAC: CD4<50=Azithromycin 3. Toxoplasmagondii Encephalitis: seropositive for T. gondii and CD4<100=Bactrim for Primary, 2ndary is Sulfadiazine and pyrimethamine and leucovorin *Continue all until CD4>200, MAC CD4>100 *Please see table on Wiki

10. Testing and Adverse Effects • There are set labs that should be done on an HIV pt and spp. Time frames they should be done in. Please see the “HAART tables” link for these. • All HAART has potential toxicities, these are very broad and can be found under “HAART tables”. Please review before starting any regimen.

11. Triage in the ED • ALL HIV PT’s know their CD4 and Viral load if they are being seen by experienced HIV doctor. All meds come with cards, ask for their card. • Treat based on previous CD4 level • If no genotype, you’ve got to get genotype before starting HAART • If AKI, cont meds until faculty sees the patient • Thinks of atypical infections when you see this complicated patient