Medical Care of the HIV Patient: 2011 Update

1. Medical Care of the HIV Patient:2011 Update Vincent Hsu, MD, MPH FAFP, April 30, 2011 No Disclosures Relevant to this Presentation

2. 14 12 10 8 6 4 2 0 Complacency in Japanese Influenza Vaccination Program: Excess Deaths Attributed to Both Pneumonia and Influenza and All Causes, Japan P&I* Mortality Rate All-cause Mortality Rate 70 60 50 40 Excess Deaths From Pneumonia and Influenza (per 100,000 Population) Excess Deaths From All Causes (per 100,000 Population) 30 20 10 0 1990 1974 1978 1970 1950 1966 1986 1998 1982 1962 1994 1954 1958 *P&I=pneumonia and influenza. Reichert TA, et al. N Engl J Med. 2001;344:889-896.

4. “HIV/AIDS is the deadliest epidemic of our time…even if a vaccine for HIV were discovered today, over 40 million people would still die prematurely as a result of AIDS.” -The Impact of AIDS, United Nations, 2004

6. Take this Home • Healthcare providers must avoid complacency and maintain a relentless focus on preventing and identifying patients with HIV

7. Case #1 • A 29 year-old white woman comes in for a routine physical. She has no complaints. She works as a medical assistant and has had two lifetime sexual partners. • Would you screen her for HIV?

9. 1993 Revised Classification System for HIV Infection and Expanded AIDS Surveillance Case Definition for Adolescents and Adults Clinical Categories Shaded boxes indicate category defined as AIDS

12. Persons Living with HIV and AIDS Cases Rates per 100,000 Population Reported by County of Residence* Florida through 2008 http://www.doh.state.fl.us/disease_ctrl/aids/trends/msr/2010/MSR0110.pdf

15. Screening Recommendations • CDC: Routine screening for patients 13-64 years, in all heathcare settings • ED, urgent care, primary care, inpatients • Repeat annually if high-risk • AAFP: Screen high-risk groups and in high-risk clinical settings

16. Case #1, continued • The patient gets tested for HIV and results show the following: • EIA: repeatedly reactive • Western blot: indeterminate (bands obscured) • Does she have HIV? What do you tell the patient? What do you do next?

17. Diagnosis of HIV • Antibody assays • Requires ELISA and Western Blot • Sensitive & specific but misses window period • False positive ELISA and indeterminate WB occurs infrequently • Nucleic acid (PCR) • Qualitative approved for diagnosis • Best for earliest detection

18. Acute Retroviral Syndrome (Primary HIV Infection) • >40,000 newly infected annually in U.S. • Diagnosis • Negative or indeterminate HIV serology • High HIV viral load (usually >100K) • Antibody positive 3-4 weeks after initial infection • Treatment with ART is controversial

19. Case #1 Summary • Offer screening to your patients, even those that are not traditional “high-risk” • Recognize acute retroviral syndrome • Retest using ELISA/WB in 6 weeks and/or use PCR to help in diagnosing difficult cases

20. Case #2 • A 26 y/o F is screened and found to be infected with HIV. Her initial CD4 count is 749 and her VL is 15,000. Pregnancy test is negative • What is the appropriate workup for her? Should she be offered antiretroviral therapy? If so, what? If she was pregnant, would your recommendation change?

21. Natural History of HIV Infection

22. www.aidsinfo.nih.gov

23. Recommended Workup for Newly HIV-Infected Adults • The usual: CMP, CBC, UA • Viral load, CD4 count • Tuberculin skin test • RPR • Hepatitis B/C • Toxoplasma titers • Resistance testing • Genotype • Phenotype

24. Primary Prophylaxis • Chemoprophylaxis • Pneumocystis (TMP-SMZ, CD4<200) • Toxoplasmosis (same as PCP) • M. aviumcomplex (azithromycin, CD4<50) • Vaccines • S. pneumoniae • Hepatitis A & B • Influenza • TDAP • MMR (if CD4>200)

25. Initiating ARV:Who to Treat and When to Start • CD4 <350 (AI) <500 (A/B-II) >500 (B/C-III) • All patients • Symptomatic with AIDS-defining illness • Pregnancy • HBV coinfection • HIV-assoc nephropathy • Trends: early and no drug holidays!

26. Targets of HIV Therapy Integrase Inhibitors Entry Inhibitors: Fusion, CD4, CCR5 CXCR4 Nucleus RNA Protease DNA Reverse transcriptase HIV CD4+ T-Cell Reverse transcriptase inhibitors: NRTI (nucleosides, nucleotides) NNRTI Protease inhibitors

27. Currently Approved HIV Antiretrovirals Non-Nucleoside RTIs (NNRTIs) Reverse Transcriptase Inhibitors Protease Inhibitors (PIs) Fusion Inhibitors CCR5 Receptor Antagonists Integrase Inhibitors

28. Initiating ARV: What to Start • 2 NRTIs (tenofovir + emtricitabine) PLUS EITHER • NNRTI (efavirenz) • PI (atazanavir/r or darunavir/r), OR • II (raltegravir)

29. Adherence & Resistance • Adherence • Simpler dosing schedule more effective(Daily 40% > BID 63% > TID+ 71%) • Reminders, pill boxes, alarms • Education and trust • Resistance • Genotypic tests • Phenotypic tests

30. NRTI Lactic Acidosis Hepatic Steatosis Lipodystrophy NNRTI Rash Drug interactions Protease Inhibitors Hyperlipidemia Lipodystrophy Insulin resistance Elevated LFTs Drug interactions (CYP450) General adverse effects of ARV

31. Selected Specific Adverse Effects

32. Case #2 Summary • Use HHS guidelines for workup and management for HIV • Trend is toward earlier and aggressive treatment with triple antiviral therapy • Always consider side effect profile

33. Case #3 • A 42 y/o F comes into your office asking for an HIV test and possible “morning-after HIV medicine” The night before, she had an unprotected one-night stand after a party. She finds out later that he is HIV-positive • What do you recommend?

34. Informed Consent and Reporting • Florida Omnibus AIDS Act • Enacted 1988, revised 1998 • Informed consent • Confidentiality, test results, transmission • Written or verbal • Can’t force sexual partner notification • Reporting requirements • Notify patient • Report to health dept

36. Non-occupational HIV Exposure

37. Percutaneous Injury and HIV in Healthcare Personnel • ~400K percutaneous injuries are sustained by healthcare personnel annually but <100 occupationally-acquired cases of HIV documented • Percutaneous 0.3%, mucous membrane 0.09% • Post-exposure use of zidovudine reduced HIV transmission (AOR=0.19) Panlilio, AL, et. al. Estimate of the Annual Number of Percutaneous Injuries in U.S. Healthcare Workers. 4th Decennial Conference, March 5-9, 2000 Cardo et al., New Engl J Med 1997;337:1485-90

38. Elements of Postexposure Management • Wound management • Exposure reporting if applicable • Assessment of infection risk • type and severity of exposure • bloodborne infection status of source person • If indicated, begin PEP ASAP (within hrs) • Appropriate treatment, follow-up, and counseling

39. Recommended HIV PEP for Percutaneous Injuries Infection Status of Source Exposure Type Less Severe More Severe HIV positive, class 1 Recommend basic PEP Recommend expanded PEP HIV positive, class 2 Recommend expanded PEP Recommend expanded PEP HIV status unknown Generally, no PEP Generally, no PEP Class 1: Asymptomatic or known low viral load Class 2: Symptomatic, AIDS, or known high viral load

40. Counseling and Prevention: Reducing the Following • Sexual transmission of HIV • Blood-borne transmission of HIV in medical • Parenteral transmission among IDU • Maternal to child transmission • Transmission of HIV by screening for high-risk behaviors Screening for HIV and Treatment of Acquired Immunodeficiency: AAFP Policy Statement, 1997

41. National HIV/AIDS Lifelines

42. Take this Home • Healthcare providers must avoid complacency and maintain a relentless focus on preventing and identifying patients with HIV

43. Web Resources • Epidemiology • www.unaids.org/en/resources/epidemiology.asp • www.cdc.gov/hiv/dhap.htm • www.doh.state.fl.us/disease_ctrl/aids/index.html • Infection Control • www.cdc.gov/ncidod/hip/Guide/guide.htm • Florida AIDS Law • www.doh.state.fl.us/disease_ctrl/aids/legal/legal.html • Clinical • www.hopkins-aids.edu • www.hivwebstudy.org (case studies) • hivinsite.ucsf.edu • aidsinfo.nih.gov (guidelines) • www.aids-ed.org (slides)