hiv clinical issues for case managers

HIV CLINICAL ISSUES for Case Managers

ADVANCED HIV CASE MANAGEMENT

COURSELeonard A. Sowah, MBChB, MPH

Assistant Professor of Medicine

Institute of Human Virology

University of Maryland School of Medicine

HIV Virus Life Cycle

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Clinical Course of HIV Infection

Acute or primary infection Rash Fever Flu like symptoms Fatigue Sore throat

Prolonged Asymptomatic Immune activation leads to CD4 cell decline

Early symptomatic phase Herpes zoster Increased risk of common infections HIV Dermatopathy

Advanced HIV or AIDS Opportunistic Infections

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CD4 Cells

A type of white blood cell that carries the CD4 surface marker and helps the body fight infection. Also known as T-cells or T-helper cells. When infected by HIV, these cells incorporate HIV RNA into their DNA and subsequently manufacture new HIV particles.

HIV Viral Load

Viral load means how much HIV is in the patient’s bloodstream (also called HIV RNA).

“Undetectable viral load” means the amount of the virus is so low, the blood tests cant detect it.

Doctor’s use a combination of medicines to try and get the patient’s viral load to an undetectable level and keep it there.

Even when a viral load is extremely low or undetectable, the client should continue taking prescribed HIV medications.

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AIDS - Acquired Immunodeficiency Syndrome

The most severe manifestation of HIV infection. Characterized by numerous opportunistic infections and malignancies or a CD4 cell count below 200/mm3, which, in the presence of HIV, constitutes a diagnosis of AIDS.

Course of HIV Infection

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From CLIN INFECT DIS  30(S1):S5-S14. © 2000 by the Infectious Diseases Society of America. All rights reserved

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Common Opportunistic Diseases in HIV

Pneumocystis pneumonia Oropharyngeal candidasis Pulmonary tuberculosis Herpes zoster Cryptococcal Meningitis CNS Toxoplasma Non Hodgkins Lymphoma HIV Encephalopathy

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© 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 2

Causes of death in the HAART era

Current Opinion in Infectious Diseases. 25(1):36-41, February 2012.04/12/23

© 2006 AmericanAnnals of Internal Medicine. 145(6):397-406, September 19, 2006. College of Physicians. Published by American College of Physicians.

Causes of Death among Persons with AIDS in the HAART Era : New York City

VIRAL ENTRY AND REPLICATION Sources of HIV virus in

an infected person blood breast milk saliva semen tears vaginal fluids

Transmission has been documented only through

blood blood products sexual fluids Breast milk

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Current HIV drugs and their targets in the viral cell cycle

Fusion InhibitorsCCR5 Antagonist

NNRTIs & NRTIs

Protease Inhibitors

Integrase Inhibitors

Copyright © 2003 by the European Molecular Biology Organization04/12/23

Current FDA Approved HIV Medications

©2006 Community Research Initiative of New England. All Rights Reserved.

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When to start therapy (DHHS Guidelines)

CD4 counts < 500 cells Observational data and cohort studies suggests clinical benefit for

patients treated with CD4 > 500 cells

History of AIDS-defining illness HIV-associated nephropathy (HIVAN) Pregnant women Hepatitis B co-infection Rapidly declining CD4 count High viral loads > 100,000 /ml

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www.aidsetc.org

When to Start ART

Exact CD4 count at which to initiate therapy not known, but evidence points to starting at higher counts

Current recommendation: ART for all patients with CD4 <500 cells/µL

For patients with CD4 >500 cells/µL, 50% of the panel recommend ART, 50% consider ART to be optional

Randomized control trial (RTC) data support benefit of ART if CD4 350

No RTC data on benefit of ART at CD4 >350, but observational cohort data

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Assessing Readiness for Therapy Knowledge about disease Prior adherence history Individual self efficacy Beliefs about Efficacy and safety of

ART regimen Age / income /education Drug use Dosing frequency Pill burden ????

J Gen. Intern Med 2002;17: 756 -76504/12/23

Choice of Initial Regimen

Efficacy Toxicity Clinical Co-morbidity Results of Genotypic resistance testing Substance abuse and psychiatric issues Potential for drug interactions Ease of Administration Consistency with patient lifestyle

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Common Side Effects of HIV Meds

LipoatrophyLoss of fat in cheeks,

temples or extremities

Rashes

Increase in the amount of fat, cholesterol, or sugar in the blood that can lead to heart disease

LipodystrophyIncrease in abdominal size, breast size, and/or dorsocervical fat pad

(buffalo hump)

Nephrotoxicity, Kidney StonesKidney damage

HepatotoxicityLiver damage

Nausea, Diarrhea and Vomiting

AnemiaLow number of blood cells; causes fatigue

FACEFACE

BODYBODY

LIVERLIVER

SKINSKIN

HEARTHEART

KIDNEYSKIDNEYS

GUTGUT

BLOODBLOOD

NeuropathyNerve damage causing

strange sensations and pain, starting in the hands/feet

NERVESNERVES

Hyperlipidemia, High Cholesteroland High Glucose

Osteoporosis, OsteopeniaBone loss

BONESBONES

Immune-Reconstitution Inflammatory Syndrome (IRIS)

What is IRIS ? Paradoxical worsening of clinical symptoms

in a HIV positive patient upon therapy initiation from pre-existing infections.

10 – 25% of patients started on HAART Within 12 weeks of onset of HAART CD4 count of HAART start <100 cells/m3 Drop in viral load of > 2.5 log copies

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Common Manifestations of IRIS

Anogenital Herpes virus infection Genital warts Molluscum contagiosum Shingles Tuberculosis MAC Infection PCP Hepatitis

Sources for pictures: http://www.medicinenet.com04/12/23

Perinatal HIV Transmission

Without antiretroviral (ARV) drugs during pregnancy, mother-to-child transmission (MTCT) has ranged from 16%–25% in North America and Europe.

21% transmission rate in the U.S. in 1994 before the standard zidovudine (ZDV) recommendation during pregnancy.

With this change in practice, transmission decreased to 11% in 1995.

Today, risk of perinatal transmission can be <2% with:

effective antiretroviral therapy (ART) elective cesarean section (C/S) as appropriate formula feeding

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Hepatitis C and HIV

30 - 40% of HIV+ people in US also infected with HCV

More rapid progression of HCV (twice as fast) Little to no affect on HIV progression (still inconclusive) Complicates medication regimens Increases risk of perinatal transmission Incarceration and injection drug use settings have

co-infection rates >75% Treatment effectiveness is heavily determined by

genotype

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Other Clinical Issues in HIV Care

Kidney Disease Hyperlipidemia Cardiovascular Disease Liver Disease COPD HIV Neuropathy Cognitive Impairments

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End of Life Needs

Advanced Directives Power of attorney Disease management Hospice Care Comfort Care Insurance Issues

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Summary

HIV viral replication can be suppressed with Anti Retroviral Therapy

Risk of development of drug resistance is high in non adherent patients.

Individualized choice of therapy regimen and when to initiate ART may reduce risk of treatment failure and development of resistance

Effective team work between case manager and HIV provider can reduce therapeutic failure and improve patient satisfaction

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THANKS VERY MUCH