hiv update and state of the art christian woods, md september 5, 2015 1
TRANSCRIPT
HIV Update and State of the ArtChristian Woods, MD
April 19, 2023
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Disclosures
• Speaker Bureau for Cubist Pharmaceuticals
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Objectives
• Brief review of advances in HIV medicine• Brief review of the current epidemiology of HIV• Brief review of advances in HIV prevention
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THE BASICSHIV Update and State of the Art
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Co-Receptor Inhibitors
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Fusion Inhibitors
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Nucleoside Reverse Transcriptase Inhibitors
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Non-Nucleoside Reverse Transcriptase Inhibitors
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Integrase Inhibitors
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Protease Inhibitors
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Acute HIV
• Fever• Fatigue and Myalgia• Lymphadenopathy• Pharyngitis
(nonexudative)• Weight Loss• Headache• Nausea & Diarrhea• Rash (erythematous,
macular)
• Thrush• Rarely Pneumocystis• Aseptic Meningitis
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CDC HIV CLASSIFICATION SYSTEM
CD4 Criteria
• Stage 1: CD4 >500• Stage 2: CD4 200-500• Stage 3: CD4 <200
Symptom Criteria
• Stage A: Asymptomatic• Stage B: B symptoms• Stage C: AIDS Defining
Conditions
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CDC HIV CLASSIFICATION SYSTEM
CD4 Criteria
• Stage 1: CD4 >500• Stage 2: CD4 200-500• Stage 3: CD4 <200
Symptom Criteria
• Stage A: Asymptomatic• Stage B: B symptoms• Stage C: AIDS Defining
Conditions
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• For example, a 21 year old man with CD4 150 and no complications other than Thrush is stage B3
Direct Viral Mediated End Organ Damage
• HIV Associated Nephropathy– Focal Segmental Glomerulonephritis with Nephrotic
Range Proteinuria– Rapid deterioration and progression to need for
Kidney Replacement Therapy
• HIV Associated Cardiomyopathy– Manifests like other viral cardiomyopathies– Can progress to need for ventricular assist device or
cardiac transplant
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Direct Viral Mediated End Organ Damage
• HIV Associated Dementia Complex– Cognitive abnormalities– Can also manifest motor abnormalities– Psychiatric disturbance is not uncommon– Significant progressive functional impairment
• HIV Associated Minor Cognitive-Motor Disorder– Minor impairments in attention, concentration,
memory, movement, coordination, memory, personality change
– Often very slow to progressApril 19, 2023
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Direct Viral Mediated End Organ Damage
• Hematologic Injury– Idiopathic Thrombocytopenic Purpura– Thrombotic Thrombocytopenic Pupura– Anemia, mild thrombocytopenia, relative leukopenia
not emergencies
• Nervous System– Peripheral Neuropathy– Vacuolar Myelopathy
• Musculoskeletal– Myositis and Rhabdomyositis
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Direct Viral Mediated End Organ Damage
• Suppression of HIV with Antiretroviral therapy can halt disease progression
• Only option in most (except ITP and TTP)• Rapid initiation of antiretrovirals and suppression
of viral load is imperative to prevent disease progression
• This is also true for the Opportunistic Infection Progressive Multifocal Leukoencephalopathy
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Primary Prophylaxis in HIV
VACCINES
• Pneumovax• Prevnar• Influenza• TDAP• Hepatitis A• Hepatitis B• Zostavax (CD4>200)• HPV Vaccine (age 13-26)
Opportunistic Infections
• Pneumocystis/Toxoplasma– CD4 <200/100– Bactrim (DS/SS, QD/TIW)– Dapsone 100 mg daily– Atovaquone 1500 mg daily
• MAC (CD4 <50)– Azithromycin 1200 mg
Weekly/divided Twice Week
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Primary Prophylaxis in HIV
• Special Cases– Residing in an area endemic for Histoplasmosis and
CD4<150: Itraconazole 200 mg daily– Residing in an area endemic for Coccidioides and
CD4<250: Fluconazole 400 mg daily– Residing in an area endemic for Penicilliosis and
CD4<100: Itraconazole 200 mg daily
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Endemic Areas for Coccidioidomycosis
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Endemic Areas for Histoplasmosis
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Endemic Areas for Penicilliosis
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TAKE HOME MESSAGES
• Mono-like illness: Consider Acute HIV• Vaccinate: Prevnar, Pneumovax, Influenza• Stage and Prophylax
– CD4 count < 200: Pneumocystis– CD4 count <100: Toxoplasmosis– CD4 count < 50: MAC
• End Organ Damage is an HIV Emergency– HIVAN– Dementia– Cardiomyopathy
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A 28 year old African American man presents to your clinic with complaints of 2 days of fever, night sweats, and sore throat. He admits to accepting money from men in exchange for unprotected sex starting three months ago. Exam reveals thrush, swollen cervical and inguinal lymph nodes, a flat erythematous rash on his trunk. Which test is most likely to be diagnostic right now?A.HIV ELISA Antibody TestB.Oraquick HIV Antibody TestC.HIV Western Blot TestD.HIV 4th Generation Antigen/Antibody TestE.CD4 count
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A 28 year old African American man presents to your clinic with complaints of 2 days of fever, night sweats, and sore throat. He admits to accepting money from men in exchange for unprotected sex starting three months ago. Exam reveals thrush, swollen cervical and inguinal lymph nodes, a flat erythematous rash on his trunk. Which test is most likely to be diagnostic right now?A.HIV ELISA Antibody TestB.Oraquick HIV Antibody TestC.HIV Western Blot TestD.HIV 4th Generation Antigen/Antibody TestE.CD4 count
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April 19, 2023
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HIV TESTINGHIV Update and State of the Art
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CDC HIV Testing Recommendations:HIV screening is normal medical practice• HIV screening is recommended for patients in
ALL health-care settings (opt-out screening) – particularly pregnant women
• High Risk Persons should be screened annually• Separate written consent should not be required• Repeat screening should occur for pregnant
women in the 3rd trimester
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Terms
• High Risk (Expanded!!)– IDU and their sex partners– Commercial sex workers– Partners of HIV infected persons– Men who have sex with men (MSM)– Persons who have had more than 1 sex partner since
their most recent HIV test (or their partners)
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Tests Available
• Antibody Tests (confirmatory WB required)– Laboratory Blood Tests– Rapid Blood Tests (multiple)– Home Access/Express HIV-1 Test System using
fingersticks– Home Rapid Tests (Oraquick, Orasure) using Saliva
• Western Blot (Confirmatory)– Positive: 2 of the following – p24, gp41, gp120/160– Indeterminate: any positive bands– Negative: no positive Bands
• 4th Generation HIV Antibody/Antigen TestsApril 19, 2023
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4th Generation
• Architect HIV-1/2/O/M Ag/Ab Combo (Lab)• Alere Determine HIV-1/2 Ag/Ab Combo (Rapid)• Reflex testing
– Reflex to HIV1 and HIV 2 specific testing– If either test is positive, then the patient has a positive
test for either HIV1 or HIV2 and no Western Blot required
– If both negative then reflex to viral load testing– If viral load test is positive, then patient has a positive
test and no Western Blot is required
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TAKE HOME MESSAGES
• All adults (and sexually active adolescents) should be tested on entry into medical care
• Repeat annual testing in high risk groups (living in DC is a high risk group – see next section!)
• Rapid Tests and Home Tests still need confirmation
• 4th Gen Test will detect infection in the “Window Period”
• Otherwise, use Nucleic Acid test to detect infection in the “Window Period”
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Which of the following locations is estimated to have a higher prevalence of HIV than the others listed?
A.Ethiopia
B.Haiti
C.Guinea-Bissau
D.Washington, DC
E.Sierra Leone
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Which of the following locations is estimated to have a higher prevalence of HIV than the others listed?
A.Ethiopia (1.4 %)
B.Haiti (1.8%)
C.Guinea-Bissau (1.4%)
D.Washington, DC (2.7%)
E.Sierra Leone (1.6%)
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Which of the following locations is estimated to have a higher prevalence of HIV than the others listed?
Washington, DC (2.7%)
Swaziland (26%) Mozambique (11.3%)
Botswana (23.4%) Malawi (10%)
Lesotho (23.3%) Uganda (7.2%)
South Africa (17.3%) Kenya (6.2%)
Zimabwe (14.9%) Tanzania (5.8%)
Nambia (13.4%) Gabon (5%)
Zambia (12.5%)
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EPIDEMIOLOGYHIV Update and State of the Art
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WHO Global summary of the AIDS epidemic 2011
34.0 million [31.4–35.9 million]
30.7 million [28.2–32.3 million]
16.7 million [15.4–17.6 million]
3.3 million [3.1–3.8 million]
2.5 million [2.2–2.8 million]
2.2 million [1.9–2.4 million]
330 000 [280 000–390 000]
1.7 million [1.5–1.9 million]
1.5 million [1.3–1.7 million]
230 000 [200 000–270 000]
Number of people living with HIV
People newly infected with HIV in 2011
AIDS deaths in 2011
TotalAdults
WomenChildren (<15 years)
TotalAdults
Children (<15 years)
TotalAdults
Children (<15 years)
Total: 34.0 million [31.4 million – 35.9 million]
Western & Central Europe
900 000[830 000 – 1.0 million]
Middle East & North Africa300 000
[250 000 – 360 000]
Sub-Saharan Africa23.5 million
[22.1 million – 24.8 million]
Eastern Europe & Central Asia1.4 million
[1.1 million – 1.8 million]
South & South-East Asia4.0 million
[3.1 million – 5.2 million]
Oceania53 000
[47 000 – 60 000]
North America1.4 million
[1.1 million – 2.0 million]
Latin America1.4 million
[1.1 million – 1.7 million]
East Asia830 000
[590 000 – 1.2 million]
Caribbean230 000
[200 000 – 250 000]
Adults and children estimated to be living with HIV 2011
Estimated adult and child deaths from AIDS 2011
Western & Central Europe
7000[6100 – 7500]
Middle East & North Africa23 000
[18 000 – 29 000]
Sub-Saharan Africa1.2 million
[1.1 million – 1.3 million]
Eastern Europe & Central Asia
92 000 [63 000 – 120 000]
South & South-East Asia250 000
[190 000 – 340 000]
Oceania1300
[<1000 – 1800]
North America21 000
[17 000 – 28 000]
Latin America54 000
[32 000 – 81 000]
East Asia59 000
[41 000 – 82 000]
Caribbean10 000
[8200 – 12 000]
Total: 1.7 million [1.5 million – 1.9 million]
New HIV infections and AIDS-related deaths, 1990–2011 P
eopl
e
New HIV infections
AIDS-related deaths
Globally new HIV infections peaked in 1997
People living with HIV, 1990–2011m
illio
ns
People living with HIV
Total number of people dying from AIDS-related causes in low- and middle-income countries, 1995–2011
0
500 000
1 000 000
1 500 000
2 000 000
2 500 000
3 000 000
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Without antiretroviral therapy
With antiretroviral therapy
1995 2000 2005 2010
District of Columbia
• Rate=2,704.3 people living with HIV per 100,000 population in DC at end 2011
• >2.7% of DC population HIV positive in 2011• Caveats: DC is a city and statistics not
muted by a non-urban populations as in the states– However, DC still had the highest rate of any US
city
• DC DOH recommends annual HIV testing for all residents 13-78 regardless of stated sexual activity or risk group
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TAKE HOME POINTS
• MSM, African Americans still the hardest hit
• Safe Sex, Needle Exchange, Education
• DC has an epidemic rate comparable to countries in Subsaharan Africa
• DC DOH recommends all residents aged 13-78 be tested ANNUALLY for HIV
• In the US, HIV is not a death sentence – now a survivable and manageable chronic disease
• Money and work required to make this true in resource limited countries, like those in Subsaharan Africa
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A 56 year old man with newly diagnosed HIV and baseline resistance on genotype to non-nucleoside reverse transcriptase drugs is recommended to start antiretrovirals. After discussing different regimens that are available to him, he settles on Truvada & Ritonavir boosted Atazanavir. Which of the following drugs can he continue to take?
A.Omeprazole 40 mg daily
B.Simvastatin 40 mg daily
C.Fluticasone nasal spray
D.Inhaled Salmeterol
E.MetoprololApril 19, 2023
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A 56 year old man with newly diagnosed HIV and baseline resistance on genotype to non-nucleoside reverse transcriptase drugs is recommended to start antiretrovirals. After discussing different regimens that are available to him, he settles on Truvada & Ritonavir boosted Atazanavir. Which of the following drugs can he continue to take?
A.Omeprazole 40 mg daily
B.Simvastatin 40 mg daily
C.Fluticasone nasal spray
D.Inhaled Salmeterol
E.MetoprololApril 19, 2023
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ANTIRETROVIRAL THERAPY
HIV Update and State of the Art
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Thinking about HIV
• 1982 – What is it?• 1985 – Incurable virus – why know?• 1987 – Toxic therapy –• 1993 – false hope of Duotherapy• 1996 – HAART!! (angel choirs and bolts of glory)• 2000 – Toxicity – delay therapy? • 2004-2009 – Non-toxic therapies (Truvada,
Atazanavir, Darunavir, Raltegravir)• 2011 – HPTN 052
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HPTN 052
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Community Viral Load
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NIH/USHHS Guidelines on HIV Treatment• All HIV-infected patients are recommended to start Antiretrovirals to prevent disease progression– CD4<350 (AI)– CD4 350-500 (AII)– CD4 >500 (BIII)
• And to prevent transmission of disease– Perinatal Transmission (AI)– Heterosexual Transmission (AI)– All other Transmission groups (AIII)
• Therapy can be deferred by provider or patient based on clinical or social factors
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Combination Pills
• Combivir (Zidovudine/Lamivudine)• Epzicom (Lamivudine/Abacavir)• Trizivir (Zidovudine/Lamivudine/Abacavir)• Truvada (Tenofovir/Emtricitabine)• Atripla (Tenofovir/Emtricitabine/Efavirenz)• Complera (Tenofovir/Emtricitabine/Rilpivirine)• Kaletra (Ritonavir/Lopinavir)• Stribild (Tenofovir/Emtricitabine/Cobicistat/
Elvitegravir)• Triumeq (Dolutegravir/Abacavir/Lamivudine)
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Highly Active Antiretroviral Therapy (HAART)
• 1 agent insufficient to suppress viral replication• Combination therapy potent enough• 2NRTI “backbone” PLUS• 1 potent agent (PI, NNRTI, Integrase Inhibitor)• Resistance Salvage regimens• Also called Potent AntiRetroviral Therapy
(PART), Combination AntiRetroviral Therapy (CART)
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Resistance
• Highly Error Prone Reverse Transcriptase– 1 mutation produced per genome copied
• Viral Turnover rate: 1x109 particles/day• Mutation Rate * Turnover Rate/# of basepairs• Mutation at every genome position every day• Drug resistance archived• Fitness Cost=Reversion to wildtype• Genotype testing unreliable absent selection
pressure
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Resistance
• Risk– Drug pressure (taking drugs)– Viral Replication (poor adherence/poor drug selection)
• Consequences: multi-drug resistance• Lessons
– Simplest regimen=better compliance=less resistance– Close monitoring to ensure viral suppression– Compliance to visits and education
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Starting Regimens
• Only start with referral to an expert• Never start without appropriate testing –
– HIV Genotype– HBV Serologies (co-treatment)– HLAB5701
• Always assess potential side effects and fit regimen to patient profile – comorbidities, drug interactions, lifestyle preferences
• Always review adherence strategies with the patient
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Starting Regimens
• Atripla• Complera• Stribild• Epzicom/Efavirenz• Truvada OR Epzicom + Ritonavir/Atazanavir• Truvada OR Epzixom +Ritonavir/Darunavir• Truvada Raltegravir• Combivir or Truvada or Epzicom + Kaletra
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Important Side Effects
• NRTIs: peripheral neuropathy, lipoatrophy• Zidovudine – headache, asthenia, anemia• Didanosine – pancreatitis, neuropathy• Stavudine – lactic acidosis, neuropathy• Tenofovir – Fanconi Syndrome• NNRTIS: rash, TEN, Stevens Johnson• Nevirapine – liver failure• Efavirenz – drowsiness, vivid dreams,
depression• Rilpivirine -- depression
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Important Side Effects
• Protease Inhibitors: Hyperlipidemia, lipodystrophy, hyperglycemia, diarrhea, nausea
• Atazanavir: nephrolithiasis, prolonged QT, benign asymptomatic hyperbilirubinemia
• Tipranavir: Intracerebral hemorrhage• Integrase Inhibitors: myositis
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Some Interactions
• Oral contraceptives• HMG Co-A Reductase (least with rosuvastatin
and atorvastain)• Steroids (avoid fluticasone, beclomethasone
preferred)• Salmeterol• Psychiatric medications• Anticonvulsants• Antifungals• Proton Pump Inhibitors (Atazanavir, Rilpivirine)April 19, 2023
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TAKE HOME POINTS
• All patients encouraged to start therapy to prevent opportunistic infections, malignancy, and to decrease community viral load
• Resistance is a problem – continuous monitoring necessary
• Do not refill HIV meds if patients are not making their follow ups with their HIV provider
• Look out for drug interactions
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A 26 year old HIV negative man who is non-monogamously partnered with an HIV positive man on antiretroviral therapy asks you if there is a drug he can take to reduce his risk of getting HIV. What do you tell him?
A.Safe sex is the only prevention available
B.Truvada has had success but needs close monitoring and compliance
C.The best option for him is abstinence
D.Combivir and Kaletra has had success with close monitoring and compliance
E.This therapy has only had success in IDU
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A 26 year old man with male who is non-monogamously partnered with an HIV positive man on antiretroviral therapy asks you if there is a drug he can take to reduce his risk of getting HIV. What do you tell him?
A.Safe sex is the only prevention available
B.Truvada has had success but needs close monitoring and compliance
C.The best option for him is abstinence
D.Combivir and Kaletra has had success with close monitoring and compliance
E.This therapy has only had success in IDU
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PRE AND POST EXPOSURE PROPHYLAXIS
HIV Update and State of the Art
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Occupational Exposures• Sep 2013 - New guidelines from USDPHHS in
Infection Control & Hospital Epidemiology• Source: body fluids from infected or high risk
patients (blood, semen, vaginal secretions, CSF, synovial, pleural, peritoneal, pericardial, amniotic)
• Excludes: feces, urine, saliva, emesis• Exposures: Percutaneous injury, mucous
membrane, non-intact skin• Risk: 0.3% percutaneous blood, 0.09% mucous
membraneApril 19, 2023
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PEP Regimens
• Timing: within 72 hours of exposure for 4 weeks• No 2 vs. 3 drug regimens based on risk – just 3
drugs!• Preferred: Truvada Raltegravir• Alternatives
– Fixed dose single agent: Stribild OR– Combine: Raltegravir, Ritonavir/Darunavir, Etravirine,
Rilpivirine, Ritonavir/Atazanavir, Kaletra– With: Truvada, Combivir, – Others: only with expert ID consultation
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PEP Regimens
• Follow Up– BASELINE: HIV test, CBC, CMP, counseling– 2 weeks: CBC, CMP, counseling– 6 wks: HIV Test, counseling– 3 months: HIV Test– 6 months: HIV Test
• If 4th Generation HIV Test is used– BASELINE: HIV test, CBC, CMP, counseling– 2 weeks: CBC, CMP, counseling– 6 wks: HIV Test, counseling– 4 months: HIV Test
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nPEP
• 2005 CDC initiated guidelines• Criteria for nPEP
– <72 hours from exposure– Source patient HIV positive or unknown– Substantial exposure risk
• Substance: Blood, Semen, Vaginal Secretions, Rectal Secretions, Breast Milk
• Exposure: Vagina, Rectum, Eye, Mouth, Other Mucous Membrane, Non-Intact Skin, Percutaneous Injury/Contact
• No Risk: urine, nasal secretions, saliva, sweat, tears
– Previous Recommendations PI based– Now most moving to PEP drugs
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PrEP
• Pre-Exposure Prophylaxis• Truvada approved by FDA for PrEP in 2012• Recommended by CDC in 2012• Evidence
– iPrEx (in HIV negative US MSM)– Partners PrEP (in serodiscordant heterosexual
couples in Kenya and Uganda)– The Bangkok Tenofovir Study (in IDU)– No significant adverse events– Success predicated on close monitoring, risk
reduction counseling, and compliance
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iPrEx
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Partners PrEP
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The Bangkok Tenofovir Study
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PrEP Guidelines• Eligibility:
– Baseline HIV negative– High Risk
• MSM• Multiple partners• Commercial Sex
Workers• Not using condoms• IDU• Partner is HIV positive• Discordant couple
trying to conceive
• Baseline Testing– Renal Function– Hepatitis B status (if
positive can treat as part of HBV therapy)
– Pregnancy Test– Pregnant: counsel on
lack of data
• Counseling– Risk Reduction!– Adherence!
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PrEP Guidelines
• Follow Up– No more than 90 day prescription and no automatic
refills– Every 2-3 months: HIV 4th gen test and pregnancy
test, adherence education– At 3 months then every 6 months thereafter: Renal
Function, HBV screen, STD Screening
• Discontinuation– Screen for pregnancy, HIV, HBV– If positive, linkage to care for appropriate therapy
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TAKE HOME POINTS
• PEP now much more simple– Truvada Raltegravir is recommended regimen– The sooner you start the better
• Truvada can be used for PrEP– High risk populations (MSM, commercial sex workers,
HIV negatives in serodiscordant couples, IVDU)– Concomitant risk reduction counseling– Close monitoring required for safety and success
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HIV CARE AT MWHCHIV Update and State of the Art
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HIV Care at MWHC
• Section of Infectious Diseases– Glenn Wortmann, Section Chief, PD– Maria Ruiz, Assistant Chief, IRB Chair– Leon L. Lai, Ryan White Program Director, APD– Christian Woods, (Pulm Crit Care), APD– Dawn Fishbein, Viral Hepatitides– Faria Farhat– Joe Kovacs and Caryn Morse from the NIH– 4 MWHC ID Fellows– 2 NIH ID Fellows
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HIV Care at MWHC
• HRSA Ryan White Part
C and D Supported– Jasmine Reid, RN,
Program Coordinator– Chizoba Anako, NP and
Women’s Health Liaison– Allison Daly, Case Manager and Medication Educator– Antonio Pineda, Treatment Navigator– Patricia Bauza, MD, Psychiatry– Allen Zemon, PhD, Psychology
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HIV Care at MWHC
• Outpatient Services• Inpatients with HIV• HIV and pregnancy
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TAKE HOME POINTS
• Call us if you have any questions!– Chris Woods, MD at 202-877-7164
• Outpatients – – Ryan White Intake: 202-877-7412– Appointments: 202-877-0333
• Pregnancy and HIV is an emergency!– Contact NP Anako at 202-877-7164
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Selected ReferencesBaeten JM et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. NEJM 2012. 367(5):
399.
Choopanya K et al. Antiretroviral prophylaxis for HIV ifnection in injecting drug users in Bangkok, Thailand (the Bangkok Tenofovir Study): a randomised, double-blind, placebo-controlled phase 3 trial. Lancet 2013. 381:2083.
Cohen MS et al. Prevention of HIV-1 infection with early antiretroviral therapy. NEJM 2011. 365(6): 493.
Das, M et al. Decreases in community viral load are accompanied by reductions in new HIV infections in San Francisco. PLoS One 2010. 5(6):e11068.
Grant RM et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. NEJM 2010. 363(27): 2587.
Kuhar DT et al. Updated US Public Health Service guidelines for the management of occupational exposures to Human Immunodeficiency Virus and recommendations for post-exposure prophylaxis. Infection Control and Hospital Epidemiology, 2013. 34(9):875.
Panel on the Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1 infected adults and adolescents. Department of Health and Human Services. February 12, 2013.
Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. July 8, 2013.
Smith DK et al. Update to interim guidance for preexposure prophylaxis for the prevention of HIV Infection. MMWR 2013. 62(23):463.
Strategic Information System, HAHSTA, DC Department of Health. Annual Epidemiology and Surveillance Report, 2011.
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Post-Test Question 1A 68 year old male resident of DC comes to you for care of his hypertension, hyperlipidemia, and diet controlled diabetes. He lives with his wife, daughter, and twin grandchildren. He says he is monogamous, is a prior smoker, and never used drugs. Which is not a routine part of his care?A.Flu shotB.HIV TestC.Abdominal UltrasoundD.Hemoglobin A1CE.PSA
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Post-Test Question 1A 68 year old male resident of DC comes to you for care of his hypertension, hyperlipidemia, and diet controlled diabetes. He lives with his wife, daughter, and twin grandchildren. He says he is monogamous, is a prior smoker, and never used drugs. Which is not a routine part of his care?A.Flu shotB.HIV TestC.Abdominal UltrasoundD.Hemoglobin A1CE.PSA
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Post-Test Question 1
A. Flu shot – recommended yearly for patients over 65 years of age and with HIV
B. HIV Test – recommended yearly in all DC residents
C. Abdominal Ultrasound – recommended once in men over the age of 65 in all smokers or previous smokers
D. Hemoglobin A1C – recommended every 6 months in patients with diabetes
E. PSA – no longer recommended screening except in high risk men
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Post-Test Question 2A 32 year old HIV negative old woman who is the partner of a 36 year old man with HIV well controlled for 10 years on antiretroviral therapy wishes to conceive. They cannot afford sperm washing. How do you advise her?A.They can use a turkey baster to decrease riskB.The risks of pregnancy are too highC.He is undetectable on his meds, so there is no riskD.She can take PrEP to reduce her riskE.They should use an HIV positive surrogacy programApril 19, 2023
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Post-Test Question 2A 32 year old HIV negative old woman who is the partner of a 36 year old man with HIV well controlled for 10 years on antiretroviral therapy wishes to conceive. They cannot afford sperm washing. How do you advise her?A.They can use a turkey baster to decrease riskB.The risks of pregnancy are too highC.He is undetectable on his meds, so there is no riskD.She can take PrEP to reduce her riskE.They should use an HIV positive surrogacy programApril 19, 2023
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Post-Test Question 2A. They can use a turkey baster to decrease risk –
does not reduce risk from HIV infected semenB. The risks of pregnancy are too high – untrue –
successful pregnancy in HIV is quite possible with appropriate care and counseling
C. He is undetectable on his meds, so there is no risk – risk is greatly reduced but data is unclear if there is NO risk
D. She can take PrEP to reduce her risk – true, and part of CDC PrEP guidelines
E. They should use an HIV positive surrogacy program – this does not exist
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Post-Test Question 3
A 48 year old woman with HIV, seasonal allergies, asthma, hypertension, dyspepsia, and coronary artery disease comes to your clinic for a routine checkup. Her med list includes Truvada, Ritonavir, Atazanavir, Inhaled Beclomethasone, Advair (Fluticasone/ Salmeterol), Metoprolol, and Aspirin. Which is causing an interaction?
A.Aspirin
B.Advair
C.Beclomethasone
D.MetoprololApril 19, 2023
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Post-Test Question 3
A 48 year old woman with HIV, seasonal allergies, asthma, hypertension, dyspepsia, and coronary artery disease comes to your clinic for a routine checkup. Her med list includes Truvada, Ritonavir, Atazanavir, Inhaled Beclomethasone, Advair (Fluticasone/ Salmeterol), Metoprolol, and Aspirin. Which is causing an interaction?
A.Aspirin
B.Advair
C.Beclomethasone
D.MetoprololApril 19, 2023
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Post-Test Question 3
A. Aspirin - there is no interaction
B. Advair – both fluticasone and salmeterol, components of Advair, have significant interactions with protease inhibitors
C. Beclomethasone – this is the preferred steroid to use in inhaled and intranasal preparations when a patient is on protease inhibitors
D. Metoprolol - there is no interaction
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Post-Test Question 4
A 26 year old man with HIV returns to care after 18 months. His viral load was undetectable on Atripla but he says he has been off medicines for over a year. You obtain a genotype and there is no resistance. Which is true?
A.He may still harbor hidden resistance
B.Resistance to Atripla is rare
C.Once a resistant virus reverts to wildtype, it becomes sensitive to drug again
D.The resistance test needs to be repeated again before starting new medicationsApril 19, 2023
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Post-Test Question 4
A 26 year old man with HIV returns to care after 18 months. His viral load was undetectable on Atripla but he says he has been off medicines for over a year. You obtain a genotype and there is no resistance. Which is true?
A.He may still harbor hidden resistance
B.Resistance to Atripla is rare
C.Once a resistant virus reverts to wildtype, it becomes sensitive to drug again
D.The resistance test needs to be repeated again before starting new medicationsApril 19, 2023
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Post-Test Question 4A. He may still harbor hidden resistance – Resistance
is archived in memory T cells, but may not be the dominant virus in a patient absent drug pressure – thus genotypic testing off therapy can be unreliable
B. Resistance to Atripla is rare – The most common mutations, M184V and K103N are induced by atripla
C. Once a resistant virus reverts to wildtype, it becomes sensitive to drug again – false – the resistant mutant is archived and will re-emerge with sufficient drug pressure
D. The resistance test needs to be repeated again before starting new medications – false, resistance test should be repeated after restarting HIV medications if there is an inappropriate response
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Post-Test Question 5
A 32 year old previously healthy man residing in New Orleans presents to his physician with a chancre. RPR is positive, HIV is positive, CD4 count is 18. He is treated for syphilis. Which of the following is not indicated?
A.Bactrim DS daily
B.Azithromycin 1200 mg weekly
C.Fluconazole 200 mg daily
D.Itraconazole 200 mg daily
E.Pneumovax
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Post-Test Question 5
A 32 year old previously healthy man residing in New Orleans presents to his physician with a chancre. RPR is positive, HIV is positive, CD4 count is 18. He is treated for syphilis. Which of the following is not indicated?
A.Bactrim DS daily
B.Azithromycin 1200 mg weekly
C.Fluconazole 200 mg daily
D.Itraconazole 200 mg daily
E.Pneumovax
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Post-Test Question 5
A. Bactrim DS daily – indicated for CD4 count <200
B. Azithromycin 1200 mg weekly – indicated for CD4 count <50
C. Fluconazole 200 mg daily – not indicated in a patient without persistent candidasis or at risk for Coccidioides imitis
D. Itraconazole 200 mg daily – indicated for a patient with CD4 <150 residing in area endemic for Histoplasmosis (New Orleans)
E. Pneumovax – indicated in all HIV patientsApril 19, 2023
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Post-Test Question 6
You see a 36 year old woman with well controlled HIV on Truvada, Ritonavir, and Atazanavir. She is asymptomatic except for icterus. Viral Load is <20 copies/ml, CD4=565, and Total Bilirubin is 2.3. Which of the following is true?
A.Abdominal Ultrasound should be done
B.Antiretrovirals should be held
C.Antiretrovirals should continue unless the icterus is intolerable to her
D.Cholecystectomy for acalculous cholecystitis is the next stepApril 19, 2023
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Post-Test Question 6
You see a 36 year old woman with well controlled HIV on Truvada, Ritonavir, and Atazanavir. She is asymptomatic except for icterus. Viral Load is <20 copies/ml, CD4=565, and Total Bilirubin is 2.3. Which of the following is true?
A.Abdominal Ultrasound should be done
B.Antiretrovirals should be held
C.Antiretrovirals should continue unless the icterus is intolerable to her
D.Cholecystectomy for acalculous cholecystitis is the next stepApril 19, 2023
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Post-Test Question 6A. Abdominal Ultrasound should be done – B. Antiretrovirals should be heldC. Antiretrovirals should continue unless the
icterus is intolerable to her – Atazanavir induces a benign moderate hyperbilirubinemia that does not require cessation of therapy or any other intervention absent patient dissatisfaction with cosmetic effects of icterus. Severe hyperbilirubinemia warrants further workup and consideration for change in therapy
D. Cholecystectomy for acalculous cholecystitis is the next step
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