hiv update dr hugh mc gann consultant in infectious diseases leeds teaching hospitals
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HIV Update
Dr Hugh Mc GannConsultant in Infectious Diseases
Leeds Teaching Hospitals
HIV 3 Things Every Respiratory
Trainee Needs to Know
Dr Hugh Mc Gann
Consultant in Infectious Diseases
Leeds Teaching Hospitals
• Including 3.3 million children less than 15 years
• 2.5 millions new infections (including 330 000 children); 22% less than in 2001
• 1.7 million people died of AIDS in 2011
• Each day almost 7 000 people newly infected
• Each day 3 950 more people on antiretroviral therapy
Globally, 34.0 million people living with HIV in 2011
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 Asia
1.4 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
Number of people newly diagnosed and people living with diagnosed HIV infection:
United Kingdom, 1980-2011
New HIV diagnoses by exposure group: United Kingdom, 2002 – 20111
Late diagnosis1 of HIV infection by exposure group: United Kingdom, 2011
Case History
• 32 year old white British lady presented with 8 weeks of increasing breathlessness. Eventually chair bound due to dysponea
• Long term partner, 2 children
• GP treated with 2 courses of antibiotics and steroids but no improvement. Arranged XR with showed bilateral infiltrates – referred to chst clinic
Case History
• 2004 – Unexplained lymphadenopathy – biopsy
• 2006- ITP
• 2008 – CIN 1
• 2009 – trated for oro-pharyngeal candidiasis
Case History
• Admitted with severe type 2 respiratory failure
• Treated for community acquired pneumonia
• 4 days after admission much worse
Case History
• HIV test.
• CD4 2
• Pneumocystis pneumonia
• 3 week stay on ITU but recovered
• Now very well CD4 546
Who to test for HIV ?• All patients where HIV including primary infection enters the
differential diagnosis
• Clinical indicator conditions
• All acute general medical admissions where the
prevalence in the local population exceeds 2/1000
• Those from a country with a prevalence >1%
• Men with a history of sex with other men
• Injecting drug users
Why to test ?
• 100,000 people in the UK with HIV
infection
• 25% undiagnosed with on-going
transmission
Why to test ?
Of deaths occurring in HIV positive
adults in the UK, about a quarter were
directly attributable to the diagnosis of
HIV being made too late for effective
treatment
58% had a “missed opportunity” within primary or secondary care
CD4
HPTN 052 Prevention Conclusion
Early ART that suppresses viral replication led to 96% reduction of sexual transmission
of HIV-1 in serodiscordant couples
How to test?
• Brief pre test explanation of rationale for the test
• We use 4th generation test - HIV antibody/antigen test
• Ensure all patients with positive tests are referred promptly to a HIV specialist
• If a patient lacks capacity, test should be done if in “best interest”
HIV POCT
Natural history of HIV infection
When to treat• AIDS defining illness (except TB)• CD4 count < 350• CD4 350-500 in patients with HBV, HCV co-infection and• The trend is to start treatment earlier
– Reduce non Aids morbidity/mortality– Increased risk of resistance/long term toxicity– Europe CD4 <500– US any patient regardless of CD4 count should be
considered for therapy• As prevention
Combination anti retroviral therapy (c-ART)
• Goal of therapy– Clinical– Virological
• Start with 2 NRTI + NNRTI or PI
• Adherence
NRTIs
• Lamivudine
• Abacavir
• Zidovudine
• Tenofovir
Non Nucleoside RTIs
• Efavirenz
• Nevirapine
• Etravirine
• Rilpivirine
Protease Inhibitors
• Lopinavir
• Atazanavir
• Darunavir
• Ritonavir – used to boost levels of other PIs = Boosted PIs
New classes
• Fusion inhibitors– Enfuvitide (T20)
• CCR5 antagonists– Maraviroc
• Integrase inhibitors– Raltegravir
NNRTI regimes
Truvada/Efavirenz
Atripla
Kivexa/EfavirenzEviplera
PI Regimes
Truvada/Rit/Darunavir Truvada/Rit/Atazanavir
HIV Prognosis
• HIV is now a treatable medical condition and the majority of those living with the virus remain fit and well on treatment.
• The prognosis in patients diagnosed early with good adherence is likely to be similar to a HIV negative individual
• Long term c-ART may be associated with toxicity
HIV Drug Resistance
• Testing for resistance
• Transmitted drug resistance
• Treatment failure due to resistance
• Multi drug resistance in HIV
Long term issues
• Cardiovascular– Increased risk of MI with HIV and with certain
ARVs, Insulin resistance, dyslipidaemia
• Bone– Increased risk of osteoporosis
• Hepatic– Steato-hepatitis related to ARVs
• Renal• Cancer
AIDS defining malignancies
•KS •Cervical cancer •NHL •Burkitt lymphoma •Diffuse large B cell lymphoma •Primary effusion lymphoma •Plasmablastic lymphoma •Primary cerebral lymphoma
Non AIDS defining malignancies
• Anal cancer
• Hodgkin lymphoma
• Other NADM (lung, germ cell, liver)
Facial lipoatrophy Lipodystrophy
Copyright ©2009 BMJ Publishing Group Ltd.
Deeks, S. G et al. BMJ 2009;338:a3172
In treated patients who achieve durable suppression of the HIV virus, natural ageing, drug specific toxicity, lifestyle factors, persistent inflammation, and perhaps residual immunodeficiency are causally associated with premature development of many
complications normally associated with ageing, including cardiovascular disease, cancer, and osteoporosis or osteopenia
Case History
• 38 Year old male asylum seeker from DRC
• Right leg swelling - ?DVT
• Multiple skin nodules/plaques in right groin and extensive lymphadenopathy
• Biopsy – kaposi sarcoma
• HIV positive – Cd4 8
Case History
• Refused to accept HIV diagnosis or take ARVs
• Defaulted from follow up but represented with dysponea and back pain
• KS with multiple metastaes
• Treated with chemotherapy (liposomal doxyrubicin) and ARVs with significant improvement
Case History
• Discharged but stopped ARVs
• 3 months later re-admitted critically ill and once again treated with chemothrapy with good response
• Unable to accept HIV diagnosis and take ARVs – deteriorated and admitted St Gemmas hospice for palliative care
Summary
• HIV is a chronic condition which if diagnosed and treated early has a good long term prognosis
• Health care workers should have a low threshold for HIV testing and in many situations this should be offered as an opt out service
• There remains considerable stigma associated with HIV
Summary
• In the UK Aids related deaths seen mainly in patients who present late with OIs, those unable to accept the diagnosis or adhere to ARVs and those with cancer.
• HIV +ve patients may be at increased risk of cancer, toxicities of long term treatment and even premature ageing
