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HIV Update 2013

HIV Update 2013. Phil Burke, PA-C, MBA, RHIA OU Infectious Disease Institute. The Texas/Oklahoma AIDS Education and Training Centers. HIV Update. Epidemiology Update International National Local Guideline changes Adult/adolescent treatment guidelines

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HIV Update 2013

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  1. HIV Update 2013 Phil Burke, PA-C, MBA, RHIA OU Infectious Disease Institute

  2. The Texas/Oklahoma AIDS Education and Training Centers

  3. HIV Update • Epidemiology Update International National Local • Guideline changes Adult/adolescent treatment guidelines • Screening Recommendations • Treatment • Current HIV Antiretroviral Medications • Common Drug Interactions • Opportunistic Infections/ Primary Prophylaxis • In the news

  4. Adults and children estimated to be living with HIV  2011 Eastern Europe & Central Asia 1.4 million [1.1 million – 1.8 million] Western & Central Europe 900 000 [830 000 – 1.0 million] North America 1.4 million [1.1 million – 2.0 million] East Asia 830 000 [590 000 – 1.2 million] Middle East & North Africa 300 000 [250 000 – 360 000] Caribbean 230 000 [200 000 – 250 000] South & South-East Asia 4.0 million [3.1 million – 5.2 million] Sub-Saharan Africa 23.5 million [22.1 million – 24.8 million] Latin America 1.4 million [1.1 million – 1.7 million] Oceania 53 000 [47 000 – 60 000] Total: 34.0 million [31.4 million – 35.9 million]

  5. Estimated number of adults and children newly infected with HIV  2011 Eastern Europe & Central Asia 140 000 [91 000 – 210 000] Western & Central Europe 30 000 [21 000 – 40 000] North America 51 000 [19 000 – 120 000] East Asia 89 000 [44 000 – 170 000] Middle East & North Africa 37 000 [29 000 – 46 000] Caribbean 13 000 [9600 – 16 000] South & South-East Asia 280 000 [170 000 – 460 000] Sub-Saharan Africa 1.8 million [1.6 million – 2.0 million] Latin America 83 000 [51 000 – 140 000] Oceania 2900 [2200 – 3800] Total: 2.5 million [2.2 million – 2.8 million]

  6. Estimated adult and child deaths from AIDS  2011 Eastern Europe & Central Asia 92 000 [63 000 – 120 000] Western & Central Europe 7000 [6100 – 7500] North America 21 000 [17 000 – 28 000] East Asia 59 000 [41 000 – 82 000] Middle East & North Africa 23 000 [18 000 – 29 000] Caribbean 10 000 [8200 – 12 000] South & South-East Asia 250 000 [190 000 – 340 000] Sub-Saharan Africa 1.2 million [1.1 million – 1.3 million] Latin America 54 000 [32 000 – 81 000] Oceania 1300 [<1000 – 1800] Total: 1.7 million [1.5 million – 1.9 million]

  7. People living with HIV millions PeoplelivingwithHIV

  8. Oklahoma Facts • HIV reportable in 1988; AIDS reportable 1983 • First 2 cases of AIDS diagnosed in 1982 • Cumulative HIV/AIDS thru 12/2011: 8770 • Cumulative deaths: 3826 • New infections in 2011: 382 • Blacks had the highest rate of new diagnoses (43%) • 51% MSM • Perinatal: ?none

  9. Commitments and targets for 2015

  10. HIV Testing Recommendations for Adults and Adolescents Routine HIV screening for all patients aged 13-64 years, in all health-care settings • Emergency departments • Urgent care clinics • Primary care settings • Inpatient services • Corrections health-care facilities • TB clinics • STD clinics • Substance use clinics • Public health clinics • Community clinics

  11. Repeat Screening • At least annually for all persons at high risk of HIV infection: • Injection-drug users (IDUs) • Sex partners of IDUs • Persons who exchange sex for money or drugs • Sex partners of HIV infected • Men who have sex with men (MSM) • Heterosexuals who themselves or their sex partners have had >1 sex partner since last HIV test • Before new sexual relationship

  12. HIV Testing Recommendations:Summary • HIV screening recommended for all patients aged 13-64 in all health-care settings • HIV screening should be voluntary • Opt-out screening: patients are notified that testing will be performed unless they decline • Separate written consent for HIV testing not recommended; general informed consent is sufficient • Prevention counseling should not be required • High-risk patients should be screened at least annually

  13. How HIV is Transmitted • Unprotected anal and vaginal intercourse • Injecting drugs with contaminated needles and/or equipment • Infected mother to infant

  14. HIV is NOT Transmitted by: • Casual contact (hugging, shaking hands) • Coughing/sneezing • Sharing food or utensils • Kissing • Donating blood • Mosquito or other insect bites

  15. Modes of Transmission and Infectivity Per contact probability of HIV transmission • Heterosexual intercourse .1% • Male-to-male ~1% • Needle stick .3% • Needle-sharing 1% • Mother-infant 15-35%

  16. Natural History Typical course is defined by 3 phases 1. Primary HIV infection 2. Chronic asymptomatic phase 3. Advanced AIDS

  17. Primary HIV Infection • Symptomatic illness in 40-90% • Illness is nonspecific and mononucleosis-like • Appears 2-4 weeks after exposure • Clinical illness lasts 1-4 weeks

  18. Acute Retroviral Syndrome Symptoms Fever 96% Lymphadenopathy 74% Pharyngitis 70% Rash 70% Myalgias 54% GI complaints 30% Encephalopathy 6%

  19. Laboratory Values Differential Diagnosis Primary HIV • Thrombocytopenia • Leukopenia • Elevated ALT, AST • Elevated ESR • ELISA often negative • Epstein-Barr virus mononucleosis • Cytomegalovirus mononucleosis • Secondary syphilis • Disseminated gonococcal infection • Viral hepatitis

  20. Diagnosis of HIV • Antibody testing • ELISA (serum, saliva): positive is confirmed by • Western blot • Positive rapid test needs Western Blot confirmation

  21. Chronic Asymptomatic Phase • Characterized by a long phase of clinical latency (median 10 yrs) • Viral replication and CD4 counts are relatively stable • Virus is actively replicating in lymphoid tissue causing anatomic and functional deterioration

  22. Advanced AIDS • Defines the end stage of HIV infection • Leads to death in 2-3 years in the absence of therapy (opportunistic infections) • Characterized by high plasma viral load and low CD4 count

  23. Viral Dynamics Viral Load CD4 Weeks Years

  24. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents Developed by the Department of Health and Human Services (DHHS) Panel on Antiretroviral Guidelines for Adults and Adolescents – A Working Group of the Office of AIDS Research Advisory Council (OARAC) www.aidsetc.org

  25. Reduce HIV-related morbidity; prolong duration and quality of survival Restore and/or preserve immunologic function Maximally and durably suppress HIV viral load Prevent HIV transmission (treatment as prevention) Goals of Treatment www.aidsetc.org

  26. Rationale for Antiretroviral Therapy (ART) • Effective ART with virologic suppression improves and preserves immune function in most patients, regardless of baseline CD4 count • Earlier ART may result in better immunologic responsesand clinical outcomes • Reduction in AIDS- and non-AIDS-associated morbidity and mortality • Reduction in HIV-associated inflammation and associated complications • ART strongly indicated for all patients with low CD4 count or symptoms • ART can significantly reduce risk of HIV transmission • Recommended ARV combinations are effective andwell tolerated www.aidsetc.org

  27. 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 www.aidsetc.org

  28. Recommendations for Initiating ART ART is recommended for treatment: • “ART is recommended for all HIV-infected individuals to reduce the risk of disease progression.” • The strength of this recommendation varies on the basis of pretreatment CD4 count (stronger at lower CD4 levels) www.aidsetc.org

  29. Recommendations for Initiating ART ART is recommended for prevention: • “ART also is recommended for HIV-infected individuals for the prevention of transmission of HIV.” www.aidsetc.org

  30. Recommendations for Initiating ART: Prevention www.aidsetc.org

  31. Current ART Medications * EVG currently available only in coformulation with cobicistat (COBI)/TDF/FTC www.aidsetc.org

  32. What’s New? Treatment 3 “one pill once daily” regimens available

  33. Laboratory values affected by ART Reyataz (atazanavir) - hyperbilirubinemia (causing jaundice and/or scleralicterus) Retrovir (zidovudine)-macrocytosis Viread (tenofovir)-Creatinine elevation

  34. Drug Interactions - ART and Other Medications • Protease inhibitors and many lipid lowering agents • Atazanavir and Complera:proton pump inhibitors • Anti-Mycobacterials, especially rifampin • Psychotropics – midazolam, triazolam • Erectile dysfunction meds • Methadone • Coumadin • PIs and Advair (fluticasone) • Herbs/Natural remedies - St. John’s Wort, concentrated garlic tabs

  35. Opportunistic Infections in HIV

  36. CD4 Lymphocyte Levels 500-1,500/L:normal range, usually symptom-free < 500/L:increased risk for HIV-related minor phenomena, e.g. seborrheic dermatitis, generalized lympadenopathy, periodontal disease < 300-350/L: increased risk for recurrent bacterial pneumonia, TB, lymphoma, Kaposi’s sarcoma, oral candidiasis, zoster

  37. CD4 Lymphocyte Levels <200/L:increased risk for major opportunistic infections: PCP, esophageal candidiasis, chronic mucocutaneous HSV, cryptosporidiosis < 50-100/L:profound increased risk for all opportunistic processes: disseminated MAC CNS toxoplasmosis histoplasmosis wasting syndromes CMV PML cryptococcal meningitis

  38. Primary ProphylaxisTake Home Points • PneumocystisJiroveci (Carinii) Pneumonia • PCP: CD4 ≤ 200: TMP/SMX DS 1 po daily • sulfa allergy: dapsone 100 mg po daily • real sulfa allergy: atovaquone 900 mg BID • Mycobacterium Avium Complex • MAC: CD4 ≤ 50: azithromycin 1200 mg po q WEEK

  39. Websites to Access the Guidelines • http://www.aidsetc.org • http://aidsinfo.nih.gov www.aidsetc.org

  40. Referrals Ryan White Care Act Part B: Grantee is the Oklahoma State Department of Health. Services provided are case management, dental, mental health/substance abuse, transportation, lab, HIV testing and counseling, medicines, & HIV Drug Assistance Program Eligibility criteria: Living with HIV/AIDS and have an income that falls within 200% of the Federal Poverty Guidelines

  41. Referrals Ryan White Care Act Part C: Medical care is provided to HIV+ persons through the OUHSC Early Intervention Services Program. It provides access to every facet of HIV/AIDs medical care under the supervision of Infectious Diseases specialist doctors. The only qualification for the Part C program is that an individual has tested positive for HIV. Note: Insurance will be applied if applicable. (405) 271-6434

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