Epidemiology Definitions Treatment Prevention

Transcription

1 HIV in Primary Care

2 Epidemiology Definitions Treatment Prevention

3 Epidemiology Presently, 1.2 million people living with HIV/AIDS in the US 40,000 new infections each year since 2006

4 NEW HIV Infections By Transmission Category 63% MSM 25% Heterosexual contact 8% Injection Drug Use 3% MSM and IDU

5 New HIV Infections By Race/Ethnicity African Americans 44% Whites 31% Hispanic/Latinos 21% Asians 2% Multiple races 1% Native American <1% Pacific Islanders <1%

6 Definitions HIV positive-person infected with HIV virus which is a single stranded RNA virus HIV most importantly infects CD4 or T helper cells Normal CD4 count is AIDS is defined as being HIV positive and having a CD4 count below 200, history of opportunistic infection or history of AIDS defining cancer such as Kaposi s Sarcoma, Non Hodgkin s Lymphoma or Cervical Cancer or AIDS Wasting Syndrome

7 Viral Load Test for monitoring how someone is doing on treatment. Directly measures number or copies of virus/ml of blood. Test is positive within 2 days of infection. Order as viral RNA by PCR

8 Viral Load In untreated infection, could be very high like greater than 100,000 copies/ml. Goal of treatment is to be undetectable, below the level of detection of the test.(<20 copies per ml)

9 Testing for HIV Recommended at least once for everyone 13-65, no matter what their risk. Those with higher risk should be tested more frequently. For example, for MSM with multiple sexual partners, does not consistently use condoms, consider every 6 months

10 Screening for HIV Questions to Ask: Are you sexually active? How many partners in the past six months? Do you have sex with men, women or both? How often do you use condoms? Any history of STDs? Do you use IV drugs? Do you know the HIV status of your partner(s)? Do you have sex while using drugs or alcohol?

11 HIV1/HIV2 Combo Test Tests for antibodies to HIV1, HIV2 virus strains and for p24 antigen. HIV 1 and HIV2 become positive 2-6 months after infection and are present lifelong. P24 antigen positive within days after infection and then fades away in a few months. So test screens for early infection and chronic infection.

12 HIV1/HIV2 combo test Test is negative if all 3 components are negative If any one component is positive, then an individual test for HIV1 and HIV2 is done. If either of these is positive, then you will get a report that the patient is HIV positive

13 HIV1/HIV2 Combo test If initial test was positive but HIV1 and HIV2 are negative, could mean that the first test was a false positive or that the p24 antigen was positive and this is an acute HIV infection. In that case, you will get a report of equivocal for the result.you ll then be prompted to get another blood sample looking directly for the virus with an HIV RNA PCR

14 HIV Testing Positive PCR=new HIV infection Negative PCR=no HIV infection. First test was a false positive

15 Acute HIV Infection When to consider: High Risk Person with acute onset of fever, exudative pharyngitis,lymphadenopathy, headache, maculopapular rash, possibly aseptic meningitis Negative testing for strep, mono Appropriate test : HIV RNA PCR positive within 2 days of infection

16 HIV Treatment Guidelines Treat everyone with CD4 count less than or equal to 500 Offer treatment to anyone who is HIV Positive Advantages of Early Treatment Help decrease longterm complications including increased risk of heart disease, dementia, cancer Help prevent spread of HIV

17 Steps in Viral Infection Attachment of virus to CCR5 receptor on T cell Fusion of virus to cell membrane of T cell and injection of contents into the T cell Creation of DNA strand that is a copy of virus s RNA Integration of the virus DNA into the genome of the Tcell Messenger RNA brings template for viral proteins into the cytoplasm String of viral proteins is made Protease cuts strand into individual functional viral proteins New viruses are assembled and bud off to infect other cells

18 HIV Medication Booster Meds: Norvir and Cobicistat Meds to actively kill the virus HAART-combine 3 and sometimes four meds to actively kill virus. Sometimes also use booster,sometimes not depending on the HIV meds

19 HIV Medication Attachment Inhibitor: Blocks attachment of virus to CCR5 receptor on T cell One med in this class-maravaroc

20 Nuceloside Reverse Transcriptase Inhibitors (NRTIs) Fake Pieces of DNA Epivir + Abacavir=Epzicom Emtricitabine +Tenofovir= Truvada Old tenofovir-tdf New Tenofovir-TAF-less renal and bone problems

21 Non-Nucloeside Reverse Transcriptase Inhibitors (NNRIs) Bind to reverse transcriptase and block making of viral DNA Efavirenz + Truvada=Atripla One tab once daily Psychiatric side effects. Can lower methadone levels

22 Integrase Inhibitors Stop integration of viral DNA into genome Raltegavir one tab twice daily Elvitegravir +Truvada +Cobicistat=Stribild with TDF. New safer form with TAF is Genvoya. One tab once daily Dolutegravir+Epzicom=Triumeq one tab once daily

23 Protease Inhibitors Stop breakup of large string of inactive viral proteins into individual functional units Reyataz + Norvir or Reyataz + Cobicistat=Evotaz Reyataz causes indirect hyperbilirubinemia Needs acid environment. Cautions with concomitant use of H2 blockers, PPIs, antacids Treatment naïve patient can take omeprazole or equivalent 20mg once daily 12 hours prior. Treatment experienced should not take PPIs Treatment naïve can take famotidine 40mg twice daily for equivalent. Treatment experienced can take 20mg twice daily. Take one dose at same time as reyataz and the other hours later Reyataz one hour before or 2 hours after anacids

24 Protease Inhibitors Darunavir + Norvir Or Darunavir +Cobicistat =Prezcobix

25 Important Drug Interactions Cobicistat and Norvir with: 1-Statins- raise statin blood level. Can t use simvastatin or lovastatin. Atorvastatin up to 20mg ok. Rosuvastatin starting with 5mg and up to 10 mg. Pravastatin levels in general lowered by these meds except for Darunavir + cobicistat (prezcobix) or Darunavir + Norvir. Combination contraindicated. Very high levels of pravastatin

26 Drug Interactions Norvir or Cobicstat with : Phosphodiesterase inhibitors-causes high levels. Use no more than 25mg of Sildenafil, 5mg of Vardenafil or 2.5mg of Tadalafil Colchicine-for acute attack, 0.6mg and then 0.3 one hour or more later than 0.3 mg every 3 days as needed. For chronic suppression 0.3mg every other day Biaxin contraindicated. Zithromax ok Warfarin levels can increase or decrease. Monitor INR closely Newer anticoagulants-dabigatran ok. Avoid rivaroxaban,apixaban Alfluzosin levels increased. Should not use. Tamsulosin is ok

27 Drug Interactions Alprazolam contraindicated with booster meds. Lorazepam is fine. Fluticasone levels increased. Can cause adrenal suppression or Cushing s Syndrome. Use mometasone instead Avoid St John s Wort with all HIV meds Use of carbamezapine, phenytoin, phenobarbital contraindicated with cobicistat and norvir. These seizure meds block the boosting effect. Use keppra or Depakote Paroxetine and sertraline levels are lowered. No effect on escitalopram Levels of birth control pills lowered by cobicistat and norvir. Depo provera, IUD, Nexplanon best birth control

28 Prevention Risk Assessment Counseling Testing Encouraging those who are HIV positive to start treatment Treating depression Addressing substance abuse

29 PREP-Prexposure Prophylaxis IPREX study-2500 MSM or M to F Transgendered People who have sex with men Multiple countries including the US Average of 18 sexual partners in past 3 months HIV negative Double Blinded Study Treatment arm received Truvada one tab daily All arms seen every month. Counseled on decreased risk behavior Adherence measured by patient report, pill count, blood levels Followed for 1-2 years

30 IPREX Overall, 44 % decrease in risk of new HIV infection in treatment group If adherence reported at 50% of doses, decrease in risk went up to 50% If adherence reported at 90 % or greater, decrease in risk was 73% 35 people in the treatment group got HIV. No detectable medication found in blood of 31 of these people Minimal side effects-headache, nausea, insomnia

31 PREP Approved in 2014 for prevention of HIV Subsequent studies showed effectiveness in prevention in heterosexual couples, IV drug users

32 PREP Indications: Someone with HIV positive sexual partner Recent sexually transmitted illness High number of sexual partners (especially if in an area of high HIV prevalence) Inconsistent or no condom use Commercial sex worker IDU who shares needles Sexual partner of IDU

33 PREP Labs: HIV1/HIV2 combo test negative Renal function-gfr greater than or equal to 70% to start. Need to stop if GFR drops below 50%. This will likely change to less than a GFR of 30% once Truvada is approved with more renal friendly TAF instead of TDF Urinalysis-refer to nephrology for significant proteinuria Screen of syphilis, gonorrhea Screen for Hepatitis. If not immune, vaccinate for hepatitis A and B

34 PREP Identify those with chronic hepatitis B infection. They need treatment with Truvada for prevention of HIV and to prevent cirrhosis and hepatocellular cancer from hep B. Should be referred to GI. If hep B infected, should not stop Truvada. Can cause acute flare of hep B

35 PREP Followup See every 3 months. Counsel on risk reduction at each visit Before visit, needs to have HIV 1/HIV2 combo test every 3 months. Check GFR every six months or sooner if falling Urinalysis every year STD screening every six months Pregnancy test every 3 months. Pregnancy category B

36 PREP Issues Can PREP be stopped? Yes if intolerant to medication, risk decreases or patient changes his mind about taking If someone becomes HIV positive on PREP, will they be resistant to Truvada? So far, only rare cases. Most people who become HIV positive are not taking the med frequently enough to become resistant Cost? Expensive but most insurances cover. Patient assistance program available Does PREP increase risky behavior? Overall risky behavior decreases. Number of partners in placebo and treatment group of IPREX dropped from 18 to 3 probably because of contact with medical providers, increased concern about health

37 NPEP Non-occupational post exposure prophylaxis within past 72 hours High risk sexual exposure-condom broke when HIV status of partner unknown Check HIV status, screen for other STDs, hepatits before and six weeks after exposure Then can treat for 28 days with 3 drug regimen-usually Truvada +raltegravir because so well tolerated but best to consult with infectious disease about choice for medication Someone who repeatedly requests NPEP should be encouraged to take PREP

38 Summary Primary care plays a vital role in : Assessing Risk factors for HIV Testing for HIV Counseling on risk factor reduction Identification of acute HIV Being on the lookout for drug interactions Providing emotional support for patients and their families Prevention of HIV Primary Care HIV treaters very much in demand