Medical Diagnoses. Hypertension, hypercholesterolaemia, glucose intolerance, gout

Transcription

1 Kevin Rebe

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3 Case 1 50 yo gay man HIV positive diagnosed in 1988 CD4 count nadir was 4 cells/mm 3 Multiple ART regimens details lost Heavy smoker Intermittent inhaled crystal meth

4 HIV on ART Medical Diagnoses Metabolic syndrome Hypertension, hypercholesterolaemia, glucose intolerance, gout Ischaemic heart disease 2 prior MI s, last ACS event in Feb 2012 Angioraphy with 3 stents Feb 2012

5 Medical Diagnoses Ischaemic cerebral events Multiple TIAs Multifocal leuco-encephalopathy on MRI Secondary polycythemia (Hb 20 / Hct 0.58/l) Cervical spondylosis with neck muscle spasm Peripheral neuropathy Recurrent HPV

6 Medication Raltegravir 400mg bd Darunavir 600mg od Ritonavir 100mg od Truvada 1 tab od Perindopril 5mg od Lercanidipine 20mg od (CCB) Pravastatin 20mg od Aspirin 150mg od Clopidigrel 75mg od Stilnox PRN Adherence VL LDL CD4 879 BP 168/95 Pulse 90 bpm Cholesterol total 6 Ongoing drug use

7 The Current Problem Medical aid failure needs to transfer into state medical clinic Current ARVs not available Cardiovascular meds not available Limited capacity to manage complex overlapping diseases at primary care level

8 Points for Discussion 1. Anti-retroviral treatment Available via DOH: TDF / 3TC / ABC / Rtv / Lpv / Atz Next steps:

9 Points for Discussion Detailed ARV History Previous meds: AZT / D4T / DDI / EFZ / Lpv / Rtv Multiple changes for side effects Multiple changes for VL failure Periods of poor adherence and treatment interruptions

10 Points for Discussion Genotype: L101, M46I, G48V, I54T, A71T, V82A, L69V Low level resistance to Darunavir / Tipranavir High level resistance to all other PIs K103N High level resistance to NVP / EFZ Sensitive to Etravirine M184V, M41L, L74V, L210W, T215Y High level resistance to 3TC / FTC High level resistance to all other NRTIs PIs NNRTIs NRTIs

11 Points for Discussion 1. Anti-retroviral treatment Private: Continue current meds Option of etravirine [Raltegravir, etravirine, darunavir] State: Essentially not-suppressible TDF / 3TC / Aluvia Refer to tertiary services Find a sponsor / co-pay options?

12 2. Vascular risks Points for Discussion Smoking cessation Stop recreational drug use Modify diet Aggressive control of all modifiable risk factors Treat for glucose intolerance Substitute meds for state alternatives

13 Points for Discussion 3. Aging MSM on ARVs Medical Concerns Co-morbidities Cardiovascular and stroke Malignancies Prostatic disease ED Cognitive impairment Osteoporosis / osteopaenia Polypharmacy and drug interactions / SE

14 Points for Discussion 3. Aging MSM on ARVs Psychosocial concerns Loss of income Social isolation Fear of aloneness old-age homes Loss of desirability invisibility and objectification as asexual ( dirty old man ) Substance abuse Depression, anxiety Major LOSSES

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16 Case 2 28 yo gay man HIV positive diagnosed 2008 Hepatitis C diagnosed 2009 Psychiatric history Bipolar affective disorder (?) Cluster B personality traits Mother BAD on chronic meds, depression

17 Substance abuse Crystal meth, MDMA, ecstasy, GHB, GBL, methcathionone (Cat) Crystal usually injected Other drugs, swallowed, smoked, snorted or bumped ICU admission requiring ventilation following crystal overdose in 2009 Contexts are social and sexual Rehab X2 with relapse Ongoing weekend / intermittent use

18 More Clinical Details HIV CD4 nadir 285 following seroconversion CD4 recovered to approx 450 cells/mm 3 VL peak copies/ml HCV Genotype 2 ALT approx 250 and AST approx 150 Normal synthetic liver function Liver biopsy: mild lobular hepatitis with spotty necrosis and portal tract expansion.

19 More Clinical Details Screened positive for syphilis in 2009 and Atypical pneumonia 2011 DVT right forearm Not related to injecting behaviour Mother had prior DVTs, PE and lifelong warfarin.

20 Points for Discussion HIV treatment When to start? What medication? How to optimize for adherence? HCV treatment Likelihood of response? What treatment? What contra-indications exist? How to achieve treatment readiness?

21 HIV Treatment Treat ASAP, irrespective of CD4 count Especially if further HCV treatment not available Avoid D4T (steatohepatitis) Use TDF even though no anti-hcv activity Avoid PI s causing metabolic syndrome if evidence of HCV-related glucose intolerance Mental health referral Drug use is NOT a contra-indication to initiating and maintaining ART!

22 HIV Treatment Atripla (TDF / FTC / EFZ) No side effects No flare in liver enzymes Excellent adherence over 2 years Current CD4 949 and VL LDL Despite periods of mood instability and ongoing intermittent substance abuse

23 HCV Treatment Inteferon and ribavirin Cost and access problematic Mental health side effects Patient self-efficacy / buy-in Genotype 2 good responder, shorter course New anti-hcv PIs (tilaprovir and bocepravir) tested in genotype 1 only. (Not appropriate but not easily available in SA.) Patient not yet treated: cost / availability / concern about mental health / lack of patient commitment

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30 26 yo gay man Case 3 Attends the clinic for advice about HIV prevention. Sexual history Exclusively MSM Versatile with NO condom use Uses water-based lubricant for UAI >50 sex partners in the last year Sex at sex-on-site venues (Hothouse) No primary (main) sexual partner

31 Case 3 Sexual history Two prior STIs treated at the clinic (Urethritis and syphilis) Recent inclusion in ASTI study where screened positive for urethral and anal GC and recurrent syphilis Substances Daily crystal meth. IDU and non IDU Also cat, coke, ecstasy, MDMA, GHB, poppers

32 Adherence Case 3 Remains in care but attends on PRN basis and defaults scheduled appointments HIV status NEGATIVE on last 3 tests. What advice to give??

33 Possible Prevention Interventions Intervention Acceptable Comments Condoms No Explore why? FC2? Use for highest risk Lubricants Yes Use water based only with condoms PEP Yes Recurrent need problematic PrEP Yes Ability to adhere? TasP No Intervention for positives only STI screen & treat Yes Unable to screen ASTI Recurrent HCT Yes Likely to modify behaviour? Address substance use No Not wanting to stop use now Address triggers of risk behaviours No Not wanting to reduce public sex or number of sex partners Sero-sorting Yes Sex with HIV neg partners (unreliable) Sero-positioning No Prefers receptive role in anal sex

34 Outcome Extensive discussion about PrEP Appropriate baseline assessments done Script provided Script not filled and patient defaulted his scheduled appointment PARADOX Those most likely to benefit from PrEP may be those least likely to achieve adherence!

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36 Case 4 30 yo non-gay identifying MSM Exclusively has sex with men Attends clinic with an anal discharge What is your approach?

37 Sexual history 30 partners in the last year (no primary partner) Oral and anal sex, exclusively receptive Condoms and lube sometimes Anonymous partners Meets men for sex at shebeens Transactional sex (received money or goods for sex) but not a sex-worker

38 Case 4 Substance use Alcohol and cannabis daily Context is sexual to facilitate meeting partners and enhance sex Lube type Hand lotion or moisturiser Health4men water-based when available Assegai when in sex-on-site-venue

39 Clinical Examination No LN Small patch of oral candida Chest and abdo normal Genitalia Penis NAD Anus: External warts (proctoscopy not done) Serous discharge

40 Differential Diagnosis Oral candida HIV / diabetes / Alcohol and drugs / malignancy Anal discharge STI: GC / CT / Syphilis / Internal HPV / HSV (less likely) / Gram neg infection / MRSA infection Non STI: polyps / anal cancer / haemorrhoids /fistulae / others

41 Investigations HIV positive CD4 102 RPR positive 1:256 TPHA positive PCR positive for anal GC PCR negative for anal CT Hepatitis B S Ag positive

42 Management Intramuscular penicillin 2.4mu X 3 Ceftriaxone 400mg orally Work up to initiate ART within two weeks as per new DOH guidelines Psychiatric assessment and referral to Cape Town Drug Counseling Centre Sexual risk reduction counseling and package of interventions

43 Contact: a Tel: