HIV Update Objectives. Epidemiology. Epidemiology, Transmission and Natural History. Transmission Risk by Exposure. Transmission 9/29/2014

Transcription

1 Objectives HIV Update 2014 Jay Sizemore, MD, MPH Medical Director Chattanooga CARES Assistant Professor UTCOM Chattanooga 2October 2014 Review HIV epidemiology and screening/testing guidelines Discuss current treatment strategies a transition from acute infection to chronic disease model Summarize successful and unsuccessful prevention approaches Epidemiology, Transmission and Natural History Epidemiology 1.1 million Americans infected 18% don t know it 50% of new sexually transmitted infections 56,000 new infections/year 8 10 year average asymptomatic period before progression to AIDS 50% MSM, 25% woman 50% Black (13% of the general population) Well controlled patient can expect near normal life span Sexual Injection Drug Use Vertical Blood Supply Transmission Transmission Risk by Exposure Type of Exposure Risk per 10,000 Exposures Parenteral Blood Transfusion 9,000 b Needle-sharing during injection 67 c drug use Percutaneous (needle-stick) 30 d Sexual Receptive anal intercourse 50 e,f Receptive penile-vaginal 10 e,f,g intercourse Insertive anal intercourse 6.5 e,f Insertive penile-vaginal intercourse 5 e,f Receptive oral intercourse Insertive oral intercourse Other h Biting Spitting Throwing body fluids (including semen or saliva) Sharing sex toys low e,i low e,i negligible j negligible negligible negligible 1

2 HIV: Natural History Diagnosis and Treatment Diagnosis HIV HIV viral load (acute infection only) HIV antibody 2 step process Screening antibody test t( (conventional or rapid) Confirmed with Western Blot At home HIV test FDA approved 7/12 Oral swab Results in minutes Confirmatory test required $40 Case Study 51yo married white female elementary school teacher Husband is an engineer No known history of HIV screening Admitted to MICU with pneumonia unresponsive to three rounds of oral antibiotics PCP; HIV+ Pt upset at primary MD for not testing for HIV Response to Lack of Change in HIV Incidence, Common Presentation with Advanced Disease Who should be tested? All sexually active adults age in a setting where the incidence of HIV is higher than 0.1% should have at least 1 test Supported by multiple medical professional societies Those at high risk (IDU, multiple sex partners, MSM) should receive interval screening All pregnant women 2

3 US Preventive Services Task Force April 2013 Grade A rec Routine screening of adolescents and adults age Rescreening in high risk populations Treatment HAART Combination of 3 or more agents active against various enzymes crucial to viral replication Goal is to decrease viral load to undetectable and raise CD4 count Labs monitored every 3 6 months HAART First used regularly in the US in 1996, 9 years after AZT approved in % reduction in HIV deaths since HAART strategy introduced HIV Medicines 2014 New HIV Medicines Nucleoside Reverse Transcriptase Inhibitors (NRTIs) AZT (zidovudine) 3TC (lamivudine) d4t (stavudine) ddi (didanosine) ddc (zalcitabine) Abacavir FTC (emtricitabine) Nucleotide Reverse Transcriptase Inhibitors Tenofovir CCR5 Inhibitors Maraviroc Integrase Inhibitors Raltegravir Elvitegravir Dolutegravir Non nucleoside Reverse Transcriptase Inhibitors (NNRTIs) Nevirapine Delavirdine Efavirenz Rilpivirine Protease Inhibitors (PI) Nelfinavir Indinavir Amprenavir Lopinavir/Ritonavir Saquinavir Atazanavir Fosamprenavir Tipranavir Darunavir Ritonavir Fusion Inhibitors T20 (enfuvirtide) Single tablet regimens (1 pill once a day) tenofovir emtricitabine efavirenz tenofovir emtricitabine rilpivirine tenofovir emtricitabine elvitegravir cobicistatemtricitabine elvitegravir cobicistat abacavir lamivudine dolutegravir (August 2014) More co formulations coming 3

4 HIV Treatment Guidelines HIV Continuum of Care All infected should be offered therapy Strength of recommendation stronger for lower CD4 counts Individual benefit Restore the immune system Reduces pro inflammatory state caused by HIV Public Health benefit Reduce number of new infections by reducing community viral load Test and treat Drug drug interactions Malignancies Obesity Tobacco use Drug use Hepatitis B/C Hypertension Hyperlipidemia Psychiatric disease Diabetes Coronary artery disease Co morbidities Health Maintenance Prevention Vaccines Hepatitis A/B Tdap Polysaccharide pneumococcal, conjugated pneumococcal HPV Influenza Other Pap, mammogram, colonoscopy, bone density, etc 4

5 Blood supply/organ screening Needle exchange Condoms Abstinence Opt out Testing in Pregnant Women Mother to child prophylaxis HAART PEP/nPEP Circumcision Awareness and Avoidance Abstinence only education? Screening hi-risk groups only Current research HSV therapy Opt-out testing in the general population Pre-exposure prophylaxis (PREP) Vaccines Two decades of research No correlate of immunity Virus with high mutation rate Live attenuated vaccines unappealing Multiple failed vaccine trials Likelihood of therapeutic vaccine appears greater than that of a preventive one Exposure to Blood, Blood Products, Organs Blood supply/organ screening Needle exchange PEP HAART Current research Rapid PCR techniques HIV and the Blood/Organ Supply Screening history HIV 1 Antibody test 1985 HIV 1/2 Antibody test 1992 HIV 1 p24 Antigen test 1996 HIV Nucleic Acid Amplification Test (NAAT) 1999 Risk is estimated to be less than 1 in 2,000,000 transfusions 400,000 transplants since last reported transmission via organ donation in patients get HIV from organ donor November 13, 2007 CHICAGO A troubling case in which a high risk organ donor infected four patients with the AIDS virus and hepatitis has led medical ethicists to warn that patients need to know more about whose organs they're getting. Public health officials said Tuesday the Chicago case is the first known instance of HIV transmission through organ transplants since Opt out Testing in Pregnant Women Mother to child prophylaxis HAART Vertical Transmission Awareness Lack of prenatal care 5

6 Mother to Child Transmission in the US 1 in 3 transmit in the absence of intervention 2000 infants born with HIV in 1990 < 200 infants born with HIV in 2005 Abstinence and safe sex education Reducing partner # Delaying sexual debut Correct and consistent condom use ART/HAART Non occupational postexposure prophylaxis (npep) Circumcision Sexual Transmission Abstinence only education? Screening hi-risk groups only Current research Genital Herpes therapy Opt-out testing in the general population Pre-exposure prophylaxis (PREP) 2005 CDC npep Guidelines 2013 PEP Guidelines Updated August 2013 Tenofovir Emtricitabine + Raltegravir replaces prior 2 (or 3) drug regimens in prior guidelines 4 week duration Circumcision Controversial subject in the US About 75% of US male population circumcised About 75% of world male population uncircumcised i Lots of observational data to suggest circumcision is protective against HIV acquisition The Three Circumcision Trials: Study Results All 3 trials stopped early because those in the circumcision group were 60% less likely to acquire HIV. The World Health Organization now includes circumcision as part of its comprehensive HIV prevention program. 6

7 Microbicides Key component to allow women to protect themselves Nonoxynol 9 Cellulose sulfate (trials halted 1/07) Tenofovir gel Pre exposure Prophylaxis Tenofovir emtricitabine Approved by FDA in July 2012 for sexually active adults at risk for HIV infection CDC releases interval guidelines for the use of PrEP In August 2012 MMWR MSM, heterosexual men and women June 2013 IDU added to the guidelines May 2014 Formal Guideline published by the CDC Conclusions Successful treatment strategies exist which have significantly increased life span and transitioned HIV into an acute care model Highly effective vaccines/cures are unlikely in the near future Effective (but not perfect) prevention tools exist Widespread screening, education, prevention and retention remain keys in the United States 7