2015 OPSC Annual Convention. syllabus. February 4-8, 2015 Hyatt Regency Mission Bay San Diego, California

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1 2015 OPSC Annual Convention syllabus February 4-8, 2015 Hyatt Regency Mission Bay San Diego, California

2 SUNDAY, FEBRUARY 8, 2015: 10:00am - 11:00am Primary Care of the HIV Patient Presented by Jim Lee, DO, AAHIVS

3 PRESENTATION Learning Objectives and Self ASSESSMENT questions LEARNING OBJECTIVES 1. Become aware of the basic issues of HIV 2. Learn how to identify HIV patients 3. Learn about testing for HIV 4. Become knowledgeable about HIV treatment 5. Learn how to maintain good health in the HIV patient 6. Learn what is not known about HIV care. SELF ASSESSMENT QUESTIONS 1. Patients who should be tested for HIV include: a. Homosexuals b. IV drug users c. 56 year old women d. all patients in their 20s e. anyone 13 to 64 years of age f. all of the above 2. The rate of new infection has decreased in the following group: a. 20 year olds b. IV drug users c. Hispanic women d. Black men e. MSM 3. Pre Exposure Prophylaxis should be not be used by this group: a. MSM b. disconcordant couples c. IV drug users d. HIV positive persons e. all the above 4. The Acute Anti Retroviral Syndrome does not include this finding: a. skin rash b. headache c. lymphadenopathy d. testicular pain e. anorexia 5. Initial treatment of the HIV positive patient should begin: a. at age 25 b. when Tcells are less than 350 c. when viral load is 50 + d. when patient is symptomatic e. immediately 6. The most recommended initial treatment regimens include: a. 2 nnrtis b. 2 Protease inhibitors c. 2 Integrase inhibitors d. only nnrtis e. Any of the above 7. The best way to find out if a drug is going to work is to do the following test: a. Chemistry panel b. HIV RNA PCR Quantitative c. Western Blot d. Elisa e. Phenosense GT plus Integrase OPSC s 54th Annual Convention and Exposition Syllabus 1148

4 OPSC s 54th Annual Convention and Exposition Syllabus 1149

5 Primary Care of HIV Patient well, one way to do it. OPSC s 54th Annual Convention and Exposition Syllabus 1150

6 Current Epidemiology US: 1.2 Million HIV positive persons 14% are unaware There are 50,000 new cases of HIV in the US each year. Highest rate in MSM. California: 120,000 HIV positive persons STDs Rate two fold higher among HIV positive MSM vs negative HIV in drug users. Decreased 80% since the late 1980s. Racial differences. 7.8 to 20 times higher in blacks, 2.8 x higher in Latinos. OPSC s 54th Annual Convention and Exposition Syllabus 1151

7 Whom to evaluate All persons 13 to 64 should be screened every year for HIV infection. Testing mechanisms HIV Elisa Western Blot to supplement OPSC s 54th Annual Convention and Exposition Syllabus 1152

8 Testing HIV Elisa Western Blot immunoassay quantitative and qualitative HIV 1 and 2 antibody differentiation Nucleic Acid Test HIV RNA PCR OPSC s 54th Annual Convention and Exposition Syllabus 1153

9 OPSC s 54th Annual Convention and Exposition Syllabus 1154

10 Acute Retroviral Syndrome maculopapular rash mucocutaneous ulceration headache lymphadenopathy myalgia/arthralgia anorexia/nausea/vomiting/diarrhea retro-orbital pain OPSC s 54th Annual Convention and Exposition Syllabus 1155

11 Treatment.. When to start: NOW What to start with: coming up How long to treat: Permanent OPSC s 54th Annual Convention and Exposition Syllabus 1156

12 OPSC s 54th Annual Convention and Exposition Syllabus 1157

13 Life Cycle and Interference nrtis NNRTIs PIs Integrase Strand Inhibitors Entry Inhibitors (Fuzeon, Selzentry) Transcription Inhibitors OPSC s 54th Annual Convention and Exposition Syllabus 1158

14 with permission from AidsMeds com OPSC s 54th Annual Convention and Exposition Syllabus 1159

15 OPSC s 54th Annual Convention and Exposition Syllabus 1160

16 Initial Antiretroviral Regimens. 2 nrtis + Int Inhib Tenofovir + Emtricitabine (Truvada) and Dolutegravir Abacavir + Lamivudine + Dolutegravir (Triumeq) Tenofovir + Emtricitabine + Elvitegravir/cobicistat (Stribild) 2 nrtis + NNRTI Tenofovir + Emtricitabine (Truvada) and Efavirenz. (Atripla) Abacavir + Lamivudine (Epzicom) and Efavirenz Tenofovir + Emtricitabine (Truvada) and Rilpivirine. (Complera) 2 nrtis + PI/r Tenofovir + Emtricitabine (Truvada) and Atazanavir Abacavir + Lamivudine (Epzicom) and Atazanavir Tenofovir + Emtricitabine (Truvada) and Darunavir (Prezista) OPSC s 54th Annual Convention and Exposition Syllabus 1161

17 Alternatives 2nRTIs plus InSTI Abacavir + Lamivudine (Epzicom) plus Raltegravir 2nRTIs plus NNRTI 2nRTIs plus PI 2nRTIs plus Nevirapine ** Abacavir + Lamivudine (Epzicom) plus Rilpilvirine 2nRTIs plus Atazanivir/colbicistat 2nRTIs plus Darunavir/colbicistat Abacavir/lamivudine (Epzicom) plus Darunavir OPSC s 54th Annual Convention and Exposition Syllabus 1162

18 OPSC s 54th Annual Convention and Exposition Syllabus 1163

19 OPSC s 54th Annual Convention and Exposition Syllabus 1164

20 Single Dose Therapy for HIV Infection Atripla Efavirenz + Tenofovir + Emtricitabine Complera Rilpivirine + Tenofovir + Emtricitabine Stribild Elvitegravir + Cobicistat + Tenofovir + Emtricitabine Triumeq Dolutegravir + Abacavir + Lamivudine OPSC s 54th Annual Convention and Exposition Syllabus 1165

21 Monitoring 200. re-evaluate. Viral load 4 weeks after starting med, then q 3 to 6 months if over 50, recheck. over Tcells every 3 to 6 months.. Average Genotype (Phenosense) testing in all new and virologic failure. and sure. Know when to switch meds: labs, clinical, options. Be clear OPSC s 54th Annual Convention and Exposition Syllabus 1166

22 Associated Disorders Opportunistic Infections Prophylaxis Pneumocystis jiroveci Sulfamethoxazole/trimethoprim Toxoplasma gondii Sulfamethoxazole/trimethoprim Mycobacterium avium complex Azithromycin Mycobacterium tuberculosis Isoniazid + pyridoxine Cryptococcus Fluconazole Cytomegalovirus Valganciclovir herpes simplex -- varicella zoster Acyclovir OPSC s 54th Annual Convention and Exposition Syllabus 1167

23 Cardiovascular and Metabolic Disorders Liver Disease Kidney Disease Cancers OPSC s 54th Annual Convention and Exposition Syllabus 1168

24 Interactions OPSC s 54th Annual Convention and Exposition Syllabus 1169

25 OPSC s 54th Annual Convention and Exposition Syllabus 1170

26 Vaccinations.. Immunizations Td/Tdap. Tetanus, diphtheria, acellular pertussis. every 10 years should have a T/dap booster Varicella vaccine (Varivax)is CONTRAINDICATED in patients with HIV who have less than 200 Tcells. Those with over 200 T cells should receive the vaccine Human Papillomavirus (HPV). All patients with HIV up to age 26. should receive 3 doses of HPV vaccine Zoster. Zostavax vaccine Pneumococcal vaccine naive HIV-infected adults should receive pneumococcal 13-valent conjugate vaccine first, followed by a dose of pneumococcal 23-polyvalent vaccine at least 8 weeks later. Boost every 5 years. OPSC s 54th Annual Convention and Exposition Syllabus 1171

27 Vaccinations.. Immunizations, cont d MMR, Measles, Mumps, Rubella vaccine. one or two doses at age 19 to 49. Booster at age +50. NO for less than 200 tcells Meningococcal vaccine. not a standardly administered vaccine to either healthy adults or to patients with HIV infection Hepatitis B vaccine (and Hepatitis A in combo administration).. check every 5 years for immunity. Hepatitis C vaccine.. Not yet available. OPSC s 54th Annual Convention and Exposition Syllabus 1172

28 PreP and PEP. Pre Exposure Prophylaxis I recommend for all patients who are having sex. Studies have shown a 60% decrease in new infection among those taking Truvada (Emtricitabine and Tenofovir). This is to be used in conjunction with condom use and safe sex. There are disconcordant couple studies which show no new infection. More to come. Renal check and HIV q 3 months or no refill. OPSC s 54th Annual Convention and Exposition Syllabus 1173

29 Post Exposure Prophylaxis Occupational: Do not delay; Test the source; Consider HIV-1 RNA of source; Include Hepatitis B testing; May discontinue if source confirmed negative. Know the patient and the source patient if possible. Risk-stratification. 72 hour window HIV testing at baseline, 6 weeks 12 weeks and 6 months. May consider HIV-1 RNA testing qualitative on day 6+. Numerous choices but primary is: Truvada(1/d) and Raltegravir (Isentress) (bid) Remember to watch and test for Hepatitis C OPSC s 54th Annual Convention and Exposition Syllabus 1174

30 more information InPractice.com is simply amazing. You will find everything there. AidsMeds.com is accurate and up to date and great for the professional and the patient. International AIDS Society.. you can find online CCO Clinical Care Options also online.. excellent information and credits too OPSC s 54th Annual Convention and Exposition Syllabus 1175

31 RETURN TO TABLE OF CONTENTS OPSC s 54th Annual Convention and Exposition Syllabus 1176

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