Principle of ART. HIV treatment experience in Latvia. Patient centered health care. How to improve adherence to ART? HIV and TB co-infection in Latvia
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1 Principle of ART. HIV treatment experience in Latvia. Patient centered health care. How to improve adherence to ART? HIV and TB co-infection in Latvia Dr. Inga Januskevica Head of HIV/AIDS Outpatient Department Riga East Clinical Hospital, Infectology Center of Latvia
2 HIV known in the World since year years experience st registered HIV patient in Latvia -25 years experience
3 HIV life circle RNK proteāze integrāze reversā transkriptāze lipīdu dubultslānis
4 HIV life circle
5 Infectology Center of Latvia HIV / AIDS Out-patient Department - centralised HIV patient health care
6 Outpatient department structure (I) Cheaf of HIV / AIDS Block Dr. I.Bērziņa, Infectologist Head of HIV / AIDS Outpatient Department Dr. I.Januškevica, Infectologist, dermatovenerologist Dr. G.Stūre, M.D.,Ph.D. Infectologist, hepatologist Dr. S.Ansone Pediatric specialist Dr. E.Selicka 4th year Infectology resident Dr. I.Zeltiņa, M.D. Infectologist Dr. V.Sitkare Pediatric specialist Dr. K.Ābeltiņa 3rd year Infectology resident Dr. G.Saulīte Infectologist Dr. A.Sangirejeva Infectologist Sen.med.nurse I.Magone HIV/AIDS Medical Nurses Vice- Sen.med.nurse V.Kaļva Six medical nurses
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8 Number of patient visits in the outpatient department (total number ) 2011.g g g g g g g
9 Number of patient visits in the outpatient department per month in 2011 (total number ) Janvāris Februāris Marts 1296 Aprīlis 925 Maijs Jūnijs Jūlijs 903 Augusts Septembris Oktobris 1039 Novembris Decembris
10 260 newly diagnosed and registered HIV patients in 2011
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12 Children visits in the HIV/AIDS outpatient department Kopā: 751
13 Statistical data on HIV/AIDS ( ) 5189 HIV+ patients registered in Latvia 3571 HIV+ patients registered at the Infectology Center of Latvia 2086 patients IVDU (59%) 1047 HIV+ patients reached the AIDS stage 549 died (372 in AIDS stage, 177 before AIDS) 556 patients on ARV therapy 40 HIV positive children 15 AIDS stage 5 Died 26 children patients on ARV therapy
14 ART guidelines in Latvia Apstiprinātas ar V/A Latvijas Infektoloģijas centrs 2007.gada 28.maija rīkojumu Nr.71 Apstiprinātas ar V/A Latvijas Infektoloģijas centrs 2009.gada 16.aprīļa rīkojumu Nr.38 HIV infekcijas ārstēšanas vadlīnijas HIV infekcijas ārstēšanas vadlīnijas Rīgā, 2007.gada maijā 4.redakcija Rīgā, 2009.gada aprīlī 5.redakcija
15 ART guidelines in Latvia Guidelines for the treatment of HIV infection, Infectology center of Latvia, 5th edition, updated April 2009 Recommendations on rational pharmacotherapy with antiretroviral therapy paid by the state budget resources for the treatment of HIV infection Methodological recommendations to regional infectologists for the health care of HIV / AIDS patients
16 Indications for initiation of the antiretroviral therapy Indications up to April 2009: Acute retroviral syndrome Symptomatic HIV infection C and B categories diseases Asymptomatic HIV infection, when CD4<200c/mm³ 200 c/mm³< CD4 <350 c/mm³ + viral load - HIV-RNA > cop/ml Indications from April 2009 up to now: 1. Acute retroviral syndrome (3-6 months) 2. Symptomatic HIV infection C categories diseases, symptomatic HIV trombocitopenia 3. CD4<200c/mm³
17 Expected improvements in the ART guidelines Infectology Center of Latvia proposed following changes in the ART guidelines: Initiation of ART if CD4<350 with clinical manifestation of HIV Infection Determination of HLA B*5701 before starting therapy with Abacavir(ABC) Inclusion of newest EMEA approved antiretroviral medicines Etravirine (Intelence, NNRTI group)
18 Treatment of HIV infection Antiretroviral therapy + Opportunistic diseases treatment + Opportunistic infection prophylaxis Prophylactic therapypostexposure prophylaxis (PEP) Vertical transmission prophylaxis
19 ARV therapy Consiliums Head of ARV Therapy Consiliums Vice - director in Medical Matters State Agency Infectology center of Latvia Dr. V.Ķūse. Number of consiliums 48 Reviewed clinical cases 1012 From them: - Consiliums with physicians from prisons 27 - Reviewed clinical cases from prisons Consiliums with physicians from TB clinic 20 - Reviewed clinical cases from TB clinic 39
20 Antiretroviral drugs Since 1 January 2010 all antiretroviral medicines for treatment of HIV infection included in the List of Reimbursed Medicines.
21 Reimbursed antiretroviral drugs 1. Nucleoside analogs - NRTI Abacavir (Ziagen) Didanosine (Videx) Emtricitabine (Emtriva) Lamivudine (Epivir) Stavudine (Zerit) Tenofovir (Viread) Zidovudine (Retrovir) Reimbursement list * List C Combinations Lamivudine/Zidovudine (Combivir) Abacavir/Lamivudine (Kivexa) Abacavir/Lamivudine/Zidovudine (Trizivir) Emtricitabine/Tenofovir (Truvada) 2. Non- nucleoside analogs- NNRTI Efavirenz (Stocrin) Nevirapine (Viramune) Etravirine (Intelence) * 3. Protease inhibitors - PI Atazanavir (Reyataz) Fosamprenavir (Telzir) Saquinavir (Invirase) Indinavir (Crixican) Darunavir (Prezista) Lopinavir/Ritonavir (Kaletra) Tipranavir (Aptivus) 4. Entry inhibitors - FI Enfuvirtide (Fuzeon) * 5. Integrase inhibitors- II 6. CCR5 antagonist Raltegravir (Isentres) * Maraviroc (Celsentri) *
22 ARV medicines according to Reimbursement list from 1st January 2011 List B - NRTI, NNRTI un PI groups List C - Isentress (Raltegravirum), Fuseon (Enfuvirtidum), Maraviroc (Celsentri), Etravirine (Intelence)
23 First line therapy 1st line regimens up to April 2009: NNRTI + 2 NRTI PI/r + 2NRTI 1st line regimens from April 2009: NNRTI (EFV or (NVP) ) + 2 NRTI (3TC+ZDV; ABC+3TC; TDF+FTC)
24 Patients on ART by gender ( ) Total number of patients on ARV treatment 535 Women 165 Man 370
25 Structure of ART by transmission group ( ) Total No of patients on ART 556 Total No on ART 556 IVDU 259 Heterosexual 196 Homosexual 63 Bisexual 31 Mother to child 26
26 Structure of ARV therapy patients by regimens ARV therapy for adult patients by regimens 2% % 76% Total number of patients on ARV treatment st line regimen 364 (76%) 389 (73%) 2nd line regimen 105 (22%) 135 (25%) Salvage regimen 11 (2%) 11 (2%)
27 ARV therapy regimens for adult patients ( ) Pieaug. sk. 1 pacientam 1 pacientam Ls gadā Ls mēn EFV + 3TC/AZT EFV + ABC/3TC EFV + 3TC + ddi EFV + 3TC + TDF EFV + ABC + AZT EFV + ABC + ddi EFV + ABC + FTC EFV + FTC/TDF EFV + FTC + TDF EFV + ABC + TDF NVP + 3TC/AZT NVP + ABC/3TC NVP + FTC/TDF NVP + ddi + AZT ABC/3TC/AZT SQV + RTV + 3TC/AZT SQV + RTV + ABC/3TC SQV + RTV + 3TC + ABC SQV + RTV + 3TC + ddi SQV + RTV + EFV + ddi SQV + RTV + ABC + AZT SQV + RTV + TDF + AZT LPV/RTV + 3TC/AZT LPV/RTV + ABC/3TC LPV/RTV + EFV + ddi LPV/RTV + 3TC + ddi LPV/RTV + ABC + AZT LPV/RTV + SQV + ABC LPV/RTV + ddi + AZT LPV/RTV + TDF + AZT LPV/RTV + ATV*300 + TDF ATV*300 + RTV + 3TC/AZT 33 ATV*300 + RTV + ABC/3TC 34 ATV*300 + ABC/3TC 35 ATV*300 + RTV + 3TC + TDF 36 ATV*300 + RTV + AZT + TDF 37 ATV*300 + RTV + FTC/TDF 38 ATV*300 + RTV + ABC + TDF 39 ATV*300 + RTV + ABC + AZT 40 ATV*300 + RTV + 3TC + ddi 41 ATV*300 + RTV + ddi + TDF 42 ATV*300 + RTV + ddi + AZT 43 FPV + RTV + 3TC/AZT 44 FPV + RTV + ABC/3TC 45 FPV + RTV + 3TC + ddi 46 FPV + RTV + AZT + ddi 47 FPV + RTV + ABC + ddi 48 FPV + RTV + ABC + AZT 49 FPV + RTV + ABC + TDF 50 FPV + RTV + FTC + ddi DRV*600 + RTV + ABC/3TC TPV + RTV + TDF ddi RTG + TPV + RTV + EFV RTG + LPV/RTV + SQV 55 RTG + DRV*600 + RTV + FTC/TDF 56 RTG + EFV + ABC/3TC MRV + ABC + TDF T20 + EFV + ddi T20 + SQV + RTV + EFV T20 + ABC + ddi 61 T20 + DRV*600 + RTV + ABC/3TC
28 ART patients monitoring Monitoring up to April 2009: Complite blood count - every 3-4 mo Immunology every 3-4 mo HIV viral load every 6 mo Monitoring from April 2009: Complite blood count 1-2 x per year Immunology 1-2 x per year HIV viral load 1 x per year
29 ARV therapy regimens for children (uz ) 1 DRV + RTV + ABC + AZT 1 2 ABC (sīr.) + 3TC + AZT 1 3 EFV (sīr.) + 3TC(sīr.) + AZT 1 4 EFV + 3TC + AZT 1 5 LPV/RTV (sīr.) + 3TC(sīr.) + AZT(sīr.) 1 6 LPV/RTV 200/50 + 3TC/AZT 3 7 LPV/RTV 200/50 + 3TC + AZT 4 8 LPV/RTV 200/50 + ABC + AZT 7 9 LPV/RTV 200/50 + ABC + EFV 1 10 LPV/RTV 100/25 + 3TC(sīr.) + AZT(sīr.) 1 11 LPV/RTV 100/25 + 3TC(sīr.) + AZT 2 12 LPV/RTV 100/25 + ABC + AZT 2 KOPĀ 25
30 HIV(+) pregnant women HIV(+) pregnant women prophylaxis of vertical transmission: HIV(+) pregnant women HIV(+) pregnant women HIV(+) pregnant women
31 Post-exposure prophylaxis medical staff -21 police - 7 children 3 others - 13
32 HIV infected patients in prisons December 2010 Name of prison On ARV treatment HIV+ patients by prisons HIV+ patients by free-regime prisons Total 1. Olaine Central Daugavgriva Jekabpils Valmiera Skirotava Ilguciema Brasa Liepaja Jelgava Cesis for adolescents Total:
33 Adherence to ART
34 What is Adherence? Adherence is a client s behavior coinciding with the prescribed health care regimen Regimen is agreed upon through a shared decision making process between the client and the health care provider 34
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36 Adherence to ART in Latvia
37 Adherence to ART in Latvia During 2011: ART initiated 251 patients ART discontinued 194 patients ART regimen changed 74 patients
38 Why is Adherence to ART Important? HAART reduces morbidity, mortality, and overall health care costs for HIV+ persons, if properly taken Achieves viral suppression Avoids development of viral resistance Prevents development of opportunistic infections and treatment failure ARV should not be prescribed in the absence of adherence assessment and support
39 Consequences of Poor Adherence Incomplete viral suppression Continued destruction of the immune system Disease progression Emergence of resistant viral strains Limited future treatment options Higher costs to the individual and ARV program
40 How Much Adherence is Required for Success? To achieve maximum and durable viral suppression (to undetectable levels) adherence must be >95% Less than 3 doses missed per month Failure rates increase sharply as adherence decreases
41 How Common is Non-Adherence? Estimated rates of non-adherence to medications range from 10% to nearly 100%, with an average incidence of about 50% Non-adherence to ART, likewise, is common in all groups of individuals on treatment >10% patients report missing one or more doses on any given day 1 >33% report missing doses in the past 2 to 4 weeks 1 Partly due to non-adherence, ART fails in approximately half of patients for whom it is prescribed 2 1. Ickovics, J.R. et al., JAIDS, Valdez L, et al., Arch Intern Med, 1999.
42 Challenges of Adherence to ART Does not cure HIV infection, therefore must be taken regularly life long High pill burden Requires near perfect adherence Specific dietary and fluid instructions Side effects: short and long term Stigma
43 Five Types of Non-adherers 1. Consistent Underdoser Regularly neglects to take one of the prescribed doses, such as the midday dose Regularly takes only some of the prescribed medications 2. Consistent Overdoser Regularly takes a drug more often or in larger doses than prescribed 3. Random Doser Takes the medications when she or he thinks of it
44 Five Types of Non-adherers (2) 4. Abrupt Overdoser Does not take medications properly and then takes an overdose prior to a clinic visit Doubles up for missed doses 5. Tourist (takes drug holidays ) Abruptly stops all medications for a few days or weeks Takes one day off per week
45 Factors Affecting Adherence A variety of factors impact a patient s ability to adhere to a prescribed treatment regimen: Patient variables Treatment regimen Disease characteristics Patient provider relationship Contextual factors Understanding these factors can increase providers attention to adherence
46 Patient Variables Socio-demographic factors Generally, socio-demographic factors do not predict adherence behavior Some studies reported the following correlates of poor adherence 1-4 Female sex Non-white race Younger age Lower income Lower literacy 1. Kleeberger CA, et al. JAcquir Immune Defic Syndr Weidle P, et al.. J Acquir Immune DeficSyndr Valdez L, et al. Arch Intern Med Gifford A, et al. J AcquirImmune Defic Syndr 2000.
47 Patient Variables (2) Psychosocial factors: Consistent associations are found between certain psychosocial factors and adherence behavior Common predictors of non-adherence include: Depression/psychiatric illness 1 Active alcohol and substance use 1 Lack of perceived efficacy of ART 2 Lack of social support 1 Lack of knowledge 1 1. Ickovics, J. and Christina S. Meade, C. JAIDS 2002; 2. Horne R, et al. 39th ICAAC, 1999;.
48 Treatment Regimen Treatment regimen factors include: The number of pills prescribed (pill burden) The complexity of the regimen (dosing frequency, ease of administration, food instructions, etc) The short- and long-term medication side effects Cost and access to medications Degree of behavioral change required
49 Disease Characteristics Disease characteristics include: The stage and duration of HIV infection Associated opportunistic infections HIV-related symptoms Reported predictors of poor adherence include: Lack of advanced disease 1 Lack of prior experience with opportunistic infections 2 1. Wenger N, et al. 6th Conference on Retroviruses and Opportunistic Infections, Singh N. et al. AIDS Care 1996.
50 Patient Provider Relationship The patient-provider relationship may influence adherence through: Patient's overall satisfaction and trust in the provider Patient's opinion of the provider's competence Provider's willingness to include the patient in treatment decisions Tone of the relationship (warmth, openness, cooperation, etc) Adequacy of referrals
51 Relationship Between Adherence and HIV Suppression * Series of 886 treatment-naive HIV patients; CD4 cell count <500 x 10 6 cells/l or plasma viral load >5000 copies/ml. 1. Low-Beer S et al. JAIDS. 2000;23: Letter. 2. Paterson DL et al. Ann Intern Med. 2000;133: Prospective, observational study of 81 HIV patients. MEMS, Medication Events Monitoring System.
52 Relationship Between Adherence and CD4 Cell Count Homer Study *1 * Observational and research study of 1522 ART-naive patients initiated on HAART; adherence was measured as prescriptions refilled. 1. Wood et al. JAIDS. 2004;35:
53 Barriers to adherence Patient Adherence Medicines Health Care System
54 Social care in HIV / AIDS out-patient department Social care specialist Uģis Lapiņš: partnership with physicians and medical nurses adherence to ART related issues for adult patients social care for HIV(+) children (getting them to physician, to monitoring and treatment) Chaplain Kristīne Vanaga Drama psychotherapy specialist Anna Šteina
55 New possibilities to improve adherence in HIV / AIDS Out-patient department Drama-therapy specialists Anna Šteina since November 2011 «Peer-to-Peer» consultations: by AGIHAS starting January 2011
56 Psychoterapy specialist support to HIV infected patients Psihotherapy specialist Dr.E.Krastiņš
57 HIV patient centered health care in Latvia
58 ARV therapy patients in Latvia by regions ( ) 7 a a 41
59 ARV therapy patients in Latvia by regional infectologists (uz )
60 HIVand TB co-infection in Latvia
61 AIDS indicatordiseases
62 Jaunie TB gadījumi uz iedzīvotājiem Registered new TB cases in Latvia Gads
63 Reģistrēto TB/HIV gadījumu skaits Registered HIV/TB cases Gads Kopējais skaits t. sk. multirezistenta tuberkuloze
64 HIV/TB and ART ART + ART - Kopā (73%) (53%) (78%) (54%) (29%) (60%) (76%) (64%) 30 74
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