HIV Symposium

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HIV Symposium

• HIV Basics
• Primary Care of HIV Patients
• Jess Fogler, MD
• National HIV/AIDS Clinicians Consultation Center

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HIV Basics

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HIV Clinical Course
Primary Infection
Seroconversion
Intermediate Stage
AIDS
CD4 Cell Count
Plasma RNA Copies
1,000
CD4 Cells
500
1-8 Weeks
Years
Apx 2-3 Years
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HIV Testing

• HIV antibody test the ONLY test for diagnosis
  ELISA, IFA, western blot
• 30 days 50 sensitive
• 90 days 95
• 6 months 99.9
• HIV viral load bad test for diagnosis
• False positives common
• Some people with HIV have undetectable VL
• USE THIS TEST for diagnosis of ACUTE HIV

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Antiretroviral Medications

• HAART highly active antiretroviral therapy
• ARV Antiretroviral medication
• Usually a combination of 3 or more drugs
• 4 classes
• NRTI (AZT, 3TV, TFV, ABC)
• NNRTI (EFV/NVP)
• PI (NFV,Kaletra)
• Fusion inhibitors (T20)

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Anti-retroviral Medications

• Combination pills
• Combivir (CBV) AZT 3TC
• Trizivir (TZV) AZT 3TC ABC
• Truvada FTC TFV
• Epzicom 3TC ABC
• Kaletra Lopinavir/ritonovir

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Drug Sites of Action
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ARV Regimens

• Usually
• 2 NRTIs (NRTI or NNRTI or PI)
• Examples
• AZT/3TC ABC
• d4T/3TC EFV
• ddI/TFV Kaletra

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Goals of Therapy

• Undetectable viral load
• Expect
• 1 log decrease in 1 month
• Complete suppression by 6 months
• CD4 count increased (esp. above 200)
• Improved quality of life
• Less illness, death

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Treatment Failure

• Detectable viral load after 6 months of Rx
• Pt not taking medications
• Pt has resistant virus
• Regimen not potent enough
• Not absorbing (chronic diarrhea)

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Adverse Drug Reactions

• All ARVs are toxic to the liver
• Most can cause GI upset
• Remember
• AZT anemia
• ABC hypersensitivity reaction
• NNRTI rash
• PI metabolic syndrome (lipids, glucose)

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Starting ARVs

• When to Start most clinicians rely on CD4
• CD4 350 Treat if symptoms of HIV
• Fatigue, weight loss, LAD, difficult to treat OIs
• CD4 200-350 Offer treatment weigh R/B
• CD4
• AND
• Patient interested
• Patient can be adherent

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OIs and Complications
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OI Primary Prophylaxis
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D/Cing Prophylaxis

• Generally ok if CD4 cutoff for 3-6 months
  (after successful treatment of OI)

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Primary Care of HIV Patients

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Goals

• What do we need to know about our HIV patients
  to manage their disease effectively?
• history
• physical exam
• lab tests
• immunizations
• health care maintenance

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The First Visit

• Establish a relationship
• Stage the disease
• Social hx disclosure
• PE
• Baseline labs

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Staging of HIV

• Where is this patient in the natural history of
  the disease?
• symptomatic HIV/AIDS, or
• a chronic asymptomatic illness

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Past Medical History

• HIV medical history
• Date of diagnosis
• HIV risk factors
• Lowest CD4 count
• Current CD4 and viral load
• ARV history

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Past Medical History

• HIV-related medical history
• OIs or AIDS defining illnesses
• Other STDs
• TB exposure
• Chickenpox or shingles
• Women hx abnl PAPs, birth control method

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Current Symptoms

• General fatigue, malaise, fever, sweats, wt loss
• Visual any changes
• Oral ulcers, thrush
• GI N,V, diarrhea
• Pulmonary cough
• Skin rash, lesions
• Gyn vaginitis
• Neuro mood, mental status, neuropathy

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Social History

• IVDU, other drugs
• Sex practices, sexual orientation
• Living situation/means of support
• Support system
• Disclosure
• Travel
• Pets

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Physical Exam

• Weight
• Skin
• Fundoscopic
• Oral exam
• Lymph nodes
• GU/anal
• Neurologic

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Initial Lab Studies

• Document HIV status!
• CD4 count and viral load
• Baseline CBC, chem panel, BUN/Cr, LFTs
• RPR
• PPD
• Viral Hepatitis panel
• Toxoplasma antibody
• In certain groups
• CMV, G6PD
• Glucose, lipids
• Testosterone

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HIV Intake Sheet

HIV History Date HIV dx Date AIDS dx Est.
date infection Lowest CD4/date Highest
VL/date Current CD4/date Current VL/date HIV
Risk Factors ? MSM ? IDU ? Hetero sex
? Transfusion ? Perinatal ? Unk OI
History ARV hx Date Regimen Clinical
info
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HIV HCM Flow Sheet

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HIV HCM Flow Sheet

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Follow Up Visits

• If healthy follow up every 3-6 months
• Check interval symptoms
• Risk assessment, prevention of transmission
• Begin discussion of ARVs early

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Follow Up Labs

• CD4, VL every 3 months
• If on meds
• CBC, chem panel, LFTs q 3mo
• If on PIs fasting glucose and lipid panel
• PPD q 6-12 months
• RPR q 6-12 months
• Pap smear q 6-12 months
• Anal paps q 6-12 months

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Immunizations

• Best to give when immune system strongest
• Pneumovax once, then repeat in 5 years
• Flu every year
• Hepatitis A and B series, then check titer
• Tetanus every 5-10yrs
• Live Vaccines ok to give for pts with good
  immune system (ie CD4 200)
• MMR
• Varicella
• Yellow fever
• OPV

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TB screening and treatment

• Patients with HIV more susceptible to TB at all
  stages of disease
• Screening
• PPD q 6-12 mos
• 5mm is positive
• Anergy possible with very low CD4 counts
• HIV is an indication for treatment of latent TB
• INH 300mg/d x 9 mos
• Pyridoxine 25mgd

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Cervical cancer screening

• Women with HIV more likely to get cervical
  dysplasia/cancer and more rapidly progressive
• Pap q 6 mo x 2, the q yr if nl
• F/u abnl results with colpo etc..
• Anal Paps/vulvar Papscontroversial

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Referrals

• Nutrition
• Ophtho CD4
• Substance abuse treatment
• Mental health
• Social Work
• Case Management

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Multidisciplinary Team

• Medical Staff
• Case manager
• Social Worker
• Pharmacist
• Nutritionist
• Substance abuse counselors
• Psych
• Warmline

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Internet Resources

• www.hivatis.org access to key federal and other
  clinical guidelines
• www.cdc.gov clinical guidelines for HIV, other
  blood-borne pathogens and STDs
• www.hivinsite.ucsf.edu comprehensive website with
  access to wide range of resources
• www.ucsf.edu National HIV/AIDS Clinicians
  Consultation Center