Upload
hangoc
View
217
Download
0
Embed Size (px)
Citation preview
Dr Steve Taylor, MB ChB, PhD, FRCPConsultant Physician Sexual Health HIV Medicine
Lead Consultant HIV Services Birmingham Heartlands Hospital
Voluntary Work: Medical Director Saving Lives Charity
twitter@HIVheartlands twitter @savinglivesuk
HIV UPDATE
Learning Objectives:1. Where is our Service?
2. How common is HIV : Nationally and Locally?
3. What is the life expectancy of people living with HIV today?
4. What is HIV Viral Load test?
5. How do you interpret CD4 Counts?
6. ARV Drug interactions: what you need to know?
7. Can ARV Treatment Prevention transmission?
8. Does PREP Pre exposure prophylaxis work?
9. How to Test for HIV?
10. When to test HIV? Ten Top Tips
11. How to refer
Learning Outcomes 1. Our Service: Heartlands HIV Service: HIVBirmingham.nhs.uk
2. Nationally 100,000 and Locally 4000 1-3/1000, 1:5 Undiagnosed, Unaware and at risk serious Morbidity & Transmission
3. Life expectancy: Normal on effective ART and early diagnosis
4. Viral Load: Infectiousness and Effectiveness of ART: AIM <50
5. CD4 Counts: Health and Risk of Infections: AIM >350
6. ART Drug interactions: Will happen- HIVdrugInteractions.org or HIV Pharmacists
7. ARV Treatment Prevents Sexual Transmission, MTCT
8. PREP Pre-exposure prophylaxis works
9. Please normalise, recommend and Test for HIV
10. When to test : ”Flu without coold” GF-Rash, Weight loss & blood tests, Hep B & C, SOB Cough &▲RR, Oral thrush & Indicator Conditions , MSM, Africans, PWIDS, Return travellers and those with STIs
11. To refer? Please just call HIV CNS’s or HAs
• Based within the Directorate of Infection Heartlands Hospital
• We currently look after over >1200 HIV positive patients
• Inpatient and outpatient service , 24h on ID call
• Very strong multi-disciplinary ethos
• Regional Paediatric HIV Service
• The National Military HIV Service
• Regional Infectious Diseases Service
• Immunology and Allergy
• Regional TB service
• Viral Hepatitis Service
• Have an active research portfolio
• Have a co-located Umbrella sexual health satellite clinic at Hawthorn House
How common is HIV : Nationally and Locally?
By the end of 2012, an estimated 98,400 people were living with HIV in the UK
21,900 are estimated to be unaware of their infection –22% of the total
6,360 new diagnoses in UK in 2012, increase on 6,220 in 2011
DID YOU KNOW?
–25% of people living with HIV in the UK do not know they have it1
1. HIV in the United Kingdom: 2011 Report. http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1317131679504. Accessed July 2012.2. HV Testing Action Plan: Second edition 2012.http://www.nat.org.uk/media/Files/Policy/2012/May-2012-Testing-Action-Plan.pdf Accessed July 2012
–25% of those unaware of their diagnosis are
responsible for 50% of new transmissions2
What is Shopshire prevelence?Diag Prev/1000 15-60 2009
Undiagnosed Prev
Undiagnosed Prevalence of other conditions
Birmingham(HOBPCT)
3.3 1.1 1 in 900 SLE in black female 1 in 5000
Coventry 2.7 0.9 1 in 1100 Inflamatory bowel disease 1 in 800
Birmingham(South)
1.9 0.63 1 in 1600 Polymyositis 1 in 25000
Sandwell PCT 1.76 0.59 1 in 1700 Homozygous for alpha one antitrypsin def 1 in 1500
Shopshire County
0.53 0.18 1 in 5550
Lambeth 13.8 4.6 1 in 220 T1 DM 1/300
Ethnic group and Sexuality determines likelihood of a positive result
• White 1 in 1000
• Black Caribbean/BB 1 in 200
• Black African 1 in 25
• Gay Men 1-10/ 1-20
• HIV prevalence by ethnic group in UK 2007 age 15-59
13
CD4 count – useful guide
CD4 Count cells/µl
Risk of (opportunistic) infection Risk of HIV associated tumours
>500 None/minimal V small
200-500 Little risk (except TB) Bacterial pneumoniaDermatological manifestationsHerpes (zoster/simplex)Oral thrush
Small:Kaposi’s SarcomaNon Hodgkins Lymph.
<200 PCPToxoplasmosisOesophageal candidiasis
Increasing risk of a number of tumours
<50-100 Atypical mycobacterium (MAI)CMV Cryptococcal meningitis
High risk/aggressive tumours
Primary HIV Infection: Common Signs & Symptoms
44
52
55
57
59
74
86
0 10 20 30 40 50 60 70 80 90 100
adenopathy
pharyngitis
headache
rash
diarrhoea
lethargy
fever
N = 160 patients with PHI inGeneva, Seattle, and Sydney
Vanhems P et al. AIDS 2000; 14:0375-0381.
% of patients
21
40
45
10
15
24
0 20 40 60 80 100
transaminitis
leukopenia
thrombocytopenia
genital ulcers
oral ulcers
aseptic meningitis
Primary HIV Infection: Other Signs & Symptoms
Kahn JO, Walker BD. N Engl J Med. 1998;339:33-39.
% of patients
THE WINDOW PERIOD
Infected but test reads Negative
Time of Infection
The earliest timea test could read
positive
The majority oftests will be
positive
All tests will be positive
D
Infected and the test reads POSITIVE
C B
Infected but the test reads NEGATIVE
A
Window Period
Incubation Time
Cost of late HIV diagnosis
• To the individual [lifetime treatment costs between £280K and £360K]
• increased morbidity: both short and longer term prognosis –increased risk of developing opportunistic infections
• 10x increased mortality for late diagnosed (90% of deaths 2000-09)
• To the wider community• increased community viral load / unchecked risk behaviours
• increased onward transmission (over 50% new infections from undiagnosed who are 3 times more likely to transmit the virus)
• To the NHS [50% of the annual £1.8bn spend on infectious diseases / £14K per patient]
• short term treatment costs .. 2x higher treatment costs in first year
• longer term treatment costs .. 50% higher treatment costs
17
Do people with undiagnosed HIV use primary care ?
A study of newly diagnosed HIV-positive Africans found:
Over 84% were registered with a GP:• 76% had seen their GP in the year prior to diagnosis• In 17% of those, the issue of HIV or HIV testing was raised
Burns et al (2008)
What symptoms and conditions are associated with HIV infection?
Recognising HIV indicator conditions
HIV indicator conditions
Conditions where HIV testing should be offered
Dermatology Severe or recalcitrant:Seborrhoeic dermatitisPsoriasisMultidermatomal or recurrent herpes zosterHerpes simplexKaposi’s sarcomaMolluscumFolliculitis
HIV indicator conditions
Conditions where HIV testing should be offered
Gastroenterology Oral candidiasisChronic diarrhoeaWeight loss of unknown causeRecurrent / persistent aphthous ulcersKaposis sarcomaOral hairy leukoplakiaGingivitisSalmonella, Shigella or Campylobacter[Hep B infection & Hep C infection because of shared transmission risks]
HIV indicator conditions
Conditions where HIV testing should be offered
Respiratory Bacterial pneumoniaAspergillosisTBPneumocystisKS can affect the lung
24
HIV indicator diseases
Conditions where HIV testing should be offered
Neurology Peripheral neuropathy
Aseptic or atypical encephalitis/meningitis (eg cryptococcal)
Encephalopathies (eg progressive multifocal leucoencephalopathy)
Space-occupying lesions: unknown origin / lymphoma / abcess
Guillain-Barré syndromeTransverse myelitis
25
HIV indicator diseases
Conditions where HIV testing should be offered
OphthalmologyInfective retinal diseases: including herpes viruses, CMV, Toxoplasma
Any unexplained retinopathy
HIV indicator diseases
Conditions where HIV testing should be offered
Gynaecology Cervical intraepithelial neoplasia grade 2 or above
Vaginal intraepithelial neoplasia
Hard to treat genital candidaHard to treat genital warts / also genital molluscum / Atypically severe herpes
ALL patients with an STI should be offered an HIV test!
27
HIV indicator diseases
Conditions where HIV testing should be offered
Haematology
Oncology
Any unexplained blood dyscrasia:Thrombocytopenia,Neutropenia,Lymphopenia, Anaemia
[And tumours below]
Anal cancer or anal intraepithelial dysplasiaLung cancerHead and neck cancerHodgkin’s lymphomaNon Hodgkins lymphomaCervical cancer – as before
Diagnostic catches for GPs
Many HIV-associated conditions… •are common•are considered benign•will respond, in the short term, to treatment
‘Watch and wait’ is NOTa good strategy for HIV!
What conditions are urgent?
• PCP/ PJP (and perhaps other respiratory conditions)
• Neurological problems
• Some tumours
• CMV retinitis
Ask about weight loss; sweats; diarrhoea.
Examine mouth; skin; nodes.
Review notes for HIV related conditions in
the last 3 years. [General Practice is THE place where all these individual episodes can be put together]
Discuss with the patient ie introduce the
subject and do a risk assessment.HIV in Primary Care (Madge at al 2011)
Is my patient immunosuppressed ?
2002 GP: Oral cold sores
2003 GP: Chest Infection “Smoker”GP: Shingles GP: Chest Infection Weight Loss ? Hospital Admission: Bacterial PneumoniaDentist: Sore Mouth Biopsy ? Thrush GP: Diarrhoea and weight Loss Referred Hospital: Ix for persistent diarrhoea, colonoscopy normal
2004 Re-referred Hospital: Anorexia, wt loss, indigestion, sore mouth Barium meal normal, coeliac ?
2005 GP: Chest infection, oral candida, molluscum face & arms, HSV, perianal warts
Margaret’s HistoryMissed Opportunities
2014 2015
Pict
ure
s sh
own w
ith p
atie
nts
per
mis
sion
to
Dr
S T
aylo
r
Pict
ure
s sh
own w
ith p
atie
nts
per
mis
sion
to
Dr
S T
aylo
r
If the clinical picture is worrying…
…you should still offer a test, even if the patient is at no apparent risk of having HIV:
‘From what you tell me you are at very low risk of having HIV.
Can I suggest that we do a test anyway - in order to rule it out?’
Studied over 1700 couples: •One HIV pos one HIV neg (‘HIV disconcordant’)•HIV positive person also had CD4 count above threshold for treatment (above 350)
Randomised to: earlier-than-usual treatment, orno treatment
39 HIV-1 transmissions occurred of which:•28 virologically linked with partner
Of the 28 linked transmissions•only 1 occurred in early treatment group
= 96% reduction!!
Those on early ART also fared better clinically:- fewer severe events, fewer deaths
THINK TALK TEST: What can you do?
–Don’t be afraid to discuss HIV with your patients
–Share your knowledge with those around you and help to dispell the myths surrounding HIV
–By helping to destigmatise the disease you can enhance the patient journey
–Speak with you local HIV specialist if you have any questions or concerns
North Africa and Middle EastSub-Saharan Africa
North AmericaSouth and Latin America
CaribbeanWestern and Central Europe
Eastern Europe and Central AsiaSouth and South East Asia
East Asia (eg China)Oceania
Which 3 world regions have thehighest adult prevalence of HIV?
Rank your choices in order of prevalence
7 New HIV diagnoses and number of persons accessing HIV care in the United Kingdom: 2012
Distribution of new HIV diagnoses by world region of birth: United Kingdom, 2003-2012
7,408 7,786 7,928 7,498 7,388 7,273 6,676 6,362 6,219 6,364
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Perc
enta
ge o
f HIV
dia
gnos
es
Year of first HIV diagnosis in the UK
UK Rest of Europe Africa Asia Australasia The Americas
*Excludes 13,899 cases diagnosed 2003-2012 where country of birth is not reported
Defined by who should have started treatment already.ie when CD4 count below 350 cells/mm3
In 2012, 47 % of new diagnoses in the UK were diagnosed late
They were ten times more likely to die within a year of diagnosis
Also •Higher risk of permanent disability•Acute serious illnesses•Slower response to treatment•Onward transmission of infection
Definition of late diagnosis
Prompt¹ and late² HIV diagnosis in black Africans and black Caribbeans with associated one-year mortality: UK, 2003 - 2012
¹Prompt diagnosis: CD4 count ≥350 cells/mm³ within three months of diagnosis²Late diagnosis: CD4 count <350 cells/mm³ within three months of diagnosis
Late diagnosis of HIV represents
a missed opportunity to protect
life and health…
..and to prevent transmission
Late HIV diagnoses and First AIDS diagnosis* by exposure group: UK, 2012
* Within three months of diagnosis
Do people with undiagnosed HIV use primary care ?
A study of newly diagnosed HIV-positive Africans found:
• 50% presented with late stage disease
• 37% had a previous negative test
Over 84% were registered with a GP:• 76% had seen their GP in the year prior to diagnosis• In 17% of those, the issue of HIV or HIV testing was raised
Burns et al (2008)
51
HIV is an entirely preventable andhighly treatable infection
…..but we are missing it
SHIP’s four approachesto HIV testing
Patient requestOpportunistic testing
of those at risk
Diagnostic testing of those with symptoms
The UK national guidelines for testing advocate the offer and recommendation to accept an HIV test to all adults registering in general practice and general medical admissions patients in areas where diagnosed HIV prevalence is greater than 2 per 1,000 population.
Prevalence of diagnosed HIV infection, UK: 2009
HIV screening
• Patient Request • Clinic posters
• Opportunistic Screening• STIs /terminations/ contraception• Travel • Hepatitis B & C• PWIDS• MSM / African/ Caribean
• Diagnostic testing of those with indicator conditions• See Saving Lives Flyer
• Screening when prevalence > 2/1000• All new GP registrants • All AMU / A and E admissions having bloods
First line therapy 1996 First line therapy 2012
Ritonavir (PI) x 6d4T x 2, 3TC x 2 (NRTIs)
TWICE A DAY
Efavirenz (NNRTI) + Truvada(= FTC + Tenofivir, NRTIs)
ONCE A DAY
Evolution of HIV Therapy
A fantastic resource……
• Proton Pump Inhibitors• Fluticasone• Some anticonvulsants• Statins• Clarithromycin, erythromycin• Benzodiazepines
• Contraception: UK Medical Eligibility Criteria 2009, Drug Interactions with Hormonal Contraception FSRHC Jan 2011 http://www.ffprhc.org.uk/
Key prescribing issues
Also
•Herbal remedies
•Recreational drugs
•More information available from:
www.hiv-druginteractions.org
Interactions