HIV treatment is::

Primary care with “benefits”

the scoop : :

• Guidelines Rule

• treat anyone who is willing

• compliance is KING

• beware of the drugs

DHHS Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected

Adults and Adolescents

www.aidsinfo.nih.gov

who to treat : :

• CD4 < 200, 350, 500, what next?

• treatment is prevention– serodiscordant couples– pregnancy

• think of the viral load of the community

who to treat::

Clinical Category CD4 Count Recommendation

AIDS defining illness or severe symptoms*

Any value TREAT

Pregnancy, HIVAN,tx HBV co-infection

Any value TREAT

Asymptomatic <350/mm3 TREAT

Asymptomatic 350-500/mm3 55% strongly 45% moderately

Asymptomatic >500/mm3 50% favored50% optional

*http://www.aegis.com/topics/definition.html

HPTN 052

who not to treat::

• anyone who is not going to take their medicine AKA: Non-compliance

It is really more like Why Not to treat

– when you know the details of a situation, the situation is unchanged. when you don’t know the details of a situation, it still is unchanged.

Zen proverb

how to treat::

• is this person sick? • No

how to treat::

• is this person sick?– CD4 < 200– CD4 < 50– Symptoms i.e. opportunistic infection

CD4 < 200

• At risk for PCP • GI symptoms?• Candidiasis?• Rash?• Needs meds as soon as ready

CD4 < 50

• This group of patients is TROUBLE• Must look for OI’s, frequently more than 1• IRIS is common• TB is bad in this group, skin test not reliable• 1/3 mortality in first year after diagnosis

what to use::

therapy naïve regimens::

• NNRTI based-regimen– efavirenz/tenofovir/emtricitabine

• PI based-regimens– atazanavir/ritonavir/tenofovir/emtricitabine– darunavir/ritonavir/tenofovir/emtricitabine

• Integrase Inhibitor based-regimen– raltegravir/tenofovir/emtricitabine

• Pregnancy– lopinavir/ritonavir/zidovudine/lamivudine

1. Fusion

2. Reverse transcription

3. Integration

4. Transcription

5. Assembly of virus particles

6. Budding of virus particles

how it works::

efavirenz• Category D, neural tube defects

– Recommend 2 birth control methods, negative HCG prior to initiation

• Caution with use in prior psychiatric disease• False + cannabinoid & benzos on screening• AEs: Drowsiness, dizziness, insomnia, abnormal

dreaming, agitation• Take at bedtime on an empty stomach to ↓CNS SE

• If need to eat, avoid taking with fatty food • Rash is possible, as long as no other symptoms keep

taking meds but need medical eval ASAP

efavirenz rash

efavirenz rash

tenofovir/emtricitabine ::

• Generally well tolerated: gas, headaches• Fanconi’s syndrome and renal insufficiency

• Check urinalysis every 6 months; PO4 suggested• Hyperpigmentation possible• Osteopenia • Active against HBV

• Know pt’s status and counsel accordingly• Once daily with or without food• Both agents need renal adjustment when <50ml/min

Fanconi’s Syndrome::

• The Fanconi syndrome refers to a generalized impairment in proximal tubular function leading to urinary wasting of compounds normally reabsorbed in the proximal tubule. The consequences are hypophosphatemia (which can lead to osteomalacia), renal glucosuria, hypouricemia, aminoaciduria, and proximal renal tubular acidosis due to bicarbonate loss in the urine (Up To Date).

Preferred Protease Inhibitors

atazanavir/ritonavir

• Interacts with PPIs, antacids, & H2A• All available OTC

• Increased unconjugated bili• Scleral icterus or jaundice

• Take with food• Less impact on lipids• Prolonged PR interval, asymptomatic 1st degree

AV block• 3 total: 1 atazanavir, 1 ritonavir, 1

tenofovir/emtricitabine

darunavir/ritonavir

• CAUTION with sulfa allergy (not contraindicated)• Take with food• Rash 10%• Abdominal pain• Headache• Hepatotoxicity• Diarrhea (usually less than Kaletra)• 4 tablets total: 1 ritonavir, 2 darunavir, 1

tenofovir/emtricitabine

preferred integrase inhibitor::

raltegravir::• Taken BID• Minimal drug interactions

• PPI increases raltegravir• AEs: diarrhea, nausea, headache, and pyrexia• Increased ALT, AST, CPK possible

• Myopathy and rhabdomyolysis reported• 3 tablets total: 1 raltegravir BID, 1

tenofovir/emtricitabine

compliance ::

• The tendency to yield to others especially in a weak or subservient way

• The strain of an elastic body expressed as a function of the force applied to it

• How many doses have you missed in the last month?

• How many have you taken late?

compliance ::

• How many doses have you missed in the last month?

• How many have you taken late?

• WHY?• How can we improve this?

compliance ::

• 95% compliance is MINIMUM required to receive maximal drug benefit

• 19/20 days or once per month for a once daily drug

• compare self-report to pill counts• works great with diabetes too

beware of the drugs::

bone disease::

• Osteoppenia• Avascular Necrosis• Vitamin D metabolism impacted• Osteoporosis down the road?

AVN on the left

energy metabolism complications::

• Lactic acidosis• Lipoatrophy• Fat redistribution• Hyperlipidemia• Glucose intolerance• Hypertriglyceridemia

Lipoatrophy

renal complications::

• Fanconi’s syndrome• Stone disease

Fanconi’s Syndrome::

• The Fanconi syndrome refers to a generalized impairment in proximal tubular function leading to urinary wasting of compounds normally reabsorbed in the proximal tubule. The consequences are hypophosphatemia (which can lead to osteomalacia), renal glucosuria, hypouricemia, aminoaciduria, and proximal renal tubular acidosis due to bicarbonate loss in the urine (Up To Date).

Fanconi’s labs::

• Creat 1.0 ->1.4->1.2• PO4 3.0 ->2.1->2.9

• Urine glucose 150-> neg• Urine protein 100 mg/dl-> neg

resources::

• consult with US – AFCAHN, phone, email• Guidelines• Warmline is AWESOME• Community providers