1. HIV Treatment: An Introduction
August 4, 2013
Dr. Joanna Eveland, MS, MD
HIV Medical Director, Clinica Esperanza
Mission Neighborhood Health Center

2. Objectives
• When, Why and What treatment to
start
• Overcoming side effects
• Working with your healthcare
providers to get the most out of
treatment

3. When to start?

4. 8/5/2013
10,000,000
1,000,000
100,000
10,000
1,000
100
10
HIV in plasma
(copies/mL) HIV in plasma (“viral load”)
800
500
200
100
50
0
CD4 Count
(cells/mL)
CD4 (T Cell) count
Months Years
Average progression without
treatment: 10 years from infection
to AIDS diagnosis
Source: HRSA HIV/AIDS Bureau

5. 2012 Treatment Guidelines
ART is recommended for all HIV+
individuals
• Strength of the recommendation
varies by CD4 count:
o CD4 count <350 (AI)
o CD4 count 350 to 500 (AII)
o CD4 count >500 (BIII)

6. 2012 Treatment Guidelines
Rating scale
A = Strong
B = Moderate
C = Optional
Rating of Evidence:
I = data from randomized
controlled trials
II = data from well-
designed
nonrandomized studies
with long-term
outcomes
III = expert opinion

7. 2012 Treatment Guidelines
Treatment encouraged for special
risk groups
• Pregnancy (AI)
• HIV-associated kidney disease
(HIVAN) (AII)
• Hepatitis B co-infection (AII)
• Older patients (>50) (BIII)

8. Why Treat Early?
Reduce Inflammation
Uncontrolled HIV might increase risk
of non-AIDS diseases:
• Heart disease
• Kidney disease
• Liver disease
• Dementia
• Cancers

9. Why Treat Early?
Treatment is Prevention
• Large 2011 studies showing 92-96%
decrease in HIV transmission with
treatment
• Guidelines say offer ART to all at risk
of transmitting HIV (AI [hetero] or
AIII [other risk groups])

10. Don’t start meds until…
• You feel ready
• You are well engaged in care
• You can commit to taking your meds
regularly
• You feel that other life factors and
potential barriers to adherence
(drugs, drama, mental health) are
under control

11. We have a long way to go…

12. What to start?

13. Where we started…
• D

14. Where we are now…
• D

15. Take Home Points
• HIV treatment continues to
improve- for the better!
• Each person’s combination of
medicines is different
• KNOW what you take, and why.

16. Know What You’re Taking
• HIV drugs have two, sometimes
three, different names
– Scientific name, brand name, chemical
name
– Zidovudine = Retrovir = AZT
• Some tablets contain more than
one ingredient
– Atripla = tenofovir + emtricitabine +
efavirenz

17. Goal of Treatment

18. General Principles
• Goals: less pills, less times/day, less side
effects
• Use at least 3 drugs, 2 classes of
medicines
• Sometimes 3 isn’t enough
– Your Protease Inhibitor may need a “Booster”
– Drug resistance usually = more pills

19. Treatment Principles:
Chinese Menu Metaphor
 “Two scoops of rice
plus chicken or beef”
In other words, usually
 2 “nukes”(NRTI) (2
scoops of rice) plus
– 1 partner drug (main dish)
 Protease Inhibitor
(beef)
 “non-nuke” NNRTI
(chicken)

20. The Drugs…
Each attacks the virus at a different point…

21. Where Do HIV Drugs Act?

22. NRTIs, “Nukes”

23. NRTIs Continued
• Backbone of treatment
• Older drugs are more toxic (AZT, “D-
drugs”)
– Peripheral neuropathy
– Lactic acidosis
– Pancreatitis
– Lipodystrophy
• Watch kidney function with
Tenofovir

24. NNRTIs, “Non-nukes”

25. NNRTI: Pros and Cons
 Ease (low pill burden)
 Well tolerated
 Less metabolic
effects
– No lipodystrophy, less
dyslipidemia
 Resistance develops
quickly if <95%
adherent
– Single mutation
– Cross resistance
among NNRTIs
 Rash; hepatotoxicity
ADVANTAGES DISADVANTAGES

26. Efavirenz considerations
• Most commonly prescribed NNRTI
• Neuropsychiatric side effects: vivid
dreams, sleep disturbance,
“spaciness”
• Caution for those with mental
health issues

27. Protease Inhibitors

28. PIs: Pros and Cons
• High potency
• Less susceptible to
resistance from
virus
• Second-line
therapy when
NNRTI fails
• Metabolic
complications
- Increased cholesterol,
blood sugar
• GI side effects
- Diarrhea, nausea
• Drug interactions
– Statins, viagra, anti-
seizure, many others
ADVANTAGES DISADVANTAGES

29. Integrase Inhibitor

30. Integrase Inhibitor
• Approved as first-
line regimen
• Less side effects
• Twice daily dosing
• Low barrier to
resistance
• Newer drug
• Drug interactions
ADVANTAGES DISADVANTAGES

31. Entry Inhibitors

32. Entry Inhibitors
• Currently used as salvage therapy
for those with drug resistance
• Fuzeon is injectable, rarely used
• Maraviroc is well tolerated, requires
CCR5 receptor on CD4 cells (not
everyone has this)

33. Side Effects
• Tend to be worst in the first 2 months
of therapy
• Severe side effects are a reason to
change medications
• Your expectations shape your
experience

34. Getting The Most Out of
Treatment

35. What If I Miss a Pill?
• Risk of resistance increases with
missing more than 1-2 doses/month
• If you miss a dose, try and learn
from it
• If stopping your meds
– All or none
– Let us know!

36. Working With Your Provider
• You deserve great
care
• Find the right fit
• Educate yourself
• Be engaged in care-
regular visits
• Uninsured? You can
still get care!

37. Focus on Wellness
• Manage stress
• Exercise regularly
• Quit smoking
• Reduce harmful drug or alcohol use
• Build a supportive community
• Define and achieve your personal
goals

38. Resources
• Project Inform: 1-800-342-2437,
• http://www.projectinform.org/
• AIDSmeds.com
• thebody.com
• HIVinsite.org
• www.aidsinfonet.org/

39. Thanks
• Drs Rick Loftus and Tri Do
• The advocates and activists who
gave us these treatments
• My patients

40. More Questions?
Dr. Joanna Eveland
Clinica Esperanza
240 Shotwell St., SF
(415) 431-3212 – Clinic Info
(415) 552-3870 # 303 –My extension
joannaeveland@mnhc.org