1. HIV
Older Patients, Women,
Perinatal Transmission
and Drug/Drug
Interactions
Danielle Gill, PharmD, MPH

2. Objectives
 Facts on Newly Diagnosed Older Patients
 Older Adults Adherence
 Women HIV Guidelines
 Perinatal, Intrapartum and Postpartem HIV
Guidelines
 Drug/Drug Interactions

3. Newly Diagnosed Older Patients:
Facts The proportion of older adults who are exposed to HIV through male-
to-male contact and injection drug use decreases with older age
groups. Exposure to HIV with heterosexual contact increases with
age
 Over 30% of persons with HIV are > age 50
 Sexual contact is the most common risk factor; IV drug use is next
 Heterosexual contact accounts for the most rapid growth in infection.
 Older adults who participate in risky behaviors are less likely than
younger adults who have the same risky behaviors to use HIV/AIDS
prevention methods

4. Clinical Question �
Relative to their younger counterparts,
elderly people diagnosed with HIV:
A. Have a shorter survival rate
B. Have fewer opportunistic infections
C. Have a less severe disease course
D. Have longer AIDS free survival intervals

5. Newly Diagnosed Older Patients
Relative to their younger counterparts, older adults living
with HIV/AIDS
have a more severe HIV disease course and a shorter survival rate;
have less desirable health indices at diagnosis (e.g., lower CD4+ cell
counts);
have shorter AIDS-free intervals;
have a higher number of opportunistic infections and
have earlier development of tumors and lesions

6. Newly Diagnosed Older Patients:
Guidelines
 Older persons experience earlier development of conditions
associated with aging, such as cardiovascular disease and
neurocognitive impairment
 Older persons may have dampened immunologic responses to ART.
ART initiation in older persons should not be delayed.
 Current Guidelines recommend ART for all patients older than 50
years of age.
 The efficacy, pharmacokinetics, adverse effects, and drug interaction
potentials of ART in the older adult have not been studied
systematically

7. Older Adults: Risky Behavior
 Older adults are less likely to use a condom as a form of protection
 Infection rate of older women surpasses older men, sexually active older
women who do not fear pregnancy and do not know about the risk of HIV
infection may not insist on using a condom
 Older women who were infected through heterosexual contact were less
likely to have been tested for HIV
 Many older men who have sex with men engage in practices that put them
at risk
 Older adults who use condoms may not know how to store them properly

8. HIV and Older Women
 The number of older women with HIV
infection is expected to increase for two
reasons:
 the rate and incidence of new infections in this
age group are increasing,
 And women already in care for HIV infection are
expected to live longer due to improved ART and
other treatment advances.

9. Treatment Experienced Patients
 Nearly 25% of patients on ART are not virologically suppressed
 Failure of virologic suppression often results in resistance mutation
 Failure of first line regimens is usually caused by
1. suboptimal adherence
 patient factors
2. transmitted drug resistance
 ARV regimen factors

10. Clinical Question: �
What are some ways to monitor
adherence in older patients with HIV?
A. Pill counting
B. Checking Refill records
C. Checking viral loads (labs)
D. All of the above

11. Adherence and the Older Patient
Combination of these measurements is best
Pill count
Self report
Measurements of Viral Load (lab)
Measurements of therapeutic drug levels
Direct observed therapy
Refill records

12. Adherence and the Older Patient
 Medication adherence >60 years old ranges from 26%-68%
 Strongly related to factors related with aging (ie. Polypharmacy, cognitive
and physical limitations, social isolation, and access to medication)
 Unstable housing is directly correlated with non adherence
 Older AA men are less likely to be adherent then older white men
 Perceptions that ART is effective and nonadherence of medications lead to
viral resistance predicts higher adherence
 Men aged 50-67 years old listed the following reasons for nonadherence:
side effects, busy schedules, fatigue, stigmatization of HIV

13. HIV Infected Women: Guidelines
 The indications for initiation of antiretroviral therapy (ART) and the goals of
treatment are the same for HIV-infected women (AI).
 Women taking antiretroviral (ARV) drugs that have significant
pharmacokinetic interactions with oral contraceptives should use an
additional or alternative contraceptive method to prevent unintended
pregnancy (AIII).
 Women of childbearing potential should undergo pregnancy testing before
initiation of efavirenz (EFV)
 Alternative regimens that do not include EFV should be strongly considered
in women who are planning to become pregnant or sexually active and not
using effective contraception (BIII).

14. HIV Infected Women
 Hormonal contraception
 Conflicting data; when drug interactions with ART occur, additional contraceptive
methods should be recommended
 Metabolic complications
 More likely to experience increases in central fat with ART, less likely to
have TG elevations
 More likely to have osteopenia/osteoporosis after menopause
 Lactic acidosis
 Female predominance with prolonged NRTI use (stavudine, didanosine,
and zidovudine)
 Nevirapine-associated hepatoxicity
 Increased risk of rash-associated liver toxicity in ARV naïve individuals
 Women with CD4>250cells/mm3 or elevated transaminases are
at greatest risk

15. Clinical Question: �
A treatment naïve, pregnant women comes into
your clinic and has just been diagnosed with HIV.
She is in her 1st
trimester. What is a reasonable
regimen to begin while waiting for resistance
results ?
A. TDF/FTC + ATV/r
B. ABC/3TC + ATV/r
C. EVG/cobi/TDF/FTC
D. TDF/FTC + T20

16. Treatment Naïve Pregnant
Women: Guidelines
 The same regimens as nonpregnant adults should be
used in pregnant women (AIII)
 Multiple factors must be considered when choosing a
regimen for a pregnant woman including comorbidities,
convenience, adverse effects, drug interactions,
resistance testing results, pharmacokinetics (PK)(AII)
 PK changes may lead to lower plasma drug levels of
drugs and necessitate increased dosages, more frequent
dosing, or boosting, especially of protease inhibitors. (AII)

17. Treatment Naïve Pregnant
Women: Guidelines
 All HIV-infected pregnant women should receive a potent
combination ARV regimen (AI)
 The decision as to whether to start the regimen in the
first trimester or delay until 12 weeks’ gestation will
depend on CD4 count, HIV RNA levels, and maternal
conditions. (AIII)
 Earlier initiation of a combination ARV regimen may be
more effective in reducing transmission,
 Fetuses are most susceptible to potential teratogenic effects in
the first trimester.

18. Initial ART Recommendations:
Treatment naïve pregnant women
Preferred regimens for the treatment of ART-naive HIV-
infected pregnant :
A dual NRTI combination (abacavir/lamivudine,
tenofovir/emtricitabine or lamivudine, or
zidovudine/lamivudine)
+ either a ritonavir-boosted protease inhibitor
(ritonavir-boosted atazanavir or ritonavir-boosted lopinavir)
or an NNRTI (efavirenz initiated after 8 weeks of
pregnancy). (AIII)
Refer to Antiretroviral Drug Resistance and
Resistance Testing in Pregnancy

19. Initial ART Recommendations:
Treatment naïve pregnant women
Preferred 2-NRTI Backbone Regimens

20. Initial ART Recommendations:
Treatment naïve pregnant women
Preferred PI Regimens

21. Initial ART Recommendations:
Treatment naïve pregnant women
Preferred NNRTI Regimen

22. Clinical Question: �
 A known HIV positive, treatment
naïve, mother comes into the hospital
to give birth. Which ART is
recommended to be given before birth
to help prevent perinatal HIV
transmission? Why?
A. Didanosine
B. Zidovudine
C. Efavirenz
D. Darunavir

23. Intrapartum ARV Therapy/Prophylaxis
 Women should continue their antepartum combination
ARV drug regimen on schedule as much as possible
during labor and before scheduled cesarean delivery.
(AIII)
 Intravenous (IV) zidovudine should be administered to
HIV-infected women with VL >1,000 copies/mL (or
unknown VL) near delivery (AI),
 In nonrandomized studies of women on cART, addition of
intrapartem AZT appears to reduce risk of perinatal transmission

24. Clinical Question: �
A newborn baby with an HIV positive
mother was just transferred into the
NICU. How soon should the baby begin
receiving ART?
A. Immediately
B. In 6 months
C. After the baby is done breastfeeding
D. Within the first year

25. Infant ART Prophylaxis:
Guidelines The 6 week neonatal component of the AZT prophylaxis regimen is
generally recommended for all HIV exposure neonates to reduce
perinatal transmission of HIV (AI).
 Zidovudine, at gestational age-appropriate doses, should be initiated
as close to the time of birth as possible, preferably within 6 to 12
hours of delivery (AII).
 Infants born to HIV-infected women who have not received cART
should receive prophylaxis with zidovudine given for 6 weeks
combined with three doses of nevirapine in the first week of life (i.e.,
at birth, 48 hours later, and 96 hours after the second dose), begun
as soon after birth as possible (AI).
 The National Perinatal HIV Hotline (1-888-448-8765) provides free
clinical consultation on all aspects of perinatal HIV, including infant
care.

26. Neonatal ART Drug Dosing: Guidelines
Zidovudin
e (ZDV)
Dosing Duration
≥35 weeks’ gestation at birth:4 mg/kg/dose PO twice
daily, started as soon after birth as possible and
preferably within 6–12 hours of delivery (or, if unable to
tolerate oral agents, 3 mg/kg/dose IV, beginning within 6–
12 hours of delivery, then every 12 hours)
Birth through 4-6
weeks
≥30 to <35 weeks’ gestation at birth:2 mg/kg/dose PO (or
1.5 mg/kg/ dose IV), started as soon after birth as
possible, preferably within 6–12 hours of delivery, then
every 12 hours, advanced to 3 mg/kg/dose PO (or 2.3
mg/kg/dose IV) every 12 hours at age 15 days
Birth through 6
weeks
<30 weeks’ gestation at birth:2 mg/kg body weight/dose
PO (or 1.5 mg/ kg/dose IV) started as soon after birth as
possible, preferably within 6–12 hours of delivery, then
every 12 hours, advanced to 3 mg/kg/dose PO (or 2.3
mg/kg/dose IV) every 12 hours after age 4 weeks
Birth through 6
weeks
All HIV-Exposed Infants
*initiate as soon as possible after delivery*

27. Drugs that Interact with ART
NRTI Drugs that Interact
Tenofovir (TDF) Ambien, didanosine, acyclovir,
ganciclovir, valacyclovir, NSAIDS,
vancomycin
Abacavir (ABC) EtOH, Amitriptyline, Fluconazole,
Isoniazid, NSAIDS, Phenobarbital
Lamivudine (3TC) Cimetidine, Ethambutol, TMP/SMX
Zidovudine (ZDV, AZT) Antineoplastics, Methadone,
Fluconazole, Pentoxifylline,
Rifampin, TMP/SMX
Didanosine (ddl) EtOH, Antineoplastics,
Ketoconazole, Methadone,
Tetracyclines
Stavudine (d4t) Cisplatin, Disulfiram, TMP/SMX,
Vincristine
Zalcitabine Antacids, Cimetidine, Cisplatin,
Disulfiram, Phenytoin, Probenecid

28. Drugs that Interact with ART

29. Drugs that Interact with ART

30. Clinical Question: �
Which of the following drugs interact with
protease inhibitors and needs to be monitored?
A. Nicardipine
B. Voriconazole
C. Simvastatin
D. All of the above

31. Drugs that interact with all PIs

32. Drugs that interact with ART

33. Drugs that Interact with ART

34. Drugs that interact with ART
Fusion Inhibitor Drugs that interact
Enfuvirtide

35. Drugs that interact with ART
PK Boosters Drugs that interact
Ritonavir Amiodarone, atorvastatin, benzos,
bupropion, clarithromycin, diltiazem,
piroxicam, quinidine, zolpidem
Cobicstat (cobi)
*potent inhibitor of CYP450 3A4 and
2D6*
Rifampin, dihydroergotamine,
cisapride, St. John’s Wort,
lovastatin/simvastatin, pimozide,
triazolam, oral midazolam

36. Key Points
 Older patients are less likely to be screened for HIV and more likely to
experience severe side effects from ART
 HIV infected women on hormonal contraceptives should be monitored and
use back up methods
 Efavirenz should not be prescribed in HIV infected women who are trying to
become pregnant
 Protease Inhibitors have multiple drug/drug interactions
 Many drugs used prophylactically against opportunisitic infections have drug
interactions with ART, monitor carefully!
 IV Zidovudine is recommended 3 hours before labor for HIV positive,
treatment naïve mothers or mothers with viral loads over 1000

37. References
 http://www.med.unc.edu/aging/elderhiv/infected.htm
 http://www.hivguidelines.org/clinical-guidelines/womens-health/medical-
care-for-menopausal-and-older-women-with-hiv-infection/
 http://www.avert.org/antiretroviral-drugs-side-effects.htm
 Assessment and Predictors of ART Adherence in Older HIV Infected
Patients. Wutoh, AK, Elekwachi, O., Clarke-Tasker, V., Daftary, M., Powell,
NJ., Campusano, G. Journal of Acquired Immune Deficiency Syndromes.
33: S106-S114. 2003
 http://www.hiv-druginteractions.org/Interactions.aspx
 Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-
Infected Women for Maternal Health and Interventions to Reduce Perinatal
HIV Transmission in the United States. Aidsinfo.nih.gov.guidelines

38. AETC Contact Information
 Pennsylvania/MidAtlantic AETC
 Website: www.pamaaetc.org
 Phone: 412-624-1895
 Consultation: 888-664-AETC
 National Clinician Consultation Service
 800-933-3413
 PEP Line
 888-448-4911
 Linda Frank, PhD, MSN, FAAN, ACRN
 412-624-9118
 frankie@pitt.edu