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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 ofAntiretroviral Agents in HIV-1-Infected        Adults and Adolescents         www.aidsinfo.n...
who to treat : :• CD4 < 200, 350, 500, what next?• treatment is prevention  – serodiscordant couples  – pregnancy• think o...
who to treat::Clinical Category          CD4 Count                  RecommendationAIDS defining illness or   Any value    ...
HPTN 052
who not to treat::• anyone who is not going to take their medicine        AKA: Non-compliance  It is really more like Why ...
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...
what to use::
therapy naïve regimens::• NNRTI based-regimen  – efavirenz/tenofovir/emtricitabine• PI based-regimens  – atazanavir/ritona...
how it works::1. Fusion2. Reverse transcription3. Integration4. Transcription5. Assembly of virus particles6. Budding of v...
efavirenz• Category D, neural tube defects   – Recommend 2 birth control methods, negative HCG     prior to initiation• Ca...
efavirenz rash
efavirenz rash
tenofovir/emtricitabine ::• Generally well tolerated: gas, headaches• Fanconi’s syndrome and renal insufficiency   • Check...
Fanconi’s Syndrome::• The Fanconi syndrome refers to a generalized  impairment in proximal tubular function  leading to ur...
Preferred Protease Inhibitors
atazanavir/ritonavir• Interacts with PPIs, antacids, & H2A   • All available OTC• Increased unconjugated bili   • Scleral ...
darunavir/ritonavir•   CAUTION with sulfa allergy (not contraindicated)•   Take with food•   Rash 10%•   Abdominal pain•  ...
preferred integrase inhibitor::
raltegravir::• Taken BID• Minimal drug interactions   • PPI increases raltegravir• AEs: diarrhea, nausea, headache, and py...
compliance ::• The tendency to yield to others especially in a  weak or subservient way• The strain of an elastic body exp...
compliance ::• How many doses have you missed in the last  month?• How many have you taken late?• WHY?• How can we improve...
compliance ::• 95% compliance is MINIMUM required to  receive maximal drug benefit• 19/20 days or once per month for a onc...
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 int...
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 ur...
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
Primary Care Perspective on HIV Treatment Bloomquist
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Primary Care Perspective on HIV Treatment Bloomquist

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Primary Care Perspective on HIV Treatment Bloomquist

  1. 1. HIV treatment is::Primary care with “benefits”
  2. 2. the scoop : :• Guidelines Rule• treat anyone who is willing• compliance is KING• beware of the drugs
  3. 3. DHHS Guidelines for the Use ofAntiretroviral Agents in HIV-1-Infected Adults and Adolescents www.aidsinfo.nih.gov
  4. 4. who to treat : :• CD4 < 200, 350, 500, what next?• treatment is prevention – serodiscordant couples – pregnancy• think of the viral load of the community
  5. 5. who to treat::Clinical Category CD4 Count RecommendationAIDS defining illness or Any value TREATsevere symptoms*Pregnancy, HIVAN, Any value TREATtx HBV co-infectionAsymptomatic <350/mm3 TREATAsymptomatic 350-500/mm3 55% strongly 45% moderatelyAsymptomatic >500/mm3 50% favored 50% optional *http://www.aegis.com/topics/definition.html
  6. 6. HPTN 052
  7. 7. 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
  8. 8. how to treat::• is this person sick?• No
  9. 9. how to treat::• is this person sick? – CD4 < 200 – CD4 < 50 – Symptoms i.e. opportunistic infection
  10. 10. CD4 < 200• At risk for PCP• GI symptoms?• Candidiasis?• Rash?• Needs meds as soon as ready
  11. 11. 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
  12. 12. what to use::
  13. 13. 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
  14. 14. how it works::1. Fusion2. Reverse transcription3. Integration4. Transcription5. Assembly of virus particles6. Budding of virus particles
  15. 15. 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
  16. 16. efavirenz rash
  17. 17. efavirenz rash
  18. 18. 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
  19. 19. 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).
  20. 20. Preferred Protease Inhibitors
  21. 21. 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
  22. 22. 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
  23. 23. preferred integrase inhibitor::
  24. 24. 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
  25. 25. 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?
  26. 26. compliance ::• How many doses have you missed in the last month?• How many have you taken late?• WHY?• How can we improve this?
  27. 27. 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
  28. 28. beware of the drugs::
  29. 29. bone disease::• Osteoppenia• Avascular Necrosis• Vitamin D metabolism impacted• Osteoporosis down the road?
  30. 30. AVN on the left
  31. 31. energy metabolism complications::• Lactic acidosis• Lipoatrophy• Fat redistribution• Hyperlipidemia• Glucose intolerance• Hypertriglyceridemia
  32. 32. Lipoatrophy
  33. 33. renal complications::• Fanconi’s syndrome• Stone disease
  34. 34. 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).
  35. 35. 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
  36. 36. resources::• consult with US – AFCAHN, phone, email• Guidelines• Warmline is AWESOME• Community providers

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