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HIV Treatment Overview
- 1. HIV Treatment: An Introduction October 20, 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
- 4. 11/7/2013 Source: HRSA HIV/AIDS Bureau
- 5. 2013 Treatment Guidelines Antiretroviral therapy is recommended for all HIV+ individuals regardless of CD4 count
- 6. Why Treat Early? Prevent irreversible damage to the immune system Reduce “Inflammation” to prevent heart disease, cancer, premature aging Treatment is prevention Reduce the size of the “HIV reservoir”, maybe making HIV easier to cure someday
- 7. 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
- 8. We have a long way to go…
- 11. Where we are now…
- 12. 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
- 13. 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
- 15. General Principles Goals: less pills, less times/day, less side effects Use at least 3 drugs, 2 classes of medicines Treatment is individualized- 4 recommended 1st line combos, lots of alternate regimens Sometimes 3 isn’t enough Your Protease Inhibitor may need a “Booster” Drug resistance usually = more pills
- 16. 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)
- 17. The Drugs… Each attacks the virus at a different point…
- 18. Where Do HIV Drugs Act?
- 19. NRTIs, “Nukes”
- 20. NRTIs Continued Backbone of treatment Older drugs are more toxic (AZT, “D-drugs”) Peripheral neuropathy Lactic acidosis Pancreatitis Lipodystrophy Watch kidney function with Tenofovir
- 22. NNRTIs: Pros and Cons ADVANTAGES Ease (low pill burden) Less metabolic effects Well tolerated DISADVANTAGES No lipodystrophy, less dyslipidemia Resistance develops quickly if <95% adherent Single mutation Cross resistance among NNRTIs Rash; hepatotoxicity
- 24. PIs: Pros and Cons ADVANTAGES DISADVANTAGES High potency Once daily dosing for many Less susceptible to resistance Second-line therapy when NNRTI fails Metabolic complications - Increased cholesterol, blood sugar GI side effects - Diarrhea, nausea Drug interactions – Statins, viagra, antiseizure, many
- 26. Integrase Inhibitors 3 agents- more to come! Well tolerated, less metabolic effects and drug interactions than other classes Can cause rash, hepatotoxicity
- 27. Entry Inhibitors
- 28. 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) More to come in this class
- 29. Once a day Fixed Dose Combos Name Pros Cons Atripla Lots of experience using it • Neuropsych side effects • Don’t stop without planning Complera Well tolerated • Only studied in treatment naïve • Not for use if VL >100K • Take with food • Can’t take PPIs Stribild Well tolerated • Only studied in treatment naïve • Drug interactions • Watch kidney function • Nausea
- 30. 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
- 31. 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!
- 32. 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!
- 33. HIV and Aging
- 34. 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
- 35. HIV Cure Research Theraputic vaccines Gene therapy BM Transplants Early/better treatment Paths to an HIV Cure “Shock and Kill” HIV infected cell suicide
- 37. Thanks To you for taking care of yourself! The advocates and activists who gave us these treatments My patients
- 38. 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