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2016 HIV TREATMENT UPDATE
John M. Conry, Pharm.D., AAHIVP, FNAP
Clinical Professor and Assistant Dean
College of Pharmacy and Health Sciences, St. John’s University
Clinical Coordinator of Pharmaceutical Care Services, Project Renewal
Pharmacist Champion, NYSDOH Clinical Education Initiative
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I have no relevant disclosures
DISCLOSURE
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1. Discuss the current epidemiology of HIV/AIDS in the US
2. Apply the current treatment guidelines for the management of HIV/AIDS in antiretroviral-naïve
patients
3. Discuss opportunities for pharmacists to assist HIV-infected patients, who are initiating
antiretroviral therapy, in attaining treatment goals
LEARNING OBJECTIVES:
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Dynamic Face of HIV
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Plan to End the AIDS Epidemic in NYS by End of Year 2020
1. Identifying persons with HIV who remain undiagnosed and linking them to health care.
2. Linking and retaining persons diagnosed with HIV to health care and getting them on anti-HIV therapy to maximize HIV virus suppression so they remain healthy and prevent further transmission.
3. Providing access to Pre-Exposure Prophylaxis (PrEP) for high-risk persons to keep them HIV negative.
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Management of HIV/AIDS in 1987
8
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Management of HIV in 1996
Fasting (1 hour before/2 hours after meals) 1.5 liters of hydration/day
8AM 4PM 12 MID
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Management of HIV in 2016(All in One Combination Tablets)
Atripla Stribild Complera Triumeq
Genvoya Odefsey
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11UNAIDS 2010 Global Report
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Global summary of the AIDS epidemic 2014
36.9 million [34.3 million – 41.4 million]
34.3 million [31.8 million – 38.5 million]
17.4 million [16.1 million – 20.0 million]
2.6 million [2.4 million – 2.8 million]
2.0 million [1.9 million – 2.2 million]
1.8 million [1.7 million – 2.0 million]
220 000 [190 000 – 260 000]
1.2 million [980 000 – 1.6 million]
1.0 million [760 000 – 1.8 million]
150 000 [140 000 – 170 000]
Number of people
living with HIV
People newly infected
with HIV in 2014
AIDS deaths in 2014
Total
Adults
Women
Children (<15 years)
Total
Adults
Children (<15 years)
Total
Adults
Children (<15 years)
www.unaids.org July 2015- Core Epidemiology Slides
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Total: 36.9 million [34.3 million – 41.4 million]
Middle East & North Africa240 000
[150 000 – 320 000]
Sub-Saharan Africa25.8 million
[24.0 million – 28.7 million]
Eastern Europe & Central Asia1.5 million
[1.3 million – 1.8 million]
Asia and the Pacific5.0 million
[4.5 million – 5.6 million]
North America and Western and Central Europe2.4 million
[1.5 million – 3.5 million]
Latin America1.7 million
[1.4 million – 2.0 million]
Caribbean280 000
[210 000 – 340 000]
Adults and children estimated to be living with HIV 2014
www.unaids.org July 2015- Core Epidemiology Slides
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About 5,600 new HIV infections a day in 2014
About 66% are in Sub Saharan Africa
About 600 are in children under 15 years of age
About 5,000 are in adults aged 15 years and older, of whom:─ almost 48% are among women
─ about 30% are among young people (15-24)
www.unaids.org July 2015- Core Epidemiology Slides
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CDC HIV/AIDS Facts-
July 2015 (www.cdc.gov)15
US HIV/AIDS Epidemiology
• 1.2 million US residents living with HIV
– 13% don’t know their HIV-infected
• Approximately 50,000 new HIV-infections/year
• 658,507 US residents have died from HIV/AIDS
• Majority of persons living with HIV
– MSM (4% of male population, 78% of new infx)
– African-Americans (12% population, 44% of new infx)
– Hispanics/Latinos (16% population, 20% of new infx)
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Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting.
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Diagnoses of HIV Infection among Adults/Adolescents, by Sex and
Transmission Category, 2014—United States and 6 Dependent Areas
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays and missing transmission category, but not for incomplete reporting.
a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection. b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.
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Stage 3 (AIDS) Classifications and Deaths of Persons with HIV
Infection Ever Classified as Stage 3 (AIDS), among Adults and
Adolescents, 1985–2013—United States and 6 Dependent Areas
Note. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting. Deaths of persons with HIV infection, stage 3 (AIDS) may be due to any cause.
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Screening/Diagnosis of HIV• Standard Blood Test
– ELISA: screening test
– Western Blot: confirmatory test
• OraQuick- Rapid Tests (OTC)
• Home Access Express HIV-1 Test (OTC)
• In emergency situations- Viral Load
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20www.aidsinfo.nih.gov
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www.aidsinfo.nih.gov 21
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www.aidsinfo.nih.gov 22
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Pathology of HIV
Fauci AS et al. Ann Intern Med.
1996;124:654-63
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CD4+ and Viral Load
CD4
• Measure of patients immune function
– cells/mm3
VL
• Measure of virus in blood
– copies of virus/ml of blood
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Pharmacotherapy Options
• Nucleoside/Nucleotide Reverse Transcriptase Inhibitors– “Nukes”, NRTI’s
• Non-nucleoside Reverse Transcriptase Inhibitors– “Non-nukes”, NNRTI’s
• Protease Inhibitors (PI’s)
• Entry Inhibitors
– Fusion Inhibitor
– CCR5 Antagonist
• Integrase inhibitors
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NRTI’s• Zidovudine (AZT) (Retrovir®)
• Didanosine (ddI) (Videx EC®)
• Stavudine (d4T) (Zerit®)
• Lamivudine (3TC) (Epivir®)
• Abacavir (ABC) (Ziagen®)
• Tenofovir (TDF) (Viread®)
• Emtricitabine (FTC) (Emtriva®)
• Combination Tablets– Combivir®: AZT + 3TC – Epzicom®: ABC + 3TC– Truvada®: TDF + FTC– Descovy®: TDF + FTC– Trizivir®: AZT + 3TC + ABC
• Other Combos including NRTIs– Atripla®:
• Efavirenz + TDF + FTC
– Complera®:• Rilpivirine + TDF + FTC
– Odefsey®:• Rilpivirine + TAF + FTC
– Stribild®:• Elvitegravir + COBI +TDF + FTC
– Genvoya®:• Elvitegravir + COBI +TAF + FTC
– Triumeq®: • Dolutegravir + ABC + 3TC
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NRTI Dosing/AdministrationGeneric
Name
Brand Name Usual Dosing
Food Notes
Abacavir
(ABC)
Ziagen
Trizivir
Epzicom
Triumeq
QD/BID
BID
QD
QD
With or without
EtOH ABC levels
Didanosine
(ddI)
Videx EC QD
( wt)
1 hr b/f or 2 hrs after meal
*renal
Emtricitabine
(FTC)
Emtriva
Truvada
Descovy
Atripla
Complera
Odefsey
Stribild
Genvoya
QD
QD
QD
QD
QD
QD
QD
QD
With or without
(*Atripla/ Complera/ Odefsey/ Stribild/ Genvoya)
* renal
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NRTI Dosing/Administration (cont’d)
Generic
Name
Brand Name
Usual Dosing
Food Notes
Lamivudine
(3TC)
Epivir
Combivir
Trizivir
Epzicom
Triumeq
QD/BID
BID
BID
QD
QD
With or without
*renal
Stavudine
(d4T)
Zerit BID
( wt)
With or without
*renal
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NRTI Dosing/Administration (cont’d)
Generic
Name
Brand Name Usual Dosing
Food Notes
Tenofovir
(TDF and TAF)
Viread
Truvada
Descovy (TAF)
Atripla
Complera
Odefsey (TAF)
Stribild
Genvoya* (TAF)
QD
QD
QD
QD
QD
QD
With or without
(*Atripla/ Complera/ Odefsey Stribild/ Genvoya)
*renal
Zidovudine (AZT/ZDV)
Retrovir
Combivir
Trizivir
BID/TID
BID
BID
With or without
*renal
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“Class” NRTI- Important Notes
• Elimination– Generally require dosage adjustment for renal insufficiency– Atripla, Combivir, Trizivir, Epzicom are not for patients with CrCl <50
ml/min– Truvada is not for patients with CrCl <30 ml/min
• Side Effects– [Rare but serious cases of lactic acidosis and severe hepatomegaly
with steatosis reported with most NRTI’s] – Hepatotoxicity– GI intolerance (nausea, vomiting, diarrhea)– HIV/HBV co-infected patients may develop severe hepatic flares when
TDF, 3TC and FTC are withdrawn or resistance
* [brackets]- denotes black box warnings
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Select NRTI Significant Side Effects
Abacavir [Hypersensitivity Syndrome], hyperlipidemia, risk MI?
Didanosine [Pancreatitis], PN, non-cirrhotic portal HTN, insulin resistance, risk MI?
Stavudine [Pancreatitis], PN, lipoatrophy, hyperlipidemia, G-B, insulin resistance
Tenofovir Nephrotoxicity, asthenia, h/a, GI, osteopenia
(TAF- less kidney and bone problems)
Zidovudine [severe anemia, neutropenia][myopathy], lipoatrophy, hyperlipidemia, insulin resistance
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NNRTI’s
• Delavirdine (Rescriptor®)
• Efavirenz (Sustiva®)
– Combination available: Atripla®
• Nevirapine (Viramune and XR®)
• Etravirine (Intelence®)
• Rilpivirine (Edurant®)
– Combination available: Complera®, Odefsey®
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NNRTI Dosing/AdministrationGeneric
Name
Brand Name
Usual Dosing
Food Notes
Delavirdine
(DLV)
Rescriptor TID With or without
*Separate antacids
*CYP 450 interactions
Efavirenz
(EFV)
Sustiva
Atripla
QD (HS)
QD (HS)
Empty stomach
* CYP 450 interactions
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NNRTI Dosing/AdministrationGeneric
Name
Brand Name
Usual Dosing
Food Notes
Nevirapine (NVP)
Viramune
Viramune XR
qd x14d, then BID
qd
With or without
* CYP 450 interactions
Etravirine (ETV)
Intelence BID Take following a meal
* CYP 450 interactions
Rilpivirine (RPV)
Edurant
Complera
Odefsey
QD
QD
QD
With food * CYP 450 interactions
** PPI
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“Class” NNRTI- Important Notes• Elimination
– Beware of drug interactions• All are CYP 450 substrates
• Depending on the NNRTI may have the ability to inhibit and/or induce CYP 450 enzymes
• Side Effects- particularly with nevirapine
– Skin rash and Stevens-Johnson Syndrome/Toxic Epidermal Necrosis- rare but serious
– Osteopenia/osteoporosis
– Hepatotoxicity
– GI intolerance (nausea, vomiting, diarrhea)
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Select NNRTI Significant Side Effects
Delavirdine GI upset, neutropenia
Efavirenz CNS disturbances, lipodystrophy, hyperlipidemia, false + cannabinoid test, teratogenic in animal studies
Nevirapine [Hepatotoxicity, particularly tx-naïve women w/ CD4 > 250 & men >400], [Skin Rash (SJS)]; [dosing titration]
Etravirine Rash, headache, GI, hypersensitivity
Rilpivirine Rash, CNS (depression, insomnia), lipodystrophy
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PI’s
• Saquinavir (Invirase®)
• Ritonavir (Norvir®)– The “boosting” PI
• Indinavir (Crixivan®)
• Nelfinavir (Viracept®)
• Lopinavir/Ritonavir (Kaletra®)
• Atazanavir (Reyataz®)– Atazanavir/COBI (Evotaz®)
• Fosamprenavir (Lexiva®)
• Tipranavir (Aptivus®)
• Darunavir (Prezista®)– Darunavir/COBI (Prezcobix®)
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PI Dosing/Administration
Generic
Name
Brand Name Usual Dosing
Food Notes
Atazanavir (ATV)
Reyataz
Evotaz
QD
QD
With food (avoid antacid)
*acidic medium
* CYP 450 interactions
Darunavir (DRV)
Prezista
Prezcobix
QD/BID (give with RTV)
QD
With food *sulfa
*CYP 450 interactions
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PI Dosing/Administration
Generic
Name
Brand Name
Usual Dosing
Food Notes
Fos-amprenavir
(FPV)
Lexiva QD/BID
(depends if naïve)
With or without
*CYP 450 interactions
*sulfa
Indinavir (IDV) Crixivan Q 8 hrs or
(+ RTV= q 12)
w/o RTV
Empty stomach
w/ RTV
w or w/o
* fluids
* CYP 450 interactions
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PI Dosing/Administration
Generic
Name
Brand Name Usual Dosing
Food Notes
Lopinavir/ RTV
(LPV/r)
Kaletra QD/BID
(depends if naïve)
With or Without
*CYP 450 interactions
Nelfinavir (NFV)
Viracept BID/TID With food * CYP 450 interactions
Ritonavir (RTV)
Norvir QD/BID
(booster)
With food Refrigerate capsules
*CYP 450 interactions
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PI Dosing/Administration
Generic
Name
Brand Name
Usual Dosing Food Notes
Saquinavir (SQV)
Invirase BID(+RTV) With food
* CYP 450 interactions
Tipranavir
(TPV)
Aptivus BID (give with RTV)
With food
*sulfa
*refrigerated caps
*CYP 450 interactions
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“Class” PI- Important Notes
• Elimination
– Metabolized by CYP 450
– Beware of drug interactions
• All are CYP 450 substrates and inhibitors of CYP 3A4
• Degree of inhibition varies with the different protease inhibitors
• Chronic Long Term Use Can Lead to Significant Side Effects
– GI intolerance (nausea, vomiting, diarrhea)
– Hepatotoxicity
– Hyperlipidemia (less with atazanavir/darunavir)- premature CAD?
– Hyperglycemia/Insulin resistance/ Type 2 DM (less with atazanavir)
– Body fat changes- lipodystrophy
– Bleeding episodes in patients with hemophilia
– Osteopenia/Osteoporosis
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PI Significant Side Effects
Atazanavir Indirect hyperbilirubinemia, EKG-prolong PR interval, nephrolithiasis, Skin Rash, SJS/TEN
Darunavir Skin Rash, SJS/TEN, hepatotoxicity
Fosamprenavir Skin Rash, SJS/TEN, hepatotoxicity
Indinavir Nephrolithiasis, Indirect hyperbilirubinemia, SJS/TEN
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PI Significant Side Effects
Lopinavir/RTV GI intolerance ( with qd), Hyperlipidemia (TG), EKG- prolong PR interval, SJS/TEN
Nelfinavir Diarrhea
Ritonavir [Drug Interactions], Significant GI distress, circumoral/ extremity paresthesias, alteration in taste
Tipranavir Skin Rash, [Hepatotoxicity], [Intracranial hemorrhage], Hyperlipidemia (TG)
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Entry Inhibitors
• Enfuvirtide (Fuzeon®)
– Fusion Inhibitor
• Maraviroc (Selzentry®)
– CCR5 Antagonist
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Entry Inhibitor Dosing/Administration
Generic
Name
Brand Name
Usual Dosing
Food Notes
Enfuvirtide(ENF)
Fuzeon BID (sub-cutaneous injection)
With or without
Teaching needed for injection technique
Maraviroc
(MVC)
Selzentry BID With or without
* CYP 450 interactions
* Need for tropism testing
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Select Entry Inhibitor Significant Side Effects
Enfuvirtide Injection site reactions, GI distress, hypersensitivity, bacterial pneumonia
Maraviroc Upper respiratory infections, fever, cough, GI distress, orthostatic hypotension, dizziness, [HSR-hepatotoxicity], musculoskeletal symptoms
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Integrase Inhibitors
• Raltegravir (Isentress®)
• Elvitegravir (Vitekta®)• Elvitegravir + COBI +TDF + FTC (Stribild®)
• Elvitegravir + COBI +TAF + FTC (Genvoya®)
• Dolutegravir (Tivicay®)• Dolutegravir + ABC + 3TC (Triumeq®)
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Integrase Inhibitor Dosing/Administration
Generic
Name
Brand Name
Usual Dosing
Food Notes
Raltegravir (RAL)
Isentress BID With or without
*UGTA1A1 Glucoronidation
*Use restricted to those with CrCl >70ml/min
Elvitegravir (EVG)
Vitekta
Stribild
Genvoya
QD with PI/r
QD
QD
With food * CYP 450 interactions
Dolutegravir (DTG)
Tivicay
Triumeq
QD or BID
QD
With or without
*CYP 450 and binding interactions
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Integrase Inhibitor Significant Side Effects
Raltegravir Common: Insomnia, h/a, GI distress
Serious: HSR, myopathy/rhabdomyolysis, SJS/TEN
Elvitegravir Common: h/a, GI distress
Serious: Proximal renal tubulopathy
Dolutegravir Common: h/a, insomnia
Serious: HSR, abnormal liver function
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Antiretroviral-Related Factors Counseling Points
• Adherence
• Allergy History
• Dosing
• Administration
• Storage
• Adverse Effects
• Drug Interactions
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Key Factors
Choosing Antiretroviral Therapy
CD4 countViral Load
ConcomitantMedications/ Herbs/ OTCPatient
Acceptance/Readiness
PriorTherapy -
Resistance
Patient’sClinicalStatus
Baseline Labs
HAART Efficacy/Toxicity
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HIV Therapeutic Guidelines
• Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. January 28, 2016. Available at: http://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf
• International Antiviral Society-USA Panel. 2014 Recommendations for Antiretroviral Treatment of Adult HIV Infection. JAMA. 2014;312(4):410-425. Published July 23, 2014.
• NYS DOH AIDS Institute (www.hivguidelines.org)
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DHHS HIV Treatment Guidelines 54
Goals of Therapy and Strategies to Achieve These Goals
Goals
• Maximal and durable suppression of VL
• Restoration and/or preservation of immunologic function
• Improvement of QOL
• Reduction in HIV-related morbidity & mortality
• Prevent HIV transmission
Strategies
• Pretreatment drug resistance testing
• Selection of HAART
• Maximize adherence
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HIV Laboratory Assessment
• CD4 cell count and Viral load (HIV-RNA)– Baseline and routine monitoring q 3-6 months
– VL should be assessed 2-8 wks following initiation
• Genotypic Resistance Testing– All treatment-naïve patients entering care
– Prior to initiating therapy
– Suspected virologic failure
• Coreceptor Tropism Assay– Prior to initiation of a CCR5 antagonist
– Consider if failing CCR5 antagonist
• HLA-B*5701 Testing– Prior to initiation of abacavir therapy
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When to Start HIV Treatment
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When to Start: 2016 DHHS Guidelines
CD4+ Cell Count Recommendation
< 350 cells/mm³ Start ART (AI)
350-500 cells/mm³ Start ART (AI)
> 500 cells/mm³ Start ART (AI)
ART is also recommended for HIV-infected individuals for the prevention of transmission of
HIV
Perinatal transmission (AI)
Heterosexual transmission (AI)
Other transmission groups (AIII)
*Patients starting ART should be willing and able to commit to treatment and understand the benefits and risks of therapy and the importance of adherence (AIII). Patients may choose to postpone therapy, and providers, on a case-by-case basis, may elect to defer therapy on the basis of clinical and/or psychosocial factors.
DHHS HIV Treatment Guidelines
Rating of Recommendations: A = Strong; B = Moderate; C = OptionalRating of Evidence: I = data from randomized controlled trials; II = data from well-designed nonrandomized trials or observational cohort studies with long-term clinical outcomes; III = expert opinion
ART is recommended for all HIV-infected individuals to reduce the risk of disease progression.
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DHHS Jan 2016: Tx-NaiveRecommended Regimens to Start
For All Pts, Regardless of
BL VL or CD4+ Count
INSTI
DTG/ABC/3TC*a
DTG + TDF/FTCa
EVG/cobi/TDF/FTCa (CrCl > 70 ml/min)
EVG/cobi/TAF/FTCa (CrCl > 30 ml/min)
RAL + TDF/FTCa
Boosted PI DRV/rtv + TDF/FTCa
*Only for pts who are HLA-B*5701 negative. a: 3TC may substitute for FTC or vice versa
DHHS HIV Treatment Guidelines
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DHHS Jan 2016: Tx-NaiveAlternative Regimens to Start
NNRTI EFV/TDF/FTCa
RPV/TDF/FTCa,b
Boosted PI
ATV/cobi + TDF/FTCa (CrCl > 70)
ATV/rtv + TDF/FTCa
(DRV/rtv or DRV/cobi) + ABC/3TC*a
DRV/cobi + TDF/FTCa,b (CrCl > 70)
*Only for pts who are HLA-B*5701 negative.
a: 3TC may substitute for FTC or vice versa
b: Only for patients with pre-treatment VL <100,000 copies/ml and CD4 count >200 cells/mm3
DHHS HIV Treatment Guidelines
Regimens that are effective and tolerable, but that have potential disadvantages when compared with the recommended regimens listed above, have, or have less supporting data from randomized clinical trials. An alternative regimen may be the preferred regimen for some patients.
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DHHS HIV Treatment Guidelines
DHHS Jan 2016: Tx-Naive“Other Regimens” to Start
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DHHS Jan 2016: ART Considerations for Tx
61DHHS HIV Treatment Guidelines
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DHHS Jan 2016: ART Considerations for Tx
62DHHS HIV Treatment Guidelines
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DHHS Jan 2016: ART Considerations for Tx
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DHHS Jan 2016: ART Considerations for Tx
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DHHS Jan 2016: ART Considerations for Tx
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DHHS Jan 2016: ART Considerations for Tx
66DHHS HIV Treatment Guidelines
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Antiretroviral Therapy Safety During Pregnancy
Class FDA Category
B C D
NRTIs ddIFTCTDF
ABC3TC d4TZDV
NNRTIs ETRNVPRPV
EFV
PIs ATVNFVRTVSQV
DRVFPVIDV
LPV/RTVTPV
Entry inhibitors ENFMVC
Integrase inhibitor RAL
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Adherence Interventions
• Establish pt readiness to start therapy
• Provide education on medication dosing
• Review potential side effects
• Anticipate and treat side effects
• Utilize educational aids including pictures, pillboxes, and calendars
• Engage family and friends
• Simplify regimens, dosing, food issues
• Utilize team approach with nurses, pharmacists, and peer counselors
• Provide accessible, trusting health care team
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Treatment Goal
DHHS Guidelines- Jan 2016
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Treatment Regimen Failure: Causes
• Patient Factors
• Suboptimal adherence
• Antiretroviral side effects (intolerance)
• Alteration of antiretroviral pharmacokinetics
• ART resistance
• Inadequate potency of HAART
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Treatment Regimen Failure
• Virologic Failure
– Inability to achieve/maintain an HIV-RNA < 200 copies/ml
• Immunologic Failure
– Failure to achieve and maintain adequate CD4 increase despite virologic suppression
• Clinical Failure
– Occurrence of HIV related events (after > 3 months of therapy)
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Treatment-Experienced Patients: Virologic Failure
• Assess drug resistance:
– Drug resistance test
– Prior treatment history
– Prior resistance test results
• Drug resistance usually is cumulative –consider all previous treatment history and test results
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Treatment-Experienced Patients: Management of Virologic Failure
• New regimen should contain at least 2 (preferably 3) fully active agents – Based on ARV history, resistance testing, and/or novel
mechanism of action
• In general, 1 active drug should not be added to a failing regimen(drug resistance is likely to develop quickly)
• Consult with experts
November 2015 www.aidsetc.org73
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Pharmacist Interventions to Assist HIV Providers
• Assess appropriateness of all ART prescriptions with respect to appropriateness of combinations and doses
• Screen and alert providers for clinically significant drug interactions
• Assess appropriateness of opportunistic infection prophylaxis regimens
• Alert providers of adverse drug reactions and appropriately document/report such reactions
• Serve as a drug information expert
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Pharmacist Interventions to Assist Patients
• Educate the public regarding risk factors for HIV transmission
• Appropriately counsel patients regarding their HIV and opportunistic infection drug regimens
• Provide patient with tools to maximize adherence
• Assist patients in preparing for and managing adverse effects of their medications
• Emphasize importance of receiving appropriate vaccinations
• Serve as a drug information expert
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Select HIV-related Resources for the Pharmacist
• DHHS guidelines/resources– Website: http://aidsinfo.nih.gov
• New York State Department of Health AIDS Institute– Website: http://www.hivguidelines.org/
• Clinical Education Initiative– Website: http://www.ceitraining.org/
– CEI Line: 1-866-637-2342
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QUESTIONS?
To set up training on HIV or Hepatitis C, please contact Naomi Harris at [email protected]
www.ceitraining.org