HIV: WHAT

IS NEW?

DR NYA EBAMA, M.D.

LOWCOUNTRY IN

FECTIO

US DISE

ASES, PA

CARETEAM PL

US, INC

SEPTEMBER

18, 20

15

INTRODUCTIONFirst recognized as AIDS in US in 1981Retrovirus AND obligate intracellular parasiteAssociated with a loss of CD4+ lymphocytes and

immunosuppression

STATISTICS• Living with HIV infection• HIV incidence • Deaths from HIV/AIDS• South Carolina in 2014– Positive tests• Males vs. females• White vs. Black vs. Hispanic• Age groups: 20-29 vs. 30-39 vs. 50

– Charleston county• Most tests done• Most positive tests• Most cumulative deaths• Most cases of persons living with HIV

MODES OF INFECTIONSexual transmissionExposure to other infected fluidsMother to infantOccupational exposure

SCREENINGBegins during the patient interviewGuidelines for screening: Persons with STD or TB Persons with new sexual partner Persons with elevated risk of HIV infection Pregnant persons

TESTING“Opt-out” approachMandatory testing in U.S. Health care workers Inmates of federal corrections facilities Military recruitment

DIAGNOSISELISAWESTERN BLOTHIV RNA

CLINICAL MANIFESTATIONS OF HIV INFECTION

Untreated Acute viral illness Immunological mediated process related to host responses to chronic

infection Opportunistic infections from impaired host responses

Treated Immune reconstitution inflammatory syndrome Syndrome of lipodystrophy Long-term non-progressors Type A – detectable RNA and elevated CD4 Type B – elite controllers – undetectable RNA and elevated CD4

TREATMENTS

NRTISBlock the RNA-dependent DNA polymerase, reverse

transcriptaseResponsible for adverse side effectsMEDS Zidovudine 300mg bid (AZT) – 1987 Lamivudine 300mg daily – 1995 Abacavir 600mg daily – 1998 Tenofovir 300mg daily – 2001 Emtricitabine 200mg daily – 2006

NNRTISBlock the RNA-dependent DNA polymerase, reverse

transcriptaseBarrier for resistance is low for this classMEDS Nevirapine 200mg bid – 1996 Efavirenz 600mg qhs – 1998 Etravirine 200mg bid – 2008 Rilpivirine 25mg daily – 2010

PISInhibit the maturation process, which uses aspartyl proteaseDecreased deaths from 1995 to 1997 Barrier for resistance is high for this class

MEDS – PIs Saquinavir 1000mg bid – 1995 Ritonavir 100mg daily or bid – 1996 Indinavir 800mg tid – 1996 Nelfinavir 1250mg bid or 750mg tid – 1997 Fosamprenavir 700mg bid – 2003 Atazanavir 400mg daily or 300mg bid – 2003 Tipranavir 200mg bid or 500mg bid – 2005 Darunavir 800mg daily or 600mg bid – 2006

Entry inhibitors Enfuvirtide 90mg SQ bid – 2003 Maraviroc 300mg bid – 2007Integrase inhibitors Raltegravir 400mg bid – 2007 Dolutegravir 50mg daily – 2013 Elvitegravir 85mg or 150mg daily – 2014

COMBINATIONSCombivir – 1997Trizivir – 2000 Kaletra – 2000 Epzicom – 2004Truvada – 2004Atripla – 2006Complera – 2011Stribild – 2012

COMBINATIONS (CONT’D)Triumeq – 2014Evotaz – 2015 Prezcobix – 2015

TREATMENT RECOMMENDATIONSAll individuals with HIV-1 infection Patients >50 years of age, regardless of CD4 cell countPregnant patients

Preferred regimen – 2 NRTIs plus NNRTI or PI or INIRecommended regimens for treatment naïve

Dolutegravir/abacavir/lamivudine Dolutegravir/tenofovir/emtricitabine Elvitegravir/cobicistat/tenofovir/emtricitabine Raltegravir/tenofovir/emtricitabine Darunavir/ritonavir/tenofovir/emtricitabine

PREVENTIONVaccine SpermicidesUnderstanding human behavior & patterns of your patients Condoms AbstinenceTreatment

PEPPost-exposure prophylaxis Involves taking ARTs as soon as possible72 hours hour windowTwo to three drugs are usually prescribed28-day regimen is recommendedNot always effective

PREPPre-Exposure ProphylaxisGoal – prevent HIV infection Follow up – repeat HIV test every 3 monthsTruvada approved for PrEP in 2012CDC recommends that PrEP be considered for people who are

HIV-negative and at substantial risk for HIV

TAKE HOME MESSAGESDesired source of HIV testing is usually the principal providers

of primary healthcareOver the past 3 decades, the natural history of HIV infection

has undergone considerable changesIf the spread of HIV can be reversed or prevented on a large

scale in the poorest countries in the world*, South Carolina can do it as well