primary care aspects of hiv 12 - primary care aspects … · •separate written consent for hiv...
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PRIMARY CARE ASPECTS PRIMARY CARE ASPECTS OF HIVAnita Fleenor, M.D.
THANK YOUTHANK YOU
Carl B LeBuhn MDCarl B. LeBuhn, MDAndrew R. Hoellein, MD
Who Should be Screened for HIV?
A) Injection Drug UsersA) Injection Drug UsersB) Persons with multiple sexual partnersC) Anyone diagnosed with tuberculosisC) Anyone diagnosed with tuberculosisD) All persons aged 13-64 y/oE) A B d CE) A,B and CF) All of the above
Primary Care Aspects of HIVy p
CDC recommendations for testing
Revised September 2006
Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings
September 22, 2006 / 55(RR14);1-17
For patients in all health-care settings •HIV screening is recommended for patients in all health-care settings after the patientis notified that testing will be performed unless the patient declines (opt-out screening). •Persons at high risk for HIV infection should be screened for HIV at least annually.
•Separate written consent for HIV testing should not be required; general consentfor medical care should be considered sufficient to encompass consent for HIV testing.
P ti li h ld t b i d ith HIV di ti t ti t•Prevention counseling should not be required with HIV diagnostic testing or as partof HIV screening programs in health-care settings.
R d ti f Ad lt d Ad l t
Screening for HIV Infection
Recommendations for Adults and Adolescents
g
In all health-care settings, screening for HIV infection should be performed routinely for all patients aged 13--64 years.
All patients initiating treatment for TB should be screened routinely for HIV infection (108).
All patients seeking treatment for STDs, including all patients attending STD clinics, should be screened routinely for HIV during each visit for a new complaint, regardless of whether the patient is known or suspected to have specific behavior risks for HIV infectioninfection.
Awareness of Serostatus Among PLWH and Estimates of Transmissionand Estimates of Transmission
~25%~25% Unaware
of Infection
Accounting for: ~54% of New
Infections
~75% AIDS 2006;20:1447 50Aware of Infection
AIDS 2006;20:1447-50
~46% of New
Infections
People Living with HIV/AIDS: ~1,000,000
New Sexual Infections Each Year: ~32,000
Primary Care Aspects of HIVy p
Educate yourself, your staff and the patientEducate yourself, your staff and the patient
HIV is transmitted via sexual contact blood and HIV is transmitted via sexual contact, blood, and sharing needles
HIV is a treatable, chronic disease
Know when to call for help
Primary Care Aspects of HIVy p
StigmaStigmafear and ignorancebehavior that led to HIVbehavior that led to HIV
Cultural Backgroundi i iminorities
Confidentialityrisk of job loss, insurance loss
Rapidly changing field – easier to refer/transfer
Conspiracy Beliefs about HIV/AIDSHIV/AIDS
f 00 fTelephone survey of 400 African-Americans
Bogart LM and Thorburn S. JAIDS. 2005;38(2):213-218.
What is the estimated life expectancy of a male diagnosed with HIV in 2009?diagnosed with HIV in 2009?
A) 10 yearsA) 10 yearsB) 17 yearsC) 22 yearsC) 22 yearsD) 30 years
Life Expectancy for persons with HIV
PLWHPLWH
Causes of Death among Persons with AIDS inCauses of Death among Persons with AIDS in the Era of Highly Active Antiretroviral Therapy– All adult NYC residents with AIDS 1999-2004All adult NYC residents with AIDS 1999 2004– Cohort analysis, death certificates– Non-HIV deaths ↑32.8% (19.8-26.3, p=.0015)↑ ( , p )
• Substance abuse – 31%• CVD – 23.8%• Cancer 20 8%• Cancer – 20.8%
– Age-adjusted mortality for AIDS ↓49.6/10,000/year (p<.0001)
Sackoff JE, Hanna DB, Pfeiffer MR, Torian LV. Ann Intern Med. 2006;145:397-406
Consider Testing for HIVg
Fatigue Thrombocytopenia
Patient Complaints Patient Labwork
Weight loss Leukopeniag
Night Sweats
p
AnemiaNight Sweats
Diarrhea
Anemia
Elevated ProteinDiarrhea Elevated Protein
M ll
Umbilicated center
Molluscum contagiosum
M llMolluscum contagiosum
S b h DSeborrheic Dermatitis
S b h dSeborrheic dermatitis
A HIV
Violaceous macular and papular
Acute HIV
O l d dOral candidiasis
S Severe psoriasis
Primary Care Aspects of HIVy p
RPRRPRTestosteroneBone Density?Bone Density?CBC- increased leukopenia, anemia and thrombocytopeniathrombocytopeniaGlucose – increased prevalenceUA d l l d C Cl ( di CG)UA and calculated CrCl (most studies use CG)TB screen (5 mm or close contact with active case)
Primary Care Aspects of HIVy p
Lipids ( HIV meds and HIV itself assoc. with)Lipids ( HIV meds and HIV itself assoc. with)Hepatitis Serology – and vaccinate if indicatedPap q 6 months X 2 then annual (anal pap?)Pap – q 6 months X 2 then annual (anal pap?)Renal (kidney function abnl in up to 30%)C diCardiacOsteoporosisCancersDrug drug interactions
Trends in standard incident rates in 3 AIDS-defining and 9 AIDS non9 AIDS non-defining types of cancer among
fHIV-infected persons and the general population g p pstratified by 3 periods from 1992-20032003.
Patel et al. Ann Intern Med. 2008;148:728-736
CounselingCounseling
• Safer sex practices• Substance Use• Tobacco use• Reproductive Health• Reproductive Health• Psychosocial Assessment
I C t t L l I– Insurance, Contacts, Legal Issues• Diet and ExerciseHIV Guidelines: New York State Department of Health AIDS Institute, 2009. http://www.hivguidelines.org/Content.aspx
CASECASE Year Total HDL LDL TriglyceridesYear Cholesterol HDL LDL Triglycerides
2003 179 31 412
2004 265 30 743
2005 161 29 101 156
2006 153 23 84 231
2007 166 29 73 3192007 166 29 73 319
2008 208 36 89 700
2009 227 46 107 3702009 227 46 107 370
PLWH and Dyslipidemia
• Untreated HIV: ↑TG and ↓HDL
• HAART: ↑TC and ↑TG ( > )• HAART: ↑TC and ↑TG ( > )– HDL may increase with NNRTIs
Oth PI t i did t h– Other PI atazanavir did not change endothelial dysfunction despite improved lipid profilelipid profile
• FLP before and 3-6 months after HAARTAHRQ National Guideline Clearinghouse. Infectious Disease Society of America. Mod 5/23/2005.
Flammer AJ, Vo NT, et al. Heart. 2009;95(5):385-90.
PLWH and D li id iDyslipidemia
Other recommendations:• Δ PI to nevirapine or abacavir (C-III)• ‘Statin for LDL and TG 200-500 (B-I)• Fibrates less optimal (C-I TC/LDL, B-I TG)• Avoid niacin and bile-sequestering resins (C-III)
– Niacin increases risk of glucose intolerance• Fish oils may be tried (C-III)
– Can combine with fibrates if necessary
Aberg JA. Lipid Management in Patients who have HIV and are Receiving HIV Therapy. Endocrinol Metab Clin N Am. 2009;38:207-222.
PLWH and DyslipidemiaPLWH and Dyslipidemia
Atorvastatin (Lipitor®)Ezetimibe (Zetia®)
Simvastatin (Zocor®) Lovastatin (Mevacor®)
Niacin (Niaspan®)Ω-3 Fatty Acids (Omacor®)
Cholestyramine(Questran®)
Colestipol (Colestid®)
Pravastatin (Pravachol®)Rosuvastatin (Crestor®)Rosuvastatin (Crestor®)Gemfibrozil (Lopid®)Fenofibrate (Lofibra®)
PLWH and Heart DiDisease
• HIV infection 1.5-2 x risk CAD– Younger (x=50)– Lower TIMI risk scores– Single vessel disease– Higher rate stent complications
• Initiation of HAART in treatment-naïveInitiation of HAART in treatment naïve short-term risk reduction
• Long-term PI use increased risk• Long-term PI use increased risk
Ho JE, Hsue PY. Cardiovascular Manifestations of HIV Infection. Heart. 2009;95:1193-1202.
Primary Care for Patients with HIV/AIDSCardiovascular Disease
All PLWH h ld b l d f CAD i kAll PLWH should be evaluated for CAD riskTraditional risk factors
tobacco HTN dyslipidemia family historytobacco, HTN, dyslipidemia, family historyEmerging risk factors
weight, HAART (PIs)
TreatmentLifestyle modification
smoking cessationTreat diabetes, HTN, dyslipidemiaLow CV risk HAARTLow CV-risk HAART
CASE
Presents in 3/07/Low back and hip painHurts anterior and medial thighSome pain in the groinPlain films negativeMRI lumbar spine negativeNo response to NSAIDS
CASE
PLWH and Bone Disorders
• Prevalence– Osteopenia in HAART-naïve = 23-28%– Osteoporosis (OP) with PIs = 50%
(vs. 23% HIV+ off PIs)– No increased rate of fragility fractures– Osteonecrosis (ON) = 4.4% of 339
asymtomatic patients
Morse CG, Kovacs JA. Metabolic and Skeletal Complications of HIV Infection. JAMA. 2006;296:844-854.
PLWH and Bone Disorders
• Pathophysiology– Low BMI, smoking, alcohol, steroids1
– Hypogonadism1
– Duration of HIV (OP)1
– Lipid oxidation products (OP)2
– Viral load (OP)3( )– HIV and HAART not independent RF for ON1
1Morse CG, Kovacs JA. Metabolic and Skeletal Complications of HIV Infection. JAMA. 2006;296:844-854.2Wiercinska-Drapalo, A, et al. Infection. 2007;35:46-48.3Fausto A, et al. Bone. 2006;38:893-897
CASE• 53 year old man
followed since 2001• Hospitalized 1/09 with
severe depression– Lowest CD4 170– Currently well
p• Recently homeless• Family turmoil
controlled on trizivirand kaletra
– 30 pound weight Year Highest Glucose30 pound weight
gain• Past Medical History
Glucose2001 822003 134
– AIDS– Depression
2003 1342005 1382007 147
– HTN– Syphylis
GERD
2009 222
PLWH and DiabetesPLWH and Diabetes
• Insulin resistance and impaired glucose tolerance in up to 50% of PLWH on PIs1
M 4 i k d t ti 2• Men – >4x risk compared to seronegative men2
• Diagnosis– Fasting glucose >126, random >200– Insulin levels and GTT* not currently
d drecommended
1. Grinspoon S, Carr A. Cardiovascular Risk and Body-Fat Abnormalities in HIV-Infected Adults. NEJM. 2005;352;48-62.2. Brown TT, Cole SR, et al. Antiretroviral Therapy and Prevalence and Incidence of Diabetes Mellitus in the Multicenter AIDS Cohort Study. Arch Intern Med. 2005;165:1179-84.
PLWH and Lipodystrophy
Li d t h• Lipodystrophy– Subcutaneous lipoatrophy ( > )
F• Face• Extremities• ButtocksButtocks
– Accumulation of central fat ( > )• Visceral fat• Dorsocervical fat pad, breasts, lipomatosis
• Lipodystrophy Syndrome– with insulin resistance and dyslipidemia
Morse CG, Kovacs JA. Metabolic and Skeletal Complications of HIV Infection. JAMA. 2006;296:844-854.
LipodystrophyLipodystrophy
PLWH and Lipodystrophy
• Prevalence– 20-84%– 20-50% will develop at least 1 sign of
lipodystrophy within 2 years of HAART• Pathophysiology
– Mitochondrial toxicity impaired ATPy p– NRTIs (stavudine > AZT >> ABC/TDF)– PIs (except atazanavir)( p )
Morse CG, Kovacs JA. Metabolic and Skeletal Complications of HIV Infection. JAMA. 2006;296:844-854.
THE END
PLWH and Bone Di dDisorders
Screening - suggested
Paccou J, et al. Bone Loss in Patients with HIV Infection. Joint Bone Spine. 2009;76:637-41.
M ll
Umbilicated center
Molluscum contagiosum
S b h DSeborrheic Dermatitis
CASE CASE
Year Total HDL LDL TriglycerideYear Cholesterol HDL LDL s
2003 179 31 412
2004 265 30 743
2005 161 29 101 156
2006 153 23 84 231
2007 166 29 73 3192007 166 29 73 319
2008 208 36 89 700
2009 227 46 107 3702009 227 46 107 370
Aberg JA. Lipid Management in Patients who have HIV and are Receiving HIV Therapy. Endocrinol Metab Clin N Am. 2009;38:207-222.
Anxiolyticsy
Avoid: triazolam and midazolam Consider: short-acting agents Consider: short acting agents -Lorazepam (Ativan®) Oxazepam (Serax®)-Oxazepam (Serax®)
Consider: Buspirone (Buspar®)Al l (X ®) h ld b Alprazolam (Xanax®) should be used cautiously with ritonavir
PLWH and Dyslipidemia
Lipid-lowering drugs:• HMG-CoA Reductase Inhibitors
– Most metabolized by CYP3A4– Simvastatin and lovastatin should not be used if on
PIs or delavirdinePIs or delavirdine– use atorvastatin with caution
• Drug-drug interactions unlikely with fibratesDrug drug interactions unlikely with fibrates• Ezetimibe
– efficacious, tolerated, interactions unlikelyefficacious, tolerated, interactions unlikely– clinical outcome data?
Negredo E, et al. AIDS. 2006;20:2159-2164; Coll B, et al. AIDS. 2006;20:1675-1677
Bone Disorders
Treatment strategiesMaintain dietary calcium and vitamin DIncorporate weight bearing exerciseBisphosphonate therapy combined with calcium and vitamin DJoint replacement therapy
PLWH and Metabolic Complications
• Higher risk for development of hyperglycemia, dyslipidemia, and cardiovascular diseaseC l th h i l• Complex pathophysiology– PI inhibition of SREBP-mediated PPAR-γ expression
NRTI inhibition of mitochondrial DNA polymerase γ– NRTI inhibition of mitochondrial DNA polymerase γ– Increased lpC-II and lpE, decreased lpD degredation
Impaired FA oxidation ± circulating FA storagep g g• Decreased glucose phosphorylation
– Decreased GLUT-4
Grinspoon S, Carr A. Cardiovascular Risk and Body-Fat Abnormalities in HIV-Infected Adults. NEJM. 2005;352;462)..
Insulin Resistance and DiabetesInsulin Resistance and Diabetes
Insulin resistance and glucose intolerance greported in up to 50% of patients on HAART (PI)HIV (+) men on HAART are 4X more likely to ( ) ydevelop diabetes compared with HIV (-) controlsSymptoms may develop within a few weeks of y p y pstarting treatmentFactor in risk factors for DM in choosing HAART gstrategy
Grinspoon S Carr A Cardiovascular Risk and Body-Fat AbnormalitiesGrinspoon S, Carr A. Cardiovascular Risk and Body-Fat Abnormalities in HIV-Infected Adults. NEJM. 2005;352;48-62AAHIVM Fundamentals of HIV Medicine 2007, 845-6
Bone DisordersHigh prevalence of Osteopenia and OsteoporosisHigh prevalence of Osteopenia and Osteoporosis
One osteoporosis prevalence study in treatment naïve patients:p
23 to 28% higher than HIV(-) controls
Study osteoporosis rates in patients on treatmentStudy osteoporosis rates in patients on treatment:50% in patients receiving PI23% in HIV patients not on PI29% in matched controls
One studyOne studyHigh prevalence (4.4%) osteonecrosis of the hip (asymptomatic patients)Symptomatic osteonecrosis of the hip 100X higher than Symptomatic osteonecrosis of the hip 100X higher than the general population
Metabolic and Skeletal Complications of HIV Infection. JAMA. 2006;296:844-854.AAHIVM Fundamentals of HIV Medicine 2007, 845-6