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Kerry Chamberlain D.O., FACOI Florida Cancer Specialists January 23, 2019

30 th Annual Pinellas County Osteopathic Medical Society Winter Seminar HIV/AIDS Treatment in Today's Medical Environment. Kerry Chamberlain D.O., FACOI Florida Cancer Specialists January 23, 2019. Objectives. Historical perspective Role of primary care

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Kerry Chamberlain D.O., FACOI Florida Cancer Specialists January 23, 2019

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  1. 30th Annual Pinellas County Osteopathic Medical Society Winter SeminarHIV/AIDS Treatment in Today's Medical Environment Kerry Chamberlain D.O., FACOI Florida Cancer Specialists January 23, 2019

  2. Objectives Historical perspective Role of primary care Recognize common presentations of HIV Update ofpre & post exposure prophylaxis

  3. Wall Street Journal January 2018 • New HIV up 48% from 2015-2016 Northern Ky • 2015 Indiana declared a public health emergency with opioid painkillers via injection with more than 200 affected individuals (as of 2017 6.67 million or 0.002998%-Alexa) • Concomitant HIV cases increased from 91 -229 in 2017 • 22% secondary to IV drug abuse in 2017 9% secondary to IV drug use in 2016

  4. HIV 2018 Men who have sex with men bear the greatest burden by risk group, representing 66% (25,748) in 2017. In 2017, 38,739 people received an HIV diagnosis. In the US the annual number of new diagnoses has remained stablefrom 2012 to 2016.

  5. HIV 2018 An estimated 1.1 million people in the United States were living with HIV at the end of 2015, Of those people ~1 in 7, did not know they were infected (WHO ~ 10% Africa) Yes people still die from HIV. In the United States, 6,721 people died from HIV and AIDS in 2014—15,807 from any cause. HIV remains a significant cause of death for certain populations. In 2014, it was the 8th leading cause of death for those aged 25-34 and 9th for those aged 35-44.

  6. Incidence 2018 New HIV infections in the United States have been in decline 1.8 million new cases in 2016 world wide 36.7 million living worldwide with HIV

  7. Global HIV • 37 million people living with HIV • 19.5 million receiving ART • TB is the leading killer of HIV infected • 25% of the worlds population is infected with TB • Nearly 2,000,000,000 people infected with TB

  8. Factoids of HIV Half life of HIV in serum is 1.2 days 24 hours intracellular 6 hours extracellular ~ 30% of total body viral burden is turned over daily– this means that AIDS is a result of continuous high level HIV-1 replication and destruction of CD4 lymphocytes Unclear why 99.7% of occupational exposures DO NOT transmit the virus

  9. Stages of HIV Infection Transmission Acute infection (primary HIV infection) Seroconversion Clinical latent period w/wo adenopathy Early symptomatic HIV infection AIDS (CD4 <200/ml & other criteria) Advanced AIDS (CD4 <50/ml)

  10. History & Perspective 1983 – discovered to be a retrovirus 1985 – discovered a serological test for diagnosis 1987- discovered the first antiviral drugs 1996 – introduction of HAART (highly active antiretroviral therapy) 1999- the mortality of AIDS diagnosis and hospitalizations fell 60-80%

  11. Early HIV Infection 6 month period following acquisition 10–20 percent will be without symptoms

  12. WHO clinical staging of HIV/AIDS • Primary • Clinical stage I • Clinical stage II • Clinical stage III • Clinical stage IV

  13. WHO clinical staging of HIV/AIDS • Primary HIV infection Asymptomatic Acute retroviral syndrome • Clinical stage I Asymptomatic Persistent generalized lymphadenopathy

  14. WHO clinical staging of HIV/AIDS • Clinical stage II • Unexplained weight loss < 10% • Recurrent infections • Herpes zoster • Angular colitis • Recurrent oral ulcerations • Papular pruritic eruptions • Several reticulocyte dermatitis • Toenail fungus infection

  15. WHO clinical staging of HIV/AIDS • Clinical stage III • Unexplained weight loss greater than 10% • Unexplained chronic diarrhea • Unexplained persistent fever greater than 37.6 • Persistent oral candidiasis • Oral hairy leukoplakia • Pulmonary tuberculosis • Severe bacterial infections • Acute necrotizing stomatitis, gingivitis, or periodontitis

  16. WHO clinical staging of HIV/AIDS • Clinical stage IV-presumptive diagnosis • HIV wasting syndrome • Pneumocystis pneumonia • Recurrent severe bacterial pneumonia • Chronic herpes simplex infection • Esophageal candidiasis • Extra pulmonary tuberculosis • Kaposi’s sarcoma • CNS toxoplasmosis • HIV encephalopathy

  17. WHO Clinical Staging of HIV/AIDS • Conditions were confirmatory diagnosis is necessary • Extrapulmonarycryptococcosis • Disseminated Mycobacterium • Progressive multifocal leukoencephalopathy • Candidiasis –pulmonary tree • Chronic cryptosporidiosis • Chronic isosporiasis • Visceral herpes • Cytomegalovirus • Disseminated atypical leishmaniasis

  18. Clinical Manifestations of Acute HIV • Fever • Pharyngitis • Fatigue • Cervical adenopathy • Myalgia & arthralgia • Rash • Pel-Ebstein fevers • Headache • Diarrhea • Dry cough

  19. Laboratory Features of early HIV Infection • Leukocytosis–varies • Heterophile antibody test— • Mucocutaneous ulceration is unusual • Rashes less common in mononucleosis • Negative during acute HIV infection -usually • Differential diagnosis • Mononucleosis, cytomegalovirus, toxoplasmosis, rubella, syphilis, hepatitis, lupus

  20. Initial Testing • Drug resistance • 15-20% will have at least one resistant mutation • Mutations in transmitted strain depend on the antiviral strain at the source • Non-nucleoside reverse transcriptase inhibitors are more common than protease inhibitor resistant mutations

  21. Early Symptomatic HIV Infection Thrush Vaginal candidiasis Oral hairy leukoplakia Herpes Zoster (2 episodes or > one dermatome) Peripheral neuropathy Bacillary angiomatosis--Bartonella

  22. Early Symptomatic HIV Infection Continued • Cervical dysplasia • Cervical carcinoma in situ • ITP • PID • Listeriosis • Constitutional symptoms • Fever (38.5) • Diarrhea > 4 fluid stools for > 3 days

  23. Risk Factors for Transmission Viral load Circumcision Sexual risk Ulcerative sexually transmitted diseases Nitrate inhalant use—no traceable link currently Host and genetic factors

  24. HIV in the Elderly Defined as greater than 50 years old ~ 40% of HIV infected will be in greater than 50 years old in the research literature 2.8 million infected are greater than 50 world wide Sexual exposures most common mode of transmission In the last 12 months 53% of those 65-74 years old for sexually active and 26% age 75–85-year-old

  25. HIV in the Elderly-continued In men MTM transmission most common in the US, Europe, & Australia–heterosexual exposure for the rest of the world In women heterosexual contact us the most common Polypharmacy is a problem–study of 89 patient’s older than 60 the median number of medications was 13 ART more effective than those less than 50

  26. Primary Care in HIV Extremely important Disease is often missed Patients are highly infectious at the time Patients are unaware of the risk of the disease and the spread*--Science is a little “goofy” here on this reference this factoid comes from a study of 235 monogamous HIV infected Ugandan couples

  27. Establishing the Diagnosis Infrequent in clinical practice? Considered in 5 of 19 patients who sought care via a primary care setting (Seattle) – in those who were enrolled in a HIV SURVEILLANCE STUDY

  28. Establishing the Diagnosis Continued Vague symptoms Financial burden on the physicians Physician bias Patients prefer the anonymous testing of “clinics” Patients don’t see themselves at high risk– remember “a alcoholic is someone who drinks more than his physician”

  29. Guidelines of HIV screening of Gay, Bisexual, and MTM • Annual (some data suggests 3-6 months)—adjustment based on risk factors such as Individual risk factors Local HIV epidemiology Local policies • For those who are prescribed pre-exposure prophylaxis HIV testing every 3 months and immediate testing when indicated

  30. HIV Transmission and Prevention among Healthcare Workers • Needle stick exposure 0.23% risk of becoming infected (2.3 out of every 1000 Cases) • Risk of exposure due to contact with body fluids is near 0

  31. HIV tests • Nucleic acid (NAT) • Antigen/antibody tests • Antibody tests

  32. Nucleic acid (NAT) • Looks for the actual virus in the blood • Test will be positive or negative–can give viral load • Typically cost prohibitive for screening • Highly accurate during the early stages • Often combined with the antibody or antigen/antibody test

  33. Antigen/Antibody test • Looks for both antibodies and antigen • The antigen P 24 is recognized even before antibodies developed

  34. HIV Home Testing Home access HIV–1 test system Blood from the vein, finger stick, or with oral fluid with results sent to a license lab Testing is anonymous If positive follow-up test is immediate

  35. HIV Home Testing OraQuick In-Home HIV Test Mouth swab 20 minutes result if positive follow-up testing needed 1-12 infected people may test falsely negative

  36. Pre-exposure Prophylaxis 2018 • Reduces the risk from sex by more than 90% when used consistently • Risk due to injectabledrugs reduced by more than 70% when used consistently • Needs to be taken daily • Maximum protection for receptive anal sex is about 7 days of daily use and 4 receptive vaginal sex and IV drug use at about 20 days of daily use

  37. Preexposure Chemoprophylaxis for HIV Prevention in Men Who Have Sex with Men NEJM December 30, 2010 Vol.363 NO. 27

  38. In this study, 2499 HIV-seronegative men or transgender women who were at high risk for HIV acquisition were enrolled in a trial of daily emtricitabine plus tenofovir (Truvada) versus placebo. Study Overview

  39. Kaplan–Meier Estimates of Time to HIV Infection (Modified Intention-to-Treat Population). Grant RM et al. N Engl J Med 2010;363:2587-2599

  40. Oral FTC–TDF (Truvada) provided protection against the acquisition of HIV infection among the subjects. Detectable blood levels strongly correlated with the prophylactic effect. Those receiving the antiretroviral medication had a 44% reduction in HIV incidence. Conclusions

  41. Postexposure Prophylaxis against Human Immunodeficiency Virus. • Am Fam Physician. 2010 Jul 15;82(2):161-6.

  42. Postexposure Prophylaxis 2018 • Emergency use only within 72 hours • Should not be used as a substitute for pre-exposure prophylaxis

  43. Treatment-The Debate Goes On Continued • Risks: • Longer drug exposure i.e. toxicity to the patient • Evolution of drug resistance

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