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HIV Update for Case Managers

HIV Update for Case Managers. February 12, 2003 Cyril K. Goshima, M.D. Clinical Assistant Professor of Medicine John A. Burns School of medicine. Case Managers. Who are you? What do you do? What do you want to know? Why do you want to know that?. HIV Disease.

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HIV Update for Case Managers

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  1. HIV Update for Case Managers February 12, 2003 Cyril K. Goshima, M.D. Clinical Assistant Professor of Medicine John A. Burns School of medicine

  2. Case Managers • Who are you? • What do you do? • What do you want to know? • Why do you want to know that?

  3. HIV Disease • Interaction between the Virus, the Immune System, Behavior, and the Socio-Economic System

  4. The Reality • AIDS is not over. • People continue to die from AIDS. • Treatment is difficult, life long, expensive, not curative • Lifetime treatment average cost $155,000 and rising

  5. The Numbers • World Wide Epidemic • There are more cases outside of the United States. • The hot spots are in Sub-Saharan Africa, South East Asia, Indian Subcontinent, Eastern Europe. • Risk Population Heterosexual, IDU.

  6. The Numbers • United States different disease • Infections occur in 40,000 persons per year • MSM continue to be the highest risk group. Increase by 17% last year. • Increases occurring in heterosexual cases and in the black population

  7. Risk Behavior Among MSM • HIV prevention fatigue among older gay men. • Fewer prevention efforts reaching marginalized MSM. • Increase popularity of bath houses and sex clubs. • Viral load beliefs. • Internet chat rooms to meet sex partners. • Treatment optimism. • Lack of fear.

  8. Treatment Targets • Based on knowledge of the life cycle of HIV and the components of replication. • Drugs are developed to specifically target aspects of the virus life cycle. • Recent approval of the fusion inhibitor, T-20 or Fuzeon. • Now there are Reverse Transcriptase Inhibitors, Protease Inhibitors, and Fusion Inhibitors.

  9. Drug to Drug Interactions • Ritonavir and NNRTI • Now Tenofovir interactions: ATZ, ddI • Now Amprenavir and fosAmprenavir interactions with Kaletra • Antivirals affect the levels of or are affected by common medications like estrogens, methadone, PPI

  10. Drug Resistance • Primary resistance in chronic untreated HIV patients is occurring. • Low level vs. High level resistance • Cross Resistance • Concepts • Limits treatment options

  11. Treatment • Does treatment earlier have better outcomes clinically, virologically, or immunologically? • In Mellors study, the risk of developing AIDS after 3 years increased significantly in patients with CD4 350 or less. • In the MACS, the risk of developing AIDS in the untreated patient increased with viral loads between 40-60,000.

  12. Treatment • Sterling reported that there was no change in disease progression in the treated vs. non-treated patients whose CD4 count was over 350. In the treated group there was viral resistance, lipodystrophy, multiple regimens used, and approximately half not having undetectable viral loads.

  13. Treatment • Adherence continues to be a concern. • Non-Adherence may be multi-factorial. • Once daily medications: NRTI: TDF, 3TC, DDI, FTC, (ABV) NNRTI: EFV, NVP PI: APVr, fAPVr, SQVr, LPVr, ATVr, ATV

  14. Resistance Testing • When to use? • What to use: Genotype, Phenotype, both? • Are they all the same? • Expert interpretation. • Expensive • Basically tell us what not to use.

  15. Weak Viruses • Wild type virus is a “strong” virus. • Resistant viruses or viruses with mutations are “weak” viruses. • Decreased Viral Replicative Capacity. • Decreased Viral Pathogenicity. • Better to be on medication than no medication in heavily treated patients who have multiple resistant viruses.

  16. Metabolic Complications • Osteopenia & Osteoporosis • Osteonecrosis/Avascular Necrosis • Alterations in Glucose Metabolism • Alterations in Lipid Metabolism • Morphological Changes • Cardiovascular Risk • Mitochondrial toxicity

  17. Bones • Contributions to osteopenia/osteoporosis: Decreased activity, weight loss, wasting syndrome, malnutrition, malabsorption, low testosterone. • Osteonecrosis/Avascular Necrosis: Alcohol, hyperlipidemia, osteoporosis, testosterone therapy

  18. Sugar, Fat, and the Heart • Glucose intolerance, diabetes, Insulin Resistance • High Triglycerides, high total cholesterol, high LDL, low HDL • Cardiovascular Risk: Insulin resistance, central obesity, glucose intolerance, hyperlipidemia

  19. Lipodystrophy • Fat accumulation: dorsocervical fat pad, neck, breast, intra-abdominal • Fat loss: face and extremities • Medications implicated • Treatment poor

  20. AIDS • Human Sexuality • Unequal Treatment between Men and Women in Society • Economic Disparity within a country and between countries • One World

  21. Questions?

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