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SUBSTANCE ABUSE & HIV DISEASE

SUBSTANCE ABUSE & HIV DISEASE. Janet L. Mitchell, M.D., M.P.H., F.A.C.O.G. Consultant on Women’s Health Addiction, Research & Treatment Corporation Brooklyn, NY. Epidemiology HIV care. EPIDEMIOLOGY. AIDS Cases by Age and Sex. Reported 1981-1999, United States. 40,000. 35,000.

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SUBSTANCE ABUSE & HIV DISEASE

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  1. SUBSTANCE ABUSE& HIV DISEASE Janet L. Mitchell, M.D., M.P.H., F.A.C.O.G. Consultant on Women’s Health Addiction, Research & Treatment Corporation Brooklyn, NY

  2. Epidemiology • HIV care

  3. EPIDEMIOLOGY

  4. AIDS Cases by Age and Sex Reported 1981-1999, United States 40,000 35,000 Male N=609,326 Female N=124,045 30,000 25,000 Number of Cases 20,000 15,000 10,000 5,000 0 0 10 20 30 40 50 70 80 90 60 Age at Diagnosis

  5. AIDS Cases in Adult/Adolescent Men, Reported July 1998 - June 1999, and Estimated AIDS incidence,* Diagnosed July 1998 – June 1999 by Risk Exposure United States Risk Exposure Men who have sex with men Injection drug 45% 53% use (IDU) MSM/IDU <1% Heterosexual 21% 21% contact <1% 27% Transfusion 13% 1% Hemophilia 8% 6% 5% Other/not <1% identified <1% AIDS Incidence Reported Estimated AIDS Incidence* July 1998 - June 1999 Diagnosed July 1998 - June 1999 * Data adjusted for reporting delays and estimated proportional redistribution of cases initially reported without risk. Data reported through March 2000.

  6. AIDS Cases in Adult/Adolescent Women, Reported July 1998 - June 1999, and Estimated AIDS Incidence,* Diagnosed July 1998 - June 1999, by Risk Exposure United States Risk Exposure Injection drug use (IDU) Heterosexual 28% 36% contact 40% Transfusion 62% <1% Hemophilia 1% 31% Other/not 1% identified <1% 2% AIDS Incidence Reported Estimated AIDS Incidence* July 1998 - June 1999 Diagnosed July 1998 - June 1999 * Data adjusted for reporting delays and estimated proportional redistribution of cases initially reported without risk. Data reported through March 2000.

  7. HIV CARE

  8. “Women should be treated for their disease first.”

  9. AIDS Cases by Age and Sex Reported 1981-1999, United States 40,000 35,000 Male N=609,326 Female N=124,045 30,000 25,000 Number of Cases 20,000 15,000 10,000 5,000 0 0 10 20 30 40 50 70 80 90 60 Age at Diagnosis

  10. Trends in Annual Rates of Death from Leading Causes of Death Among Black Women 25-44 Years Old, USA, 1982-1998 *Preliminary 1998 data National Center for Health Statistics National Vital Statistics System

  11. Trends in the Percentage Distribution of Deaths from HIV Infection, By Sex, USA, 1987-1997 National Center for Health Statistics National Vital Statistics System

  12. Trends in the Percentage Distribution of Deaths from HIV Infection, By Race, USA, 1987-1997 *Asian, Pacific islander, or American Indian National Center for Health Statistics National Vital Statistics System

  13. Age-adjusted* Mean Rate of Death from HIV Infection during 1993-1997, By Race / Ethnicity and Geographic Region, USA *Adjusted to the age distribution of the projected year 2000 U.S. population National Center for Health Statistics, National Vital Statistics System

  14. Is the Disease Different? • Diagnosis • Presenting complaints • Presenting diagnosis • Presentation • Heterosexual • Over 50 age group • Treatment response • CD4/Viral load • Response to therapies

  15. HIV Care • Anti-retrovirals • Prophylaxis • Co-morbid conditions

  16. HIV Care & Women’s Health • Pre-conceptual Counseling • Pregnancy Planning? • Anti-retrovirals • Efavirenz? • Prophylaxis • Co-morbid conditions • Diabetes • HTN

  17. Pharmacokinetic of Indinivir in Menstruating Womenn=6 (age 37±5.4 years, CD4 count 354±137 cells/mm3)

  18. ARV Effect on EE Recommendation Nevirapine  EE AUC 19% Do not use Efavirenz  EE AUC 37% Usual doses Indinavir No interaction Usual doses Nelfinavir  Levels EE Do not use Amprenavir No interaction Usual doses Ritonavir  Levels EE Do not use Interactions Between ARV and Ethinyl Estradiol

  19. “Lipodystrophy”What does it mean?

  20. HIV-Associated Lipodystrophy Hyperlipidemia Insulin resistance Fat accumulation Fat atrophy

  21. Aims: Guidelines • Glucose metabolism • Lipid metabolism • Body composition • Cardiovascular risk • Lactic acidemia • Osteopenia

  22. Lipid Control Contrast of PI Reported Data Activella ™ 1mgE/.5mg NETA Ortho-Prefest™ 1mgE/.09 mg NGM Prempro® .625mgE/2.5 mg MPA FemHRT ™ 5mcgE/1mg NETA 3.5 HDL 9.7 -6.7 -12.4 -4.9 -7.5 LDL -8.8 -10.8 9.4 2.2 12.1 24.1 Triglycerides Lipid Profile (mean % change from baseline after 1 year of treatment)

  23. OBSTETRICAL CARE

  24. Pregnancy • Pregnancy does not accelerate HIV disease • Stage of HIV disease can impact pregnancy outcome • Perinatal transmission rates depend on multiple factors • The use of anti- retrovirals for the treatment of the woman’s disease  transmission rates > than elective c/sections

  25. Current Standard of Care for Pregnant Women in Developed Countries Combination Anti-retroviral Therapy (should include AZT if appropriate)

  26. Perinatal Transmission Rates • Zidovudine/ ACTG 076 • Combination therapy/HAART • Nevirapine • Elective c/section

  27. Safety and Toxicity of Individual Antiretroviral Agents in Pregnancywww.hivatis.org/guidelines/adult/text/pregnancy1.html

  28. Antiretroviral Pregnancy Registry 1410 Commonwealth Drive Wilmington, NC 28403 telephone (800) 258-4263 fax (800) 800-1052

  29. CDC WEBSITE:http://www.cdc.gov/hiv/graphics.htm

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