Hiv management ppt for counselors 2013
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  • Instant generation. <br />
  • Please refer to the Ethiopian DACA for current availability of drugs. <br />
  • Notes: showing features of ascites, hepaotmegaly, and cervical lymphadenopathy. <br />
  • Hepatotoxicity <br /> If occurs in first 8 weeks: appears to be a hypersensitivity reaction and may be accompanied by drug rash, eosinophilia, and systemic symptoms. <br /> Some patients have presented with nonspecific symptoms of hepatitis and progressed to hepatic failure. <br /> Some patients on NVP develop hepatotoxicity later in the course of treatment. This form of hepatitis is more benign and similar to hepatitis seen with other anti-HIV drugs. <br />
  • Most commonly appears on the body and arms <br /> Two forms <br /> Milder form – erythematous, maculopapular rash <br /> continue medication with close observation <br /> antihistamines may be administered <br /> Severe form – with mucous membrane involvement, SJS & TEN <br /> DRESS: Drug rash, eosinophilia, systemic symptoms <br /> D/C if fever, blisters mucous membrane, conjunctivitis, edema, arthalgias <br /> Usually appears within the first month of therapy, although occasionally it may start a few weeks later. <br /> Patients that do experience a rash during the 2-week lead-in should not increase the dose until the rash has resolved (mean duration of rash is 14 days). <br /> If the patient experiences rash and stops nevirapine on their own, provider would not reintroduce nevirapine with the dose escalation until the rash has resolved. <br /> Patients should call their provider or pharmacist or return to clinic if they develop a rash or have any blistering in the mouth, and if they develop fever, arthralgias, or myalgias. <br />
  • Rash <br /> Usually morbiliform <br /> Symptoms can be treated as needed (e.g., hydrocortisone cream and antihistamines for itching). <br /> If patient develops a more serious rash (blistering of mucous membranes or skin, seen in about 1%-2% of cases; or SJS) EFV should be discontinued. <br /> Median time of onset of the rash is 11 days and the duration is 14 days. <br /> Hepatotoxicity <br /> Rate is less frequent and less severe than seen with NVP. <br /> Increase risk of occurrence if co-infected with HCV or also taking other hepatotoxic medications <br /> Bioavailability (F): 40%-45% with or without food. <br /> CSF Levels: .25%-1.2% of serum levels (these levels are above the IC95 for wild-type HIV) <br /> T1/2: 40-55 hours <br /> Elimination: Metabolized by CYP450 3A4. 14% to 34% excreted in urine as glucuronide metabolites and 16% to 61% in stool. Do not need to adjust dose for renal or hepatic compromis. <br />
  • Nausea <br /> Most common side effect for AZT <br /> Eating prior to dose helps reduce nausea <br /> Macrocytosis is common and not associated with anemia, see increase in MCV of 25-40 units after 6-24 weeks, serves as crude indicator of adherence. <br />
  • Characterized by thinning of the buccal fat pad. May result or exacerbate stigma associated with HIV. <br /> Appears to be most common with long-term stavudine use. <br /> Usually not reversible, but changing medications may prevent progression. <br />
  • This slide puts “CD4 cells” in context of all cellular blood elements. <br /> CD4 cells are identified in the lab by a process called “flow cytometry.” <br />
  • Accurate and reliable enumeration of CD4 T cell counts is crucial for monitoring the rate of progression to AIDS, both for initiating prophylaxis for opportunistic infections as well as monitoring the impact of antiretroviral therapy (ART). <br />
  • Methodologies used to determine viral load. <br />
  • Changes in CD4 count that would be evidence of treatment failure include: <br /> Decline after previous increase; return to pre-ART baseline; failure to rise when ART is started <br /> Changes in viral load that would be evidence of treatment failure include: <br /> Possibilities: failure to achieve 1 log drop in viral load within first 4 weeks treatment; failure to achieve undetectable viral load within first 4-6 months of ART; persistent detectable virus after becoming undetectable; rise after achieving a stable, low level of persistent virus <br /> Resistance testing should be ordered when: <br /> available, a change in ART is being considered, and while patient is still taking the failing regimen <br />
  • Pharmacists play a critical role in detecting drug interactions, before they happen. <br /> Pharmacists need to ask patients what other medications they are currently taking whenever dispensing a new medication to avoid potential interactions. Be aware that changing or discontinuing medications may result in altered drug levels and potential adverse outcomes. <br />

Hiv management ppt for counselors 2013 Presentation Transcript

  • 1. Dr Madhu Oswal Samvad HIV AIDS Helpline Muktaa Charitable Foundation
  • 2. Overview PEP How to monitor after diagnosis ? When to start ART? What to start? How to monitor after starting ART? When to refer? 12/07/13 Samvad HIV Helpline 020-26381234
  • 3. Mayur Mr Mayur, 24 yr old, IT guy called at 10 am on Sunday morning. H/O Unprotected exposure (condom slipped) night before. Wants to know if he is HIV infected- TODAY. What to do? 12/07/13 Samvad HIV Helpline 020-26381234
  • 4. “Window Period” Following HIV Infection Acute HIV syndrome Primary HIV infection Antibod Asymptomatic Viremia ------------------------------------ PCR P24 a.g ELISA a 0 12/07/13 b 2 3 4 (Weeks since infection) Years Samvad HIV Helpline 020-26381234 Source: S Conway and J.G Bartlett, 2003 6
  • 5. Diagnosis in the window period After 12 weeks-antibody tests Elisa/Rapid At approx 4 weeks- HIV Duo At approx 2 weeks- HIV RNA HIV DNA P24 Ag test 12/07/13 Samvad HIV Helpline 020-26381234
  • 6. HIV DNA or RNA HIV DNA or RNA tests are NOT recommended for diagnosis in adults False positive results in almost 20% of patients Costs around Rs 4000. The patients have to be subjected to antibody testing for confirmation after 6 TO 12 weeks. 12/07/13 Samvad HIV Helpline 020-26381234
  • 7. What to do? Take history: was the risk significant? Explain about window period Any symptoms or signs of STD-Treat Test for baseline HIV status, Hbs Ag, ? Anti HCV Start PEP for HIV if indicated Start Heb B vaccine course, if not vaccinated or HbS Ag neg. Risk reduction counseling If woman( Mayuri), Emergency contraception 12/07/13 Samvad HIV Helpline 020-26381234
  • 8. Post Exposure Prophylaxis 12/07/13 Samvad HIV Helpline 020-26381234
  • 9. Drugs for Post exposure prophylaxis Basic regimen: 1. Tenofovir 300+ Emtricitabine 200mg OD OR 2. AZT 300 mg + Lamivudine 150 mg BD Expanded regimen: 1. Above plus Atazanavir 300 + Ritonavir 100 mg OD 2. Lopinavir 400mg +Ritonavir 100 mg BD All for 4 weeks Test after 6 weeks and 3 months for HIV and Hep B 12/07/13 Samvad HIV Helpline 020-26381234
  • 10. After 3 months…….. Mayur ‘s HIV test is Negative Risk reduction counseling . 12/07/13 Samvad HIV Helpline 020-26381234
  • 11. After 3 months…….. Mayur ‘s HIV test is Positive (……..May be because I didn’t take his call on Sunday ) Now what? 1. Disclose Mayur that he is HIV positive? 2. Do Western Blot test 3. Do HIV DNA/ RNA test? 4. Repeat Elisa test? 12/07/13 Samvad HIV Helpline 020-26381234
  • 12. Mayur has confirmed HIV test Now what? Don’t know how to break the news, so keep silent Refer to HIV specialist Manage further 12/07/13 Samvad HIV Helpline 020-26381234
  • 13. Mayur goes into depression Don’t turn up for 5 to 6 years
  • 14. Then one fine day Mayur comes with ……. 12/07/13 Samvad HIV Helpline 020-26381234
  • 15. Initial evaluation: history Fever, night sweats, weight loss, cough (any duration): TB Past H/o OI’s: herpes zoster, chronic diarrhoea ARV use in past Co-morbidities: DM, HTN, CKD, Jaundice Smoking, alcohol High risk behaviour Ask if he has any sexual partner, marital status , children 12/07/13 Samvad HIV Helpline 020-26381234
  • 16. Initial evaluation: physical examination Weight Lymphadenopathy Oral cavity Hepato-spleenomegaly, doughy feel of abdomen Fundoscopic Dermatological exam 12/07/13 Samvad HIV Helpline 020-26381234
  • 17. Initial evaluation: Laboratory workup  CBC with differential  Urinanalysis, creatinine  Blood sugar  Liver enzymes (optional)  Chest Xray/USG abdomen (before starting ART)  VDRL, TPHA  HbsAg, anti-HCV  CD4 Count  Cervical PAP smear in Mayuri CD4 to be taken after treating Herpes Zoster 12/07/13 Samvad HIV Helpline 020-26381234
  • 18. Tests NOT recommended routinely Plasma viral load ARV resistance testing Fasting lipids CMV, Toxo serology  sCRAG (in pts with CD4<200) TB ELISA Tuberculin testing IGRA assays( TB Gold, Quantiferon) 12/07/13 Samvad HIV Helpline 020-26381234
  • 19. Rule out TB Need to screen all HIV patients for TB Thorough history and physical to identify “TB suspects” CXR and sputum AFB for all “TB suspects” Need to screen all TB patients for HIV Active promotion and routine offering of VCT 19
  • 20. Mayur LOOKS very gloomy- as he he has given up on his life He has been keeping well for last 5 -6 years. No OI or co –morbidity. But he has taken to smoking and alcohol No abnormal findings on physical examination He has never married (He feels he won’t live long anyway). He has a girlfriend, whom he has not disclosed his status. All reports are normal. CD4 count 325 cells/ml 12/07/13 Samvad HIV Helpline 020-26381234
  • 21. What to do next? 1. Start ART? 2. Wait till CD4 falls upto 250 and start Septran 3. Start ayurvedic treatment or Amway products? 4. Refer? 12/07/13 Samvad HIV Helpline 020-26381234
  • 22. Reassurance!! Reassurance!!!!Reassurance !!!!!!! HIV is a chronic manageable disease like Diabetes, like Hypertension, like asthma. One can expect a near NORMAL lifespan with HIV infected individuals There is no cure, but with regular medicines one can lead a normal life 12/07/13 Samvad HIV Helpline 020-26381234
  • 23. More than just medicines… Mental health Diet Hygiene-water, air Exercise Lifestyle Addictions Financial security Disclosure / testing of partner, if indicated 12/07/13 Samvad HIV Helpline 020-26381234
  • 24. Chemoprophylaxis Medication Dose Indication Benefit TMP-SMX 1 DS qd CD<200 PCP Toxo Isospora, cycospora Typhoid Malaria Community UTI Dapsone 1 qd CD4<200 TMP_SMX HSR PCP Pyrimethamine 50 mg qwk CD4<200 With dapsone Toxo Azithromycin 1.2 qwk CD4<50 MAC INH 300 mg qd Rule out active TB MTB Hepatitis B vaccine to all Hbs Neg 12/07/13 Samvad HIV Helpline 020-26381234
  • 25. When to start ART? All Pt with hx of AIDS-defining condition All patients with CD4 T-cell count of <350 cells/mm3 All Pt that are pregnant, HIV nephropathy, HBV co- infection when HBV Rx is needed Recommended for all Pt with 350-500 cells/mm3 Optional for Pt with >500 cells/mm3 DSHS,January 10, 2011 12/07/13 Samvad HIV Helpline 020-26381234
  • 26. Benefits of ART The survival after development of advanced HIV disease increased from 18 months to over 25 years for those who can access medicines. Prevention of transmission Secondary prevention Post-exposure prophylaxis  Occupational and non-occupational Mother to child transmission Pre-exposure prophylaxis 12/07/13 Samvad HIV Helpline 020-26381234
  • 27. Fusion RNA Reverse transcriptase ZDV, ddI, ddC, d4T, 3TC, ABC, TDF, FTC DLV, NVP, EFV, ETV 12/07/13 Viral protease ENF CCR5 antag. maraviroc RNA Proteins RT RNA RNA RT DNA DNA DNA Samvad HIV Helpline 020-26381234 Provirus Integrase raltegravir SQV RTV IDV NFV fAPV LPV ATV DRV TPV
  • 28. Nucleoside Reverse Transcriptase Inhibitors( NRTIs) Tenofovir (TDF)Zidovudine (AZT) Lamivudine (3TC) Emtricitabine (FTC) Stavudine (d4T) Didanosine (ddI) Abacavir (ABC) Zalcitabine (ddC) Helpline 020-26381234 Samvad HIV 12/07/13
  • 29. Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) Nevirapine (NVP) Efavirenz (EFV) Etravirive Delaverdine 12/07/13 Samvad HIV Helpline 020-26381234
  • 30. First line regimens Preferred TDF/XTC/EFV or NVP( Trustiva, Effoday, ) Alternative AZT/3TC/EFV or NVP No options available d4T/3TC/EFV or NVP 12/07/13 Samvad HIV Helpline 020-26381234
  • 31. How to monitor when on ART? 1. Look for IRIS: Immune reconstitution inflammatory syndrome 2. Look for adverse effects- clinical and lab investigations 3. Watch for drug drug interaction 4. Monitor response to ART: CD4 and Viral load 12/07/13 Samvad HIV Helpline 020-26381234
  • 32. How to monitor when on ART? IRIS: Immune reconstitution inflammatory syndrome Iris is occurrence or manifestations of new OIs within six weeks to six months after initiating ART; with increase in CD4 count Two types: Unmasking and Paradoxical 12/07/13 Samvad HIV Helpline 020-26381234
  • 33. IRIS 3 weeks after ART (TDF+3TC+EFV) 12/07/13 Samvad HIV Helpline Source: Dr.Rajasekaran, Superintendent, GHTM,Chennai 020-26381234 33
  • 34. IRIS 12/07/13 Samvad HIV Helpline 020-26381234 34 Source: GHTM,Chennai
  • 35. How to monitor when on ART? TDF: Renal, bone( Do urine R, S creat) AZT: Anemia( Hb) EFV: CNS Nev: HSR, Hepatitis( LFT if symptomatic) d4T: Neuropathy, lactic acidosis 12/07/13 Samvad HIV Helpline 020-26381234
  • 36. Nevirapine (NVP) Rash Hepatitis Risk is greatest in first 6 weeks of therapy Could be benign or fatal Increased risk if started in women with CD4 above 250 and men with CD4 above 400 Not to use in concomitant Anti TB drugs 12/07/13 Samvad HIV Helpline 020-26381234
  • 37. 12/07/13 Samvad HIV Helpline 020-26381234 Courtesy of HIV Web Study, www.hivwebstudy.org
  • 38. Efavirenz Toxicity CNS Changes (excessive sleep or loss of sleep, delusions, nightmares) Rash Hepatotoxicity ( Contraindicated during pregnancy Teratogenic—Class D? Useful in TB with HIV Useful when stsrting ART in higher CD4 count 12/07/13 Samvad HIV Helpline 020-26381234
  • 39. Long term Toxicity (After few years) Bone Marrow Suppression Myalgia Anemia Myopathy Neutropenia Pigmentation of nail Peripheral Neuropathy beds Lipoatrophy Lactic acidosis, fatty Fat accumulation Osteoporosis Metabolic syndrome liver Pancreatitis Cardiovascular side effects Renal dysfunction Hepatic dysfunction 12/07/13 Samvad HIV Helpline 020-26381234
  • 40. 12/07/13 Samvad HIV Helpline 020-26381234
  • 41. Lipodystrophy 12/07/13 Samvad HIV Helpline 020-26381234
  • 42. Side effects/Toxicity of ART Acute side effects: Rash, headache, nausea, vomiting, loose motions, jaundice, anemia, excessive sleep or loss of sleep, delusions, nightmares. Chronic toxicity: Lipodystrophy- i.e change in body shape with reduces fat on face and extremities and increased fat deposition on abdomen and nape of neck. Diabetes, bone loss, increased fats in blood, tingling numbness in limbs 12/07/13 Samvad HIV Helpline 020-26381234
  • 43. Test On starting ART 2-8 weeks after starting ART Every 3 to 6 months Heamogram √ √ (If on ZDV) √ Urine R √ √ (If on TDF, esp in DM, HT) √ BSL -F √ ALT, AST ,S-bili √ √ √ S. creatinine √ √ √ S elec, S Ca, S Phos, Cr Cl √ √ √ Lipid profile √ CD4 count √ √ √( If very stable and high counts) Viral load √ √ √( If stable and adherent) 12/07/13 Every year √ Samvad HIV Helpline 020-26381234 √(If last report √ (If last report abnormal) normal)
  • 44. WBCs PMNs Eos CD4 (T helper) 12/07/13 RBCs Lymphs CD8 (T helper) Samvad HIV Helpline 020-26381234 platelets Grans others Macroph.
  • 45. Uses of CD4 Cell Count  Decision to initiate ARV  Guide in initiating OI prophylaxis  Assess progression of disease  Measure response to treatment (prognostication)  Detect immunologic treatment failure  Pneumocystis pneumonia  CD4 <200  TLC <1200  Toxoplasmosis  CD4 <100 and positive Toxoplasma serology  Cryptococcal meningitis  CD4 <100 12/07/13 Samvad HIV Helpline 020-26381234
  • 46. CD4 COUNT Normal CD4 count is 800-1050 cells/cu.mm CD4 decreases at a rate of 40-60 cells per yr in an HIV infected person. Diurnal variation. Treat OI before testing for CD4 count. Sample :3 ml in EDTA bulb CD4 count increases > 50 cells/mm3 at 4-8 weeks after ART and then increases an additional 50 – 100 cells / mm3 per year thereafter. Change more than 30% is significant. Ideally CD4 count to be measured every 6 months. 12/07/13 Samvad HIV Helpline 020-26381234
  • 47. 148 12/07/13 Samvad HIV Helpline 020-26381234
  • 48. Viral Load test of RNA PCR test Commercial methods/kits in use: Amplicor B-DNA NASBA Preferable use the same kit/ method for repeat testing Sample :3 ml in EDTA bulb Viral load should be below detectable level after 6 months of effective ART 12/07/13 Samvad HIV Helpline 020-26381234
  • 49. Viral Load Monitoring Where available, PCR or NASBA monitoring provide valuable information about ART effectiveness Viral load should be checked: Every 3-6 months when not on ART 6 months after starting ART Every 6 -12 months in stable ART patients 12/07/13 Samvad HIV Helpline 020-26381234
  • 50. 12/07/13 Samvad HIV Helpline 020-26381234
  • 51. Detection of Treatment Failure Immunological failure: If the CD4 cell count fail to rise, increase < 25-50 in 1st yr, decline after previous increase; return to pre-ART baseline. Viral load testing : Failure to achieve undetectable viral load within first 4-6 months of ART or rise after achieving a stable, low level of persistent virus In cases of 1st line treatment failure, refer to HIV specialist. 12/07/13 Samvad HIV Helpline 020-26381234
  • 52. Drugs with Potential to Interact with PIs or NNRTIs Statins (simvistatin & lovastatin) Azole antifungals Anticonvulsants Anti-TB (Rifampicin) Warfarin 52 Midazolam, trizolam Alternative medicine Clarithromycin Oral contraceptives Amitriptyline
  • 53. 12/07/13 Samvad HIV Helpline 020-26381234
  • 54. 3 years after starting ART….. Mayur has undetectable viral load, CD4 945 cells/cu mm No toxicity Mayur comes with Mayuri, his girl friend who wants to marry him , pretty well knowing his positive status. She is HIV negative. 12/07/13 Samvad HIV Helpline 020-26381234
  • 55. What would you ADVISE? Its illegal. They cannot marry. 2. She would get infected 3. They won’t have an option of having children 4. They can marry provided they are ready to adopt safer methods. 1. 12/07/13 Samvad HIV Helpline 020-26381234
  • 56. HPTN O52: The effectiveness of antiretroviral drugs in reducing sexual transmission of HIV, by up to 96% in serodiscordant couples. Prep trials ((iPrEx study, Partners PrEP, and TDF2, FEMPrEP) Circumcision : Male circumcision is associated with lower risk for HIV. May reduce female to male transmission( 50 to 60 %). 12/07/13 Samvad HIV Helpline 020-26381234
  • 57. Advise for discordant couple who want to have a child If male positive Undetectable viral load Sperm washing with IUI Timed intercourse with Prep If female positive Undetectable viral load IUI or Timed intercourse with Prep ART at-least from 14th weeks of pregnancy, till she stops breast feeding her child ART drugs for newborn for 4 to 6 weeks 12/07/13 Samvad HIV Helpline 020-26381234
  • 58. Mayur and Mayuri have a cute little baby girl To test or not to test? When to test and which tests to use? 12/07/13 Samvad HIV Helpline 020-26381234
  • 59. Diagnosis in child born to HIV +ve mother After 18 months- Before 18 months- 12/07/13 Antibody tests (Elisa/Rapid/WB) Antigen test (HIV DNA PCR) Samvad HIV Helpline 020-26381234
  • 60. Advise for PPTCT ART throughout pregnancy If viral load undetectable close to labour, no need of Caesarian section Breast feeding advisable , but mother should continue ART ART drugs for newborn for 4 to 6 weeks Chances of baby getting infection below 5% . AIDS FREE GENERATION 12/07/13 Samvad HIV Helpline 020-26381234
  • 61. Ending AIDS: AIDS 2012   12/07/13 Samvad HIV Helpline 020-26381234
  • 62. Will AIDS really end? Most unlikely. No.s will fall for some time It will restrict itself again among those who practice risky behaviour, eg People practicing risky behaviour; Sex workers; MSM But complacency will bring it back again as our track record against any STD is poor. First line- Second line-Third line –Salvage regimen 12/07/13 Samvad HIV Helpline 020-26381234
  • 63. Thank You 12/07/13 Samvad HIV Helpline 020-26381234