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Hiv

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Hiv

  1. 1. HIV/AIDS Pascale Gèhy-Andrè PA-C
  2. 2. <ul><li>Infection with HIV is Associated with many complications including: </li></ul><ul><li>Social </li></ul><ul><li>Emotional </li></ul><ul><li>Neuro-Phychiatric </li></ul><ul><li>Spiritual </li></ul>
  3. 3. Epidemiology <ul><li>Heterosexual transmission accounts for 75% of all HIV infections worldwide </li></ul><ul><li>40 million infected with HIV worldwide </li></ul><ul><li>Worldwide one in every 100 adults aged 15 to 49 is HIV Infected </li></ul><ul><li>Leading cause of death among all Americans age 25-44 </li></ul><ul><li>41% or 29.5 million adults with HIV/AIDS worldwide are women </li></ul>
  4. 5. Overview-Modes of Transmission <ul><li>Blood products </li></ul><ul><li>IVDA- sharing needles </li></ul><ul><li>Sexual contact- via exchange of body fluids </li></ul><ul><li>anal </li></ul><ul><li>oral </li></ul><ul><li>penile- vaginal </li></ul><ul><li>Accidental needle sticks </li></ul>
  5. 6. <ul><li>Phychosocial Impact of HIV-AIDS </li></ul><ul><ul><li>Anxiety </li></ul></ul><ul><ul><li>Discouragement </li></ul></ul><ul><ul><li>Discrimination </li></ul></ul><ul><ul><li>Change in Social Status </li></ul></ul><ul><ul><li>Coggnitive Dysfunction </li></ul></ul>
  6. 7. Prevention <ul><li>Cultural and Behavioral Diversity </li></ul><ul><li>Establishing Comprehensive HIV Prevention Program </li></ul><ul><li>Promotion of Condom use. www. Condomdirectory.com </li></ul><ul><li>Drug use interventions-risk reduction </li></ul><ul><li>Needle Exchange </li></ul><ul><li>Education </li></ul><ul><li>Refer to support groups </li></ul>
  7. 8. ROUTINE LABORATORY TESTS <ul><li>HIV + serology CMV serology </li></ul><ul><li>CBC Toxoplasma IgG </li></ul><ul><li>VDRL or RPR Pap Smear </li></ul><ul><li>Viral Load PPD test </li></ul><ul><li>Chest X-ray Cd4 count </li></ul><ul><li>Chemistry panel </li></ul><ul><li>Hepatitis serology </li></ul>
  8. 9. History <ul><li>Mode of transmission </li></ul><ul><li>Recent CD4 count if known </li></ul><ul><li>Any other chronic diseases </li></ul><ul><li>Any recent hospitalizations </li></ul><ul><li>Allergies </li></ul><ul><li>Sexual practices </li></ul><ul><li>Medications </li></ul>
  9. 10. Physical Exam <ul><li>Vitals- weight, body habitus </li></ul><ul><li>Bi-temporal wasting </li></ul><ul><li>Skin- any lesions </li></ul><ul><li>Mouth- oral thrush, leukoplakia </li></ul><ul><li>Lymphadenopathy- cervical, axillary, inguinal </li></ul><ul><li>Ophthalmologic exam </li></ul><ul><li>Neurological and Dementia Scale </li></ul>
  10. 11. PSYCHIATRIC COMPLICATIONS <ul><li>DRUG EFFECTS </li></ul><ul><li>DEPRESSION </li></ul><ul><li>ANXIETY </li></ul><ul><li>DELIRIUM </li></ul><ul><li>MANIA </li></ul><ul><li>PSYCHOSIS </li></ul><ul><li>HIV ASSOCIATED DEMENTIA </li></ul>
  11. 12. Counseling of HIV Patients <ul><li>Once diagnosed patient should be offered counseling. </li></ul><ul><li>Clinician should : </li></ul><ul><li>Be emphatic </li></ul><ul><li>Alert to emotional response </li></ul><ul><li>Provide information and emotional support. </li></ul>
  12. 13. When To Initiate Therapy <ul><li>Acute HIV or < 6 months after seroconversion </li></ul><ul><li>Symptomatic (AIDS, thrush, unexplained fever) </li></ul><ul><li>Asymptomatic- CD4 + T Cells <500/mm3 </li></ul><ul><li>HIV RNA>10,000 (bDNA) or >20,000 (RT-PCR) </li></ul>
  13. 14. Continued <ul><li>Asymptomatic -CD4+ T Cells>500/mm3 and HIV RNA <10,000 (bDNA) or <20,000 (RT-PCR) </li></ul><ul><li>Many experts would delay therapy and observe; however, some experts would treat. Some experts would observe patients </li></ul><ul><li>with CD4+ T cell counts of 350-500/mm3 and HIV RNA levels <10,000 (bDNA) or <20,000 (RT-PCR). </li></ul>
  14. 15. ANTIRETROVIRAL THERAPY: DRUGS
  15. 16. INITIAL DRUG REGIMEN <ul><li>Preferred: </li></ul><ul><li>2NRTIs + protease inhibitor or 2NRTIs + NNRTI </li></ul><ul><li>Alternatives for selected patients: </li></ul><ul><li>2 NRTIs plus Efavirenz </li></ul><ul><li>Abacavir plus 2 NRTIs </li></ul><ul><li>Minimal/suboptimal therapy: monotherapy (except in pregnancy) </li></ul>
  16. 17. INITIAL REGIMEN (CONT’D) <ul><li>Column A </li></ul><ul><li>Indinavir </li></ul><ul><li>Nelfinavir </li></ul><ul><li>Ritonavir </li></ul><ul><li>Ritonavir + Saquinavir </li></ul><ul><li>Saquinavir (Fortovase) </li></ul><ul><li>Amprenavir </li></ul><ul><li>Column B </li></ul><ul><li>AZT +ddI </li></ul><ul><li>d4t +ddI </li></ul><ul><li>AZT +ddC </li></ul><ul><li>AZT +3TC </li></ul><ul><li>d4t + 3TC </li></ul>
  17. 18. WHEN TO CHANGE THERAPY <ul><li>The goal of therapy is to reduce the level of HIV RNA to as low a level as possible for as long as possible. </li></ul><ul><li>Virologic failure is defined as a viral burden of >500 copies/ml at 4-6 months after starting a new regimen. </li></ul>
  18. 19. What to Change To <ul><li>Prior regimen </li></ul><ul><li>2 NRTIs +PI </li></ul><ul><li>2 NRTIs + nevirapine </li></ul><ul><li>2 NRTIs </li></ul><ul><li>1 NRTI </li></ul><ul><li>New Regimen </li></ul><ul><li>2 new NRTIs + PI </li></ul><ul><li>2 Pis +/- NRTI </li></ul><ul><li>PI + Nevirapine +>1 new NRTI </li></ul><ul><li>2 new NRTIs + a PI </li></ul><ul><li>2 new NRTIs + PI </li></ul><ul><li>2 new NRTIs +Ritonavir +Saquinavir </li></ul><ul><li>1 new NRTI + PI+NNRTI </li></ul><ul><li>2 Pis +NNRTI </li></ul><ul><li>2 new NRTIs +PI </li></ul><ul><li>2 new NRTIs +NNRTI </li></ul><ul><li>1 new NRTI +NNRTI+ PI </li></ul>
  19. 20. Questions to ask before starting a new drug. <ul><li>What is the patient taking? </li></ul><ul><li>Prescription or nonprescription </li></ul><ul><li>Can you and the patient identify what drugs the patient is taking? </li></ul><ul><li>How confident are you that the patient is taking the drugs prescribed? </li></ul><ul><li>Does the pt. Understand the effects and side effects of all medications they are taking? </li></ul>
  20. 21. THE “RED FLAG “ LIST <ul><li>P450 INHIBITORS </li></ul><ul><li>P450 INDUCERS </li></ul><ul><li>METABOLIZED DRUGS WITH NARROW THERAPEUTIC INDICES </li></ul><ul><li>RENALLY CLEARED DRUGS WITH NARROW THERAPEUTIC INDICES </li></ul><ul><li>DRUGS WITH SPECIFIC REQUIREMENTS FOR ABSORPTION </li></ul><ul><li>VIAGRA AND DRUG INTERACTIONS </li></ul>
  21. 22. ORAL THRUSH
  22. 23. ORAL HAIRY LEUKOPLAKIA
  23. 24. CHEST X-RAY- PNEUMOCYSTIS CARINII PNEUMONIA
  24. 25. ANAL - PENILE CONDYLOMATA
  25. 26. MULTIDERMATOMAL HERPES ZOSTER
  26. 27. VULVO-VAGINAL ANAL WARTS
  27. 28. Summary <ul><li>ESTABLISHING A TRUSTY PA -PATIENT RELATIONSHIP IS IMPORTANT </li></ul><ul><li>EACH VISIT STRESS ADHERENCE TO MEDICATION AND SAFE SEX PRACTICES </li></ul><ul><li>KNOW ALL DRUGS PATIENT IS TAKING </li></ul><ul><li>MONITOR BLOOD WORK AT LEAST 3-4 MONTH INTERVALS </li></ul><ul><li>UPDATE YOURSELF ON ALL RELEVANT NEW INFORMATION ON HIV THERAPY. LOG ON www. Anybody.com ! </li></ul><ul><li>IF YOU NEED HELP DON’T BE AFRAID TO ASK FOR A CONSULTATION. </li></ul>

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