August 2013 PLUS HIV Treatment

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August 2013 PLUS HIV Treatment

  1. 1. HIV Treatment: An Introduction August 4, 2013 Dr. Joanna Eveland, MS, MD HIV Medical Director, Clinica Esperanza Mission Neighborhood Health Center
  2. 2. Objectives • When, Why and What treatment to start • Overcoming side effects • Working with your healthcare providers to get the most out of treatment
  3. 3. When to start?
  4. 4. 8/5/2013 10,000,000 1,000,000 100,000 10,000 1,000 100 10 HIV in plasma (copies/mL) HIV in plasma (“viral load”) 800 500 200 100 50 0 CD4 Count (cells/mL) CD4 (T Cell) count Months Years Average progression without treatment: 10 years from infection to AIDS diagnosis Source: HRSA HIV/AIDS Bureau
  5. 5. 2012 Treatment Guidelines ART is recommended for all HIV+ individuals • Strength of the recommendation varies by CD4 count: o CD4 count <350 (AI) o CD4 count 350 to 500 (AII) o CD4 count >500 (BIII)
  6. 6. 2012 Treatment Guidelines Rating scale A = Strong B = Moderate C = Optional Rating of Evidence: I = data from randomized controlled trials II = data from well- designed nonrandomized studies with long-term outcomes III = expert opinion
  7. 7. 2012 Treatment Guidelines Treatment encouraged for special risk groups • Pregnancy (AI) • HIV-associated kidney disease (HIVAN) (AII) • Hepatitis B co-infection (AII) • Older patients (>50) (BIII)
  8. 8. Why Treat Early? Reduce Inflammation Uncontrolled HIV might increase risk of non-AIDS diseases: • Heart disease • Kidney disease • Liver disease • Dementia • Cancers
  9. 9. Why Treat Early? Treatment is Prevention • Large 2011 studies showing 92-96% decrease in HIV transmission with treatment • Guidelines say offer ART to all at risk of transmitting HIV (AI [hetero] or AIII [other risk groups])
  10. 10. Don’t start meds until… • You feel ready • You are well engaged in care • You can commit to taking your meds regularly • You feel that other life factors and potential barriers to adherence (drugs, drama, mental health) are under control
  11. 11. We have a long way to go…
  12. 12. What to start?
  13. 13. Where we started… • D
  14. 14. Where we are now… • D
  15. 15. Take Home Points • HIV treatment continues to improve- for the better! • Each person’s combination of medicines is different • KNOW what you take, and why.
  16. 16. Know What You’re Taking • HIV drugs have two, sometimes three, different names – Scientific name, brand name, chemical name – Zidovudine = Retrovir = AZT • Some tablets contain more than one ingredient – Atripla = tenofovir + emtricitabine + efavirenz
  17. 17. Goal of Treatment
  18. 18. General Principles • Goals: less pills, less times/day, less side effects • Use at least 3 drugs, 2 classes of medicines • Sometimes 3 isn’t enough – Your Protease Inhibitor may need a “Booster” – Drug resistance usually = more pills
  19. 19. Treatment Principles: Chinese Menu Metaphor  “Two scoops of rice plus chicken or beef” In other words, usually  2 “nukes”(NRTI) (2 scoops of rice) plus – 1 partner drug (main dish)  Protease Inhibitor (beef)  “non-nuke” NNRTI (chicken)
  20. 20. The Drugs… Each attacks the virus at a different point…
  21. 21. Where Do HIV Drugs Act?
  22. 22. NRTIs, “Nukes”
  23. 23. NRTIs Continued • Backbone of treatment • Older drugs are more toxic (AZT, “D- drugs”) – Peripheral neuropathy – Lactic acidosis – Pancreatitis – Lipodystrophy • Watch kidney function with Tenofovir
  24. 24. NNRTIs, “Non-nukes”
  25. 25. NNRTI: Pros and Cons  Ease (low pill burden)  Well tolerated  Less metabolic effects – No lipodystrophy, less dyslipidemia  Resistance develops quickly if <95% adherent – Single mutation – Cross resistance among NNRTIs  Rash; hepatotoxicity ADVANTAGES DISADVANTAGES
  26. 26. Efavirenz considerations • Most commonly prescribed NNRTI • Neuropsychiatric side effects: vivid dreams, sleep disturbance, “spaciness” • Caution for those with mental health issues
  27. 27. Protease Inhibitors
  28. 28. PIs: Pros and Cons • High potency • Less susceptible to resistance from virus • Second-line therapy when NNRTI fails • Metabolic complications - Increased cholesterol, blood sugar • GI side effects - Diarrhea, nausea • Drug interactions – Statins, viagra, anti- seizure, many others ADVANTAGES DISADVANTAGES
  29. 29. Integrase Inhibitor
  30. 30. Integrase Inhibitor • Approved as first- line regimen • Less side effects • Twice daily dosing • Low barrier to resistance • Newer drug • Drug interactions ADVANTAGES DISADVANTAGES
  31. 31. Entry Inhibitors
  32. 32. Entry Inhibitors • Currently used as salvage therapy for those with drug resistance • Fuzeon is injectable, rarely used • Maraviroc is well tolerated, requires CCR5 receptor on CD4 cells (not everyone has this)
  33. 33. Side Effects • Tend to be worst in the first 2 months of therapy • Severe side effects are a reason to change medications • Your expectations shape your experience
  34. 34. Getting The Most Out of Treatment
  35. 35. What If I Miss a Pill? • Risk of resistance increases with missing more than 1-2 doses/month • If you miss a dose, try and learn from it • If stopping your meds – All or none – Let us know!
  36. 36. Working With Your Provider • You deserve great care • Find the right fit • Educate yourself • Be engaged in care- regular visits • Uninsured? You can still get care!
  37. 37. Focus on Wellness • Manage stress • Exercise regularly • Quit smoking • Reduce harmful drug or alcohol use • Build a supportive community • Define and achieve your personal goals
  38. 38. Resources • Project Inform: 1-800-342-2437, • http://www.projectinform.org/ • AIDSmeds.com • thebody.com • HIVinsite.org • www.aidsinfonet.org/
  39. 39. Thanks • Drs Rick Loftus and Tri Do • The advocates and activists who gave us these treatments • My patients
  40. 40. More Questions? Dr. Joanna Eveland Clinica Esperanza 240 Shotwell St., SF (415) 431-3212 – Clinic Info (415) 552-3870 # 303 –My extension joannaeveland@mnhc.org

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