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HIV clinical issues for case managers


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HIV patient outcomes have been shown to improve with appropriate support by case management. HIV case managers need to have a working understanding of clinical management issues to improve on the great work that they do for their patients. This presentation attempts to provide case managers with this information.

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HIV clinical issues for case managers

  1. 1. HIV CLINICAL ISSUES for Case Managers ADVANCED HIV CASE MANAGEMENT COURSE Leonard A. Sowah, MBChB, MPH Assistant Professor of Medicine Institute of Human VirologyUniversity of Maryland School of Medicine
  2. 2. HIV Virus Life Cycle09/29/12
  3. 3. Clinical Course of HIV Infection Acute or primary infection  Rash  Fever  Flu like symptoms  Fatigue  Sore throat Prolonged Asymptomatic  Immune activation leads to CD4 cell decline Early symptomatic phase  Herpes zoster  Increased risk of common infections  HIV Dermatopathy Advanced HIV or AIDS  Opportunistic Infections
  4. 4. CD4 Cells  A type of white blood cell that carries the CD4 surface marker and helps the body fight infection. Also known as T-cells or T-helper cells. When infected by HIV, these cells incorporate HIV RNA into their DNA and subsequently manufacture new HIV particles.09/29/12
  5. 5. HIV Viral Load  Viral load means how much HIV is in the patient’s bloodstream (also called HIV RNA).  “Undetectable viral load” means the amount of the virus is so low, the blood tests cant detect it.  Doctor’s use a combination of medicines to try and get the patient’s viral load to an undetectable level and keep it there.  Even when a viral load is extremely low or undetectable, the client should continue taking prescribed HIV medications.09/29/12
  6. 6. AIDS - Acquired Immunodeficiency Syndrome  The most severe manifestation of HIV infection. Characterized by numerous opportunistic infections and malignancies or a CD4 cell count below 200/mm3, which, in the presence of HIV, constitutes a diagnosis of AIDS.09/29/12
  7. 7. Course of HIV Infection09/29/12
  8. 8. From CLIN INFECT DIS 30(S1):S5-S14. © 2000 by the Infectious Diseases Society of America. All rights reserved09/29/12
  9. 9. Common Opportunistic Diseases in HIV  Pneumocystis pneumonia  Oropharyngeal candidasis  Pulmonary tuberculosis  Herpes zoster  Cryptococcal Meningitis  CNS Toxoplasma  Non Hodgkins Lymphoma  HIV Encephalopathy09/29/12
  10. 10. Causes of death in the HAART era Current Opinion in Infectious Williams & Wilkins, 25(1):36-41, February 2012. © 2012 Lippincott Diseases. Inc. Published by Lippincott Williams & Wilkins, Inc. 209/29/12
  11. 11. Causes of Death among Persons with AIDS in the HAART Era : New York City © 2006 AmericanAnnals of Internal Medicine. 145(6):397-406, September 19, 2006. College of Physicians. Published by American College of Physicians.
  12. 12. VIRAL ENTRY AND REPLICATION Sources of HIV virus in an infected person blood breast milk saliva semen tears vaginal fluids Transmission has been documented only through blood blood products sexual fluids Breast milk 09/29/12
  13. 13. Current HIV drugs and their targets in the viral cell cycleCCR5 Antagonist Fusion Inhibitors NNRTIs & NRTIs Protease Inhibitors Integrase Inhibitors Copyright © 2003 by the European Molecular Biology Organization 09/29/12
  14. 14. Current FDA Approved HIV Medications ©2006 Community Research Initiative of New England. All Rights Reserved.09/29/12
  15. 15. When to start therapy (DHHS Guidelines)  CD4 counts < 500 cells  Observational data and cohort studies suggests clinical benefit for patients treated with CD4 > 500 cells  History of AIDS-defining illness  HIV-associated nephropathy (HIVAN)  Pregnant women  Hepatitis B co-infection  Rapidly declining CD4 count  High viral loads > 100,000 /ml09/29/12
  16. 16. When to Start ART  Exact CD4 count at which to initiate therapy not known, but evidence points to starting at higher counts  Current recommendation: ART for all patients with CD4 <500 cells/µL  For patients with CD4 >500 cells/µL, 50% of the panel recommend ART, 50% consider ART to be optional  Randomized control trial (RTC) data support benefit of ART if CD4 ≤350  No RTC data on benefit of ART at CD4 >350, but observational cohort data www.aidsetc.org09/29/12
  17. 17. Assessing Readiness for Therapy  Knowledge about disease  Prior adherence history  Individual self efficacy  Beliefs about Efficacy and safety of ART regimen  Age / income /education  Drug use  Dosing frequency  Pill burden ????09/29/12 J Gen. Intern Med 2002;17: 756 -765
  18. 18. Choice of Initial Regimen  Efficacy  Toxicity  Clinical Co-morbidity  Results of Genotypic resistance testing  Substance abuse and psychiatric issues  Potential for drug interactions  Ease of Administration  Consistency with patient lifestyle09/29/12
  19. 19. Common Side Effects of HIV Meds FACE SKIN Lipoatrophy Rashes Loss of fat in cheeks, temples or extremities HEART BODY Hyperlipidemia, High Cholesterol and High Glucose Lipodystrophy Increase in the amountIncrease in abdominal size, breast of fat, cholesterol, or size, and/or dorsocervical fat pad sugar in the blood that (buffalo hump) can lead to heart disease LIVER KIDNEYS Hepatotoxicity Liver damage Nephrotoxicity, Kidney Stones Kidney damage NERVES GUT Neuropathy Nausea, Diarrhea and Vomiting Nerve damage causing strange sensations and pain, starting in the hands/feet BLOOD BONES BONES Anemia Osteoporosis, Osteopenia Low number of blood cells; Bone loss causes fatigue
  20. 20. Immune-Reconstitution Inflammatory Syndrome (IRIS)  What is IRIS ?  Paradoxical worsening of clinical symptoms in a HIV positive patient upon therapy initiation from pre-existing infections.  10 – 25% of patients started on HAART  Within 12 weeks of onset of HAART  CD4 count of HAART start <100 cells/m3  Drop in viral load of > 2.5 log copies09/29/12
  21. 21. Common Manifestations of IRIS  Anogenital Herpes virus infection  Genital warts  Molluscum contagiosum  Shingles  Tuberculosis  MAC Infection  PCP  Hepatitis Sources for pictures: http://www.medicinenet.com09/29/12
  22. 22. Perinatal HIV Transmission  Without antiretroviral (ARV) drugs during pregnancy, mother-to-child transmission (MTCT) has ranged from 16%–25% in North America and Europe.  21% transmission rate in the U.S. in 1994 before the standard zidovudine (ZDV) recommendation during pregnancy.  With this change in practice, transmission decreased to 11% in 1995.  Today, risk of perinatal transmission can be <2% with:  effective antiretroviral therapy (ART)  elective cesarean section (C/S) as appropriate  formula feeding09/29/12
  23. 23. Hepatitis C and HIV  30 - 40% of HIV+ people in US also infected with HCV  More rapid progression of HCV (twice as fast)  Little to no affect on HIV progression  (still inconclusive)  Complicates medication regimens  Increases risk of perinatal transmission  Incarceration and injection drug use settings have co-infection rates >75%  Treatment effectiveness is heavily determined by genotype09/29/12
  24. 24. Other Clinical Issues in HIV Care  Kidney Disease  Hyperlipidemia  Cardiovascular Disease  Liver Disease  COPD  HIV Neuropathy  Cognitive Impairments09/29/12
  25. 25. End of Life Needs  Advanced Directives  Power of attorney  Disease management  Hospice Care  Comfort Care  Insurance Issues09/29/12
  26. 26. Summary  HIV viral replication can be suppressed with Anti Retroviral Therapy  Risk of development of drug resistance is high in non adherent patients.  Individualized choice of therapy regimen and when to initiate ART may reduce risk of treatment failure and development of resistance  Effective team work between case manager and HIV provider can reduce therapeutic failure and improve patient satisfaction09/29/12