HIV Treatment Overview

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HIV Treatment Overview

  1. 1. HIV Treatment: An Introduction October 20, 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. 11/7/2013 Source: HRSA HIV/AIDS Bureau
  5. 5. 2013 Treatment Guidelines Antiretroviral therapy is recommended for all HIV+ individuals regardless of CD4 count
  6. 6. Why Treat Early?  Prevent irreversible damage to the immune system  Reduce “Inflammation” to prevent heart disease, cancer, premature aging  Treatment is prevention  Reduce the size of the “HIV reservoir”, maybe making HIV easier to cure someday
  7. 7. 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
  8. 8. We have a long way to go…
  9. 9. What to start?
  10. 10. Where we started…
  11. 11. Where we are now…
  12. 12. 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
  13. 13. 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
  14. 14. Goal of Treatment
  15. 15. General Principles  Goals: less pills, less times/day, less side effects  Use at least 3 drugs, 2 classes of medicines  Treatment is individualized- 4 recommended 1st line combos, lots of alternate regimens  Sometimes 3 isn’t enough  Your Protease Inhibitor may need a “Booster”  Drug resistance usually = more pills
  16. 16. 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)
  17. 17. The Drugs… Each attacks the virus at a different point…
  18. 18. Where Do HIV Drugs Act?
  19. 19. NRTIs, “Nukes”
  20. 20. NRTIs Continued  Backbone of treatment  Older drugs are more toxic (AZT, “D-drugs”)  Peripheral neuropathy  Lactic acidosis  Pancreatitis  Lipodystrophy  Watch kidney function with Tenofovir
  21. 21. NNRTIs, “Non-nukes”
  22. 22. NNRTIs: Pros and Cons ADVANTAGES  Ease (low pill burden)  Less metabolic effects  Well tolerated  DISADVANTAGES  No lipodystrophy, less dyslipidemia Resistance develops quickly if <95% adherent  Single mutation  Cross resistance among NNRTIs  Rash; hepatotoxicity
  23. 23. Protease Inhibitors
  24. 24. PIs: Pros and Cons ADVANTAGES DISADVANTAGES  High potency  Once daily dosing for many  Less susceptible to resistance  Second-line therapy when NNRTI fails    Metabolic complications  - Increased cholesterol, blood sugar GI side effects  - Diarrhea, nausea Drug interactions – Statins, viagra, antiseizure, many
  25. 25. Integrase Inhibitors
  26. 26. Integrase Inhibitors  3 agents- more to come!  Well tolerated, less metabolic effects and drug interactions than other classes  Can cause rash, hepatotoxicity
  27. 27. Entry Inhibitors
  28. 28. 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)  More to come in this class
  29. 29. Once a day Fixed Dose Combos Name Pros Cons Atripla Lots of experience using it • Neuropsych side effects • Don’t stop without planning Complera Well tolerated • Only studied in treatment naïve • Not for use if VL >100K • Take with food • Can’t take PPIs Stribild Well tolerated • Only studied in treatment naïve • Drug interactions • Watch kidney function • Nausea
  30. 30. 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
  31. 31. 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!
  32. 32. 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!
  33. 33. HIV and Aging
  34. 34. 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
  35. 35. HIV Cure Research Theraputic vaccines Gene therapy BM Transplants Early/better treatment Paths to an HIV Cure “Shock and Kill” HIV infected cell suicide
  36. 36. Resources Project Inform: 1-800-342-2437, http://www.projectinform.org/ AIDSmeds.com thebody.com HIVinsite.org www.aidsinfonet.org
  37. 37. Thanks  To you for taking care of yourself!  The advocates and activists who gave us these treatments  My patients
  38. 38. 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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