aids approach patients
DESCRIPTION
AIDSTRANSCRIPT
UNDERSTANDACQUIRED
IMMUNODEFICIENCYSYNDROME
WE NEED TO KILL THEM
BEFORE THEY KILL US?
SOWE
KEEP TRYINGMUST
…AND K
EEP TRYIN
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THE ENDUNTIL
Prof Adeeba
Normal Immune System
…will protects the body
It consists ofLYMPHOIDorgans andtissues
..which killsbad organism
HIV will attackTHE SYSTEM
and it becomesAIDS
AIDSCOMES FROM
also from…
blood transfusion
Mot
her
to
baby
IF UHAVE THESE
ORAL CANDIDIASIS
Oral Hairy Leukoplakia
…or these…
The human immunodeficiency virus, upon entry into the human body seeks out the CD4+ receptors on T-helper Iymphocytes and other cells with CD4+ molecule.
The virus then enters into the cell and incorporates itself into the cellular genome eventually causing cell death.
With the decline in CD4+ Tlymphocytes, the body's defence mechanism will be compromised.
This will allow opportunistic organisms to cause life-threatening infections.
Atypical tumours may also develop.
Acquired Immunodeficiency Syndrome (AIDS)
• Acquired Immunodeficiency Syndrome (AIDS) is caused by a retrovirus known as the Human immunodeficiency Virus (HIV).
HIV-1
HIV -1 is known to cause AIDS
It is thought that 80% of people infected with HIV-1 will progress to clinical AIDS
within 10 years.
HIV-2HIV -2 may eventually lead to an
immunodeficiency state
severe immunodeficiency due to HIV-2 may require a longer latent period.
Acquired Immunodeficiency Syndrome (AIDS) - definition
• Is a conglomerate of signs and symptoms arising from the development of opportunistic infections and unusual tumours which arise as a result of a failing immune system.
• Clinical definition of AIDS consist:
1. A positive test for HIV antibodies by the ELISA and or Particle Agglutination test(s), and a positive supplementary test
2. AIDS Defining Diagnosis
3. A CD4+ T cell Iymphocyte count of less then 200/uL
AIDS defining diagnosis
disseminated TB
oesophageal candidiasis
kaposis sarcoma
CMV retinitis NHL cryptosporidial diarrhoea
PCPAIDS
associated dementia
IMMUNOLOGY AND NATURAL HISTORY OF HIV/AIDS
The Normal lmmune System
Protects the body
Consists of lymphoid organs and tissues
Produce B-cells and T-cells(CD4 lymphocytes)
Regulate the immune system and kill invading organisms
When the immune system is weakened and destroyed by a virus such as HIV, the body is vulnerable to opportunistic infections (OIs)
Human Immunodeficiency Virus
• HIV is a retrovirus. (RNA)• Uses host’s DNA (lymphocytes) to make viral DNA and to replicate itself.
• Host lymphocytes infected with HIV have a very short lifespan. • HIV continuously uses new lymphocyte to replicate itself. • Up to 10 million individual viruses are produced daily. Causing severe damage to and eventually destroys the immune system.
HIV Co-receptors
C-C chemokine receptor CCR-5
• - expressed by monocytes and lymphocytes
• - mediates entry of non-syncytium-inducing (NSI), monocytotropic stains of HIV
• - ccr5delta32, resistant to HIV infections
C-X-C chemokine receptor CXCR-4 (fusin)
• - expressed only on T lymphocytes
• - mediates entry of syncytium-inducing (SI), T-cell tropic strains
CCR-2 and CCR-3 chemokine receptors
• - mediates HIV-1 entry on circumstances
Viral variation in HIV infection
Early after HIV infection,
most patients harbor NSI virus. NSI virus grows relatively slowly, does not induce fusion of T cells (syncytium formation) in vitro, grows equally well in monocytes and lymphocytes. NSI stains are called R5 strains, use only the CCR-5 co-receptor.
Later HIV infection,
a highly cytopathic, SI variant appeared. SI virus grows more rapidly than NSI, characterized by the ability to grow in T-cell lines (T-cell tropism). Emergence of SI variants is associated with rapid decline in CD4+ lymphocytes, progress more rapidly to AIDS and SI isolateis a significant independent risk factor for disease progression and death. SI isolates utilize CXCR-4 (fusin) co-receptor and CCR-5, also referred as X4 stains SI isolates are not inhibited by RANTES, MIP-1 alpha or beta.
Duotropic R5/X4 viruses
use both CCR-5 and CXCR-4 co-receptors, infect monocytes and CD4+ lymphocytes, intermediate forms in the evolution.
• The effect of HIV on the immune system is monitored by measuring the CD4 lymphocyte count in the blood.
• A normal CD4 count 600 and 1,200 cells/µ.
• CD4 counts <350 cells/µL indicate that some impairment of immune function.
• CD4 counts <200 cells/µL - risk of serious opportunistic
infections
HIV: Two Types RecognizedHIV-1 HIV-2
Both transmitted through sexual contact, blood, from mother to child, and cause
indistinguishable AIDSPredominant virus Less easily
transmittable
Due to high rate of replication, mutates rapidly into subtypes
Period between initial infection and illness
longer than HIV-1
Epidemiology
Fourth biggest killer in the world
Estimated 42 million persons
living with HIV/AIDS
About one-third are between 15-
24 years
Most people are unaware they are
infected.
Malaysia: 70 000 reported
cases
AIDS - Classification
Group 1- Acute Seroconversion illness.
Group 2 - Asymptomatic HIV infection
Group 3 - Persistent Generalised Lymphadenopathy (PGL)
Group 4 - AIDS
HIV CLASSIFY BY TREATMENT
1 Asymptomatic HIV infection
2 Advanced HIV disease
3 Opportunistic Infections
4 AIDS-related tumours and Neuro-Psychiatric disease
Modes of Transmission
• Male-to-female, • female-to-male, • male-to-male,• female-to-female
Sexual contact
• Blood transfusion, • IDU through needle-sharing, • needle stick accidentsParenteral
• In utero, • during labor/delivery, postpartum through BFPerinatal
CLINICAL MANIFESTATION OF HIVMOHD HANAFI RAMLEE
The human immunodeficiency virus, upon entry into the human body seeks out the CD4+ receptors on T-helper Iymphocytes and other cells with CD4+ molecule.
The virus then enters into the cell and incorporates itself into the cellular genome eventually causing cell death.
With the decline in CD4+ Tlymphocytes, the body's defence mechanism will be compromised.
This will allow opportunistic organisms to cause life-threatening infections.
Atypical tumours may also develop.
Incubation
• 2 - 4 weeks after exposure but may be as long as 6 weeks.
• Symptoms tend to develop abruptly and last for 1.5 - 2 weeks.
Acute Sero-conversion Phase or Primary HIV-1 infection
• 60-90%• difficult to identify (not remember the flu-like illness, common cold). • This glandular fever 2 to 6 weeks after exposure. • However this mononucleosis-like illness prolonged and may last 2-4
weeks. • acute encephalitis-like illness with reversible encephalopathy
– disorientation, – impairment of consciousness – cognitive functions
• Recovery is complete and the patient will feel well. • Occasionally the acute seroconversion illness may be completely
asymptomatic.
Asymptomatic HIV infection
• early stages• progressive fall of CD4+ T-lymphoeyte • symptoms and signs will become apparent. • 2 to 7 years before the appearance of
constitutional symptoms which may herald the onset of AIDS.
Persistent Generalised Lymphadenopathy (PGL) - Symptoms
• CD4+ T-lymphocytes progressively decline• The commonest not specific symptoms and
signs encountered in the early stages are:– · Malaise– · Lethargy– · Loss of appetite– · Loss of weight– · Diarrhoea– · Intermittent fever
Persistent Generalised Lymphadenopathy (PGL) - Signs
• weight loss of more the 10% the ideal body weight,
• prolonged fevers of more than 3 months, • Persistent generalised Iymphadenopathy of
more than two groups of Iymph nodes. • multi-dermatomal herpes zoster, • oral candidiasis • oral hairy leukoplakia
Herpes ZosterHerpetic lesions in HIV-infected patients are caused by reactivation of the latent virus. Although mucocutaneous lesions may appear in any region of the body, the most common sites are the genital, perianal area.
Oral CandidiasisOral candidiasis "thrush" is an infection of yeast fungi of the genus Candida on the mucous membranes of the mouth. It is frequently caused by Candida albicans, or less commonly by Candida glabrata or Candida tropicalis.
Oral Hairy LeukoplakiaHairy leukoplakia is seen in severe defects of immunity, particularly in HIV infection. The cause of this condition is an opportunistic infection by the Epstein-Barr virus (EBV). After the primary EBV infection has been overcome, the virus stays latent in the B cells and also causes lytic infection in the oropharynx, controlled by the immune system. Uncontrolled lytic infection in the oropharynx is manifested as oral hairy leukoplakia in immunosuppressed hosts. Oral hairy leukoplakia is not associated with any malignant potential.
Persistent Generalised Lymphadenopathy (PGL) - Labs
• Lymphopenia• Leukopenia• Thrombocytopenia• Anaemia• Reduced CD4+ T-lymphocyte count• Decrease ratio of CD4+/CD8+• Raised gamma-globulins• Cutaneous Anergy
Persistent Generalised Lymphadenopathy (PGL) - Markers• Absolute platelet counts
• Total Lymphocyte count• CD4+ T-lymphocyte count (cells/uL)• CD4+/CD8+ Ratio• p24 antigen• beta 2-microglobulins• Serum Neopterin• PCR-RNA-HIV
AIDS
• 10% of patients develop an AIDS-defining illness with a CD4 count above 200 cells/mm3.
• The median time to development of an AIDS defining illness is 12 – 18 months (if not on opportunistic infection prophylaxis or antiretroviral therapy).
• Median CD4 count at the time of developing an AIDS-defining illness is 67 cells/mm3.
• Median survival after CD4 count falls below 200 cells/mm3 is 38 – 40 months.
AIDS
• Consist of– Pulmonary TB, Recurrent pneumonia, Invasive
Cervical Cancer– CD4+ T-lymphocyte counts– declining immunity– opportunistic infections – atypical tumours.
Advance AIDS (CD4 < 50)
• Median survival is 12 – 18 months (if not on opportunistic infection prophylaxis or antiretroviral therapy).
• Cytomegalovirus disease and disseminated Mycobacterium avium complex tend to occur at this stage.
Factors affecting rate of progression
• Acute HIV syndrome: – Prolonged presence of symptoms correlates with a more
rapid progression of disease.– Strong HIV-specific CD8 cytotoxic T cell and CD4 T cell
responses correlate with a slower progression of CD4 cell decline.
• Co-infections– Hepatitis – Cytomegalovirus
• Mode of transmission – Blood transfusion recipients progress more rapidly than
patients who acquire it sexually or by injection drug use.
Factors affecting rate of progression
• Age. – Older patients progress faster than younger patients.
• Viral load. – Patients with higher viral loads will progress more rapidly.
• Genetic modifiers.
• Strain variations.
Factors affecting rate of progression
• Effect of prophylaxis of opportunistic infections on the course of HIV disease– PCP– Disseminated MAC
• Experience of the medical provider
Factors affecting rate of progression
• Effect of antiretroviral therapy on the course of HIV disease.
3-drug therapy (HAART) >> 2-drug therapy > Monotherapy
When therapy is started in the early asymptomatic infection period the estimated mean time to development of AIDS is 8 months for patients treated with monotherapy, 9.8 years with double therapy and 20 years with HAART
Kaposi’s Sarcoma
• tumour of the blood vessel. • Classical:
– elderly males of Mediterranean descent.• confined to the lower limbs.• previously healthy young males will suggest the
presence of concomitant HIV• numerous and fairly extensive. • confined to the skin, lungs with hemorrhagic
pleural effusion.
Kaposi SarcomaWith the rise of the AIDS epidemic, KS, as initially one of the most common AIDS symptoms, was researched more intensively in hopes that it might reveal the cause of AIDS. The disease was erroneously referred to as the "AIDS rash".
Natural History:
Primary HIV Infection
• 2-4 week period of intense viral replication.
• Non specific symptoms – flu like, neurological, gastro, skin.
• Lasts from 1-2 weeks and occurs in 53% to 93% of cases.
• Clinical manifestations resolve as antibodies to the virus become detectable in patient serum.
Stage of Disease Progression
• Patients then enter a stage of asymptomatic infection
• Lasts months to years.• CD4 declines• Opportunistic infection eg
bacterial, fungal, viral
Clinical Features
Nausea / Vomiting;
27
Hep-atosplenomegaly;
14
Weight Loss; 13
Oral Thrush; 12
Meningoen-cephalitis /
Lymphocytic; 6
Peripheral Neu-ropathy; 6
Acute Retroviral Rash
• 5-10 mm macular or papular erythematous lesions usually on face and trunk but may involve extremities.
• Rash usually starts 48-72 hours after the fever starts and may last for 5 – 8 days.
• It may be slightly pruritic but usually is not.
• Oral, esophageal, anal or genital ulcerations are painful, shallow and well demarcated.
OPPORTUNISTIC INFECTION
CD4 count and OIs
Below 200
TB
PCP, thrush
Toxo, Esoph thrush
PML
HIV-Related Complications
CD4>300
• Lymphadenopathy• Pneumonia (Strep)
Thrush• TB• Cryptosporidium• KS Lymphoma
CD4 < 200
• Esophagitis• Candida Vaginitis• PCP• Cryptococcus
CD4<100
• Toxoplasmosis• Zoster, PML, CMV,
MAC
Pneumocystis Carinii (PCP)
• Pneumonia with hypoxemia• Insidious• CXR with bilateral disease but can vary• High morbidity and mortality• CD4 generally below 200 or < 14%• Significant alveolar disease (elevated LDH)• Silver stain of sputum or BAL for diagnosis
PCP - Interstitial Infiltrates
Treatment of PCP
• Determine level of hypoxemia and need for hospitalization
• TMP-SMX is the most efficacious treatment• Alternatives exist in those allergic to sulfa• Steroids indicated if pO2 < 70• May get worse before improvement seen • Usually need to R/O other pathogens
Prevention of PCP
• Oral TMP-SMX is prophylaxis of choice• Alternatives exist (dapsone, pentamidine, etc)• 10 prophylaxis: CD4 < 200• 20 prophylaxis with history of prior PCP• Still being determined is whether prophylaxis
can be withdrawn after beneficial effects of HAART
CNS Toxo vs CNS Lymphoma
Toxoplasmosis
Toxo IgG +
Multiple Lesions
No TMP-SMX
Responds empirically
Lymphoma
Toxo IgG -
Single Lesion
TMP-SMX prophylaxis
No Response
Toxoplasmosis
Treatment / Prevention of Toxo
• Rx: Sulfadiazine + Pyrimeth. + Folinic Acid• Sulfa allergic: Clinda + Pyrimeth. + Folinic A.• Repeat MRI to make sure lesions smaller• Maintenance therapy after induction• Consider steroids and anticonvulsants• TMP-SMX is adequate 10 prophylaxis
– dapsone and pentamidine is not protective– should protect when CD4 < 100 if IgG +
Cryptococcal Meningitis
• Very subtle presentation at times– HA, fever, lethargy, nausea
• Imaging studies usually normal• CSF generally with high opening pressure, mild
lymphocytic pleocytosis• CSF with + India Ink, crypto Ag, yeast• Serum crypto Ag can screen HIV cohorts
Cryptococcus - India Ink Stain
Treatment of Crypto Meningitis
• Most induce with ampho B +/- 5FC• Can also use high dose fluconazole if unable to
tolerate Ampho B• Will need chronic maintenance to control
infection as cannot be generally cured• High risk for recurrent elevated ICP which can
result in hydrocephalous• May require periodic removal of CSF
CMV Retinitis
• Results in floaters and decreased vision• Seen in those with CD4 < 50-100• Diagnosis by ophthalmologic exam• It is a disseminating infection• Difficult systemic treatment with an induction
and maintenance treatment– gancyclovir, foscarnet, cidofovir
Mycobacterium Avium Complex
• Not uncommon when CD4 < 75• Chronic constitutional symptoms such as
fever, sweats, and weight loss• Labs may reveal anemia, leukopenia,and
elevated alk phos• CT of abdomen may see periaortic or
retroperitoneal adenopathy and HSM with a relative paucity of peripheral adenopathy
MAC Diagnosis and Treatment
• AFB BC has high yield but takes weeks• Bone marrow staining and culture• Treatment requires a minimum of 2 meds
chronically as it is quite resistant– macrolide, ethambutol (amikacin, rifabutin, cipro)
• 10 Prophylaxis with macrolide in those with CD4 <75
Oropharyngeal Infections
• Candidiasis• Oral Hairy Leukoplakia (OHL)• Ulcer Disease• Periodontal Disease• Kaposi’s Sarcoma
Oral Candidiasis
• >60% of patients with CD4 <100 cells/mm3• Often Asymptomatic or altered taste, burning,
odynophagia• Four Forms
– Pseudomembranous– Erythematous– Angular Cheilitis– Hyperkeratotic
Pseudomembranous Oral Candidiasis
White patches that can be scraped off leaving erythematous base
Erythematous Oral Candidiasis
Smooth red patches, found on tongue and cheeks
Angular Cheilitis
Cracking and fissures at corner of mouth
Hyperkeratotic Oral Candidiasis
Thickened white patches, do not scrape off
Oral Candidiasis: Diagnosis
• Diagnosis is often clinical, based on typical appearance
• KOH preparation of scraping for hyphae, pseudohyphae, and budding yeast– Helpful especially for erythematous and
hyperkeratotic disease
Oral Candidiasis: Treatment
• Initial topical therapy– Clotrimazole troches 10mg 5x/day– Nystatin swish & swallow 500,000 units QID
• Refractory to topical treatment– Fluconazole 100 mg QD– Itraconazole 100 mg BID
Oral Candidiasis: Treatment
• Fluconazole Refractory Disease– Higher dose fluconazole (200-800 mg/d)– Itraconazole 200 mg BID– Amphotericin B 0.3-0.5 mg/kg/day– Capsofungin 50mg IV QD
• Duration of Therapy– 7-14 days or until disease resolution
Oral Candidiasis: Treatment
• Relapsing Disease– Intermittent therapy vs. chronic suppressive
treatment • Decreased azole resistance with chronic suppression vs.
intermittent therapy if recurrences are very frequent.• Avoid maintenance therapy unless relapses are
frequent – increased azole resistance
Oral Hairy Leukoplakia
• Caused by Epstein-Barr Virus infection• Does not scrape off with tongue blade• NOT a premalignant condition• Targeted therapy not recommended• Responds to HAART
Oral Hairy Leukoplakia
Linear white patches at edge of tongue. Do not scrape off.
Oral Ulcer Diseases
• Several Etiologies• Most Important Differential Diagnoses:
– Herpes Simplex Virus– Cytomegalovirus– Aphthous Ulcers
Herpes Simplex Virus
• Multiple vesicular lesions of lips, buccal mucosa, soft palate
• Diagnosis often clinical, also may diagnose by Tzanck smear, viral culture, immunofluorescence assay
• Treatment recommended in patients with HIV
Herpes Simplex Virus
Multiple ulcers with some confluence of buccal mucosa
Herpes Simplex Virus
Tzanck smear with multinucleated giant cells
Herpes Simplex Virus:Treatment
• Oral Therapy:– Acyclovir 400 mg 5x/day 14-21d– Famciclovir 500 mg BID x 7d– Valacyclovir 1g PO BID x 7d
• Parenteral Therapy (severe disease)– Acyclovir 5mg/kg q 8 hours– Foscarnet or Cidofovir
• for acyclovir resistant disease
Cytomegalovirus (CMV)
• Visually indistinguishable from HSV oral ulcer disease
• Often associated with other systemic manifestations of CMV (esophagitis, colitis, retinitis)
• Usually diagnosed in “HSV” refractory to therapy– Viral Culture/ cytology, IFA, CMV serum antigen
testing, CMV PCR
CMV Oral Ulcers
Viral swab demonstrated typical “owl’s eye” intracytoplasmic inclusions. CMV PCR (+)
CMV - Treatment
• Limited oral ulcer disease management unclear, but likely a precursor to manifestation at other site (esophagitis, colitis, retinitis)
• Induction Therapy– Ganciclovir 5mg/kg IV Q 12 hours– Valganciclovir 900 mg BID– Foscarnet 90 mg IV Q 12 hours– Cidofovir 5 mg/kg IV q week PLUS
• Probenecid (to decrease renal toxicity)
• Each then followed by suppressive treatment
Aphthous Ulcers
• Present as crops of ulcers from 1-2 mm to 2-3 cm
• Painful lesions lead to odynophagia, dysphagia, secondary weight loss
• Can involve esophagus, other parts of GI tract• Visually similar to HSV and CMV
Aphthous Ulcers
1.5 cm ulcer of buccal mucosa
Aphthous Ulcers
• Diagnosis: – viral studies for HSV, CMV (-)– Biopsy: nonspecific inflammatory changes
• Treatment– Anesthetic mouth washes– Topical fluocinonide 0.05%– SEVERE DISEASE
• Prednisone 40 mg/day 4-6 weeks• Thalidomide 200 mg po QD
Kaposi’s Sarcoma
• Can involve any portion of the GI tract.• Usually symptomatic if oral lesions or
intestinal obstruction• Associated with HHV-8 infection
Oral Kaposi’s Sarcoma
Kaposi’s Sarcoma
• Presentation:• Usually in patients with CD4 <200 cells/mm3
• Skin most common site of involvement, but GI tract involved in 40% of visceral cases
• Diagnosis– Usually based on pathologic specimen– Must be distinguished from Bacillary Angiomatosis
(Bartonella Henselae)
Kaposi’s Sarcoma: Treatment
• Often improves with HAART• Localized Disease
– HAART– Sclerotherapy– Intralesional Chemotherapy– Cryotherapy– Radiation therapy
• Widespread– Systemic Chemotherapy
• interferon-alfa ,etoposide, vincristine, vinblastine and bleomycin
AIDS Cholangiopathy
• Late manifestation of HIV– CD4 < 100 cells/mm3
• May be present with or without papillary stenosis• Clinical Presentation
– Fever, RUQ pain, nausea, vomiting. Weight loss– Markedly Elevated Alkaline Phosphatase
• Causes Include:– Cryptosporidium, CMV, microsporidia– 40% of cases – no clear etiology
AIDS Cholangiopathy
• Diagnosis– Ultrasound: may be normal or show intra- and
extra-hepatic ductal dilatation– ERCP: allows imaging of biliary ductal system,
sampling of fluid for culture and cytology• Treatment
– Sphincterotomy for papillary stenosis, biliary stents, targeted therapy at causative agent (if identified)
Diarrhea in HIV/AIDS
• Occurs in 50-60% of AIDS patients• Evaluation should include travel history, pets,
medications, foods• Stool studies
– Stool culture for Shigella, Salmonella, E. Coli, campylobacter
– Stool O&P, acid fast staining– C. Difficile Toxin Assay– If Fever: Blood Culture, AFB blood Culture, CMV
Antigenemia/ PP65
Salmonella
• Commonly S. typhimurium, S. enteritidis • 20-100 greater incidence in AIDS• Bacteremia common
– Recurrent bacteremia – AIDS defining• Diagnosis: stool and/or blood cultures• Treatment: ciprofloxacin, ceftriaxone, amoxicillin,
TMP/SMX• Suppressive Therapy: consider for recurrent
disease
Shigella
• S. flexneri, S. dysenteriae• Presentation: bloody diarrhea, fever,
abdominal pain• Complications: megacolon, perforation,
bacteremia (50%)• Treatment: Same as salmonella
– ciprofloxacin, ceftriaxone, amoxicillin, TMP/SMX
Clostridium Difficile
• Approximately 8% of AIDS diarrhea• Diagnosis:
– Detection of toxin in stool– Thickened bowel wall on CT– Pseudomembrane on colonoscopy
• Treatment– Metronidazole 250 mg po QID x 10-14 days– Vancomycin 125 mg po QID x 10-14 days (if failure
of metronidazole)
Mycobacterium Avium Complex
• Usually seen with CD4 <100 cells/mm3• Presentation: fever, abdominal pain, diarrhea, weight
loss• Diagnosis• Culture: stool, tissue, blood
– CT scan: hepatosplenomegally, abdominal lymphadenopathy• Treatment
– Clarithromycin 500 mg BID OR azithromycin 500 mg po QD– PLUS ethambutol 15-20 mg/kg/day
Cryptosporidium
• Found in stool of 10-20% of AIDS patients with diarrhea
• Acquired via contaminated water or fecal-oral route
• May also cause biliary tract disease• Diagnosed by acid fast stain of stool,
immunofluorescence
Cryptosporidium
Acid-fast stain of stool demonstrating oocysts
Cryptosporidium: Treatment
• Mainstay is restoration of immunity with HAART• Specific Therapy (disappointing efficacy)
– Paromomycin 1500-2000 mg/d x 14-28 days then 500 mg BID
– Paromomycin 1 g BID PLUS Azithromycin 600 mg QD x 28 days THEN Paromomycin alone
• Octreotide 50-500 units SQ TID– Reduces stool volume
• Nitazoxanide 500 mg BID– Currently under clinical trial
Isospora Belli
• Acid Fast protozoan• Symptoms: watery diarrhea, weight loss,
cramps• AFB of stool; larger than cryptosporidium;
typical elliptical shape• Treatment: TMP/SMX DS po QID x 10 days• Pyrimethamine (for sulfa allergy)
Isospora Belli
Oocyte on modified acid-fast stain of stool
Microsporidia
• 2 species implicated in most diarrheal disease in AIDS– Enterocytozoon bieneusi– Encephalitazoon intestinalis
• Found in 5-50% of AIDS patients with unexplained diarrhea
• Clinical: chronic non-bloody diarrhea, malabsorption, cholangitis, cholecystitis
Microsporidia
• Diagnosis – stool modified trichrome or chemofluorescent
staining– Small bowel biopsy
• Treatment:– Albendazole 400-800 mg PO >21 days [for E.
septata]– E. bieneusi – limited efficacy
• Metronidazole, atovaquone
AIDS Wasting Syndrome
• Unintentional Loss of 10% of body weight• AIDS defining illness in 15-20% of cases• Contributing factors:• Medication related anorexia, depression,
oral/esophageal disease, malabsorption
AIDS Wasting Syndrome
• Treatment– Nutritional Supplements
• Oral supplements usually adequate• TPN for excessive diarrhea from cryptosporidiosis
– Appetite Stimulants• Megestrol, Dronabinol – weight gain mostly fat
– Resistance Exercise
AIDS Wasting Syndrome• Anabolic Steroids
– Most weight gain is lean body mass (anabolic>androgenic effect)
– Nandrolone – Oxandrolone– Oxymetholone– Testosterone
• Indicated for hypogonadism with or without wasting
• Improved quality of life, libido, energy, lean body mass
Non TB Mycobacteria
• MAC rarely cause pulmonary disease• M.kansasii most common• CD4< 50• Interstitial / lobar pneumonia• Nodules, cavities, adenopathy• Diagnosis: Cx from respiratory specimen• Treatment: RIF/ETB/INH 15-18 mo
CMV Pneumonias
• Most important AIDS associated viral pulmonary pathogen
• Late • B/L interstitial/alveolar infiltrates• Diagnosis:
– CMV culture( not specific)– CMV inclusions
CMV: Treatment
• GCV 2.5 mg/kg Q 8h x 20 d or Valgancyclovir 900 mg BID
• + IVIG 500mg/kg QOD x 10 days– then GCV 5 mg/kg/d x3-5/wk + IVIG 500mg/kg 2x/wk x8
doses
• Foscarnet 90 mg/kg IV Q 12h x 14-21 days• then 90 mg/kg QD maintenance
• Cidofovir 5 mg/kg IV Q wk w/ probenecid
Pulmonary Cryptococcosis
• Inhaled pathogen• <15% develop pneumonia• UL lesions, lobar, B/L, miliary pneumonia• Pleural effusion, cryptococcoma• Cavity: rare• meningitis primary presentation in HIV
Pulmonary Cryptococcosis
• Treatment• Ampho B 0.7-1 mg/kg/d + 5-FC 25 mg/kg q 6h
x 2 wks– Then Fluconazole 400 mg/d x 10wks
• Suppression 200 mg/d until CD4 > 100• Surgery for cryptococcoma
Pulmonary Penicillosis
• Endemic: SE Asia, China, Manipur State of India
• Thermally dimorphic fungus• Infiltrates, nodules, cavities, abscess,
adenopathy• Disseminated diseases• Diagnosis: Fungal Culture• Treatment: Ampho B Itra, 50% relapse
Rhodococcus equi
• GP coccobacilli• Synergistic hemolysis• Antagonism : IMP, β-lactam
Rhodococcus equi
• TB like syndrome with negative smear• cavitary/nodular pneumonia• bacteremia• ½ extrapulmonary• 2/3 mortality• Tx: 2-3 drugs
– Vanc, IMP,AMG, cipro, Rifampim, E-mycin
Non Infectious Pulmonary Diseases
• KS• Lymphoma• Nonspecific interstitial pneumonitis• Lymphocytic interstitial pneumonitis• BOOP• PE
TB: Early Clinical Picture
• General complaints:– non-specific – excessive fatigue – weight loss– anorexia – irritability
• Symptoms of chronic infection:– low-grade fever – night sweats – vague digestive disturbances – recurrent headaches
TB: Early Clinical Picture
• SPUTUM:– at first dry, and later productive– purulent sputum – hemoptysis
• Pleuritic pain from TB pleurisy with effusion, may be a presenting symptom in early stages
• Cough rarely associated with pulmonary TB in children.
Severe Pulmonary TB
• Most INFECTIOUS CASES • Extensive cavities• Positive smear• High bacilli output • > 10 /HPField or >500,000/ml• High mortality • without treatment (75%)• Very infectious• 50% of close contacts infected• RAPID evolution
Chest Xrays in TB Control
• DIAGNOSTIC EXAMINATION of a suspected case
• EVALUATION OF A CASE during treatment – BUT not a substitute to SPUTUM EXAM
• only sputum monitors response of MTB to drugs• only sputum provides early warning about resistance
• BASELINE XRAY at the end of treatment• Evaluation of a CONTACT or an INFECTED
Tuberculin Test
Tuberculosis Screening – Skin Tests
• 15mm• Person from LOW prevalence area• NO medical risk factors• NO known exposure to TB
• 10mm• Person from HIGH prevalence area:• Asia, Africa, Latin America ³1%• MEDICAL RISK factors
• 5mm• CLOSE CONTACTS to infectious TB• OLD TB LESIONS• HIV INFECTION
TB Treatment
• Start with 4 drugs in all patients– INH, RIF, PZA and EMB or SM until sensitivities return– If pan sensitive, D/C EMB or SM– After 2 months of therapy, D/C PZA– Continue INH & RIF for 4 more months for total of 6 months
• Must have culture conversion by 2 months• 6 month regimen good for HIV(-) and (+)• Can use BIW regimen / TIW for HIV (+)• Monitor adherence and toxicity• DOT, combination pills for self administered (exceptions)
Resistance
• Primary resistance to any of the 4 major drugs (INH, Rif, Emb, Sm) was estimated at 12% in the USA in 1995. It ranged in 1994-97 from a low of 2.0 in the Czech Republic to a high of 41% in the Dominican Republic (Global surveillance for anti-tb drug resistance. NEJM 1998, 338,23).
• Median prevalences were:– INH 7.3%– Streptomycin 6.5%– Rifampin 1.8%– Ethambutol 1%– All 4 0.2%
Clinical Significance of Resistance
• If pan sensitive>95% chance of cure• If resistant to INH>90% chance of cure• If resistant to rifampin>70% chance of cure• If resistant to INH and RIF~50% chance of cure• Before chemotherapy~50% chance of cure
Causes of Resistance
• Irregular Self Administration with Failure to closely supervise
• Care of patients by non specialists• Increased immigration
Epidemiology of TB and HIV
• Both have afflicted similar populations• Both are socially stigmatizing• Globally, TB is the 2nd leading cause of death
from an infectious disease (behind HIV)• TB is the leading cause of death in HIV globally• Active TB may accelerate HIV replication
TB/HIV: Epidemiology
• Thirty-six million HIV infected individuals worldwide
• One-third of them co-infected with MTB• 68%- Sub Saharan Africa, 22%- SEA• Leading cause of death amongst HIV infected
individuals worldwide• Prevalence of HIV in TB patients (India) 20%
TB/HIV: Pathogenesis
• Immunity to MTB partly under control of MHC Class II restricted CD4 cells
• Loss of CD4 cells increases risk of– Reactivation of latent infection– Primary infection
• Active TB up-regulates HIV replication, leading to accelerated progression of HIV
TB/HIV: Pathogenesis
• Life time risk in HIV negative persons: 10%– 5% within first two years– 5% remainder of their lives
• HIV positive persons have 8% risk per year• HIV+ incidence: 5-16/100 person-years• Two mechanism
– Reactivation– Re-infection
• Immune reconstitution TB on HAART
HIV/TB: Treatment
• Do you need to add higher number of drugs?• Do you need to prolong duration of therapy?• Can ARV be used concomitantly with ATT (anti-
Tuberculosis Therapy)?• Is there increased incidence of AE’s?• Is there increased incidence of MDR-TB?• Should latent tuberculosis be treated?
(international)
LABORATORY TESTING
Serologic Tests
ELISA/EIA
• Screening test• Positive result
means sample needs to be tested by western blot or different ELISA test
Western blot test (WB)
• Confirmatory test
DNA PCR
• Primarily used for viral detection with :- neonatal infection
• indeterminate serology
Rapid Tests
• Various tests that provide results in ~10 minutes
• Useful in situations where immediate results are important to manage decisions
Baseline Laboratory Tests
• CD4 count and viral load to establish the stage of the disease
• Exposed other infectious diseases• Other recommended baseline tests include:
• CBC• Serum Chemistry Panel• Syphilis serology• Chest X-ray
• Mantoux • PAP smears Hep B and C
Laboratory features
• Leukopenia and lymphopenia initially, then lymphocytosis.
• Elevated CD8 cells, decreased CD4 cells.
Diagnosis of Acute HIV
• Seroconversion usually occurs within 4 –10 weeks (median 63 days).
• Plasma viral load peaks in three weeks post-exposure (100,000 – 1,000,000 copies RNA/mm3) and then declines to nadir at ~120 days.
• p24 antigen levels may be as high as 100 pg/ml.
MANAGEMENT OF HIV INFECTIONMOHD HANAFI RAMLEE
Medical and Nursing CareCounseling and
testing
Prophylaxis of opportunistic
infections (OIs)
Management of HIV-related illnesses,
including OIsTB control
STI management Management of HIV disease Palliative care Access to HIV-related
drugs
Interventions to reduce parent-to-child transmission
Clinical HIV/AIDS care for mothers and
infants
Support systems such as functional
laboratories and drug management systems
Nutritional support
Health education Adequate universal precautions
Human Rights & Legal Support
stigma & discrimination reductionsuccession planning PLHA participation
Clinical Care (medical & nursing)
VCT , PMTCTpreventive therapy (OIs, TB) management of STIs and OIs
palliative care, nutritional support antiretroviral therapy
Socioeconomic Support
material supporteconomic security
food security
Psychosocial Support
counseling orphan care
community support servicesspiritual support
Adults and Children Affected by
HIV/AIDS
r
ev
e
p
i
n
o
n
t
Stage of Management
Risk Assessm
ent
Establish
Diagnosis
aScertain Stage
Useful
Laboratory tests
Initiate
Antiretroviral
therapy
Initiate
PCP prophylaxi
s
Asymptomatic HIV infection Advanced HIV disease,
AIDS-related Opportunistic Infections and
Tumours.
Neuropsychiatric illness
Mx 1 – Risk Assessment
• full history + detailed sexual + drug history• physical examination stage • Initial laboratory tests will include:
– a. A Full Blood Count with differential count, particular attention to be given to platelet and Iymphocyte counts
– b. A Mantoux Test with 1 Tuberculin unit intradermally
– c. A Chest Radiograph
Mx 2 – Establish Diagnosis
• HIV antibody Testing:– ELISA and or Particle agglutination tests– Confirmed by supplementary test
– a. voluntary basis– b. anonymously or– c. confidential basis
Mx 3 – Ascertain Stage
• to assess progression of the disease is by measuring the CD4+ Tlymphocyte count and percentage.
• recommended all HIV infected individuals should have a baseline CD4+
• Infants born ELISA positive. • If the infant is not HIV infected ELISA fall within 18
months after birth.• Therefore, a better indicator of HIV infection in an infant
younger then 18 months will be the measurement of p24 antigen, by doing a polymerase chain reaction (PCR) test, or detection of the virus itself
SPECTRUM OF HIVMohd Hanafi Ramlee
Group 1 HIV disease (acute seroconversion illness)
• 2-4 weeks after the initial HIV• The symptoms include:
– Flu-like illness– fever– arthralgia– malaise– myalgia– headache– photophobia– maculopapular rash– GI disturbances and– neurological manifestations
Acute neurological disease meningitis encephalitis olyneuritis myelopathy brachial neuritis Guillian Barre syndrome
lasts 2-4 weeks low platelet and Iymphocyte counts, and a low CD4+ T-lymphocyte counts, with a reversed CD4+/CD8+ ratio.
In the asymptomatic phase the CD4+ Tlymphocyte counts will rise to almost normal levels (600-1200/uL).
Group 2 Asymptomatic Phase disease
• 3-7 years from the initial HIV infection.• feels and looks well• CD4+ T-cell counts can be normal. • counselled
– towards change of behaviour, – maintain good health and practise behaviour– prevent further transmission of HIV.
• assessment for antiretroviral therapy • 6-monthly CD4+ T cell count.
Symptomatic Phase (Group 3 and 4) disease
• Preliminary investigations – Chest X-ray– Full blood count and differential count,
ESR– Stool examination for cryptosporidia/
isospora (when diarrhoea is present)– Blood cultures for MAI/Mtb,
Cryptococcus, Salmonella sp.– Toxoplasma, Cytomegalovirus, Herpes
Antibody titres.– Sputum for PCP
• Immunological markers – CD4+ T-cell counts– CD4+/CD8+ ratio – CD4+ percentage
Viral markers p24 antigen polymerase chain reaction (PCR) p24 antibody (babies, health care
workers) clinical predictors
herpes zoster (multi-dermatornal) oral candidiasis oral hairy leukoplakia Prolonged fever, might sweets Progressive weight loss
Laboratory predictors of progression to AIDS: thrombocytopenia falling CD4+ T. cell counts high p24 antigen
Perinatal HIV Transmission• Can occur:
– during pregnancy (intrauterine), 25%--40% – during labor and delivery (intrapartum), 60%--75% – after delivery through breast-feeding (postpartum). – In a randomized trial of formula feeding versus breast-feeding, approximately 44% of HIV infection
was attributed to breast-feeding
• Risk factors are associated with perinatal HIV transmission – immunologically or clinically advanced HIV disease in the mother – high plasma viral load – maternal injection-drug use during pregnancy – preterm delivery – breast-feeding – No antiretroviral therapy– HIV subtype– Obstetric factors : Delivery >4 hours after the rupture of the fetal membranes; maternal infection
with another sexually transmitted disease or coinfection with HSV-2 increased risk of HIV transmission; chorioamnionitis
Diagnosis of HIV Infection in Newborns
• Nearly all infants born to HIV-infected mothers passively acquire maternal antibody and, antibody will remain positive until age 18 months regardless of whetherthey are infected.
• Definitive diagnosis of HIV infection in early infancy requires: – nucleic acid amplification (e.g., polymerase chain reaction [PCR])
or viral culture. – HIV infection is diagnosed by two positive assays (PCR or viral
culture) on twoseparate specimens.– Infant HIV testing should be done as soon after birth as possible so
appropriate treatment interventions can be implemented quickly.– UMMC: PCR quantitative assay
HIV: Reproductive and Women’s Health Issues
• Differences in HIV disease between men and women – Levels of HIV RNA may be lower in women at seroconversion. – Mean VL becomes similar within 5-6 yrs. – CD4 may be higher in women. – Rates of disease progression do not differ – No changes in treatment guidelines
• Abnormal Pap Smears– 30%-60% Pap smears have cytologic abnormality – Cervical cancer presents with high grade pathologic features
• - Uniform relapse after therapy (prior to HAART) • - Short survival
– HAART has been independently associated with regression of cervical disease.
NRTI / NNRTI
Protease inhibitor
Entry inhibitor
Receptor inhibitorsCCR5 or CXCR4 Integrase inhibitors
Immune Reconstitution Syndrome
Immune Reconstitution Syndrome
• The use antiretroviral therapy resulted dramatic improvement in outcomes typically associated with an increase in CD4+ lymphocytes, reduced HIV viral loads and partial recovery of T-cell–specific immune responses.
• Recovery of immune function correlates with the number of circulating CD4+ cells. It is safe to discontinue prophylaxis (primary or secondary) for a variety of pathogens including Pneumocystis jiroveci, Mycobacterium avium complex (MAC), and Toxoplasma gondii.
• Some patients experience a clinical deterioration following the introduction of potent antiretroviral therapy believed to be related to the restored ability to mount an inflammatory response.
• The incidence of IRS to be 10% to 25%. In patients undergoing simultaneous treatment of HIV infection and tuberculosis, the incidence of IRS has been reported to be 11% to 45%.
Diagnosis of IRS
Required Criteria
• Worsening symptoms of inflammation/infection
• Temporal relationship with starting antiretroviral therapy
• Symptoms not explained by newly acquired infection or disease, or the usual course of a previously acquired disease
• ≥1 log10 decrease in HIV RNA level
Supportive Criteria
• Increase in CD4+ count of ≥ 25 cells/µL
• Biopsy demonstrating granulomatous inflammation or unusually exuberant inflammatory response
MANAGEMENT OF ADVANCED HIV DISEASE
MOHD HANAFI RAMLEE
Antiretroviral Agent: Zidovudine
• Zidovudine (ZDV)– a nucleoside analogue, when it is phosphorylated inside HIV -
infected cell, inhibits reverse transcriptase. • Usage
– improved survival– decreases frequency of opportunistic infections– Improve quality of life– cuts down length of hospital stay.
• effective against replicating virus• can inhibit replication of sensitive strains.• gold standard in HIV management.
Zidovudine: When to Start?
• assessment first– weight – opportunistic infections – immunological status
• if the CD4+ counts are below 200/uL, – Give zidovudine at 500-600mg per day in 2 or 3 divided doses
(250mg b.i.d. or 200mg t.i.d).• If the CD4+ counts are 200 or less,
– chemoprophylaxis against Pneumocystis carinii pneumonia (PCP)
• Close monitoring & Follow up: 1x/2w 1x/3m 1x/36ml
Zidovudine: Site effects
General symptoms (first few weeks of
therapy)
• Headache• Nausea• Diarrhoea• Myalgia• Anorexia• Vomitting• Malaise• Fatigue
Haematologic
• Macrocytosis• Anaemia• Neutropenia
Others
• Proximal myopathy• Encephalomyelopat
hy• Hepatotoxicity• Nail pigmentation
COMMENCING ANTIRETROVIRAL THERAPY
WHEN ?
General Goals of Antiretroviral Therapy
• to prolong survival • decrease morbidity in those infected • to improve the patient’s quality of life and
reduce the burden on his family and the community.
• To promote prevention of transmission
Specific Goals of Antiretroviral Therapy
• to suppress HIV replication • to reduce plasma viral load to below
undetectable levels for a maximum duration • to improve, maintain and prevent the ongoing
decline of CD4 cells.
Recommendation on when to commence HAART [MSIDC]
Selection of Antiretroviral Agents
Factors to be considered
Pharmacology
Adherence
Potency
Drug Interacti
on
Convenience
Adverse Effects
Efficacy Tolerability Convenience
Adherence
Successful Therapy Durable viral load Suppression
-
-
Successful Antiretroviral Therapy: Critical Factors
Antiretroviral Agents in Malaysia
Nucleoside reverse transcriptase
inhibitors
• Zidovudine (AZT/ Retrovir)
• Didanosine (ddI/Videx)
• Zalcitabine (ddC/Hivid)
• Lamivudine (3TC/Epivir)
• Stavudine (d4T/Zerit)
• Combivir (AZT+3TC)
Protease inhibitors
• Indinavir (Crixivan) • Ritonavir (Norvir) • Saquinavir- hgc
(Invirase)• Saquinavir- sgc
(Fortovase)• Nelfinavir (Viracept)
Non-nucleoside reverse transcriptase
inhibitors
• Efavirenz ( Stocrin )• Nevirapine
(Viramune )
COMMENCING ANTIRETROVIRAL THERAPY
WHAT ?
HAART
H = HighlyA = Active SLOWS DOWNA = Anti- VIRALR = Retroviral REPLICATION!T = Therapy
3 or more ARVs. Only recommended ARV treatment – for long term effect.
What makes ARVs work?
• Function of ARVs suppress viral replication• Virus suppressed immune system recovers• Immune system recovery means CD4 count
goes up • CD4 count up no more opportunistic
infections
Mechanism of Action of ARVs
NNRTI
NRTI
Protease Inhibitor
Illustration by David Klemm
Fusion Inhibitor &ChemokineReceptor Antagonist
Integrase Inhibitor
The virus
Entering CD4 cell
New virus ‘budding’
The ‘factory’
NRTI (nukes) & nucleotide
3TC, d4T
NNRTI
NVP, Stocrin
How do PIs work?
1. Attachment to host cell
4. Reproduction of viral components
3. Integration into
host cell’s nucleus
5. Assembly and release of new viruses
2. The virus changes from RNA to DNA
Pharmacokinetics
• Absorption, Distribution, Metabolism, Elimination• Renal Elimination• Liver/GI Metabolism
– Phase I: Oxidation (ie, CYP 450 enzymes)– Phase II: Conjugation (ie, glucuronidation)
• Antiretrovirals– Many ARVs (and other medications) undergo Phase I
metabolism– Many ARVs increase or decrease activity of CYP450
(Phase I) enzymes
CYP 450 Inhibition
• Leads to blocking of the specific CYP 450 enzyme
• If a drug is metabolized by the CYP 450 enzyme that is blocked– drug concentration
• Example: Ritonavir
CYP 450 Induction
• Leads to production of more CYP 450 enzyme• If a drug is metabolized by the CYP 450
enzyme that is now in high amounts– drug concentration
• Example: Efavirenz
Drug Interaction Potential
NRTIs (Nucleoside Reverse Transcriptase Inhibitors)
Zidovudine (AZT)
Tymidine
Adenosine
Cytidine
Guanosine
NRTIs (Nucleoside Reverse Transcriptase Inhibitors)
Drug Standard Dose* Dosage forms Common Side Effects
Metabolism/
Elimination
Zidovudine (ZDV/AZT) Retrovir
300mg bid* 300mg tab, 100mg cap, iv, oral soln
Fatigue, headachemyalgia, anemia, GI, lactic acidosis, hepatic steatosis
Renal
Lamivudine (3TC) Epivir
150mg bid* or 300mg qd
150, 300mg tab, oral soln
Well tolerated Renal
Emtricitabine(FTC) Emtriva
200mg qd* 200mg cap Well tolerated Renal
Didanosine (ddI) Videx
400mg EC qd ( 60kg)250mg EC qd (<60kg)*
125,200,250, 400mg cap, pwdr for soln
Pancreatitis, peripheral neuropathy, LA/HS
Renal
*dose reduce for renal dysfunction
•Note: Lactic acidosis can occur with any NRTIs
NRTIs
Drug Standard Dose* Dosage forms Common Side Effects
Metabolism/Elimination
Stavudine (d4T) Zerit IR
40mg bid ( 60kg) 30mg bid (<60kg) *
15,20,30,40 mg cap,oral soln
Peripheral neuropathy,
Pancreatitis, LA/HS,Lipoatrophy, facial
wasting
Renal
Abacavir (ABC) Ziagen
300mg bid, 600mg qd
300mg tabs, oral soln
hypersensitivity Hepatic by alcohol
dehydrogenase and glucuronyl
transferase
Tenofovir(TDF) Viread
300mg qd* 300mg tabs Few SEs, renal toxicity
Renal
Zidovudine/ Lamivudine
(COM) Combivir
300/150mg BID 300/150mg tabs See above See above
Abacavir/ Lamivudine
(EPZ) Epzicom
600/300mg QD 600/300mg tabs See above See above
Tenofovir/ Emtricitabine (TRU) Truvada
300/200mg QD 300/200mg tabs See above See above
*dose reduce for renal dysfunction
NNRTIs (Non-nucleoside reverse
transcriptase inhibitors)
NNRTIsDrug Standar
d DoseDosage forms
Common AEs
Metabolism
Delavirdine (DLV) Rescriptor
400 mg tid 100mg tab, 200mg cap
Rash Potent CYP3A inhibitor; 3A4 substrate
Nevirapine (NVP) Viramune
200 mg qd x 14 d then200 mg bid
200mg tabs, Oral susp
Rash (SJ), hepatotoxicity
CYP3A inducer, auto inducer; 3A4, 2B6 substrate
Efavirenz* (EFV) Sustiva
600 mg qhs 50, 100, 200mg cap, 600mg tab
Vivid dreams, drowsiness or insomnia, rash (SJ), hyperlipidemia
CYP3A, 2B6 inducer; 2B6, 3A4 substrate
Etravirine(ETV)Intelence
200 mg bid 100mg tabs Rash, nausea CYP3A inducer, CYP2C9 and 2C19 inhibitor; CYP3A, 2C9, 2C19 substrate;
Tenofovir/ Emtricitabine/ Efavirenz*Atripla
300/200/ 600 mg qd
300/200/600 mg tabs
See above See Above
*Pregnancy Class D
Protease Inhibitors (PIs):
• Protease enzyme cleaves HIV precursor proteins (gag/pol polyproteins) into active proteins that are needed to assemble a new, mature HIV virus.
• PIs bind to protease preventing the cleavage and inhibiting the assembly of new HIV viruses
X
Protease Inhibitors
Ritonavir as a PI Booster
• Ritonavir used only to ‘boost’ concentrations of other protease inhibitors
• Dosed 100-200mg QD-BID• Available as 100mg capsules and tablets• Side effects: GI upset; hyperlipidemia*; insulin
resistance*
* All PIs except atazanavir alone
Lipodystrophy Illustrations
“Buffalo hump”
“Central obesity”“Facial and peripheral wasting”
Protease InhibitorsStandard
DoseDosage Forms Metabolism Common AEs**
Saquinavir(Invirase) (1)
1000/ rtv 100 bid or 1600/ rtv 100 qd
200mg caps, 500mg tabs
3A, Pgp substrate; weak 3A inhibitor
GI intolerance
Nelfinavir (Viracept) (1)
1250 bid, 750mg tid 250mg, 625mg tabs, 50mg/g oral pwdr
2C19 (M83A) substrate; weak 3A inhibitor
Diarrhea
Lopinavir/ritonavir(Kaletra) (1,2)
400/100 bid 200/50 mg tabs, 80/20mg/5mL soln
3A, Pgp substrate; 3A inhibitor; 2C9, 2C19 inducer
Dyspepsia, Nausea, vomiting, diarrhea, flatulence
Indinavir(Crixivan) (1-when taken with rtv)
800/ rtv 100 bid, 800mg tid
100, 200, 333, 400mg caps
3A, Pgp substrate; weak 3A inhibitor
Nephrolithiasis Drink 7-8 glasses of water per day; hyperbilirubinemia
(1) Take with Food (2) Must be refrigerated** All PIs except atazanavir can increase lipids and cause insulin resistance
Protease InhibitorsStandard
DoseDosage Forms Metabolism Common
AEs**
Atazanavir (Reyataz) (1)
400qd or 300/ rtv 100qd
150, 200, 300 mg caps
3A substrate; 3A and UGT1A1 inhibitor
Hyperbilirubinemia, PR prolongation
Fosamprenavir (Lexiva) (1)
1400mg bid; 700/100 RTV mg bid; 1400/200 RTV mg qd
700mg tabs (Agenerase-APV liq available)
3A4, Pgp substrate; 3A4 inducer/Inhibitor
Rash, GI intolerance, caution with sulfur allergy
Tipranavir(Aptivus) (1,2)
500/200 RTV mg bid
250mg caps 3A4, Pgp substrate; 3A4, inducer/inhibitor??; Pgp inducer
Hepatotoxicity, Increased bleedingcaution with sulfur allergy
Darunavir(Prezista) (1)
600/100 RTV mg bid
400, 600mg tabs 3A4 substrate;3A4 inhibitors
Diarrhea, nausea, HA, nasopharyngitis
(1) Take with Food (2) Must be refrigerated** All PIs except atazanavir can increase lipids and cause insulin resistance
Entry Inhibitors:Fuzeon : Enfuvirtide (T-20)
• FDA-approved fusion inhibitor; 36 AA peptide– Requires 106 steps to
manufacture• Dose: 90 mg sq bid• side effects:
– injection site rxn, hypersensitivity (rare)
• resistance: changes in gp41 (cell surface protein)
Chemokine Receptor Antagonists
• Maraviroc (Selzentry®)• CCR5 or CXCR4 receptors on cell surface • Virus will bind to one of the 2 receptors
– Some patients’ virus will bind to either receptor• Maraviroc blocks viral entry at CCR5• Dosed 300mg BID
– 150mg BID with P450 – inhibitors– 600mg BID with P450 – inducers
Tropism
Integrase Inhibitors
• Raltegravir (Isentress™)• Dosed 400mg BID (1 tab BID)• No induction or inhibition on CYP450 enzymes
or Pgp• Metabolized by UGT1A1 (glucuronidation)
– Only affected by drugs – that inhibit or induce UGTs – (ie, rifampin)
Integrase Inhibitor
215
Metabolic Dysfunction in HIV-Infected Patients on HAART
Body Fat Redistributio
n
HIV INFECTION
HAART
DyslipidemiaInsulin
Resistance
Toxicities in Summary• NRTIs: Lactic acidosis
– Zidovudine: Anemia– Stavudine and Didanosine: Pancreatitis and Peripheral Neuropathy– Abacavir: Hypersensitivity (can lead to death); ? CVD– Tenofovir: renal toxicity
• NNRTIs:– Efavirenz: nervous system side effects; rash– Nevirapine: rash, liver toxicity– Etravirine: rash
• PIs: GI effects, increased lipids, increased BG– Atazanavir: increased bilirubin, PR prolongation– Indinavir: kidney stones (LOTS of water)– Fosamprenavir: rash– Tipranavir: liver toxicity; bleeding
HOW DO WE TREAT HIV?
Antiretroviral Therapy
• DHHS Guidelines– Last updated December 1, 2009– www.aidsinfo.nih.gov
• International AIDS Society- 2008– Hammer, et al. JAMA Aug 6, 2008
• IDSA Primary Care HIV Guidelines-2009– Aberg, et al CID Sept 1, 2009
Factors to Consider for Initial Regimen Selection
• Co-morbidities• Adherence potential• Dosing convenience (pill
burden, dosing frequency, food, fluid restriction)
• Potential adverse effects
• HIV Resistance Testing
• Potential drug interactions
• Pre-treatment CD4+ T cell count
• Gender• Pregnancy potential• Patient lifestyle/ social
situation
DHHS 4/7/2005, http://AIDSinfo.nih.gov
Initiating Therapy in Treatment Naïve Patients
• If AIDS-defining illness or CD4 < 350• Regardless of CD4 count in:
– Pregnancy– HIV-associated nephropathy – HBV co-infection
• Recommended if CD4 count between 350 – 500• Panel split on initiating in CD4 > 500• Make a lifelong commitment and understand
adherence importance
DHHS 2009 Guidelines
Preferred Regimens for Naïve Patients
NNRTI-based regimen – Efavirenz+ tenofovir+ emtricitabine
PI-based regimen – Atazanavir/r + tenofovir+ emtricitabine– Darunavir/r QD + tenofovir + emtricitabine
INSTI-based regimen– Raltegravir + tenofovir+ emtricitabine
DHHS 2009 Guidelines
HIV Resistance Testing• Genotypes
– Sequences patient’s virus by blood sample– Mutations reported as compared to wild type
• Phenotypes– Similar to antimicrobial susceptibility testing– Reports IC50 for patient’s virus – Compares to wild type virus
• Virtual Phenotypes– Often reported along with genotypes– Information obtained from a database of
genotypes and matching phenotypes– An estimate of patient’s phenotype
Summary• HIV infection rates are not declining• Combination Therapy is CRITICAL• 100% Adherence is ABSOLUTELY NECESSARY• Drug Interactions are ANTICIPATED• Adverse Effects occur often
– Some can be managed– Some are dangerous
• If any doubt, call the physician or ME!