Module 8

1
Module 8

• Treatment Guidelines for the Management of
  Patients with HIV and AIDS

2
Objective

• To instill an understanding of the diagnosis,
  treatment and management of HIV/AIDS patients

3
Outline

• Initial Evaluation of Newly Diagnosed
  HIV-Positive Patient
• Initiation of ART with or without CD4 Count
• Goals of Therapy
• What is HAART?
• Basic Components of HAART
• Antiretroviral Drugs Dosage and Side Effects

4
The Outcome Gap
5
Initial Evaluation of Newly Diagnosed
HIV-Positive Patient

• Detailed History
• Presenting signs and symptoms
• Review of systems for AIDS-related complications
• Other health problems
• Socioeconomic situation
• Contacts (i.e. partners and children)
• Attitude toward illness
• Degree of engagement with health system

6
Initial Evaluation of Newly Diagnosed
HIV-Positive Patient

• Physical Exam
• - Search for any AIDS-related complications
• - Pelvic exam for all women to assess for STIs
• - Assess nutritional status
• Laboratory and radiographic exames
• - Must rule out TB! (sputum/ Mantoux/ chest
  x-ray)
• - pregnancy test
• - RPR
• - STI screening
• - CD4, if available

7
Initial Evaluation of Newly Diagnosed
HIV-Positive Patient

• Home Visit by physician, nurse or social worker
  to evaluate patients economic and social
  situation
• Accompagnateur
• Counseling of patient and partner(s)- testing
  partner(s) and children
• Social worker assistance
• Family planning

8
Protocol 3.10 Initiation of ART with or without
CD4 Count
CD4 count available?
No

• Defer ART if
• No weight loss
• No symptoms of OIs

• Consider ART and TMP/SMX prophylaxis if
• Mild weight loss by history (5-10)
• Herpes zoster
• OIs not responsive to treatment
• Active TB with poor bacteriologic/clinical
  response

• Begin ART and TMP/SMX prophylaxis if
• Severe weight loss (gt10) or cachexia
• Recurrent OIs
• Oral candidiasis (thrush)
• Chronic enteropathy with wasting
• Severe neurologic complications
• Anemia, leukopenia, or thrombocytopenia
• Prolonged fever gt1 month
• Total lymphocyte count lt1200 cells/mm3

Defer ART work up symptomatic illnesses
CD4 gt350 cells/mm3

• Begin ART and TMP/SMX prophylaxis if
• Occurrence of any OI
• Patient febrile or wasting, not due to TB or
  other etiology
• Mild weight loss, 5-10

Yes
CD4 200-350 cells/mm3
Begin ART and TMP/SMX prophylaxis even if patient
is asymptomatic
CD4 lt200 cells/mm3
9
Original Guidelines for Inclusion HIV Equity
Initiative

• Absence of tuberculosis
• Recurrent opportunistic infections
• Chronic enteropathy with wasting
• Significant weight loss
• Neurologic complications attributable to HIV
• Severe anemia, leukopenia or thrombocytopenia

10
Review of Syndromic Approach, 1999-2000
Group A First 100 pts who received gt 1 month of
DOT-HAART from a community health worker
(CHW) Group B 100 pts diagnosed with HIV
infection during the same period and from within
the catchment area received regular care, but
deemed less sick than those receiving ARVs Group
C 100 pts diagnosed with HIV infection during
the same period but living outside the area
served by CHWs received free care in clinic
11
Mortality at End of Study Period
24
Number of Deaths
11
0
12
Current indications for HAART for HIV Equity
Initiative

• TREAT ALL
• Symptomatic (AIDS, severe symptoms)
• Symptomatic, CD4 lt350 cells/mm3
• Asymptomatic, CD4 lt200 cells/mm3
• CONSIDER TREATMENT
• Asymptomatic CD4 200-350 cells/mm3

13
Goals of Therapy

• Restoration of immunologic function
• Improvement of quality of life
• Reduction of HIV-related morbidity and mortality
• Maximal and durable suppression of viral load

14
What is HAART?

• HAART highly active antiretroviral therapy
• Relies on a combination of antiviral drugs that
  attack HIV at different parts of its replication
  cycle
• Minimum of 3 drugs (from two classes)

• NRTI Nucleoside Reverse Transcriptase Inhibitors
• NNRTI Non-Nucleoside Reverse Transcriptase
  Inhibitors
• PI Protease Inhibitors
• New
• Fusion inhibitors T20
• Nucleotide analogs Tenofovir

15
HAART in the United States

• HAART has reduced AIDS-related mortality by 75
  and morbidity by 73 over a period of 3 years
• HAART in US 18,000 per person per year
• Deemed cost effective in decreasing
  hospitalizations

16
Impact of HAART

• In Brazil, which manufactures several of its own
  antiretrovirals, AIDS related mortality in Sao
  Paulo has declined by 50.
• HAART decreases transmission as 50-90 of
  patients obtain undetectable viral loads

17
Implementation of HAART in Central Haiti

• All medicines provided for free
• Limited number of regimens available
• TB aggressively rule out prior to starting HAART
• Opportunistic infections treated (or stabilized)
  prior to HAART

18
Figure 3.1 Basic Components of the ART Regimen
Nucleoside Reverse Transcriptase Inhibitors
(NRTI) Zidovudine (AZT)a Lamivudine
(3TC) Stavudine (d4T)a,b Didanosine
(ddI)b Abacavir (ABC)
First line 2 NRTIs and 1 NNRTI Second line 2
different NRTIs and 1 PI
Protease Inhibitors (PI) Indinavir
(IDV) Ritonavir (RTB) Saquinavir (SQB) Nelfinavir
(NFV) Amprenavir (APV) Lopinavir (LPV)
Non-nucleoside Reverse Transcriptase Inhibitors
(NNRTI) Efavirenz (EFV) Nevirapine (NVP)
OR
a. AZT and d4T are antagonistic and should never
be used together. b. The combination of d4T and
ddI has been shown to have increased toxicity and
should be avoided if possible.
19
Table 3.1 Antiretroviral Drugs
20
Table 3.1 Antiretroviral Drugs
21
Table 3.1 Antiretroviral Drugs
22
Monitoring therapy

• Monthly
• Physician evaluation, including assessment of
  AIDS-related complications and toxicities
• Weight
• Assess adherence
• Social work evaluation counseling
• Labs
• AST, ALT, Complete blood count (1st mo then q6
  mo)
• CD4 q3-6 months

23
(No Transcript)