HIV Update for Case Managers

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HIV Update for Case Managers

• February 12, 2003
• Cyril K. Goshima, M.D.
• Clinical Assistant Professor of Medicine
• John A. Burns School of medicine

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Case Managers

• Who are you?
• What do you do?
• What do you want to know?
• Why do you want to know that?

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HIV Disease

• Interaction between the Virus, the Immune System,
  Behavior, and the Socio-Economic System

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The Reality

• AIDS is not over.
• People continue to die from AIDS.
• Treatment is difficult, life long, expensive, not
  curative
• Lifetime treatment average cost 155,000 and
  rising

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The Numbers

• World Wide Epidemic
• There are more cases outside of the United
  States.
• The hot spots are in Sub-Saharan Africa, South
  East Asia, Indian Subcontinent, Eastern Europe.
• Risk Population Heterosexual, IDU.

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The Numbers

• United States different disease
• Infections occur in 40,000 persons per year
• MSM continue to be the highest risk group.
  Increase by 17 last year.
• Increases occurring in heterosexual cases and in
  the black population

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Risk Behavior Among MSM

• HIV prevention fatigue among older gay men.
• Fewer prevention efforts reaching marginalized
  MSM.
• Increase popularity of bath houses and sex clubs.
• Viral load beliefs.
• Internet chat rooms to meet sex partners.
• Treatment optimism.
• Lack of fear.

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Treatment Targets

• Based on knowledge of the life cycle of HIV and
  the components of replication.
• Drugs are developed to specifically target
  aspects of the virus life cycle.
• Recent approval of the fusion inhibitor, T-20 or
  Fuzeon.
• Now there are Reverse Transcriptase Inhibitors,
  Protease Inhibitors, and Fusion Inhibitors.

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Drug to Drug Interactions

• Ritonavir and NNRTI
• Now Tenofovir interactions ATZ, ddI
• Now Amprenavir and fosAmprenavir interactions
  with Kaletra
• Antivirals affect the levels of or are affected
  by common medications like estrogens, methadone,
  PPI

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Drug Resistance

• Primary resistance in chronic untreated HIV
  patients is occurring.
• Low level vs. High level resistance
• Cross Resistance
• Concepts
• Limits treatment options

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Treatment

• Does treatment earlier have better outcomes
  clinically, virologically, or immunologically?
• In Mellors study, the risk of developing AIDS
  after 3 years increased significantly in patients
  with CD4 350 or less.
• In the MACS, the risk of developing AIDS in the
  untreated patient increased with viral loads
  between 40-60,000.

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Treatment

• Sterling reported that there was no change in
  disease progression in the treated vs.
  non-treated patients whose CD4 count was over
  350. In the treated group there was viral
  resistance, lipodystrophy, multiple regimens
  used, and approximately half not having
  undetectable viral loads.

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Treatment

• Adherence continues to be a concern.
• Non-Adherence may be multi-factorial.
• Once daily medications
• NRTI TDF, 3TC, DDI, FTC, (ABV)
• NNRTI EFV, NVP
• PI APVr, fAPVr, SQVr, LPVr, ATVr, ATV

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Resistance Testing

• When to use?
• What to use Genotype, Phenotype, both?
• Are they all the same?
• Expert interpretation.
• Expensive
• Basically tell us what not to use.

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Weak Viruses

• Wild type virus is a strong virus.
• Resistant viruses or viruses with mutations are
  weak viruses.
• Decreased Viral Replicative Capacity.
• Decreased Viral Pathogenicity.
• Better to be on medication than no medication in
  heavily treated patients who have multiple
  resistant viruses.

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Metabolic Complications

• Osteopenia Osteoporosis
• Osteonecrosis/Avascular Necrosis
• Alterations in Glucose Metabolism
• Alterations in Lipid Metabolism
• Morphological Changes
• Cardiovascular Risk
• Mitochondrial toxicity

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Bones

• Contributions to osteopenia/osteoporosis
  Decreased activity, weight loss, wasting
  syndrome, malnutrition, malabsorption, low
  testosterone.
• Osteonecrosis/Avascular Necrosis Alcohol,
  hyperlipidemia, osteoporosis, testosterone therapy

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Sugar, Fat, and the Heart

• Glucose intolerance, diabetes, Insulin Resistance
• High Triglycerides, high total cholesterol, high
  LDL, low HDL
• Cardiovascular Risk Insulin resistance, central
  obesity, glucose intolerance, hyperlipidemia

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Lipodystrophy

• Fat accumulation dorsocervical fat pad, neck,
  breast, intra-abdominal
• Fat loss face and extremities
• Medications implicated
• Treatment poor

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AIDS

• Human Sexuality
• Unequal Treatment between Men and Women in
  Society
• Economic Disparity within a country and between
  countries
• One World

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Questions?