HIV Flashcards
What is U=U?
Undetectable = untransmissable.
TREATMENT AS PREVENTION
Creates a financial case as a 15 fold return on investment
Where is the epidemic now concentrated?
1.7 million new infections last year, 1.2 million in SSA
% treatment for those that need it?
38 million people need ART. 25 million are on it. 66% coverage.
What are the evidence-based interventions to reduce HIV transmission?
• Sexual behaviour change interventions
– VCT (voluntary counselling and testing)
– Community-wide sexual health education
– Adolescent sexual health interventions
– Interventions among groups most at risk (CSW, MSM, IDU, etc)
– Interventions among HIV-positive individuals
• Biomedical interventions – STI treatment – HSV2 suppressive or episodic therapy – Male circumcision – Vaginal microbicides – HIV vaccines – Male and female condoms, female diaphragm – ARV: PMTCT, HAART, PEP, PrEP
• Other interventions
– Blood screening and sterile medical equipment – Clean injecting equipment
– Structural interventions
Public Health interventions
- Universal Test & Treat HIGHLY EFFECTIVE. Now SSA policy. “Population viral suppression” is the goal.
When should ART start?
Can start same day as diagnosis. Some evidence this increases loss to followup. 2 weeks seems acceptable.
What do we start?
Combination therapy
• HIV mutates rapidly – combination treatment needed to prevent resistance
• We (usually) use THREE drugs:
Two nucleoside analogues (NRTI)
+
3rd drug from a different drug class
• Increasing evidence for two drugs (if it’s the right two drugs)
What governs the decision to deicde on which HIV drug?
Patient factors • Genetics: abacavir • Hepatitis B status: need HBV- active drugs • Pregnancy: evidence, safety, drug levels • Co-morbidities: renal, CVD • Other medications • Choice: lifestyle, food requirements, pill burden
Virus factors
• Viral load: some drugs underperform at high VL
• Baseline resistance: if testing available
Practical factors
• Access • Cost!
Current antiretrovirals (in use)
Current antiretrovirals (in use) NRTI, NNRTI, INI, PI, Entry inhib
Zidovudine Nevirapine Raltegravir Lopinavir/r Enfuvirtide
Abacavir
Tenofovir-DF (old: renal and bone se)
Tenofovir-AF (new, less se)
What are the key HIV drug interactions and why do they occur?
Drug interactions
• Can alter concentrations of the HIV drug or the co-administered drug
– Increased concentrations–TOXICITY
– Decreased concentrations–LOSS OF EFFICACY
• Some HIV drugs need BOOSTING
– Using a drug to inhibit metabolism of the HIV drug
– BlockCYP3A4(ritonavir/cobicistat)
– Many, many other drugs metabolised this way so many, many drug interactions
Key drug interactions
• Boosters increasing levels of other drugs – Steroids (e.g. inhaled, intranasal, injectable) – Simvastatin
– Club drugs e.g GHB deaths
• Other drugs that reduce HIV drug levels – Rifampicin
– St John’s Wort
– Acid-reducing drugs
– Multivitamins (chelation)
Appropriate information for other health professionals and for patients
• Promoting Liverpool website to HCPs & PLWH
• Key interaction information at top of HCP letters
• Regular feedback & teaching
• Patient information cards e.g. steroids: – Bootshayfeverrelief=beclomethasone
– Bootsallergyrelief=fluticasone
HIV medication side-effects
Side effects • Hepatotoxicity • Rash • Diarrhoea,nausea • Renal impairment • Reduced bone density • Anaemia • CNS symptoms (efavirenz, newer drugs) • Mirochondrial toxicity (older NRTI e.g. zidovudine)
How many lives are estimated to be lost as a result of HIV medication interruptions in 2021 due to covid?
500,000.
FUUUUUCK.
Not including transmission from those who become infectious again.
HIV & Ageing
Manage complications; renal, cv and bone density
plan regimens for the long-term
Smoking and lipid status seem key.
What testing strategies better target children and adolescents?
Self testing and parental testing
What compromises HIV treatment adherence in Adolescents?
As in other chronic diseases, adherence lower in adolescence
Correlates of adherence:
• Adolescent factors (age, knowledge of status, mental health, conformity,
reminder of mortality)
• Family structure (type of caregiver, in loco parentis arrangements, disorganised families)
• ART(burdensomeregimens,treatmentliteracy)
• Other risk behaviours (Drug use)
• Health care and environmental factors (distance from clinics, schooling, disrupted routine, stigma, health care worker attitudes)
Specific HIV complications in children
Stunting and Growth Failure
• Retardation in linear growth ± pubertal delay
• Definition: Height for age z-score < -2
• More obvious in adolescence: growth spurt and development of puberty
• Sub-maximal catch-up growth with delayed ART
• Associated with:
• Increased mortality
• Delayed physical and cognitive development • Poor educational attainment
Beyond TB: Chronic lung disease
Up to 20% of adolescents (despite ART) in sub-Saharan Africa:
• Phenotype: hypoxia, chronic cough, can’t exercise, poor lung function
• Risk increases with age & occurring despite ART
• Recurrent treatment with antibiotics and /or TB treatment
• Small airways disease: constrictive obliterative bronchiolitis (unlike lymphocytic interstitial pneumonitis in pre-ART era)
Decreased bone mineral density
Planar warts
Chronic uveitis and ulceration causing blindness
Often orphans due to HIV: much worse outcomes socially
