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HIV Care Flashcards

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) (63 cards)

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1
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Recommended testing to establish HIV infection

***exam

A
  • CDC no longer recommends ELISA w/western blot
  • Use 4th generation HIV 1/2 immunoassay (detects Ag & Abs = better in acute setting)
    • If 4th gen positive
      • >> confirmatory HIV-1/HIV-2 antibody differentiation immunoassay (better in acute infection)
      • >>If indeterminate or acute HIV suspected: HIV RNA testing
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2
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Important questions/education for patients newly diagnosed w/HIV

A
  • Start with what do they know
  • How are they coping?
  • sources of support
  • offer counseling
  • how/when contracted
  • HIV is no longer a ‘death sentence’
    • Diabetes mellitus can be a useful analogy
      • Chronic, incurable disease
      • Not immediately fatal
      • Eventually requires medications in most cases
      • Can usually be controlled with careful adherence, management, and follow-up
      • As with the care of persons with diabetes, working in a team and providing continuing education is essential throughout the course of the disease
  • Patients educated about HIV and the potential for resistance have better adherence to therapy
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3
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Relationship between HIV and CD4

A

HIV Infection is characterized by a steady decline in the number of CD4 cells

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4
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

At what CD4 count do HIV infected patients develop a high risk for opportunistic infections?

***exam

A
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5
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

How did AIDS mortality changed from 1996 to 2001

A

show how haart has changed mortality. After 1996 – had PIs, which changed the game. At that time, AIDS was #1 cause of death in youngmen

Can keep from opportunist infections and death

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6
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Common responses to how they are coping w/dx of HIV

A

Common responses (in my experience):

  • “I’ve tried not to think about it, ever since I found out”
  • “I’ve watched so many friends die, and now I’m next”
  • “My friends tell me it’s not that big a deal”
  • “I’ve been researching this on the internet and I have a 10-page list of questions for you”
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7
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Why is it important to know how/when a patient contracted HIV?

A
  • Risk factor identification can guide counseling and prevention
  • Resistance
    • Increasing transmission of drug-resistant HIV strains
    • Resistance testing indicated for patients infected for ALL newly diagnosed patients, even if antiretroviral therapy is not being considered in the near future
    • Primary HIV Infection (PHI)
      • Loss of HIV-specific CD4 cells occurs immediately after PHI
      • Some evidence that early treatment of PHI may favorably influence subsequent course of disease
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8
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

CD4 Count, Viral Load, and Clinical Course

***exam

A

Early infection – may have rash, pharyngitis, lad, but pass off as sth else

Some progress quickly, but typically several years until CD4 count

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9
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Consideration if HIV+, HCV ab negative, elevated transaminases?

***exam

A
  • Up to 19% of HIV+ individuals with chronic hepatitis C have negative HCV Ab titers
  • HCV RNA PCR (viral load) testing is indicated if chronic hepatitis C suspected
  • # 1 cause of death for aids is End stage liver dz, predominantly 2/2 chronic hep c
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10
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Goals of Treatment with ART

A
  1. Reduce HIV-related morbidity
  2. Prolong the duration and quality of survival
  3. Restore and/or preserve immunologic function
  4. Maximally and durably suppress HIV viral load
  5. Prevent HIV transmission
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11
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

What is ART recommended for and why?

A
  • ALL Persons Living with HIV
  • To reduce morbidity and mortality
  • To prevention transmission of HIV
    • Perinatal
    • Heterosexual
    • MSM
    • PWID
  • * Patients starting ART should be willing and able to commit to treatment and understand the importance of adherence.
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12
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

How have ART initiation guidelines changed over the years?

A
  • Used to be much more conservative - concern regarding SEs (obs studies not sufficient evidence)
  • HPTN 052 – major study that was pivotal in looking at reduction in transmission w/HAART vs deferral showing HAART significantly reduced transmission such that the trial was stopped
  • TEMPRANO: final big RCT that showed benefit of immediate start >500
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13
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

HAART vs ART

A

used to be “highly active” after introduction of Pis which lead to drop in death rates. Now all are highly active, so we just call combo art.

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14
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

How has ART eligibility changed over time?

A

Now finally recommend all be treated!

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15
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Currently available ARTs

A
  • TAF is new – same as tenofovir but less renal toxicity
  • Complera: RPV/TDF/FTC (not for VL >100K or CD4
  • Stribild: EVG/COBI/TDF/FTC (COBI inhibits active tubular secretion of creatinine, resulting in increases in serum creatinine and a reduction in estimated creatinine clearance (CrCl) without reducing glomerular function.73 A
  • Atripla : EVF/TDF /FTC
  • Truvada: TDF/FTC
  • Ziagen: ABC/3TC
  • Atazanavir/cobicistat?
  • Darunavir/ cobisstat?
  • Genvoya EVG/COBI/FTC/TAF
  • TAF Tenofovir Adlafenamide (TAF) prodrug of TDF
  • Triumeq (DTG/ABC/3TC)
  • Evotaz (ATZ+ Cobicistat)
  • Prezcobix (DRV+ COBI)
  • TAF is being evaluated in 3 combinations:
    • elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide
    • darunavir/cobicistat/emtricitabine/tenofovir alafenamide
    • emtricitabine/tenofovir alafenamide
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16
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

HIV Replication Cycle and Sites of Drug Activity

A
  • Key is trying to attack virus where it replicates. Now say use either a PI combo w/ritonavir, or II. Have removed NNRTIs as primary tx.
  • Ritonavir is booster – boosts effectiveness w/o increasing Ses
  • Fewer interactions w/IEs as they don’t go through same pathway
  • Reverse Transcriptase
  • HIV is a retrovirus, uses RT to make RNA into proviral DNA. Humans don’t have RT.
  • Protease
  • functions to cut the long protein precursors made in the translation process into functional pieces. If not performed properly HIV is not viable.
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17
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Necessary steps, tests before starting ART

A
  • HIV Ab Confirmation, HIV VL, CD4, HIV Genotype
  • Assess understanding of disease
  • Assess Readiness to start
  • Current and PMH
  • Social History: Travel, Sexual, Substance use
  • Alcohol and Drug Use Disorder Screen
  • Mental Illness Screen
  • Housing status
  • Support systems
  • Pregnancy/ contraceptive use
  • Baseline labs: CBC, Renal Function, LFTs, Hep A, B, C status, TB status
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18
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

When is HLA-B*5701 screening recommended?

A
  • before starting ABC (abacovir), to reduce risk of hypersensitivity reaction (HSR)
  • HLA-B*5701-positive patients should not receive ABC
  • Positive status should be recorded as an ABC allergy
  • If HLA-B*5701 testing is not available, ABC may be initiated after counseling and with appropriate monitoring for HSR
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19
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

When is Coreceptor tropism assay recommended?

A
  • Should be performed when a CCR5 antagonist
  • is being considered
  • Phenotype assays have been used; genotypic test now available but has been studied less thoroughly
  • Consider in patients with virologic failure on a CCR5 antagonist (though does not rule out resistance to CCR5 antagonist)
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20
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Initial ART regimens: recommended

A

Main are integrase inhibitor based and one PI based

RAL must take once a day = used less often

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21
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

For which patients are integrase inhibitors approved?

A

all are approved for naive pts

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22
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Pros and Cons to the IE raltegravir

A
  • Pro: the longest clinical trial and post-marketing experience and has been shown to have durable potency.
  • Cons: twice daily dosing, II resistance mutations.

(don’t memorize)

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23
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Pros and Cons to the IE Elvitegravir

A
  • Pro: within a fixed-dose combination product taken as a single-tablet, once-daily regimen.
  • Cons:
  • must be given with food.
  • Cobi is a potent CYP3A4 inhibitor that may result in drug-drug interaction with other concomitant medications.
  • the fixed-dose combination product is only approved for patients with estimated creatinine clearance of ≥70 mL/min.

(don’t memorize)

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24
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Pros and Cons to the IE Dolutegravir

A
  • the most recently approved INSTI
  • Pro: It can be given once daily with or without food.
  • Pro: In randomized trials, DTG was non-inferior to RAL and was superior to both DRV/r and EFV (because of fewer drug discontinuations in those who received DTG).
  • Con: DTG has the shortest duration of follow-up and limited post-marketing experience to date.

(don’t memorize)

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25
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) Recommended ART in CKD (eGFR
* Consider avoiding TDF * If eGFR * EVG/c/TDF/FTC * ATV/c + TDF * DRV/c + TDF * Options: * ABC/3TC if HLA-B\*5701 negative (if HIV RNA \>100,000, do not use with EFV or ATV/r; if CrCl * DRV/r + RAL * LPV/r + 3TC * Modify TDF dose
26
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) Recommended ART in Osteoporosis
* Consider avoiding TDF: associated with greater decrease in BMD, osteomalacia, urine phosphate wasting * Use ABC/3TC if HLA-B\*5701 negative * (if HIV RNA \>100,000 copies/mL, do not use with EFV or ATV/r)
27
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) Recommended ART in Psychiatric illness
Consider avoiding EFV: can exacerbate psychiatric symptoms; may be associated with suicidality
28
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) Recommended ART in high cardiac risk
Consider avoiding ABC and LPV/r: increased CV risk in some studies
29
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) Recommended ART in hyperlipidemia
* Adverse effects on lipids: * PI/r * ABC * EFV * EVG/c * Beneficial lipid effects: * TDF
30
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) Recommended ART in pregnancy and in HCV
§Consult current recommendations
31
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) Recommended ART in HBV
* Use TDF/FTC (or TDF + 3TC) if possible: use 2 NRTIs with activity against both HIV and HBV * If TDF contraindicated: cotreat HBV with FTC or 3TC + entecavir or another HBV-active drug
32
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) ARV regimens not recommended:
* Monotherapy with NRTI\* * Monotherapy with boosted PI * Dual-NRTI therapy * 3-NRTI regimen (except ABC + 3TC + ZDV or possibly TDF + 3TC + ZDV) ARV components not recommended: * ddI + d4T * ddI + TDF * FTC + 3TC * d4T + ZDV * DRV, SQV, or TPV as single PIs (unboosted) * ATV + IDV * EFV during first trimester of pregnancy and in women with significant potential for pregnancy\* * NVP initiation in women with CD4 counts of \>250 cells/µL or in men with CD4 counts of \>400 cells/µL * ETR + unboosted PI * ETR + RTV-boosted ATV, FPV, or TPV * 2-NNRTI combination * \* Exception: when no other ARV options are available and potential benefits outweigh the risks
33
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) ARV Components in Initial Therapy: INSTIs advantages
* ADVANTAGES * Virologic response noninferior to EFV * Fewer adverse events than with EFV or PIs * RAL, DTG have fewer drug-drug interactions than with PIs or NNRTIs (not true of EVG/COBI) * Single-pill combination regimens available with DRV, EVG/COBI
34
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) ARV Components in Initial Therapy: INSTIs disadvantages
* DISADVANTAGES * Lower genetic barrier to resistance than PIs * COBI has many drug-drug interactions * COBI may cause or worsen renal impairment * Myopathy, rhabdomyolysis, skin reactions reported with RAL (rare)
35
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) ARV Components in Initial Therapy: PIs advantages
* ADVANTAGES * Higher genetic barrier to resistance * PI resistance uncommon with failure of boosted PIs
36
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) ARV Components in Initial Therapy: PIs disadvantages
* DISADVANTAGES * Metabolic complications * (fat maldistribution, dyslipidemia, insulin resistance) * GI intolerance * Potential for drug interactions (CYP450), especially with RTV * No single-pill combination regimens
37
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) ARV Components in Initial Therapy: NNRTIs advantages
* ADVANTAGES * Long half-lives * Less metabolic toxicity (dyslipidemia, insulin resistance) than with some PIs * Single-pill combination regimens available with EFV and RPV
38
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) ARV Components in Initial Therapy: NNRTIs disadvantages
* DISADVANTAGES * Low genetic barrier to resistance – single mutation * Cross-resistance among most NNRTIs * EFV: high rate of CNS-related side effects * RPV: lower efficacy if HIV RNA \>100,000 or CD4 * Rash; hepatotoxicity * Potential drug interactions (CYP450) * Transmitted resistance to NNRTIs more common than resistance to PIs
39
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) Adverse Effects: NRTIs
All NRTIs: * Lactic acidosis and hepatic steatosis (highest incidence with d4T, then ddI and ZDV, lower with TDF, ABC, 3TC, and FTC) * Lipodystrophy * (higher incidence with d4T)a A**BC** * **HSR\*** * **Rash** * **Possible increased risk of MI** * ddI * GI intolerance * Peripheral neuropathy * Possible increased risk of MI * Pancreatitis * Possible noncirrhotic portal hypertension d4T * Peripheral neuropathy * Lipoatrophy * Pancreatitis **TDF** *(shouldn't be an issue w/taf)* * **Renal impairment** * **Decrease in bone-mineral density** * **Headache** * **GI intolerance** ZDV * Headache * GI intolerance * Lipoatrophy * Bone-marrow suppression *\* Screen for HLA-B\*5701 before treatment with ABC; ABC should not be given to patients who test positive for HLA-B\*5701.​*
40
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) Adverse Effects: INSTIs
* DTG * Headache * Insomnia * Rash, hypersensitivity reaction * EVG/COBI * Decreased CrCl * Increased risk of TDF-related nephrotoxicity * Nausea, diarrhea * RAL * Nausea * Headache * Diarrhea * CPK elevation, myopathy, rhabdomyolysis * Rash
41
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) Adverse Effects: PIs
•All PIs: –Hyperlipidemia –Lipodystrophy –Hepatotoxicity –GI intolerance –Possibility of increased bleeding risk for hemophiliacs –Drug-drug interactions **•ATV** –Hyperbilirubinemia –PR prolongation **–Nephrolithiasis, cholelithiasis** •DRV –Rash –Liver toxicity •FPV –GI intolerance –Rash –Possible increased risk of MI •IDV –Nephrolithiasis –GI intolerance –Diabetes/insulin resistance •LPV/r –GI intolerance –Diabetes/insulin resistance –Possible increased risk of MI –PR and QT prolongation •NFV –Diarrhea •SQV –GI intolerance –PR and QT prolongation •TPV –GI intolerance –Rash –Hyperlipidemia –Liver toxicity –Contraindicated if moderate-to-severe hepatic insufficiency –Cases of intracranial hemorrhage
42
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) Adverse Effects: Pharmacokinetic Boosters
•Ritonavir –GI intolerance –Hyperlipidemia, hyperglycemia –Hepatitis * Cobicistat * GI intolerance * Increase in serum creatinine
43
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) Adverse Effects: NNRTIs
•All NNRTIs: –Rash, including Stevens-Johnson syndrome –Hepatotoxicity (especially NVP) –Drug-drug interactions **•EFV** **–Neuropsychiatric, Suicidality, Depression** –Teratogenic in nonhuman primates + cases of neural tube defects in human infants after first-trimester exposure –Dyslipidemia •NVP –Higher rate of rash –Hepatotoxicity (may be severe and life-threatening; risk higher in patients with higher CD4 counts at the time they start NVP, and in women) •RPV –Depression
44
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) Concern with EFV-based initial ART
associated with 2-fold increase in hazard of suicidality\* vs EFV-free ART efavirenz
45
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) Adverse Effects: CCR5 Antagonist
•MVC –Drug-drug interactions –Rash –Abdominal pain –Upper respiratory tract infections –Cough –Hepatotoxicity –Musculoskeletal symptoms –Orthostatic hypotension, especially if severe renal disease
46
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) Adverse Effects: Fusion Inhibitor
•ENF –Injection-site reactions –HSR –Increased risk of bacterial pneumonia
47
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) Predictors of Poor Adherence \*\*\*exam
* Active alcohol or substance abuse * Work outside the home for pay * Depressed mood * Lack of perceived efficacy of ART * Lack of advanced disease * Concern over side effects * Regimen complexity •
48
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) Factors Associated with Higher Levels of Adherence \*\*\*exam
* Twice-daily or once-daily regimens * Belief in own ability to adhere to regimen * Not living alone * Dependent on a significant other for support * History of opportunistic infection or advanced HIV disease * Belief in efficacy of antiretroviral therapy * Belief that non-adherence will lead to viral resistance * Treatment of depression * Treatment of opioid dependency with OST
49
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) St John's Wort for depression in HIV pts treated with ART \*\*\*exam
significant interactions with many antiretroviral agents and not as effective as other antidepressants such as SSRIs
50
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) Accuracy of Clinicians’ Estimates of Adherence
Not Much Better Than Random
51
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) Drug use and adherence to ART
Drug use is related to decreased adherence to medical care and HAART adherence need tx for SAD!
52
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) Efficacy of HIV treatment in setting of opioid dependence \*\*\*exam
* In IDU who are not actively using, efficacy similar to other populations * Active drug use may interfere with adherence and ARV success * DAART (Directly Administered Antiretroviral therapy ) * Substance abuse treatment may be required for ARV success * Methadone, Buprenorphine, Extended-release Naltrexone * Many other support mechanisms may be effective
53
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) Relationship btwn HIV and HCV \*\*\*exam
* HIV accelerates the course of hepatitis C, but variable rates of progression still seen * Avoiding alcohol, other insults to the liver is critical * Co-infection with HIV also reduces the response rate to treatment for hepatitis C – but treatment can be curative! * Focus on HIV first, but discuss the possibility of future treatment and a Hepatology consultation is a good idea
54
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) What is the goal of ART for viral load? \*\*\*exam
VR \< 20 can see as early as 6-8wks with dolutegravir
55
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) ART: goal response in terms of CD4? \*\*\*exam
Usually increase cd4 by 100 to 200 cells / yr if caught early If older and caught late, may not be able to raise so significantly
56
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) RHM in HIV infected patients: vaccines \*\*\*exam
•Vaccines –Hepatitis A, hepatitis B (if not immune) –Pneumococcal –Influenza –Tetanus –VZV
57
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents. December 2015. \*\*\*exam (PCP)
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# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) RHM in HIV infected pts: paps \*\*\*exam
•Pap smears –Every year –If ASCUS or more significant abnormalityà colposcopy per latest guidelines (do not triage by HPV status)
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# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) RHM in HIV infected pts: ca screening \*\*\*exam
•Breast, prostate, colorectal cancer screening –Same as for HIV-negative patients
60
# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) RHM in HIV infected pts: CHOL screening \*\*\*exam
•screening (every 6 months) –Protease inhibitors, efavirenz, some NRTIs associated with dyslipidemia –Check baseline lipids before treatment and periodically after initiation of treatment –Higher rates of CAD among HIV-infected patients starting to be seen (ABC)
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# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) RHM in HIV infected pts: STI screening \*\*\*exam
–Annual anal/pharyngeal/urethral screening for GC, urethral chlamydia recommended for MSM –Annual RPR –More frequent STI screening may be appropriate for some patients
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# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) Summary of recommendations when starting ART
* When starting ARTS- be PRO-ACTIVE! * •Must know about co-infections or co-morbid medical conditions before starting therapy. * •Important to discuss potential adverse effects with patient * •Adherence issues need to be assessed prior to start * •Must frequently follow laboratory parameters, CBC, chemistries including LFTs and bun/creat
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# Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap) NYS AIDS Institute recommendations for anal pap screening \*\*\*exam
Baseline & annually o For men who have sex with men o Any patient with a history of anogenital condylomas o Women with abnormal cervical/vulvar histology
SPRING16 757 PC Adults
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