August 2013 PLUS HIV Treatment

HIV Treatment: An IntroductionAugust 4, 2013

Dr. Joanna Eveland, MS, MDHIV Medical Director, Clinica EsperanzaMission Neighborhood Health Center

Objectives

• When, Why and What treatment to start

• Overcoming side effects• Working with your healthcare

providers to get the most out of treatment

When to start?

04/09/2023

10,000,000

1,000,000

100,000

10,000

1,000

100

10

HIV in plasma (copies/mL) HIV in plasma (“viral load”)

800

500

200

100

50

0

CD4 Count (cells/mL)

CD4 (T Cell) count

Months Years

Average progression without treatment: 10 years from infection to AIDS diagnosis

Source: HRSA HIV/AIDS Bureau

2012 Treatment Guidelines

ART is recommended for all HIV+ individuals

• Strength of the recommendation varies by CD4 count: o CD4 count <350 (AI) o CD4 count 350 to 500 (AII) o CD4 count >500 (BIII)

2012 Treatment Guidelines

Rating scale  A = StrongB = ModerateC = Optional

Rating of Evidence:  I = data from randomized controlled trialsII = data from well-designed nonrandomized studies with long-term outcomes

III = expert opinion

2012 Treatment Guidelines

Treatment encouraged for special risk groups

• Pregnancy (AI)• HIV-associated kidney disease

(HIVAN) (AII) • Hepatitis B co-infection (AII) • Older patients (>50) (BIII)

Why Treat Early?

Reduce InflammationUncontrolled HIV might increase risk

of non-AIDS diseases:• Heart disease • Kidney disease• Liver disease• Dementia • Cancers

Why Treat Early?

Treatment is Prevention• Large 2011 studies showing 92-96%

decrease in HIV transmission with treatment

• Guidelines say offer ART to all at risk of transmitting HIV (AI [hetero] or AIII [other risk groups])

Don’t start meds until…

• You feel ready

• You are well engaged in care

• You can commit to taking your meds regularly

• You feel that other life factors and potential barriers to adherence (drugs, drama, mental health) are under control

We have a long way to go…

What to start?

Where we started…

• D

Where we are now…

• D

Take Home Points

• HIV treatment continues to improve- for the better!

• Each person’s combination of medicines is different

• KNOW what you take, and why.

Know What You’re Taking

• HIV drugs have two, sometimes three, different names– Scientific name, brand name, chemical

name– Zidovudine = Retrovir = AZT

• Some tablets contain more than one ingredient– Atripla = tenofovir + emtricitabine +

efavirenz

Goal of Treatment

General Principles• Goals: less pills, less times/day, less side

effects• Use at least 3 drugs, 2 classes of

medicines• Sometimes 3 isn’t enough

– Your Protease Inhibitor may need a “Booster”– Drug resistance usually = more pills

Treatment Principles:Chinese Menu Metaphor

“Two scoops of rice plus chicken or beef”

In other words, usually

2 “nukes”(NRTI) (2 scoops of rice) plus– 1 partner drug (main dish)

Protease Inhibitor (beef)

“non-nuke” NNRTI (chicken)

The Drugs…

Each attacks the virus at a different point…

Where Do HIV Drugs Act?

NRTIs, “Nukes”

NRTIs Continued

• Backbone of treatment• Older drugs are more toxic (AZT, “D-

drugs”)– Peripheral neuropathy– Lactic acidosis– Pancreatitis – Lipodystrophy

• Watch kidney function with Tenofovir

NNRTIs, “Non-nukes”

NNRTI: Pros and Cons

Ease (low pill burden) Well tolerated Less metabolic

effects– No lipodystrophy, less

dyslipidemia

Resistance develops quickly if <95% adherent– Single mutation– Cross resistance

among NNRTIs

Rash; hepatotoxicity

ADVANTAGES DISADVANTAGES

Efavirenz considerations

• Most commonly prescribed NNRTI• Neuropsychiatric side effects: vivid

dreams, sleep disturbance, “spaciness”

• Caution for those with mental health issues

Protease Inhibitors

PIs: Pros and Cons

• High potency• Less susceptible to

resistance from virus

• Second-line therapy when NNRTI fails

• Metabolic complications- Increased cholesterol,

blood sugar• GI side effects

- Diarrhea, nausea• Drug interactions

– Statins, viagra, anti-seizure, many others

ADVANTAGES DISADVANTAGES

Integrase Inhibitor

Integrase Inhibitor

• Approved as first-line regimen

• Less side effects

• Twice daily dosing• Low barrier to

resistance• Newer drug• Drug interactions

ADVANTAGES DISADVANTAGES

Entry Inhibitors

Entry Inhibitors

• Currently used as salvage therapy for those with drug resistance

• Fuzeon is injectable, rarely used• Maraviroc is well tolerated, requires

CCR5 receptor on CD4 cells (not everyone has this)

Side Effects

• Tend to be worst in the first 2 months of therapy

• Severe side effects are a reason to change medications

• Your expectations shape your experience

Getting The Most Out of Treatment

What If I Miss a Pill?

• Risk of resistance increases with missing more than 1-2 doses/month

• If you miss a dose, try and learn from it

• If stopping your meds– All or none– Let us know!

Working With Your Provider

• You deserve great care

• Find the right fit• Educate yourself• Be engaged in care-

regular visits• Uninsured? You can

still get care!

Focus on Wellness

• Manage stress• Exercise regularly• Quit smoking• Reduce harmful drug or alcohol use• Build a supportive community• Define and achieve your personal

goals

Resources

• Project Inform: 1-800-342-2437, • http://www.projectinform.org/

• AIDSmeds.com• thebody.com• HIVinsite.org• www.aidsinfonet.org/

Thanks

• Drs Rick Loftus and Tri Do• The advocates and activists who

gave us these treatments• My patients

More Questions?

Dr. Joanna EvelandClinica Esperanza240 Shotwell St., SF(415) 431-3212 – Clinic Info(415) 552-3870 # 303 –My [email protected]