HIV Treatment in Saskatchewan Kurt E. Williams MD FRCPC 2012/Feb/9 Saskatoon

Objectives To review Saskatchewan epidemiology of HIV. To identify cofactors which affect the way we prescribe antiretrovirals in Saskatchewan. To illustrate with brief case studies, some of the issues in ARV access and use.

HIV Epidemiology: Current HIV Epidemic The number of new diagnoses of HIV positive people has increased 5 fold in the last few years. The primary risk behavior is IDU. Heterosexual sex is likely under-rated as a risk factor in this epidemic. First Nations people are disproportionately affected.

Insert risk factors here Fig. 3: Selected Risk Factors Among HIV Cases in Saskatchewan,

Fig 2: HIV cases reported by Age and Gender in Saskatchewan, 2010 (Preliminary) Number of cases male female

Proportion of HIV cases reported by Year & Health Jurisdictions

Geographic Challenges in Saskatchewan , rural – urban split. Some Reserves are among the hardest hit areas so transportation is an issue.

Dealing With Geography Outreach clinics in Prince Albert, La Ronge and LaLoche. Partnering with the TB program for transport. Directed visits to Reserves to facilitate testing, provide medical care. Visits involve a team (ID doc, ID nurse, pharmacist, social worker, MHO).

Dealing With Geography: Goals of Rural Team Visits To provide expert medical care. To mentor local health care providers (peer to peer). To provide subsequent backup by telephone, etc for increased patient well being and decreased patient travel. To enhance local capacity, decrease travel.

Prescription of ARVs Generally prescribed by sub-specialists in Infectious Diseases. Generally prescribed according to published guidelines which are similar around North America. Guidelines are specific enough that first regimens in the absence of viral resistance can be prescribed by non-ID specialists- some HIV- experienced Internists and Family Physicians.

Peculiarities of the Saskatchewan Formulary They allow appropriate latitude in prescribing practices for qualified prescribers. ARVs are not (yet) provided free of charge for all HIV infected people in Saskatchewan. Some ARVs remain free of charge: chronologically, all ‘old’ drugs are ‘free’ ie AZT, ddI, ddC, d4T, 3TC, saquinavir, ritonavir and indinavir. The newer ARVs are all ‘co-pay’.

Peculiarities of the Saskatchewan Formulary Only ritonavir and 3TC are among the ARVs recommended as ‘preferred components’ in current guidelines. Current first regimens still consist of two NRTIs plus either an NNRTI or a PI (Protease inhibitor) usually boosted with ritonavir. Preferred NRTIs = tenofovir and emtricitabine. But abacavir and lamivudine may be equal.

Peculiarities of the Saskatchewan Formulary Preferred NNRTI = Efavirenz. Preferred PIs = either Atazanavir or Darunavir, with ritonavir boost. Preferred Integrase Inhibitor = Raltegravir.

Why Embrace Early HIV Treatment in Saskatchewan? The appearance of ‘Rapid Progressors’ in unusual numbers: AIDS develops after 1 -3 years after infection vs 50% by 10 years. Reduced toxicity of current ARVs with less cumulative toxicity. Could decrease chances of further spread: treatment as a public health measure. Prolonged immune suppression, even with reconstitution, leads to more cancer.

Frequent Patient Factors to Consider in Saskatchewan Younger women account for more of our new cases than elsewhere. Co-infection with HCV in 80% of new cases. Co-infection with Mycobacterium tuberculosis provides well-recognized drug interactions and IRIS (Immune Reconstitution Syndrome). PI side-effects can include elevated lipids and cholesterol = cardiovascular disease, in already vulnerable population (First Nations).

Case #1 37 year old caucasian male with high school education, no other training. HIV Escalating viral load (200,000), CD4 count 348 (23.2%) prompted initiation of ARVs. Combivir (AZT/3TC) + Efavirenz fall Viral load ‘not detected’, CD4 count > 1000 (37 – 50%) essentially normal immune system.

Case # April: viral load = 1001, CD4 = 725 (30.3%) early June: viral load = 59,000, CD4 = 524 (23.3%). Claimed complete adherence January: acknowledged some physical problems and missing appointments. Taking ARVs one month on, one off, for most of $200 co-pay for a minimum wage earner not able to work full time.

Case #1: Illustrates 3 Issues 1.Working poor are especially vulnerable where co-payment is required. 2.Pharmacists rock but you must talk to them before they can help you with emergency support. 3.If you won’t talk to a pharmacist you’d better learn about pharmacokinetics and how the long half life of Efavirenz can be trouble.