Update in HIV/AIDS New millennium, New challenge 王永衛 醫師 台北榮民總醫院感染科主治醫師

Global summary of the HIV/AIDS epidemic, December 2001 Number of people living with HIV/AIDS Total40 million Adults37.2 million Women17.6 million Children under 15 years2.7 million People newly infected with HIV in 2001 Total5 million Adults4.3 million Women1.8 million Children under 15 years AIDS deaths in 2001 Total3 million Adults2.4 million Women1.1 million Children under 15 years

Regional HIV/AIDS statistics and features, end of 2001 Sub-Saharan Africa North Africa & Middle East South and South-East Asia East Asia & Pacific Latin America Caribbean Eastern Europe & Central Asia Western Europe North America Australia & New Zealand TOTAL late ’70s early ’80s late ’80s late ’70s early ’80s late ’70s early ’80s early ’90s late ’70s early ’80s late ’70s early ’80s late ’70s early ’80s 28.1 million million 1 million 1.4 million million million 8.4% 0.2% 0.6% 0.1% 0.5% 2.2% 0.5% 0.3% 0.6% 0.1% 1.2% 55% 40% 35% 20% 30% 50% 20% 25% 20% 10% 48% Hetero Hetero, IDU IDU, Hetero, MSM MSM, IDU, Hetero Hetero, MSM IDU MSM, IDU MSM, IDU, Hetero MSM Epidemic started Adults & children living with HIV/AIDS Adult prevalence rate * % of HIV- positive adults who are women Main mode(s) of transmission for those living with HIV/AIDS ** * The proportion of adults (15 to 49 years of age) living with HIV/AIDS in 2001, using 2001 population numbers ** Hetero: heterosexual transmission – IDU: transmission through injecting drug use – MSM: sexual transmission among men who have sex with men Adults & children newly infected with HIV 3.4 million million

Update in HIV/AIDS - New millennium, New challenge

中華民國愛滋病統計報告 台灣地區感染者危險因素別統計 民國 91 年 9 月 1 曰

中華民國愛滋病統計報告 台灣地區感染者年齡別統計 民國 91 年 9 月 1 曰

Update in HIV/AIDS - New millennium, New challenge

STD and HIV Factors Associated with Increased Risk of Transmission MALE->FEMALEFEMALE->MALE MALE->MALE Anal intercourseYesUnknownYes No. of sexual contactsYesYesYes Advanced HIV diseaseYesYesYes Primary HIV infectionYesYesYes Genital sores/ infectionsYesYesYes Sex during mensesNoYesNA Lack of circumcisionPossiblyYes Unknown Cervical ectopyYesPossiblyNA Oral contraceptivesYesUnknownNA IUD usePossiblyUnknownNA PregnancyUnknownPossiblyNA

STD and HIV Factors Associated with Decreased Risk of Transmission MALE->FEMALEFEMALE->MALEMALE- >MALE Condom useYesYesYes Antiretroviral therapyPossiblyPossibly Possibly Spermicide usePossiblyUnknown Unknown MicrobicidalUnknownUnknownNA

Natural History of HIV Infection

Life Cycle of HIV-1 and Targets of Anti-retroviral agents Fusion inhibitor T20

Update in HIV/AIDS - New millennium IDSROC, Med. Found. In Memory of Dr. DL Cheng, March 2001 Strongly Recommended Column AColumn B Indinavircombivir Saquinavird4T+3TC Nelfinavir Saquinavir+ritonavir Indinavir+Ritonavir Efavirenz Nevirapine Recommended as Alternatives Column AColumn B AbacavirAZT+3TC RitonavirAZT+ddI AZT+ddC D4T+ddI ddI+3TC Acute / asymptomatic HIV Infection

Update in HIV/AIDS - New millennium IDSROC, Med. Found. In Memory of Dr. DL Cheng, March 2001 HIV infected pregnant women Strongly Recommended Column AColumn B Saquinavir (B)Combivir (C) Ritonavir (B)AZT+ddI (B) Nevirapine (C) Post Exposure Prophylaxis Column AColumn B IndinavirCombivir Recommended as Alternatives Column AColumn B IndinavirAZT+3TC Nelfinavird4T+3TC Column AColumn B SaquinavirAZT+3TC Nelfinavird4T+3TC

Update in HIV/AIDS - New millennium

3-Year Suppression of HIV Viremia with Indinavir, Zidovudine, and Lamivudine

Update in HIV/AIDS - New millennium

Update in HIV/AIDS - New challenge

Factors Affecting Adherence in HIV-infected Patients l Food effects l Pill burden l Drug interactions l Spacing of medications l Side effects l Adherence issues l Confusion with drug names

Factors Affecting Adherence in HIV-infected Patients Regimen Pills per day Trizivir 2 Combivir / Abacavir 4 Combivir / Efavirenz 5 Combivir / Kaletra 8 d4T / 3TC / Indinavir 10 d4T / 3TC / Nelfinavir 13 ZDV / ddI / Ritonavir / Saquinavir 22 ddI / d4T / Saquinavir 22

Factors Affecting Adherence in HIV-infected Patients

Metabolic and Morphologic Complications Associated With HAART

Kaplan-Meier curves for the occurrence of hypercholesterolemia in protease inhibitor (PI)–exposed vs – nonexposed patients. The graphic representation shows the proportion of patients in whom hypercholesterolemia does not develop.

Kaplan-Meier curves for the occurrence of hypertriglyceridemia on protease inhibitor (PI)–exposed vs –nonexposed patients. The graphic representation shows the proportion of patients in whom hypertriglyceridemia does not develop.

Metabolic and Morphologic Complications Associated With HAART

Immune Therapy: Non-HAART Management of HIV-infected Patients Rebuilding the Immunity - Immune Booster –CD4 Repertoire naive CD4 cell memory CD4 cell Loss of CD4 cells produce 'gaps' in the repertoire where the immune system can no longer respond to certain antigens –RES architecture

Immune Therapy: Non-HAART Management of HIV-infected Patients Rebuilding the Immunity - Immune Booster (cont.) - IL2 pooled analysis of 157 participants in 3 placebo- controlled studies 6 OIs occurred among IL-2 recipients 14 among placebo recipients Early treatment may prevent irreversible damage from occurring in the first place

Immune Therapy: Non-HAART Management of HIV-infected Patients

Vaccination in HIV Infection

Update in HIV/AIDS - New millennium, New challenge Post exposure prophylaxis –Health-care Workers average 0.3% for percutaneous and mucosa exposure risk increased for deep injury, visible blood on device, device had been placed in vessels, or patients died of AIDS within 60 days chemoprophylaxis initiated within 1 to 2 hours and continued for 4 weeks zidovudine plus lamivudine 1 (+PI 2 ) 1 Johnson MA, Goodwin C, yen GJ, et al. 11th Int. Conf. On AIDS Centers for Diseases Control and Prevention. JAMA 1996

Update in HIV/AIDS - New millennium, New challenge Post exposure prophylaxis Risk FactorAdjusted OR (95%CI) –deep injury 16.1 ( ) –visible blood on device 5.2 ( ) –device had been placed in vessels 5.1 ( ) –patients died within 60 days 6.4 ( ) –chemoprophylaxis 0.2 ( ) Sepkowitz KA. Ann Intern Med 1996