HIV: WHAT IS NEW? DR NYA EBAMA, M.D. LOWCOUNTRY INFECTIOUS DISEASES, PA CARETEAM PLUS, INC SEPTEMBER 18, 2015

INTRODUCTION First recognized as AIDS in US in 1981 Retrovirus AND obligate intracellular parasite Associated with a loss of CD4+ lymphocytes and immunosuppression

STATISTICS Living with HIV infection HIV incidence Deaths from HIV/AIDS South Carolina in 2014 – Positive tests Males vs. females White vs. Black vs. Hispanic Age groups: vs vs. 50 – Charleston county Most tests done Most positive tests Most cumulative deaths Most cases of persons living with HIV

MODES OF INFECTION Sexual transmission Exposure to other infected fluids Mother to infant Occupational exposure

SCREENING Begins during the patient interview Guidelines for screening:  Persons with STD or TB  Persons with new sexual partner  Persons with elevated risk of HIV infection  Pregnant persons

TESTING “Opt-out” approach Mandatory testing in U.S.  Health care workers  Inmates of federal corrections facilities  Military recruitment

DIAGNOSIS ELISA WESTERN BLOT HIV RNA

CLINICAL MANIFESTATIONS OF HIV INFECTION

Untreated  Acute viral illness  Immunological mediated process related to host responses to chronic infection  Opportunistic infections from impaired host responses

Treated  Immune reconstitution inflammatory syndrome  Syndrome of lipodystrophy Long-term non-progressors  Type A – detectable RNA and elevated CD4  Type B – elite controllers – undetectable RNA and elevated CD4

TREATMENTS

NRTIS Block the RNA-dependent DNA polymerase, reverse transcriptase Responsible for adverse side effects MEDS  Zidovudine 300mg bid (AZT) – 1987  Lamivudine 300mg daily – 1995  Abacavir 600mg daily – 1998  Tenofovir 300mg daily – 2001  Emtricitabine 200mg daily – 2006

NNRTIS Block the RNA-dependent DNA polymerase, reverse transcriptase Barrier for resistance is low for this class MEDS  Nevirapine 200mg bid – 1996  Efavirenz 600mg qhs – 1998  Etravirine 200mg bid – 2008  Rilpivirine 25mg daily – 2010

PIS Inhibit the maturation process, which uses aspartyl protease Decreased deaths from 1995 to 1997 Barrier for resistance is high for this class

MEDS – PIs  Saquinavir 1000mg bid – 1995  Ritonavir 100mg daily or bid – 1996  Indinavir 800mg tid – 1996  Nelfinavir 1250mg bid or 750mg tid – 1997  Fosamprenavir 700mg bid – 2003  Atazanavir 400mg daily or 300mg bid – 2003  Tipranavir 200mg bid or 500mg bid – 2005  Darunavir 800mg daily or 600mg bid – 2006

Entry inhibitors  Enfuvirtide 90mg SQ bid – 2003  Maraviroc 300mg bid – 2007 Integrase inhibitors  Raltegravir 400mg bid – 2007  Dolutegravir 50mg daily – 2013  Elvitegravir 85mg or 150mg daily – 2014

COMBINATIONS Combivir – 1997 Trizivir – 2000 Kaletra – 2000 Epzicom – 2004 Truvada – 2004 Atripla – 2006 Complera – 2011 Stribild – 2012

COMBINATIONS (CONT’D) Triumeq – 2014 Evotaz – 2015 Prezcobix – 2015

TREATMENT RECOMMENDATIONS All individuals with HIV-1 infection Patients >50 years of age, regardless of CD4 cell count Pregnant patients

Preferred regimen – 2 NRTIs plus NNRTI or PI or INI Recommended regimens for treatment naïve  Dolutegravir/abacavir/lamivudine  Dolutegravir/tenofovir/emtricitabine  Elvitegravir/cobicistat/tenofovir/emtricitabine  Raltegravir/tenofovir/emtricitabine  Darunavir/ritonavir/tenofovir/emtricitabine

PREVENTION Vaccine Spermicides Understanding human behavior & patterns of your patients Condoms Abstinence Treatment

PEP Post-exposure prophylaxis Involves taking ARTs as soon as possible 72 hours hour window Two to three drugs are usually prescribed 28-day regimen is recommended Not always effective

PREP Pre-Exposure Prophylaxis Goal – prevent HIV infection Follow up – repeat HIV test every 3 months Truvada approved for PrEP in 2012 CDC recommends that PrEP be considered for people who are HIV-negative and at substantial risk for HIV

TAKE HOME MESSAGES Desired source of HIV testing is usually the principal providers of primary healthcare Over the past 3 decades, the natural history of HIV infection has undergone considerable changes If the spread of HIV can be reversed or prevented on a large scale in the poorest countries in the world*, South Carolina can do it as well