1. Human Immunodeficiency Virus – HIV and the correctional system

2. Prison inmates with HIV Medical (and practical) problem for the correctional services but also An marvellous opportunity for the individual and for society!

3. Swedish Prison and Probation Authorities 1987 Fight HIV and AIDS by prevention Information and education Discussions about route of transmission Testing Contact tracing and drug rehabilitation (and since 1996 ART treatment run by the civil health care)

4. The over all goal (at least from the inf dis epidemiologist point of view) …is to reduce the risk for further transmission from a HIV positive individual to another inside the prison and later, after release, in the society. …is to educate the ones who are still healthy to live their life in such a way that their risk of contracting the infection themselves is reduced

5. Harm reduction programmes Harm reduction ”hot potatoes” in Sweden but must be considered Needle and syringes exchange Belach distribution Substitution therapy (Methadone) – opioid IDA

6. HIV epidemiology

7. HIV prevalens 2006

9. HIV in Europe Slowly increasing prevalence in Western Europe Quickly increasing prevalence in Eastern Europe

12. Why so few cases of HIV among iv drug abusers in Sweden? Of cause many reasons but…

13. (IV) Drug abuse - HIV - Crime - Imprisonment

14. Swedish Prison and Probation Authorities 1987 Fight HIV and AIDS by prevention Information and education Discussions about route of transmission Testing Contact tracing and drug rehabilitation (and since 1996 ART treatment)

15. The disease (Here symbolized by a dying T-helper cell)

16. HIV Lifecycle- why is HIV harmful? HIV CD4+ cell 5000 new HIV HIV infects CD4+ cells (T-helper cells) HIV grows quickly inside CD4+ cells – CD4+ cells dies Immunodeficiency developes due to lack of CD4+ cells Enemy General

17. HIV infection - natural history AIDS CD4+ cells HIV nivå Death in AIDS Prim HIV infection

18. HIV treatment

19. Effect of antiviral treatment (ART)

20. Reported cases of AIDS and related death 1983-2006 Aids Dead

21. HIV drugs- 4 different classes NRTI RT= Reverse Transcriptase (the enzyme that rewrites the virus RNA to DNA form) NRTI= Nucleoside RT Inhibitor NRTI is nucleoside analogues (false DNA building blocks) that replases the real nucleosid in the new DNA chain and prevents it´s extension (chain terminator)

22. HIV drugs- 4 different classes NRTI PI protease inhibitor The protease is the enzyme that splits the new established virus in smaller that can later be put together to a new functional contagious virus PI bindes to the protease and obstructs it´s function

23. HIV drugs- 4 different classes NRTI PI protease inhibitor NNRTI NNRTI= non-nucleoside RT inhibitors Obstructs the same RT enzyme as NRTI but in a different way NNRTI inhibits RT through binding to the enzyme

24. HIV drugs- 4 different classes NRTI PI protease inhibitor NNRTI FI-Fusions inhibitor FI prevents HIV to enter the cell by preventing the virus to bind to the cell surface

25. New HIV drug classes (in the pipe-line) CCR5-antagonist Maraviroc Integrase inhibitors Raltegravir (Mk-0518) Elvitegravir(GS9137)

26. Start of treatment: Not too early - not too late Less long time side effects Before symptoms develope CD4+ cell count 200-300 HIV treatment principles

27. Only patients with undetectable viral load have a durable effect If virus is not fully suppressed- resistance will always develop Only fully adherent patients reach undetectable viral load HIV treatment principles 2 Undetectable is <40 copies/ml

28. Favored Initial Combinations (HAART) PI 2 NRTI’s + NNRTI Backbone 3 rd agent HAART = Highly Active Anti-Retroviral Treatment (a combination of 3 or more HIV drugs)

29. Favored Initial Combinations (HAART) PI 2 NRTI’s + NNRTI Truvada Kivexa (Combivir) Stocrin Kaletra Reyataz

30. Why resistance? Detectable viral levels during treatment (HIV- RNA >50 kop/mL) Selection of resistant virus Incomplete viral suppression always leads to development of resistance !!

31. What are the major causes of Treatment Failure ? –Suboptimal adherence –ARV toxicity and intolerance –Pharmacokinetic problems –Suboptimal drug potency / viral resistance

32. Resistance test: NRTI- 8 mut NNRTI-1 mut PI- 13 mut

33. Conclusion! Treatment and follow up of treatment of HIV is complex Viral levels, CD4 cells, combination possibilities, side effects, resistance…. And if it isn´t conducted properly one might harm the patient – resistance. And remember. Treatment must be followed up carefully also after the patient leaves the prison! Can an active IVDA fix that? Co-op with specialist in HIV treatment (that is now a ”specialty of it´s own”) and rehab drug abuse

34. Conclusion Co-operation between experts and authorities The HIV patient and the prison system The hospital And the doctor (me?) Other org and authorities Communicable Disease Control

35. HIV – risk of transmission Blood transfusion ~100 % Pregnancy mother/child 15-35 % Iv drug abuse - sharing syringes 1-10 % ? Coitus (vaginal intercource) < 1 % Anal intercource < 3 % Needle-stick incidents at hospitals 0.3 % Mucosal exposure at hospitals 0.09 %

36. HIV – risk of transmission

39. Conclusion Complex situation! Opportunity! Only treat the treatable! Combine with treatment of drug dependancy Beware of the resistance!

40. Thank You!