1. SUBSTANCE ABUSE & HIV DISEASE Janet L. Mitchell, M.D., M.P.H., F.A.C.O.G. Consultant on Women’s Health Addiction, Research & Treatment Corporation Brooklyn, NY

2. Epidemiology HIV care

3. EPIDEMIOLOGY

4. Age at Diagnosis AIDS Cases by Age and Sex Reported 1981-1999, United States Number of Cases 01020304050 60 708090 Female N=124,045 Male N=609,326 0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000

5. AIDS Cases in Adult/Adolescent Men, Reported July 1998 - June 1999, and Estimated AIDS incidence,* Diagnosed July 1998 – June 1999 by Risk Exposure United States * Data adjusted for reporting delays and estimated proportional redistribution of cases initially reported without risk. Data reported through March 2000. AIDS Incidence Reported July 1998 - June 1999 Estimated AIDS Incidence* Diagnosed July 1998 - June 1999 <1% 1% <1% 45% 21% 5% 8% 53% 13% 27% 6% Risk Exposure Injection drug use (IDU) Men who have sex with men Hemophilia Transfusion Heterosexual contact MSM/IDU Other/not identified

6. 36% 62% 28% 31% 40% AIDS Incidence Reported July 1998 - June 1999 Estimated AIDS Incidence* Diagnosed July 1998 - June 1999 2% <1% 1% <1% 1% Injection drug use (IDU) Hemophilia Transfusion Heterosexual contact Other/not identified Risk Exposure * Data adjusted for reporting delays and estimated proportional redistribution of cases initially reported without risk. Data reported through March 2000. AIDS Cases in Adult/Adolescent Women, Reported July 1998 - June 1999, and Estimated AIDS Incidence,* Diagnosed July 1998 - June 1999, by Risk Exposure United States

10. HIV CARE

11. “Women should be treated for their disease first.”

12. Age at Diagnosis AIDS Cases by Age and Sex Reported 1981-1999, United States Number of Cases 01020304050 60 708090 Female N=124,045 Male N=609,326 0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000

13. *Preliminary 1998 data Trends in Annual Rates of Death from Leading Causes of Death Among Black Women 25-44 Years Old, USA, 1982-1998 National Center for Health Statistics National Vital Statistics System

14. Trends in the Percentage Distribution of Deaths from HIV Infection, By Sex, USA, 1987-1997 National Center for Health Statistics National Vital Statistics System

15. Trends in the Percentage Distribution of Deaths from HIV Infection, By Race, USA, 1987-1997 *Asian, Pacific islander, or American Indian National Center for Health Statistics National Vital Statistics System

16. *Adjusted to the age distribution of the projected year 2000 U.S. population Age-adjusted* Mean Rate of Death from HIV Infection during 1993-1997, By Race / Ethnicity and Geographic Region, USA National Center for Health Statistics, National Vital Statistics System

17. Is the Disease Different? Diagnosis –Presenting complaints –Presenting diagnosis Presentation –Heterosexual –Over 50 age group Treatment response –CD4/Viral load –Response to therapies

18. HIV Care Anti-retrovirals Prophylaxis Co-morbid conditions

19. HIV Care & Women’s Health Pre-conceptual Counseling –Pregnancy Planning? Anti-retrovirals – Efavirenz? Prophylaxis Co-morbid conditions –Diabetes –HTN

20. Pharmacokinetic of Indinivir in Menstruating Women n=6 (age 37±5.4 years, CD4 count 354±137 cells/mm 3 )

22. Interactions Between ARV and Ethinyl Estradiol Do not use  Levels EE Ritonavir Usual dosesNo interactionAmprenavir Do not use  Levels EE Nelfinavir Usual dosesNo interactionIndinavir Usual doses  EE AUC 37% Efavirenz Do not use  EE AUC 19% Nevirapine RecommendationEffect on EEARV

24. “Lipodystrophy” What does it mean?

25. HIV-Associated Lipodystrophy FatatrophyFataccumulation Hyperlipidemia Insulin resistance

26. Aims: Guidelines Glucose metabolism Lipid metabolism Body composition Cardiovascular risk Lactic acidemia Osteopenia

27. Lipid Control Contrast of PI Reported Data HDL Activella ™ 1mgE/.5mgNETA Prempro®.625mgE/2.5 mg MPA 3.5 FemHRT ™ 5mcgE/1mgNETA -6.7 Ortho-Prefest™1mgE/.09 mg NGM 9.7 Triglycerides Lipid Profile (mean % change from baseline after 1 year of treatment) 9.4 -12.4 2.2 24.1 12.1 LDL -4.9 -7.5 -8.8 -10.8

28. OBSTETRICAL CARE

29. Pregnancy Pregnancy does not accelerate HIV disease Stage of HIV disease can impact pregnancy outcome Perinatal transmission rates depend on multiple factors The use of anti- retrovirals for the treatment of the woman’s disease  transmission rates > than elective c/sections

30. Current Standard of Care for Pregnant Women in Developed Countries Combination Anti-retroviral Therapy (should include AZT if appropriate )

31. Perinatal Transmission Rates Zidovudine/ ACTG 076 Combination therapy/HAART Nevirapine Elective c/section

32. Safety and Toxicity of Individual Antiretroviral Agents in Pregnancy www.hivatis.org/guidelines/adult/text/ pregnancy1.html

33. Antiretroviral Pregnancy Registry 1410 Commonwealth Drive Wilmington, NC 28403 telephone (800) 258-4263 fax (800) 800-1052

34. CDC WEBSITE: http://www.cdc.gov/hiv/graphics.htm