1. Current Concepts in HIV/AIDS A Pharmacy Perspective Carol Schneiderman, Pharm D Clinical Pharmacist, University of Arizona

2. Objectives Discuss important clinical features of HIV disease in 2006 Discuss important clinical features of HIV disease in 2006 Identify the subclasses of antiretrovirals and list the primary approved combinations of antiretrovirals Identify the subclasses of antiretrovirals and list the primary approved combinations of antiretrovirals Identify common doses, food restrictions and adverse effects of the antiretroviral agents Identify common doses, food restrictions and adverse effects of the antiretroviral agents Interpret CD4 and viral load levels and correlate them with degree of illness and approach to treatment Interpret CD4 and viral load levels and correlate them with degree of illness and approach to treatment Discuss issues of adherence Discuss issues of adherence

3. Acute Retroviral Syndrome Fever80-90% Fever80-90% Fatigue70-90% Fatigue70-90% Rash40-80% Rash40-80% Headache32-70% Headache32-70% Night Sweats50% Night Sweats50% Lymphadenopathy40-70% Lymphadenopathy40-70% Pharyngitis50-70% Pharyngitis50-70% Myalgia/Arthralgia50-70% Myalgia/Arthralgia50-70% GI Symptoms30-60% GI Symptoms30-60% Oral Ulcers/Thrush10-20% Oral Ulcers/Thrush10-20% Neurologic Symptoms12% Neurologic Symptoms12%

4. Treatment US DHHS Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents US DHHS Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents aidsinfo.nih.gov aidsinfo.nih.gov

5. When to Treat

8. With What?

9. Antiretrovirals (ARVs) NRTI – Nucleoside/nucleotide reverse transcriptase Inhibitors NNRTI – Non- nucleoside Reverse Transcritase Inhibitors PI- Protease Inhibitors FI – Fusion Inhibitors

10. Nucleosides/Nucleotides (NRTI) Retrovir zidovudineAZT Retrovir zidovudineAZT VidexdidanosineddI VidexdidanosineddI Zerit stavudine d4T Zerit stavudine d4T Epivir lamivudine 3TC Epivir lamivudine 3TC Hivid zalcitabineddC Hivid zalcitabineddC Ziagen abacavir ABC Ziagen abacavir ABC Viread tenofovir TNF Viread tenofovir TNF Emtriva emtracitabine FTC Emtriva emtracitabine FTC CombivirRetrovir/Epivir CombivirRetrovir/Epivir TrizivirRetrovir/Epivir/Ziagen TrizivirRetrovir/Epivir/Ziagen TruvadaViread/Emtriva TruvadaViread/Emtriva EpzicomZiagen/Epivir EpzicomZiagen/Epivir

11. NRTIs All - Black Box warning – lactic acidosis All - Black Box warning – lactic acidosis Retrovir – nausea, headaches, muscle aches, anemia Retrovir – nausea, headaches, muscle aches, anemia Videx – pancreatitis, peripheral neuropathy Videx – pancreatitis, peripheral neuropathy Zerit – lipodystrophy, peripheral neuropathy Zerit – lipodystrophy, peripheral neuropathy Ziagen – hypersensitivity syndrome Ziagen – hypersensitivity syndrome Viread – nausea, headache, diarrhea Viread – nausea, headache, diarrhea

12. Non-Nucleosides (NNRTI) Delavirdine – Rescriptor Delavirdine – Rescriptor Nevirapine – Viramune Nevirapine – Viramune Efavirenz - Sustiva Efavirenz - Sustiva

13. NNRTIs All - Rash All - Rash Viramune – increased incidence of acute hepatic events in women w/CD4 > 250 Viramune – increased incidence of acute hepatic events in women w/CD4 > 250 Sustiva - teratogenic in monkeys, CNS effects Sustiva - teratogenic in monkeys, CNS effects Some drug interactions Some drug interactions

14. Protease Inhibitors (PI) Saquinavir – Invirase/Fortovase Saquinavir – Invirase/Fortovase Indinavir – Crixivan Indinavir – Crixivan Ritonavir – Norvir Ritonavir – Norvir Nelfinavir – Viracept Nelfinavir – Viracept Amprenavir – Lexiva Amprenavir – Lexiva Lopinavir/r – Kaletra Lopinavir/r – Kaletra Atazanavir – Reyataz Atazanavir – Reyataz Tipranavir – Aptivus Tipranavir – Aptivus TMC 114 TMC 114

15. PIs Fat Redistribution Fat Redistribution Hyperlipidemias Hyperlipidemias Hyperglycemia Hyperglycemia GI Inolerance GI Inolerance Elevated transaminase enzymes Elevated transaminase enzymes Increased bleeding in hemophilia Increased bleeding in hemophilia Drug Interactions Drug Interactions Reyataz – hyperbilirubinemia Reyataz – hyperbilirubinemia

16. Aptivus® Tipranavir Tipranavir 500 mg bid with Norvir 100 mg bid 500 mg bid with Norvir 100 mg bid Useful in salvage regimens Useful in salvage regimens Hepatic Events Hepatic Events Rash – sulfonamide moiety Rash – sulfonamide moiety Hyperlipidemia Hyperlipidemia Hyperglycemia Hyperglycemia Fat Redistribution Fat Redistribution Multiple Drug Interactions Multiple Drug Interactions

17. Entry Inhibitors (EI) Fuzeon enfuvirtideT-20 Fuzeon enfuvirtideT-20 (fusion inhibitor)

18. EIs Injection Site Reactions Injection Site Reactions Increased rate of bacterial pneumonia Increased rate of bacterial pneumonia Hypersensitivity reaction Hypersensitivity reaction

19. The Past

20. Why is it Hard to take ARVs? Adverse effects Adverse effects Pill Burden Pill Burden Consistency Consistency Drug Interactions Drug Interactions Food Issues Food Issues

21. Food Issues Videx Videx Sustiva Sustiva Crixivan Crixivan Viracept Viracept Invirase/Fortovase Invirase/Fortovase Kaletra Kaletra Reyataz Reyataz Aptivus Aptivus

22. Why is Adherence Important?

23. Gotta Take Those Meds

25. Resistance Patterns

29. Adherence Strategies Assess Readiness Assess Readiness Education Education Family/Friends Family/Friends Adherence Tools Adherence Tools Pill Burden/Food Requirements Pill Burden/Food Requirements Trust/Communication Trust/Communication Monitoring Monitoring

31. AETC Clinical Consultants AETC Clinical Consultants Stephen Klotz, MD Stephen Klotz, MD Carol Schneiderman, PharmD Carol Schneiderman, PharmD 626-6887 626-6887 Warmline 800 933-3413 Warmline 800 933-3413 PEPline 888 448-4911 PEPline 888 448-4911 Perinatal HIV Hotline 888 448-8765 Perinatal HIV Hotline 888 448-8765