Transcript Diagnoses of HIV Infection among Adults and

26th Annual PCOMS Winter
Conference
HIV Infection or Infestation
Kerry Chamberlain D.O., FACOI
Florida Cancer Specialists
January 28, 2015
Objectives
• Historical perspective
• Update on the status of HIV in the world & our
community and how it impacts us.
• Update on post exposure prophylaxis
Disclosure
• I have no financial relationship in regard to the
content of this presentation
• Although I wish I did
The Revolution at the Corner
Drugstore
Wall Street Journal January 24, 2015
• CVS is the largest supplier -25% of the $86
BILLION industry
• Expected growth 38% to 50%
• Fee for service is fading out
• CVS- becoming “integrated pharmacy-care
organization. Our purpose, our goal is to help
people on their path to better health”
The Revolution at the Corner
Drugstore
• 960 walk in clinics in 31 states and growing
• “a shelf of academic research shows the quality
of care at such clinics is the same or sometimes
better than the ER”
• “Advanced pharmaceutical therapies , for
diseases like multiple sclerosis and HIV, are often
more complex than simply taking a pill”
• “adherence --- ensuring that patients take the
medications' they are prescribed --- is one area
where CVS can contribute”
The Revolution at the Corner
Drugstore
• “manage the pharmacy patient, not just the
administration of the drug”—Larry Merlo CEO
of CVS
New England Journal of Medicine
January 22, 2015
• South Africa – 6.2 million infected with HIV---18%
of all adults
• Highest rate among sexually active women
• 2.4 million HIV adults and 156,000 children are in
active treatment
• Annual exams – goal is undetectable level of viral
load
• Initial regimen is tenofvir, lamivudine, and
emtricitabine as a single pill costs ~ $8/ month
New England Journal of Medicine
January 22, 2015
• In Africa 25% of patients who begin ART are
lost to F/U by a year later
• 25% viral suppression is not achieved
• Annual viral load measurements should
replace routine CD-4 testing for stable healthy
ART recipients
Factoids on HIV in the US
• Southern states in the U.S. had the nations
lowest 5 year survival rate – diagnosed with
HIV or AIDS 2003-2004
• Alabama, Florida, Georgia, Louisiana,
Mississippi, North Carolina, South Carolina,
Tennessee, and Texas
– Clinical Advisor January 14, 2015
Factoids of HIV
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•
•
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Half life of HIV in serum is 1.2 days
24 hours intracellular
6 hours extracellular
30% of total body viral burden is turned over
daily– this means that AIDS is a result of
continuous high level HIV-1 replication and
destruction of CD4 lymphocytes
• Unclear why 99.7% of occupational
exposures DO NOT transmit the virus
Factoids of HIV
• US- more than 80% of current infections of
HIV occur through heterosexual
transmission
• Over 50% of all HIV infected people in the
world are women
• Over 50 year old crowd is a growing
population.
• Nine subtypes in worldwide circulation
Where did
HIV Come
From?
History & Perspective
• 1983 – discovered to be a retrovirus
• 1985 – discovered a serological test for
diagnosis
• 1987- discovered the first antiviral drugs
• 1996 – introduction of HAART (highly
active antiretroviral therapy)
• 1999- the mortality of AIDS diagnosis and
hospitalizations fell 60-80%
Stages of HIV Infection
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Transmission
Acute infection (primary HIV infection)
Seroconversion
Clinical latent period w/wo adenopathy
Early symptomatic HIV infection
AIDS (CD4 <200/ml & other criteria)
Advanced AIDS (CD4 <50/ml)
Risk Factors for Transmission
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•
•
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•
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Viral load
Circumcision- lowers risk by ~ 60%
Sexual risk
Ulcerative sexually transmitted diseases
Nitrate inhalant use
Host and genetic factors
Epidemiology of
HIV Infection
through 2012
National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention
Division of HIV/AIDS Prevention
Diagnoses of HIV Infection among Adults and Adolescents,
by Sex, 2008–2012—United States and 6 Dependent Areas
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been
statistically adjusted to account for reporting delays, but not for incomplete reporting.
Diagnoses of HIV Infection among Adults and Adolescents, by
Transmission Category, 2008–2012—United States and
6 Dependent Areas
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been
statistically adjusted to account for reporting delays and missing transmission category, but not for incomplete reporting.
a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.
Diagnoses of HIV Infection among Adults and Adolescents, by
Transmission Category, 2012—United States and
6 Dependent Areas
N = 48,651
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically
adjusted to account for reporting delays and missing transmission category, but not for incomplete reporting.
a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.
Diagnoses of HIV Infection among Adults and Adolescents, by Sex and
Transmission Category, 2012—United States and 6 Dependent Areas
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically
adjusted to account for reporting delays and missing transmission category, but not for incomplete reporting.
a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.
Diagnoses of HIV Infection among Adults and Adolescents,
by Race/Ethnicity, 2008–2012—United States and
6 Dependent Areas
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically
adjusted to account for reporting delays, but not for incomplete reporting.
a Hispanics/Latinos can be of any race.
Diagnoses of HIV Infection among Adults and Adolescents,
by Sex and Race/Ethnicity, 2012—United States and
6 Dependent Areas
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically
adjusted to account for reporting delays, but not for incomplete reporting.
a Hispanics/Latinos can be of any race.
Rates of Diagnoses of HIV Infection among Adults and Adolescents,
2012—United States and 6 Dependent Areas
N = 48,651 Total Rate = 18.4
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been
statistically adjusted to account for reporting delays, but not for incomplete reporting.
Rates of Diagnoses of HIV Infection among Adults and Adolescents,
by Sex and Race/Ethnicity, 2012—United States
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been
statistically adjusted to account for reporting delays, but not for incomplete reporting. Rates are per 100,000 population.
a Hispanics/Latinos can be of any race.
Diagnoses of HIV Infection among Adult and Adolescent Males,
by Race/Ethnicity, 2012—United States
Race/ethnicity
American Indian/Alaska Native
Asian
Black/African American
Hispanic/Latino
a
Native Hawaiian/other Pacific Islander
White
Multiple races
b
Total
No.
183
Rate
20.2
801
12.9
16,112
108.9
8,516
42.0
67
31.8
11,638
14.0
842
46.0
38,160
29.9
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been
statistically adjusted to account for reporting delays, but not for incomplete reporting. Rates are per 100,000 population.
a Hispanics/Latinos can be of any race.
b Because column totals for estimated numbers were calculated independently of the values for the subpopulations, the values in each column
may not sum to the column total.
Diagnoses of HIV Infection among Adult and Adolescent
Females, by Race/Ethnicity, 2012—United States
Race/ethnicity
American Indian/Alaska Native
Asian
Black/African American
Hispanic/Latino
a
Native Hawaiian/other Pacific Islander
White
Multiple races
b
Total
No.
45
Rate
4.7
146
2.1
6,293
37.8
1,289
6.5
11
5.1
1,620
1.9
184
9.3
9,586
7.2
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been
statistically adjusted to account for reporting delays, but not for incomplete reporting. Rates are per 100,000 population.
a Hispanics/Latinos can be of any race.
b Because column totals for estimated numbers were calculated independently of the values for the subpopulations, the values in each
column may not sum to the column total.
Deaths of Persons with Diagnosed HIV Infection,
by Race/Ethnicity, 2011—United States
Race/ethnicity
American Indian/Alaska Native
Asian
a
Black/African American
Hispanic/Latino
b
Native Hawaiian/other Pacific Islander
White
Multiple races
c
Total
No.
Rate
64
2.8
96
0.6
8,329
21.7
2,806
5.4
13
2.5
5,257
2.7
775
13.3
17,339
5.6
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. Deaths of persons with a diagnosed HIV
infection may be due to any cause. All displayed data have been statistically adjusted to account for reporting delays, but not for
incomplete reporting. Rates are per 100,000 population.
a Includes Asian/Pacific Islander legacy cases.
b Hispanics/Latinos can be of any race.
c Includes persons of unknown race/ethnicity. Because column totals for estimated numbers were calculated independently of the values for
the subpopulations, the values in each column may not sum to the column total.
Adults and Adolescents Living with Diagnosed HIV Infection, by Sex
and Race/Ethnicity, Year-end 2011—
United States and 6 Dependent Areas
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically
adjusted to account for reporting delays, but not for incomplete reporting.
a Includes Asian/Pacific Islander legacy cases.
b Hispanics/Latinos can be of any race.
Adults and Adolescents Living with Diagnosed HIV Infection, by Sex
and Transmission Category, Year-end 2011—
United States and 6 Dependent Areas
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically
adjusted to account for reporting delays and missing transmission category, but not for incomplete reporting.
a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
b Includes hemophilia, blood transfusion, and risk factor not reported or not identified.
Rates of Adults and Adolescents Living with Diagnosed HIV
Infection, Year-end 2011—United States and
6 Dependent Areas
N = 896,621 Total Rate = 342.1
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been
statistically adjusted to account for reporting delays, but not for incomplete reporting.
Stage 3 (AIDS) Classifications and Deaths of Persons with HIV
Infection Ever Classified as Stage 3 (AIDS), among Adults and
Adolescents, 1985–2011—United States and 6 Dependent Areas
Note. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting. Deaths of persons with
HIV infection, stage 3 (AIDS) may be due to any cause.
Stage 3 (AIDS) Classifications among Adults and Adolescents with HIV
Infection, by Race/Ethnicity and Year of Diagnosis, 1985–2012—
United States and 6 Dependent Areas
Note. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting.
a Hispanics/Latinos can be of any race.
b Includes Asian/Pacific Islander legacy cases.
Percentages of Stage 3 (AIDS) Classifications among Adults and
Adolescents with HIV Infection, by Race/Ethnicity and Year of Diagnosis,
1985–2012—United States and 6 Dependent Areas
Note. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting.
a Hispanics/Latinos can be of any race.
b Includes Asian/Pacific Islander legacy cases.
Stage 3 (AIDS) Classifications among Adults and Adolescents with HIV
Infection, by Transmission Category and Year of Diagnosis, 1985–2012—
United States and 6 Dependent Areas
Note. All displayed data have been statistically adjusted to account for reporting delays and missing transmission category, but not for
incomplete reporting.
a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.
Percentages of Stage 3 (AIDS) Classifications among Adults and
Adolescents with HIV Infection, by Transmission Category and Year of
Diagnosis, 1985–2012—United States and 6 Dependent Areas
Note. All displayed data have been statistically adjusted to account for reporting delays and missing transmission category, but not for
incomplete reporting.
a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.
Stage 3 (AIDS) Classifications among Adults and Adolescents
with HIV Infection, by Sex and Transmission Category, 2012—
United States and 6 Dependent Areas
Note. All displayed data have been statistically adjusted to account for reporting delays and missing transmission category, but not for
incomplete reporting.
a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.
Stage 3 (AIDS) Classifications among Adults and Adolescents
with HIV Infection, by Race/Ethnicity, 2012—United States
Race/ethnicity
American Indian/Alaska Native
Asian
No.
114
Rate
6.1
418
3.2
14,094
44.8
5,418
13.5
32
7.7
6,932
4.1
910
23.8
27,918
10.7
a
Black/African American
Hispanic/Latino
b
Native Hawaiian/other Pacific Islander
White
Multiple races
c
Total
Note. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting. Rates
are per 100,000 population.
a Includes Asian/Pacific Islander legacy cases.
b Hispanics/Latinos can be of any race.
c Because column totals for estimated numbers were calculated independently of the values for the subpopulations, the values
in each column may not sum to the column total.
Persons Living with Diagnosed HIV Infection Ever Classified
as Stage 3 (AIDS), by Race/Ethnicity, 1993–2011—United
States and 6 Dependent Areas
Note. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting.
a Hispanics/Latinos can be of any race.
b Includes Asian/Pacific Islander legacy cases.
HIV Testing
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Antibody detection
Window period of antibody development
Detectable antibodies in 2-8 weeks avg-25 days
97% will have antibodies in 3 months
Rare cases can take up to 6 months
All positive tests MUST be confirmed
Factoid
• The deferral of ART beyond 12 months of
estimated Seroconversion reduces the
likelihood of immunologic health in patients
with HIV-1
• Subjects with CD4 counts > 500 cells/ul at ART
initiations had significantly higher CD4
normalization rates compared to those with
CD4 counts less than 500
Revised Recommendations for HIV
Testing of Adults, Adolescents, and
Pregnant Women in Health-Care
Settings-I
• HIV screening for pt in all health-care setting
after the pt is notified that testing will be
performed unless the pt declines
• Persons at high risk for HIV should be
screened at least annually
• Separate written consent for HIV testing
should not be required
Revised Recommendations for HIV
Testing of Adults, Adolescents, and
Pregnant Women in Health-Care
Settings-II
• Prevention counseling should not be required
with HIV diagnostic testing or a as part of HIV
screening programs in health-care settings.
• HIV screening should be included In the routine
panel of prenatal screening tests.
• HIV screening is recommended after the pt is
notified that testing will be performed unless she
opts out
HIV 2
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1986 Isolated from AIDS patient in West Africa
Same mode of transmission
Immunodeficiency slowly develops/less infectious
Predominantly found in Africa
HIV 1 inhibited by HIV 2 –NEJM 2012
Modes of Transmission
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Sharp object
Blood or tissue donation
Medical or dental practices
Eating pre-chewed food
Bitten
Broken skin
French kissing
Tattooing
Infants to mother via breastfeeding- Europe only
Mode of Transmission
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Not by air or water or insects
Not by spitting
Not by shaking hands
Not by sharing dishes
Not by social kissing
Role of Primary Care in HIV
• ART has altered the natural history
• Infections less common
• Greater than 50% of deaths NOT related
to HIV
• HIV and its treatment increase
cardiac/renal/hepatic/malignancies
Background
• June 5, 2011 marked the 30th year of the
CDC identifying HIV/AIDS
• Initially 100% fatal now average life
expectancy is more than 20 years
• Still not under control
• Success is possible – remember polio,
chickenpox & smallpox
• No STD has ever been under control in a
free democratic society except by vaccine
Initial Visit
• Document the HIV antibody
– Chamberlain’s law: patients lie to you doctors
lie to you!
– Repeat the test! Unless it is right in front of
you
Initial Visit- continued
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Gage the patients level of understanding
Risk Factors past and present
History of previous infections
Quantitation of CD4/viral load
Hepatitis studies of A/B/C
Document TB-ppd
Initial Visit --Continued
• Cardiovascular Risk Factors
• Hypertension/DM/Dyslipidemia– will
influence ART
• Protease inhibitors increase glucose intolerance
and dyslipidemia
Initial Visit --Continued
• STD’s
– Herpes simplex and anal or genital warts will
require treatment
Initial Visit --Continued
• Cancer– higher incidence of malignancy
Initial Visit --Continued
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Psychiatric- as in any chronic diseases
Medication history
Immunization history
Substance abuse
Family History
Role of ART
• Prolong life
• Greater quality of life
• Restore an preserve immunological
function
• Suppress HIV viral load
Health Maintence
• Immunizations
CD4 greater than 200
give pneumococcal every 5 years
influenza yearly-ok for yearly inactivated
Hepatitis B vaccine
Hepatitis A vaccine
Cervical Cancer Screening every 6 – 12
months
Health Maintance
• Anal Cancer– both male and female
• STD’s
• Age appropriate screening
– Breast
– Prostate
– Colon
General Considerations
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Avoid raw eggs/seafood
Avoid colon cleansing
Don’t drink where fish dogs cattle pee
Fully cook your food
Wear gloves when cleaning out litter box
Occupationally Acquired HIV Among
Healthcare Workers
• Since 1999 only one confirmed case reported
to the CDC (data from 58 confirmed and 150
possible cases 1985-2013)
• Post Exposure Management- 2013
• Pre-Exposure Prophylaxis (PrEP)- 2014
Determining need for Prophylaxis
Postexposure Prophylaxis for
HIV Infection
• NEJM October, 29, 2009 Vol. 361. NO. 18
Regimens for 28-Day Postexposure Prophylaxis for HIV Infection
Landovitz R, Currier J. N Engl J Med 2009;361:1768-1775
Clinical Manifestations of the Acute HIV
Infection
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Fever
Lymphadenopathy
Sore throat
Rash
Myalgia
Headache
Cough
Establishing the Diagnosis Continued
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Vague symptoms
Financial burden on the physicians
Physician bias
Patients prefer the anonymous testing of
“clinics”
• Patients don’t see themselves at high
risk– remember “a alcoholic is someone
who drinks more than his physician”
Conclusions

After rapidly increasing since the 1980s, the annual
rate of death due to HIV infection peaked in 1994 or
1995 (depending on the demographic group),
decreased rapidly through 1997, and continued to
decrease much more slowly thereafter.
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Persons dying of HIV infection increasingly consist of:
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women (27% in 2010)
blacks/African Americans (54% in 2010)
residents of the South (52% in 2010)
persons 45 years of age or older (67% in 2010)
HIV infection remains as one the leading causes of
death among persons 25 to 44 years old, particularly
among blacks/African Americans.
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of HIV/AIDS Prevention
HIV Vaccine Status
• 16,000 volunteers in Thailand –Thai specific
• ALVAC-HIV & AIDSVAX in combination
• Prime the immune process and a booster for
later immunity
• Decrease in contracting HIV by 31.2%
The End