AIDS 101AIDS 101

Current status and HistoryCurrent status and History

Challenges and issuesChallenges and issues

TRANSITION PERIOD FORTRANSITION PERIOD FORMANAGEMENT OF HIV/AIDSMANAGEMENT OF HIV/AIDS

1995 David Ho – HIV Replication1995 David Ho – HIV Replication 10,000,000,000/day 10,000,000,000/day1996 John Mellors – Viral load1996 John Mellors – Viral load1996 Introduction of PIs1996 Introduction of PIs1997 Triple therapy1997 Triple therapy

HIV PREVENTION: BEYOND ABCHIV PREVENTION: BEYOND ABC

HSV – 2HSV – 2 Acyclovir prophylaxisAcyclovir prophylaxis

TDF prophylaxis TDF prophylaxis Partial efficacy – monkeysPartial efficacy – monkeys

MicrobicidesMicrobicides Detergents or buffersDetergents or buffers

AntiviralsAntivirals

DiaphragmDiaphragm Protects cervixProtects cervix

Circumcision Circumcision ARNS – 65% reductionARNS – 65% reduction

Early detection Early detection Counseling & treatmentCounseling & treatment

Depression Depression Bupropion Bupropion

Complications of HIV Complications of HIV InfectionInfection

500

200

100

50

skin diseasevaginal candidiasis

fatigue

bacterial pneumonia

herpes zosteroral hairy leukoplakia, thrush, fever, diarrhea, weight loss

Pneumocystis carinii pneumonia

Toxoplasmosis, esophageal candidiasis, cryptococcosis

CMV, MAC, CNS lymphoma

Kaposi’s sarcoma, non-Hodgkin’s lymphoma

Time

CD

4 C

ount

Indications for Indications for Voluntary Voluntary HIV TestingHIV Testing

• STDsSTDs• pregnancypregnancy• tuberculosistuberculosis• recurrent pneumoniarecurrent pneumonia• refractory/recurrent vaginal refractory/recurrent vaginal

candidiasis candidiasis • generalized generalized

lymphadenopathylymphadenopathy• unexplained dementia, unexplained dementia,

aseptic meningitis, or aseptic meningitis, or peripheral neuropathyperipheral neuropathy

• B-cell lymphomaB-cell lymphoma

• chronic, unexplained chronic, unexplained fever, diarrhea, or weight fever, diarrhea, or weight lossloss

• shingles (young adults) or shingles (young adults) or generalized HSVgeneralized HSV

• unexplained cytopeniasunexplained cytopenias• evidence of cellular evidence of cellular

immuno- deficiencyimmuno- deficiency• hospitalized adults (if AIDS hospitalized adults (if AIDS

rate > 1/1000 rate > 1/1000 discharges or discharges or seroprevalence > 1%)seroprevalence > 1%)…or upon request

CandidiasisCandidiasis

Pseudomembranous candidiasis (“thrush”)

Angular cheilitis

Universal HIV Testing of All Universal HIV Testing of All Pregnant WomenPregnant Women

1998 Institute of Medicine 1998 Institute of Medicine recommended universal routine recommended universal routine HIV testing with the right of HIV testing with the right of refusal for all pregnant women in refusal for all pregnant women in the US.the US.

CDC plans to recommendCDC plans to recommend

a second test offered ina second test offered in

third trimester.third trimester. ACOG recommends universal ACOG recommends universal

testing and third trimester testing testing and third trimester testing in high risk women (Nov 2004)in high risk women (Nov 2004)

Elizabeth: pregnant HIV+Elizabeth: pregnant HIV+ 19 year old Hispanic female, 19 year old Hispanic female,

diagnosed with HIV when 17 yrs diagnosed with HIV when 17 yrs (April, 2003) in a family planning (April, 2003) in a family planning clinic when she presented with clinic when she presented with a discharge which was positive a discharge which was positive for Chlamydia. for Chlamydia.

She has been in your care since She has been in your care since that time. She has not been on that time. She has not been on ART due to poor adherence with ART due to poor adherence with apts.apts.

She presents with a complaint of She presents with a complaint of delayed menses.delayed menses.

Timing of TransmissionTiming of Transmission

12

3

1/3

Antepartum (in utero)

2/3

peripartum

Birth

Obstacles to Good Care for Obstacles to Good Care for Women with HIVWomen with HIV

Not going to clinicNot going to clinic Poverty (can’t afford, can’t get to clinic, other Poverty (can’t afford, can’t get to clinic, other

pressing priorities)pressing priorities) Forget to take medicationsForget to take medications Poor support systemPoor support system DepressionDepression History of abuseHistory of abuse Chemical Dependency (current alcohol and drug Chemical Dependency (current alcohol and drug

use)use) Housing instabilityHousing instability Distrust/ Lack of disclosureDistrust/ Lack of disclosure

Gender Issues and AdherenceGender Issues and Adherence

DepressionDepression AlcoholAlcohol Mental health TreatmentMental health Treatment

Low Educational LevelLow Educational Level UnemploymentUnemployment Absence of Social worker in Clinical Absence of Social worker in Clinical

centercenter

Late Testing Results in Missed Late Testing Results in Missed OpportunitiesOpportunities

for Treatment and Prevention of HIVfor Treatment and Prevention of HIV

Importance of HIV Importance of HIV DiagnosisDiagnosis

Benefits to individualBenefits to individual Influencing the course of infectionInfluencing the course of infection Prevention of opportunistic infectionsPrevention of opportunistic infections Prevention of morbidityPrevention of morbidity Prevention of mortalityPrevention of mortality

Benefits to othersBenefits to others Prevention of transmissionPrevention of transmission Ability to care for others Ability to care for others

Proud Woman

Letwin Mugavezi

Linkage to Care

Linking Person with HIV to Linking Person with HIV to CareCare

One third of individuals aware of their HIV One third of individuals aware of their HIV infection are not receiving careinfection are not receiving care

Possible reasons:Possible reasons: Fear, denial, stigmaFear, denial, stigma Substance use, mental illnessSubstance use, mental illness Unaware of availability of care and treatmentUnaware of availability of care and treatment Lack of care programsLack of care programs Difficulty in access: e.g. financial barriers, Difficulty in access: e.g. financial barriers,

distancedistance

The Mosaic of ServicesThe Mosaic of Services

Women’s Health

Social Support&

Counseling

Mental Health

HIV PrimaryCare Adults

Children

Harm Reduction

Adherence Support

Peer Program

Nutrition

Research

Outreach

Epidemiology of HIV in U.S.Epidemiology of HIV in U.S.

marginalized populationsmarginalized populations Blacks = 50% of all new HIV/AIDS Blacks = 50% of all new HIV/AIDS

cases in 2003cases in 2003 AIDS cases 1999-2003AIDS cases 1999-2003

blacks, blacks, Latinos, Latinos, whites whites 15% women, 15% women, 1% men 1% men

After AIDS dx, survival lowest in After AIDS dx, survival lowest in IDUs IDUs

CDC

Rapid Spread of HIV Rapid Spread of HIV among IDUsamong IDUs

Injection Drug Use and HIV in Injection Drug Use and HIV in the USthe US

1.5 million injection drug users1.5 million injection drug users 800,000 in need of drug treatment 800,000 in need of drug treatment 120,000 in treatment programs 120,000 in treatment programs 10-30% with HIV disease10-30% with HIV disease

~355,000 IDUs with HIV/AIDS ~355,000 IDUs with HIV/AIDS 100,00 receiving HIV care100,00 receiving HIV care

Second highest risk for incident HIV Second highest risk for incident HIV infectionsinfections

25% new HIV infections 25% new HIV infections

HIV and injecting drug use HIV and injecting drug use ((2003)2003)

No IDU reported (55)

IDU and HIV (114)IDU without HIV (22)

Source: WHO Programme on Substance Abuse98036-E-29 – 15 July 1998

Principles of Harm Principles of Harm ReductionReduction

Minimize harmful effects of drugsMinimize harmful effects of drugs Success not necessarily abstinenceSuccess not necessarily abstinence Low threshold servicesLow threshold services Patient vs. provider agendaPatient vs. provider agenda Addressing “non-medical” issuesAddressing “non-medical” issues Redefine health, goals, and Redefine health, goals, and

success/failuresuccess/failure

Risk (Harm) Reduction in Risk (Harm) Reduction in Drug UsersDrug Users

•The chronic and relapsing pattern of drug misuse, wide The chronic and relapsing pattern of drug misuse, wide array of serious medical consequences and increased HIV array of serious medical consequences and increased HIV transmission risk require realistic, flexible and sustainable transmission risk require realistic, flexible and sustainable preventive risk reduction strategies. preventive risk reduction strategies.

•Risk reduction does not promote injection or non-Risk reduction does not promote injection or non-parenteral drug use, but seeks to decrease the frequency parenteral drug use, but seeks to decrease the frequency of adverse events related to this practice.of adverse events related to this practice.

•Successful risk reduction strategies are based on the Successful risk reduction strategies are based on the underlying principle that injection and non-injection drug underlying principle that injection and non-injection drug misuse is a medical illness which may not be cured in the misuse is a medical illness which may not be cured in the individual or eliminated from society but can be individual or eliminated from society but can be conducted in a way that minimizes harm to the user and conducted in a way that minimizes harm to the user and others. others.

•While complete cessation of drug use remains a laudable While complete cessation of drug use remains a laudable goal, reduction in drug use frequency and safer injection goal, reduction in drug use frequency and safer injection and non-injection practices is more realistic for many drug and non-injection practices is more realistic for many drug users until abstinence can be achieved. users until abstinence can be achieved.

The Real World

HIV Transmission Risk Behavior HIV Transmission Risk Behavior Among Active HIV+ IDU in Clinical Among Active HIV+ IDU in Clinical

Care (n=55)Care (n=55)A. HIV+ IDUA. HIV+ IDU sharing needles/works, N=22

5 (23%) 5 (23%)

ART[R]ART[R]

6 (27%) 6 (27%)

ND HIV ND HIV VLVL

11 (50%)11 (50%)

VL>400VL>400

No ART[R]No ART[R]

B. Sharing EventsB. Sharing Eventsin the previous month, N=128

61 (51%) 61 (51%)

ND HIV VLND HIV VL

43 (34%)43 (34%)

VL>400VL>400

No ART[R]No ART[R]

24 (19%) 24 (19%)

ART[R]ART[R]

C. Sharing Partners C. Sharing Partners exposed in the previous month

N=284

42 (15%)42 (15%)

ART[R]ART[R]

170 (60%) 170 (60%)

ND HIV VLND HIV VL

72 (25%) 72 (25%) VL>400VL>400

No ART[R]No ART[R]

Kozal JAIDS 2005

STD in HIV+ PersonsSTD in HIV+ PersonsSTI Men

N=796Women N=354

GC 5% 3%

Syphilis 1.1% 3.1%

NGU 11% --

Trich -- 8%

Any STI 7/100K p-y 5.6/100K p-y

Median days to STI

415 176

Incidence of STI in 1,350 STD clinic

attendees followed after initial HIV

diagnosis 1993-8 in Baltimore [Erbelding

J AIDS 2003]

See also: Bachmann 2005, Taylor 2005

Further: Primary HIV infection is common among STD clinic attendees in high HIV prevalence areas: 5% of 476 HIV antibody negative men in Malawi [Pilcher AIDS 2005]

Changing Causes of Death Changing Causes of Death in the Era of ART, 1996-in the Era of ART, 1996-

20022002 (n=5561)(n=5561) Death Rate-TotalDeath Rate-Total

1996: 1996: 6.36.3/100 patient-years/100 patient-years 2002: 2002: 2.22.2/100 patient-years/100 patient-years

Death Rate due to OIsDeath Rate due to OIs 1996: 23/100patient-years (1996: 23/100patient-years (54%54% of all deaths) of all deaths) 2002: 6/100 patient-years (2002: 6/100 patient-years (28%28% of all death) of all death)

CD4 Count Closest to DeathCD4 Count Closest to Death 1996: 1996: 6565 cells cells 2002: 2002: 148148 cells cells

Causes of death in 2002Causes of death in 2002 Opportunistic: Opportunistic: 28%28% Non-OpportunisticNon-Opportunistic 72%72%

Hepatic Hepatic 36%36% Cardiovascular Cardiovascular 17%17% Pulmonary Pulmonary 23%23% Renal Renal 10%10%

Palella, HOPS DATA BASE, CROI 2004, #873Palella, HOPS DATA BASE, CROI 2004, #873

Drug Names: Drug Names: ScrabbleScrabble Scores Scorestenofovir 15Trizivir 20Truvada 11Videx 16Viread 10zalcitabine 24Zerit 14Ziagen 16zidovudine 24delavirdine 16efavirenz 24enfuvirtide 18

nevirapine 13Rescriptor 14Stocrin 9Sustiva 10Viramune 13Agenerase 10amprenavir 17atazanavir 22Crixivan 20Fortovase 15indinavir 13Fuzeon 18

Invirase 11Kaletra 11Lexiva 16lopinavir 14nelfinavir 16Norvir 9Reyataz 19ritonavir 12saquinavir 22Telzir 15Viracept 15

abacavir 15 Combivir 17didanosine 12emtricitabine 19Emtriva 12Epivir 11Epzicom 22Hivid 12Kivexa 20lamivudine 16Retrovir 11stavudine 13

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