HIV Treatment: An IntroductionOctober 20, 2013Dr. Joanna Eveland, MS, MDHIV Medical Director, Clinica Esperanza/Mission Neighborhood Health Center

Objectives

When, Why and What treatment to start

Overcoming side effectsWorking with your healthcare

providers to get the most out of treatment

When to start?

04/12/2023 Source: HRSA HIV/AIDS Bureau

2013 Treatment Guidelines

Antiretroviral therapy is recommended for all HIV+ individuals regardless of

CD4 count

Why Treat Early?

Prevent irreversible damage to the immune system

Reduce “Inflammation” to prevent heart disease, cancer, premature aging

Treatment is prevention

Reduce the size of the “HIV reservoir”, maybe making HIV easier to cure someday

Don’t start meds until…

You feel ready

You are well engaged in care

You can commit to taking your meds regularly

You feel that other life factors and potential barriers to adherence (drugs, drama, mental health) are under control

We have a long way to go…

What to start?

Where we started…

Where we are now…

Take Home Points

HIV treatment continues to improve- for the better!

Each person’s combination of medicines is different

KNOW what you take, and why

Know What You’re Taking

HIV drugs have two, sometimes three, different names Scientific name, brand name, chemical name

Zidovudine = Retrovir = AZT

Some tablets contain more than one ingredient Atripla = tenofovir + emtricitabine + efavirenz

Goal of Treatment

General Principles

Goals: less pills, less times/day, less side effects

Use at least 3 drugs, 2 classes of medicines

Treatment is individualized- 4 recommended 1st line combos, lots of alternate regimens

Sometimes 3 isn’t enough Your Protease Inhibitor may need a “Booster”

Drug resistance usually = more pills

Treatment Principles:Chinese Menu Metaphor

“Two scoops of rice plus chicken or beef”

In other words, usually

2 “nukes”(NRTI) (2 scoops of rice) plus– 1 partner drug (main dish)

Protease Inhibitor (beef)

“non-nuke” NNRTI (chicken)

The Drugs…

Each attacks the virus at a different point…

Where Do HIV Drugs Act?

NRTIs, “Nukes”

NRTIs Continued

Backbone of treatment

Older drugs are more toxic (AZT, “D-drugs”) Peripheral neuropathy

Lactic acidosis

Pancreatitis

Lipodystrophy

Watch kidney function with Tenofovir

NNRTIs, “Non-nukes”

NNRTIs: Pros and Cons

ADVANTAGES

Ease (low pill burden)

Well tolerated Less metabolic

effects No lipodystrophy, less

dyslipidemia

DISADVANTAGES

Resistance develops quickly if <95% adherent Single mutation

Cross resistance among NNRTIs

Rash; hepatotoxicity

Protease Inhibitors

PIs: Pros and Cons

ADVANTAGES

High potency

Once daily dosing for many

Less susceptible to resistance

Second-line therapy when NNRTI fails

DISADVANTAGES

Metabolic complications - Increased

cholesterol, blood sugar

GI side effects - Diarrhea, nausea

Drug interactions– Statins, viagra, anti-

seizure, many

Integrase Inhibitors

Integrase Inhibitors

3 agents- more to come!

Well tolerated, less metabolic effects and drug interactions than other classes

Can cause rash, hepatotoxicity

Entry Inhibitors

Entry Inhibitors

Currently used as salvage therapy for those with drug resistance

Fuzeon is injectable, rarely used

Maraviroc is well tolerated, requires CCR5 receptor on CD4 cells (not everyone has this)

More to come in this class

Once a day Fixed Dose Combos

Name Pros Cons

Atripla Lots of experience using it

• Neuropsych side effects• Don’t stop without planning

Complera Well tolerated • Only studied in treatment naïve

• Not for use if VL >100K• Take with food• Can’t take PPIs

Stribild Well tolerated • Only studied in treatment naïve

• Drug interactions• Watch kidney function• Nausea

Side Effects

Tend to be worst in the first 2 months of therapy

Severe side effects are a reason to change medications

Your expectations shape your experience

What If I Miss a Pill?

Risk of resistance increases with missing more than 1-2 doses/month

If you miss a dose, try and learn from it

If stopping your meds All or none

Let us know!

Working With Your Provider

You deserve great care

Find the right fit

Educate yourself

Be engaged in care- regular visits

Uninsured? You can still get care!

HIV and Aging

Focus on Wellness

Manage stress

Exercise regularly

Quit smoking

Reduce harmful drug or alcohol use

Build a supportive community

Define and achieve your personal goals

HIV Cure Research

Paths to an HIV Cure

Gene therapyBM Transplants

“Shock and Kill”

Theraputic vaccines

HIV infected cell suicide

Early/better treatment

Resources

Project Inform: 1-800-342-2437,http://www.projectinform.org/

AIDSmeds.comthebody.comHIVinsite.orgwww.aidsinfonet.org

Thanks

To you for taking care of yourself!

The advocates and activists who gave us these treatments

My patients

More Questions?

Dr. Joanna Eveland

Clinica Esperanza

240 Shotwell St., SF

(415) 431-3212 – Clinic Info

(415) 552-3870 # 303 –My extension

joannaeveland@mnhc.org