HIV patient outcomes have been shown to improve with appropriate support by case management. HIV case managers need to have a working understanding of clinical management issues to improve on the great work that they do for their patients. This presentation attempts to provide case managers with this information.

1. HIV CLINICAL ISSUES
for Case Managers
ADVANCED HIV CASE
MANAGEMENT
COURSE
Leonard A. Sowah, MBChB, MPH
Assistant Professor of Medicine
Institute of Human Virology
University of Maryland School of Medicine

2. HIV Virus Life Cycle
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3. Clinical Course of HIV Infection
 Acute or primary infection
 Rash
 Fever
 Flu like symptoms
 Fatigue
 Sore throat
 Prolonged Asymptomatic
 Immune activation leads to CD4 cell decline
 Early symptomatic phase
 Herpes zoster
 Increased risk of common infections
 HIV Dermatopathy
 Advanced HIV or AIDS
 Opportunistic Infections

4. CD4 Cells
 A type of white blood cell that
carries the CD4 surface marker and
helps the body fight infection. Also
known as T-cells or T-helper cells.
When infected by HIV, these cells
incorporate HIV RNA into their DNA
and subsequently manufacture new
HIV particles.
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5. HIV Viral Load
 Viral load means how much HIV is in the patient’s
bloodstream (also called HIV RNA).
 “Undetectable viral load” means the amount of the
virus is so low, the blood tests cant detect it.
 Doctor’s use a combination of medicines to try and
get the patient’s viral load to an undetectable level
and keep it there.
 Even when a viral load is extremely low or
undetectable, the client should continue taking
prescribed HIV medications.
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6. AIDS - Acquired
Immunodeficiency Syndrome
 The most severe manifestation of HIV
infection. Characterized by numerous
opportunistic infections and
malignancies or a CD4 cell count below
200/mm3, which, in the presence of HIV,
constitutes a diagnosis of AIDS.
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7. Course of HIV Infection
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8. From CLIN INFECT DIS 30(S1):S5-S14.
© 2000 by the Infectious Diseases Society of America. All rights
reserved
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9. Common Opportunistic Diseases in
HIV
 Pneumocystis pneumonia
 Oropharyngeal candidasis
 Pulmonary tuberculosis
 Herpes zoster
 Cryptococcal Meningitis
 CNS Toxoplasma
 Non Hodgkins Lymphoma
 HIV Encephalopathy
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10. Causes of death in the HAART era
Current Opinion in Infectious Williams & Wilkins, 25(1):36-41, February 2012.
© 2012 Lippincott
Diseases. Inc. Published by Lippincott Williams & Wilkins, Inc. 2
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11. Causes of Death among Persons with AIDS
in the HAART Era : New York City
© 2006 AmericanAnnals of Internal Medicine. 145(6):397-406, September 19, 2006.
College of Physicians. Published by American College of Physicians.

12. VIRAL ENTRY AND REPLICATION
 Sources of HIV virus in
an infected person
 blood
 breast milk
 saliva
 semen
 tears
 vaginal fluids
 Transmission has been
documented only through
 blood
 blood products
 sexual fluids
 Breast milk
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13. Current HIV drugs and their targets in the viral cell
cycle
CCR5 Antagonist Fusion Inhibitors
NNRTIs &
NRTIs
Protease
Inhibitors
Integrase Inhibitors
Copyright © 2003 by the European Molecular Biology Organization
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14. Current FDA Approved HIV Medications
©2006 Community Research Initiative of New England. All Rights Reserved.
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15. When to start therapy (DHHS Guidelines)
 CD4 counts < 500 cells
 Observational data and cohort studies suggests clinical benefit for
patients treated with CD4 > 500 cells
 History of AIDS-defining illness
 HIV-associated nephropathy (HIVAN)
 Pregnant women
 Hepatitis B co-infection
 Rapidly declining CD4 count
 High viral loads > 100,000 /ml
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16. When to Start ART
 Exact CD4 count at which to initiate therapy not
known, but evidence points to starting at higher
counts
 Current recommendation: ART for all patients
with CD4 <500 cells/µL
 For patients with CD4 >500 cells/µL, 50% of the panel
recommend ART, 50% consider ART to be optional
 Randomized control trial (RTC) data support benefit of
ART if CD4 ≤350
 No RTC data on benefit of ART at CD4 >350, but
observational cohort data
www.aidsetc.org
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17. Assessing Readiness for Therapy
 Knowledge about disease
 Prior adherence history
 Individual self efficacy
 Beliefs about Efficacy and safety of
ART regimen
 Age / income /education
 Drug use
 Dosing frequency
 Pill burden ????
09/29/12 J Gen. Intern Med 2002;17: 756 -765

18. Choice of Initial Regimen
 Efficacy
 Toxicity
 Clinical Co-morbidity
 Results of Genotypic resistance testing
 Substance abuse and psychiatric issues
 Potential for drug interactions
 Ease of Administration
 Consistency with patient lifestyle
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19. Common Side Effects of HIV Meds
FACE SKIN
Lipoatrophy Rashes
Loss of fat in cheeks,
temples or extremities HEART
BODY Hyperlipidemia, High Cholesterol
and High Glucose
Lipodystrophy Increase in the amount
Increase in abdominal size, breast of fat, cholesterol, or
size, and/or dorsocervical fat pad sugar in the blood that
(buffalo hump) can lead to heart disease
LIVER
KIDNEYS
Hepatotoxicity
Liver damage Nephrotoxicity, Kidney Stones
Kidney damage
NERVES
GUT
Neuropathy
Nausea, Diarrhea and Vomiting
Nerve damage causing
strange sensations and pain,
starting in the hands/feet BLOOD
BONES
BONES Anemia
Osteoporosis, Osteopenia Low number of blood cells;
Bone loss causes fatigue

20. Immune-Reconstitution
Inflammatory Syndrome (IRIS)
 What is IRIS ?
 Paradoxical worsening of clinical symptoms
in a HIV positive patient upon therapy
initiation from pre-existing infections.
 10 – 25% of patients started on HAART
 Within 12 weeks of onset of HAART
 CD4 count of HAART start <100 cells/m3
 Drop in viral load of > 2.5 log copies
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21. Common Manifestations of IRIS
 Anogenital Herpes virus infection
 Genital warts
 Molluscum contagiosum
 Shingles
 Tuberculosis
 MAC Infection
 PCP
 Hepatitis
Sources for pictures: http://www.medicinenet.com
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22. Perinatal HIV Transmission
 Without antiretroviral (ARV) drugs during pregnancy,
mother-to-child transmission (MTCT) has ranged from
16%–25% in North America and Europe.
 21% transmission rate in the U.S. in 1994 before the
standard zidovudine (ZDV) recommendation during
pregnancy.
 With this change in practice, transmission decreased to
11% in 1995.
 Today, risk of perinatal transmission can be <2% with:
 effective antiretroviral therapy (ART)
 elective cesarean section (C/S) as appropriate
 formula feeding
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23. Hepatitis C and HIV
 30 - 40% of HIV+ people in US also infected with
HCV
 More rapid progression of HCV (twice as fast)
 Little to no affect on HIV progression
 (still inconclusive)
 Complicates medication regimens
 Increases risk of perinatal transmission
 Incarceration and injection drug use settings have
co-infection rates >75%
 Treatment effectiveness is heavily determined by
genotype
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24. Other Clinical Issues in HIV Care
 Kidney Disease
 Hyperlipidemia
 Cardiovascular Disease
 Liver Disease
 COPD
 HIV Neuropathy
 Cognitive Impairments
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25. End of Life Needs
 Advanced Directives
 Power of attorney
 Disease management
 Hospice Care
 Comfort Care
 Insurance Issues
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26. Summary
 HIV viral replication can be suppressed with Anti
Retroviral Therapy
 Risk of development of drug resistance is high in non
adherent patients.
 Individualized choice of therapy regimen and when to
initiate ART may reduce risk of treatment failure and
development of resistance
 Effective team work between case manager and HIV
provider can reduce therapeutic failure and improve
patient satisfaction
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27. THANKS VERY MUCH