Hiv management ppt for counselors 2013

Dr Madhu Oswal
Samvad HIV AIDS Helpline
Muktaa Charitable Foundation

Overview
PEP
How to monitor after diagnosis ?
When to start ART?
What to start?
How to monitor after starting ART?
When to refer?

12/07/13

Samvad HIV Helpline 020-26381234

Mayur
Mr Mayur, 24 yr old, IT

guy called at 10 am on
Sunday morning.
H/O Unprotected
exposure (condom
slipped) night before.
Wants to know if he is
HIV infected- TODAY.
What to do?
12/07/13


“Window Period” Following HIV Infection
Acute HIV
syndrome

Primary
HIV
infection

Antibod
Asymptomatic

Viremia

------------------------------------ PCR
P24 a.g
ELISA
a
0
12/07/13

b
2

3 4
(Weeks since infection)

Years

Source: S Conway and J.G Bartlett, 2003

6

Diagnosis in the window period
After 12 weeks-antibody tests

Elisa/Rapid
At approx 4 weeks- HIV Duo
At approx 2 weeks- HIV RNA
HIV DNA
P24 Ag test

12/07/13


HIV DNA or RNA
HIV DNA or RNA tests are NOT recommended for

diagnosis in adults
False positive results in almost 20% of patients
Costs around Rs 4000.
The patients have to be subjected to antibody testing
for confirmation after 6 TO 12 weeks.

12/07/13


What to do?

Take history: was the risk significant?
Explain about window period
Any symptoms or signs of STD-Treat
Test for baseline HIV status, Hbs Ag, ? Anti HCV
Start PEP for HIV if indicated
Start Heb B vaccine course, if not vaccinated or HbS

Ag neg.
Risk reduction counseling

If woman( Mayuri), Emergency contraception
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Post Exposure Prophylaxis

12/07/13


Drugs for Post exposure prophylaxis
Basic regimen:
1. Tenofovir 300+ Emtricitabine 200mg OD OR
2. AZT 300 mg + Lamivudine 150 mg BD
Expanded regimen:
1. Above plus Atazanavir 300 + Ritonavir 100 mg OD
2. Lopinavir 400mg +Ritonavir 100 mg BD

All for 4 weeks
Test after 6 weeks and 3 months for HIV and Hep B
12/07/13


After 3 months……..
Mayur ‘s HIV test is Negative
Risk reduction counseling .

12/07/13


After 3 months……..
Mayur ‘s HIV test is Positive (……..May be because

I didn’t take his call on Sunday )

Now what?
1. Disclose Mayur that he is HIV positive?
2. Do Western Blot test
3. Do HIV DNA/ RNA test?
4. Repeat Elisa test?

12/07/13


Mayur has confirmed HIV test
Now what?
Don’t know how to break the news, so keep silent
Refer to HIV specialist
Manage further

12/07/13


Mayur goes into depression
Don’t turn up for 5 to 6 years

Then one fine day Mayur comes
with …….

12/07/13


Initial evaluation: history
Fever, night sweats, weight loss, cough (any duration):

TB
Past H/o OI’s: herpes zoster, chronic diarrhoea
ARV use in past
Co-morbidities: DM, HTN, CKD, Jaundice
Smoking, alcohol
High risk behaviour

Ask if he has any sexual partner, marital status , children
12/07/13


Initial evaluation: physical examination
Weight
Lymphadenopathy
Oral cavity
Hepato-spleenomegaly, doughy feel of abdomen
Fundoscopic
Dermatological exam

12/07/13


Initial evaluation: Laboratory workup
 CBC with differential
 Urinanalysis, creatinine
 Blood sugar
 Liver enzymes (optional)
 Chest Xray/USG abdomen (before starting ART)
 VDRL, TPHA
 HbsAg, anti-HCV
 CD4 Count

 Cervical PAP smear in Mayuri

CD4 to be taken after treating Herpes Zoster

12/07/13


Tests NOT recommended routinely
Plasma viral load
ARV resistance testing
Fasting lipids
CMV, Toxo serology
 sCRAG (in pts with CD4<200)

TB ELISA
Tuberculin testing
IGRA assays( TB Gold, Quantiferon)

12/07/13


Rule out TB
Need to screen all HIV patients for TB
Thorough history and physical to identify “TB suspects”
CXR and sputum AFB for all “TB suspects”

Need to screen all TB patients for HIV
Active promotion and routine offering of VCT

19

Mayur LOOKS very gloomy- as he he has given up on

his life
He has been keeping well for last 5 -6 years. No OI or
co –morbidity.
But he has taken to smoking and alcohol
No abnormal findings on physical examination
He has never married (He feels he won’t live long
anyway).
He has a girlfriend, whom he has not disclosed his
status.
All reports are normal.
CD4 count 325 cells/ml
12/07/13

What to do next?
1. Start ART?
2. Wait till CD4 falls upto 250 and start

Septran
3. Start ayurvedic treatment or Amway
products?
4. Refer?

12/07/13


Reassurance!! Reassurance!!!!Reassurance !!!!!!!
HIV is a chronic manageable disease like Diabetes,

like Hypertension, like asthma.
One can expect a near NORMAL lifespan with HIV
infected individuals
There is no cure, but with regular medicines one can
lead a normal life

12/07/13


More than just medicines…
Mental health
Diet
Hygiene-water, air
Exercise
Lifestyle
Addictions
Financial security
Disclosure / testing of partner, if indicated

12/07/13


Chemoprophylaxis
Medication

Dose

Indication

Benefit

TMP-SMX

1 DS qd

CD<200

PCP
Toxo
Isospora, cycospora
Typhoid
Malaria
Community UTI

Dapsone

1 qd

CD4<200
TMP_SMX HSR

PCP

Pyrimethamine

50 mg
qwk

CD4<200
With dapsone

Toxo

Azithromycin

1.2 qwk

CD4<50

MAC

INH

300 mg qd Rule out active TB

MTB

Hepatitis B vaccine to all Hbs Neg
12/07/13


When to start ART?
All Pt with hx of AIDS-defining condition
All patients with CD4 T-cell count of <350 cells/mm3
All Pt that are pregnant, HIV nephropathy, HBV co-

infection when HBV Rx is needed
Recommended for all Pt with 350-500 cells/mm3
Optional for Pt with >500 cells/mm3

DSHS,January 10, 2011

12/07/13


Benefits of ART
The survival after development of advanced HIV

disease increased from 18 months to over 25 years for
those who can access medicines.
Prevention of transmission
Secondary prevention
Post-exposure prophylaxis


Occupational and non-occupational

Mother to child transmission
Pre-exposure prophylaxis

12/07/13


Fusion

RNA

Reverse
transcriptase
ZDV, ddI,
ddC, d4T,
3TC, ABC,
TDF, FTC
DLV, NVP,
EFV, ETV

12/07/13

Viral protease

ENF

CCR5 antag.
maraviroc

RNA

Proteins

RT
RNA
RNA
RT

DNA
DNA
DNA


Provirus

Integrase
raltegravir

SQV
RTV
IDV
NFV
fAPV
LPV
ATV
DRV
TPV

Nucleoside Reverse
Transcriptase Inhibitors( NRTIs)
Tenofovir (TDF)Zidovudine (AZT)
Lamivudine (3TC)
Emtricitabine (FTC)
Stavudine (d4T)
Didanosine (ddI)
Abacavir (ABC)
Zalcitabine (ddC) Helpline 020-26381234
Samvad HIV

12/07/13

Non-Nucleoside Reverse
Transcriptase Inhibitors (NNRTIs)
Nevirapine (NVP)
Efavirenz (EFV)
Etravirive
Delaverdine

12/07/13


First line regimens
Preferred
TDF/XTC/EFV or NVP( Trustiva, Effoday, )

Alternative
AZT/3TC/EFV or NVP

No options available
d4T/3TC/EFV or NVP

12/07/13


How to monitor when on ART?
1.

Look for IRIS: Immune reconstitution inflammatory
syndrome

2. Look for adverse effects- clinical and lab

investigations
3. Watch for drug drug interaction
4. Monitor response to ART: CD4 and Viral load

12/07/13


IRIS: Immune reconstitution inflammatory

syndrome
Iris is occurrence or manifestations of new OIs

within six weeks to six months after initiating
ART; with increase in CD4 count

Two types: Unmasking and Paradoxical

12/07/13


IRIS

3 weeks after ART
(TDF+3TC+EFV)

12/07/13

Samvad HIV Helpline Source: Dr.Rajasekaran, Superintendent, GHTM,Chennai
020-26381234

33

IRIS

12/07/13


34
Source: GHTM,Chennai

TDF: Renal, bone( Do urine R, S creat)
AZT: Anemia( Hb)
EFV: CNS
Nev: HSR, Hepatitis( LFT if symptomatic)
d4T: Neuropathy, lactic acidosis

12/07/13


Nevirapine (NVP)
Rash
Hepatitis
Risk

is greatest in first 6 weeks of therapy
Could be benign or fatal
Increased risk if started in women with CD4
above 250 and men with CD4 above 400
Not to use in concomitant Anti TB drugs

12/07/13


12/07/13

Courtesy of HIV Web Study, www.hivwebstudy.org

Efavirenz Toxicity
CNS Changes (excessive sleep or loss of sleep,

delusions, nightmares)
Rash
Hepatotoxicity (
Contraindicated during pregnancy
Teratogenic—Class D?
Useful in TB with HIV

Useful when stsrting ART in higher CD4 count
12/07/13


Long term Toxicity (After few
years)
Bone Marrow Suppression Myalgia
Anemia
Myopathy
Neutropenia
Pigmentation of nail
Peripheral Neuropathy
beds
Lipoatrophy

Lactic acidosis, fatty

Fat accumulation
Osteoporosis
Metabolic syndrome

liver
Pancreatitis

Cardiovascular side effects
Renal dysfunction
Hepatic dysfunction

12/07/13


12/07/13


Lipodystrophy

12/07/13


Side effects/Toxicity of ART
Acute side effects: Rash, headache, nausea, vomiting,

loose motions, jaundice, anemia, excessive sleep or
loss of sleep, delusions, nightmares.

Chronic toxicity: Lipodystrophy- i.e change in body

shape with reduces fat on face and extremities and
increased fat deposition on abdomen and nape of
neck. Diabetes, bone loss, increased fats in blood,
tingling numbness in limbs

12/07/13


Test

On starting
ART

2-8 weeks after
starting ART

Every 3 to 6
months

Heamogram

√

√ (If on ZDV)

√

Urine R

√

√ (If on TDF,
esp in DM, HT)

√

BSL -F

√

ALT, AST ,S-bili

√

√

√

S. creatinine

√

√

√

S elec, S Ca, S
Phos, Cr Cl

√

√

√

Lipid profile

√

CD4 count

√

√

√( If very
stable and
high counts)

Viral load

√

√

√( If stable and
adherent)

12/07/13

Every year

√


√(If last report √ (If last report
abnormal)
normal)

WBCs

PMNs

Eos

CD4 (T helper)

12/07/13

RBCs

Lymphs

CD8 (T helper)


platelets

Grans

others

Macroph.

Uses of CD4 Cell Count
 Decision to initiate ARV
 Guide in initiating OI prophylaxis
 Assess progression of disease
 Measure response to treatment (prognostication)
 Detect immunologic treatment failure
 Pneumocystis pneumonia
 CD4 <200
 TLC <1200

 Toxoplasmosis
 CD4 <100 and positive Toxoplasma serology

 Cryptococcal meningitis
 CD4 <100
12/07/13


CD4 COUNT
Normal CD4 count is 800-1050 cells/cu.mm
CD4 decreases at a rate of 40-60 cells per yr in an HIV

infected person.
Diurnal variation.
Treat OI before testing for CD4 count.
Sample :3 ml in EDTA bulb
CD4 count increases > 50 cells/mm3 at 4-8 weeks
after ART and then increases an additional 50 – 100
cells / mm3 per year thereafter.
Change more than 30% is significant.
Ideally CD4 count to be measured every 6 months.
12/07/13


148

12/07/13


Viral Load test of RNA PCR test
Commercial methods/kits in use:
Amplicor
B-DNA
NASBA
Preferable use the same kit/ method for repeat

testing
Sample :3 ml in EDTA bulb
Viral load should be below detectable level after 6
months of effective ART
12/07/13


Viral Load Monitoring
Where available, PCR or NASBA monitoring provide

valuable information about ART effectiveness
Viral load should be checked:
Every 3-6 months when not on ART
6 months after starting ART
Every 6 -12 months in stable ART patients

12/07/13


Detection of Treatment Failure
Immunological failure: If the CD4 cell count fail to

rise, increase < 25-50 in 1st yr, decline after previous
increase; return to pre-ART baseline.
Viral load testing : Failure to achieve undetectable
viral load within first 4-6 months of ART or rise after
achieving a stable, low level of persistent virus
In cases of 1st line treatment failure, refer to HIV

specialist.

12/07/13


Drugs with Potential to Interact
with
PIs or NNRTIs
Statins (simvistatin &

lovastatin)
Azole antifungals
Anticonvulsants
Anti-TB (Rifampicin)
Warfarin

52

Midazolam, trizolam
Alternative medicine
Clarithromycin
Oral contraceptives
Amitriptyline

3 years after starting ART…..
Mayur has undetectable

viral load, CD4 945
cells/cu mm
No toxicity
Mayur comes with Mayuri,
his girl friend who wants
to marry him , pretty well
knowing his positive
status. She is HIV
negative.
12/07/13


What would you ADVISE?
Its illegal. They cannot marry.
2. She would get infected
3. They won’t have an option of having children
4. They can marry provided they are ready to adopt
safer methods.
1.

12/07/13


HPTN O52: The effectiveness of antiretroviral drugs in

reducing sexual transmission of HIV, by up to 96% in
serodiscordant couples.
Prep trials ((iPrEx study, Partners PrEP, and TDF2, FEMPrEP)

Circumcision : Male circumcision is associated with lower

risk for HIV. May reduce female to male

transmission( 50 to 60 %).
12/07/13


Advise for discordant couple
who want to have a child
If male positive
Undetectable viral load
Sperm washing with IUI
Timed intercourse with Prep

If female positive
Undetectable viral load
IUI or Timed intercourse with Prep
ART at-least from 14th weeks of pregnancy, till she stops

breast feeding her child
ART drugs for newborn for 4 to 6 weeks
12/07/13


Mayur and Mayuri have a cute
little baby girl
To test or not to test?
When to test and which tests to use?

12/07/13


Diagnosis in child born to HIV +ve
mother
After 18 months-

Before 18 months-

12/07/13

Antibody tests
(Elisa/Rapid/WB)

Antigen test
(HIV DNA PCR)


Advise for PPTCT
ART throughout pregnancy
If viral load undetectable close to labour, no need of

Caesarian section
Breast feeding advisable , but mother should
continue ART
ART drugs for newborn for 4 to 6 weeks

Chances of baby getting infection below 5% .
AIDS FREE GENERATION
12/07/13


Ending AIDS: AIDS 2012

12/07/13


Will AIDS really end?
Most unlikely.
No.s will fall for some time
It will restrict itself again among those who practice

risky behaviour, eg People practicing risky behaviour;
Sex workers; MSM
But complacency will bring it back again as our track
record against any STD is poor.
First line- Second line-Third line –Salvage regimen

12/07/13


Thank You

12/07/13


Hiv management ppt for counselors 2013

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