1. HIV Treatment: An Introduc2on
December 4, 2011
Dr. Joanna Eveland, MS, MD
HIV Medical Director, Clinica Esperanza
Mission Neighborhood Health Center

2. Objec2ves
• When, Why and What treatment to
start
• Overcoming side effects
• Working with your healthcare
providers to get the most out of
treatment

3. When to start?

4. 10,000,000 Average progression without 800
treatment: 10 years from infection
1,000,000 to AIDS diagnosis
100,000 500
10,000
1,000 200
100 100
50
10 Months Years 0
CD4 Count
HIV in plasma
HIV in plasma (“viral load”) (cells/mL)
(copies/mL)
CD4 (T Cell) count
12/4/11
Source: HRSA HIV/AIDS Bureau

5. 2011 DHHS Treatment
Guidelines
• CD4 <500
• Any AIDS defining condi2on
• Special circumstances: Hepa22s B,
Pregnancy, Kidney Disease, Viral
load >100,000
• CD4 >500 ?‐ Expert panel split!

6. What to do with CD4 >
500?
Test and Watch and wait
Treat

7. Test and Treat Argument
What are we wai2ng for?
• Treatment is safe
• Treatment is preven2on
• Early treatment may reduce
inflamma2on ‐ less heart disease,
cancer, demen2a?

8. Watch and Wait
What s the rush?
• Treatment has side effects
• Where s the data that this works?
• Treatment is expensive
• There s more to HIV preven2on than
pills
• Star2ng before you re ready is the
most dangerous

9. Don t start meds un2l…
• You feel ready
• You are well engaged in care
• You can commit to taking your meds
regularly
• You feel that other life factors and
poten2al barriers to adherence
(drugs, drama, mental health) are
under control

10. What to start?

11. Where we started…
• D

12. Where we are now… HIV Medication Chart
Nucleoside/Nucleotide Analogue Reverse Transcriptase Inhibitors (NRTI)
Emtriva* Epivir* Retrovir*† Zerit* Ziagen*
• D
Videx EC† Viread
(emtricitabine, FTC) (lamivudine, 3TC) (zidovudine, AZT, ZDV) (didanosine, ddl) (tenofovir,TDF)* (stavudine, d4T) (abacavir, ABC)
Protease Inhibitors (PI) Fixed Dose Combinations
Atripla Combivir
Aptivus Crixivan Invirase Kaletra* Lexiva
(tipranavir, TPV) (TDF+FTC+EFV) (AZT plus 3TC)
(indinavir, IDV) (saquinavir hard (lopinavir/ritonavir, (fosamprenavir, FPV)
gel capsules, SQV) LPV/r)
FDA Pregnancy Category D
Trizivir
Epzicom (AZT plus 3TC plus ABC)
Reyataz Viracept (ABC plus 3TC)
Norvir* Prezista
(darunavir, DRV) (atazanavir, ATV) (nelfinavir, NFV)
(ritonavir, RTV)
Truvada
(TDF plus FTC)
Non-Nucleoside Reverse Entry Inhibitors Integrase Inhibitors
Transcriptase Inhibitors (NNRTI)
Fuzeon Selzentry
Intelence Rescriptor (maraviroc, MVC) Isentress
(enfuvirtide, T-20)
(etravirine, ETV) (delavirdine, DLV) CCR5 Antagonist (raltegravir, RAL)
Fusion Inhibitor
Sustiva* Viramune*
All pills shown in actual size.
(efavirenz, EFV) (nevirapine, NVP)
Medication brand names appear in bold. Generic names and
commonly used abbreviations appear in parentheses.
*Also available in liquid form. 7/08
FDA Pregnancy Category D †Generic formulation available.

13. Take Home Points
• HIV treatment con2nues to
improve‐ for the beder!
• Each person s combina2on of
medicines is different
• KNOW what you take, and why.

14. Know What You re Taking
• HIV drugs have two, some;mes
three, different names
– Scien2fic name, brand name, chemical
name
– Zidovudine = Retrovir = AZT
• Some tablets contain more than
one ingredient
– Atripla = tenofovir + emtricitabine +
efavirenz

15. Goal of Treatment

16. General Principles
• Goals: less pills, less 2mes/day, less side
effects
• Use at least 3 drugs, 2 classes of
medicines
• Some2mes 3 isn t enough
– Your Protease Inhibitor may need a
Booster
– Drug resistance usually = more pills

17. 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)

18. The Drugs…
Each adacks the virus at a different
point…

19. Where Do HIV Drugs Act?

20. NRTIs, Nukes
HIV Medication Chart
Nucleoside/Nucleotide Analogue Reverse Transcriptase Inhibitors (NRTI)
Emtriva* Epivir* Retrovir*† Videx EC† Viread Zerit* Ziagen*
(emtricitabine, FTC) (lamivudine, 3TC) (zidovudine, AZT, ZDV) (didanosine, ddl) (tenofovir,TDF)* (stavudine, d4T) (abacavir, ABC)
Protease Inhibitors (PI) Fixed Dose Combinations
Atripla Combivir
Aptivus Crixivan Invirase Kaletra* Lexiva
(tipranavir, TPV) (TDF+FTC+EFV) (AZT plus 3TC)
(indinavir, IDV) (saquinavir hard (lopinavir/ritonavir, (fosamprenavir, FPV)
gel capsules, SQV) LPV/r)
FDA Pregnancy Category D
Trizivir
Epzicom (AZT plus 3TC plus ABC)
Reyataz Viracept (ABC plus 3TC)
Norvir* Prezista
(darunavir, DRV) (atazanavir, ATV) (nelfinavir, NFV)
(ritonavir, RTV)
Truvada
(TDF plus FTC)
Non-Nucleoside Reverse Entry Inhibitors Integrase Inhibitors
Transcriptase Inhibitors (NNRTI)
Fuzeon Selzentry
Intelence Rescriptor (maraviroc, MVC) Isentress
(enfuvirtide, T-20)
(etravirine, ETV) (delavirdine, DLV) CCR5 Antagonist (raltegravir, RAL)
Fusion Inhibitor
Sustiva* Viramune*
All pills shown in actual size.
(efavirenz, EFV) (nevirapine, NVP)
Medication brand names appear in bold. Generic names and
commonly used abbreviations appear in parentheses.
*Also available in liquid form. 7/08
FDA Pregnancy Category D †Generic formulation available.

21. NRTIs Con2nued
• Backbone of treatment
• Older drugs are more toxic (AZT, D‐
drugs )
– Peripheral neuropathy
– Lac2c acidosis
– Pancrea22s
– Lipodystrophy
• Watch kidney func2on with
Tenofovir

22. NNRTIs, Non‐nukes
HIV Medication Chart
Nucleoside/Nucleotide Analogue Reverse Transcriptase Inhibitors (NRTI)
Emtriva* Epivir* Retrovir*† Videx EC† Viread Zerit* Ziagen*
(emtricitabine, FTC) (lamivudine, 3TC) (zidovudine, AZT, ZDV) (didanosine, ddl) (tenofovir,TDF)* (stavudine, d4T) (abacavir, ABC)
Protease Inhibitors (PI) Fixed Dose Combinations
Atripla Combivir
Aptivus Crixivan Invirase Kaletra* Lexiva
(tipranavir, TPV) (TDF+FTC+EFV) (AZT plus 3TC)
(indinavir, IDV) (saquinavir hard (lopinavir/ritonavir, (fosamprenavir, FPV)
gel capsules, SQV) LPV/r)
FDA Pregnancy Category D
Trizivir
Epzicom (AZT plus 3TC plus ABC)
Reyataz Viracept (ABC plus 3TC)
Norvir* Prezista
(darunavir, DRV) (atazanavir, ATV) (nelfinavir, NFV)
(ritonavir, RTV)
Truvada
(TDF plus FTC)
Non-Nucleoside Reverse Entry Inhibitors Integrase Inhibitors
Transcriptase Inhibitors (NNRTI)
Fuzeon Selzentry
Intelence Rescriptor (maraviroc, MVC) Isentress
(enfuvirtide, T-20)
(etravirine, ETV) (delavirdine, DLV) CCR5 Antagonist (raltegravir, RAL)
Fusion Inhibitor
Sustiva* Viramune*
All pills shown in actual size.
(efavirenz, EFV) (nevirapine, NVP)
Medication brand names appear in bold. Generic names and
commonly used abbreviations appear in parentheses.
*Also available in liquid form. 7/08
FDA Pregnancy Category D †Generic formulation available.

23. NNRTI: Pros and Cons
ADVANTAGES DISADVANTAGES
 Ease (low pill burden)  Resistance develops
 Well tolerated quickly if <95%
 Less metabolic
adherent
effects – Single mutation
– Cross resistance
– No lipodystrophy,
among NNRTIs
less dyslipidemia
 Rash; hepatotoxicity

24. Efavirenz considera2ons
• Most commonly prescribed NNRTI
• Neuropsychiatric side effects: vivid
dreams, sleep disturbance,
spaciness
• Cau2on for those with mental
health issues

25. Protease Inhibitors
HIV Medication Chart
Nucleoside/Nucleotide Analogue Reverse Transcriptase Inhibitors (NRTI)
Emtriva* Epivir* Retrovir*† Videx EC† Viread Zerit* Ziagen*
(emtricitabine, FTC) (lamivudine, 3TC) (zidovudine, AZT, ZDV) (didanosine, ddl) (tenofovir,TDF)* (stavudine, d4T) (abacavir, ABC)
Protease Inhibitors (PI) Fixed Dose Combinations
Atripla Combivir
Aptivus Crixivan Invirase Kaletra* Lexiva
(tipranavir, TPV) (TDF+FTC+EFV) (AZT plus 3TC)
(indinavir, IDV) (saquinavir hard (lopinavir/ritonavir, (fosamprenavir, FPV)
gel capsules, SQV) LPV/r)
FDA Pregnancy Category D
Trizivir
Epzicom (AZT plus 3TC plus ABC)
Reyataz Viracept (ABC plus 3TC)
Norvir* Prezista
(darunavir, DRV) (atazanavir, ATV) (nelfinavir, NFV)
(ritonavir, RTV)
Truvada
(TDF plus FTC)
Non-Nucleoside Reverse Entry Inhibitors Integrase Inhibitors
Transcriptase Inhibitors (NNRTI)
Fuzeon Selzentry
Intelence Rescriptor (maraviroc, MVC) Isentress
(enfuvirtide, T-20)
(etravirine, ETV) (delavirdine, DLV) CCR5 Antagonist (raltegravir, RAL)
Fusion Inhibitor
Sustiva* Viramune*
All pills shown in actual size.
(efavirenz, EFV) (nevirapine, NVP)
Medication brand names appear in bold. Generic names and
commonly used abbreviations appear in parentheses.
*Also available in liquid form. 7/08
FDA Pregnancy Category D †Generic formulation available.

26. PIs: Pros and Cons
ADVANTAGES DISADVANTAGES
• High potency • Metabolic
• Less suscep2ble to complica2ons
resistance from ‐ Increased cholesterol,
virus blood sugar
• Second‐line • GI side effects
therapy when - Diarrhea, nausea
NNRTI fails • Drug interac2ons
– Sta2ns, viagra, an2‐
seizure, many others

27. Integrase Inhibitor
HIV Medication Chart
Nucleoside/Nucleotide Analogue Reverse Transcriptase Inhibitors (NRTI)
Emtriva* Epivir* Retrovir*† Videx EC† Viread Zerit* Ziagen*
(emtricitabine, FTC) (lamivudine, 3TC) (zidovudine, AZT, ZDV) (didanosine, ddl) (tenofovir,TDF)* (stavudine, d4T) (abacavir, ABC)
Protease Inhibitors (PI) Fixed Dose Combinations
Atripla Combivir
Aptivus Crixivan Invirase Kaletra* Lexiva
(tipranavir, TPV) (TDF+FTC+EFV) (AZT plus 3TC)
(indinavir, IDV) (saquinavir hard (lopinavir/ritonavir, (fosamprenavir, FPV)
gel capsules, SQV) LPV/r)
FDA Pregnancy Category D
Trizivir
Epzicom (AZT plus 3TC plus ABC)
Reyataz Viracept (ABC plus 3TC)
Norvir* Prezista
(darunavir, DRV) (atazanavir, ATV) (nelfinavir, NFV)
(ritonavir, RTV)
Truvada
(TDF plus FTC)
Non-Nucleoside Reverse Entry Inhibitors Integrase Inhibitors
Transcriptase Inhibitors (NNRTI)
Fuzeon Selzentry
Intelence Rescriptor (maraviroc, MVC) Isentress
(enfuvirtide, T-20)
(etravirine, ETV) (delavirdine, DLV) CCR5 Antagonist (raltegravir, RAL)
Fusion Inhibitor
Sustiva* Viramune*
All pills shown in actual size.
(efavirenz, EFV) (nevirapine, NVP)
Medication brand names appear in bold. Generic names and
commonly used abbreviations appear in parentheses.
*Also available in liquid form. 7/08
FDA Pregnancy Category D †Generic formulation available.

28. Integrase Inhibitor
ADVANTAGES DISADVANTAGES
• Approved as first‐ • Twice daily dosing
line regimen • Low barrier to
• Less side effects resistance
• Newer drug
• Drug interac2ons

29. Entry Inhibitors
HIV Medication Chart
Nucleoside/Nucleotide Analogue Reverse Transcriptase Inhibitors (NRTI)
Emtriva* Epivir* Retrovir*† Videx EC† Viread Zerit* Ziagen*
(emtricitabine, FTC) (lamivudine, 3TC) (zidovudine, AZT, ZDV) (didanosine, ddl) (tenofovir,TDF)* (stavudine, d4T) (abacavir, ABC)
Protease Inhibitors (PI) Fixed Dose Combinations
Atripla Combivir
Aptivus Crixivan Invirase Kaletra* Lexiva
(tipranavir, TPV) (TDF+FTC+EFV) (AZT plus 3TC)
(indinavir, IDV) (saquinavir hard (lopinavir/ritonavir, (fosamprenavir, FPV)
gel capsules, SQV) LPV/r)
FDA Pregnancy Category D
Trizivir
Epzicom (AZT plus 3TC plus ABC)
Reyataz Viracept (ABC plus 3TC)
Norvir* Prezista
(darunavir, DRV) (atazanavir, ATV) (nelfinavir, NFV)
(ritonavir, RTV)
Truvada
(TDF plus FTC)
Non-Nucleoside Reverse Entry Inhibitors Integrase Inhibitors
Transcriptase Inhibitors (NNRTI)
Fuzeon Selzentry
Intelence Rescriptor (maraviroc, MVC) Isentress
(enfuvirtide, T-20)
(etravirine, ETV) (delavirdine, DLV) CCR5 Antagonist (raltegravir, RAL)
Fusion Inhibitor
Sustiva* Viramune*
All pills shown in actual size.
(efavirenz, EFV) (nevirapine, NVP)
Medication brand names appear in bold. Generic names and
commonly used abbreviations appear in parentheses.
*Also available in liquid form. 7/08
FDA Pregnancy Category D †Generic formulation available.

30. 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)

31. Side Effects
• Tend to be worst in the first 2 months
of therapy
• Severe side effects are a reason to
change medica2ons
• Your expecta2ons shape your
experience

32. Gerng The Most Out of
Treatment

33. 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!

34. Working With Your
Provider
• You deserve great
care
• Find the right fit
• Educate yourself
• Be engaged in care‐
regular visits
• Uninsured? You can
s2ll get care!

35. Focus on Wellness
• Manage stress
• Exercise regularly
• Quit smoking
• Reduce harmful drug or alcohol use
• Build a suppor2ve community
• Define and achieve your personal
goals

36. Resources
• Project Inform: 1‐800‐342‐2437,
• hdp://www.projec2nform.org/
• AIDSmeds.com
• thebody.com
• HIVinsite.org
• www.aidsinfonet.org/

37. Thanks
• Drs Rick Lovus and Tri Do
• The advocates and ac2vists who
gave us these treatments
• My pa2ents

38. More Ques2ons?
Dr. Joanna Eveland
Clinica Esperanza
240 Shotwell St., SF
(415) 431‐3212 – Clinic Info
(415) 552‐3870 # 303 –My extension
joannaeveland@mnhc.org