Human Immunodeficiency Virus HIV and the correctional system

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Human Immunodeficiency Virus HIV and the
correctional system
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Prison inmates with HIV

• Medical (and practical) problem for the
  correctional services
• but also
• An marvellous opportunity for the individual and
  for society!

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Swedish Prison and Probation Authorities 1987

• Fight HIV and AIDS by prevention
• Information and education
• Discussions about route of transmission
• Testing
• Contact tracing
• and drug rehabilitation
• (and since 1996 ART treatment
• run by the civil health care)

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The over all goal(at least from the inf dis
epidemiologist point of view)

• is to reduce the risk for further transmission
  from a HIV positive individual to another inside
  the prison and later, after release, in the
  society.
• is to educate the ones who are still healthy to
  live their life in such a way that their risk of
  contracting the infection themselves is reduced

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Harm reduction programmes

• Harm reduction hot potatoes in Sweden but must
  be considered
• Needle and syringes exchange
• Belach distribution
• Substitution therapy (Methadone) opioid IDA

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HIV epidemiology
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HIV prevalens 2006
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HIV in Europe

• Slowly increasing prevalence in Western Europe
• Quickly increasing prevalence in Eastern Europe

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Why so few cases of HIV among iv drug abusers in
Sweden?

• Of cause many reasons but

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(IV) Drug abuse - HIV - Crime - Imprisonment
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Swedish Prison and Probation Authorities 1987

• Fight HIV and AIDS by prevention
• Information and education
• Discussions about route of transmission
• Testing
• Contact tracing
• and drug rehabilitation
• (and since 1996 ART treatment)

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The disease (Here symbolized by a dying T-helper
cell)
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HIV Lifecycle- why is HIV harmful?
HIV CD4 cell 5000 new
HIV
Enemy
General

• HIV infects CD4 cells (T-helper cells)
• HIV grows quickly inside CD4 cells CD4 cells
  dies
• Immunodeficiency developes due to lack of CD4
  cells

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HIV infection - natural history
Prim HIV infection
CD4 cells
AIDS
HIV nivå
Death in AIDS
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HIV treatment
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Effect of antiviral treatment (ART)
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Reported cases of AIDS and related death 1983-2006
Aids Dead
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HIV drugs- 4 different classes
NRTI

• RT Reverse Transcriptase (the enzyme that
  rewrites the virus RNA
• to DNA form)
• NRTI Nucleoside RT Inhibitor
• NRTI is nucleoside analogues (false DNA
  building blocks) that replases the
• real nucleosid in the new DNA chain and
  prevents its extension (chain
• terminator)

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HIV drugs- 4 different classes
PI protease inhibitor
NRTI

• The protease is the enzyme that splits the new
  established virus in smaller
• that can later be put together to a new
  functional contagious virus
• PI bindes to the protease and obstructs its
  function

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HIV drugs- 4 different classes
PI protease inhibitor
NRTI
NNRTI

• NNRTI non-nucleoside RT inhibitors
• Obstructs the same RT enzyme as NRTI but in a
  different way
• NNRTI inhibits RT through binding to the enzyme

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HIV drugs- 4 different classes
PI protease inhibitor
NRTI
FI-Fusions inhibitor
NNRTI

• FI prevents HIV to enter the cell by preventing
  the virus to bind to
• the cell surface

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New HIV drug classes (in the pipe-line)

• CCR5-antagonist
• Maraviroc
• Integrase inhibitors
• Raltegravir (Mk-0518)
• Elvitegravir (GS9137)

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HIV treatment principles

• Start of treatment Not too early - not too
  late
• Less long time
  side effects Before symptoms develope
  

CD4 cell count 200-300
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HIV treatment principles 2

• Only patients with undetectable viral load have
  a durable effect
• If virus is not fully suppressed- resistance
  will always develop

Undetectable is lt40 copies/ml
Only fully adherent patients reach undetectable
viral load
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Favored Initial Combinations (HAART)

• PI
• 2 NRTIs
• NNRTI

Backbone
3rd agent
HAART Highly Active Anti-Retroviral
Treatment (a combination of 3 or more HIV drugs)
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Favored Initial Combinations (HAART)
Kaletra Reyataz

• PI
• 2 NRTIs
• NNRTI

Stocrin
Truvada Kivexa (Combivir)
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Why resistance?

• Detectable viral levels during treatment (HIV-RNA
  gt50 kop/mL)
• Selection of resistant virus

Incomplete viral suppression always leads to
development of resistance !!
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What are the major causes of Treatment Failure ?

• Suboptimal adherence
• ARV toxicity and intolerance
• Pharmacokinetic problems
• Suboptimal drug potency / viral resistance

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• Resistance test
• NRTI- 8 mut
• NNRTI-1 mut
• PI- 13 mut

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Conclusion!

• Treatment and follow up of treatment of HIV is
  complex
• Viral levels, CD4 cells, combination
  possibilities, side effects, resistance.
• And if it isnt conducted properly one might harm
  the patient resistance.
• And remember. Treatment must be followed up
  carefully also after the patient leaves the
  prison! Can an active IVDA fix that?
• Co-op with specialist in HIV treatment (that is
  now a specialty of its own) and rehab drug
  abuse

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ConclusionCo-operation between experts and
authorities
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HIV risk of transmission

• Blood transfusion 100
• Pregnancy mother/child 15-35
• Iv drug abuse - sharing syringes 1-10 ?
• Coitus (vaginal intercource) lt 1
• Anal intercource lt 3

• Needle-stick incidents at hospitals 0.3
• Mucosal exposure at hospitals 0.09

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HIV risk of transmission
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I have HIV. I know how to live so that I do not
transmit my infection to others
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I do not have HIV. I know how to live in such a
way that I do not contract HIV
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Conclusion

• Complex situation!
• Opportunity!
• Only treat the treatable!
• Combine with treatment of drug dependancy
• Beware of the resistance!

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Thank You!