AIDS 101

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• AIDS 101
• Current status and History
• Challenges and issues

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TRANSITION PERIOD FOR MANAGEMENT OF
HIV/AIDS1995 David Ho HIV Replication
10,000,000,000/day1996 John Mellors Viral
load1996 Introduction of PIs1997 Triple
therapy

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HIV PREVENTION BEYOND ABC

• HSV 2 Acyclovir prophylaxis
• TDF prophylaxis Partial efficacy monkeys
• Microbicides Detergents or buffers
• Antivirals
• Diaphragm Protects cervix
• Circumcision ARNS 65 reduction
• Early detection Counseling treatment
• Depression Bupropion

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Complications of HIV Infection
500
vaginal candidiasis
skin disease
fatigue
bacterial pneumonia
CD4 Count
herpes zoster
oral hairy leukoplakia, thrush, fever, diarrhea,
weight loss
200
Kaposis sarcoma, non-Hodgkins lymphoma
Pneumocystis carinii pneumonia
100
Toxoplasmosis, esophageal candidiasis,
cryptococcosis
50
CMV, MAC, CNS lymphoma
Time
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Indications for Voluntary HIV Testing

• STDs
• pregnancy
• tuberculosis
• recurrent pneumonia
• refractory/recurrent vaginal candidiasis
• generalized lymphadenopathy
• unexplained dementia, aseptic meningitis, or
  peripheral neuropathy
• B-cell lymphoma

• chronic, unexplained fever, diarrhea, or weight
  loss
• shingles (young adults) or generalized HSV
• unexplained cytopenias
• evidence of cellular immuno- deficiency
• hospitalized adults (if AIDS rate gt
  1/1000 discharges or seroprevalence gt 1)

or upon request
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Candidiasis
Angular cheilitis
Pseudomembranous candidiasis (thrush)
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Universal HIV Testing of All Pregnant Women

• 1998 Institute of Medicine recommended universal
  routine HIV testing with the right of refusal for
  all pregnant women in the US.
• CDC plans to recommend
• a second test offered in
• third trimester.
• ACOG recommends universal testing and third
  trimester testing in high risk women (Nov 2004)

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Elizabeth pregnant HIV

• 19 year old Hispanic female, diagnosed with HIV
  when 17 yrs (April, 2003) in a family planning
  clinic when she presented with a discharge which
  was positive for Chlamydia.
• She has been in your care since that time. She
  has not been on ART due to poor adherence with
  apts.
• She presents with a complaint of delayed menses.

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Timing of Transmission
1/3 Antepartum (in utero)
2/3 peripartum
1
2
3
Birth
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Obstacles to Good Care for Women with HIV

• Not going to clinic
• Poverty (cant afford, cant get to clinic, other
  pressing priorities)
• Forget to take medications
• Poor support system
• Depression
• History of abuse
• Chemical Dependency (current alcohol and drug
  use)
• Housing instability
• Distrust/ Lack of disclosure

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Gender Issues and Adherence

• Depression
• Alcohol
• Mental health Treatment
• Low Educational Level
• Unemployment
• Absence of Social worker in Clinical center

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Late Testing Results in Missed Opportunitiesfor
Treatment and Prevention of HIV
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Importance of HIV Diagnosis

• Benefits to individual
• Influencing the course of infection
• Prevention of opportunistic infections
• Prevention of morbidity
• Prevention of mortality
• Benefits to others
• Prevention of transmission
• Ability to care for others

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Linkage to Care
Proud Woman Letwin Mugavezi
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Linking Person with HIV to Care

• One third of individuals aware of their HIV
  infection are not receiving care
• Possible reasons
• Fear, denial, stigma
• Substance use, mental illness
• Unaware of availability of care and treatment
• Lack of care programs
• Difficulty in access e.g. financial barriers,
  distance

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The Mosaic of Services
HIV PrimaryCare Adults Children
Mental Health
Womens Health
Social Support Counseling
Research
Harm Reduction
Adherence Support
Outreach
Peer Program
Nutrition
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Epidemiology of HIV in U.S.

• ? marginalized populations
• Blacks 50 of all new HIV/AIDS cases in 2003
• AIDS cases 1999-2003
• ? blacks, ? Latinos, ? whites
• ? 15 women, ? 1 men
• After AIDS dx, survival lowest in IDUs

CDC
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Rapid Spread of HIV among IDUs
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Injection Drug Use and HIV in the US

• 1.5 million injection drug users
• 800,000 in need of drug treatment
• 120,000 in treatment programs
• 10-30 with HIV disease
• 355,000 IDUs with HIV/AIDS
• 100,00 receiving HIV care
• Second highest risk for incident HIV infections
• 25 new HIV infections

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HIV and injecting drug use (2003)
(55)
No IDU reported
(22)
IDU without HIV
(114)
IDU and HIV
Source WHO Programme on Substance Abuse
98036-E-29 15 July 1998
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Principles of Harm Reduction

• Minimize harmful effects of drugs
• Success not necessarily abstinence
• Low threshold services
• Patient vs. provider agenda
• Addressing non-medical issues
• Redefine health, goals, and success/failure

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Risk (Harm) Reduction in Drug Users

• The chronic and relapsing pattern of drug misuse,
  wide array of serious medical consequences and
  increased HIV transmission risk require
  realistic, flexible and sustainable preventive
  risk reduction strategies.
• Risk reduction does not promote injection or
  non-parenteral drug use, but seeks to decrease
  the frequency of adverse events related to this
  practice.
• Successful risk reduction strategies are based on
  the underlying principle that injection and
  non-injection drug misuse is a medical illness
  which may not be cured in the individual or
  eliminated from society but can be conducted in a
  way that minimizes harm to the user and others.
• While complete cessation of drug use remains a
  laudable goal, reduction in drug use frequency
  and safer injection and non-injection practices
  is more realistic for many drug users until
  abstinence can be achieved.

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The Real World
STDs
Superinfection
Tina - Not Turner
transmitted resistance
HIV Fatigue!
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HIV Transmission Risk Behavior Among Active HIV
IDU in Clinical Care (n55)
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STD in HIV Persons
Incidence of STI in 1,350 STD clinic attendees
followed after initial HIV diagnosis 1993-8 in
Baltimore Erbelding J AIDS 2003
Further Primary HIV infection is common among
STD clinic attendees in high HIV prevalence
areas 5 of 476 HIV antibody negative men in
Malawi Pilcher AIDS 2005
See also Bachmann 2005, Taylor 2005
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Changing Causes of Death in the Era of ART,
1996-2002 (n5561)

• Death Rate-Total
• 1996 6.3/100 patient-years
• 2002 2.2/100 patient-years
• Death Rate due to OIs
• 1996 23/100patient-years (54 of all deaths)
• 2002 6/100 patient-years (28 of all death)
• CD4 Count Closest to Death
• 1996 65 cells
• 2002 148 cells
• Causes of death in 2002
• Opportunistic 28
• Non-Opportunistic 72
• Hepatic 36
• Cardiovascular 17
• Pulmonary 23
• Renal 10

Palella, HOPS DATA BASE, CROI 2004, 873
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Drug Names Scrabble Scores
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The Community Health Care Van
DAART Specialist
HIVPhysician
Drug Treatment Coordinator
Outreach Workers