1. HIV treatment is::
Primary care with “benefits”

2. the scoop : :
• Guidelines Rule
• treat anyone who is willing
• compliance is KING
• beware of the drugs

3. DHHS Guidelines for the Use of
Antiretroviral Agents in HIV-1-Infected
Adults and Adolescents
www.aidsinfo.nih.gov

5. who to treat : :
• CD4 < 200, 350, 500, what next?
• treatment is prevention
– serodiscordant couples
– pregnancy
• think of the viral load of the community

6. who to treat::
Clinical Category CD4 Count Recommendation
AIDS defining illness or Any value TREAT
severe symptoms*
Pregnancy, HIVAN, Any value TREAT
tx HBV co-infection
Asymptomatic <350/mm3 TREAT
Asymptomatic 350-500/mm3 55% strongly
45% moderately
Asymptomatic >500/mm3 50% favored
50% optional
*http://www.aegis.com/topics/definition.html

7. HPTN 052

8. who not to treat::
• anyone who is not going to take their medicine
AKA: Non-compliance
It is really more like Why Not to treat
– when you know the details of a situation, the
situation is unchanged. when you don’t know the
details of a situation, it still is unchanged.
Zen proverb

9. how to treat::
• is this person sick?
• No

10. how to treat::
• is this person sick?
– CD4 < 200
– CD4 < 50
– Symptoms i.e. opportunistic infection

11. CD4 < 200
• At risk for PCP
• GI symptoms?
• Candidiasis?
• Rash?
• Needs meds as soon as ready

12. CD4 < 50
• This group of patients is TROUBLE
• Must look for OI’s, frequently more than 1
• IRIS is common
• TB is bad in this group, skin test not reliable
• 1/3 mortality in first year after diagnosis

13. what to use::

14. therapy naïve regimens::
• NNRTI based-regimen
– efavirenz/tenofovir/emtricitabine
• PI based-regimens
– atazanavir/ritonavir/tenofovir/emtricitabine
– darunavir/ritonavir/tenofovir/emtricitabine
• Integrase Inhibitor based-regimen
– raltegravir/tenofovir/emtricitabine
• Pregnancy
– lopinavir/ritonavir/zidovudine/lamivudine

15. how it works::
1. Fusion
2. Reverse transcription
3. Integration
4. Transcription
5. Assembly of virus particles
6. Budding of virus particles

16. efavirenz
• Category D, neural tube defects
– Recommend 2 birth control methods, negative HCG
prior to initiation
• Caution with use in prior psychiatric disease
• False + cannabinoid & benzos on screening
• AEs: Drowsiness, dizziness, insomnia, abnormal
dreaming, agitation
• Take at bedtime on an empty stomach to ↓CNS SE
• If need to eat, avoid taking with fatty food
• Rash is possible, as long as no other symptoms keep
taking meds but need medical eval ASAP

17. efavirenz rash

18. efavirenz rash

19. tenofovir/emtricitabine ::
• Generally well tolerated: gas, headaches
• Fanconi’s syndrome and renal insufficiency
• Check urinalysis every 6 months; PO4 suggested
• Hyperpigmentation possible
• Osteopenia
• Active against HBV
• Know pt’s status and counsel accordingly
• Once daily with or without food
• Both agents need renal adjustment when <50ml/min

20. Fanconi’s Syndrome::
• The Fanconi syndrome refers to a generalized
impairment in proximal tubular function
leading to urinary wasting of compounds
normally reabsorbed in the proximal tubule.
The consequences are hypophosphatemia
(which can lead to osteomalacia), renal
glucosuria, hypouricemia, aminoaciduria, and
proximal renal tubular acidosis due to
bicarbonate loss in the urine (Up To Date).

21. Preferred Protease Inhibitors

22. atazanavir/ritonavir
• Interacts with PPIs, antacids, & H2A
• All available OTC
• Increased unconjugated bili
• Scleral icterus or jaundice
• Take with food
• Less impact on lipids
• Prolonged PR interval, asymptomatic 1st degree
AV block
• 3 total: 1 atazanavir, 1 ritonavir, 1
tenofovir/emtricitabine

23. darunavir/ritonavir
• CAUTION with sulfa allergy (not contraindicated)
• Take with food
• Rash 10%
• Abdominal pain
• Headache
• Hepatotoxicity
• Diarrhea (usually less than Kaletra)
• 4 tablets total: 1 ritonavir, 2 darunavir, 1
tenofovir/emtricitabine

24. preferred integrase inhibitor::

25. raltegravir::
• Taken BID
• Minimal drug interactions
• PPI increases raltegravir
• AEs: diarrhea, nausea, headache, and pyrexia
• Increased ALT, AST, CPK possible
• Myopathy and rhabdomyolysis reported
• 3 tablets total: 1 raltegravir BID, 1
tenofovir/emtricitabine

26. compliance ::
• The tendency to yield to others especially in a
weak or subservient way
• The strain of an elastic body expressed as a
function of the force applied to it
• How many doses have you missed in the last
month?
• How many have you taken late?

27. compliance ::
• How many doses have you missed in the last
month?
• How many have you taken late?
• WHY?
• How can we improve this?

28. compliance ::
• 95% compliance is MINIMUM required to
receive maximal drug benefit
• 19/20 days or once per month for a once daily
drug
• compare self-report to pill counts
• works great with diabetes too

29. beware of the drugs::

30. bone disease::
• Osteoppenia
• Avascular Necrosis
• Vitamin D metabolism impacted
• Osteoporosis down the road?

31. AVN on the left

32. energy metabolism complications::
• Lactic acidosis
• Lipoatrophy
• Fat redistribution
• Hyperlipidemia
• Glucose intolerance
• Hypertriglyceridemia

33. Lipoatrophy

34. renal complications::
• Fanconi’s syndrome
• Stone disease

35. Fanconi’s Syndrome::
• The Fanconi syndrome refers to a generalized
impairment in proximal tubular function
leading to urinary wasting of compounds
normally reabsorbed in the proximal tubule.
The consequences are hypophosphatemia
(which can lead to osteomalacia), renal
glucosuria, hypouricemia, aminoaciduria, and
proximal renal tubular acidosis due to
bicarbonate loss in the urine (Up To Date).

36. Fanconi’s labs::
• Creat 1.0 ->1.4->1.2
• PO4 3.0 ->2.1->2.9
• Urine glucose 150-> neg
• Urine protein 100 mg/dl-> neg

37. resources::
• consult with US – AFCAHN, phone, email
• Guidelines
• Warmline is AWESOME
• Community providers