Prevention of HIV

The World Health Organization publishes a set of comprehensive guidelines to the prevention of HIV and AIDS; the most recent version was published in 2010. I’ve tried to distill down the 174-page document here. It’s especially interesting to see how treatment and prevention come together as research has demonstrated that ARV treatment reduces the risk of transmission.

Know your HIV status

·       Client-initiated HIV testing and counseling

·       Provider-initiated HIV testing and counseling

·       Blood donor HIV testing and counseling

·       Laboratory support

Prevent sexual transmission of HIV

·       Promote condom use

·       Detect and manage STIs

·       Risk reduction counseling

·       Male circumcision

·       Prevention among those living with HIV: ARV treatment

·       At-risk populations: interventions targeting sex workers, MSM & transgendered, adolescents

·       Vulnerable populations: interventions targeting displaced, mobile, and migrant populations; prisoners

·       Post-exposure prophylaxis

Prevention in intravenous drug users (IDUs)

·       Needle exchange programs

·       Drug treatment

·       Information, education, and communication

Prevention in childbearing women, infants, children

·       Family planning, counseling, contraception

·       ARV treatment in pregnancy to prevent infection in infants

·       Education and support for women living with HIV and their children and families

Treatment scale-up

·       Intervene to prevent illness

o   Cotrimoxazole prophylaxis (vs. PCP and toxoplasmosis)

o   Prevent fungal infections

o   Vaccinations

o   Nutritional care and support

o   Safe water, sanitation, and hygiene

o   Prevent malaria

Treatment proper

·       ARV for adults, adolescents, and children; support monitoring and adherence

·       Manage opportunistic infections and conditions

·       Palliative care

·       TB prevention, diagnosis, and treatment

Strengthen health systems to optimize priority interventions

·       Increase service delivery

·       Strengthen health workforce

·       Support development and dissemination of medical products and technologies

·       Improve financing, leadership, and governance

Invest in strategic information

·       Strengthen health informatics

·       Improve surveillance of HIV and STIs

·       Monitor and evaluate the health sector response

·       Research

·       Analyze and implement evidence-based improvements

Reference:

World Health Organization (2010). Priority interventions: HIV/AIDS prevention, treatment, and care in the health sector. Retrieved November 2011 from: http://www.who.int/hiv/pub/guidelines/9789241500234/en/index.html

Side Effects of HIV Treatment

I am a little confused this week. Some of us are posting about prevention and some about side effects of treatment. But here I go with...

 

Side Effects of HIV Treatment

The NIH has a handy booklet detailing the major side effects of HIV medications. I’ll address only those medications recommended by WHO in this post.

As a refresher, the WHO medications are four nucleoside reverse transcriptase inhibitors (emtricitabine, lamivudine, tenofovir, and zidovudine) and two non-nucleoside reverse transcriptase inhibitors (efavirenz and nevirapine).

Hepatotoxicity (includes hepatitis, hepatic necrosis, and hepatic steatosis)

Signs and Symptoms

·       Elevated liver enzymes (ALT, AST, GGT)

·       Nausea/vomiting

·       Abdominal pain

·       Loss of appetite

·       Diarrhea

·       Feeling tired or weak

·       Jaundice

·       Hepatomegaly

Implicated Meds

NRTIs and NNRTIs (i.e., all WHO-recommended meds)

Likely Treatment

Stop or change meds

Lactic Acidosis

Signs and Symptoms

·       Low blood pH

·       Persistent nausea, vomiting, and abdominal pain

·       Unexplained tiredness

·       Shortness of breath

·       Rapid breathing

·       Enlarged or tender liver

·       Cold or blue hands or feet

·       Abnormal heartbeat

·       Weight loss

Implicated Meds

NRTIs, although the two prime suspects (stavudine and didanosine) are not on WHO’s list.

Likely Treatment

Medical emergency, likely hospitalization with IV fluids and potential respiratory support. Stop meds.

Lipodystrophy

Signs and Symptoms

·       Maldistribution of fat

·       Accumulation (buffalo hump, potbelly, breasts, lipomas)

·       Loss (face, arms/legs, buttocks)

Implicated meds

NRTIs, NNRTIs, with stavudine the prime suspect (not on WHO’s list).

Likely Treatment

Med change, diet/exercise to build muscle and reduce fat

Skin Rash

Emergency Signs and Symptoms of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)

·       Red spots with blisters in the center

·       Blisters in moist areas of body

·       Peeling skin leaving painful sores

·       Fever

·       Headache

·       General feeling of illness

Implicated meds

NRTIs, NNRTIs. Nevirapine (WHO) and abacavir (not WHO) most often implicated.

Likely Treatment, Mild

Med change, antihistamine.

Likely Treatment, Severe

Emergency. Hospitalization, likely in a burn unit.

The booklet also mentions three side effects which are associated only with protease inhibitors (which are not recommended by WHO): hyperglycemia, hyperlipidemia, and bone disorders (osteonecrosis, osteopenia, and osteoporosis).

References

U.S. Department of Health and Human Services (2005). Side effects of anti-HIV medications. Retrieved November 2011 from: http://www.aidsinfo.nih.gov/ContentFiles/SideEffectAnitHIVMeds_cbrochure_en.pdf

If, like me, you find the alphabet soup of generic names, brand names, and combination drugs mystifying, the FDA has a terrific chart that breaks it all down:

http://www.fda.gov/ForConsumers/byAudience/ForPatientAdvocates/HIVandAIDSActivities/ucm118915.htm

Treatment Guidelines for HIV Infection

The World Health Organization has eight key recommendations for treatment of HIV infection.

Recommendation 1: When to start antiretroviral treatment

1.    Any patient with HIV infection and a CD4 count less than 350, regardless of clinical symptoms, should start treatment.

2.    Any patient with HIV infection and a WHO clinical stage 1 or 2 disease should have CD4 testing done to see whether #1 applies.

3.    Any patient with HIV infection and a WHO clinical stage 3 or 4 disease should start treatment, no matter the CD4 count.

Recommendation 2: What treatment to start

·      AZT + 3TC + EFV
(zidovudine, lamivudine, efavirenz)

·      AZT + 3TC + NVP
(zidovudine, lamivudine, nevirapine)

·      TDF + 3TC or FTC + EFV
(tenofovir disoproxil fumarate + lamivudine or emtricitabine + efavirenz)

·      TDF + 3TC or FTC + NVP
(tenofovir disoproxil fumarate + lamivudine or emtricitabine + nevirapine)

Recommendation 3: How to use ART in HIV/TB co-infection

1.    Initiate ART in all patients with HIV and active TB, no matter the CD4 count.

2.    Start with TB treatment, follow closely with ART.

3.    Use one of the above drug combinations that includes EFV (efavirenz).

Recommendation 4: How to use ART in HIV/HBV co-infection

1.    Initiate ART in all patients with HIV and HBV requiring treatment, no matter the CD4 count or WHO clinical stage.

2.    Use one of the above drug combinations that includes TDF (tenofovir).

Recommendation 5: How to use ART in pregnant women

1.    Initiate ART in all pregnant women with HIV infection and a CD4 count less than 350, regardless of clinical symptoms.

2.    Any pregnant women with HIV infection and a WHO clinical stage 1 or 2 disease  should have CD4 testing done to see whether #1 applies.

3.    Any pregnant woman with HIV infection and a WHO clinical stage 3 or 4 disease should start treatment, no matter the CD4 count.

4.    Use one of the regimens listed in Recommendation 1.

5.    Do not use EFV during the first trimester of pregnancy.

Recommendation 6: When to switch ART

1.    Use viral load measure to confirm treatment failure.

2.    Use viral load measure every six months to detect viral replication.

3.    Treatment failure is confirmed at a persistent viral load > 5000.

4.    If viral load measure is not available, use immunological criteria instead.

Recommendation 7: Second-line ART

1.    Use a boosted protease inhibitor (PI/r) plus two nucleoside analogues (NRTIs).

2.    The preferred boosted PIs are ATV/r (atazanavir) and LPV (lopinavir).

3.    Use simplified NRTI options:

·      If d4T (stavudine) or AZT was used first-line, use TDF + 3TC or FTC in their place.

·      If TDF was used first-line, use AZT + 3TC in its place.

Recommendation 8: Third-line ART

1.    Policies should be determined by national agencies according to funding, sustainability, and equitable access.

2.    Use new drugs such as integrase inhibitors and second-generation NNRTIs and PIs.

3.    A patient who fails a second-line regimen and has no new drug options should continue with a tolerable regimen.

Source: World Health Organization (2009). Rapid advice: antiretroviral therapy for HIV infection in adults and adolescents. Retrieved November 2011 from: www.who.int/hiv/pub/arv/advice/en/index.html