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Slide 1: HIV/AIDS Pascale Gèhy-Andrè PA-C
Slide 2: Infection with HIV is Associated with many complications including:  Social  Emotional  Neuro-Phychiatric  Spiritual 
Slide 3: Epidemiology      Heterosexual transmission accounts for 75% of all HIV infections worldwide 40 million infected with HIV worldwide Worldwide one in every 100 adults aged 15 to 49 is HIV Infected Leading cause of death among all Americans age 25-44 41% or 29.5 million adults with HIV/AIDS worldwide are women
Slide 5: Overview-Modes of Transmission Blood products  IVDA- sharing needles  Sexual contact- via exchange of body fluids anal oral penile- vaginal  Accidental needle sticks 
Slide 6:  Phychosocial Impact of HIV-AIDS • • • • • Anxiety Discouragement Discrimination Change in Social Status Coggnitive Dysfunction
Slide 7: Prevention    Cultural and Behavioral Diversity Establishing Comprehensive HIV Prevention Program Promotion of Condom use. www. Condomdirectory.com     Drug use interventions-risk reduction Needle Exchange Education Refer to support groups
Slide 8: ROUTINE LABORATORY TESTS HIV + serology  CBC  VDRL or RPR  Viral Load  Chest X-ray  Chemistry panel  Hepatitis serology  CMV serology Toxoplasma IgG Pap Smear PPD test Cd4 count
Slide 9: History Mode of transmission  Recent CD4 count if known  Any other chronic diseases  Any recent hospitalizations  Allergies  Sexual practices  Medications 
Slide 10: Physical Exam Vitals- weight, body habitus  Bi-temporal wasting  Skin- any lesions  Mouth- oral thrush, leukoplakia  Lymphadenopathy- cervical, axillary, inguinal  Ophthalmologic exam  Neurological and Dementia Scale 
Slide 11: PSYCHIATRIC COMPLICATIONS DRUG EFFECTS  DEPRESSION  ANXIETY  DELIRIUM  MANIA  PSYCHOSIS  HIV ASSOCIATED DEMENTIA 
Slide 12: Counseling of HIV Patients Once diagnosed patient should be offered counseling.  Clinician should :  Be emphatic  Alert to emotional response  Provide information and emotional support. 
Slide 13: When To Initiate Therapy Acute HIV or < 6 months after seroconversion  Symptomatic (AIDS, thrush, unexplained fever)  Asymptomatic- CD4 + T Cells <500/mm3 HIV RNA>10,000 (bDNA) or >20,000 (RT-PCR) 
Slide 14: Continued  Asymptomatic -CD4+ T Cells>500/mm3 and HIV RNA <10,000 (bDNA) or <20,000 (RT-PCR) Many experts would delay therapy and observe; however, some experts would treat. Some experts would observe patients with CD4+ T cell counts of 350-500/mm3 and HIV RNA levels <10,000 (bDNA) or <20,000 (RT-PCR).
Slide 15: ANTIRETROVIRAL THERAPY: DRUGS Nucleosides Analogues (NRTIs) -Zidovudine, AZT, Retrovir -Videx-(ddI) -HIVID-(ddc) -Zerit, Stavudine, (d4t) -Lamivudine-(Epivir, 3TC -Combivir -Abacavir -Adeforvir Protease Inhibitors (Pis) Saquinivir (Invirase) FortovaseRitonavir -Norvir Indinavir-Crixivan Nelfinavir-Viracept Non-Nucleoside RT Inhibitor(NNRTIs) Nevirapine-Viramune Delarvidine-Rescriptor Efavirenz-Sustiva 300mg bid or 200mg tid 200mg bid 0.375 &0.75 mg tabs 40mg bid 150mg bid 1 tab bid 300mg bid 60 mg or 120mg qd 600mg tid 1200mg tid 600mg bid 800mg tid 500-750mg tid 200mg p0 qd x 14 days, then 200mg bid 400mg tid 600mg qd Empty stomach With a high fat meal Escalating dose; refrigerate Empty stomach or light meal With meals
Slide 16: INITIAL DRUG REGIMEN Preferred: 2NRTIs + protease inhibitor or 2NRTIs + NNRTI  Alternatives for selected patients: 2 NRTIs plus Efavirenz  Abacavir plus 2 NRTIs  Minimal/suboptimal therapy: monotherapy (except in pregnancy) 
Slide 17: INITIAL REGIMEN (CONT’D)       Column A Indinavir Nelfinavir Ritonavir Ritonavir + Saquinavir Saquinavir (Fortovase) Amprenavir      Column B AZT +ddI d4t +ddI AZT +ddC AZT +3TC d4t + 3TC
Slide 18: WHEN TO CHANGE THERAPY The goal of therapy is to reduce the level of HIV RNA to as low a level as possible for as long as possible.  Virologic failure is defined as a viral burden of >500 copies/ml at 4-6 months after starting a new regimen. 
Slide 19: What to Change To  Prior regimen 2 NRTIs +PI      2 NRTIs + nevirapine 2 NRTIs    New Regimen 2 new NRTIs + PI 2 Pis +/- NRTI PI + Nevirapine +>1 new NRTI 2 new NRTIs + a PI 2 new NRTIs + PI 2 new NRTIs +Ritonavir +Saquinavir
Slide 20: Questions to ask before starting a new drug. What is the patient taking? Prescription or nonprescription  Can you and the patient identify what drugs the patient is taking?  How confident are you that the patient is taking the drugs prescribed?  Does the pt. Understand the effects and side effects of all medications they are taking? 
Slide 21: THE “RED FLAG “ LIST P450 INHIBITORS  P450 INDUCERS  METABOLIZED DRUGS WITH NARROW THERAPEUTIC INDICES  RENALLY CLEARED DRUGS WITH NARROW THERAPEUTIC INDICES  DRUGS WITH SPECIFIC REQUIREMENTS FOR ABSORPTION  
Slide 22: ORAL THRUSH
Slide 23: ORAL HAIRY LEUKOPLAKIA
Slide 24: CHEST X-RAY- PNEUMOCYSTIS CARINII PNEUMONIA
Slide 25: ANAL - PENILE CONDYLOMATA
Slide 26: MULTIDERMATOMAL HERPES ZOSTER
Slide 27: VULVO-VAGINAL ANAL WARTS
Slide 28: Summary       ESTABLISHING A TRUSTY PA -PATIENT RELATIONSHIP IS IMPORTANT EACH VISIT STRESS ADHERENCE TO MEDICATION AND SAFE SEX PRACTICES KNOW ALL DRUGS PATIENT IS TAKING MONITOR BLOOD WORK AT LEAST 3-4 MONTH INTERVALS UPDATE YOURSELF ON ALL RELEVANT NEW INFORMATION ON HIV THERAPY. LOG ON www. Anybody.com ! IF YOU NEED HELP DON’T BE AFRAID TO ASK FOR A