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HIV Treatment: An IntroductionOctober 20, 2013Dr. Joanna Eveland, MS, MDHIV Medical Director, Clinica Esperanza/Mission Neighborhood Health Center
Objectives
When, Why and What treatment to start
Overcoming side effectsWorking with your healthcare
providers to get the most out of treatment
When to start?
04/12/2023 Source: HRSA HIV/AIDS Bureau
2013 Treatment Guidelines
Antiretroviral therapy is recommended for all HIV+ individuals regardless of
CD4 count
Why Treat Early?
Prevent irreversible damage to the immune system
Reduce “Inflammation” to prevent heart disease, cancer, premature aging
Treatment is prevention
Reduce the size of the “HIV reservoir”, maybe making HIV easier to cure someday
Don’t start meds until…
You feel ready
You are well engaged in care
You can commit to taking your meds regularly
You feel that other life factors and potential barriers to adherence (drugs, drama, mental health) are under control
We have a long way to go…
What to start?
Where we started…
Where we are now…
Take Home Points
HIV treatment continues to improve- for the better!
Each person’s combination of medicines is different
KNOW what you take, and why
Know What You’re Taking
HIV drugs have two, sometimes three, different names Scientific name, brand name, chemical name
Zidovudine = Retrovir = AZT
Some tablets contain more than one ingredient Atripla = tenofovir + emtricitabine + efavirenz
Goal of Treatment
General Principles
Goals: less pills, less times/day, less side effects
Use at least 3 drugs, 2 classes of medicines
Treatment is individualized- 4 recommended 1st line combos, lots of alternate regimens
Sometimes 3 isn’t enough Your Protease Inhibitor may need a “Booster”
Drug resistance usually = more pills
Treatment Principles:Chinese Menu Metaphor
“Two scoops of rice plus chicken or beef”
In other words, usually
2 “nukes”(NRTI) (2 scoops of rice) plus– 1 partner drug (main dish)
Protease Inhibitor (beef)
“non-nuke” NNRTI (chicken)
The Drugs…
Each attacks the virus at a different point…
Where Do HIV Drugs Act?
NRTIs, “Nukes”
NRTIs Continued
Backbone of treatment
Older drugs are more toxic (AZT, “D-drugs”) Peripheral neuropathy
Lactic acidosis
Pancreatitis
Lipodystrophy
Watch kidney function with Tenofovir
NNRTIs, “Non-nukes”
NNRTIs: Pros and Cons
ADVANTAGES
Ease (low pill burden)
Well tolerated Less metabolic
effects No lipodystrophy, less
dyslipidemia
DISADVANTAGES
Resistance develops quickly if <95% adherent Single mutation
Cross resistance among NNRTIs
Rash; hepatotoxicity
Protease Inhibitors
PIs: Pros and Cons
ADVANTAGES
High potency
Once daily dosing for many
Less susceptible to resistance
Second-line therapy when NNRTI fails
DISADVANTAGES
Metabolic complications - Increased
cholesterol, blood sugar
GI side effects - Diarrhea, nausea
Drug interactions– Statins, viagra, anti-
seizure, many
Integrase Inhibitors
Integrase Inhibitors
3 agents- more to come!
Well tolerated, less metabolic effects and drug interactions than other classes
Can cause rash, hepatotoxicity
Entry Inhibitors
Entry Inhibitors
Currently used as salvage therapy for those with drug resistance
Fuzeon is injectable, rarely used
Maraviroc is well tolerated, requires CCR5 receptor on CD4 cells (not everyone has this)
More to come in this class
Once a day Fixed Dose Combos
Name Pros Cons
Atripla Lots of experience using it
• Neuropsych side effects• Don’t stop without planning
Complera Well tolerated • Only studied in treatment naïve
• Not for use if VL >100K• Take with food• Can’t take PPIs
Stribild Well tolerated • Only studied in treatment naïve
• Drug interactions• Watch kidney function• Nausea
Side Effects
Tend to be worst in the first 2 months of therapy
Severe side effects are a reason to change medications
Your expectations shape your experience
What If I Miss a Pill?
Risk of resistance increases with missing more than 1-2 doses/month
If you miss a dose, try and learn from it
If stopping your meds All or none
Let us know!
Working With Your Provider
You deserve great care
Find the right fit
Educate yourself
Be engaged in care- regular visits
Uninsured? You can still get care!
HIV and Aging
Focus on Wellness
Manage stress
Exercise regularly
Quit smoking
Reduce harmful drug or alcohol use
Build a supportive community
Define and achieve your personal goals
HIV Cure Research
Paths to an HIV Cure
Gene therapyBM Transplants
“Shock and Kill”
Theraputic vaccines
HIV infected cell suicide
Early/better treatment
Resources
Project Inform: 1-800-342-2437,http://www.projectinform.org/
AIDSmeds.comthebody.comHIVinsite.orgwww.aidsinfonet.org
Thanks
To you for taking care of yourself!
The advocates and activists who gave us these treatments
My patients
More Questions?
Dr. Joanna Eveland
Clinica Esperanza
240 Shotwell St., SF
(415) 431-3212 – Clinic Info
(415) 552-3870 # 303 –My extension