HIV patient care at a dermatology clinic

Transkriptio

1 HIV patient care at a dermatology clinic Annamari Ranki, Professor of Dermatology and Venereal Diseases, Chairperson, Helsinki University Hospital, Helsinki, Finland

2 UNAIDS World AIDS Day Report 2011

3 HIV infection remains of major public health importance with a steady number of cases reported

4 HIV-lääkitystä saavien potilaiden määrät eri maanosissa (WHO, UNAIDS 2010)

5 Characteristics of European HIV epidemic western Europe: stabile, 55 new cases/ million inhabitants; IDU, HBM, increase among heterosexuals eastern Europe: explosive increase since 1995 : 349 new cases/ mill. inhabitants, mostly young and IDU eastern Europe: 3/4 also have TBC!

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7 UNAIDS World AIDS Day Report 2011

8 HI-virus

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12 HI-virus

13 HIV budding

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15 Current HIV prevention behavioral messages on abstinence, faithfulness and condom promotion have had limited impact on HIV incidence rates in women, especially in sub-saharan Africa

16 Vaginal Gel Renews Hope for HIV/AIDS Prevention in Women A vaginal microbicide reduced chances of contracting HIV by 39 % in women who used it in about threequarters of their sexual encounters and by 54 % in women who used it consistently. The gel contains 1 % of the antiretroviral tenofovir (Viread or in Truvada). It was tested, starting in 2007, in a double-blind, randomized controlled trial of 889 sexually active women ages 18 to 40, in the KwaZulu-Natal province, which is "at the epicenter of South Africa's 'explosive' HIV

17 Voluntary medical male circumcision Voluntary medical male circumcision in countries with high HIV prevalence may be an option to reduce female-to-male sexual transmission Clinical trials in Kenya, South Africa and Uganda indicate that voluntary medical male circumcision reduces the risk of female-to-male sexual transmission by about 60%

18 Centers for Disease Control and Prevention Estimates of HIV Transmission Risk per 10,000Exposures to Infected Source Blood transfusion 9000 (90%) Needle-sharing injection-drug use 67 (0.67%) Receptive anal intercourse 50 (0.5%) Percutaneous needlestick 30 (0.3%) Receptive penile-vaginal intercourse 10 (0.1%) Insertive anal intercourse 6.5 (0.065%) Insertive penile-vaginal intercourse 5 (0.05%) Receptive oralintercourse 1 (0.01%) Insertive oralintercourse 0.5 (0.005%)

19 PEP = post exposure prophylaxis Occupational accidents Sexual exposure Aim to start <2h (<48-72h) Prophylaxis with 3 drugs for 4 wk PEP drugs should be kept available round-the the-clock in at least three locations (casualty,, ICU and labour room). Every hospital should have a written protocol and SOP for handling occupational exposure.

20 ? PEP = post exposure profylaksia otetaan HIV-vasta vasta- ainetesti ennen lääl ääkityksen aloittamista odotetaan vasta-ainetestin ainetestin tulosta lääkityksen kestoksi riittää kaksi viikkoa

21 PEP = post exposure profylaksia

22 NPEP guideline, Finland Arvo webpage Recommned if the exposure is considerable and if the person seeks care within 72 hours of exposure First check that the exposed person is HIV negative Duration of PEP is 28 days

23 PEP flow-chart

24 HIV-infektion diagnostiikka vasta-ainetesti: ELISA ja immunoblot varmennus positiivinen 2-4 viikkoa tartunnasta HIVAgAB, tunnistaa myös HIV-antigeenin (proteiini), voi olla + tai alussa viremian ja hoidon seurantaan : phivnh (RNA-kopioiden määrä/ml verta)

25 Tapauksia nainen 20v Gc:-, Card -, klamydia HIVAgAb: vasta-ainetestin tulos raja-arvoinen

26 ? Miten menetellään? 1. otetaan HIV antigeenitesti 2. odotetaan 2 viikkoa ja otetaan uusi testi 3. mahdollinen ristireaktio, etsitään autoimmuunitautia

27 Miten menetellään?

28 Characteristics of HIV infection at individual level chronic, prolonged course infected individuals asymptomatic but infectious no cure but effective treatment with combination drugs: costs ca / yr life expectancy: comparable to that of cancer patients successfully treated

29 B-T-CD4: CD4-solujen tuhoutuminen HIVinfektiossa

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31 In early SIV and HIV-1 infections, GALT, the largest component of the lymphoid organ system, is a principal site of both virus production and depletion of primarily lamina propria memory CD4+ T cells. (Li et al, Nature 2005)

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33 Terve nuori mies, ei atopia-anamneesia, ei psoriasista suvussa phiv copies/ml ; CD4 cells x109/l,

34 Kuvan iho-oire on

35 ? Kuvan iho-oire on? 1. acne 2. primaari HIV-infektio 3. sekundaari-lues

36 Kuvan iho-oire on?

37 Tuore HIV-tartunta

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40 ? Kuvan käsi-ihottuma voi liittyä 1. sekundaari-lues 2. id-reaktio silsasieneen liittyen 3. primaari HIV-infektio

41 Kuvan käsi-ihottuma voi liittyä

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44 Mitä näet? Dg-vaihtoehdot?

45 ? Suun limakalvolla näkyy 1. proteesistomatiitti 2. normaali limakalvo 3. atrofinen hiivainfektio

46 Suun limakalvolla näkyy

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48 Mikä HIV-infektion vaihe?

49 Tuumorimainen muutos iholla

50 ? Tuumorimainen muutos on 1. basalioma 2. molluscum contagiosum 3. ihon histoplasmoosi

51 Tuumorimainen muutos on

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53 Hairy leukoplakia huono ennusmerkki

54 Tinea

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62 Terve nuori mies, jolla kuvan ihottuma mitä pitää epäillä?

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64 HAART= highly active antiretroviral therapy significantly decreases the morbidity of HIV-infected individuals NRTI= nucleoside analogues, reverse transcriptase (RT) inhibitors NNRTI = non-nucleoside RT inhibitors PI= protease-inhibitors fusion inhibitors (enfuvirtide) 31 licensed drugs antiretroviral drugs inhibit HIV replication and infection of new host cells but do not provide complete cure

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66 Can HAART be interrupted? - structured treatment interruption interruption of HAART results in viral rebound within the next 1-6 months HIV primary syndrome may reappear resistant mutants may develop significant CD4 cell decline may follow (Lawrenve J et al., NEJM 2003, Alexander TH et al., J.AIDS 2003)

67 The effect of HAART interruption on HIV viral load after 5 years of successful therapy CD x10 9 /l HAART stopped CD x 10 9 /l Dec Jan Feb 04

68 Case with HIV since 1987, now on HAART and leads normal life phiv RNA / ml ZDV+lamiv+indinav CD4 cells Feb 2000 prophylaxis: TMP-SMX Apr

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71 Optimal outcome of the HAART therapy no disease progression undetectable viral load, increase or stabilizisation of CD4 cell values no side-effects necessitating change of drug patients with earlier category B symptoms become asymptomatic even some patients with earlier opportunistic infections (category C) improve their immune status and no longer need secondary prophylaxis for the opportunistic infections

72 When to start antiretroviral therapy? the patient has to be motivated -> incompliance increases the risk of resistant virus strains recommended choice: e.g. emtrizitabine + tenofovir (Truvada) + efavirenz (NNRTI) adverse reactions usually during the first 2-6 weeks of therapy indicated when CD4 cell values decrease to 0,350 x 10 9 /l and/or phiv load > copies/ ml

73 Do not start HAART if the patient is not ready to adhere to therapy! Adherence to drugs Viral load decreased 90% 100% 70% 48% < 70% 23% * in the US, about 50% of patients viral suppression is incomplete cross-resuistance between the ARV drugs!

74 Voidaanko HIV eradikoida elimistöstä?

75 HAART therapy may be associated with severe skin reactions NRTI: AZT, lamivudine, abacavir,ddc nail and hair alterations, mucocutaneous pigmentation, vasculitis and severe hypersensitivity reaction (abacavir) NNRTI: efavirenz, nevirapine, delaviridine, loviride nevirapine: rash in up to 32%; hypersensitivity syndrome (fever, maculopapular rash and hepatitis) in 7% > efavirenz SJS and TEN in 0.3% of nevirapine patients PI: indinavir, nelfinavir, ritonavir, saquinavir, amprenavir, lopinavir maculopapular rashes (morbilliform) and urticaria; ritonavir: hypersensitivity reactions; alopecia, paronychia SJS and TEN associated with amprenavir

76 AIDS patients have x 10 3 higher risk of severe cutaneous reactions TMP-SMX, anticonvulsants, allopurinol antiretroviral drugs (ARV) discuss in detail the administration and toxicity of the ARV drug with your patient

77 A drug eruption or something else 32-year old man, visited St.Petersburg a year ago to find a wife -> got HIV infection instead on HAART therapy for 4 months now recent muscle pain, malaise, no fever basic laboratory tests normal except for CRP 46, which raised to 53 two weeks later received ibuprofen for muscle pains thereafter a rash (next slide) further examinations revealed normal muscle enzyme levels, normal chest and NSO x-ray but SR was 100

78 Future: vaccination in venereology

79 UNAIDS World AIDS Day Report 2011