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04/09/2013
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Living with HIV in 2013
A Good Prognosis
David M. Mushatt, MD, MPH&TM
Chief, Adult Infectious Diseases Section
Director, Adult ID Fellowship Training Program
Tulane University School of Medicine
Objectives
1. Become familiar with the epidemiology and trends in HIV
infection
2. Become familiar with the latest treatment approaches in HIV
infection
3. Be knowledgeable about the impact of combination
antiretroviral therapy (HAART) on mortality and longevity in
HIV
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Awareness of HIV Status among
Persons with HIV in US
� Number HIV infected: 1,106,400
� Number unaware of
their HIV infection: 232,444 (21%)
� Estimated new 56,300 (1 every 9.5 minutes)
infections annually:
CDC: August 2009
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WHO – HIV department | September 4, 201310 |
2011||||Global Summary of the AIDS Epidemic
34.0 million [31.4–35.9 million]
30.7 million [28.2–32.3 million]
16.7 million [15.4–17.6 million]
3.3 million [3.1–3.8 million]
2.5 million [2.2–2.8 million]
2.2 million [1.9–2.4 million]
330 000 [280 000–390 000]
1.7 million [1.5–1.9 million]
1.5 million [1.3–1.7 million]
230 000 [200 000–270 000]
Number of people
living with HIV
People newly infected with HIV in 2011
AIDS deaths in 2011
Total
Adults
Women
Children (<15 years)
Total
Adults
Children (<15 years)
Total
Adults
Children (<15 years)
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WHO – HIV department | September 4, 201311 |
New HIV Infections and AIDS-Related Deaths, 1990–2011P
eo
ple
New HIV infections
AIDS-related deaths
0
500 000
1 000 000
1 500 000
2 000 000
2 500 000
3 000 000
3 500 000
4 000 000
4 500 000
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Globally new HIV infections peaked in 1997
WHO – HIV department | September 4, 201312 |
Total: 34.0 million [31.4 million – 35.9 million]
Western & Central Europe
900 000[830 000 – 1.0 million]
Middle East & North Africa300 000
[250 000 – 360 000]
Sub-Saharan Africa23.5 million
[22.1 million – 24.8 million]
Eastern Europe & Central Asia1.4 million
[1.1 million – 1.8 million]
South & South-East Asia4.0 million
[3.1 million – 5.2 million]
Oceania53 000
[47 000 – 60 000]
North America1.4 million
[1.1 million – 2.0 million]
Latin America1.4 million
[1.1 million – 1.7 million]
East Asia830 000
[590 000 – 1.2 million]
Caribbean230 000
[200 000 – 250 000]
Adults and Children Estimated to be Living with HIV |||| 2011
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Human
T-Lymphotropic
Retroviruses(C-Type Particle Assembly)
HTLV - I
HTLV - II
HTLV - III(renamed HIV)
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AIDSinfo/DHHS
HIV Life Cycle
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Months after
Infection
Years after Infection
Generalized Time Course of HIV Infection and Disease
MMWR 47 (RR-5): April
1998
CD
4
cells
/mm
3
Opt-Out HIV Screening
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CDC Recommendation for HIV Testing in Adults and Adolescents
• Routine, voluntary, HIV screening for all persons aged 13–64 years, not based on risk
• Opt-out HIV screening• Opportunity to ask questions and
option to decline
• Consent for HIV test is part of general consent for care
• Separate consent not recommended
• Prevention counseling not required in conjunction with HIV screening
• Low-prevalence setting• If yield from screening <0.1%,
continued routine screening not warranted
Branson BM et al. MMWR Recomm Rep. 2006;55(RR-14):1-17.
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Opportunistic Infections
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Intermediate Disease: CD4 200-500
� Start to see HIV-related conditions:� Oral hairy leukoplakia, thrush
� Recurrent vaginal candidiasis
� HSV, shingles, skin conditions
� Recurrent bacterial infections as well as TB and KS
� Often completely asymptomatic
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Insert slide with picture of
OHL
Insert slide with picture of
thrush
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Kaposi’s
Sarcoma
� Homosexual and
bisexual men
� Associated with HHV-8; is multifocal and can be limited to skin or disseminated
CDC/ Sol Silverman, Jr., D.D.S., University of California, San Francisco
CDC/ Dr. Steve Kraus
AIDS: CD4 < 200
� Start to see AIDS-related infections and cancers:
� Opportunistic infections� PCP pneumonia, etc
� Opportunistic cancers� Non-Hodgkin’s Lymphoma (NHL)
� Kaposi’s Sarcoma
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Pneumocystis Pneumonia (PCP)
� Caused by the fungus, Pneumocystis jiroveci
� Symptoms� Triad of:
� Shortness of breath
� Dry cough
� Fever
� Treatment� Trimethoprim-sulfamethoxazole
� Pentamidine
� Clindamycin + primaquine
Candida Esophagitis
� Caused mostly by Candida
albicans
� Symptoms� Thrush
� Difficulty swallowing
� Pain on swallowing
� Treatment� Fluconazole
� Amphotericin B
slackbooks.com
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Advanced AIDS: CD4 < 50
� Increased frequency of AIDS-defining conditions
� CMV retinitis, disseminated MAC
CMV Retinitis
� Cytomegalovirus
� Reactivation in the retina when CD4 < 50
� Causes visual disturbances, blindness
� Treatment� IV ganciclovir/IV foscarnet
� Oral valganciclovir
� Intraocular ganciclovir implants
www.utsouthwestern.edu/utsw/cda/dept28050/files/63964.html
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The Road to Good Health
Highly Active Antiretroviral Therapy
HAART
cART
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http://aidsinfo.nih.gov/guidelines
Current Antiretroviral Medications
NRTI� Abacavir ABC
� Didanosine DDI
� Emtricitabine FTC
� Lamivudine 3TC
� Stavudine D4T
� Zidovudine ZDV
� Tenofovir TDF
NNRTI� Efavirenz EFV
� Nevirapine NVP
� Etravirine EVR
� Rilpivirine
CCR5 Co-Receptor Antagonist� Maraviroc MVC
PI� Atazanavir ATV
� Darunavir DRV
� Fosamprenavir FPV
� Indinavir IDV
� Lopinavir LPV
� Nelfinavir NFV
� Ritonavir RTV
� Saquinavir SQV
� Tipranavir TPV
Fusion Inhibitor
� Enfuvirtide T-20
Integrase Inhibitors� Raltegravir
� Elvitegravir +cobicistat
� Dolutegravir
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AIDSinfo/DHHS
Entry Inhibitors
Maraviroc
Integrase Inhibitors
Raltegravir
February 2013 www.aidsetc.org
Initial Treatment: Preferred
NNRTI based �EFV/TDF/FTC1,2
PI based �ATV/r + TDF/FTC²
�DRV/r (QD) + TDF/FTC²
II based �RAL + TDF/FTC²
Pregnant women �LPV/r (BID) or ATV/r + ZDV/3TC²
1. EFV should not be used during the first trimester of pregnancy or in women trying to conceive or not using effective and consistent contraception.
2. 3TC can be used in place of FTC and vice versa.
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0
5
10
15
20
25
30
35
40
1995 1996 1997 1998 1999 2000 2001
Death
s p
er
100 p
ers
on
-years
0
25
50
75
100 Perc
en
tag
e o
f patie
nt-d
ays o
n A
RT
DEATHS
USE OF HAART
Mortality vs. ART utilization
Palella F et al. 8th CROI 2001; abstract 268b.
AIDS Mortality Rates: 1996-2001
Slide by M. Glesby
One Pill a Day
= FTC + Tenofovir + Efavirenz (Atripla)
FTC + Tenofovir + Rilpivirine
Cobicistat + Elvitegravir + FTC + Tenofovir
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HAART Treatment Goals
� HIV RNA < 50 copies by 6 months
= Undetectable
� Immune restoration
Tenofovir + FTC + Efavirenz
vs.
ZDV + 3TC + Efavirenz
Antiretroviral-Naïve Patients
J Gallant. NEJM 354:251, 2006.
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Immune Restoration
Median CD4
Median ∆ CD4
Copyright © 2009 Wolters Kluwer. Published by Lippincott Williams & Wilkins. JAIDS 2007;45:183-92
Lohse, N. et. al. Ann Intern Med 2007;146:87-95
Survival from Age 25 Years
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Shiels M S et al. JNCI J Natl Cancer Inst 2011;103:753-762Published by Oxford University Press 2011.
ADC number and incidence
in AIDS in USA 1991-2005
Kaposi’s sarcoma
NHL
Cervical Cancer
Accelerated Aging
� Due to
� chronic inflammation
� medications
� CAD, osteoporosis, frailty
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From DA Wohl, MD, at New York, NY: May 03, 2012, IAS-USA
Cognitive Impairment in HIV
HIV Infection
HIV Asymptomatic
Neurocognitive
Impairment
Mild
Neurocognitive
Disorder (MND)
HIV-associated
Dementia
(HAD)
Victor G. Valcour, MD
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Non-AIDS Complications
� Diabetes� PIs cause insulin resistance/metabolic syndrome
� Dyslipidemias� HIV and/or ARVs are a CAD risk factor
� Lipodystrophy
� Liver disease� Due to hep C
� Kidney disease� Due to HIV-associated nephropathy (HIVAN)
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Facial lipoatrophy
Central adiposity
Peripheral lipoatrophy
Breast enlargement
Dorsocervical Fat Pad
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Valantin MA et al. AIDS 2003, 17:2471–2477
Categorizing Cancers in PWHA
• AIDS-defining Cancer (decreasing)
– KS
– NHL (BL, CNS, DLCBL)
– Cervical Cancer (added in 1993)
• Non-AIDS-defining Cancers (increasing)
– Anal Cancer
– Lung Cancer
– Hodgkin Lymphoma
– Liver Cancer
• Unchanged Incidence
– Breast
– Colorectal
– Prostate
– Follicular lymphomaFrom RT Mitsuyasu, MD, at San Francisco, CA: March 29, 2013, IAS-USA
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Life Expectancy of HIV-Positive Patients
• Comparison of life expectancy of Athena cohort patients to general population (n=4,174)
• Expected life years remaining at age 25 was 53.1 (44.9-59.5) for general population and 52.7 for asymptomatic HIV+ patients
• The modeled life expectancy of patient presenting at an older age and women were slightly lower that general population
General Population
Asymptomatic HIV+ Patients
Years of Life Remaining
Age at time of death
Remaining Life Years
Age at 24 weeks (years)
Yea
rs l
ive
d
van Sighem A, et al. 17th CROI; San Francisco, CA; February 16-19, 2010. Abst. 526.
A 35 yo man, non-IDU, diagnosed with HIV starting HIV therapy at CD4>200 can expect to live into his 70’s
ART-CC, The Lancet , 2008, 372:293-299
From DA Wohl, MD, at New York, NY: May 03, 2012, IAS-USA
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Life Expectancy Estimates at Age 20
Life Expectancy Estimates at Age 20
Hogg RS, et al: IAS 2013, poster TUPE260
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Age Distribution of HIV in the US
Extrapolation of CDC data through 2008Victor G. Valcour, MD
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