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Untitled Prezi

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Jill Swan

on 30 January 2014

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Transcript of Untitled Prezi

Epidemiology
Almost 70 million people infected with HIV
35 million AIDS deaths

34 million people living with HIV at end 2011
Sub-saharan Africa accounts for 69% of people infected - almost 1 in 20 adults

Around 98,000 people living with HIV in UK
approx 42% in London
Jill Swan, Senior Pharmacist HIV/GUM
Chelsea and Westminster Hospital

An Introduction to HIV
& the role of the specialist pharmacist

History and Origin
Viral Replication
1981 - new epidemic described in USA

N Engl J Med. 1981 Dec 10;305(24):1425-31.Pneumocystis carinii pneumonia and mucosal candidiasis in previously healthy homosexual men: evidence of a new acquired cellular immunodeficiency.Gottlieb MS et al.

Lentivirus identified (subfamily of retroviruses)

Term HIV accepted in 1986
Transmission Routes
Unprotected sex with an infected person

Receiving a blood transfusion from an infected person

Vertical transmission

Sharing of needles/injection equipment
Fusion Inhibitors
Fuzeon (enfuvirtide, T20)

Entry Inhibitor
Binds to gp41
Subcutaneous injection
90mg bd
Celsentri (maraviroc)

CCR5 antagonist
Selectively binds to chemokine receptor CCR5
300mg bd
Susceptible to drug drug interactions
How does HIV cause AIDS?
Destruction of CD4 cells
What is a CD4 cell?
Cluster of Differentiation 4
T-helper cells
What is a normal CD4 range?
>500cells mm3
NRTIs
N
ucleoside/tide
R
everese
T
ranscriptase
I
nhibitors
First drug available to treat HIV infection
AZT (Zidovudine)
Often 'backbone' of therapy

Several now available
Abacavir (VL<100,000cp/ml)
Tenofovir
Emtricitabine
Lamivudine
Stavudine
Didanosine
Protease Inhibitors
Inhibiting viral protease
Usually 'boosted' with ritonavir
Drug interactions!
Monotherapy

Several available
Atazanavir
Darunavir
Lopinavir
Fosamprenavir
Saquinavir
Tipranivir
NNRTIs
N
on-
N
ucleoside
R
everse
T
ranscriptase
I
nhibitors


Efavirenz
Nevirapine
Etravirine
Rilpivirine
Case Study 1
Jane
34 year old female
Diagnosed 5 years ago
Infected via unprotected heterosexual sex
PHx: anaemia
DHx: nil
NKDA
Today's results
CD4 = 375
VL = 86,000

Should we start treatment?
Case Study 1
Jane
BHIVA guidelines recommend treatment when CD4 count reaches 350

Patient involvement

What do you start her on?
Kivexa vs Truvada
Third agent?
Case Study 1
Jane
Efavirenz 600mg on & Kivexa 1 tablet od

6/12 later:
VL < 40cpml, CD4 = 789
c/o nightmares, sleep disturbance

What should we do?
1. Reassure her that SEs will improve and to continue on her current regimen
2. Perform efavirenz TDM and consider reducing her dose
3. Switch her on to an alternative regimen
Case Study 1
Jane
3/12 later....

VL = 272
CD4 = 777

What's happened?
Not maintaining adherence
Taking something else
Developed resistance
Case Study 1
Jane
4/12 later.....

VL<40
CD4 = 762

c/o nausea and vomiting
When to start treatment?
BHIVA guidelines

Limits for starting ART have increased over recent years

Current guidelines, for established non-symptomatic HIV-1 injection are to treat once CD4 count reaches 350cpml

Many other considerations to take into account prior to starting therapy
What to start with?
Established HIV-1 infection in mono-infected adults

NRTI backbone - Truvada or Kivexa
3rd Agent - London policy is Efavirenz

Adherence is key - 95%
Risk of development of resistance
Patient involvement and preparation for starting ART
Co-morbidities
DHx
TasP
PEPSE
P
ost
E
xposure
P
rophylaxis following
S
exual
E
xposure

28 day

course of treatment
Kaletra and Combivir
Commenced with 72 hours of exposure
HIV test at point of presentation and 3/12 post
Consider DHx and potential for drug interactions

Sexual Health Clinic, A&E departments
What's the risk?
Generics
Patent expiry dates

Financial savings

Patient education

Post switch surveillance

Change from STRs?
Integrase Inhibitors
Raltegravir
400mg bd
Lack of drug interactions
Other integrase inhibitors in develoment
Objectives for the session
An understanding of the origin and history of HIV infection
An understanding of HIV replication in the host
An understanding of the drug classes available and how these are used (including current guidelines available)
Work through two case studies exploring treatment of HIV
An understanding of the role of the HIV specialist pharmacist
An understanding of strategies to reduce infection once a person has been potentially exposed to HIV
An appreciation of current research within the HIV field and recent developments
Case Study 2
James
51 year old MSM
New diagnosis
CD4 = 259
VL = 1.1 million
Although unsurprised by his diagnosis, is very anxious about starting treatment
PMHx: depression, hypertension
FHx: CV
DHx: Amlodipine 5mg od
Case Study 2
James
Should we start treatment?
What should we start with?
Counselling points
What support is available to James?
Case Study 2
James is admitted to hospital

PC: severe muscle pain, difficulty in walking

Investigations show: raised CK at 9300iu/L (range 40-320)

Normal renal and hepatic function
VL<40 and CD4=699

What is the cause of his raised CK?
James
NRTIs
Combination tablets formulated
Renal toxicity with tenofovir
Pharmacogenomics - Abacavir and HLA B*5701
STRs
2 x NRTIs plus 1 x NNRTI
Atripla
Eviplera
References
www.bhiva.org
www.aidsmap.com
www.hiv-druginteractions.org
www.medicines.org.uk
www.tht.org.uk
www.bmj.com
Questions
Side effects
Usually within 1/12 and are transient
Nausea and vomiting
Rash
Tenofovir - renal and bone toxicity
Abacavir - hypersensitivity
Stavudine/AZT - lipodystrophy
STRs (cont.)
Stribild

Tenofovir + Emtricitabine + Elvitegravir + Cobicistat

Key roles of HIV specialist pharmacist

Patient education
Adherence support
Management of drug/drug interactions
Working as a member of MDT
Financial reporting
Adherence to guidelines
Role in research, education and training
Latest addition.....

Dolutegravir

Licensed in UK Jan 2014
Plans for 'tri' pill in near future

HIV Pharmacy Service at C&W

Team of 7 specialist pharmacists
4 specialist pharmacy technicians (ACTs, plus rotational staff)
Outpatient services across 3 sites
Inpatient tertiary referral unit
Clinical trial workload
Directorate/MDT working
Full transcript