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Future LGBTQ+ Healthcare Sessions th • 4 February – Sexual Health • 12 February – Transgender Health • 19 February – Reproduction and Fertility • 26 February – Dermatology • 5 March – Children and Elderly • 12 March - Mental Health • 19 March – Social Factors th • 26 Match – Communication Skills nd • 2 April – Inclusivity th • 9 April – Q and AHIV in Clinical Practice DR STUART RASHBROOK (FY1) HE / HIMOutline of Session  A brief history of HIV and some key statistics  The HIV / AIDS crisis of the 1980s  Pathophysiology and transmission  The course of disease and AIDS-defining illnesses  Testing, treatment and monitoring  Adverse effects of treatment  Additional management  Prevention: PREP and PEP Extra: prevention during pregnancyA Brief History of HIV  Old world monkeys are naturally infected with simian immunodeficiency viruses  Some of these have crossed the species barrier  HIV-1 can be traced back to 1910- 30, emerging in colonial West Africa  in 1983s first reported in 1981, HIV • Improving life expectancy in people on early ART • A significant proportion diagnosed late: Key Statistics • A late HIV diagnosis is defined as a CD4 count <350 cells/mm3 within three months of diagnosis Globally • This is most likely to be women, older age-groups (aged 50+) and people of Black-African ethnicity •Nearly 40 million people were • Increased risk of developing an AIDS-defining illness + more living with HIV at the end of 2023 •1.3 million people acquired HIV than a 10-fold increased risk of death in following year in 2023 •Number of people qcquiring HIV since 2010 reduced by 39% The UK •~113,500 people are living with HIV. Over 5,200 are undiagnosed. •New diagnoses have been increasing since 2021. Prior to 2021, new diagnoses were declining since their peak in 2005The AIDS crisis of the 1980sPathophysiology of HIVHIV Transmission HIV cannot be transmitted through day-to-day activities, including kissing. It is spread through: • Unprotected anal, vaginal or oral sexual activity (including the sharing of sex toys) • Mother to child at any stage of pregnancy, birth or breastfeeding (called vertical transmission) • Mucous membrane, blood or open wound exposure to infected blood or bodily fluids, for example, through sharing needles, needle-stick injuries or blood splashed in an eye The Natural Disease Course of HIV Common symptoms of seroconversion: • Sore throat • Lymphadenopathy • Malaise, myalgia, arthralgia • Diarrhoea • Maculopapular rash AIDS / advanced HIV disease: defined by CD4+ T-cell count under 200 cells/mm and/or any AIDS-defining illnessAIDS-defining Illnesses AIDS-defining Illnesses Pneumocystis Jiroveci Pneumonia (PCP) Generally classified as a fungus. The Kaposi’s Sarcoma most common opportunistic infection An AIDS-defining malignancy in AIDS. All patients with a CD4 count and the most common tumour < 200/mm³ should receive PCP in people with HIV. Caused by prophylaxis. HHV8 (human herpes virus 8). • Purplish lesions (brown red, • Dyspnoea blue) found on skin or • Dry cough (atypical pneumonia) mucosa (GI and respiratory • Fever tract), which can then • Classic SpO2 drop on exertion ulcerate • Perihilar haze / ground glass • Respiratory involvement may opacity on CXR cause massive haemoptysis or melaena and pleural effusion • LN involvement • LymphoedemaScreening and Testing Who to test? •Sexual health services • Offer and recommend to everyone •Secondary and emergency care • Offer and recommend an HIV test to everyone at drug dependency programmes, termination of pregnancy services, and services providing treatment for: hepatitis B or C, lymphoma and tuberculosis. • Offer and recommend HIV testing on admission to hospital to everyone where HIV is part of the differential diagnosis in line with indicator conditions or is known to be from a country or group with a high rate of HIV infection • In areas of extremely high prevalence (>5:1000 people), also offer and recommend HIV testing on admission to hospital, including ED, to everyone not previously been diagnosed with HIVMonitoring CD4 Count  The CD4 count is the number of CD4 T cells in the blood. These are the cells destroyed by the virus. The lower the count, the higher the risk of opportunistic infection: • Normal range: 450-1500 cells/ml is the normal range • Under 200 cells/ml is considered end-stage HIV (AIDS) and puts the patient at high risk of opportunistic infections Viral Load (VL) • Viral load is the number of copies of HIV RNA per ml of blood. • “Undetectable” refers to a viral load below the lab’s recordable range (usually 50 – 100 copies/ml). • The viral load can be in the hundreds of thousands in untreated HIV. Treatment Treatment of HIV infection in treatment-naive patients is initiated with a combination of • Two nucleoside reverse transcriptase inhibitors (NRTIs) as a backbone regimen (usually emtricitabine and tenofovir) • Plus one of the following as a third drug: an integrase inhibitor (INI), a non-nucleoside reverse transcriptase inhibitor (NNRTI), or a boosted protease inhibitor (PI). https://www.hiv- druginteractions.org/c hecker Adverse Effects of Treatment • Hypersensitivity: typically causes fever or rash and can cause other non-specific symptoms such as vomiting, or myalgia • Neurological and psychiatric conditions: nightmares, sleep disturbance, mood or behaviour changes may occur; psychosis and suicidal ideation have also been reported. • Peripheral neuropathy. • Hyperlipidaemia (common): rises in cholesterol or triglycerides can be extreme, lipids need to be regularly monitored and managed. Drug interactions with statins and fibrates occur frequently and can be serious — seek specialist advice before prescribing. • Lipodystrophy (changes in the distribution of body fat) and lipoatrophy (loss of subcutaneous fat): may be associated with diabetes, and hyperlipidaemia. • Type 2 diabetes: likely occurs through insulin resistance and can be associated with ART. • Bone density loss: higher risk of osteopenia, osteoporosis, and fractures — this is likely due to a combination of factors such as ART, lifestyle, and previous steroid treatment. • Renal problems: decline in renal function may indicate Fanconi’s syndrome (dysfunction of the proximal tubule) — seek renal advice. • Ureteric colic, renal and ureteric stones may also occur. • Lactic acidosis and hepatic toxicity: may present with non-specific symptoms such as nausea, anorexia, or abdominal pain — potentially life threatening. • Bone marrow suppression. • Pancreatitis: most often associated with older ART.Additional Management Contraception  Monitor cardiovascular health May be complicated by potential drug interactions with ART  Regular cervical screening • Oral contraceptives and patches may have  Up to date immunisations reduced effectiveness with some ART  Research international travel combinations. • Long-acting reversible contraceptives such  Practice safe sex (regular STI as the copper intrauterine device (Cu-IUD), checks every 3 months: HIV, the levonorgestrel-releasing intrauterine chlamydia, gonorrhoea and system (IUS), or depot medroxyprogesterone syphilis) acetate (DMPA) injection do not appear to be affected by enzyme-inducing drugs.  Prophylactic co-trimoxazole https://geekymedics.com/pre- exposure-prophylaxis-prep-counselling- PREP and PEP osce-guide/ People who may be offered PrEP • Men have unprotected anal sex with other men • Trans men or trans women who have unprotected anal sex or front sex • Those who regular partner is living with HIV and is not undetectable • Those who have sexual partners who are at higher risk of HIV (for example, from a country where the number of people living with HIV is high). • Sex workers • People who inject drugs, who do not have access to clean needles. Pre-exposure Prophylaxis • Emtricitabine with tenofovir disoproxil is a combination used for pre-exposure prophylaxis to reduce the risk of sexually acquired HIV-1 infection in combination with safer sex practices • PrEP reduces the chance of being infected with HIV via sexual intercourse by up to 99% if it is taken as prescribed. • Clinics should check U&Es before starting (creatinine levels) due to potential risk of renal toxicity • May include a full STI screen before starting including hepatitis B Post Exposure Prophylaxis • PEP can be initiated within 72 hours of exposure but should be given as early as possible (ideally within 24 hours of exposure). • HIV tests are done immediately and also a minimum of three months after exposure to confirm a negative status. Individuals should abstain from unprotected sexual activity for a minimum of three months until confirmed as negative.Preventing HIV during PregnancyFeedback form! Thank you ☺