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Ok. Uh, let's get going then. So I'm gonna turn off my M and camera and hand it over to Stuart Cheers. Thank you. Uh, so hello everyone. Um, so my name's Stu. Um, I'm a resident doctor in general surgery, um, in York Hospital at the moment. Um, I hope everyone's doing ok. Uh, I'm sure there'll be a mixture of people watching this session so there might be some med students. Um, I hope you guys are doing ok. I hope you're feeling all right about your exams and I hope sort of the fellow rest of doctors are doing ok as well. Um, but yeah, I'm gonna be doing a presentation on HIV. Um, I'm not an expert in HIV at all. Um, but I am passionate about LGBTQ Plus healthcare. Um, so, yeah, I think it's quite an important topic, um, bearing in mind some of this stuff in terms of your exams might be relevant, but I think some of the clinical aspects of HIV treatment can be quite specialist. Um, but I still think a lot of it's good to be aware of so kind of an outline of the session. Um, we'll be doing a, we'll be, I'll be showing you sort of a brief history of HIV, some key statistics, um, the AIDS crisis, um, some pathos and trans and the transmission of HIV. Um, how the sort of disease progresses and AIDS, defining illnesses, um, how it's tested treated for and monitored, er, adverse effects of the treatment, um, any additional management and also prevention via prep and pep. Um, and I've also added an extra slide about prevention during pregnancy. But, um I think this might just be a little bit extra. So a brief history of HIV. Um, so it all started with old world monkeys. Um, and they're a species that are naturally infected with more than 40 different lentiviruses. Um And these are called simian immunodeficiency viruses. Um Some of these crossed the species barrier to the great apes and humans. Um, and they generated new pathogens, um including HIV one and HIV two. It probably occurred when humans came into contact with the blood of infected chimpanzees. Um, and it was likely when humans were hunting the chimpanzees for food. Phylogenetic analyses have dated HIV one back to 1910 to 1930 showing it emerged in colonial West Africa um around this time and it continued to spread for over 50 years before AIDS was first reported in 1981. HIV was first identified in 1983. Um A HIV kit became commercially available in 1985 and in 1987 the World Health organization launched a global program on AIDS. Um, this infographic at the back I think is really interesting. Um, it sort of chronicles some key landmarks in HIV. Um, especially in the UK, er, particularly in the UK. Um, we've got, um, Terry Higgins. Um, and that was, he was a person that died of HIV. Um, and AIDS and his friends launched the Terrence Higgins Trust. Um, so they specialize in, um, they were the first HIV charity, um, and also quite an important landmark as well was this character in Eastenders, Mark Fowler. Um, he was diagnosed with HIV and because they showed that on sort of a national TV program, um, it caused a massive spike in, um, testing for HIV. But it's a really, it's quite an interesting, um, sort of infographic if you wanna have a look at it. Um, so some key statistics. So globally there's nearly 40 million people living with HIV. And that was at the end of 2023. Um, and over 1 million people acquired HIV in 2023. Um, some amazing news that the number of people since 20 to 10 acquiring HIV is reduced by 39%. And that's kind of the result of these global public health efforts, um, to try and reduce transmission. Um, in the UK, there's around 100,000 people living with HIV. And over 5000 of those are undiagnosed and there's kind of been quite a concerning trend of, um HIV diagnoses increasing since 2021. Um, so, and they, they, they think that some of these diagnoses are coming from people that maybe have come abroad. Um, so they're not necessarily new diagnoses. Um, but yeah, it's something that we have to sort of keep an eye on, um, uh, the life expectancy of people with HIV, um, has massively improved, um, back in the 19 eighties when it first arrived, it was a death sentence. It was a terminal illness, but now it's seen more as a chronic illness. Um, if you start a RT S antiretroviral therapy in your twenties, then you have nearly the same life expectancy. Uh pretty much the same life expectancy as someone that does not have HIV. Um, a problem that we do have with people being diagnosed is being diagnosed late. So that is a CD four count of less than 350 cells within three months of the diagnosis. Um, and there's more people, there are some people that are more likely to be in this group. Um, so it's women, older age groups, so above 50 people of an black African ethnicity and it's important that we identify those groups so that we can really target those public health messages at them. Um, because this being diagnosed late increases your risk of death, um and developing an AIDS defining illness. So the AIDS crisis of the 19 eighties, I think when learning about HIV, it's really important to understand the historical context. Um, it's quite an important, it's, it's, uh, it's a very important sort of matter in the queer community. Um, it was, um, people have terrible memories that were around from that time. Um, and I think we still feel the impact of that today. Um, so it was in the late 19 seventies and early 19 eighties that a virus, this virus that had been appearing sporadically around the world began to cluster within the United States. So it first materialized the sort of groups um appearing of Kaposi sarcoma um and PCP which is a type of pneumonia in gay men in Los Angeles. Um New New York City and San Francisco in 1981. Um It quickly became known as a gay disease um in quotes because gay men were one of the primary groups afflicted. Um HIV in its syndrome. It causes um aids were unknown in 1981 but they have become household terms and a number one public health wreck by the 19 eighties for several years. I this is so this is all kind of talking about the US at the moment for several years after the Center for Disease Control realized that the illness is cropping up in communities around the country were the work of the same virus. The American government did very little to address the epidemic and the failure to act on this people. Would attribute to the fact that it was primarily gay men, intravenous drug users, immigrants and ethnic minorities that were affected by the virus. Ronald Reagan's um administration was widely criticized for um dragging its feet when dealing with the crisis. Um And they believe this was due to the homophobia. Whilst the gay community viewed a lot of the early reports and public health measures with distrust. Um And that further allowed the disease to spread and infect 100s of thousands more. Um But eventually HIV and AIDS activists, medical professionals, artists and a number of people with AIDS went public with their diagnoses despite the stigma surrounding the disease. And that spurred a huge response from the US government. And by the mid 19 nineties HIV slash AIDS numbers were um dwindling. Um One of those famous um sort of public figures was Princess Diana. It was in 1987 that she um she opened up a ward in a hospital dedicated um to HIV patients. Um And she notably quite famously shook the hands of AIDS patients without wearing any gloves, which is kind of mad to think about that. Now, looking back um in 1981 the first case of AIDS occurred in the UK. Um and it was a man called John Ed. He was a 49 year old male um who was admitted to Brompton Hospital and he was suffering from PCP. He died 10 days later. Um And he'd been a frequent traveler to the US. Um I can't recommend enough watching. It's a sin. Um It's a drama which is based on the AIDS crisis in the UK. It's really heartbreaking, it's really well done and it talks, it kind of chronicles the shame and the guilt and the fear that happened during this time. Um So by 1985 there had been 58 aids related deaths in the UK. Um, and it was ignored by a large chunk of the general public apart from when sort of the public health messages really ramped up. And there's, if you ask people that were around from this time, they'll probably remember this tombstone advert. Um It was quite a famous advert that was supposed to scare people. Um And I think it did, did, did the job. Um the as in the US, the UK sort of society and media were deeply homophobic during the AIDS crisis. Um So authority figures um such as the Greater Manchester Police chief constable James Anderton was, was commented saying that um those living with HIV slash AIDS were quote swirling in a human cesspit of their own making. Um So there was sort of, there was some really horrible language used in this time. Um And the sort of sentiments towards homosexuality peaked in 1987. Um the year before section 28 was enacted and I'll mention that later. Um According to the British Social Attitude survey, 75% of the population at this time believed that homosexual activity was always or mostly wrong. Um In 1988 section 28 was passed and that stated that councils and schools shall not intentionally promote homosexuality or publish material with the intention of promoting homosexuality or promote the teaching of any maintained school of the acceptability of homosexuality. As a pretended family relationship. It caused many organizations such as LGBT student support groups to either close limitless activities or self censor. And it was only repealed in 2003 in England and Wales. Um I, the harmful legacy of that I still felt today. And I um and II think a lot of gay people will see so many similarities between the way that there was mass hysteria and panic whipped up in the 19 eighties and the way that trans people are treated now with the hysteria about public bathrooms. Um and just sort of the erosion of trans rights and a lot of people see a lot of um similarities. Um and it's uh whilst it was back then, it was pre pre predominantly known as sort of the gay disease. The statistics currently show that actually the rise in HIV diagnoses is steepest between heterosexual men and women. Um testing in sexual health clinics has increased by 34% since 2019. In gay, bisexual and other men who have sex with men where they've fallen in heterosexual and bisexual. Um heterosexual man and heterosexual and bisexual women. Um I know it's sort of an exam, uh a good case study and how the gay community actually is on the whole, practicing quite safe sex is monkey pox. So in 2022 by the end of 2022 there were 3732 confirmed or highly probable er monkeypox cases in the UK. Um but by 2023 and 2024 so two years combined, there was a total of 286. Um and 82 of these were acquired outside of the UK. So there was a massive drop and people can um attribute this to er, a rise in vaccine uptake good public health messages, um, behavioral changes, risk communication and community engagement. Um So it's a kind of a, a good case study and showing about how large amount of the gay community actually are very good at getting tested regularly, um getting vaccines if it means they're gonna be protected from these sort of sexually transmitted illnesses. So, II feel like I've rambled on a lot enough about that. Um Let's talk a little bit more about HIV itself. So HIV refers to human immunodeficiency virus. Um, it's an RNA virus. Um and HIV, one is the most common type HIV two is rare outside of West Africa. It's less, less infectious and it progresses more slowly. So essentially HIV, it enters and destroys the CD four to help us out of the immune system, you have an initial sero conversion flu like illness within a few weeks of the infection and then it becomes asymptomatic until the condition progresses to immunodeficiency. And that's referred to as late stage HIV or acquired immunodeficiency syndrome aids. Um And this is when you get these opportunistic infections and lots of AIDS, defining illnesses like Kaposi sarcoma. So the structure of HIV, um it's kind of got quite a classic. Um I think people would see that and know straight away that it's a virus. Um It's a lentivirus, it's from the lentivirus genus. Um and these are characterized by having a very long incubation period which HIV does have um it's a feral in shape. Um And it's got two copies of single stranded RNA enclosed by a capsid of the viral protein P 24. Um There's a matrix composed of viral protein P 17 around the capsid and there's an en there are envelope proteins. GP 120 GP 41. This, I think, I don't know how relevant this is to someone um in clinical practice, but this could sort of come up in medical exams, maybe, um maybe more the preclinical years. Um And then part of the structure of HIV, that's really important is these enzymes like reverse transcriptase, integrase and HIV protease. Um So how does HIV attack the cells? So HIV works very similarly to a lot of viruses. It's essentially exploiting the, the machinery of a cell to hijack it and produce its own proteins. Um But the, the special thing about HIV is that it's attacking CD four T helper cells. So it cells that are directly involved in the immune system. So firstly, you've got your attachment. So HIV attacks a cell and it binds to molecules or receptors on the surface of the cell. Um after it's attached itself to the cell, um the HIV envelope fuses with the CD four cell membrane and that's called endocytosis and that allows it to enter the CD four cell and that's when it releases its special enzymes HIV um RNA um reverse transcriptase and integrase. Um It uses its reverse transcriptase to convert its genetic material which is RNA into HIV DNA. Um And whilst, and wh when that HIV RNA becomes DNA, it allows it to enter the cell nucleus of the CD four cell. So, whilst inside the cell nucleus, the HIV releases integrase which is an enzyme that inserts the viral DNA into the DNA of the host cell. Um and then once it's inside the cell DNA, um the virus can sort of be exploiting the machinery of the CD four cells. So it's organelles to produce these long chains of HIV proteins. Um Now you've got assembly, so during this assembly, you've got um the CD four cell which has been exploited. Um It's producing um long chains, chains of HIV er proteins and then you've got budding. So, during budding, you've got non infectious or immature HIV, which pushes itself outside of the CD four cell. Noninfectious HIV, can't actually go on to infect other CD four cells. So that's when protease comes in, it breaks down those lung protein chains that form this noninfectious virus. And then the smaller HIV chains combine to form mature infectious DNA. Um HIV. So how is HIV, transmitted? Um I'm sure most people will be aware that HIV cannot be transmitted through day to day activities and that includes kissing. Um It is spread through unprotected, anal vaginal or sex, um oral sexual activity, including the sharing of sex toys. Um it can be passed from mother to child at any stage of pregnancy, birth or breastfeeding and that's vertical transmission. Um and also mucous membranes, blood or open wound exposure to infected blood or bodily fluids. So for example, sharing needles, a needle stick injury um or blood being splashed in the eye. So what is the natural disease course of HIV? So, um firstly, you've got your acute HIV stage. So after an initial infection, there's this sero conversion and that kind of shows up as a glandular like er type illness um in most patients. Um and that's where you've got a very high viral load and you've also got antibodies being produced um against the HIV. And that's what's causing those symptoms that normally occurs around 3 to 12 weeks after infection um and it, and sort of increased um severity of symptoms at this point is associated with a poorer long term prognosis. You might get things like sore throat, lymphadenopathy, um malaise myalgia, arthralgia, diarrhea, and a maculopapular rash. So they can be quite kind of nonspecific in a way. Um People might not, people would not necessarily be aware that they've acquired HIV. Um The HIV is rapidly multiplying and spreading throughout the body at this point. Um and the viral load becomes very high. Um At this point, the person is very transmissible, they're very infectious. Um But it's also the most beneficial time to start a RT. Now we have a period of chronic HIV infection. Um and that's also called, called, um called asymptomatic HIV infection or clinical latency. It continues to multiply but at very low levels and it's described as asymptomatic, but there may be subtle signs during this time. So you might get indicated diseases like recurrent bacterial pneumonia or shingles. Um And there's a few others as well. Um on a, on average, there's around 80 CD, four T cells lost every year and without treatment, chronic HIV, infection will progress to end stage to HIV in around 10 years or even faster in some individuals. End stage H HIV, advanced stage HIV or AIDS. I've used these terms interchangeably. Um There's maybe a general, there's a consensus to maybe towards moving towards advanced stage HIV as like preferred over AIDS. Um But again, it depends on who you ask really. Um But yeah, this is described as clinically apparent disease. So your CD four T cells have now dropped below 200 cells per millimeter cubes. And at this point, the immune system, it does not have a fun enough functioning T uh CD four T cells to function normally. Um And this is when you kind of get these opportunistic infections, kind of weird malignancies that you would not normally get in a person with a healthy immune system. Um Again, at this point, the viral load becomes very high and you become very infectious. Um And a patient with end stage HIV will typically live for 2 to 3 years before. Um they would die essentially. Um So, um AIDS defining illnesses. Um There's a long list of these, there's quite a few of them. Um But I'll mention a couple of them which might be relevant for your exams. Um And they're also kind of the most common ones. Um But some of these are more classically associated with a CD four count dropping below a certain level. Um So you've got your Kaposi sarcoma PCP, um Cytomegalovirus um kind of thrush lymphoma tuberculosis, you've got your um cryptococcal meningitis aids, dementia complex. Um So yeah, there's quite a few different things um that are part of this sort of category. Um So in terms of AIDS, defining illnesses, um two I think are of note because they're quite, they were part of why it was identified in the first place, but they, even now they are kind of the most common. So, Pneumocystis pneumonia. PCP um is generally classified as a fungus. Um and it's the most common option infection in AIDS. Anyone with a CD four count of below 200 should have PCP prophylaxis which is co trimoxazole. Um and some features are dyspnea, a dry cough, uh fever and classically um and this is what might be tested in exam sort of questions. Um is a oxygen saturation drop on exertion on a chest X ray. You might see a ground glass opacity or a peri hilar glaze. Um and then Kaposi sarcoma, that's an AIDS, defining malignancy and it's the most common tumor in people with HIV. It's caused by human herpes virus. Eight. And you get these purplish lesions er on the skin or the mucosa um and you can get them in the gi and the respiratory tract which can then ulcerate. Um and you can kind of get this massive bleeding as well. So, er screening and testing, um this has been such a vital part of um the development of how we're progressing and advancing with HIV. Um Lots of people with HIV do not know they're infected and these are at a higher risk of complications and also of course, spreading the disease. We wanna identify these people earlier so that we can get them on a RT um as with any test, you need consent. Um And there are a few tests that are available in the UK. Um So generally we have a combined antibody and antigen test. So, antibodies against HIV might not be present in the early infection because it takes time for the immune system to produce them. But most will have developed by 4 to 6 weeks and 99% by 12 weeks. Um The antigens are PP 24 is what you're looking for. Um is present much earlier in the infection as the viral RNA levels rise and that indicates an acute infection as the levels reduce over time. Uh PCR testing, um We can look for HIV RNA. Um And that directly looks for the number of viral copies in the blood and that gives a viral load that's used more for monitoring. Um But essentially UK guidelines recommend testing at four weeks and then a second test is used to confirm 12 weeks later. Um But it does depend on the clinical circumstance. So later on, we'll talk a little bit about pep. Um And in that case, generally, you would test immediately after the potential infection and then you would confirm it um 12 weeks later. Um And then who to test. So, um this is something that I used to kind of be a bit confused about. Um But a lot of this information that I'm actually using in this presentation is from the British HIV Association, um, Beaver. Um, they're a great source of information. Um They've got really extensive guidelines. I think most of their information is really designed for gum clinics, sexual health centers. But um it's good, it's a good reference point. Um, so sexual health centers, um, anyone that goes to a sexual health service will be offered and recommended a HIV test. Um at secondary or emergency care, anyone who is attending a drug dependency program, um termination of pregnancy services, um or any service providing treatment for HEP C HEP B, lymphoma and tuberculosis. Um Anyone that's admitted to hospital and HIV is part of the differential diagnosis. So if they're showing any of those signs of indicated conditions, um maybe they're potentially from a country or group with a high rate of HIV infection. Um Maybe the symptoms are sort of indicating that this could be AIDS or, or HIV. Um Then that's something that you would also want to do. Um and also in areas of extremely high prevalence. So more than five in 1000 people. Um So I trained in Saint George's in London. Um and that was a hospital where everyone that came through A&E would be tested for HIV. Obviously they'd be asked about it. It was, I think it's called an opt out system which I've learned recently. Um And the opt out system is part of the UK government's HIV action plan. Um And they want to end the HIV cases by 2030. Um which is a brilliant, but I would say ambitious goal. Um And part of this is this opt out HIV testing program. So essentially if, if a, if a service is in this program, then they would automatically test all blood samples for HIV HEP B and HEP C in emergency departments. Patients can opt out if they want to. Um, but they have to opt out. Um, and it's been really useful at identifying lots of people that would not have been previously um identified. Um And it's constantly expanding. So I think currently, um there's 89 emergency departments in the UK that have this opt out system. Um and it's been really good for identifying lots of more HIV patients. Um So monitoring, um there are two main parts to monitoring a HIV patient. So you've got your CD four count. Um As we, we learnt before the CD four count is the number of CD four T cells in the blood. Um And these are obviously destroyed by the virus. The normal range is between 451,500. Um And as we go below 200 that's end stage or advanced stage HIV. Um CD four count is a good, a good way of looking at CD four count is kind of a measure of how well that immune system is working. So as the CD four count drops, then the immune system is gonna be weaker viral load. On the other hand, um that's the directly the number of copies of HIV RNA per mill of blood. Um, if a patient is undetectable, that means their viral load is below the detectable range of er, labs, recording equipment. So it's usually 50 to 100 copies per mill. Um, if someone's untreated that it could be in the 100s of thousands. Um and a really important campaign that came out of sort of monitoring um was undetectable equals. And what that means is, well, they, they did two studies, they did a partner, one study and a partner two study in, in around sort of 2015, 2016. Um As part of one study, there were 58,000 condom anal sex acts. And in the part of two study, there were 76,000 condom anal sex acts. Um and the, the, the, the couples that were in these studies um were se disc concordant. So that means that one was HIV positive, but they had an undetectable load and the other partner was HIV negative. And through these literally thousands, over 100,000 condom anal sex acts, they found that there was zero transmission. Um It was a really important study. Um And it's used a lot now to try and break down that stigma because people that do have are HIV positive may still really suffer with stigma even in the gay community with dating. Um And that sort of stuff. So this has been quite an important and powerful campaign. So, treatments. Um, so it's important to sort of state with HIV, as I mentioned before. Um, that it is quite specialist. I don't think that you would ever be initiating someone on HIV treatment kind of early on in your career. Um, there are specialist HIV doctors, infectious disease, doctors and gum centers that manage patients with HIV. Um, but essentially treatment involves, it's a combination of antiretroviral therapy medications. Um, and these are offered to anyone with a diagnosis of HIV, irrespective of the viral load or CD four count. Um, it used to be dependent on the CD four cell count. Um, but they've scrapped that now and it's just everyone that's been diagnosed. Um It's an amazing as well, this, this sort of picture just to show that the, the progression that we've had. So it was up to 20 pills spread across the day and now in lots of cases, it's only one pill, um which is brilliant. Um But yeah, so the British HIV Association guidelines, as I mentioned before is a great source of knowledge for HIV treatment. Um They recommend a triple therapy. Um and that, so that's two nuclear side reverse transcriptase inhibitors. So one of these is Tenofovir. Um and, and, and Tri Oban, I can't pronounce any of these words. But um yeah, those two and a third agent. So um a nonnucleoside reverse transcriptase inhibitor, a protease inhibitor and an integrase inhibitor. And if you remember back to sort of how HIV works, then these are all those really important enzymes and we, we're really exploiting those and targeting those as part of our treatment. Um And the aim is to achieve a normal CD four count and an undetectable viral load. Um These are lifelong treatments. So people will be on these permanently and if they came off them, then the HIV would continue to infect the rest of their CD four cells. Um, as a general rule, if someone, if a patient has a normal CD four sep count and an undetectable viral load and they're on antiretroviral therapy. Treat them as if you would treat any HIV negative patient when you're looking at their physical health problems. Um, a really important part of A RT, um is it can interact with a lot of medications. So, whilst you, I doubt you would ever be, like I said, early on sort of F four and F two be initiating someone on HIV treatment. Um You will come into contact with HIV patients and you might have to do medication reviews. You might have to prescribe them pain relief. Um I came across a patient the other day and I think it was just, I had to prescribe paracetamol. It wasn't anything major, but it is something to be aware of that. A RT can interact with. Um some quite commonly used medications. So, um, I can't list all of them, but some of them are a PPI S antiacids, calcium, iron and magnesium supplements. Rifampicin, a funny toe in and nsaids as well. But there's this great website, um HIV drug interactions. You can go on there and you can check kind of a RT combinations and compare it and see if there's an interaction with commonly used drugs. Um, if a person has HIV and chronic Hepatitis B, then they need to have antiretroviral antivirals against both of those diseases. Um And then in the sort of the footnotes of this, which I'd like to be able to like spread this presentation if anyone wants it afterwards. But I've got more about the sort of mechanisms and how we inhibit that. Um But I won't go into that too much. So, next, we've got some of the an adverse effects of treatment. Um So with, with a RT, whilst they're amazing drugs and they've done amazing things. There are some potential adverse effects. So I've put in bold, some of the most the ones that you need to kind of look out for. Um But we've got hypersensitivity as you can with any medication um causing like kind of nonspecific features like a fever, vomiting, myalgia. A rash is quite a rash and a fever is quite common um when starting A RT. Um And that also involves PEP as well as post exposure prophylaxis. People starting on that can quite commonly get a rash, um, and not have a very nice sleep that first night of um, starting it. Um, yeah, you've got these hypersensitivity reactions as with any drug, um, some psychiatric and neurological conditions. So you can get peripheral neuropathy, uh nightmares, sleep disturbances. Um Again, a lot of these are rare but it's just kind of good to be aware of um hyperlipidemia. So, uh A RT can have quite a significant um interaction with uh cholesterol and triglyceride levels. Um and those days they can rise. So as part of managing someone with HIV, you need to be looking at their cardio vascular risk factors, um measuring their cholesterol levels and making sure um that they're not rising too high. Um Kind of what complicates this even further is that um some of the A RT can interact with the statins and fibrates. Um So again, need to look at that. Um and see if there's any interactions, I also should state that some of the advert, the worst adverse effects are from the older treatments. So A RT S been out for a long time. We've got newer agents now and the newer agents are generally a little bit, they're tolerated a little bit better, uh type two diabetes. And um so that can occur through insulin resistance. Um and then bone density loss. So I did a selective, a student, selective component at the Courtyard Clinic which is a sexual health clinic in um Tooting in London and we looked at bone health of people on a RT that have been on it for a long time and we did see there was, there is significant increase in people with osteoporosis, osteopenia. Um So it's definitely something to be aware of. Um, again, Beaver have good guidelines on when to check people for those um, adverse effects. So you've got your Frax score. So, um people might have heard of this before, but that's a way of risk assessing or um someone um for their risk of osteoporosis and osteopenia. And then you've got your dexa scans and that's when you're, you're properly scanning someone to look at the bone mineral density. If it is too low, then you might consider starting a bisphosphonate. Um and looking at those ways to build up that bone health uh renal problems as well. Um That can, that can be a problem with a RT and I'll mention this a bit later as well with prep. Um And yeah, there's a few other ones which kind of are weird and wonderful but good, always good to be aware of. Uh So additional management. So, like I mentioned before, cardiovascular disease is a really important part of managing someone with HIV. Um So there are at high risk of dyslipidemia, insulin resistance and therefore cardiovascular disease. So you wanna be giving them good advice on diet, exercise, alcohol reduction, smoking, cessation, measuring the BP, regularly screening for diabetes and high cholesterol. Um, cervical screening. So that's really important as well. So HIV predisposes to developing HPV and therefore all cervical cancer. So all women who are newly diagnosed with HIV should have, um, they should have an initial colposcopy following diagnosis um and annual cytology as well. Um immunizations as well. So, vaccines need to be up to date. So you want your influenza pneumococcal hep B HEP A tetanus diphtheria and polio. Um you can get full sort of again from the Beaver guidelines. Um And generally with someone with a HIV infection, you should avoid live vaccines. So that includes BC um BCG cholera or the oral Typhoid vaccine, um be aware as well. There are some restrictions on international travel. Um and also you need to be wary of the vaccinations when traveling as well because that can um some of those will be live as well. Um So, er, another another important medication to give if someone's got a CD four count below 200 is co trimoxazole or I think it's brand name Sceptrin. Um and that's to protect against Pneumocystis, um juicy pneumonia, um contraception as well. Um That's another element that I think is quite important um and can interact with the A RT. Um and that's a lot of the oral contraceptives. So the hormonal contraceptives and the patches. Um but the long acting reversible contraceptives like the copper coil, the Mirena or the depo um don't tend to be affected by enzyme inducing drugs. So, prep and pep um these have been again, I know I keep talking about how revolutionary it's all been. But these are amazing medi amazing medications. Um prep in particular, I think um has made a huge difference. So prep um essentially prep is well to start off, I would say the people that would be potentially offered prep are um a cer certain groups of people. So men who have unprotected anal sex or other men, trans men or trans women who have unprotected anal or front sex. Um, those who have a regular partner who's living with HIV, and is not detectable, er, not undetectable. Um, those who have sexual partners who are at a higher risk of HIV sex workers, people who inject drugs and who do not have access to clean needles. So these could all be good people. Um, good candidates for having prep and what actually is prep. So, prep is a antiretroviral medication. So it's called the brand name is Truvada. Um, and it's a medic, it's a combination of those two drugs that I talked about before, um, including Tenofovir. Um, there's two ways of taking these medications. You can take it regularly so once daily or you can have event space dosing and a little guide to sort of how the event based dosing works is there. So you have two pills, 2 to 24 hours before sex. Um, one pill, 24 hours after the first dose and then one more pill 24 hours after that. Um And if you continue to have sex, then you should just keep taking the prep regularly. Um And it's highly effective. If it's taken properly as it's prescribed, then it's 99% effective. Um And in 2020 the UK government announced that preps will be freely available in England to anyone at risk. Um So yeah, it was a really important um milestone there um with prep. So this is a really good resource. So it's geeky medics, geeky medics. I mean, I absolutely relied on so much during my med school journey, great website. But they all have, they have a counseling station, er, guide on prep. Um And there's some really useful information in this. Um It could come up on your oss potentially. Um And they've got advice about missed pills. So missed pills were, was an aspect of contraception that I dreaded because I just couldn't get my head round it. Um But with prep, um they've got some advice about that. I think essentially if you're using events based prep dosing, then you're a lot more susceptible to a missed pill. So if you miss a pill, then I think most cases you probably have to go on to PAP. But if you've got regular daily dosing, then um I think you're a little bit more protected, but it explains it in that um article um and there's some s speci specific advice in that for so prep in women. Um So prep will not affect contraception, um and vice versa. Um Studies have not shown any pregnancy complications from prep. However, the sample sizes were small in this. So women should still speak to their doctor. Um and daily prep can be used safely when breastfeeding. Um And some specific advice for prep in trans and non binary people. Um if you're having vaginal sex, daily dosing is needed. If you're only having anal sex, then you can use event based dosing. Um, and prep will not affect any hormone treatment being given. Um, the other medications that's, that's to stop you. Um, acquiring HIV. The other medication is post exposure, prophylaxis. So that's taken after potential exposure to HIV. Um, and there's a few cases where this might be given. So if you've got an uninfected sexual partner or a person who is known to have HIV, and it's to prevent infection after sex without a condom or where the condom is split. Peps generally not recommended if a HIV, positive partner is adherent to a A RT and has had confirmed as having it sustained. So, more than six months undetectable plasma viral load. Um, if someone has had unprotected sex with a person in a high risk group for HIV, whose infection status is not known. Um And it can also be offered to victims of sexual assault depending on their risk assessment. Um, and it also may be given it in occupational incidents as well. So maybe if there was a needle stick injury, um, it's not 100% effective. Um, but it is very effective if it's taken within the proper window. So, ideally it should be taken within 24 hours. Um, it cannot be taken any less than 72 hours. It doesn't, it becomes ineffective after that or I think it becomes a lot less effective. Um And it's exactly the same, it's, it's, it's the same as perhaps so it's Truvada um and also r raltegravir as well for um 28 days. So you have to take it for the full 28 days. A HIV test is generally done immediately after exposure, potential exposure and then a minimum of three months after to confirm a negative status and individuals should, should obviously abstain from unprotected sex um for a minimum of three months until confirmed as negative. Mm. So, and I had a little bit extra um on preventing HIV during pregnancy. Um But again, I think this is probably a little bit specialist um and a little bit advanced, but I can, I just, I'll just include in there as like a little extra. Um But yeah, that's the, that's the end of my presentation. Thank you for watching.