Reznik

HIV/AIDS 35 years and counting
David A. Reznik, D.D.S.
President, HIVdent
Disclosures
• I do not have any relationships with companies
that would influence this presentation.
• The HIV Dental Alliance www.HIVdent.org;
www.Facebook.com/HIVdent is funded by
Colgate Oral Pharmaceuticals and Gilead.
Objectives
• Be able to recount the history of the U.S.
HIV/AIDS epidemic.
• Be aware of when, if at any time, PLWH should
be premedicated prior to invasive dental
procedures.
• Be familiar with the CDC’s HIV Cascade
• Be aware of the latest PEP regimens
We have come a long way….
• June 5, 1981: 5 cases of PCP in
gay men from UCLA (MMWR)
• July 3, 1981: 26 additional cases
• Dec 10, 1981: 3 NEJM papers
describe cases
• 1984 – OSAP is founded!!
Gottlieb MS NEJM 2001;344:1788-91
The Bad Old Days
• 1987: AZT
1990:Ryan White Care Act passed
• 1991-92:
– ddI, ddC → sequenHal monotherapy
– Ryan White funded by Congress
• 1993: sequential monotherapy doesn’t work
– Concord Study – single therapy leads to resistance
– ACTG 076: AZT PMTCT
– Two drugs better than one, but not long term
• 1995-96: HAART era (triples) begins
NAAT technology: “viral load” monitoring
Treatment Planning and
Ongoing Care for PLWHA - 1995
• Guidelines for managing patients living with
HIV/AIDS published by the American Academy of
Oral Medicine and the American Dental
Association.
• http://www.hivdent.org/_dentaltreatment_/DT_
treatment1.htm
Important lab values
• CD4 count1
– No need to premedicate prior to invasive dental care no matter how low.
• HIV Viral Load1
– No need to premedicate prior to invasive dental care no matter how low.
• Platelet count1
– Normal – male/female: 150,000 – 450,000 per microliter (mcl) of blood
– Dental procedures can safely be performed with a platelet count of 60,000 mcl or
greater
–
1Dental
Management of the HIV-Infected Patient, copyright © 1995 American
Dental Association, published by the ADA and the American Academy of Oral
Medicine.
Important lab values
• INR for patients on warfarin
– No alteration of anticoagulation is necessary for INR that is in therapeutic
range (INR 2-3), given that local hemostatic measures are used.2
• Absolute Neutrophil Count1
– An Absolute Neutrophil Count <500 cells/mcl requires premeditation
prior to invasive dental procedures.
• Follow the American Health Association/ADA guidelines
• Glucose/ A1c
– A1c > 8% is poorly controlled; <7% is well controlled.
• 2J Am Dent Assoc, Vol 134, No 11, 1492-1497.
© 2003 American Dental Association
AIDS Mortality Rates: 1996-2001
Mortality vs. ART utilization
Deaths per 100 person-years
35
USE OF ART
30
25
75
DEATHS
20
50
15
10
25
5
0
1995
1996
1997
1998
1999
2000
Percentage of patient-days on ART
100
40
0
2001
Palella F et al. 8th CROI 2001; abstract 268b.
Advances in Antiretroviral Therapy:
Easier Regimens
• Once-daily dosing
•
•
•
•
•
•
•
•
Tenofovir (TDF)
3TC, FTC
Abacavir (ABC)
Efavirenz (EFV)
Atazanavir (ATV)
Lopinavir/ritonavir (LPV/r)
Rilpivirine (RPV)
Elvitegravir/cobicistat
(ELV/COB)
• Dolutegravir (DLG)
• Lower pill burden
Fixed dose combinations
• TDF/FTC
• ABC/3TC
• AZT/3TC
• AZT3TC/ABC
• TDF/FTC/EFV
• TDF/FTC/RPV
• TDF/FTC/ELV/COB
• ABC/3TC/DLG
ART is Recommended for
All HIV-Infected Individuals
(US DHHS, 2014; WHO, 2015)
• To reduce the risk of disease progression
(based on Lundgren J, NEJM, 2015, START study)
• To prevent transmission of HIV
(based on Cohen MS, NEJM, 2012)
– Perinatal transmission
– Heterosexual transmission
– Other transmission risk groups
Patients starting ART should be willing and able to commit to treatment and
understand the benefits and risks of therapy and the importance of adherence.
Patients may choose to postpone therapy, and providers, on a case-by-case
basis, may elect to defer therapy on the basis of clinical and/or psychosocial factors
DHHS. http://aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Revision May 1, 2014.
The New Paradigm: Treatment as Prevention
• HIV NAAT led to quantification of burden of infection
• HIV Transmission a function of viral burden
• Antiretrovirals can decrease HIV burden
Anderson DJ, O'Brien TR, Politch JA, Martinez A, Seage GR, Padian N, Horsburgh R,
Mayer KH: Effects of disease stage and zidovudine therapy on the detection of HIV-1
in semen. JAMA 267:2769 1992.
PEP Regimens
• Preferred HIV PEP regimen:
– Dolutegravir (Tivicay) 50 mg once daily or
Raltegravir (Isentress) 400 mg BID + TDF/FTC
(Truvada) once daily.
Continuum of HIV Care - U.S. 2012
100%
90%
85%
85%
80%
85%
87%
81%
39%
36%
30%
VL
Published in AIDS Patient Care and STDs. March 2014, 28(3): 128-135.
DOI: 10.1089/apc.2013.0345
© Mary Ann Liebert, Inc.
FIG. 1.
Estimated cascade of care in HIV-infected youth (ages 13–29 years) in the United States.
Summary/Takeaways
• Although HIV/AIDS is no longer a death sentence for
patients who test early, are linked to care, prescribed
cART, and achieve undetectable viral load, we are still
seeing nearly 50,000 new infections per year.
• Young minority MSM < 24 years of age are
approximately 25% of the new cases we see per year.
• We still have work to do!
• Visit www.HIVdent.org for the latest information on
HIV/AIDS