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概要
The science of HIV infection and its application in outpatient clinics
本スライドの対象者
専攻医／専門医
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HIV感染の科学と外来クリニックでの応用
#1.
ศาสตร์ ของการติดเชื้อเอชไอวี และการประยุกต์ ใช้ ในคลินิกผู้ป่วยนอก อาจารย์ พญ.รพีพรรณ รัตนวงศ์นรา มอร์ด สาขาวิชาโรคติดเชือ้ ภาควิชาอายุรศาสตร์ คณะแพทยศาสตร์ โรงพยาบาลรามาธิบดี มหาวิทยาลัยมหิดล วันที่ 21 ตุลาคม พ.ศ. 2565
#2.
Slides
#3.
Pre-test
2020年のHIV感染者数と統計
#4.
Adults and Children Estimated to Be Living with HIV 2020 UNAIDS. https://www.unaids.org/en/resources/documents/2021/core-epidemiology-slides. Accessed on 28th June 2022)
#5.
Case Newly Infected and Estimated to Be Living with HIV 1990-2020 Adults and Children Newly Infected with HIV Adults and Children Estimated to Be Living with HIV • Every day, 4000 new HIV infections (adults and children) in 2020 • 60% are in sub-Saharan Africa • 90% are among adults >15 years old • 51% are women • 31% are young people (15-24 years old) UNAIDS. https://www.unaids.org/en/resources/documents/2021/core-epidemiology-slides. Accessed on 28th June 2022)
#6.
Thailand 2020 New HIV infection (all age) HIV incidence per 1000 population AIDS-related deaths (all age) 6600 (6000-7200) 0.1 (0.09-0.11) 12,000 (9800-16,000) Number of people living with HIV (all age) 500,000 (450,000-550,000) Number of people living with HIV (women 15+) 220,000 (190,000-240,000) Number of people living with HIV (0-14) HIV prevalence rate (aged 15 to 49) People living with HIV on treatment 2400 (2000-2700) 1% (0.9%-1.2%) 79% (71%-87%) UNAIDS. https://www.unaids.org/sites/default/files/media_asset/JC3032_AIDS_Data_book_2021_En.pdf. Accessed on 28th June 2022)
HIV検査とカウンセリングのプロセス
#8.
HIV testing and counselling (HTC)
#9.
HIV continuum of care Prevention Testing Confirmed HIV diagnosis Link to care Treatment Chronic care Impact (monitoring)
#10.
Who should be tested for HIV? Everyone who - might be at risk - no obvious risk but would like to know HIV status
同日結果と抗レトロウイルス療法の開始
#12.
HIV testing process Individual Group counselling counselling Pre-test counselling Individual Group counselling counselling HIV testing Post-test counselling Individual trusted friend counselling or family
#13.
ตรวจแล้วจะรูผ้ ลเลยไหม จะได้ยาต้านเลยในวันเดียวกัน เลยได้ไหม
#14.
Same-day result ป้องกันผูร้ บั บริการจานวนหนึ่งไม่กลับมาฟั งผลเลือด ลดความกังวลของผูร้ บั บริการ ปรับกระบวนการจัดการตัง้ แต่เจาะเลือด ส่งผลเลือดไปห้องปฏิบตั ิการ และออกผล การตรวจเอชไอวีได้ภายใน 2 ชั่วโมง พิจารณาใช้ชดุ ตรวจเร็ว (rapid test) และคานึงถึงระยะเวลาในการตรวจ ยืนยัน มีความเป็ นส่วนตัว หาพืน้ ที่มิดชิดเพื่อฟั งผล
#15.
Same-day antiretroviral therapy (ART) • Start with same-day result • Who are designated to prescribe the ART in each settings? • Availability of clinic and staff • Has possible opportunistic infections been excluded?
差別化されたHIV検査サービスの提供方法
#16.
• serious concern regarding the reduced rate of retention among same-day ART initiators, particularly in the short term • interventions to support client readiness for treatment are therefore essential. Lilian RR, et al. PLOS ONE. 2020
#17.
Same-day ART PLUS • Approach to improve uptake • Encourage treatment adherence and retention • Tailor patient’s education and health insight • Continue counselling • Ensure the support https://www.aidsmap.com/news/may-2021/same-day-art-initiation-linked-increased-risk-negative-outcomes. Accessed on 9th July 2022
#18.
Differentiated HIV testing service (HTS) delivery approaches Facilitybased HTS Communitybased HTS HIV selftesting (HIVST) HIV partner services
#19.
HIV viral testing • HIV antibody • • • • Enzyme immunoassay (EIA) Chemiluminescent immunoassay (CLIA) Agglutination assay Immunochromatography • p24 antigen • HIV RNA or proviral RNA • HIV qualitative NAAT https://www.medicinenet.com/hiv_testing/article.htm. Accessed on 10th July 2022
WHOのHIV検査サービスに関するガイドライン
#22.
WHO Policy Brief: consolidated guidelines on HIV testing services for a changing epidemic 2019 HIV self-testing Social networkbased approaches Dual HIV/syphilis rapid diagnostic tests + HbSAg in all pregnant woman Western blotting and line immunoassays should not be used
#23.
HIV testing ข้อมูลความชุกของการติดเชือ้ เอชไอวีในผูใ้ หญ่ ของประเทศไทย ณ มีนาคม 2563 เท่ากับ 0.795 WHO Policy Brief: consolidated guidelines on HIV testing services for a changing epidemic 2019 Thailand National Guidelines on HIV/AID Diagnosis, Treatment and Prevention 2021/2022
#24.
Thailand National Guidelines on HIV/AID Diagnosis, Treatment and Prevention 2021/2022
HIV感染の自然史と治療目標
#25.
Natural History of HIV Infection 1. Acute HIV infection: 2-4 weeks after infection with HIV 2. Chronic HIV infection: progress to AIDS in >10 years Asymptomatic HIV infection/clinical latency 3. Symptomatic HIV infection 4. AIDS: typically survive about 3 years without treatment Https://www.researchgate.net/publication/332800241_HIV_PHC_Manual_2019. Accessed on 10th July 2022 Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/hiv-aids/symptoms-causes/syc-20373524. Accessed on 10th July 2022 NIH. https://hivinfo.nih.gov/understanding-hiv/fact-sheets/stages-hiv-infection. Accessed on 10th July 2022.
#26.
Second sample before confirmin HIV infection is necessary to decrease human error Second sample with CD4 count and only 1 test (not 3)
#27.
Lab alert to HIV coordinators for HIV testing Both negative and positive results To ensure that there is no HIV test result missing
#28.
Do not perform HIV test again in already diagnosed people living with HIV infection
#29.
HIV Treatment Goals Restore and preserve immunologic function Maximally and durably suppress plasma HIV RNA Reduce HIV-associated morbidity and prolong the duration and quality of survival U=U Prevent HIV transmission • Predictors of virologic success: • Low baseline viremia • High potency of the ARV regimen • Tolerability of the regimen DHHS ART Guidelines. January 2016. ̶ Convenience of the regimen ̶ Excellent adherence to the regimen
ARVレジメンの選択基準と推奨
#30.
HIV Life Cycle and HIV Medicine
#31.
US FDA Approved Antiretroviral Agents 2022 NRTI abacavir (ABC) didanosine (ddI) emtricitabine (FTC) lamivudine (3TC) stavudine (d4T) Tenofovir disoproxil fumarate (TDF) tenofovir alafenamide (TAF) zidovudine (ZDV) CCR5 Antagonists maraviroc (MVC) Post-Attachment Inhibitors ibalizumab (IBA) NNRTI doravirine (DOR) efavirenz (EFV) etravirine (ETR) nevirapine (NVP) rilpivirine (RPV) Fusion Inhibitor enfuvirtide (T20) Integrase Inhibitors raltegravir (RAL) elvitegravir (EVG) dolutegravir (DTG) bictegravir (BIC) cabotegravir (CAB) PI atazanavir (ATV) darunavir (DRV) fosamprenavir (FPV) indinavir (IDV) lopinavir/r (LPV/r) nelfinavir (NFV) ritonavir (RTV) saquinavir (SQV) tipranavir (TPV) gp120 Attachment Inhibitor fostemsavir (FTR)
#32.
How can we select ARV regimen? Does the same size fit all?
#33.
Selecting Initial ART: Factors to Consider Initial characteristics to consider in all persons with HIV Pretreatment HIV RNA Regimen’s barrier to resistance Pretreatment CD4 cell count Potential AEs and drug toxicities, including risk of development of comorbid diseases HIV genotype results HLA-B*5701 status Regimen-specific considerations Known/potential DDIs Individual preferences Convenience Anticipated adherence Cost and access ART timing postdiagnosis Presence of specific conditions/ factors Comorbid conditions Pregnancy or wish to become pregnant Coinfections: HBV, HCV, TB DHHS ART Guidelines. June 2021.
#34.
Thailand National Guidelines: First-line Regimen Standard regimen Recommend TAF TDF 3TC FTC DTG Alternative ABC AZT Optional regimen 3TC EFV OR RPV BIC DTG 3TC แนวทางการตรวจรักษาและป้ องกันการติดเชื้ อเอชไอวี ประเทศไทย ปี 2563/2564 • Contraindication to TDF and TAF • Considerations ➢HBsAg negative ➢Baseline VL <500,000 copies/mL or count >200 cells/mm3 ➢No 3TC and INSTIs RAMs CD4
抗レトロウイルス療法の副作用と管理
#35.
Common side effects of antiretroviral therapy (ARV)
#36.
Common and/or Severe Adverse Effects 1 NRTIs Adverse effect Bone density effects TDF, TAF Bone marrow suppression AZT Cardiac conduction effects - Cardiovascular disease ABC Cholelithiasis NNRTIs PIs INSTIs BMD observed after initiation of any ART regimen - - ATV/r, LPV/r - - Boosted DRV, LPV/r - - - ATV - DM and insulin resistance AZT - LPV/r - Dyslipidemia AZT > ABC TAF All RTV- or COBIboosted PIs - Modified from DHHS Guidelines. June 2021. RPV, EFV - EFV
#37.
Common and/or Severe Adverse Effects 2 NRTIs Adverse effect NNRTIs GI effects AZT > Other NRTIs Hepatic effects AZT EFV, NVP Hypersensitivity reaction ABC NVP Lactic acidosis d4T, AZT, and ddI Lipodystrophy d4T > AZT Myopathy or CK AZT: myopathy Modified from DHHS Guidelines. June 2021. - - PIs INSTIs GI intolerance LPV/r > DRV/r and ATV/r: diarrhea EVG/c All PIs: hepatitis ATV: jaundice DTG: persons with HBV or HCV coinfection may be at higher risk of DTGassociated hepatotoxicity - RAL, DTG (<1%) - - Trunk fat increase observed with EFV-, PI-, and RAL-containing regimens - - RAL and DTG: CPK, rhabdomyolysis, and myopathy or myositis
#38.
Common and/or Severe Adverse Effects 3 Adverse effect NRTIs NNRTIs PIs Nervous system/ psychiatric effects ddI, ddC, or d4T: peripheral neuropathy EFV > RPV, DOR, ETR Rash FTC: hyperpigmentation All NNRTIs ATV, DRV, and LPV/r All INSTIs Renal effects/ urolithiasis TDF, TAF RPV: inhibits Cr secretion without reducing renal glomerular function ATV, LPV/r: increased risk of chronic kidney disease ATV: stone or crystal formation DTG and BIC: inhibits Cr secretion without reducing renal glomerular function NVP > EFV, ETR, RPV Some reported cases for DRV, LPV/r, and ATV RAL SJS/TEN Weight gain - - INSTIs Weight gain has been associated with initiation of ART and subsequent viral suppression. Greater weight increase has also been reported with TAF > TDF, and DOR > EFV Modified from DHHS Guidelines. June 2021. All INSTIs: insomnia, depression, and suicidality, primarily in patients with pre-existing psychiatric conditions INSTI > other ARV drug classes
#39.
Follow-up : CD4 count (absolute and percent) • Check CD4 count once a year if CD4 count ≥350 cells/mm3 otherwise twice a year • Single platform VS Dual platform (need CBC within 6 hours) • Use EDTA tube • Process within 48 hours of blood draw • Caution when interpret the result in a patient with high nucleated RBC or children less than 5 years old
HIVウイルス負荷とCD4カウントのフォローアップ
#40.
Follow up: HIV viral load (HIV VL) Thailand National Guidelines on HIV/AID Diagnosis, Treatment and Prevention 2021/2022
#41.
Thailand National Guidelines on HIV/AID Diagnosis, Treatment and Prevention 2021/2022
#42.
Lab alert to HIV coordinators and clinicians for HIV VL > 1,000 copies/mL
#43.
HIV drug resistant testing เพื่อตรวจหาการเปลี่ยนแปลงของลาดับเบสในสารพันธุกรรมของเชือ้ เอชไอวี วัตถุประสงค์ของการตรวจ เพื่อใช้เป็ นข้อมูลประกอบการพิจารณาการ ตัดสินใจ ของแพทย์ในการวินิจฉัยการรักษาล้มเหลว การติดตามการระบาด ของเชือ้ เอชไอวีดอื ้ ยา การเลือกใช้และปรับเปลี่ยนสูตรยา Thailand National Guidelines on HIV/AID Diagnosis, Treatment and Prevention 2021/2022
HIV薬剤耐性検査と品質管理
#44.
https://hivinfo.nih.gov/understanding-hiv/infographics/hiv-drug-resistance. Accessed on 28th June 2022
#47.
HIV drug resistant testing Thailand National Guidelines on HIV/AID Diagnosis, Treatment and Prevention 2021/2022
#48.
Quality Control Thailand National Guidelines on HIV/AID Diagnosis, Treatment and Prevention 2021/2022
#49.
Post-test
#50.