10/20/2015. Presenters Robin Gallagher, PhD, CRNP Sr. Ruth Neely, MSN, CRNP

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1 Presenters Robin Gallagher, PhD, CRNP Sr. Ruth Neely, MSN, CRNP To discuss the state of new antiretroviral therapy To review pap frequency and STD treatment guidelines To discuss preconception care of discordant couples To review care of the HIV positive woman in the intrapartum period To discuss care of the newborn of an HIV positive woman To review a complex female case study Established in 1985 Covers a 7 county area, approximately 5500 miles Ryan White Grant Funded since 2003 Provides comprehensive, state of the art care to patients with HIV disease Medical Home for patients 1

2 Multidisciplinary team approach with 2 infectious disease physicians, nurse practitioners, nurses, a nutritionist, case managers and a mental health counselor Currently 387 active patients Men 65 % /Women 35 % Age range Racial Breakdown: 60 % Caucasian 24 % African-American 15 % Hispanic 2 % more than one race 1 % Asian Note: exceeds 100 % due to rounding 23 % of all HIV cases in the US 45 % in care 32 % achieved viral suppression African-Americans and Hispanics disproportionately affected African-Americans and Hispanics 79 % of all HIV cases in women ( ( The Foundation for AIDS research) Source: AIDSVu ( Emory University, Rollins School of Public Health. (accessed 7/6/15). 2

3 Source of prior slide: AidsVu ( Emory University, Rollins School of Public Health. (accessed 7/6/15). HIV Medications are grouped into 6 drug classes depending on how they work The US Department of HHS provides guidelines on the use of HIV medications to treat HIV infection The choice of HIV medicines depends on a person s individual needs Many new once a day combination drugs ART can t cure HIV but makes it a chronic disease and reduces the risk of HIV transmission Source: Non-nucleoside reverse transcriptase inhibitors (NNRTIs) : blocks reverse transcriptase, an enzyme HIV needs to make copies of itself ( ex. niverapine: Viramune) Nucleoside reverse transcriptase inhibitors (NRTI s): bind to and alters reverse transcriptase (ex. Tenofovir: Viread) Protease Inhibitors (PIs): Block HIV protease needed for HIV to copy itself (ex. Darunavir: Prezista) Source: 3

4 Fusion Inhibitors: blocks HIV from entering CD4 cells of the immune system (ex. enfuviritide/fuzeon) Entry Inhibitors: Blocks proteins on the CD4 that HIV needs to enter cells (ex. Maraviroc/Selzentry) Integrase Inhibitors: Block integrase, an enzyme HIV needs to make copies of itself (ex. raltegavir/isentress) Source: History of illnesses and medications Physical Exam Lab studies: CD4 cell count HIV antibody and resistance testing HLA-B*5701 (abacavir) CBC, chemistry profile ALT, AST Urinalysis, creatinine clearance, and GFR Viral Hepatitis A,B,C screening Urine pregnancy test for women of child-bearing age Quantaferon Gold blood test (TB) RPR or VDRL Chlamydia and gonorrhea screening Fasting Lipid Profile Source: pages C2 and 3. 4

5 All HIV Infected patients to reduce transmission to others All pregnant women with HIV When the patient is ready to comply with the drug regime Adherence is very important According to DHHS guidelines ( Virologic failure and drug resistance with increase in HIV RNA viral load Medication toxicity Patient tolerance Noncompliance Physical Examination including: Pap and pelvic STD screening Breast and colon cancer screening Osteoporosis prevention Smoking cessation counseling Domestic Violence screening Secondary prevention Adherence counseling 5

6 First year of HIV diagnosis or first visit to clinic: Pap smear every 6 month for 1 year If normal, annual pap smear (CDC, 2015) Pap and pelvis exam every six months for women with: Previous abnormal pap smears HPV infection Prior treatment for cervical dysplasia Symptomatic HIV infection with a CD4 < 200 Higher rates of infection with HPV subtypes strongly associated with invasive cervical cancer Significantly higher rates of cervical intraepithelial neoplasia (CIN) Rates times greater than HIV negative women % of Pap smears exhibit abnormalities % have evidence of dysplasia Chlamydia: first visit and annually. Gonorrhea: first visit and annually. More frequent depending on risk behaviors Syphilis: first visit and at least annually. More frequent depending on risk behaviors. Trichomonas: first visit and annually Hepatitis C: Serologic testing at first visit Hepatitis B: Serologic testing for HBsAG and anti-hbc Herpes: Type specific serologic testing in persons presenting with an STD 6

7 If planning pregnancy in a sero-discordant couple, Smoking cessation Alcohol cessation Folic acid Take a comprehensive HIV history Include OB/GYN history General medical-surgical history Immunization history Complete medication list Nutrition assessment Social History Family History Relevant Male partner history, Note if HIV infected Comprehensive Examination Laboratory: STI screening CBC CD4/ HIV-RNA Rubella Hepatitis: HBV, HBsAg, HCV antibody, HCV-RNA, if indicated Pap Teach about ovulation Can teach CM/BBT Egg can be fertilized for up to 12 hours after ovulation Sperm can live 3 to 5 days in a woman s cervix in the presence of fertile mucus 7

8 Initiate ART therapy in an infected partner with a CD4 cell count < 550/mm3 Consider ART to all patients at risk for transmitting HIV to a sexual partner Treatment of an infected partner does not fully protect against HIV transmission, even with viral load suppression Male to use condoms with intercourse Timed insemination at ovulation at home or by health care provider Male semen analysis Current data insufficient to recommend PrEP (pre-exposure prophylaxis) Assisted reproductive technology: lowest reported rate of transmission with sperm washing Timed unprotected intercourse 8

9 Key is to prevent transmission to the infant Universal HIV screening of pregnant by ACOG, CDC, and AAP 3 stages of prevention transmission Antepartum Intrapartum Postpartum Antepartal, Intrapartal and infant antiretroviral (ARV) therapy reduce transmission Lower maternal viral load Provides the infant with pre and postexposure prophylaxis HIV cases in women in the US is 23% Maternal diagnosis and prophylaxis in the perinatal period can prevent all but less than 2% of cases. 9

10 Intrauterine (before 36 weeks): 20 % Intrapartum and Postpartum: 80 % Onset of placental separation Mother to fetus micro-transfusions Labor and rupture of membranes Less than 1 % if consistent ART From per 100,000 live births with 46 states surveyed: 9.9% Black/African- American 1.7 % Hispanic/ Latino 0.1 % White Source: ntwomen/index.html All pregnant women should receive combination antiretroviral therapy (ARV) regardless of CD4 count or plasma HIV RNA copy number ARV drug-resistance studies should be done before starting on or modifying ARV Counseling should focus an adherence to the drug regime Monitor CD4 every 3 months. This can be reduced to 6 months on ART with viral suppression 10

11 Sustiva/Atripla (Pregnancy category D) may cause birth defects in the first trimester Viramune increases the risk of serious liver damage in women with CD4 >250 Continue ART during labor IV zidovudine with HIV RNA > 1000 copies/ml or unknown HIV RNA near delivery IV zidovudine not required if HIV RNA <1000 copies with no concern about adherence Women with suboptimal viral suppression near delivery (HIV RNA > 1000 copies/ml)should be scheduled for a C- section Women with unknown HIV status should undergo rapid testing. If positive, maternal zidovudine and infant prophylaxis should be started, pending the results of the confirmatory test 11

12 Decisions about continuing ART should be made by the woman and her HIV provider, preferably before delivery ART is recommended for all HIV infected individuals to reduce the risk of disease progression and to prevent HIV sexual transmission A 4 week neonatal zidovudine regimen can be considered when the mother has received standard ART during pregnancy with consistent viral suppression and no concerns related to maternal adherence 2 drug infant prophylaxis of 6 weeks of zidovudine plus 3 doses of nevirapine in the first weeks of life continues to be the recommendation for infant prophylaxis For infants born to mothers who did not receive ARV drugs or received only intrapartum drugs. This should be initiated as soon after delivery as possible 12

13 A prescription and recommendation to purchase ZDV for use by the infant are not adequate to ensure appropriate prophylaxis. (AAP, p.1129). At discharge, the family should be supplied the medication itself and careful instructions for administration. In the U.S., breast-feeding is discouraged. Virologic tests are required to diagnose HIV infection in infants < 18 months. Virologic testing should be performed within the first days of life, age 1-2 months and age 4-6 months To prevent Pneumocystis pneumonia (PCP), all infants born to HIV infected mothers should begin PCP prophylaxis at 4-6 weeks, after ARV regimen, unless there is adequate test information to exclude HIV. 13

14 (Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States) Sweeney and Witmer Move away from physical health Interdisciplinary: Addresses health, quality of life and longevity 14

15 M.S.W. 30 years old female G3, P3: 3 C-Sections Undetectable 9 years Working Married History of TL CD4 560 Viral Load < 20 On Complera Thank-you Questions? 15

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