March, 2011

March 2011 HIV conference summary

Dear All,

       Thanks to everyone who was able to attend today's conference.  For those of you who were not able to make it here is a summary of what we discussed.

Case 1:
Presented by Magni Hamso
58yo M former smoker & IVDU on methadone for last three years, HIV/AIDS (dx 1987, on HAART, h/o PCP PNA 1996, CD4 247, VL 25K 3mo ago), HCV s/p interferon therapy 2yrs ago, depression w/ h/o 3 suicide attempts, h/o 2 8yr-long incarcerations, here to establish care.  He followed at Bellevue until December, when he decided to transfer his care here to the South Bronx, where he lives.  It took him a while to get an appointment at our clinic, so when he came to see me he had been off HAART for 1mo (has been taking Prezista, Truvada & Norvir for the last 3yrs).

Of note, he has signs of liver disease on exam (caput medusae), so I set him up for an abd US w dopplers for next week.  He had an appt w/ Dr. Voyages today, which he unfortunately missed.  And I am referring him to dental & SW.  I already sent an e-mail to his doc at NYU and faxed in a release of information; so far have not heard back.

Question: After a patient has been off their ARVs for any reason when is it okay to restart them? 

The concern is that patients have developed resistance while being off their medications and this is most worrisome in patients who are on NNRTI containing regimens such as Atripla/Efavirenz.  The reason we worry is that the half-life for the NNRTI (Efavirenz /nevirapine) is much longer than for the NRTI's (truvada, lamivudine, AZT, abacavir, epzicom, emtricitabine, stavudine, didanosine) meaning that after the patient stops the atripla the efavirenz component hangs out for several more days in their system after the truvada has been metabolized.  This can result in "monotherapy" because only one drug is in the patient's system.  So if your patient is on atripla you might consider checking a genotype prior to restarting therapy.  This is something you would want to discuss with Rob, Elliot, Angela or me.

For patients on Protease inhibitors such as reyataz, prezista, kaletra this is less of an issue and it is usually okay to resume the therapy.

In the absence of known resistance to a regimen (as documented by prior genotype results) it is generally acceptable to resume the medications the patient was taking prior to the interruption.  You should then monitor them closely to make sure that their VL is dropping appropriately.  I recommend checking a VL within 1-2weeks of resuming therapy to confirm this and then follow the VL regularly, every 2-4wks until the patient achieves suppression. 

If you do not see a significant steady decline in the VL and/or they fail to reach suppression (not detected or <50 copies/mL) after being back on ARV therapy for several weeks ORDER A GENOTYPE (genosure MG on the form is usually the right test, but check with Angela, Elliot, Rob or me before ordering) and think about:

-Poor adherence: You need to consider this even if the patient reports perfect adherence
-Drug interactions: OTC and Rx drugs (such as acid reducing meds like PPIs, H2 blockers, Tums etc with Reyataz/Atazanavir.  Patients on Reyataz (AKA atazanvir) should NOT be on prescription or OTC meds that reduce gastric acid b/c this interferes with absorption of the ARV medication and could result in treatment failure),
Check out this website for more info on ARV interactions
-Resistance: need to check a genotype (typically need VL of at least 500 for this), also make sure to review ALL prior genotypes. 

In general it is best to order the genotype while the patient is TAKING their ARV medications.  The reason for this is that the mutated virus needs to comprise a certain amount of the total virus population in order for the mutation to be detected.  Many times once a patient is off their ARVs the virus reverts to wild-type   and the mutations, while still present are not able to be picked up by the genotype testing.  The selective pressure of the ARV medications will cause the population of virus with mutations to increase proportionally and therefore allow you to see them on the results of your genotype.

Once a patient develops a mutation to a drug it is PERMANENT even if you donà  à  à  à ¢  t see the mutation on a subsequent genotype test.  This is why it is important to look at ALL the genotypes that the patient has ever had when you are thinking about restarting or changing ARV medications.

To obtain genotype results you can call Monogram Biosciences at 1-800-777-0177 and they will fax all genotype results performed by their lab to you.  For genotypes ordered by non-Montefiore providers they require the patient to sign a release of information prior to sending you the results.  You can fax this release to 650-615-0177.  Both numbers are on the top of the genotype ordering form.

Completing the genotype order form
Please do not put a sticker on the genotype form.
Just fill in the patient name at the top.  Then fill out Dx 042, most recent VL and CD4 (They will not run the test without this information.  If you need a genotype for a new patient the lab can hold the specimen until the results of the CD4 and VL are back and then send the genotype once the results are ready).
Complete the physician information section and then choose the type of test you need.  Generally GenoSure MG is appropriate, but as I said check with Rob, Angela, Elliot or me before ordering if there are any questions.

It is also important to obtain records from previous providers just as

Case #2
Presented by Dr. Glover and Dr. Voyages

44 yo M with h/o AIDS, polysubstance abuse, sz disorder, depression, anxiety, and frequent disturbing hallucinations.  He has been seeing Dr. Glover regularly but is not adherent with his antipsychotic medications.  He also sees Dr. Voyages regularly but is not engaged in a formal treatment program.  Dr. Glover and Dr. Voyages have informed him that he needs more intensive psychiatric care beyond what we are able to offer at CHCC.  He is not interested in treatment for his heroin use.  He is insisting that if he is to obtain psychiatric care elsewhere it needs to be in Manhattan.  Norma Howard is in the process of making a referral to St Lukes comprehensive mental health program for him.  Dr. Voyages will provide Norma with a summary of his psych history and care so she can provide this for the intake process. 

HIV Precepting and HIV AMR concept
Since the HIV preceptor assignments have been instituted I have noticed that some residents are not regularly communicating with their HIV preceptors about their HIV positive patients.  I spoke with the residents who attended today's conference about how to best meet their educational needs as well as provide the highest quality of care for HIV patients cared for by residents.  The residents suggested that it should be mandatory that they communicate with their HIV preceptor every time they see an HIV positive patient.

I suggested the possibility of developing a new format for HIV AMR where on the day residents have AMR with me we go over their HIV positive patients even if they are doing fine as a learning tool.  I could develop a special form including CD4, VL, resistance mutations, opportunistic infections, PPD testing, SW referral, mental health screen, nutrition needs etc.  In addition we could go over any clinical questions they have about those patients.  Please let me know if you think this would be valuable for you and your patients. 

Our next case conference is Wed, April 20th from 1-2pm in the basement conference room.

As always you are welcome to contact me with any questions, problems or suggestions.


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