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Gregory S. Felzien, M.D. AAHIVSDiplomat: Internal Medicine and Infectious Disease
Georgia Department of Public HealthMedical Advisor
Division of Health Protection/IDI-HIV
November 19, 2014
HIV Adherence & Resistance to Medications
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Disclosure
ve no vested interests that relate to this presentation
Nor do I have any relationships with;pharmaceutical companiesbiomedical device manufacturersand/or other corporations
Whose products or services are related to pertinent therapeutic areas
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Learning Objectives
Discuss Perceived and Actual Barriers to Care/Adherence
Challenges in care within healthcare systems
Barriers to receive, engage, and retain individuals in care
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Guidelinesptimal ARV regimen for treatment-naive2 NRTIs + a drug from one of 3 drug classes: NNRTI, boosted PI, or an INSTI
cognizant of interpreting statementsrequires use of ARV regimens with at least 2, preferably 3, active drugs from 2 or more drug classes
ents should receive 3 active drugs from 2 or more classes multiple studies:
• dual therapy does not offer long-term HIV viral suppression
all of the recommended regimens in the guidelines • contain 3 medications from at least 2 classes of HIV medications • do not recommend mono or dual therapy
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Treatment Interruptions
opping Meds for a short time (<1 to 2 days) medical/surgical procedures
opping medications for > 2 days can place the client at risk for developing resistanceeach component is metabolized at a different rate stopping all drugs simultaneously
• may result in functional monotherapy
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Half-Life
andout Page 3
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Additional Issues
ct adherence is key:
sustained HIV suppression
reduced risk of drug resistance
improved overall health
quality of life, and survival
decreased risk of transmission
critical determinant of long-term outcome
• Poor adherence:
– major cause of therapeutic failure
• Skipping medications– easier for drug resistance
– limiting treatment options
– increased risk of transmission
– increased rate of hospitalization
– longer hospital stays
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hallenges, Needs and Resources
ternal and External Barriers
ducation
ase Management
elivering Standard of Care
esources & Community Partners
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Educationigma & Discrimination
enial, fear, low self-esteem
isinformation / Mixedfamily, friends, churchproviders, work, media
strust of the system
egal issuesTitle 16-5-60
• Hawthorne Effect
• STDs & safe sex
• Pharmacy issues– Understanding medications– Refilling medications
• Clinic policies– Calling for appropriate medical issues– Avoiding refilling ART i.e. ER
• Knowing one’s health– CD4 / viral load
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Case ManagementLife 101”
nstructured lifestyle
ear of disclosure
ck of supportfamily, friends, churchproviders, work, media
oss of entitlements/insurance
consistent access to careIncarceration
• Transportation
• Housing
• Daily necessities
• Inaccessible clinics– Hours of operation– Travel for specialist
• Substance use & abuse
• Disbanding myths
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Transition Spots in Life
Family & Household Changes
Puberty
Dating
Use & Abuse of new substances
Sexual Debut
Family Planningexual Identity
Graduation
try into college & work force
Change in health status
Pregnancy & Parenting
alth insurance Marriage
Death – family/friends
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Delivering Standard of Careultural competency
ender issues
ostitution / Parthenon house
ex education: mixed messagesfamily, friends, churchproviders, work, media
o-morbiditiesMental health
scuss alternative careAvoiding hydrogen peroxide
• Improving communication– Provider & client– Provider & provider
• Keeping abreast of guidelines
• Avoid filling other provider meds
• PEP• PrEP• Treatment as prevention
• TeleHealth
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esources & Community PartnersPUS
alth Inform Exchange
source HUB
igent Care Clinics
ing
entionClients & Staff
ctronic Health RecordsCan be a barrier
b announcementsNO HIV CARE
• www.panfoundation.org• www.panfoundation.org/hiv-aids• health.state.ga.us/programs/st
dhiv/adap.asp• www.rxassist.org• www.needymeds.org • www.goodrx.com• www.rxoutreach.org• www.publix.com/pharmacy/fre
e-medications.do
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Georgia DPH Resource HUB
https://www.gacapus.com/p/
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Persons with HIV Engaged in Selected Stages of the Continuum of Care, United States
82
66
37 3325
Hall et al. XIX International AIDS Conference, 2012ART, antiretroviral therapy
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Cases
me Now – Some Later
Call: Wrong Med
ong Dr. – Wrong Orders
ong Dose – Wrong Dr.
• Shipping delay: “no big deal”
• ER: “Just Fill It”
• Pregnant: 5 is better than 3
• Who knows who wrote for that
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Virtual Genotype/Phenotype
andout page 4
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Thank youGregory S. Felzien, M.D. AAHIVS
Diplomat: Internal Medicine and Infectious Disease
Georgia Department of Public HealthMedical Advisor
Division of Health Protection/IDI-HIV
November 19, 2014
African Proverb
If you want to go quicklyGo Alone
If you want to go furtherGo Together