Warning

This lecture contains materials that

may be offensive to non-professional
viewers
Which of the following would not be
considered a normal aging change in the
skin?
a. Diminished hair
b. Reduced healing ability
c. Thickening of skin
d. Dryness of skin (Xerosis)
 Itchiness
Match the symptoms with types of medications:
1. H2 receptor antagonist
2. H1 receptor antagonist
3. NSAIDs
4. Methotrexate
5. Cyclosporin
6. Tricyclic anti-depressants
7. Gabapentine
8. 5HT3 receptor antagonist
Which drug is effective for Candida
infection only?
1. Clotrim-azole
2. Nystatin
3. Flucon-azole
4. Amphotericin B
Read:

Chapter 41: Management of Clients with Sexually

transmitted infections

Jordon, K. (2008). Sexually transmitted infections: a

major challenges for Advanced Practice Nurses.
Advanced Emergency Nursing Journal. 30(1), 63-
74.

Skin Cancers in Hong Kong

http://www.fmshk.org/database/articles/03mb7.pdf
Primary prevention of STI/HIV

 Syphilis: RR = 0.67***
 HSV 2: RR = 0.88*
 Chancroid: RR = 0.12-1.11 (n.s.)
Symptomatic treatment (WHO)

 Urethral discharge
 Genital ulcers
 Vaginal discharge
 Abdominal pain
 Scortal swelling: torsion of testes
 Inguinal bubo: LGV and lymphadenopathy
 Dysuria (painful micturition)
WHO, 2007
 Poor compliance of treatment to existing
guidelines ~ 70 - 75%
 Use of drugs of known resistance
 Use of new drugs that may possible
promote drug resistance

Wong, Chan &

Dickinson, 2005
SYPHILIS
Tertiary: It usually occurs after a latent period of 10-20 or more years.
1) Cardiovascular syphilis (3A)
a) Angina pectoris due to coronal ostial stenosis
b) Aortic incompetence
c) Aortic aneurysm (ascending aorta is the commonest site)
2) Neurosyphilis
a) Asymptomatic neurosyphilis: abnormal CSF
b) Meningovascular neurosypilis: occurs 3-7 years after infection,
affecting cerebral and/or spinal meninges.
c) General paralysis of insane (GPI)
- dementia with recent memory loss, loss of insight, euphoria with
delusion of grandeur, tremor, spastic paraparesis, convulsions,
incontinence and finally bed-ridden.
d) Tabes dorsalis
- pain in legs, paraesthesia, sensory ataxia, sensory loss in proprioception
and vibration, deep pain in Achilles tendon, absent reflexes, overflow
incontinence, Argyll Robertson (A-R) pupils, optic atrophy, Charcot's
joints and visceral crises.
e) Ocular syphilis
ocular atrophy, optic neuritis, chorioretinitis with pepper and salt fundus.
Colposcopy & High vaginal swab
Laboratory investigations: Dark field
microscopy for Syphilis
Charcot’s joint & A-R pupil

The pupils are small and irregular, they do not

react to light but react to accommodation.

Stamping gait & Romberg sign

Rapid Plasma Reagent & VDRL
 Treatment of Treponema pallidum
 Diagnosed by EIA (AIA), FTA-ABS (Bld + CSF) & MHA-TP
(Anitibody), RPR and VDRL (titre, non-treponemal) screening
test
 Case management
 Contact tracing / Rx (within 90 days and treat all potential cases)
 Syndrome management
 Ulcer
 Urethral discharge
 Chancre: 硬疳
Rx: Benzathine penicillin G (not Penicillin G) 2.4 million units
IMI (single dose) or x 3 dose weekly in late latent case > 2 year)
 Procaine Penicillin G 1.2 2.4 (NS) million units x 10-14 IMI
Doxycyclin 100 mg b.d. / t.d.s for 2/52
Azithromycin 2d po single dose CDC, 2015
Gonorrhea
Neisseria gonorrhoeae
Average incubation
period: 3-8 days
Close contact /STI
Local/systemic infection
 Gonorrhea
May be asymptomatic in women***
PID / UTI with purulent discharge Rx: single dose Ceftriaxone
250mg IMI (Cefixime
Epididymitis / Prostatitis in man 400mg po) PLUS
Conjunctivitis or pharngitis Azithromycin 1g p.o. x 1 or
Doxycycline 100 mg b.d. x
Proctitis / Dermatitis 1/52
Gonococcal bacteremia  septic arthritis
Endocarditis / Meningitis
Ophthalmia Neonatorum prophylaxis: Erythromycin (0.5%) ointment
Note: Quinolone resistance N. gonorrhoeae QRNG is common…
Non Gonorrhoea Urethritis (NGU)
Chlamydia trachomatis (Group D to K) 40%
Ureaplasma urealyticum 20-40%
Trichomonas vaginalis (rare) < 2%
Candidiasis (rare) < 2%
Herpes simplex (rare) < 2%
Secondary to bacterial urinary tract infection < 2%
Unknown 10-20%
Rx: Azithromycin 1g - single dose p.o. OR
Doxycylcine 100 mg b.d. x 1/52 (Erythromycin x infant x 2/52)
Trichomonas vaginalis
陰道毛滴蟲

flagellated protozoa also seen on PAP smear

 Trichomonas vaginalis
- Associated with adverse pregnancy outcomes,
premature rupture of membranes, pre-term
delivery and LBW infant
- MSP & increase frequency
- Yellow, frothy, odor, discharge, dyspareunia
Rx: Metronidazole 2g single dose or
500 mg p.o. b.d. x 1/52, avoid pregnancy and
alcohol use
Tinidazole 2g p.o. x 2
CDC, 2015
Bacterial vaginosis: not STI
 Also lead to adverse preganancy and
outcome
 Replacement of normal hydrogen peroxide-
producing Lactobacillus sp. by anaerobes
e.g. Mycoplasma and Gardneella
 Avoid use of antiseptic / vaginal
preparations / vaginal douching
 Rx: Metronidazole 500 mg p.o. b.d. x 1/52
& Tinidazole 1g/2g as above OR
Metonidazole/Clindamycin cream x 5-7/7
CDC 2015
 Lymphogranuloma Venereum
LGV 腹股溝淋巴肉芽腫
 Less common now
 caused by Chlamydia
trachomitis + …
  protocolitis and stricture

Rx: Doxycycline 100 mg

b.d. x 2-3/52 + surgery
Erythromycin/
Tetracycline
500 mg x 3/52
Summary for all STIs (Bacterial)
Nobel Prize for Medicine
Viral Infections : Warts
Caused by Human Papilloma Virus (HPV)
Common dermatological problem :
- Common Warts (Verruca Vulgaris): usual/common
- Flat Warts (Verruca Plana): face
- Plantar Warts: foot
- Ano-genital Warts (Condylomata Acuminata)
Hyperkeratotic Papules or Plaques
Benign
Chronic & slow growing may develop into low-grade
Squamous Cell Carcinoma
WARTS

Fleischer et al (2000)

Fleischer et al (2000)
Viral Infections : Warts
Treatment
Surgical Therapy :
Cryosurgery - Common & Relatively Effective
Electrodesiccation or curettage
Surgical excision
Carbon Dioxide Laser
Pulsed-Dye and Other Laser Systems

A Combination of treatment may be required for complete

resolution of the lesion
Viral Infections : Warts
Treatment
Topical Therapy :
Imiquimod cream 5%
Podophyllotoxin 0.5% solution or gel b.d. x 3 days (self
administer)
Podophyllin 10-25% in tincture benzoin: must avoid
normal skin and washed adjacent skins after 4 hr,
repeat x 1/52 (Provider administered)
Oral Therapy :
Cimetidine - Immune System Enhancer (RCT: n.s.)
Intralesional Therapy :
Bleomycin
Interferon 
Patient-applied: podofilox, imiquimod, or
 sinecatechins
Provider-applied: cryotherapy, podophyllin,
 trichloroacetic acid, bichloroacetic
 acid, or surgical removal
Gardasil (M+F since 2013 in AUS)
- is a vaccine indicated in girls and women 9 to 26 45
years of age for the prevention of cervical cancer,
precancerous or dysplastic lesions, and genital warts caused
by human papillomavirus (HPV)
Types 6, 11, 16, 18, 31, 33, 45, 52, and 58
- protects against 70% of HPV causing Ca cervix and 90%
of HPV causing genital warts
- achieve 50-60% reduction of genital warts reported x 3yr
in Australia
Cervarix:
- better protection against types 16 & 18 (Ca Cervix)
- other strains not known…but possible
- provided by NHS for routine vaccination
Gardasil, 2017 & GSK, 2008
Herpes simplex type II
Incubation period: 3-7 days
Burning sensation and vesicles
Healed by 2-4 /52 & recurrent in 1 year > 70%  Ca
cervix + spontaneous abortion
Investigations: viral culture and PCR
50 million cases in US and 1 million new cases in
one year
Rx: Acyclovir 200mg x 5 times , Famiciclovir 250
mg x 3 times x 5 (SHC) - 7 ~10 (WHO) days
Suppression therapy for clients with > 6 episodes per
year: Daily acyclovir 400m b.d. daily x …..
Miscellaneous Skin Diseases

- Infestation
Scabies
Pediculosis

- Vitiligo
- Alopecia
Scabies

Caused by a Mite - Sarcoptes Scabiei

A Human Parastie
Burrows tunnels downwards into the epidermis
Transmitted by Close Personal Contact
Epidemics in long-term health-care elderly people
Incubation – 3/52
Clinical Manifestations :
- Predominant nocturnal itchiness
- Scabious burrows with tiny vesicles at interdigital web
spaces of the hands
- Scabious nodules at genital organs or armpits
- Non-Specific 2o lesions are most common -
Excoriation
Eczematous Eruptions: rash
- Generalized crusted scabies in immuno-deficient clients
with prior blisters and pustules
Treatment: Ivermectin 200mg p.o. repeat in 2/52
Benzyl Benzoate Emulsion (BBE) 10% & 25% Lotions
BBE + Sulfiram 25% Solution
Permethrin 5% (once only application) 8-14 hrs then wash
Different Treatment Regimens :
- Swabbing Only Once
- 2 Applications Separted by
- 10 Minutes Interval
- 24 Hours Interval
- 1 Week Interval
Application to finger & toe, nails, scalp & face & behind
the ears
Scabies 疥瘡
- Change clothes & linen AFTER completion of the
Treatment
Side Effects :
Irritant on the Face & Genitals
Puritus and Eczematous Lesions
Individuals with close contact of the infested client,
even Asymptomatic should be treated at the same
time
Persistent itchiness up to 1-2/52 should be explored
Contact isolation
Flinders & De Schweinitz, 2004 in AFP
DermNet NZ Classic Scabies with Involvement of
Male Genitalia and inter-digital web
space
 The New England Journal of Medicine
(1996)

Pediculus Capitis
Pediculus Corporis
Pediculus Pubis
- blood sucking parasites
- nits hatch 6-10 Days  nymphs  adults
- direct or indirect contact
- Sexually Transmitted P. pubis are not prevented by using
Condom
Pediculosis 虱病
Treatment :
- Pyrethrin and Permethrin Lotion to Scalp
- leave on hair for 10 min before rinsing; second application
may be used in 1/52 prn
- remove dead lice & nits with fine -toothed comb
- risk of resistance with excessive application
- all linen, clothes, hairbrushes & hair accessories are
washed
- antipruritic corticosteroid & antihistamine
e.g. Eurax
KPA survey and actions in STI
Knowledge: Knowledge do not guarantee a desired
behaviour but do educate as they don’t know

Practice: you cannot change practice on one day and

do concentrate on harm reduction strategies that
work

Attitude: do not stereotype your clients and be open

to their own value and belief systems

TONG, 2008
 CDC 5 strategies and recommendations
 Education and counselling
 Identification of people with asymptomatic
infections and those not seeking medical
care
 Accurate diagnosis and effective treatment
 Evaluation and Rx of sexual partners
(within 60 days)
 Pre-exposure vaccination if a/v
CDC (2006). Sexually Transmitted Diseases Treatment Guidelines. Atlanta: CDC.
http://www.cdc.gov/std/treatment/SexualHistory.pdf
Assement & Investigations
 Read health assessment related to GU System and
Reproductive system
 Most of the common STIs may be asymptomatic

Investigations
- High Vaginal Swab, Urethral swab x C/St and cytology
- Blood for EIA / ELISA, VDRL (titre), PCR
- OMT: oral mucosal transudate  HIV
- Biopsy for possible malignancy / histopathology
- Urine for culture, PCR, microscopy
- X ray / USG / CT Scan
- Colposcopy using vaginal speculum
References
The Electronic Textbook of Dermatology http://www.telemedicine.org/stamford.htm
Buchanan, P. (1998). Dermatology. Nursing Standard. 12 (40), 48-55.
Centre for Disease Control and Prevention (2015). Sexually Transmitted Diseases Treatment
Guidelines. Atlanta, GA: CDC. http://www.cdc.gov/std/tg2015/tg-2015-print.pdf
Jackson, K. (2002). Chronic plague psoriasis: an overview. Nursing Standard. 16(51), 45-52,
54-55.
Jordon, K. (2008). Sexually transmitted infections: a major challenges for Advanced
Practice Nurses. Advanced Emergency Nursing Journal. 30(1), 63-74.
Jones, R. & Barton, R. (2004). Introduction to history taking and principles of sexual health.
Postgraduate Med J. 80, 444-446.
Freak, J. (2004). Promoting knowledge and awareness of skin cancer. Nursing Standard.
18(35), 45-56.
Price, B. (2005). Practical guidiance on sexual lifestyle and risk. Nursing Standard. 19(27),
46-52.
WHO (2007). Training modules for the syndromic management of Sexually transmitted
infections (2nd ed.). Geneva: WHO.
HIV & AIDS

Human Immunodeficiency Virus

It is not a matter that you like it or not. It is a must in your

practice. The advancement of the research in HIV has lead to the
development of new lab techniques, new study design and new
drugs not solely used in HIV only.
The only thing that hasn’t change is the mind set of some people.
Some people just go further and faster.
 HIV Epidemiology Facts
33.4 HIV
 36.7 Epidemiology Facts WITH HIV
MILLION PEOPLE LIVING

40% KNOW THEIR STATUS 2 1.1 MILLION

DEATHS THIS
5 million on therapy
YEAR

10 million waiting for therapy

2.7  2.1 MILLION
NEW INFECTIONS

UNAIDS Outlook Report | 2010

Injecting Drug Users and not Drug addicts
- Estimated to be 18513 (2001) -13204 (2006) from
Central Registry of Drug Abuse
- 61.7% use Heroin and 57.7% are IDUs (n=4700)
CRDA 56th report
- 9000 registered drug users of MMT & 7056 attendance in
2004 Lee, 2005

Men who have sex with men: MSM

- 2% (active) & 4.5% (life long) MSM by telephone
interview
- 34000 (2004 population)  42000 (2009) Lau et al, 2002
-  4% HIV +ve in PRiSM Study (2008)
PRSiM, 2010
-  same 4.08% HIV in 2010 and 5% Chlamydia
Global HIV prevalence in MSM, from studies published 2007–11

Chris B., Baral, S. D., van Griensven, F., Goodreau, S. M., Chariyalertsak, S., Wirtz, A. L. & Brookmeyer, R. (2012). Lancet. 380(9839), 367–
377.
Commercial sex workers CSW
- Ranged from 20,000 to 100,000 by
estimation
- At least 10,000  ~7000 by mapping
(geographical matching & from advertisement)
- 90% of them were come from China
- + 10,000  3000 arrest per year (majority
of mainlander) Work Group on HIV for CSWs & Clients, 2006
Client of FSW: 14% among all age groups
(~300,000)
Community Forum on AIDS, DH, 2012
HIV Replication and Life Cycle
http://www.youtube.com/watch?v=l-2ilZA-
_aw&feature=related

http://hk.youtube.com/watch?v=rqDkYJn7w9Y

https://www.youtube.com/watch?v=HhhRQ4t9
5OI
The HIV-1 life cycle and the antiretroviral drug class
intervention points
 Clinical manifestation of primary HIV
infection

(Kelley, Barbour & Hecht, 2007)

Frequency of self-reported acute HIV symptoms. Solid bars represent preseroconversion

subjects (n = 57), and hollow bars represent postseroconversion subjects (n = 120).
Nature Reviews Immunology 8, 447-457 (June
2008) | doi:10.1038/nri2302 HIV invasion site
Type of exposure Risk per 10000
exposure
Blood transfusion 9250
Needle sharing IDU 63
Needle stick 23
Sexual intercourse
Receptive anal 138
Insertive anal 11
Receptive Penile-Vaginal 8
Insertive Penile-Vaginal 4
Estimating per-act HIV transmission risk: a systematic review. AIDS. 2014
HIV Life cycle
 Stages of HIV
 CD4 & Viral load
 Opportunistic infections and AIDS
defining illnesses
 Diagnostic tests of HIV infection
HIV Life cycle

David A. C. (1994). Early antiretroviral therapy. AIDS, 8(supp 3),S9-S14.

Opportunistic infections & AIDS
defining illneses
STAGE 4:
Pulmonary tuberculosis (INAH, Isoniazid)
Extrapulmonary tuberculosis (excluding lymphadenopathy)
HIV wasting syndrome Unexplained weight loss (more than 10% within 6 months)
Pneumocystis carinii now Pneumocystis jiroveci pneumonia (Bactrim / Co-trimoxazole)
Recurrent severe or radiological bacterial pneumonia (2 or more episodes with 1 year)
CMV retinitis (+/-colitis)
HSV (chronic or persistent , ≥1 month)
Encephalopathy
HIV associated Cardiomyopathy
HIV associated Nephropathy
PML Progressive Multifocal Leukoencephalopathy
Kaposi's sarcoma & HIV related malignancies (IDU & MSM)
Toxoplasmosis
Disseminated Fungal infection (e.g. candida,, Coccidiomycosis, Histoplasmosis)
Cryptosporidiosis
Cryptoccocal Meningitis
Non tuberculous mycobacterial infection or Disseminated MOTT
Diagnostic tests
 EIA / ELISA: antibody test
 Western blot: confirmation
 HIV RNA level / Plasma viral load (PVL)
0 < 40/50 copies/ml (barely detetable)
Other tests
 CD4 count > 500/mL or 350/mL
 Other investigations for OIs
Prevention of HIV infection
 Mode of transmission
 S
 A
 V
 E
 A_B_C
Christian AID
Prevention of HIV infection
 Mode of transmission
 Safe practice
 Adherene to treatment
 Voluntary counselling and testing
 Empowerment
Christian AID

 Abstinence, Be faith & Condom use

Most US federal sponsored programmes
Antiretroviral drugs are broadly classified by the
phase of the retrovirus life-cycle that the drug
inhibits.
Nucleoside & nucleotide reverse transcriptase inhibitors (NRTI) inhibit
reverse transcription by being incorporated into the newly synthesized viral
DNA and preventing its further elongation.
Non-nucleoside reverse transcriptase inhibitors (nNRTI) inhibit reverse
transcriptase directly by binding to the enzyme and interfering with its
function.
Protease inhibitors (PIs) target viral assembly by inhibiting the activity of
protease, an enzyme used by HIV to cleave nascent proteins for final
assembly of new virons.
Integrase inhibitors inhibit the enzyme integrase, which is responsible for
integration of viral DNA into the DNA of the infected cell. There are several
integrase inhibitors currently under clinical trial, and raltegravir became the
first to receive FDA approval in October 2007.
Entry inhibitors (or fusion inhibitors) interfere with binding, fusion and entry of
HIV-1 to the host cell by blocking one of several targets. Maraviroc and
enfuvirtide are the two currently available agents in this class.
Maturation inhibitors: under investigation…
Initial Combination Regimens for the Antiretroviral Naive Patient
An antiretroviral (ARV) regimen for a treatment-naive patient generally consists of two nucleoside
reverse transcriptase inhibitors (NRTIs) in combination with a third active ARV drug from one
of three drug classes: an integrase strand transfer inhibitor (INSTI), a non-nucleoside reverse
transcriptase inhibitor (NNRTI), or a protease inhibitor (PI) with a pharmacokinetic (PK) enhancer
(booster) (cobicistat or ritonavir).
The Panel on Antiretroviral Guidelines for Adults and Adolescents (the Panel) classifies the
following regimens as Recommended regimens for antiretroviral therapy (ART)-naive patients:
Integrase Strand Transfer Inhibitor-Based Regimens:
• Dolutegravir/abacavir/lamivudinea —only for patients who are HLA-B*5701 negative (AI)
• Dolutegravir plus either tenofovir disoproxil fumarate/emtricitabinea (AI) or tenofovir
alafenamide/emtricitabine (AII)
• Elvitegravir/cobicistat/tenofovir alafenamide/emtricitabine (AI)
• Elvitegravir/cobicistat/tenofovir disoproxil fumarate/emtricitabine (AI)
• Raltegravir plus either tenofovir disoproxil fumarate/emtricitabinea (AI) or tenofovir
alafenamide/emtricitabine (AII)
Protease Inhibitor-Based Regimens:
• Darunavir/ritonavir plus either tenofovir disoproxil fumarate/emtricitabinea (AI) or tenofovir
alafenamide/emtricitabine (AII)
Recommendations:
 First-line ART should consist of 2
nucleoside reverse transcriptase inhibitors
(NRTIs) plus 1 non-nucleoside reverse-
transcriptase inhibitor (NNRTI).
 TDF + 3TC (or FTC) + EFV
 If contraindicated or not available, one of the
following options is recommended:
 AZT + 3TC + EFV
 AZT + 3TC + NVP

 TDF + 3TC (or FTC) + NVP

 RAL

TDF + FTC
Truvada
Atripla (EFZ)

ABC + 3TC DTG

 IAS-USA Guidelines: Recommended Third
Drug Component for Initial ARV Therapy
Central nervous system toxicity may be limiting
Efavirenz Standard-of-care comparator in many trials Potentially teratogenic in first trimester of
pregnancy
Available as a once-daily fixed dose with
NNRTI tenofovir/emtricitabine Associated with lipoatrophy when given with
thymidine reverse transcriptase inhibitors

Substantial clinical trial data and phase 4 experience

Lopinavir supporting efficacy Gastrointestinal adverse effects
Heat-stable tablet 1 or 2 doses per day for treatment-naïve Hyperlipidemia, especially hypertriglyceridemia
PI patients
Hyperbilirubinemia (UGT1A1-28 alleles and
T3435C polymorphism in MDR1 gene)
Atazanavir Noninferior to ritronavir-boosted lopinavir
Occasionally associated with nephrolithiasis
Less hyperlipidemia and diarrhea
Acid-reducing agents decrease atazanavir
PI Once-daily dosing
concentrations; proton pump inhibitors should be
used cautiously

Fosamprenavir Noninferior to ritonavir-boosted lopinavir Similar adverse effect profile to ritonavir-booster

lopinavir
Once-daily or twice-daily dosing possible; more robust data
PI with twice-daily dose Rash

Noninferior to ritonavir-boosted lopinavir and superior in

Darunavir those with viral load ≥ 100 000 HIV RNA copies/mL
Rash
Less nausea, lower triglyceride levels
PI 800mg + 100mg ritonavir once daily

Integrase Inhibitor (the only), more rpaid viral load decline

Raltegravir and not affecting the lipid profile as Pis, for resistance to other
ARTs
Hammer S, et al. JAMA 2008;300(5):555-570.
Newsworthy New Drugs
 Integrase: Raltegravir RAL)

 Fusion inhibitor: Maraviroc

(CCR5 receptor)
Screening for HLA-B*5701 & ABC
resistance: 0% in China & HKG

HLA-B27 Syndromes - Acute Anterior Uveitis & Ankylosing Spondylitis

Human Leukocyte Antigen
Sad failure of a promise: Vaccine
HIV as a chronic illness

Wohl: Top 10 HIV Clinical Developments of 2007

Incidence of non-AIDS Defining
Malignancies 1997-2004
 33,420 HIV+ and 66,840 HIV- veterans followed for median 5.1 and 6.4 years during 1997 to
2004
 Compared to HIV-, the incidence rate ratio (IRR) of non-ADM in HIV+ was 1.6 (95% CI: 1.5-
1.7).
 Compared to HIV+ without cancer, median CD4 counts were lower for those with non-ADM
(249 vs. 270, p=0.02), anal cancer (154 vs. 270; p<0.001), and Hodgkin’s (217 vs. 270; p=0.03).
 The rate of non-ADM declined among HIV-, but not HIV+, from 1998-1999 to 2000-2001
(p=0.03)

Incidence per Median CD4 cells/L

HIV+ to HIV-
Cancer Type Frequency 100,000 person (HIV+)
years IRR* (95% CI) Cancer
HIV+ HIV- HIV+ HIV- Yes No P-value
anal 195 29 111.2 7.4 14.9 (10.1-22.1) 154 270 <0.001
lung 503 604 287.4 155.5 2.0 (1.7-2.2) 246 269 0.2
melanoma 96 124 54.7 31.9 1.7 (1.3-2.3) 267 268 0.3
prostate 443 1042 254.8 271.8 1.0 (0.9-1.2) 310 267 <.001
Hodgkin’s 135 62 76.9 15.9 4.6 (3.6-6.6) 217 269 0.03
liver 172 144 97.8 36.9 2.8 (2.2-3.5) 271 268 0.3
*Adjusted for age, race and gender
All non-ADM2 2127 3139 1260.0 841.0 1.6 (1.5-1.7) 249 270 .02
Bedimo RJ, et al. 17th IAC; Mexico City, Aug 3-8, 2008; Abst. MOPE0243.
Individualized treatment plan
Considerations:
- include high viral load (>100,000 HIV
RNA copies/mL)
- rapid decline in CD4 cell count (>100/µL
per year)
- high risk of cardiovascular disease, active
hepatitis B or C co-infections
- presence of HIV-associated nephropathy.

Hammer SM, et al. JAMA. 2008;300:555-570.

Multi-Pronged Approach to Control
HIV Transmission Required
Pre-exposure prophylaxis,
Microbicides
STI
Treatm PEP
ent

Behavioral Antiviral
Change Therapy
Cohen, M. 17th IAC; Mexico City, Aug 3-8, 2008; Abst. TUPL0101.
Common symptoms: Hyperthermia

 Hypermetabolic state, OIs, Dehydrations,

side effect of medications, malnutrition and
sites for potential organism invasion
- non-pharmacological interventions
- Avoid tepid sponging
- Increase caloric and fluid intake
- Maintain comfort and safety

Black & Hawk, 2009

Fatigue
Hypermetabolic state, viral infections, muscle
wasting, anaemia, dehydration and psychological
and situational factors
- Promote self care and awareness by having a
daily fatigue diary
- Advise avoiding coffee, alcohol and smoking
- Promote sleep and avoid sleep interruption
- Conserve energy: sitting down to perform ADLs
- Plan activities ahead and an exercise schedule
- Natural techniques e.g. progressive relaxation and
acupressure
Black & Hawk, 2009
Nutrition: BMI < 18…
Side effects of medications and infections such as
anorexia, nausea, vomiting and altered taste,
impaired swallowing or chewing, diarrhea,
fatigue, depression and impaired cognition
- Prevent weight loss
- Increase dietary intake
- Increase availability of food
- Teach nutritional requirement

Black & Hawk, 2009

Acute pain and chronic pain
 Arthalgia, myalgia or neuropathy associated with OIs or
cancers, side effects of medications, co-morbidity such as
diabetic neuropathy or interventions
- Provide comfort measures and promote a sense of
normalcy and dignity during illness
- Provide physical therapy
- Administer pain medications and observe its EFFECT /
side effects
- Constipation may be a benefit in PIs
- Encourage use of complemntary therapy
- Cognitive behavioural therapy, elaxation, imagery…

Black & Hawk, 2009

Prevention of infections + +
- Observe for OIs
- CD4 count may reflect the possibility of
occurence
- Prophylaxis of PTB, PCP & MAC
- Mycobacterium avium intracellulare complex
(using azithromycin)
- Vaccination e.g. pneumococcal and
influenza
- Food and Drink (clean water)
 How would you enhance the compliance
of drugs in clients on HAART?
 education on effect and side effect of drugs
 ways to enhance compliance

 How would you prevent infections after

discharge?
 Airborne / contact / droplet
 Transmission based / standard precautions
HIV long term complications
 Protease inhibitors
 Insulin resistance: 20%  60 - 85%
 Dyslipidaemia: High TG & Low HDL
especially Ritovavir (RAL)
 Cardiovascular risk: 2 x men & 3 x women
 Interventions:
 Change regime or use Pravastatin only as it
is least affected by PIs except Atazanavir

Kirton, C. A. (2008). Managing long term complications of HIV. Nursing. 38(8) 44-51.
Osteoporosis
Dual Energy X ray Absorptiometry - Bone Mineral Densitometry

 Longitudinal analysis: followed-up for a median of 2.5 years, with follow-

up time exceeding 5 years for 105 patients.
 n = 391
 On their first DXA scan, 193 + 4 (49%) of those patients had osteopenia.
 Osteoporosis was detected on the initial DXA scan in 86 patients (22%).
 By the final study, osteoporosis was seen in 105 patients (27%).
 2.5% of the patients progressed to osteopenia between their first and final
DXA studies, and 15.6% progressed to osteoporosis.
 The risk factors most strongly associated with osteopenia or osteoporosis
in this patient population were male sex, advancing age, low body mass
index, and time on protease inhibitors or tenofovir.

Bonjoch and Bedimo, 2010

 Long Term Benefit of
Circumcision Rate of HIV Infection (Month 54)

 Extended follow-up of Kenyan P=0.0007

immediate vs. delayed circumcision
2.45
trial (N=2784)
 60% protection reported

# per 100 PY
 Trial unblinded 12/2006 and
circumcision offered to all 0.91
 89% reconsented to participate in
long-term follow-up study
 767 circumcised (Circ)
 785 uncircumcised (Uncirc) Circ Uncirc
 Uncircumcised offered Cumulative
circumcision throughout follow-up Incidence (%) 4.0 10.6

RR = 0.36, 95% CI 0.24, 0.55

Bailey RC, et al. 18th IAC; Vienna, July 18-23, 2010; Abst. FRLBC101.
 Efficacy of Quadrivalent HPV
Vaccine in Men
 Randomized, double-blind, placebo controlled trial of Quadrivalent
(6/11/16/18) HPV vaccine
• 3 doses (0, 2, 6 months)
 3,463 men ages 16-23; 602 MSM ages 16-26
• 1-5 partners in past year
• No history of genital warts
Per protocol analysis*
% 95%
Population, endpoint Quad vaccine Placebo Efficacy CI
Cases Rate Cases Rate
All subjects, external genital
3/1397 0.1 31/1,408 1.1 90.4 69.2, 98.1
lesions
MSM, 6/11/16/18-related AIN 5/299 1.3 24/299 5.8 77.5 39.6, 93.3
MSM, persistent HPV 0.6 per 4.1 per
15 101 85.6 73.4, 92.9
6/11/16/18 DNA 100 PY 100 PY

AIN = anal intraepithelial neoplasia

* Completed 3 injection series within time windows, endpoint after month 7.

Jessen H, et al. 18th IAC; Vienna, July 18-23, 2010; Abst. THLBB101.
Commitments and targets for 2015