Hiv & gay men over fifty - leonard alberts md

• HE, 63 yo retired gay male schoolteacher. MI at age 46, angioplasty. Smoker, drinker, in allegedly monogamous relationship for 20 years until 2001. Multiple male partners after he discovers Viagra. • On Zocor, Atenolol, HCTZ, Trental. Primary care • Cholesterol fairly well controlled, as is blood • Comes to see me with thrush.
• HIV tested for first time, HIV +, CD4 168, vl • Begun on Viread, Epivir, Sustiva• Major psych problems, exacerbation of depression with Sustiva, switched to Viramune • Rapid development of abnormal LFTs with • Switched to Kaletra, continues on Epivir and Viread. VL <50, CD4 224, but cholesterol rises to 275, and Triglycerides to 312, switched Zocor toLipitor.
• Cholesterol down to 225, but minimal change in • Depression better, but having trouble following low cholesterol diet, and still smoking and drinking • Awakens, after a night of “partying” with negative, MRI: Small Occipital infarct.
• Now stable on Plavix, Kaletra switched to • VL <50, CD4 267.
• Stay tuned• 17 % of people living with HIV > 50 y.o.
– Psych effects of Efavirenz– Hepatotoxicity of Nevirapine – Metabolic effects– ? Advantages of Atazanavir • Aging Immune System• Androgen Deficiency (Hypogonadism)• Cardiovascular Risk Factors – Atherosclerosis– Hypertension– Smoking– Substances ( Including Viagra) • Depression• Wasting/Anorexia/Nutritional Issues • Male gonadal dysfunction• Low testosterone levels/insufficient testosterone secretion• Results from insufficient testosterone secretion• Associated with: – Primary testicular failure1– Hypogonadotropic hypogonadism1– Other combined or individual conditions2 1. Winters SJ. Arch Fam Med. 1999;8:257-263.
2. Tenover JL. Endocrinol Metab Clin North Am. 1998;27:969-987. • Muscle mass ↑• Muscle strength ↑• Fat mass ↓• Bone mass ↑• Libido ↑• Erectile function ↑• Sense of well being ↑↓ = decrease; ↑ = increase Tenover JL. Endocrinol Metab Clin North Am. 1998;27:969-987.
• Regression of secondary sexual characteristics Tenover JL. Endocrinol Metab Clin North Am. 1998;27:969-987.
Initial Tests:• Plasma total testosterone – Measures free plus protein-bound fractions– Morning sample recommended1– <300 ng/dL (10 nmol/L) suggests hypogonadism*2 – Measures non-protein–bound testosterone fractions– Recommended in older patients– <50 pg/mL (173 pmol/L) suggests hypogonadism*3 1. Tenover JL. Endocrinol Metab Clin North Am. 1998;27:969-987.
2. Hypogonadism Task Force. Available at: www.aace.com/clin/guides/hypogonadism.html. Accessed on June 22, 2000.
3. Braunstein JD. In: Greenspan FS, Strewleter GJ, eds. Basic & Clinical Endocrinology. 5th ed. Stamford, Conn: – To ascertain whether cause is primary or secondary – High prolactin levels may suggest presence of Tenover JL. Endocrinol Metab Clin North Am. 1998;27:969-987.
– To ascertain whether cause is primary or secondary – High prolactin levels may suggest presence of Tenover JL. Endocrinol Metab Clin North Am. 1998;27:969-987.
• Restore libido and improve erectile function1-3• Improve lean body mass2,3• Decrease total body fat3• Improve bone density1,2• Improve psychological disposition1-3• Improve energy level3• Improve mood/sense of well being2,3 1. Hypogonadism Task Force. Available at: www.aace.com/clin/guides/hypogonadism.html. Accessed on June 22, 2000.
2. Tenover JL. Endocrinol Metab Clin North Am. 1998;27:969-987.
3. Wang C, Swerdloff RS, Iranmanesh A, et al. JCEM. 2000;85:2839-2853.
• Known or suspected prostate cancer1• Male breast cancer1• Women (patches, gel)2-4 1. Hypogonadism Task Force. AACE clinical practice guidelines for the evaluation and treatment of hypogonadism in adult male patients. Available at: www.aace.com/clin/guides/hypogonadism.html. Accessed on June 22, 2000.
2. Unimed Pharmaceuticals, Inc. AndroGel® (testosterone gel) 1% CIII product information.
3. Testoderm® TTS, Testoderm,® and Testoderm with Adhesive product information. Physicians’ Desk Reference. 54th ed. Montvale, NJ: Medical Economics Co; 2000:515-518.
4. Androderm® product information. Physicians’ Desk Reference. 54th ed. Montvale, NJ: Medical Economics Co; 2000:3170-3172.
• Increased rates of STD Transmission• Increased use of party drugs• Undiagnosed HIV infections • Safe sex “fatigue”• Safe sex vs. “safer” sex• Depression• Barebacking – 541 tests; 18 new cases, 2 chronic cases, 3 false positives – 117 cases in 2000– 282 cases in 2001 (93% male) • Median age 35• Increases in ALL ethnic groups• 79% MSM – 75 % more than one sex partner– 48% HIV +– 36% used alcohol or drugs combined with sexual • 31% clubs• 22% public cruising sites• 14% Internet chat rooms• 11% bathhouses• 5% exchanged sex for money • Syphilis outbreaks also in Seattle, Chicago, San • Concomitant increases in gonorrhea• Factors involved – HAART availability– “AIDS burnout”– Alcohol and drugs– Misperception of risks– Unrecognized HIV infection • 433 HIV+ MSM monitored prospectively with anal pap, colposcopy (high resolution anoscopy), and Bx of any visible lesions; baseline and • 12% AIN-3 at baseline• Prevalence and incidence higher in pts on HAART, despite correcting • Screening to identify and treat AIN should be considered for all HIV+ • 3 cases of invasive anal neoplasia in men over 50 in Ptown • 592 HIV patients in Alabama• Interviewed in private rooms in clinics by trained – sociodemographics – Drug history and current meds– Sexual history (#of partners, type of intercourse, frequency of intercourse, frequency of condom use) • Data divided into MSM, MSW and women• Participants on PI’s were 2X more likely to • 1.6x more likely to inconsistently use • MSM on PI, 4x more likely to never use, • Intentional anal sex without a condom with a man • Any unprotected anal intercourse• Raw sex• San Francisco survey of 554 MSM – 28% African-American, 27%Latino– 79%gay, 21%bisexual– 14% barebacked in past 2 years– Median # of partners 3gay-10bisexual • Greater physical stimulation• Emotionally closer• Do something taboo or racy• Take a major risk; be daring• Don’t like condoms• High on drugs and/or alcohol• Move on with life • GHB and metabolites• Crystal methamphetamine• Ketamine• Cocaine• Ecstasy• Viagra • Abstinence• Oral sex with condoms• Anal sex with condoms• Oral sex with cum• Topping without condom• Bottoming with condom• Sex while high• Not asking status• Bottoming without condom• Taking multiple “loads” – 0.82% (partner +)– 0.27 % (partner unknown) – 0.06 % (partner +)– 0.04% (partner unknown) – 8/123 new cases attributable to oral sex– 7/8 took cum in mouth and had poor dentition • 40% with cum in mouth• 20% with HIV + partners • Near linear reduction of HIV transmission • Serum viral load < 1500 decreases risk of • Maintain STD surveillance• Immunize for Hep A and Hep B• Offer PEP when appropriate• Maintain oral health• Screen for and treat depression• Maintain regular visit schedule• Educate about substances • 49% female• 62 % African-American• 35% Hispanic• 3% white• 2% MSM – 40% unprotected sex despite knowledge of HIV • 25% had a new STD after HIV infection• 50% traded sex for money and/or drugs• 40% used IV drugs prior to HIV Dx• 15% continued IV drugs after Dx • 38 yo male, acute ARS after multiple male • Viral load decreased from > log6 to <200.
– Rebounded to 200,000 after STI; but had several – Viral studies conclusively demonstrate superinfection – Safe sex still a necessity for HIV positive patients • Transmission of resistant virus• Boston Statistics• 20% of acutely infected have some resistance• Chronically infected

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