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Management of HIV Infection

Management of HIV Infection. Donna E. Sweet, MD, AAHIVS, MACP Professor of Medicine Director, Ryan White Programs The University of Kansas School of Medicine - Wichita. Overview of The HIV Pandemic. There is…. One New Infection. Every 12 Seconds in the World

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Management of HIV Infection

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  1. Management of HIV Infection Donna E. Sweet, MD, AAHIVS, MACP Professor of Medicine Director, Ryan White Programs The University of Kansas School of Medicine - Wichita

  2. Overview of The HIV Pandemic There is…. • One New Infection... • Every 12 Seconds in the World • Every 9 Minutes in the United States • Every day in San Francisco

  3. Overview of The HIV Pandemic There were…. 1.2 Million People Who Started ARV Therapy in 2009 2 New Infections For Everyone Starting Therapy

  4. Number of People Living with HIV Continues to RiseJune 2, 2011 – MMWR The CDC reported that the number of people living with HIV continues to rise. That’s mainly because of highly effective drugs that allow people infected with HIV to live longer, healthier lives.

  5. Therapy Simplified - Once a Day Dosing Simplified Dosing: One Pill / Once a Day Stribild Atripla Complera Image Source: AIDS Info.org Image Source: AIDS Info.org Image Source: Photos.com

  6. “I’m very optimistic that we are going to increasingly see treatment being supervised by people other than the specialists” • Julio Montaner, member of the IAPAC TasP/PrEP Advisory Committee. Internal Medicine News, August 12, 2012

  7. Marty, a 27-Yr-Old Man • Marty is a 27-yr-old man who comes to you to establish you as his primary care physician • No significant past medical history • Employed as a service representative for a major financial services company • Drinks socially; does not smoke • Denies illicit drug use • States that he is single

  8. Based on current guidelines, would you recommend HIV testing for Marty? • Yes, all adult patients should be screened for HIV • No, prevalence of HIV in my area is low, so we do not test our patients • No, based on his history, he has no risk factors so he is not a candidate for testing • I would only test him if he requested it • No, HIV testing is not available at my practice

  9. Sexual Health History • You ask Marty if he has sex • He does • You ask Marty if he has sex with men, women, or both • He says, “Yes” • With further discussion you learn that Marty has been sexually active with men and women over the past 3 mos • He says he uses condoms “most of the time” • He had gonorrhea diagnosed more than 1 yr ago • He was last tested for HIV 5 yrs ago

  10. Who Should Be Tested for HIV?

  11. 2006 Recommendations From CDC: Routine Opt-Out Testing for HIV • Routine voluntary testing for patients aged 13-64 yrs in healthcare settings—not based on patient risk • Opt-out testing • No separate consent for HIV • Pretest counseling not required • Repeat HIV testing at discretion of provider, based on patient risk Branson BM, et al. MMWR Recomm Rep. 2006;55(RR-14):1-17.

  12. Additional CDC Recommendations • High-priority screening for • Patients who seek treatment for STDs • Patients beginning treatment for tuberculosis • Annual screenings in patients at high risk for HIV • IDUs and their sex partners • Persons who exchange sex for money or drugs • Sex partners of HIV-infected persons • MSM or heterosexuals who have multiple sex partners Branson BM, et al. MMWR Recomm Rep. 2006;55(RR-14):1-17.

  13. Benefits of Enhanced HIV Screening Program—Washington, DC • Number of HIV tested subjects increased from 19,000 to 73,000 between 2004 and 2008 after HIV testing campaign started in Washington, DC in 2006 • Median CD4+ cell count at the time of diagnosis increased 57% CD4+ Cell Count at Time of Presentation 400 343 336 350 296 275 300 250 216 Median CD4+ Cell Count (cells/mm3) 200 150 100 50 0 2004 2005 2006 2007 2008 Yr of Diagnosis Castel A, et al. CROI 2010. Abstract 34.

  14. Community Viral Load Mirrors Reduced Rate of New HIV Cases in San Francisco Das M, et al. PLOS 2010;5:e11068.

  15. Potential Barriers to HIV Testing • Insufficient time • Consent process • Precounseling requirements • Inadequate reimbursement • Posttest counseling requirements • Clinician lack of knowledge regarding sexual and drug-related risk behaviors • Fear/concern of offending the patient • Lack of educational materials to provide to patient Which of these are the most significant obstacles to routine HIV testing in your practice? Burke RC, et al. AIDS. 2007;21:1617-1624.

  16. Implementing HIV Screening in Primary Care Practices • Take systematic approach to integrating HIV screening • Include HIV test in listing of routine screening evaluations • Use reminder mechanism to prompt testing • Inform patients of opt-out screening procedures recommended by CDC as part of routine care • Educate patient that anyone who is or has been sexually active may be at risk for HIV • Assure patient of confidentiality (eg, HIPAA) based on local statutes and policies

  17. Entry Into Care After HIV Diagnosis

  18. Case Evolution: Test Results • Marty’s rapid HIV test is positive and blood is drawn that day and sent for combination HIV antibody and p24 testing • HIV positivity is confirmed and reported to the health authorities per state regulations • Given his risk behavior he was also screened for syphilis (RPR), gonorrhea (swab of throat and anus, urine for NAT), chlamydia (swab of anus, urine for NAT) • His RPR is reactive at 1:128 and confirmed with a treponemal test • This is also reported to the state communicable disease branch and he receives IM penicillin treatment

  19. Case: Posttest Counseling and Linkage to Care • You explain to Marty that HIV is treatable and not a “death sentence” • You share data that a young man such as he can expect to live decades with HIV and enjoy a high quality of life • Marty spends time with the clinic nurse counselor who reviews the meaning of the testing, explores Marty’s reactions to his diagnoses (both HIV and STI), and provides basic information on HIV transmission risk reduction approaches • The counselor establishes a rapport with Marty and emphasizes that the clinic staff including you, the clinician, are a team and will work together with Marty • You arrange for him to return in 10 days to discuss pending lab results including his CD4+ cell count

  20. Models of Successful HIV Management Systems “Blueprint” for HIV Treatment Success Retention in Care HIV Diagnosis Linkage to Care ART Receipt ART Adherence Clinical Outcomes Ulett KB, et al. AIDS Patient Care STDS. 2009;23:41-49.

  21. Improving Control of HIV Begins With Enhanced Detection and Linkage to Care • Data from CDC and Prevention National HIV Surveillance System used to calculate HIV prevalence, undiagnosed HIV prevalence, and linkage to HIV care N = 1,148,200 100 82% 941,524 80% 80 82% 757,812 66% 60 56% Patients (%) 89% 424,834 378,906 40 75% 37% 287,050 33% 20 25% 0 Diagnosed Linked to Care Retained in Care Prescribed ART Viral Suppression Hall HI, et al. AIDS 2012. Abstract FRLBX05.

  22. Linkage/Retention in HIV Care Associated With Improved Clinical Outcomes • Retrospective statewide study in South Carolina • Retention defined as ≥ 1 visit in each of four 6-mo periods over 2 yrs • Retention categorized as • Optimal (visits in 4 intervals) • Suboptimal (visits in 3 intervals) • Sporadic (visits in 1 or 2 intervals) • Dropout (no visits) 1.00 0.99 0.98 0.97 0.96 0.95 0.94 0.93 Probability of Survival 0.92 0.91 Retention in Care 0.90 Optimal Suboptimal Sporadic Dropout 0.89 0.88 0.87 0.86 0.85 0 3 6 9 12 15 18 21 24 27 30 33 36 Time to Death (Mos) Tripathi A, et al. AIDS Res Hum Retroviruses. 2011;27:751-758.

  23. NEW Recommendations • Systematic monitoring of successful entry into HIV care is recommended for all individuals diagnosed with HIV (II A) • Systematic monitoring of retention in HIV care is recommended for all patients (II A) • Brief, strengths-based case management for individuals with a new HIV diagnosis is recommended (II B) • Intensive outreach for individuals not engaged in medical care within 6 mos of a new HIV diagnosis may be considered (III C) • Use of peer or paraprofessional patient navigators may be considered (III C) June 5, 2012 Thompson M, et al. Ann Intern Med. 2012;156:817-833.

  24. Linkage to Care • Screening patients for HIV is only the first step • Referral to HIV specialist may be necessary for some patients • Establishing a relationship with an experienced HIV care provider prior to providing routine HIV testing is essential to ensure successful referrals • Implement procedures to ensure successful referrals • Follow-up to determine if referral appointment kept • Determine who will manage other primary care issues

  25. Retention in Care Associated With Better Outcomes • Data from University of Birmingham 1917 Clinic • Higher rates of early linkage to HIV care associated with achieving HIV-1 RNA suppression and lower cumulative HIV-1 RNA burden[1] • In multivariate analysis of different study, nearly 3x higher hazard of mortality among patients who missed a primary care clinic visit in the first yr vs those who did not[2] • HR: 2.90 (95% CI: 1.28-6.56) 1. Mugavero M, et al. J Acquir Immune Defic Syndr. 2012;59:86-93. 3. Mugavero MJ, et al. Clin Infect Dis. 2009;48:248-256.

  26. Case Evolution: Further Test Results • Marty returns in to clinic to receive results of routine tests

  27. Aberg J, et al. Clin Infect Dis. 2009;49:651-681.

  28. Case: Initial HIV Care • Vaccinated for influenza, pneumococcus, and HAV • Follow-up meeting with nurse counselor • Review questions and coping • Assess for depressive symptoms • Remind about measures to prevent transmission of HIV and acquisition of other STDs • Condoms given • Refer to support group at local AIDS Service Organization • Appointment made to return in 2 wks for results of genotypic resistance test and to consider HIV treatment

  29. HIV-Related Tests to Be Performed at Entry Into HIV Care • HIV parameters • CD4+ cell count • HIV-1 RNA • Genotypic resistance testing • HLA-B*5701, if considering initiation of abacavir; otherwise optional • Tropism testing, if considering initiation of maraviroc; otherwise optional • Others • CBC, chemistry profile • Fasting lipid panel • Urinalysis • Hepatitis A, B, C serologies • STD screening (gonorrhea, chlamydia, syphilis) • Consider serum, urine, anal, vaginal, and oral sampling depending on patient history • Pap smear for women if not done in last yr 1. DHHS Guidelines for Antiretroviral Therapy in Adults and Adolescents. March 2012. 2. Aberg J, et al. Clin Infect Dis. 2009; 49:651-681.

  30. DHHS Guidelines for Antiretroviral Therapy in Adults and Adolescents. March 2012.

  31. When Should Patients Be Referred to an HIV Specialist? Consider the Following • Acute HIV • Transmitted drug resistance • Pregnant women • Those with malignancies • Viral coinfection • Infection with HIV-2 • Patients who may benefit from resources available at a multidisciplinary center dedicated to HIV care, such as adherence and drug counselors; psychiatric, gynecologic, and dental services; financial counseling; and peer and group support • Or, whenever you feel the challenges are beyond your capabilities

  32. Local Healthcare System-Level Steps • Visit AAHIVM Referral Link to find an HIV provider near you • Inquire about HIV programs in your area • Contact local AIDS service organizations for information on HIV clinicians in your area

  33. The Mountain-Plains AETC

  34. Retention in Care

  35. Case Evolution • Marty fails to report for his appointment to review genotype and discuss starting HIV therapy • What do you do when HIV-positive patients miss appointments? • What systems do you have in place to remind people of upcoming appointments?

  36. CDC: Largest Drop in Treatment Cascade Occurs in Retention in Care • Data from CDC National HIV Surveillance System used to calculate HIV prevalence, undiagnosed HIV prevalence, and linkage to HIV care N = 1,148,200 100 80 82% 66% 60 Patients (%) 40 37% 33% 20 25% 0 Diagnosed Linked to Care Retained in Care Prescribed ART Viral Suppression Hall HI, et al. AIDS 2012. Abstract FRLBX05.

  37. Predictors of Poor Linkage, Appointment Adherence, or Retention in Care • Demographic characteristics • Younger age • Female sex • Racial/ethnic minority status • No or public insurance • Lower socioeconomic status • Rural residence • No usual source of care Giordano TP. 2010 Ryan White HIV/AIDS Program Clinical Conference.

  38. Predictors of Poor Linkage, Appointment Adherence, or Retention in Care • Disease severity • Less advanced HIV disease • Fewer non-HIV comorbidities • Psychosocial characteristics • Substance use/HCV coinfection • Low readiness to enter care • Less social support • System and patient factors • Less use of ancillary services/greater unmet need Giordano TP. 2010 Ryan White HIV/AIDS Program Clinical Conference.

  39. Recently Published Interventions in HIV Primary Care Settings • Special Projects of National Significance Outreach Initiative[1] • Nonrandomized intervention • 10 demonstration sites to implement and evaluate strategies to engage and retain underserved populations living with HIV/AIDS in HIV primary medical care • ARTAS-I (2005)[2] and II (2008)[3] • Randomized controlled trials on case management strategies as a way to improve linkage to care • ARTAS-I in university settings; ARTAS II in community-based organizations 1. Rajabiun S, et al. AIDS Patient Care STDS. 2007;21(suppl 1):S9-S19. 2. Gardner LI, et al. AIDS. 2005;19:423-431. 3. Craw JA, et al. J Acquir Immune Defic Syndr. 2008;47:597-606.

  40. SPNS Model for Opportunities to Improve Adherence to Care Persons in Care Interventions to Prevent Falling Out of Care Pivotal Points Opportunities Interventions to Engage in Care Persons Unstable in Care Rajubiun S, et al. AIDS Patient Care STDS. 2007;21(suppl 1):S9-S19.

  41. Techniques Used to Improve Retention • Case management (eg, strengths model) • Clinic appointment reminders • Help with appointment scheduling and rescheduling • Service coordination via a “system navigator” or “buddy” • Mental health counseling and treatment • Substance abuse counseling and treatment • Housing assistance • Food and nutrition support • Transportation

  42. Recommendations for Improvement of Processes • Track no-show rates and patients out of care • Bringing patients back is much more difficult once they are completely out of care • Work with ED and inpatient services, community-based organizations, public health agencies, jails/prisons, other RW providers to identify those who have dropped out of care and build or strengthen relinkage processes • Build or strengthen outreach or peer navigator programs Giordano TP. 2010 Ryan White HIV/AIDS Program Clinical Conference.

  43. Recommendations for Improvement of Processes • Work with the resources you have • Have staff and peer counselors advocate with patients for retention • Improve the client’s experience • Minimize unmet need: strengthen substance use, mental health, case management, and social services • Minimize time between appointment making and appointment date • Pilot wider appointment availability, open access to clinic Giordano TP. 2010 Ryan White HIV/AIDS Program Clinical Conference.

  44. Case Evolution • Your front desk staff leaves a message on Marty’s home phone asking him to reschedule his missed appointment • No response • Nurse counselor, however, sends a text message to Marty’s cell phone to which he responds and then calls him on a Monday, a day she knows Marty does not work • Marty states he was too stressed out to come to the visit. He has had a tough time disclosing his HIV status to friends and family • Nurse convinced him to come to clinic the next day to talk. They work out a disclosure plan and a referral to a local psychologist

  45. You Can Do This!

  46. Slide #50 HJ, a 31-Yr-Old Newly Diagnosed HIV-Positive Adult • 31-year-old black woman who went for her biannual women’s health visit • Diagnosed with HIV infection based on a routine HIV test • Upset upon learning about her HIV diagnosis • Baseline CD4+ cell count: 843 cells/mm3; HIV-1 RNA: 12,350 copies/mL • HIV genotype: no resistance mutations detected

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