COVID-19, the BC-CfE Response Acknowledgements We acknowledge with - - PowerPoint PPT Presentation

Welcome to the BC-CfE Special Webinar

COVID-19, the BC-CfE Response

Acknowledgements

We acknowledge with gratitude that our place of work is within the unceded traditional home lands of the Musqueam, Squamish, and Tsleil-Waututh Nations.

Webinar Main Objectives

• An update on BC-CfE’s position regarding the COVID-19

pandemic

• An overview of the COVID-19 pandemic, clinical

presentations and prevention

• Update on the BC-CfE’s precision medicine testing

services in view of the COVID-19 pandemic

• Information on what the BC-CfE is doing to facilitate

access to ART in view of the COVID-19 pandemic

Presenters

• Dr. Julio Montaner

Executive Director & Physician-in-Chief BC Centre for Excellence in HIV/AIDS

• Dr. Peter Phillips

Clinical Professor Division of Infectious Diseases, University of British Columbia

• Dr. Zabrina Brumme

Laboratory Director, BC Centre for Excellence in HIV/AIDS Professor, Faculty of Health Sciences, Simon Fraser University Scholar, Michael Smith Foundation for Health Research Junine Toy, Pharm D Senior Manager, BC Centre for Excellence in HIV/AIDS Drug Treatment Program Clinical Pharmacy Specialist, St. Paul’s Hospital

A Brief Update

• n the BC-CfE’s activities

during the COVID-19 Pandemic

Julio Montaner, OC, OBC, MD Executive Director & Physician-in-Chief, BC-CfE March 25, 2020

Slides and related information are available at: http://cfenet.ubc.ca/

March 20th 2020 DHHS - Interim Guidance for COVID-19 and Persons with HIV https://aidsinfo.nih.gov/guidelines/html/8/covid-19- and-persons-with-hiv--interim-guidance- /0?utm_source=AIDSinfo&utm_medium=email&utm_cam paign=3-20-20-COVID19_Guidance The following is a summary of the key messages, which are in keeping with the BC-CfE guidance

* PLWH >60 y.o. and those with DM, hypertension, CVD,

• r lung disease (incl’ chronic smoking) are at high risk of

severe/life-threatening COVID-19 * Limited data available do not suggest HIV under effective ART changes the course of COVID-19 * However, until more is known, additional caution for all PLWH, especially those with advanced or poorly controlled disease, is warranted.

General Guidance

* PLWH should follow all applicable recommendations to prevent COVID-19, such as social distancing and proper hand hygiene * Influenza and pneumococcal vaccinations should be kept up to date

General Prevention

* Maintain ≥90-day supply of ARVs and other medications * Defer any elective ART changes until close follow-up and monitoring are reliably available * LPV/r has not been shown effective as treatment for COVID-19 and further RCTs are underway, globally

• In an open-label trial, 199 hospitalized pts with COVID-19 were

randomized to 14 days of LPV/r plus SoC or SoC alone. There was no statistically significant difference re: time to clinical improvement or

• mortality. NEJM March 19th 2020

* Effective ART should not be switched to a PI based regimen to prevent/treat COVID-19

Antiretroviral Therapy

* Encourage telephone or virtual visits for routine or non- urgent care and adherence counseling * PLWH on ART, with a consistently undetectable plasma HIV viral load and in stable health, should be encouraged to defer routine medical and laboratory visits

Clinic or Laboratory Monitoring Visits

* Maintain ≥90-day supply * Encourage telephone or virtual visits * Defer routine medical and laboratory visits

Note: PrEP is not anticipated to have an impact on COVID-19

Pre-Exposure Prophylaxis (PrEP)

COVID-19 Clinical Prevention, Presentation and Management

Peter Phillips, MD, FRCPC Division of Infectious Diseases, St Paul’s Hospital March 25, 2020

• 1. Vaccine (none)
• 2. Antiviral prophylaxis (none)
• 3. Public Health Interventions

Containment & Mitigation – case finding isolation – contact tracing quarantine – high risk travel quarantine – social distancing, school closures etc. – mass quarantine (“lockdown”)

COVID-19 Prevention

Mitigation: – flattening the Curve

Total Coronavirus Cases in Canada

Daily New Cases in Canada

Fever 94% Cough 79% Sputum 23% Diarrhea 5% Nausea /vomit 4% (URTI symptoms ?)

Zhou F et al. Lancet March 9th 2020

COVID-19 Clinical presentation

COVID-19 mortality rate by age

1. Supportive

• oxygen
• ICU, +/- ventilator, +/- ECMO

2. Investigational

• antiviral therapy

– remdesivir – hydroxychloroquine +/- azithromycin – lopinavir-ritonavir – tocilizumab (IL-6 inhibitor)

• immunotherapy

– convalescent plasma

COVID-19 Management

Update on the BC-CfE’s precision medicine testing services during COVID-19

Zabrina Brumme, PhD Director, BC-CfE Laboratories March 25, 2020

Key information in today’s presentation is available at: http://cfenet.ubc.ca/

Key information has also been emailed to provincial labs and mailed to all HIV care providers in British Columbia

The BCCfE’s HIV precision medicine testing service IS OPERATIONAL, however:

• 1. We request that health care providers limit test requests to
• nly those urgently needed to guide clinical care. Please defer

non-essential requests to a later date.

• 2. The BC-CfE Laboratory will be temporarily reducing the

routine availability of some of our Precision Medicine tests.

• 3. We aim to maintain our standard turnaround times, but

delays in reporting may occur.

The BC-CfE will continue to routinely perform the following essential precision medicine tests:

• Genotypic testing for resistance to HIV Protease Inhibitors,

NRTI and NNRTI

• Genotypic testing for resistance to HIV Integrase Inhibitors
• HLA-B*57:01 genotyping for abacavir hypersensitivty reaction

The following tests will not be routinely available, but will be performed if urgently needed

• HIV gp41 resistance testing for enfuvirtide (T20)
• RNA and proviral DNA-based HIV genotypic co-receptor

tropism testing for maraviroc

• Therapeutic Drug Level Monitoring and Untimed Drug Level

testing of HIV antiretrovirals

• HCV genotypic drug resistance testing

Please contact the BC-CfE lab at 1-800-517-1119 if you urgently require any of the above tests

Scenarios where tests should still be

• rdered

Tests required to make critical treatment decisions should be ordered. These include, but are not limited to:

• Resistance testing of a patient's first positive pVL sample to decide an

initial regimen

• Resistance testing in patients failing therapy with pVL > 250 copies/ml
• Resistance testing required to support treatment switches in patients

experiencing toxicity or other adverse events

• Any test required to support treatment decisions in hospitalized patients.

Contact us if necessary.

Scenarios where testing could be deferred

These may include, but are not limited to:

• Tests in samples with low-level viremia (including transient

"blips" or persistent low-level viremia below 250 copies/mL)

• Retrospective testing of archived specimens to support

treatment change decisions in patients with suppressed viremia who are not experiencing adverse events (i.e. "elective" therapy changes or treatment simplification)

A request RE: specimen courier deliveries to BC-CfE

The BCCfE requests that clinics and labs sending specimens by courier alert us to incoming shipments. Please provide the courier name and tracking number to: lab@cfenet.ubc.ca

Requests from labs doing COVID-19 testing in BC:

• 1. Please limit routine viral load testing for these viruses:

HIV EBV BK HBV HCV Routine CMV viral load testing should proceed as normal. This is to reserve instrument/reagent capacity for COVID-19 testing

• 2. Please defer all non-essential serology.

Note: BCCDC has temporarily halted routine HCV antibody, RNA and genotyping. HCV antibody and RNA will continue to be performed for those hospitalized and those requiring organ donor testing

• 3. Please do not phone COVID-19 testing labs for results.

Outpatients can access COVID-19 results through my ehealth

HIV Treatment and Prevention Programs Access to Antiretrovirals

Junine Toy, Pharm D Senior Manager, BC-CfE Drug Treatment Program March 25, 2020

Objectives

• 1. An update on BC-CfE’s position regarding the COVID-

19 pandemic

• 2. An overview of the COVID-19 pandemic, clinical

presentation and prevention

• 3. Update on the BC-CfE’s precision medicine testing

services in view of the COVID-19 pandemic

• 4. Information on what the BC-CfE is doing to facilitate

access to ARVs in view of the COVID-19 pandemic

HIV treatment HIV prevention PrEP PEP

BC-CfE Drug Treatment Program

• St. Paul’s Hospital Ambulatory Pharmacy

Central program operations as per usual …

BC-CfE HIV treatment and prevention programs

ARV Dispensing Pharmacies in BC

Vancouver

• St. Pauls Hospital (SPH) Ambulatory Pharmacy

Ph: 604-806-8151 (M-F) Downtown Clinic Pharmacy *clinic patients only Ph: 604-216-4257 (7d/wk) Fax: 604-216-4270 BC Children’s Hospital Ambulatory Care Pharmacy Ph: 604-875-2205 (M-F) Fax: 604-875-3063 Victoria Royal Jubilee Prescriptions Ph: 250-370-8153 (M-F) Fax: 250-519-1823 Nanaimo Nanaimo Regional General Hospital Pharmacy Ph: 250-740-6924 (M-F) Fax: 250-740-6934 Kelowna Lakeside Medicine Centre Ph: 250-860-3100 (M-Sa) Fax: 250-860-3104 Other Designated community pharmacy, prescriber office,

• ther healthcare facility

Arrange by calling SPH

Contingency ARV supplies @ BC Correctional facilities, Northern Health Sites http://www.cfenet.ubc.ca/drug-treatment-program/how-obtain-hiv-medication

Check for updates at cfenet.ubc.ca

Check for updates at cfenet.ubc.ca

Facilitating ARV access

– Medication supply

• Increased drug inventory
• Communication with vendors
• Monitoring drug shipments, drug shortages

– Temporary adjustments to ARV medication dispensing

• Larger dispensed quantities for stable clients
• Preparation of medication in advance when possible
• Check cfenet.ubc.ca for updates

– Clinics, providers, supporting community pharmacies, please

• Communicate changes in your hours of operations, patient

management

• Provide ARV prescriptions for your patients directly to program

Prescribers

• Fax ARV refill prescriptions to SPH or designated pharmacy in

advance whenever possible

• Specify medication pick-up date if known
• Provide adequate time for medication preparation
• 3 days for pick-up
• 7 days for courier
• Defer routine, non-essential HIV viral load testing up to 6

months in stable, virologically suppressed PLWH on ART

• Extended supply provided to stable clients
• Refrain from elective, non-urgent regimen changes (e.g.

simplification)

Prescribers

• Do not defer regimen change if medically needed

– Treatment failure – Adverse reaction – Clinically significant drug interaction

• When HIV viral load testing is advised

– Baseline testing in a person newly diagnosed with HIV infection – After ART initiation, until virologically suppressed – If poorly adherent to ART

Participants

• Arrange refill in advance and avoid drop-in to pharmacy

whenever possible

• If calling to arrange refill, specify pick up date if known
• Provide adequate time for medication preparation
• You may send a delegate to pick up medication

– Inform pharmacy in advance of delegate’s full name – Ensure delegate knows your full name and a second identifier (e.g. your date of birth, health card number)

Participants

• Please refrain from coming to the pharmacy and seek the

guidance of your healthcare provider if

– You have fever, cough or difficulty breathing – Are feeling unwell

• If you are unable to arrange a delegate to pick-up

medication

– Call SPH Pharmacy (604-682-2344 ext. 63151) or your designated pharmacy to arrange an alternative method to obtain your medication (e.g. courier)

Prescribers: Fax prescriptions in advance whenever possible

Program Fax Phone New Prescription Requests / Regimen Changes / Program Re-Enrolment BC-CfE Drug Treatment Program 604-806-9044 604-806-8515 Refill Prescriptions to Designated Program SPH Ambulatory Pharmacy

• HIV treatment – NAN

604-806-9665 604-806-8937

• HIV treatment – Outreach

604-806-8255 604-806-8456

• HIV prevention – PrEP

604-806-9665 604-806-8081

• HIV prevention – PEP

604-806-8675 604-806-8429

• Main Dispensary

604-806-8675 604-806-8429 SPH Ambulatory Pharmacy: 604-806-8151 or 1-800-547-3622 After hours / weekends (urgent issues): 1-888-511-6222

NAN (no appointment needed); Outreach (courier to community pharmacy, healthcare site); PrEP (pre-exposure prophylaxis); PEP (post-exposure prophylaxis)

Drug interaction resources

https://www.hiv-druginteractions.org/ http://www.covid19-druginteractions.org/

Resources

• BC-CfE website

http://www.cfenet.ubc.ca/

• BC-CDC Update on COVID-19

http://www.bccdc.ca/health-info/diseases- conditions/covid-19

• Interim Guidance for COVID-19 and

Persons with HIV, US department of Health and Human Services https://aidsinfo.nih.gov/guidelines/html/8/co vid-19-and-persons-with-hiv--interim- guidance-/0

• EACS & BHIVA Statement on risk of

COVID-19 for people living with HIV (PLWH) https://www.eacsociety.org/home/covid-19- and-hiv.html

• University of Liverpool COVID-19 Drug

Interactions http://www.covid19-druginteractions.org/ Program Fax Phone New Prescription Requests / Regimen Changes / Program Re-Enrolment BC-CfE Drug Treatment Program 604-806-9044 604-806-8515 Refill Prescriptions to Designated Program SPH Ambulatory Pharmacy HIV treatment – NAN 604-806-9665 604-806-8937 HIV treatment – Outreach 604-806-8255 604-806-8456 HIV prevention – PrEP 604-806-9665 604-806-8081 HIV prevention – PEP 604-806-8675 604-806-8429 Main Dispensary 604-806-8675 604-806-8429

BC-CfE lab at 1-800-517-1119

• BC-CfE Clinical Education Team
• BC-CfE Communications Team
• BC-CfE IT Team

Acknowledgements

This webinar will be recorded and uploaded to the BC-CfE educational website at https://education.cfenet.ubc.ca/webinars/