Roadmap HIV in the United States Key Messages: HIV epidemiology - - PDF document

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Roadmap HIV in the United States Key Messages: HIV epidemiology - - PDF document

Jun 21, 2023 178 likes •337 views

I have no disclosures. HIV for the Primary Care Provider Elizabeth Imbert, MD MPH Division of HIV, ID and Global Medicine Zuckerberg San Francisco General Zuckerberg San Francisco General Roadmap HIV in the United States Key Messages:

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Zuckerberg San Francisco General

HIV for the Primary Care Provider

Elizabeth Imbert, MD MPH Division of HIV, ID and Global Medicine

Zuckerberg San Francisco General

  • I have no disclosures.

Zuckerberg San Francisco General

Roadmap

  • HIV epidemiology
  • HIV prevention
  • HIV testing & disclosure
  • Antiretroviral treatment

considerations

  • OIs and OI prophylaxis

Key Messages:

  • Test all
  • Treat all
  • Treat early
  • caution with some

OIs

  • ART: Simple, tolerable

combinations preferred

  • Goal is viral suppression

Zuckerberg San Francisco General

HIV in the United States

CDC 2019

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New HIV diagnoses in the United States

CDC 2019

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PrEP Uptake Increasing in the United States

www.prepwatch.org

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We are far off from meeting the need!

CDC 2015

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SFDPH HIV Epi Report 2018

HIV in San Francisco

v

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KEY INITIATIVES: 2010: Universal ART 2012: PrEP & RAPID (immediate linkage to HIV care and ART start) 2013: Getting to Zero: Expand PrEP/RAPID/LINCS (linkage to care and partner services)

SFDPH HIV Epi Report 2018

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Zuckerberg San Francisco General

SFDPH HIV Epi Report 2018

Lower rates of viral suppression among: Women (56%) Trans Women (68%) African Americans (68%) People who Inject Drugs (65%) Homeless (33%)

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Zuckerberg San Francisco General

Roadmap

  • HIV epidemiology
  • HIV prevention
  • HIV testing & disclosure
  • Antiretroviral treatment

considerations

  • OIs and OI prophylaxis

Key Messages:

  • Test all
  • Treat all
  • Treat early
  • caution with some

OIs

  • ART: Simple, tolerable

combinations preferred

  • Goal is viral suppression

Zuckerberg San Francisco General

Ending the HIV Epidemic: A Plan for the United States

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  • Focus on hotspots in

19 states, Washington DC and PR where majority of new HIV cases are reported and 7 states with disproportionate

  • ccurrence of HIV in

rural areas

Fauci JAMA 2017

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Prevention: U=U

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Calabrese & Meyer Lancet 2019; CDC 2018

Zuckerberg San Francisco General

Prevention: U=U

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CDC 2018

Zuckerberg San Francisco General

Prevention: PrEP and PEP

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aidsetc.org

Zuckerberg San Francisco General

Roadmap

  • HIV epidemiology
  • HIV prevention
  • HIV testing & disclosure
  • Antiretroviral treatment

considerations

  • OIs and OI prophylaxis

Key Messages:

  • Test all
  • Treat all
  • Treat early
  • caution with some

OIs

  • ART: Simple, tolerable

combinations preferred

  • Goal is viral suppression
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Case 1

  • 33 M who presents with 2 days history of headaches,

diarrhea, nausea, generalized weakness, fever, and body aches.

  • Has sex with wife x 10 years, denies sex with men. Uses

meth (denies IV).

  • In ED, febrile to 38.9, exam with b/l conjunctival injection, mild

epigastric tenderness and labs showing leukopenia, thrombocytopenia and transaminitis AST/ALT in 200s.

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  • Symptoms consistent with acute or chronic HIV
  • Possible HIV exposure
  • Routine screening:
  • Recommend one-time screening for adults 15-65
  • Pregnant women

Who to test for HIV

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More frequent screening for those at risk

  • Persons who use injection drugs and their sex partners
  • Persons who exchange sex for money or drugs
  • Sex partners of HIV-infected persons
  • Men who have sex with men (MSM) or heterosexual

persons who themselves or whose sex partners have had more than one sex partner since their most recent HIV test

  • Seeking evaluation or treatment for STI/PrEP/staring TB

treatment

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Zuckerberg San Francisco General

Deutsch LGBT Health 2018

A note about taking a sexual history

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HIV testing

Slide credit : D. Sachdev

  • Routine testing: order HIV Ag/Ab (4th gen; window period of 2-4 weeks post infection)
  • If positive, automatic reflex to confirmatory HIV 1/2 differentiation assay
  • Positive: HIV infected
  • Negative/Indeterminate: False positive or ACUTE HIV. Need to order HIV viral

load (PCR)

  • If high suspicion for acute HIV: order HIV viral load with HIV Ag/Ab

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Case 1

  • Initial work up of his viral syndrome showed + HIV Ag/Ab, HIV

1/2 differentiation negative which is suggestive of false positive or ACUTE HIV.

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Zuckerberg San Francisco General

Case 1

  • HIV Ag/Ab resubmitted and + and HIV VL returned at 1.6

million.

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Zuckerberg San Francisco General

Sharing new HIV diagnosis

  • If your clinical setting uses HIV Ag/Ab testing, this will come

back prior to the HIV confirmatory Ab test result. When this

  • ccurs, share with patients based on their risk factors how

concerned you are that they have HIV and that you are awaiting the confirmatory test.

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Sharing a new HIV diagnosis: staring the conversation

  • Inquire about what they know about HIV and tailor the

information to the patient’s literacy, knowledge, and readiness.

  • Ask what they have heard about HIV meds. Discuss starting

antiretroviral therapy, ideally even beginning today. Share U=U.

  • Acknowledge that while this diagnosis changes things for them,

if they take their meds, they can lead long, heathy lives with HIV.

Zuckerberg San Francisco General

Sharing a new HIV diagnosis: staring the conversation

  • Suggest that they notify partners so they can get tested.
  • Address practical needs of the patient.
  • Make it clear that you and your team are here to support

them.

  • Most importantly, lay the groundwork through

rapport building to ensure that they come for follow- up.

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Zuckerberg San Francisco General

Baseline labs for new HIV diagnosis

  • HIV VL
  • CD4 cell count and percentage
  • CBC with diff/CMP
  • Lipid panel/A1C
  • Hep A/B/C testing
  • UA
  • GC/CT (urine, throat, rectal), RPR and for HIV + women, trichomonas
  • Pregnancy test (if childbearing age)
  • Genotype
  • TB testing unless there is a history of a prior positive test
  • G6PD should be considered in patients of African, Asian, or Mediterranean descent
  • HLAB5701 (if considering abacavir)

DHHS Adult/Adolescent ART GL 2018

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Zuckerberg San Francisco General

Roadmap

  • HIV epidemiology
  • HIV prevention
  • HIV testing & disclosure
  • Antiretroviral treatment

considerations

  • OIs and OI prophylaxis

Key Messages:

  • Test all
  • Treat all
  • Treat early
  • caution with some

OIs

  • ART: Simple, tolerable

combinations preferred

  • Goal is viral suppression
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Why and When to Treat: DHHS Recommendations

  • Antiretroviral therapy (ART) is recommended for all

HIV-infected individuals, regardless of CD4 T lymphocyte cell count, to reduce the morbidity and mortality …(AI).

  • ART is also recommended for HIV-infected individuals

to prevent HIV transmission (AI).

DHHS Adult/Adolescent ART GL 2018

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Zuckerberg San Francisco General

RAPID ART Start: Treatment on Diagnosis

  • STANDARD of CARE (SF DPH):
  • Start ART w/in 5 days of HIV diagnosis, ideally

same day

  • (Ward 86 Standard of Care: Start ART same

day as HIV diagnosis, if possible)

  • Unless clear contraindication, or patient

unwilling

Slide credit: S Coffey

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Why RAPID ARV

  • Early ARV lowers HIV RNA and DNA set point & prevents

colonic mucosal mononuclear cell infection (reduced reservoir)

  • Reduces immune activation and inflammation
  • Preserves immune function and enhances CD4 cell recovery
  • Limits evolution to advanced stages of HIV and reduced AIDS

and non-AIDS morbidity and mortality

  • Might reduce severity of acute symptoms as well as

depression/anxiety

  • Reduces transmission

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Zuckerberg San Francisco General

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Slide credit: S Coffey

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What to start

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Slide credit: Vivek Jain

Zuckerberg San Francisco General

What to Start

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Zuckerberg San Francisco General

Selecting ART Regimen

Consider:

  • HIV RNA, CD4 count (if available), HLA B5701 (if available)
  • Resistance (if available)
  • Comorbidities (HBV, CKD, cardiac, psychiatric, pregnancy,

etc.)

  • Pill burden
  • Once-daily vs BID
  • Adverse effects
  • Drug-drug interactions
  • Food requirements
  • Adherence concerns

Slide credit: S Coffey

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Case 1 continued

  • Patient started on TAF/FTC/DTG and linked to HIV primary

care clinic.

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Co-formulated ARVS are common!

  • Epzicom = ABC+3TC
  • Descovy = TAF+FTC
  • Truvada =TDF/FTC
  • Triumeq = Dolutegravir/ABC/3TC
  • Biktarvy = Bictegravir/TAF/FTC
  • Symtuza =DRV/cobi/TAF/FTC
  • Genvoya = Elvitegravir/COBI/TAF/FTC

Complete regimens Need a 3rd active drug

Slide credit: S Coffey

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Injectables coming…

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eatg.org

Zuckerberg San Francisco General

ARV Adverse Effects

  • Renal toxicity:
  • Tenofovir DF: ↑ SCr, proteinuria, hypophosphatemia,

urinary phosphate wasting, glycosuria, hypokalemia, and non-anion gap metabolic acidosis.

  • Tenofovir AF (TAF): Less impact on renal biomarkers

and lower rates of proteinuria than TDF.

  • ARVs associated with ↑ creatinine:
  • Inhibits Cr secretion without reducing renal

glomerular function: cobicistat, dolutegravir, bictegravir, rilpivirine

Slide credit: S Coffey

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ARV Adverse Effects

  • What to do if new renal failure in patient on tenofovir?
  • Stop tenofovir (definitely if TDF; probably if TAF), but avoid

ART treatment interruption

  • Discuss with HIV expert re: alternatives – perhaps

abacavir (if HLA B5701 neg) (perhaps TAF??)

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Slide credit: S Coffey

Zuckerberg San Francisco General

ARV Adverse Effects

  • Cardiovascular risk
  • ?abacavir (controversial, conflicting data)
  • Lipid abnormalities
  • Protease inhibitors
  • Weight gain
  • Integrase Inhibitors/TAF (ongoing research)

Slide credit: S Coffey

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ARV adverse effects

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For more information: aidsinfo.hiv.gov

Zuckerberg San Francisco General

Check for Drug-Drug Interactions

  • CYP 3A4 interactions are common:
  • Protease inhibitors (esp. ritonavir) generally increase

levels of other drugs

  • Cobicistat, similar to ritonavir, generally increases

levels of other drugs

  • Other mechanisms (UGT, P-gp, etc) also important

Slide credit: S Coffey

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Other ART Issues

  • Avoid interruptions in ART, if possible
  • If interruption is needed, discuss with HIV expert
  • Give ARVs together (especially PK boosters with

their companion ARV)

  • Make sure the dosages are correct! (some ARVs

have >1 dosing possibility)

  • Beware of food requirements
  • What if my patient can’t eat?
  • Sometimes NPO means can take pills but not food
  • If intubated, ARVs can be given through NGT
  • Some liquid formulations available

Slide credit: S Coffey

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Zuckerberg San Francisco General

Case 2

  • 37 M with HIV last CD4 177 VL 80K with methamphetamine use,

presenting with 3 days cough, chills, nasal congestion, fever, myalgias, and headache, found to have influenza.

  • On further history, he reports he hasn’t been taking his ARVs lately.

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Zuckerberg San Francisco General

Patient presents off ARVs or concerns re: adherence

  • Please discuss with HIV expert.
  • Helpful information to gather…
  • History
  • do they want to be on ARVs
  • prior regimens
  • when did they stop (did they stop all at once or has adherence been

erratic/intermittent?)

  • why did they stop (gather insights into co-morbid conditions, pill burden, dosing

schedule, side effects etc is essential when considering alternative options)

  • Review their HIV history, in particular prior regimens and genotypes
  • Send HIV VL
  • Obtain genotype

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Considerations re: ARV choice when concerned for non- adherence

  • Pending HIV viral load/genotype result, it may be appropriate

to change the patient’s HIV regimen.

  • Considerations:
  • drug-drug interactions, drug-food interactions, drug tolerability
  • treatment history (prior VLs and CD4s)
  • results of previous genotypes
  • prior regimens and response
  • reasons for nonadherence (pill burden, dosing frequency, drug

use, mental health, housing status etc.)

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When can you just restart their prior regimen?

  • There are certain circumstance when a patient can re-start their

last regimen, without any changes, especially if the reason and nature of the treatment interruption is known, and concern for acquired HIV resistance is low.

  • Please discuss with HIV expert.

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Zuckerberg San Francisco General

Roadmap

  • HIV epidemiology
  • HIV prevention
  • HIV testing & disclosure
  • Antiretroviral treatment

considerations

  • OIs and OI prophylaxis

Key Messages:

  • Test all
  • Treat all
  • Treat early
  • caution with some

OIs

  • ART: Simple, tolerable

combinations preferred

  • Goal is viral suppression

Zuckerberg San Francisco General

A word about OIs

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Slide credit: C Koss

Zuckerberg San Francisco General

OI prophylaxis

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DHHS Adult/Adolescent ART GL 2018

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OI prophylaxis

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DHHS Adult/Adolescent ART GL 2018

Zuckerberg San Francisco General

Resources

  • InSite: http://hivinsite.ucsf.edu
  • DHHS: http://aidsinfo.nih.gov
  • HIV Warm line (ART, PEP, PrEP, Perinatal)
  • Call: (800) 933-3413, Mon-Fri 9 AM - 8 PM ET
  • Submit case online:

http://nccc.ucsf.edu/clinician-consultation/hiv- aids-management

  • AETC NCRC National HIV Curriculum:

https://www.hiv.uw.edu/

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Take Home Points

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  • Test all
  • Treat all
  • Treat early
  • caution with some OIs
  • ART for 1st line: Simple, tolerable combinations preferred
  • Goal is viral suppression