HIV: What Every Clinician Needs to Know ARIZONA STATE ASSOCIATION OF PHYSICIAN ASSISTANTS SPRING CONFERENCE BETTIE COPLAN MARCH 2018

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Aubrey Garrett
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1 HIV: What Every Clinician Needs to Know ARIZONA STATE ASSOCIATION OF PHYSICIAN ASSISTANTS SPRING CONFERENCE BETTIE COPLAN MARCH 2018 Overview Overview recent trends in HIV incidence in the U.S. HIV screening & signs & symptoms that should prompt diagnostic testing Referral for management Considerations for managing HIV+ individuals presenting for evaluation & management of non HIV conditions HIV United States Annual incidence of HIV infections fell 18% between 2008 & 2014, from 45,700 to 37,600; new infections in ,792 At end of 2015, 1.1 million persons 13 y/o living with HIV / AIDS [incl.162,500 (15%) undiagnosed] Arizona 780 newly infected in ,464 living with HIV / AIDS 1 is < 2 y/o, 48 are 2 12 y/o (2 with AIDs) CDC 2018 AZ Dept of Health Services 2017 report 1

2 Rates of Diagnoses of HIV Infection among Adults and Adolescents 2016 United States and 6 Dependent Areas N = 40,202 Total Rate = 14.7 Note. Data for the year 2016 are preliminary and based on 6 months reporting delay. Rates of Adults and Adolescents Living with Diagnosed HIV Infection Year end 2015 United States and 6 Dependent Areas N = 988,955 Total Rate = Note. Data are based on address of residence as of December 31, 2015 (i.e., most recent known address). Diagnoses of HIV Infection among Adults and Adolescents, by Sex United States and 6 Dependent Areas 2

New HIV Diagnoses in the United States by Age, 2016 CDC: https://www.cdc.gov/hiv/statistics/overview/ataglance.

Note. Unknown race/ethnicity is not displayed because it comprises less than 1% of cases. a Includes Asian/Pacific Islander legacy cases.

3 New HIV Diagnoses in the United States by Age, 2016 CDC: Adults and Adolescents Living with Diagnosed HIV Infection, by Sex and Race/Ethnicity, Year end 2015 United States and 6 Dependent Areas Note. Unknown race/ethnicity is not displayed because it comprises less than 1% of cases. a Includes Asian/Pacific Islander legacy cases. b Hispanics/Latinos can be of any race. Estimated New HIV Infections in the United States by Transmission Category, 2014 CDC: 3

4 New HIV Diagnoses in the United States for the Most-Affected Subpopulations, 2016 CDC: HIV TRENDS IN THE U.S. Incidence declining for several years, now stable / increasing slightly Rates are higher among men than women* year olds with highest rates of new infection African Americans & Hispanic/Latino populations disproportionately affected Highest risk categories: male to male sex; heterosexual sex; IV drug use ARIZONA diseasecontrol/disease integrated services/hiv epidemiology/reports/2017/annualreport.pdf 4

http://www.azdhs.gov/documents/preparedness/epidemiology diseasecontrol/disease integrated services/hiv epidemiology/reports/2017/annualreport.pdf ARIZONA http://www.azdhs.gov/documents/preparedness/epidemiology diseasecontrol/disease integrated services/hiv epidemiology/reports/2017/annualreport.pdf ARIZONA http://www.azdhs.gov/documents/preparedness/epidemiology diseasecontrol/disease integrated services/hiv epidemiology/reports/2017/annualreport.pdf 5

5 diseasecontrol/disease integrated services/hiv epidemiology/reports/2017/annualreport.pdf ARIZONA diseasecontrol/disease integrated services/hiv epidemiology/reports/2017/annualreport.pdf ARIZONA diseasecontrol/disease integrated services/hiv epidemiology/reports/2017/annualreport.pdf 5

6 ARIZONA diseasecontrol/disease integrated services/hiv epidemiology/reports/2017/annualreport.pdf HIV TRENDS IN ARIZONA Incidence declining for several years, now increasing slightly Rates are higher among men than women* year olds with highest rates of new infection African Americans, American Indian, & Hispanic/Latino populations disproportionately affected Highest risk categories: male to male sex; heterosexual sex; IV drug use Screen just about everyone for HIV at least once Everyone years old: voluntary opt out testing Anyone in whom TB treatment is being initiated At each presentation for an STD Annually for patients at risk more often for Men who have Sex with Men (MSM)? Pregnant women CDC: 6

7 Diagnostic testing for HIV more often than you think Opportunistic infections (e.g. fungal infections) & TB Symptoms consistent with established HIV Weight loss Recurrent fever, night sweats Extreme tiredness Lymphadenopathy Diarrhea > 1 week Sores of mouth, anus, genitals Pneumonia Unexplained neurologic symptoms Symptoms consistent with acute HIV (aka acute retroviral syndrome) ACUTE HIV LOOKS LIKE OTHER INFECTIONS Clinical signs/symptoms Fever Adenopathy Sore throat Rash* Mucocutaneous ulcers* Myalgia Arthralgia Headache Diarrhea Nausea/Vomiting Laboratory abnormalities Elevated transaminases(lfts) Leukopenia Diagnosis is usually missed Anemia Thrombocytopenia KNOW WHICH HIV TEST YOU RE USING CDC Updated Recommendations for Lab Testing for HIV: 7

8 KNOW WHICH HIV TEST YOU RE USING If you suspect acute HIV & you only test for antibody, you will miss acute HIV Use antigen/antibody combination test or order HIV RNA test CDC Updated Recommendations for Lab Testing for HIV: Inexpensive / no insurance testing Maricopa County STD Clinic $20: Testing Rapid test available only tests for antibody In AZ, minors can access STD testing without parental consent HIV not explicitly included (may want to send to / or contact County)* *Guttmacher Institute: policy/explore/minors access sti services care/pmtct who hhs cmpntsm1.html 8

9 When to refer / when to treat? Antiretroviral therapy (ART) recommended for all with HIV, incl. those with acute/early infection* *Clinical trial data suggest that individuals treated during early infection experience immunologic & virologic benefits refer asap! Genotypic drug resistance testing performed before initiation of ART will guide selection of ART Patients must be willing / able to commit to lifelong treatment with strict adherence Patients may postpone therapy, can be decided on case by case basis Treatment goal suppress plasma HIV 1 RNA levels to undetectable and adolescent arv/20/acute andrecent early hiv infection Where to refer HIVAZ.ORG Other HIV considerations Possible exposure Unprotected sex with someone who tells you they have HIV (or you think may have HIV) Condom broke or fell off during sex Rape or sexual assault Work related exposure to HIV (e.g. needle stick injury) Sharing needles to inject any type of drug Post Exposure Prophylaxis (PEP) Must start within 72 hours can call local health department HIVAZ.ORG CDC Pre Exposure Prophylaxis (PrEP) Daily medication, Truvada prescribed by HIV specialist 9

10 Seeing patients with HIV CD4 T cell count is king Normal CD4 T cell count is cells per cubic/mm May see thrush May see Kaposi sarcoma at any count People do very well at 350 Hovering around 200 will see opportunistic infections < 200 = AIDS or any CD4 T cell count & 1 of 27 AIDS defining illnesses Pneumocystis jirovecipneumonia (formerly PCP) Kaposi sarcoma Invasive candidiasis (esophagus, trachea) Invasive cervical cancer Others Must consider medications Clue to CD4 T cell count CD 4 T cell < 200 Bactrim DS prophylaxis for Pneumocystis jiroveci pneumonia CD 4 T cell < 100 Bactrim DS prophylaxis for Toxoplasma gondii encephalitis CD 4 T cell < 50 Azithromycin prophylaxis for disseminated Mycobacterium avium complex (MAC) Consider drug interactions New Developments Past (multiple pills multiple times / day) Present (once daily regimens) Future (once weekly regimens) Cancer drugs to treat HIV Berlin patient cured after bone marrow transplant in 2007 HIV vaccine trials ongoing (none currently FDA approved) index/2018/2/15/novel methods to eradicate hiv reservoirs brown berlin patient celebrates decade cured hiv/ myths facts.html 10

11 References & Resources CDC website. HIV/AIDS CDC. Laboratory testing for the diagnosis of HIV infection : updated recommendations HIVAZ.org. Information on local providers & resources Maricopa County Health Department website. STD / HIV Services HIV Arizona Department of Health Services Arizona HIV/AIDS Epidemiology Annual Report diseasecontrol/disease integrated services/hiv epidemiology/reports/2017/annual report.pdf U.S. Department of Health & Human Services. AIDSinfo Guttmacher Institute. Minor s Access to STI Services policy/explore/minors access sti services 11

INTEGRATING HIV INTO PRIMARY CARE

INTEGRATING HIV INTO PRIMARY CARE ADELERO ADEBAJO, MD, MPH, AAHIVS, FACP NO DISCLOSURE 1.2 million people in the United States are living with HIV infection and 1 in 5 are unaware of their infection.