OR: Steps you can take in the clinic to prevent HIV infections

Transcription

1 Implementing Changes to Reduce HIV Incidence: Synergies between Public Health and Primary Care Kevin Ard, MD, MPH Brigham and Women s Hospital, Massachusetts General Hospital, and the Fenway Institute OR: Steps you can take in the clinic to prevent HIV infections 1

2 A person at risk 26-year-old male with no chronic medical problems Sexually active with multiple male partners; rarely uses condoms Most consistent sexual partner is HIVinfected and on antiretroviral therapy Treated in the past for HSV, gonorrhea, and LGV Agenda Conceptualize the integration ti of public health and primary care Discuss two bio-behavioral approaches to HIV prevention Treatment as prevention (TasP) Pre-exposure prophylaxis (PrEP) 2

3 Public Health assuring conditions in which people can be healthy Surveillance and Outbreak Investigation Policies and Laws Food and Environmental Safety Personal Health Care (Primary and Specialty) IOM 1988 Primary Care Activities BENEFITS PERSONAL HEALTH Colonoscopy HTN treatment BENEFITS POPULATION HEALTH Notifying authorities of reportable conditions BENEFITS PERSONAL AND POPULATION HEALTH Alcohol abuse treatment Vaccinations HIV prevention Treatment of Chlamydia/gonorrhea 3

4 What prevents HIV transmission? Courtesy of Patrick Sullivan Treatment as Prevention (TasP) Das

5 Treatment as Prevention (TasP) 1,763 serodiscordant couples Early ART Delayed ART (at enrollment) (when CD4 250) 1 transmission 27 transmissions Cohen 2011 Barriers to TasP (and what you can do about them) Lapses in the HIV care continuum 5

6 Most HIV-infected individuals do not have suppressed viral loads HIV-infected Diagnosed Linked to care Retained in care 72 % On ART Viral load < 200 MMWR 2011 Improvement at multiple levels is needed to fix the treatment cascade Gardner

7 Black MSM are less likely to be aware of HIV infection Wejnert CROI 2013 Question: You screen a 35-year-old man for HIV at a routine preventive health care visit. He is sexually active with one male partner. His HIV ELISA is positive, but his Western blot is negative. What should you do? A. Send an HIV-1 viral load B. Send a Western blot for HIV-2 C. Reassure him; this is likely a false (+) result D. Repeat the ELISA/Western blot in 1 month 7

8 Question: You screen a 35-year-old man for HIV at a routine preventive health care visit. He is sexually active with one male partner. His HIV ELISA is positive, but his Western blot is negative. What should you do? A. Send an HIV-1 viral load B. Send a Western blot for HIV-2 C. Reassure him; this is likely a false (+) result D. Repeat the ELISA/Western blot in 1 month HIV Testing Logistics Window periods impact test accuracy: Viral load: ~10 days post infection 4 th generation Ag/Ab test: ~15 days 3 rd generation EIA: ~20 days Western blot: up to 60 days New testing algorithms may eliminate the Western blot A viral load should be sent if acute HIV is suspected Branson

9 Next steps: Linkage to and Retention in Care HIV-infected Diagnosed Linked to care Retained in care On ART Viral load < 200 MMWR 2011 Who is at risk for not engaging in care? Young age Heterosexual identification African-American race Less education Lower income Lack of insurance Injection drug use Mental illness Horstmann

10 What would you do if, while seeing a 42-year-old woman for a sprained ankle, you notice: 1. She had a breast biopsy with invasive ductal carcinoma 8 months ago; she s not seen an oncologist or received any treatment since? 2. She was diagnosed with active pulmonary tuberculosis 8 months ago but has not received treatment? 3. She was diagnosed with HIV 8 months ago (CD4 178, HIV RNA 82,000) and has not seen an HIV provider or begun ARVs? What you can do Promptly link any newly diagnosed HIV patients to HIV care Active versus passive referrals Identify out-of-care persons and do what you can to reconnect them to HIV care Address substance abuse and mental illness 10

11 Public health-emr information exchanges may facilitate engagement in care 39 year old male with asthma flare Information transmitted to DPH database Identified as HIVinfected with no VL or CD4 in 12 months Linkage to, retention in care Information on the provider s actions sent back to DPH database Clinical alert sent to EMR with decision support tools Louisiana Public Health Information Exchange (LaPHIE) 419 persons identified over 30 months 24% had not had labs since diagnosis Median time out of care = 19 months 42% had CD4 counts < % had a CD4/VL after identification Herwehe 2012, Magnus

12 Additional Approaches INTERVENTION STEP IN THE CASCADE REFERENCE EFFICACY Strengths based case Improved linkage from Linkage to care Gardner 2005 management 60% to 78% Patient navigators Retention in care Bradford 2007 Clinic wide messaging Retention in care Gardner 2012 Contingency management Retention Clinic Linkage/retention, viral suppression Retention in care, viral suppression Project HOPE Project RETAIN Improved retention from 64% to 87% Improved retention by 10.4% Under study Under study Project Hope (CTN 0049) Population: HIV-infected drug users admitted to the hospital Outcome: Viral suppression i Interventions: Patient navigators Contingency management 12

13 Project Retain Population: HIV-infected crack users Outcome: Viral suppression Interventions: Patient navigators, substance abuse treatment Barriers to TasP (and what you can do about them) Lapses in the HIV care continuum Transmission during acute HIV infection 13

14 The special case of acute HIV infection HIV viral load P24 antigen HIV antibody Days Adapted from Branson 2010 Addressing HIV transmission from acutely infected individuals Intensive contact tracing: David Goudreau, DPH Division of STD Prevention, Can be available when the diagnosis is given 14

15 Hallmarks of Acute Infection Features of Acute Infection Percent of Patient Fever 75 Rash 48 Headache 45 Pharyngitis 40 Cervical LAD 39 Diarrhea 27 HIV Test Results Consistent with Acute Infection Positive viral load*, negative EIA, negative Western blot Positive viral load*, positive EIA, negative Western blot *HIV viral load should be high in acute infection. Daar 2008 Addressing HIV transmission from acutely infected individuals Intensive contact tracing: David Goudreau, DPH Division of STD Prevention, Can be available when the diagnosis is given Other preventive measures: Safer sex, condoms Pre-exposure exposure prophylaxis (PrEP) 15

16 Pre-Exposure Prophylaxis (PrEP) PrEP works (but adherence is vital) Trial Agent Population Risk Reduction MSM, iprex TDF-FTC transgender women 44% TDF2-CDC Partners PrEP TDF-FTC TDF, TDF-FTC Heterosexual men and women 62.2% Heterosexual couples FEM-PrEP PEP TDF-FTCFTC Women --- VOICE TDF-FTC Women --- ( TDF-FTC = tenofovir-emtricitabine) 75% TDF-FTC, 67% TDF Adapted from van der Straten

17 Better adherence = better efficacy Courtesy of Doug Krakower PrEP is safe for most patients No major safety concerns in PrEP trials Nausea more common with TDF-FTC FTC than placebo No difference in creatinine elevations or bone fractures (potential TDF toxicities) No risk compensation 17

18 The PrEP Package Determine eligibility: Document a negative HIV test Confirm high risk of infection Check that the creatinine clearance is 60 ml/minute Other steps: Check a pregnancy test Check for chronic hepatitis B infection CDC

19 Prescribe: TDF-FTC, 1 tablet by mouth daily While on PrEP: Check an HIV test, pregnancy test, and creatinine every 2-3 months* Assess for STIs at least every 6 months Counsel regarding risk reduction and adherence; provide condoms *Initially, then creatinine can be checked every 6 months CDC 2012 Questions and Controversies What is the lower limit of adherence? What level of risk warrants PrEP? Who should prescribe it? 19

20 Back to our case: 26M at high risk of HIV infection Counseled that his main partner s use of ART likely reduces the risk of transmission to him Elected to begin PrEP with tenofoviremtricitabine to further reduce risk Remains HIV-uninfected to date Condom use is still inconsistent; i t he has had repeated episodes of rectal gonorrhea Summary HIV prevention is a key area of collaboration between public health and primary care. Lapses in the HIV care cascade prevent full realization of the benefits of treatment as prevention. Primary care providers can improve the cascade through universal testing and treatment, efforts to engage patients in care, and treatment of substance abuse and mental illness. PrEP is a powerful HIV prevention tool for highrisk individuals, but adherence is vital. 20

21 Thank You Kevin L. Ard, MD MPH Brigham and Women s Hospital kard@partners.org 21