Clinical Education Initiative THE ROLE OF THE PRIMARY CARE CLINICIAN IN HIV CARE. Speaker: Antonia Urbina, MD

Transcription

1 Clinical Education Initiative THE ROLE OF THE PRIMARY CARE CLINICIAN IN HIV CARE Speaker: Antonia Urbina, MD 2/1/2017

2 The Role of the Primary Care Clinician in HIV Care [video transcript] 00:00:08 - [Dr. Urbina] I'm gonna give a very brief presentation on the role of the primary care clinician in HIV care. 00:00:14 These are my disclosures. 00:00:18 The learning objectives are to describe the HIV epidemiology in both New York State and the US and review the latest CDC treatment guidelines for the management of HIV infection in adults. 00:00:28 So here on the left of the screen, you have the estimated number of new HIV infections in New York State. 00:00:35 So you'll see that that number is dropping, for the latest data, 2014, So that's substantially down, so incidence is going down. On the right, you'll see estimated HIV incidence, New York State, based on density. So, we've gone from a high of 30.7 to 14.8 new infections per 100,000. Next slide, okay. 00:01:06 So here is a graph of New York based on counties, looking at the density of newly diagnosed HIV cases by county of residence at diagnosis across New York State. You'll see the counties in darker blue that have higher densities across New York State, including New York City. 00:01:28 Next slide, okay. Here's the New York State cascade. So it starts off with the estimated number of HIV infected persons, and it's comparing 2013 to is in the green. Estimated HIV infected persons is now at 123,000. Persons living with diagnosed HIV infections, so those diagnosed, so out of the 123,000, we've diagnosed 113,000. Of those that have had at least any contact with HIV care, 91,000, and then those with continuous care, 77,000, and then those virologically suppressed, also 77,000. So we're doing a lot better: About 66% of those persons living with HIV and AIDS have a suppressed viral load. Again, that's one of the arms of the End V AIDS Epidemic Initiative. It's to really bring our patients to virologic suppression. 00:02:26 So the key provisions of the New York State HIV Testing Law, it's the required offering of HIV testing for any individual aged 13 years, without an upper-age cut-off, and written consent is no longer required for testing, but before being asked, you need to verbally consent, patients need to verbally consent to HIV 1

3 testing, and you must review, and this can be done via poster or handouts, these points of information about HIV, which I'm gonna go over. 00:02:56 We had a case about a call where there was a patient in the emergency room. They declined HIV testing. The provider did a chest X-ray, which was consistent for PCP, and without the patient's consent, ordered HIV testing. You can't do that. The patient has to verbally consent to HIV testing. 00:03:23 These are the points that need to be relayed to the patient, is briefly that HIV causes AIDS, that there is treatment for HIV infection, that patients with HIV can adopt safer practices to not transmit, that testing is voluntary, that there still are options to do testing anonymously, that the law does protect the confidentiality, that the law does prohibit against discrimination, and that the law allows an individual's informed consent for HIV-related testing to be valid, until that individual wants to revoke it. Again, these can just be a handout or on a poster. 00:04:00 Basically, HIV, that's the little virions on top, and you'll see that little purple line; that's the mucosal surface. It's theorized that the first immune cell that HIV seizes, this dendritic cell, and its job is to ferry HIV to a regional lymph node. That takes about two days. From there, HIV starts to replicate, to about three days later, HIV spills out of the lymph node into the blood stream. Game over. Viremia, established infection. Once a patient becomes viremic, you can't reverse the infection. Hence, PEP, or post-exposure prophylaxis, get those meds in very early, within three days, so that you keep the infection localized before it becomes viremic. 00:04:47 So what are some of the signs and symptoms of acute HIV infection? Obviously, fever, morbilliform rash, pharyngitis, generalized lymphadenopathy, meningeal symptoms, 'cause it does cross the blood-brain barrier, and then with the labs, it's like any acute viral syndrome: You can have low platelets, low white counts, and mild elevation of your liver enzymes. In young individuals, it can look very similar to Epstein- Barr mononucleosis. Here we have the differentiations between acute HIV and EBV. 00:05:21 Alright, so you'll see on the left there, exposure to HIV. Viral loads become detectable by about day 11. The third generation antibody tests become detectable by about three weeks. 00:05:41 The p24 antigen, which is now part of the fourth generation combo tests, can become detectable by day :06:09 2

4 You'll see that the fourth generation test, because of the inclusion of the HIV p24, now can detect as early as day :06:19 This is the new CDC-recommended algorithm. The first screen is an HIV-1, -2, antigen, that's that p24 antibody test. If that is negative, then you can say that they're negative for HIV-1, -2, and -4, HIV-1 p24 antigen. Only if it's positive does it go to the differentiation assay. Most times it'll be positive for HIV-1, but you'll see that it can either be positive for HIV-2 or very rarely positive for both. If the initial screen is reactive and then the differentiation is negative or indeterminate, what it means is that maybe that p24 NAT is actually detectable, and this may be early infection, so it will automatically reflex then to a viral load to pick up acute HIV-1. This is the new testing algorithm. Alright, why do we wanna start early? The START Trial, when they did an analysis, the biggest driver of starting earlier is that you reduce infectionrelated cancers. So the START Trial looked at immediate versus deferred anti-retrovirals, and what they found is that persons that started on anti-retrovirals earlier had less cancers. Those cancers were Kaposi sarcoma, Hodgkin's, non-hodgkin's, and the HPV-related cancers. 00:07:41 Also, starting anti-retrovirals earlier also increased the quality of life with person, so we think, "Wow, these ARVs are gonna be burdensome, "cumbersome side-effects," but because the new agents are easier, simpler, and because you restore that patient's immune system to health, they actually feel better. 00:08:01 Alright, the basics of anti-retroviral regimens are the new TAF-containing regimens, which is that tweaked version of tenofovir, are better on kidney and bone. You'll see they're co-formulated into Genvoya, Odefsey, and Descovy. Cobicistat is the newer booster, like ritonavir, and it's been added to atazanavir, that's called Evotaz, and to darunavir, Prezcobix. The fine-tuning, again, I think, based on that first case, if possible, get patients off of their D drugs like stavudine and didanosine, alright, because those have a lot of mitochondrial toxicity. Consider switching patients off of efavirenz-containing regimens because of the central nervous system, psychiatric, and lipo-atrophic changes. Also, consider switching patients off of older protease inhibitors like saquinavir, indinavir, Kaletra. 00:08:58 The recommended initial regimens are really integrase-based, so those are dolutegravir, abacavir, 3TC, also called Triumeq; dolutegravir with Truvada; elvitegravir COBI with the older version of tenofovir or the newer version, so Stribild versus Genvoya; and then the raltegravir, twice daily, with Truvada. The only protease-inhibitor-based recommended is boosted darunavir with Truvada. 00:09:29 Baseline labs for newly diagnosed, you wanna do CD4 count and CD4 count percent, HIV RNA, the genotype, CBC. You also wanna draw G6PD; the reason for this is that if they are G6PD-deficient, and you need to start them on PCP prophylaxis, you would want to avoid Bactrim and go to an agent like 3

5 dapsone. If they're G6PD-deficient, then you can't use dapsone, because it puts them at risk for hemolytic anemia. You wanna get a lipid panel; if you do want to consider abacavir, HLA-B57*01; comprehensive metabolic panel. Check for TB, either using tuberculin skin test or IGRA. Get a Toxo IgG to see if they've had previous exposure. You wanna do your hepatitis serology, and then, of course, RPR, 3-site STI testing, and if their CD4 counts are less than 50, screen for cryptococcal antigen. 00:10:27 For OI prophylaxis, you wanna start CD4 count less than 200 or percent less than 14. You wanna start MAI prophylaxis if their CD4 count is less than 50. Importantly, you can safely discontinue MAI if their CD4 counts are greater than 100 for at least three months, and for PCP if their CD4 counts are greater than 200 for at least three months. 00:10:48 These are the immunizations. I like to wait for CD4 counts to get to above 200. You definitely wanna immunize against A; B; HPV; influenza; pneumococcal, first do the Prevnar-13, then at least two months later, do the pneumococcal-23; TdAP; varicella; and then zoster if they're over the age of 60 and their CD4 counts are less than :11:14 So, briefly, any questions before we get to our second case? [end] 4