HIV and Primary Care PDF

HIV and Primary Care • HIV • Types of HIV o HIV -1 § More common worldwide § Easier perinatal transmission • STOP breastfeeding § Reduced valiance with slower rate of CD4 and T-Cell decline o HIV-2 § Less easily transmitted • Rare in the US à unless direct travel to West Africa • HIV-2 may be dx wh...

HIV and Primary Care • HIV • Types of HIV o HIV -1 § More common worldwide § Easier perinatal transmission • STOP breastfeeding § Reduced valiance with slower rate of CD4 and T-Cell decline o HIV-2 § Less easily transmitted • Rare in the US à unless direct travel to West Africa • HIV-2 may be dx when treatment is not working § Less pathogenic • Period btw infection and symptoms is longer § Less likelihood perinatal transmission • May need to stop breastfeeding • • • HIV vs AIDS o HIV § § § o AIDS § § § Breaks down body’s defense Infects specific white blood cells Weakens immune system Attacks the immune system Reduces white blood cells Symptoms or illnesses that result from HIV infection • AIDS comes from HIV HIV Transmission Categories o Male to Male Sexual contact à Most Common o Injection drug use o Male to male sexual contact and injection drug use o Heterosexual contact o Perinatal Goals of Care o Diagnose à Establish Care à Retention in Care à Viral Suppression § Diagnose – 86% • Screening in PCP o Cultural humility o Leave bias alone o 14% Unaware of dx of HIV Establish Care – 64% • How soon can we start care o (1mo or 30days is GOAL) § Retention in Care – 49% • Follow up, engaged in the care à prevent further infection § Viral Suppression – 53% • Get dx to start tx and get pt suppressed Risk Factors for HIV o Unprotected Intercourse o Vaginal, Anal o Needle sharing o Perinatal Transmission – mother to baby o Substance Abuse History - decrease adherence to safe practices o Accidental Needle stick - occupational hazard o Blood transfusion (prior to 1985) o STIs § increase susceptibility for non-infected § increase of spread to others if already have HIV o Mental Illness § Behavioral health support Pathophysiology – 5 Stages o Binding and entry § HIV varrions bind to glycoprotein to help attach to CD4 receptors of a susceptible cell à Interact with CD4 & CCR5 receptors to initiate fusion btw the viral envelope and plasma membrane to facilitate entry of the core of the virus to the cytoplasm o Reverse transcription § RNA released • RNA à DNA provirus à integrates into Host cell then into host nucleus o Integration § Into host DNA o Synthesis of viral proteins § May be LATENT or ACTIVE • Active: creates proteins o Budding § Proteins bud then start cycle over Natural Course of HIV o Viral Transmission o Acute Retroviral Syndrome § Primary Infection § • • • • Presents like infectious mono Increased Viral Load • Period of Viral Replication o > 1 Million Copies o Recovery and Seroconversion § Antibodies develop (take up to 3mo) • HIV Antibodies have NO protection o Asymptomatic chronic HIV infection § Able to transmit (3mo-15yr) • Shorter for children with HIV o Symptomatic Infection § Physical Signs of HIV o Death Spectrum of Infections: Acute HIV Infection S/S o Common: § Fever § Adenopathy Cough is NOT part of § Sore Throat Acute HIV infections § Rash § Myalgia § HA § Night Sweats o Occasional (<50%) § Oral Ulcers § Thrombocytopenia § Leukopenia § Diarrhea § Nausea § Elevated ALT or AST § Aseptic Meningitis Initial History o HIV test § When? Why? Previous test, if any? Results? o Thorough sexual hx o PMH o MH childhood trauma o Family Hx o Social Hx o Housing and support Exam o Skin à Kaposis Sarcoma § Purplish Lesions à sign of AIDS o HEENT § • • • • • • § Eye Exam, Sinus tender, fund exam § Thrush à indicates disease progression o Lymph Nodes o Chest § Murmur, PCPneumonia à normal lung sounds • CXR o Abdomen § Enlarg liver and spleen o Rectum/Genitalia § Cervical Carcinoma o Neuro § Detailed exam à myopathy, neuro changes Initial Labs o CBC with differentials à anemias o CMP à get baselines o Urinalysis à Proteinuria o Hepatitis serologies à best o RPR à Syphlis co-infection o Gonorrhea/Chlamydia à STI check o Cytomeglavirus/ Toxoplasmosis o HLA B* 5701 à test for hypersesnitivy and SJS risk o Other labs to consider: § Fasting Blood Sugar § Lipid panel à ART increase Lipids § Hemoglobin A1c § Pap Smear with GC/CT § Oral swab (GC/CT) § Anal swab Additional Labs (typically done by infectious disease) o HIV Viral Load (or HIV RNA) § Idea of severity, cannot determine duration o CD4 T-cell count/percentage (200/14) § Idea of immune system § More info about % of WBC § Best test for progression and for dertemining ART o Resistance testing – Genotype and Phenotype § Baseline resistane info for tx o Quantiferon or T-spot (substitution for PPD) § TB test o Toxoplasmosis and Cytomeglovirus (CMV) IgG o Glucose 6 Phosphate Dehydrogenase (G6PD) o Dilated retina exam (especially if CD4 count <50) o Tropism Assay Plan of Care Patient’s desires How long since diagnosis Motivation to succeed over time Barriers and facilitators to § Care § Medication adherence o Access to care, support services, medications o History with medical care o Patient’s social, emotional, spiritual milieu o o o o • ART: Antiretroviral Therapy o Five Major Classes § 1. Nucleoside Reverse Transcriptase Inhibitors (NUKES) • Works on Reverse Transcription § 2. Non-nucleoside Reverse Transcriptase Inhibitors • Works on Reverse Transcription § 3. Protease Inhibitors • Hinders develop of protein § 4. Fusion inhibitors/Entry Inhibitors • Injury prevent stop the CCR5 receptors of cell and enter host cell § 5. Integrase Inhibitors • Prevent from RNA integrate into host DNA • When to start ART o “ART is recommended for all HIV-infected individuals.” § Pregnancy • Prevent transmission to fetis § History of AIDS-defining illness • Thrush, KS (rash lesion) § HIV-associated nephropathy (HIVAN) • Attack renal à seen in labs § Hepatitis B (HBV) coinfection • Some ART treat both § Age > 50 years • Because delayed immunity • Typical Treatment o Two NRTIs + 3rd Drug § 2 NUKES and another • Balance Now Favors Early ART • Potential Benefits of Early Therapy o Potential decrease in risk of many complications, including: § HIV-associated nephropathy (HIVAN) § Liver disease progression from Hepatitis B or C § Cardiovascular disease § Malignancies (AIDS defining and non-AIDS defining) § Neurocognitive decline § Blunted immunological response owing to ART initiation at older age § Persistent T-cell activation and inflammation Consider Deferral of ART o Clinical or personal factors may support deferral of ART § If CD4 count is low, deferral should be considered only in unusual situations, and with close follow-up • Low CD4 = Need meds o When there are significant barriers to adherence o If co-morbidities complicate or prohibit ART Unique Side Effects with ART o Peripheral neuropathies and pancreatitis o Hypersensitivity with Abacavir à test HALB5701 for SJS o CNS toxicity (EFV) § dizziness, aggravation of mental health complications, vivid dreams • DO not give to those who suffer from PTSD or military • • • • • • o Metabolic complications § Lipid abnormalities, altered glucose metabolism, body fat redistribution, mitochondrial toxicity, neuropathies. Immune Reconstitution Inflammation Syndromes (IRIS) o IRIS: 3 types § Undx comorbidities can be heightened with ART therapy o Practical definition § Paradoxical worsening of a preexisting infection of a previously undiagnosed condition o Paradoxical IRIS § Improvement of known infection with treatment but deteriorate with ART o Unmasking IRIS § Detection of previously unknown pathogen that shows a prominent clinical expression with immune recovery Prophylaxis Regimens o Prevention of Opportunistic Infection – CD4 determines not symptoms § T-cell Count Driven § Pneumocystis Jiroveci pneumonia, CD4 <200 • No allergy to Sulfa à Bactrim DS 1 tab QD or QOD • Allergy to Sulfa and G6PD sufficient: Dapsone 100mg QD or Aerosolized Pentamidine Inhalation monthly • G6PD insufficiency: Mepron 750mg BID § Mycobacterium Avium Complex, CDV <50 • Zirthromax IG weekly or Clarithromycin 500mg BID § Toxoplasmosis IgG positive and no active disease (CD4) • Bactrim DS 1 tab daily • Follow Up o Labs o 1 month after initiating therapy § CBC with diff; CMP; CD4+, CD4%, HIV viral load § 3– 6 months: CBC with diff; CMP; CD4+, CD4%, HIV viral load • Lipid panel and Hemoglobin A1c every 6 months § Goal: <40 copies or “undetectable” o With each visit check mouth, lymph nodes, feelings, and emotions, and well being Prevention: Behavior Modification o Consistent condom use o Monogamy vs Partner reduction o Safer sex and drug practices o Opiate substitution treatment à Methadone o Prevention message every clinic visit o Screen and treat for mental health • HIV Primary Care Considerations o Consider § Vaccines/Immunizations § Preventative Screenings § Co-Morbidities § DDI o Vaccines/Immunizations § Follow CDC Schedule for Immunocompromised • HEP B àget titler 1 mo post vaccine o Low CD4 wait for vaccine • Pneumonia o 13 o 23 à get >200 CD4 • HPV: 3 series o 13-26 year olds • Tdap = every 10 years • Influenza annually • Herpes Zoster o 60+ and >200 CD4 • Meningococcal: 2 series o College student § Having a HIV not a reason o ROUTINE SCREENINGS • PREVENTATIVE SCREENINGS • • • Metabolic Co-Morbidities o Dyslipidemia o Diabetes Mellitus o HTN § Others o ***Chronic infection and inflammation increase risk of co morbidities Metabolic Comorbidities and HIV o Clinical Implications § Physical Change à Weight Gain § Hypertriglyceridemia § Low HDL § Increase LDL § Increased diastolic BP § Increased Metabolic syndrome profile § Increased cardiovascular risk Dyslipidemia o Treatment § High Intensity Statin • Lowers LDL by >50% § Moderate Intensity Statin • Lowers LDL by 30-50% § Low Intensity Statin • Lowers LDL by <30% o Choices: § Rosuvasatin § Atrovastatin § Pravastatin o Contraindicated (with PIs) § Lovastatin § Simvastatin o Other § Fibric Acids § Bile Acid Sequestrants (BAS) § Nicotinic Acid • What to look for o Target measurements o BMI o Hypothyroidism o Metabolic Syndrome o Primary vs Secondary o ASCVD risk o Hepatotoxicity o Hypertriglyceridemia § Pancreatitis o Myopathy o Diabetes/Insulin Resistance o Neuro Concerns • Diabetes Mellitus o Impaired glucose tolerance o Insulin resistance o Dyslipidemia o Lipodystrophy o Mitochondrial dysfunction o What to look for o Target Measures o BMI o Metabolic Syndrome o Type 1 vs Type 2 o ASCVD risk o Lipodystrophy o Dyslipidemia o Lactic acidosis o Nephrotoxicity o Complications related to DM • • Hypertensions o Chronic inflammation by HIV causes enlarge and stiffening o What to Look for: § Goal BP: 140/90 § BMI § Metabolic Syndrome § ASCVD risk § Renal Insufficency § Dyslipidemia § DM § Proteinuria § Complications related to HTN o Non Pharm Approach § Diet § Exercise § Alcohol § Weight § Tobacco Cessation • Common Problems in HIV Care o Folliculitis o Candida § Oral, Esophageal, Rectal, Vaginal o Herpes Simplex o Herpes Zoster o Anal Fistula o Genital Warts (HPV) o P. jirovecii (PCP) o Toxoplasmosis o Mycobacterium avium complex (MAC) o Histoplasma capsulatum o Coccidioidomycosis • Drug-Drug Interactions o Vitamins o Tums o Oral Contraceptives o PPIs o ABX § Increased risk of C.Diff o Steriods o Fluticasone and Advair § Increase steroid toxicity § Immuno deficiency • Special Considerations o Pregnancy - Contraception and preconception care o Children - Advisory Committee on Immunization Practices for HIV-infected infants and children o Adolescents -Transition to adult care o Transgender Care - Address specific biological, psychological, and social needs • Occupational Risk Exposures in Health Care Personnel o Types of Stick: § Percutaneous Injury (needlestick,cut) OR § Contact of mucous membrane or non-intact skin o WITH: § Blood § Tissue § Other body fluids that are potentially infectious (cerebrospinal, synovial, pleural, pericardial, peritoneal, or amniotic fluids: semen or vaginal secretions) o NOT Considered Infectious for HIV, Unless visibly bloody § Feces § Nasal Secretions § Salvia § Sputum § Sweat § Tears § Urine § Vomit • PEP: Initiating Post-Exposure Prophylaxis o PEP should be started as soon as possible, preferably within 72 hours of an exposure. o 28 day course recommended for persons exposed to someone with a known HIV status or someone whose status is unknown o Three drug regimen recommended § Maximal suppression of viral replication § Resistance protection o PEP Evaluation § Regardless if provider is taking PEP, reevaluation must occur within 72 hours, especially as additional information about the exposure or source patient becomes available § If the source is found to be negative, PEP should be discontinued § Rapid HIV testing of the source patient can facilitate decisions regarding PEP when the source patient’s HIV status is unknown o Monitoring § Baseline • HIV antibody test • Hep B and C • CBC, CMP • HCG § After initiating ART • HIV antibody test o If symptomatic o 6 weeks o 12 weeks o 6 months • Hepatitis C o 12 weeks o 24 weeks • Drug toxicities o HIV antibody test, CBC, CMP, and HIV RNA • Side effects o Toxicity of Post Exposure Prophylaxis (PEP) Regimens § PEP should be given for a full 4 weeks § Side effects of ART drugs are common, and a major reason for not completing PEP regimens § • Therefore, to the extent possible, regimens that are tolerable for shortterm use should be selected PREP – Pre-Exposure Prophylaxis o TDF/FTC or Truvada® § All persons at risk through sex or injection drug use. o TAF/FTC or Descovy® § All persons at risk through sex, excluding those at risk through vaginal sex. o Who should receive PrEP? § Sexually active gay and bisexual men without HIV § Sexually active heterosexual men and women without HIV § Sexually active transgender persons without HIV § Persons without HIV who inject drugs § Persons who have been prescribed nonoccupational post-exposure prophylaxis (PEP) and report continued risk behavior, or who have used multiple courses of PEP o Monitoring § At least every 3 months • Repeat HIV testing and assess for signs or symptoms of acute infection • Repeat pregnancy testing for women who may become pregnant • Assess side effects, adherence, and HIV acquisition risk behaviors • Monitor adherence and sexual behaviors § At least every 6 months • Monitor creatinine clearance. • Conduct STI testing recommended for sexually active adolescents and adults § At least every 12 months • Evaluate the need to continue PrEP as a component of HIV prevention