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

 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:  HIV epidemiology • Test all  HIV prevention • Treat all • Treat early  HIV testing & disclosure • caution with some  Antiretroviral treatment OIs considerations • ART: Simple, tolerable combinations preferred  OIs and OI prophylaxis • Goal is viral suppression CDC 2019 Zuckerberg San Francisco General Zuckerberg San Francisco General 1 | [footer text here]

New HIV PrEP Uptake Increasing in the United States diagnoses in the United States www.prepwatch.org CDC 2019 Zuckerberg San Francisco General 5 Zuckerberg San Francisco General 6 We are far off from meeting the need! HIV in San Francisco v SFDPH HIV Epi CDC 2015 Report 2018 Zuckerberg San Francisco General 7 Zuckerberg San Francisco General 8 2 | [footer text here]

Lower rates of KEY INITIATIVES: viral suppression 2010: Universal ART among: Women (56%) 2012: PrEP & Trans Women RAPID (immediate (68%) linkage to HIV care African Americans and ART start) (68%) People who Inject 2013: Getting to Drugs (65%) Zero: Expand Homeless (33%) PrEP/RAPID/LINCS (linkage to care and partner services) SFDPH HIV Epi Report 2018 SFDPH HIV Epi Report 2018 Zuckerberg San Francisco General 9 Zuckerberg San Francisco General 10 Ending the HIV Epidemic: A Plan for the United States Roadmap Key Messages:  HIV epidemiology • Test all • Focus on hotspots in  HIV prevention • Treat all 19 states, Washington • Treat early DC and PR where  HIV testing & disclosure • caution with some majority of new HIV  Antiretroviral treatment OIs cases are reported considerations • ART: Simple, tolerable and 7 states with combinations preferred disproportionate  OIs and OI prophylaxis • Goal is viral suppression occurrence of HIV in rural areas Fauci JAMA 2017 Zuckerberg San Francisco General Zuckerberg San Francisco General 12 3 | [footer text here]

Prevention: U=U Prevention: U=U Calabrese & Meyer Lancet 2019; CDC 2018 CDC 2018 Zuckerberg San Francisco General 13 Zuckerberg San Francisco General 14 Roadmap Prevention: PrEP and PEP Key Messages:  HIV epidemiology • Test all  HIV prevention • Treat all • Treat early  HIV testing & disclosure • caution with some  Antiretroviral treatment OIs considerations • ART: Simple, tolerable combinations preferred  OIs and OI prophylaxis • Goal is viral suppression aidsetc.org Zuckerberg San Francisco General 15 Zuckerberg San Francisco General 4 | [footer text here]

Who to test for HIV Case 1  33 M who presents with 2 days history of headaches,  Symptoms consistent with acute or chronic HIV diarrhea, nausea, generalized weakness, fever, and body  Possible HIV exposure aches.  Routine screening:  Has sex with wife x 10 years, denies sex with men. Uses meth (denies IV). - Recommend one-time screening for adults 15-65  In ED, febrile to 38.9, exam with b/l conjunctival injection, mild - Pregnant women epigastric tenderness and labs showing leukopenia, thrombocytopenia and transaminitis AST/ALT in 200s. Zuckerberg San Francisco General 17 Zuckerberg San Francisco General 18 A note about taking a More frequent screening for those at risk sexual history - 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 Deutsch LGBT Health 2018 Zuckerberg San Francisco General 19 Zuckerberg San Francisco General 20 5 | [footer text here]

HIV testing 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. Routine testing: order HIV Ag/Ab (4 th 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 Slide credit : D. Sachdev Zuckerberg San Francisco General 21 Zuckerberg San Francisco General 22 Sharing new HIV diagnosis Case 1  HIV Ag/Ab resubmitted and + and HIV VL returned at 1.6  If your clinical setting uses HIV Ag/Ab testing, this will come million. back prior to the HIV confirmatory Ab test result. When this occurs, share with patients based on their risk factors how concerned you are that they have HIV and that you are awaiting the confirmatory test. Zuckerberg San Francisco General 23 Zuckerberg San Francisco General 24 6 | [footer text here]

Sharing a new HIV diagnosis: staring the conversation Sharing a new HIV diagnosis: staring the conversation  Inquire about what they know about HIV and tailor the  Suggest that they notify partners so they can get tested. information to the patient’s literacy, knowledge, and readiness.  Address practical needs of the patient.  Ask what they have heard about HIV meds. Discuss starting  Make it clear that you and your team are here to support antiretroviral therapy, ideally even beginning today. Share U=U. them.  Acknowledge that while this diagnosis changes things for them, if they take their meds, they can lead long, heathy lives with HIV.  Most importantly, lay the groundwork through rapport building to ensure that they come for follow- up. Zuckerberg San Francisco General 25 Zuckerberg San Francisco General 26 Roadmap Baseline labs for new HIV diagnosis HIV VL  Key Messages:  HIV epidemiology CD4 cell count and percentage  • Test all CBC with diff/CMP  HIV prevention  • Treat all Lipid panel/A1C • Treat early   HIV testing & disclosure • caution with some Hep A/B/C testing   Antiretroviral treatment OIs UA  • ART: Simple, tolerable considerations GC/CT (urine, throat, rectal), RPR and for HIV + women, trichomonas  combinations preferred Pregnancy test (if childbearing age)  OIs and OI prophylaxis  • Goal is viral suppression 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  Zuckerberg San Francisco General 27 Zuckerberg San Francisco General 7 | [footer text here]

RAPID ART Start: Treatment on Diagnosis Why and When to Treat: DHHS Recommendations  STANDARD of CARE (SF DPH): - Start ART w/in 5 days of HIV diagnosis, ideally  Antiretroviral therapy (ART) is recommended for all same day HIV-infected individuals, regardless of CD4 T lymphocyte cell count, to reduce the morbidity and - (Ward 86 Standard of Care: Start ART same mortality … (AI) . day as HIV diagnosis, if possible)  ART is also recommended for HIV-infected individuals to prevent HIV transmission (AI) . - Unless clear contraindication, or patient unwilling Slide credit: S Coffey DHHS Adult/Adolescent ART GL 2018 Zuckerberg San Francisco General 29 Zuckerberg San Francisco General 30 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 Slide credit: S Coffey Zuckerberg San Francisco General 31 Zuckerberg San Francisco General 32 8 | [footer text here]

What to start Slide credit: Vivek Jain Zuckerberg San Francisco General 33 Zuckerberg San Francisco General 34 Selecting ART Regimen What to Start 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 Zuckerberg San Francisco General 35 Zuckerberg San Francisco General 36 9 | [footer text here]