Dr. Danny Toub, our local HIV expert, gave an information-packed grand rounds presentation this week on HIV. In the 1990s, HIV was the #1 cause of death among US persons ages 25-44. Great strides have been made over the last two decades. While HIV death rates continue to downtrend, there are still 1.17 million people living with HIV in the US. There are 149,500 people living with HIV in California and about 2,000 in Sonoma County.
Unfortunately, rates of new infection are disproportionately highest in black and brown men who have sex with men (MSM). In fact, the lifetime risk of acquiring HIV for an African American MSM is 1 in 2!
The Basics:
CD4 counts are used to stage disease
- normal CD4 >500
- HIV (not AIDS) > 200
- AIDS: <200 or Opportunistic infection (OI)/Cancer
HIV Viral Load is used to monitor response to antiviral therapy
- normal: undetectable
- goal: unmeasurable
- high: >200K
Take home point #1: Viral suppression is KEY KEY KEY in HIV management
- 2018 viral suppression rates now reach 81-90% in most populations (lower in youth and patients with unstable housing, but much better than a decade ago)
- The US Government has rolled out a program with the goal of reducing HIV new diagnoses by 75% in 5 years and 90% in 10 years using the FOUR Pillars of ending the HIV epidemic:
- Diagnose all people with HIV as early as possible
- Treat people with HIV rapidly and effectively to reach viral suppression
- Prevent new HIV transmission by using PrEP and syringe services
- Respond quickly to new HIV outbreaks
Take home point #2: There are so many HIV Resources for you to rely on for help. Here are Dr. Toub's recommendations
- Team VIDA MD on call 707-583-8823 (24/7)
- National HIV curriculum: www.hiv.uw.edu
- CCC (Clinical Consultation Center): http://nccc.ucsf.edu
- Pacific AETC Quick Guide (26 page): http://paetc.org/
- Podcasts: https://thecurbsiders.com/tag/hiv
- Crushing and Liquid formulations of ART: https:/hivclinic.ca
Take home point #3: Antiviral Therapies (ART) are so much simpler than they used to be. Many regimens are just one pill once a day!
- Current ART Guidelines include an initial regimen of 2 NRTIs + INSTI (now available in combination forms)
- Nucleoside Reverse Transcriptase Inhibitors (NRTIs) are in: abacavir, emtricitabine, lamivudine, and tenofovir (AF or DF)
- Integrase inhibitors (INSTI) are in: bictegravir, dolutegravir, raltegravir
- Protease inhibitors (PIs) are out
- Boosters are out
Take home point #4: Start ART in anyone diagnosed with HIV as soon as possible (within 2 weeks in anyone with OI), call team VIDA for any questions.
- HIV replication increases mortality
- Benefits of early treatment outweighs risk (ACTG A5164 Study)
- this is particularly true in PCP but also in cryptosporidiosis, microsporidiosis, PML, Kaposi's sarcoma and serious bacterial infections
- possible exceptions: cryptococcal meningitis, TB, CNS toxoplasmosi
Take home point Point #5: Ambulatory Care of stable patient with HIV is much like care of all our patients with any chronic disease:
- Chronic Disease 101 (a la Danny Toub)
- Is the medicine you are taking effective? (--> viral load)
- Are you able to take your medications? (access ($$, pharmacy issues), adherence, tolerance)
- Can we do better? (i.e. side effects, pill burden, etc)
- Routine labs (DHHS ART Guidelines table 3: www.aidsinfo.nih.gov/guidelines)
- HIV Viral load and CMP q 6 months
- HbA1C, lipids, urinalysis (if CKD), RPR, GC/CT (3 site),, +/- HCV, CBC (CD4)
- Health Care Maintenance: www.hiv.uw.edu/go/basic-primary care
- Vaccination
- Cancer Screening
Take home point #6: Treatment=Prevention
- "People who take ART daily as prescribed and achieve and maintain an undetectable viral load have effectively NO risk of sexually transmitting the virus to an HIV negative partner"
- Undetectable= Untransmittable (U=U)
Take home point #7: Pre-exposure prophylaxis (PreP) is an amazing and underutilized HIV biomedical prevention tool. If you do reproductive services in your primary care practice (i.e. birth control and STD testing), you should also be doing PrEP
- PrEP is safe
- PrEP is effective
- if men take >4x/week
- if women take 6-7 times per week
- PrEP is patient centered
- PrEP is paid for! (as a Grade A USPSTF recommendation
- However, only 1% of African Americans and 3% of Latinos who would benefit are on PrEP
- We should be offering PrEP to ALL:
- Sexually active adults and adolescents who have had any anal or vaginal sex in the past 6 months AND 1) have an HIV+ sexual partner OR 2) Recent bacterial STI OR 3) Hx of inconsistent or no condom use with partners
- Person who injects drugs AND has a HIV+ injecting partner OR shares drug prep or injection equipment
- Just need negative HIV test before rx, no s/sx of acute infection, normal renal function, no contraindicated meds
- Rx TDF/FTC OR TAF/FTC once daily
- Monitoring visit q90 days: check HIV status, pregnancy test, renal function, STI screen, risk reduction counseling
- Online Prep learning opportunities:
- Quick HIV clinical guide
- National HIV curriculum
- HIV prevention Certified Provider Program
And finally, my own personal reflections from working with Danny and listening to him speak:
be strength based
be non-judgemental
be kind
be there for patients ALWAYS
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