Updates in HIV Care and Prevention: The Critical Importance of Choice (Pastor, 2/5/2025)

 A recording of this presentation is available HERE.

Check back for my notes soon!

Care of Acute HIV in the Hospital (Fenning, 11/29/2023)

  A recording of this presentation is available HERE.

***

Many thanks to Dr. Reece Fenning for an excellent presentation this week on Acute HIV in the Hospital. A recording of his presentation is available above. 

My notes:

• 75% of the HIV+ population in Sonoma County is >40 years old
• HIV disproportionately affect African American and Latinx people, who make up 65% of the new diagnoses each year
• Whereas in California 73% of people living with HIV are engaged in care and 64% are virally suppressed, in Sonoma County, 86% are engaged in care, and 82% are virally suppressed
• Patients with HIV have 1.5x the hospitalization rate as their HIV- counterparts

The CDC recommends that ALL US adults receive a one time HIV screening. People who should be tested more frequently (annually) include: 1) people with partners who are known HIV+ or have a known exposure, 2) pregnant patients, 3) patients who use IV drugs, and 4) people who exchange money (or other goods) for sex. 

Luckily, our HIV testing sensitivity has improved in the last decade, and the so-called "window period" is now much shorter than the past -- it is only around 10 days (but up to 3 weeks) between viral acquisition and possibility of a false negative test. 

When seeing patients with HIV in the hospital and/or outpatient, you should check their CD4 count AND their viral load. Also, screen for common co-morbid infections: TB (the most common worldwide), acute viral hepatitis (A, B, C), and other STI testing (RPR, GC/CT), and lipids.

HIV is staged based on CD4 count and/or CD4 percentage:

• Stage 1: CD4 count >500
• Stage 2: CD4 count 200-500
• Stage 3: CD4 count <200 and/or CD4 percent <14%

Newly diagnosed HIV should be treated immediately (rapid tx induction), except in rare cases of specific comorbidities. These exceptions include Cryptococcus meningitis and active TB. Both require initiation of treatment of these conditions prior to treating the HIV disease. (see chart below):

Standard anti-retroviral treatment for HIV includes 2NRTIs and 1 NSF. You ideally want to know the viral load and genotype prior to starting treatment, but this may not always be possible.

• Biktarvy (bictegravir/emtricitabine/TAF) is a single pill containing all three meds
• Alternate options includes a couple of different dolutegavir-containing regimens
• Trivicay + Descovy (2 pills)
• Trovicay + Truvada (2 pills)
• Triumeq (only one pill, but requires HLA testing, so not great for rapid treatment)
  

What about empiric prophylaxis Opportunistic Infections (OIs)? 

You should be worried about OIs if CD4<200 and/or CD4 percentage<14%. The most common OIs for which to consider ppx are PCP pnuemonia (aka PJP) if CD4<200-- ppx is TMP-SMX daily,  and MAC (if CD4<50) -- ppx is azithromycin once weekly.

How should we think about OIs in the acute setting? There are a couple of different ways to think about OIs:

Time with HIV

• newly acquired (<6 months)
• previously on treatment but now stopped
• on treatment, but its not working

Presenting symptoms:

• AMS --> think CNS infection (Crypto
• respiratory symptoms --> think PCP, MAC
• dermatologic symptoms --> think HSV, VZV, MRSA, KS

Random acute HIV symptoms and pearls:

• Acute HIV: The large majority of patients will have viral/flu-like symptoms with acute HIV that will self-resolve. Most are not sick enough to present to the ER during this acute illness.
• 
  
  
  
• Immune reconstitution inflammatory syndrome (IRIS) usually appears 2-4 weeks after starting tx, it is a diagnosis of exclusion. Greatest risk with high viral load and very low CD4 (<50). Treatment is NSAID (outpatient) or steroids (inpatient)
• HIV wasting syndrome: acute weight loss (>10% of body weight), often with acute diarrhea. Looks like cancer. May need an EGD and/or colonoscopy for biopsy to diagnose. See testing algorithm below.

• 

  

  
  

  
  
  
• Odynophagia: pain with eating may be a sign of oral thrush and/or esophageal candidiasis
• 
• Dermatologic infections in HIV are very confusing and also often require a biopsy (see images)

• 

  (L>R clockwise: Kaposi's Sarcoma, HSV, MRSA Shingles)

  
  
• Respiratory illness in HIV disease should be evaluated like non-HIV with CXR, blood work, but also add beta-D-glucan (for fungal infections). You likely will need tissue (bronchoscopy or induced sputum) to get a diagnosis. 
• Neurologic symptoms in someone with HIV require a head CT, followed by CSF studies. Also don't forget a fundoscopic exam (CMV retinitis)

Additional resources:

PEP/PrEP Update (Krumland - 7/26/23)

 A recording of this presentation can be viewed HERE.

***

Many thanks to Dr. Stephen Krumland of Team Vida at SRCH for an excellent update on HIV Pre-exposure Prophylaxis (PrEP) and Post-exposure Prophylaxis (PEP). This is such an important primary care topic! 

Take homes up front:

• PrEP
• All primary care providers can and should prescribe PrEP for any patient who wants it. Yes you can!
• A few specific labs should be ordered and resulted before starting PrEP (see below for details; the labs are slightly different depending on the medication being prescribed).
• PrEP is a USPSTFGrade A Recommendation, which means most health plans are required to provide it without a co-pay. 
• Yes, PHP covers PrEP and there are Patient Assistance Programs for patients who are totally uninsured.
• NCCC PrEP line (WARM): 1-855-448-7737 (M-F 9am-8pm EST)
• PEP
• The need for PEP is considered a medical emergency and requires urgent management by clinicians.
• PEP should be started within 72 hours of high risk exposure, the sooner the better.
• Clinics should have a PEP "starter pack" to ensure patients can start PEP asap after exposure (SRCH has this).
• NCCC PEP line (HOT): 1-888-448-4911 (7 days a week, 11am-8pm EST)

Pre-Exposure Prophylaxis (PrEP) is safe, effective and reliable. It is estimated that 1.8 million patients in the US are eligible for PrEP, but only 25% receive it. In a study from 2019, only 13.6% of primary care providers reported prescribing PrEP. Of note, women comprise only 8% of PrEP prescriptions even though they make up 18% of new HIV diagnoses. 

People with an increased risk for HIV via sexual exposure include: people with a known HIV-positive partner, people with one or more partners of unknown HIV status, and people who have contracted a bacterial STI (e.g. GC/CT or syphilis) in the last 6 months. People with increased risk for HIV via injection drugs include anyone who has injected drugs in the last 6 months. 

We should definitely be screening people with a good sexual and substance use history and prescribe PrEP for anyone who is at high risk, BUT also NOTE that the 2021 update from the CDC recommends we offer PrEP to anyone, even those without these risk factors, if requested!

PrEP consists of 1 of 3 possible medications (4 ways to take):

1) Truvada (F/TDF) is a DAILY single pill, ALL patients can take (including pregnant and breastfeeding). Possible side effects include AKI and worsening of CKD and decreased bone density (with continued use). Truvada is effective if taken 6 days per week for those having vaginal sex, and a minimum 4 days/week for cisgender men and transgender women having non-vaginal sex. Absolute contraindication: Do not rx for CrCl<60.

2) Descovy  (F/TAF)is also a DAILY single pill. It has not been tested or approved for use in vaginal sex. Side effects include elevated lipids and weight gain (but does NOT have renal or bone effects, so may be preferable in patients with CKD and/or osteopenia). Contraindication: Do not rx for people having vaginal sex

3) Cabotegavir (brand name Apretude) is a newer Q8 week IM injection, which takes away adherence issues of taking a daily pill. The main side effect is pain at the injection site. It has no renal effect, no bone effect. 

Alternate dosing:

There is good evidence for on demand PrEP, as an alternate to daily PrEP dosing. On Demand PrEP is not FDA approved but is recognized by the same body as an "alternate dosing" schedule. On Demand PrEP is often referred to as "event-driven PrEP", which means you take it when risky behavior is anticipated to happen. This is how you take it:

• 2 tabs, 2-24 hours prior to sexual encounter
• 1 tab,  24 hours after sexual encounter
• 1 tab, 48 hours after sexual encounter

        TOTAL 4 tabs

This is a great method for either folks who are terrible about taking a daily pill OR those who have intermittent and predictable high risk exposures. 

Okay, so which labs should I order prior to initiating PrEP?

• Check HIV status prior to starting any PrEP
• check HIV Ag/Ab for anyone who is starting for the first time or people restarting PrEP after a long stop
• check HIV Ag/Ab AND HIV RNA for anyone who is on PrEP or who has recently taken any PrEP
• Screen for other STIs prior to starting any PrEP (site-specific testing)
• gonorrhea, chlamydia and syphilis
• Check a pregnancy test (HCG) for any patient who is at risk of getting pregnant.
• Check renal function (BMP) before starting ORAL PrEP (F/TDF and F/TAF). You do not need to check renal function for Cabotegavir (Apretude)
• F/TDFis approved if CrCl>60
• F/TAF is approved if CrCl>30
• Check HBV status prior to starting ORAL PrEP (F/TDF and F/TAF) because some of these agents are used to treat HBV and can reactivate a patient's dormant HBV (do no harm).
• Check a Lipid panel for anyone starting F/TDF

What lab testing do I need to do for people on PrEP?

• Test for HIV q3 months (Ag/Ab, unless they have s/sx of acute HIV then you should add HIV RNA)
• Renal function (if ORAL PrEP) q3 months at first, then q6 months
• Routine STI screening (site specific) q3 months 

Post-Exposure Prophylaxis (PEP)

There have been no recent updates to the 2016 Guidelines. You must have had contact with a high risk body fluid -- that is blood OR something with blood in it -- to qualify for PEP. Whether it's an occupational exposure (e.g. needlestick) or a non-occupational exposure (e.g. unprotected sex), the need for PEP should be treated as a medical emergency.

PEP is 3 meds regimen (there are multiple options) x 30 days

Okay in pregnancy

Most commonly Biktarvy (coformulated BIC/FTC/TAF) or Truvada (tenofavir, emtricitabine) + Raltegravir 

Biktarvy is one pill daily x 28 days, studies show it is well-tolerated

SRCH has starter packs (5-7 days) to allow patients to start immediately while the meds are obtained for the month

Baseline PEP labs:

• HIV Ag/Ab
• Rneal, liver function
• HBV
• HCG
• STI labs

Follow-up PEP labs

Recheck HIV Ab/Ag in 4 weeks, then again in 3 months

Be sure to evaluate need for starting PrEP at the 4 week visit, again at the 3 month visit

What is DoxyPEP?

DoxyPEP is a one time doxycycline dose after high risk sexual exposure (oral, anal or vaginal). It has been shown to significantly decrease the risk of gonorrhea, chlamydia and syphilis

Doxcycline dosing: 200mg x 1 within 72 hours of high risk exposure

DoxyPEP was added in April to CDPH recommendations to anyone at high risk for STI exposure,  likely will be by the CDC soon

Note: doxycycline should NOT be given in pregnancy

If you have questions, concerns, us the PrEP warmline, the PEP hotline, and don't forget Team VIDA at SRCH!

HIV Derm (Leslie - 3/22/23)

 A recording of the presentation can be viewed HERE. 

HIV Pre-Exposure Prophylaxis (PrEP) (Toub - 7/27/22)

 A recording of the presentation can be found HERE.

Is the answer always syphilis? (Le, 2021)

Thanks to Dr. Jimmy Le for an excellent Grand Rounds presentation this week on Syphilis. Rates of syphilis have been on the rise in the US and in Sonoma County for the last decade.

A recording of his excellent presentation is available HERE.

For those of you who want the notes, here are my notes:

Epidemiology:

• Before 2013, cases of syphilis in the US were generally concentrated in men who have sex with men (MSM) 
• From 2013-2018, there has been increase of 170% primary and secondary syphilis diagnosis in women AND rising rates in black/Latinx populations
• There is a high rate of co-infection w/HIV (42% MSM with syphilis also have HIV)
• In 2019, 129K cases of syphilis in the US (MSM and MSMW), 1870 cases reported of congenital syphilis (unfortunately more common in BIPOC mothers)
• In SoCo, as well, rates have been increasing, similarly transitioning from primarily a disease in MSM to a wider category of folks, including more women, homeless, persons who inject drugs

What is syphilis?

• A spirochete infection caused by treponema pallidum
• Multiple stages of syphilis can be confusing (see graphic below from Emory)
• The incubation period 9 days-3 months (can be asymptomatic)
• Neurosyphilis, ocular syphilis and otic syphilis can happen at ANY time during infection (should have low threshold to test for these)

Primary syphilis: 3-90 days after exposure, painless chancre, round and firm, can appear anywhere, generally 3 weeks after infection, heal on own in days/weeks, place where chancre appears is where exposure occurred (e.g. anus, vagina, penis). Gets missed, people don't notice because it doesn't hurt!

Secondary syphilis: 3-6 months after initial infection: "bigger rashes", more widespread (hands, feet, trunk, tongue, hair loss)

Tertiary syphilis: years to decades after exposure, "the great imitator", can show up in any tissues: cardiovascular, skin, bone, etc

Early latent: asymptomatic, <12 months of exposure

Late latent: asymptomatic  infection >12 months of exposure, "syphilis of unknown duration"

Neurosyphilis: CNS infection (meningitis), general paresis, tabes dorsalis

Ocular syphilis: vision loss, blurry vision, eye pain, redness

Otic syphilis: sensorineural hearing loss, tinnitus, vertigo

Transmission:

• Primary syphilis is VERY transmittable (lots of treponemes in primary chancres-- any surface is vulnerable), likelihood of transmission is ~30%
• As you move through stages, you become less and less infectious, can definitely still transmit but less than primary
• Syphilis is also one of TORCHES infections, the spirochete crosses the placenta very readily

Diagnosis:

• Two types of tests:
• Non-treponemal test: tests for cardiolipin cholesterol-lecithin antigen (RPR, VDRL), always presented as titers
• Treponemal test: detection of Ab against Ag. once positive, will always test positive (FTA-ABS, TPPA)
• Two methods for testing, decision which algorithm to use is based on prevalence. Generally thought higher prevalence area should use reverse testing algorithm 
• Traditional (see image) starts with RPR, reflex to TPPA confirmation
• Reverse (see image), do the opposite (start with TPPA), if that tests positive, reflexes to RPR)
• Once a patient is positive, Treponemal tests will ALWAYS be positive, so you always need RPR and titers
• Do note, you can have false negative RPR in latent period and upon appearance of chancre 1-3 weeks (e.g. if you are testing "too early", if you see a chancre, treat treat treat)
• Dx of neurosyphilis requires high clinical suspicion and low threshold for doing LP and getting CSF: test for protein, WBC, CSF-VDRL (which has poor sensitivity, 70% can test negative)

Treatment

Penicillin is ALWAYS the treatment (see chart above for details)

• Don't forget to get an RPR on the day of treatment (to get baseline)
• If a patient reports contact with anyone with syphilis in the last 90 days, treat empirically! 
• including partner treatment!
• www.dontspreadit.com (anonymous texting about exposure)
• Primary, secondary, early latent (<12 months): PCN 2.4 million units IMx 1
• Late latent (>12 months), unknown duration of tertiary with normal CSF: need to be treated with IM injections x 3 (one week apart)
• Neuro/ocular/otic syphilis: treatment is IV PCN 10-14 days (usually initial hospitalization)
• If a patient has PCN allergy, desensitization and treatment with PCN is still recommended (JAMA article on PCN desensitization available HERE)
• Follow-up testing is KEY: 
• for primary/secondary, early latent, retest with RPR at 6, 12 month (looking for 4x decrease in titer)
• for late latent, unknown, you should retest at 6, 12, and 24 months
• RPR baseline will be your guideline to determine if someone has been reinfected (4x increase demonstrates reinfection)

Questions about staging/treatment, can always call: Team Vida 707-583-8823 or SoCo Health Department 707-565-4566

Congenital Syphilis:

• complex diagnosis and treatment algorithms (see diagram from California DPH below)
• steady rise of congenital syphilis since 2012, 400% increase since 2012
• syphilis readily crosses placenta or via contact with chancre during delivery
• can affect ALL organs of the body, can lead to infant death and miscarriage
• wide clinical presentation: < 2 year old, usually presents by 5w-3 months of age, 60-90% will be symptomatic
• sx include hepatomegaly, jaundice, rhinitis ("snuffles"=white discharge, more severe than common cold, mucous discharge VERY infectious because lots of treponemes in them), rash, generalized LAD, skeletal abnormalities
• Treatment: IV PCN 50K units/kg q8 hours x 1 week, then q12 hours OR PCM IM x daily x 10 days
• Evaluation: neurodevelopmental, hearing, eye, serologic testing with RPR until negative or 4x decrease (usually non-reactive by 6 months)

https://californiaptc.com/in-the-news/new-tool-for-clinicians-unveiled-to-ensure-appropriate-treatment-of-congenital-syphilis/

Screen for STIs!

Screen all sexually active patients for HIV, RPR, GC/CT (including swabbing every site they use to have sex, including mouth, vagina, rectal)

Other STIs predict HIV risk (see infographic)

Offer partner treatment always

https://californiaptc.com/wp-content/uploads/2017/03/Slide7.jpg

HIV Update for Primary Care (Toub 9/2/2020)

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