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CME / ABIM MOC / CE

Managing HIV in Primary Care: Best Practices for Primary Care Clinicians

  • Authors: Sampath Wijesinghe, DHSc, PA-C, AAHIVS; Linda-Gail Bekker, MD, PhD
  • CME / ABIM MOC / CE Released: 7/29/2022
  • Valid for credit through: 7/29/2023
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  • Credits Available

    Physicians - maximum of 0.50 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.50 ABIM MOC points

    Nurses - 0.50 ANCC Contact Hour(s) (0.25 contact hours are in the area of pharmacology)

    Pharmacists - 0.50 Knowledge-based ACPE (0.050 CEUs)

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for primary care physicians, nurses, nurse practitioners, and pharmacists.

The goal of this activity is that learners will be better aware of the need for HIV testing and treatments for those starting therapy.

Upon completion of this activity, participants will:

  • Have increased knowledge regarding the
    • Selection of patients for HIV screening
    • Considerations when selecting antiretroviral therapy (ART) for treatment-naive people living with HIV (PLWHIV)
  • Demonstrate greater confidence in their ability to
    • Manage PLWHIV in primary care


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Faculty

  • Sampath Wijesinghe, DHSc, PA-C, AAHIVS

    Clinical Assistant Professor
    Stanford University School of Medicine
    HIV Specialist
    Adventist Health Central Valley Network
    CDC Clinical Ambassador
    Fresno, California

    Disclosures

    Sampath Wijesinghe, MD, has no relevant financial relationships.

  • Linda-Gail Bekker, MD, PhD

    Professor of Medicine
    Desmond Tutu HIV Center
    University of Cape Town
    Cape Town, South Africa

    Disclosures

    Linda-Gail Bekker, MD, PhD, has the following relevant financial relationships:
    Consultant or advisor for: Gilead Sciences, Inc.; Janssen Pharmaceuticals; MSD Pty Ltd; ViiV Healthcare
    Speaker or member of speakers bureau for: Cepheid; Cipla Ltd.; Gilead Sciences, Inc.; Janssen Pharmaceuticals; Johnson & Johnson; MSD Pty Ltd; ViiV Healthcare
    Research funding from: Johnson & Johnson

Editor

  • Shanthi Voorn, PhD

    Medical Education Director, WebMD Global, LLC

    Disclosures

    Shanthi Voorn, PhD, has no relevant financial relationships.

  • Eloise Ballard, PhD

    Scientific Content Manager, WebMD Global, LLC

    Disclosures

    Eloise Ballard, PhD, has no relevant financial relationships.

Compliance Reviewer/Nurse Planner

  • Stephanie Corder, ND, RN, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Stephanie Corder, ND, RN, CHCP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has disclosed no relevant financial relationships.


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    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.50 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Aggregate participant data will be shared with commercial supporters of this activity.

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CME / ABIM MOC / CE

Managing HIV in Primary Care: Best Practices for Primary Care Clinicians

Authors: Sampath Wijesinghe, DHSc, PA-C, AAHIVS; Linda-Gail Bekker, MD, PhDFaculty and Disclosures

CME / ABIM MOC / CE Released: 7/29/2022

Valid for credit through: 7/29/2023

processing....

Activity Transcript

Sampath Wijesinghe, MD: Hello, I'm Sam Wijesinghe, clinical assistant professor at Stanford University School of Medicine, HIV specialist at the Adventist Health Central Valley Network in Fresno, California, and CDC Clinical Ambassador to Fight Against HIV. Welcome to this program titled, "Managing HIV in Primary Care: Best Practices for Primary Care Clinicians." Joining me today is Linda-Gail Bekker, professor of medicine at the Desmond Tutu HIV Center, University of Cape Town in South Africa. I'm very honored to be here with Linda-Gail Bekker today. And welcome.

Linda-Gail Bekker, MD, PhD: Thank you.

Dr Wijesinghe: So, a quick overview about the program today. We are going to talk about HIV management in primary care, and then some of the best practices about the initial evaluation. And then ongoing patient management. Then review some of the guidelines about antiretroviral therapy. And then have the conclusion at the end. Key imperatives in HIV management in primary care. So early diagnosis, linkage to care, antiretroviral therapy, and retention in care. All these are important in preserving the health of patients living with HIV and preventing further transmission. Known as "U" is equal to "U." "U" is undetectable. And then the other "U" here is untransmittable. Linda-Gail, can you tell us bit about the global 90-90-90 goal?

Dr Bekker: Yeah. Thanks Sam. And so, this was formulated by UNAIDS probably about, I want to say, 5 to 7 years ago, 2014, 2015, when it was recognized that there was great value in people being suppressed on antiretroviral therapy. We get primary benefit in the individual, but we get secondary benefit from the individuals that they may have sex with. In other words, as you say, undetectable is untransmittable, it really protects their intimate sexual partners.

And so, for this reason, the formulation of 90-90-90 was thought of. Now, what that means is, around the world, we want 90% of the population to have been tested. And then of those who test positive, we want 90% of those individuals to be on antiretrovirals. And then of those people on antiretrovirals, we want 90% of those individuals to be virally suppressed. So where are we in the world at the moment?

Globally, we're about 84%-73%-66%. So, you can see there's quite a way for us to go still. And it's important to know that around the world, this is not equal. So, there's certain regions of the world, for example, eastern Europe and central Asia, where these numbers are, in fact, really not very good. Same as central Africa, we have work to do there. And that's what today is about, it’s about keeping people in treatment. And we can think about HIV care as a revolving door. And this speaks to not only the 90-90-90, but it talks about a fourth 90, which is quality of care. We want individuals to experience quality care, such that they stay in our programs. So, Sam, you practice medicine in the US, what is your epidemic looking like today in the States?

Dr Wijesinghe: I know that we have made some good progress here in the country, but we still have a long way to go. Missed opportunities for HIV testing is still a big problem in the US. And so, when we were looking at recent numbers, about 29% of men who have sex with men, and 42% of people who inject drugs, and then about 59% of heterosexual-at-increased-risk, they were seen by their primary care providers. And then 7 out of 10 patients at risk for HIV were not tested for HIV in the past year, even though they had seen their primary care provider.

So missed opportunities for HIV testing continue to be a problem. So, with sharing all that information, I just want to highlight that HIV diagnosis through routine screening is the critical first step in this HIV prevention and care continuum. So primary care providers have this opportunity that they will be able to make an impact, by taking the first step by screening their patients.

Dr Bekker: So, Sam, through the decades, we initially held off with antiretroviral therapy quite far into a person's infection. In other words, quite advanced HIV before antiretrovirals were offered. That's really changed around now. And we recognize the benefit of early HIV diagnosis and therapy. Do you want to just describe a little bit what some of those benefits are?

Dr Wijesinghe: I think this is also another place to mention that regardless of CD4 count, you will start antiretroviral therapy now. And when we start antiretroviral therapy early, there are 4 main benefits that I like to mention briefly that will be decreasing the size of the HIV reservoir when followed by long-term viral suppression, and studies have clearly shown that. And then protection against serious AIDS-related events, and serious non-AIDS-related events. So that's another benefit. And then faster achievement of viral suppression is another benefit when you start antiretroviral therapy early. And then an increased likelihood of viral suppression 1 year after diagnosis.

And then one other thing I like to point out, when you start antiretroviral therapy early, there is a very good chance that patients will be able to have normal life expectancy. And we have seen data that people who achieve viral suppression and attain a CD4 cell count more than 350 within 1 year of starting antiretroviral therapy have a normal life expectancy.

Who, and when to screen? According to CDC guidelines, anyone between 13 and 64 should be tested once as part of routine care. And those with high risk, should be tested once a year. And then US Preventive Services Task Force, they have come up with the recommendation to screen everyone ages between 15 and 65. So, who is at risk? On our slide, we have included all the people who are at high risk for your review.

One other thing that I would like to highlight here, when it comes to routine HIV screening, when somebody is diagnosed with tuberculosis and then we need to start treatments, and then obviously we need to screen them for HIV. And then if somebody has a sexually transmitted infection (STI), we highly recommend adding HIV screening for those. And then also if somebody's starting a new relationship with somebody that they're going to have a sexual relationship, we recommend them getting HIV screening. And then, obviously, as we all know, during pregnancy, we do HIV screening. I would love to hear about what's happening in your part of the world, Linda, how do you categorize high risk?

Dr Bekker: Yeah, thanks, Sam. And of course, I'm sitting here in South Africa, which is one of the most burdened countries in the world when it comes to numbers of people living with HIV. But when you think about my region, eastern and southern Africa, then I'm afraid we're contributing 40% of all new infections. But I absolutely agree with those categories of people you have highlighted already. And then I want to draw attention to this notion of key populations. So, the way I describe a key population is an individual who is particularly burdened with HIV. So, because of their behaviors, or because of some of the relationships they have, they may be at increased risk of acquisition of HIV. And then they simultaneously find it very hard to access services, perhaps because of the fact that their behavior is criminalized. In some parts of the world, men are not allowed to openly have sex with men. In other parts of the world, women are not allowed to sell sex, or indeed, people may not be able to inject drugs. So those individuals find themselves not easily able to access services. And so, they're even more marginalized when it comes to our care. And really, even just being able to be screened for HIV.

Again, in my part of the world, we include young women and adolescent girls as a key population, because they are very highly burdened with HIV as a population. And yet, they struggle sometimes to get the services that they need. And this terminology is not prejudicial. What it helps us to understand is not only do we need to reach those individuals, but we also need to provide better services for them, because they often feel marginalized and not included in the mainstream services that we provide.

At the same time, we should not turn a blind eye to the general population. And that particularly pertains to me here, in sub-Saharan Africa. And here, I also want to highlight heterosexual older men, who typically are not in our care. They don't see health services as something they need to take cognizance of, and so we really need to attract them into our services and make sure that we screen them when we can. So, as you've already said, HIV counseling and testing is the gateway to all of our HIV services.

And then the last group, I particularly want to highlight because they're important around the world, are young people. So young people in adolescents, whether they're in the key population category, or whether they are young women and adolescent girls, they really are very important. The reason being that, again, they often are not in our services, and when we do get them into care, they struggle to take antiretrovirals. We'll come back in a moment to adherence, but this is the population who really find it difficult to take a daily pill. And so, we find with this population, we haven't shifted the dial, the needle on reducing mortality and morbidity in adolescents living with HIV around the world. And that, I think, warrants our attention in making sure that this population is one that we are thinking about carefully.

Dr Wijesinghe: And so, what is the criteria for screening in South Africa?

Dr Bekker: So, a very important population I want to raise again are pregnant women. We have not yet eliminated what we call mother-to-child transmission or vertical transmission of HIV. So that's one population that, as you've already said, we really do need to screen. You've already mentioned people who present with STIs, with tuberculosis (TB), children who are under 5 may be at risk, particularly, if they've got a parent who is living with HIV. HIV tends to track in family populations. So, what I tend to say to people particularly here in sub-Saharan Africa is, always think, "Could HIV be a screening test I want to offer?" And in most cases, we should be thinking about opting out, rather than opting in, as it were. Making sure that we've considered HIV. It's a very easy test to do. It really is noninvasive in many ways. And yet the return, if we find that somebody's living with HIV is enormous, it's lifesaving to get them onto antiretrovirals. And now, because we have such better prevention options, we can also direct people into prevention services. So, Sam, I think we're moving on now into what is the best option for primary care of individuals who may test positive for HIV, and what is it that you're doing in your practice at the moment?

Dr Wijesinghe: This is one of my favorite topics to talk about. I think we need to offer routine HIV screening, along with other standard preventive screenings. I want to make sure my patients have stable blood pressure. They have no high cholesterol. And if they have diabetes, I would like to start treatment. So, I would like to include HIV screening as part of one of those preventive screenings. And then, it is important to offer a routine screening, regardless of patients' race and ethnicities, sexual orientation, sex or gender, relationship status, or socioeconomic status.

So, I'll tell you exactly what I do in my practice for you to have an idea what I'm talking about here. So, when I have a patient coming to me for routine care, and then I say, "Okay, it is time to get your blood work done. I'm going to make sure that you have no diabetes or high cholesterol, and I'll check your kidney functions and liver functions. And then I'm going to include an HIV screening along with those tests, because that's the recommendation." Ninety-nine percent of the time, people are just fine with that. They're like, "Oh yeah, let's do that." And very rarely somebody might ask a follow-up question. Then I take it as a teachable moment, and then most of the time they will be okay with that HIV screening test. And that is what I encourage other primary care providers to do, keep a neutral tone, and then make it like any other screening preventive measure that you do in your practice.

I’d like to talk about the tests that we have available. We have antibody tests, and then we have an antigen antibody combination test. And then we have nucleic acid test, also known as HIV RNA test. The antigen antibody test, also known as HIV fourth-generation test. And this one has HIV P24 antigen. So, this antigen test will be able to detect someone as early as 2 weeks. So, in general, in my practice, I use fourth-generation tests because it has the antigen antibody, both. And then if I have a patient that maybe had the exposure with someone [who was] HIV positive last week, I will do an HIV viral load, HIV RNA test, a nucleic acid test, because it has the ability to detect somebody very early.

Dr Bekker: So, Sam, of course, it's really important that we talk to our patients, as well. So, at that first visit, not only is the physical examination important, and it is, [but] we also want to be sure that we obtain an HIV-related history from the patient. So, this will include medical information, and there's certain things we may want to find out at the first visit, for example, previous medical history and a family history. And then thereafter, we're going to want to check what other medications individuals may be taking. Of course, drug-drug interactions are important with the antivirals, as well as polypharmacy can have an impact on adherence. Plus, of course, any new comorbidities that may have come along. And we always want to check what sort of vaccines our patients have taken in a last 12-month period.

The psychosocial history is also very, very important. Mental health is such an important determinant of adherence, but also so many other aspects. We want to understand what other societal issues are at play in this individual. And of course, a little bit of the story around partners, intimate partners, other kinds of partners, and also children that may be around.

And then probably one of the most important components that we are not always good about doing is the sexual and reproductive health history. Understanding a partner's status. Is this individual planning a pregnancy, and what does that look like? And again, this will impact perhaps what kind of antivirals they go onto, also how we might manage them. And in fact, also their prevention options, even if they don't test positive. As life goes on, we really want to know the life course of the individual. So maybe there may be issues around menopause or aging with HIV. So many of these factors are important to elicit not only at the first visit, but then in subsequent visits.

Dr Wijesinghe: Very comprehensive, Linda-Gail. So, what lab tests do you order in those initial visits?

Dr Bekker: So again, I think here we want to advise healthcare workers to turn to their guidelines. And there are some terrific guidelines for every region, and in most cases, for every country. But obviously, besides HIV serology, you may or may not want to get a CD4 cell count. Certainly, in most instances you would want a viral load. And in certain instances, you may think about antiviral resistance testing. That does not apply in my part of the world, just because resistance testing is so expensive. But again, hepatitis B serology, there may be basic chemistry you want to think about, liver, renal profile, fasting lipid profiles. Looking for evidence of other comorbidities. And then as we've already reflected on, pregnancy may be a consideration if this is a woman of reproductive potential.

We also might want to think of other coinfections. Again, in my part of the world, tuberculosis is so important, but don't forget sexually transmitted infections and other possible infections. And then, finally, you may want to think about what kind of immunizations are needed and the timing for those. Sam, talking about vaccines, what actually is recommended at the moment in your practice when it comes to vaccines?

Dr Wijesinghe: So, I confirm the hepatitis B vaccine status and then administer that if necessary. Then HPV, that's another vaccine I pay close attention to with the patients with HIV. And then obviously, annual flu shot influenza vaccine. And then the MCV, also known as meningococcal vaccine. And then pneumonia vaccine, pneumococcal, PCV vaccine. And then, obviously, we make sure that they're up to date with their tetanus-diphtheria-acellular pertussis (Tdap) vaccine.

Dr Bekker: And then, of course, Sam, it's the all-important question of antiretrovirals, particularly in the treatment-naive individual. And here, we typically talk about first-line therapy. And the idea here is that our countries, our regions, and for example, the World Health Organization has stipulated guidance around which are the best antiretrovirals to offer people first line, and then if they can't take that first line or they fail the first line, the second and further lines thereafter. So again, I encourage people to look at their region and their guideline.

What you see on the screen here is the guidance for Europe, but there will be guidance for the US. And of course, as I mentioned for my region, the World Health Organization puts terrific guidelines together at regular intervals and updates that guidance. Important though, in principle, is that we want to offer antiretrovirals to all people living with HIV, following confirmed HIV diagnosis, and after we've done our clinical assessment. And today we can even offer same-day antiretrovirals. But just to say, in principle, we also want to be sure that we offer a triple-therapy regimen. And here, by and large, we've moved to the integrase inhibitors as a class of drugs, but that should be accompanied by at least 2 other antiretroviral agents. And again, a principle here is we want to simplify treatment as much as possible for this person living with HIV. Wherever possible, make sure it is 1 pill a day. And we are so lucky in 2022, that we are now able to offer a single pill once a day for most of the people who may be starting antiretrovirals around the world.

When it comes to rapid initiation, there are some recommendations that we make a rapid ART initiation. In other words, we say to people, you can start your antiretrovirals today if you wish. And the reason for this is, again, people may leave your room or your clinic, and immediately have second thoughts, get lost to treatment and lost to follow-up, and find themselves then in a hiatus of treatment, which is a missed opportunity. So, it's for this reason that many of the guidelines have now said, "Where possible, let's offer antiretroviral initiation as a rapid intervention." But the individual needs to be on board. So, at no point do we force individuals to start their treatment on the same day, but if they wish to, we should enable that, if at all possible.

And now you may be asking, well, what about those labs you were suggesting? Again, within the WHO guidelines, those labs can be done today, and the results obtained. And as long as that individual is in care, you can follow up with the results of those laboratories down the line. The most important thing being that the individual starts the antiretrovirals. 

Dr Wijesinghe: So, with that being said, integrase inhibitor and then 2 nucleoside reverse transcriptase inhibitors, that is recommended initial regimens for most people with HIV. And then, for example, you can do bictegravir, and then that is your integrase inhibitor. And then you can have the tenofovir plus emtricitabine as the dual nucleoside reverse transcriptase inhibitor. That is the backbone. And then, the other options might be dolutegravir, abacavir, and lamivudine. And if you do that, I would like to remind you to make sure that you do the HLAB 5701 blood test, and then make sure that's a negative test before you initiate that treatment.

And then lastly, 1 of the other initial regimens that we can start, integrase inhibitor plus 1 NRTI, known as nucleoside reverse transcriptase inhibitor. So, for that, you are able to use a dolutegravir and lamivudine combination. So those are recommended initial regimens for most people with HIV. And then there are some other regimens that we can use in some specific populations, depending on the scenario and situation. And then I encourage primary care providers to visit a reliable website where there are some updated guidelines. I recommend the clinicalinfo.hiv.gov website, because they do a very, very good job as far as updating the guidelines.

Dr Bekker: Thanks Sam. And a shout out for the WHO guidelines again. From my part of the world, we have far fewer choices I'm afraid in low- to middle-income countries (LMICs). So, we rely heavily on the TLD option. So that will be dolutegravir with lamivudine and tenofovir. And then, if that's not possible, then we substitute dolutegravir for efavirenz. But do look up your WHO guidelines, and it really is very clearly stipulated there. Of course, beyond initiating antiretrovirals, our patients will be coming back to us, Sam. So, do you want to talk a little bit about the follow-up and what that looks like?

Dr Wijesinghe: Yeah. So, when I first started practicing several years ago, I used to do CD4 count and viral load for every patient every 3 months. Now I personalize quite a bit, depending on how well they're doing. For example, if somebody's doing very well, I might not even do the CD4 count once a year. And viral load, if it's a very stable patient for like 3 years, then I will probably do a viral load every 6 months now.

Dr Bekker: Sam, and I think that is a cost-effective approach, but also, I think what we're finding is that because treatments are easier to take, people are taking their treatment and they're virally suppressed. But that really does raise that it is important that our patients who come into our services do feel that they are receiving person-centered care. Another way of describing that is differentiated service.

And so that means we also need to think about the individual, take a good history, simplify and adapt wherever we can. And doing so not only makes it easier for the individual, but also reduces the burden on our health services. Because if that individual is stable and undetectable, they actually don't have to come to our services that often. And in fact, we are now moving to what we call multimonth dispensing, where we're able to give an individual 1, 2, 3, 4 months of care of antiviral treatment, to take home at any time. Sam, I know you're a wiz at this, so do you want to talk a little bit about retaining people in care?

Dr Wijesinghe: This is the area that we continue to struggle and have some barriers. I want to say, from the patients that link to care, maybe about 60%, 65% patients are retaining care. So, it is very important in preserving the health of patients living with HIV and preventing further transmission. So, to do that, retention in care is very important, even though we have come a long way with our HIV treatment, there is still a high proportion of patients living with HIV who do not consistently receive treatment in the long term. And, for example, I intentionally have a small practice. I do primary care medicine, plus HIV medicine. So, I intentionally have a smaller practice, because in case if they don't show up, I actually call them, I call them and find out how they're doing. And then I make sure that they will do the follow-up appointments. Not every primary care provider can do that. So, I think, as primary care providers, we have an opportunity to develop a really good, healthy relationship with our patients. I think that can go a long way when it comes to retention in care.

Dr Bekker: And I think we have to, of course, the burden of disease is such here that we really do have large clinics with large numbers of people coming through. And then it's important to think of other ways that we can differentiate service delivery. In particular, you may think about how far this individual is from the clinic, and it may be transport costs that hold them back. It may be around stigma or disclosure. And again, here we can intervene to say, how can we improve the experience of this individual?

There was a systematic review conducted awhile ago now that looked at this and found topics such as substance use, financial constraints, the amount of social support the individual has. And of course, mental health, absolutely key to thinking about here. Also, simplification of the regimen. And then of course, it is so important to think about the healthcare provider-patient rapport and relationship.

So, as we are thinking about not only retaining people in care, it's important also to think about how well people adhere to their medication. And there are predictors of adherence that are very important. So, a systematic review conducted now in 2019, showed that there were very similar determinants that affected adherence to ART, similar to retention in care. There are other ways we can help with adherence, and some of those methods may involve partner services. And here, Sam, I think you can elaborate on that.

Dr Wijesinghe: If someone tests positive for HIV, partner services can provide linkage to treatment and care, and then also risk reduction counseling and other services. And then, if those people who test negative during that process, I think we have a great opportunity for those patients. We can talk about HIV, preexposure prophylaxis, known as PrEP. Only about 25% of people are on PrEP when we think about all the eligible individuals. So, partner services are a great way to start identifying people who are qualified for PrEP, and then educate them about PrEP.

So, to wrap up, with this activity, it was Professor Bekker's and my intention to increase knowledge regarding which patients should be offered HIV screening. Then, some considerations when selecting antiretroviral therapy for treatment-naive patients living with HIV. And then in the management of certain patients living with HIV in routine clinical care. And as primary care providers, you have an immense opportunity [to] prevent HIV stigma and discrimination. Every patient represents an opportunity for you to make a difference in HIV diagnosis, prevention, treatment, and care. You, as a primary care provider, can be part of the solution by fighting this epidemic. Thank you for participating in this activity.

This transcript has been edited for style and clarity.

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