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Episode #13 – Fresh stART: The new diagnosis of HIV

13 Cover Art OPT

Summary

Join Dr. Darcy Wooten in HIV clinic to discuss a new diagnosis of HIV!

Credits

Host(s): Sara Dong

Guest: Darcy Wooten

Writing/Producing/Editing/Cover Art: Sara Dong

Infographics: Sara Dong

Our Guest

Darcy Wooten, MD

Darcy Wooten is a 6th generation Californian and Associate Professor of Medicine in the division of Infectious Diseases and Global Public Health at the University of California, San Diego (UCSD).  She did her undergraduate studies in Human Virology at Stanford University before completing medical school and Internal Medicine residency training at UCSF.  She also earned a Master of Science degree from UC Berkeley doing research on Pseudomonas aeruginosa infections.  She completed her ID fellowship at Harbor UCLA before joining the faculty at UCSD in 2014.  Her clinical interests include HIV Medicine and General Infectious Diseases.  She serves as the ID Fellowship Program Director and as a course director for the Clinical Foundations course for first and second-year medical students.  She is a self-proclaimed Medical Educationist and Med Ed Enthusiast (!).

Twitter

Culture

Darcy enjoys drawing cartoon characters in sidewalk chalk with her toddler, and she has even gotten a few books recently on how to draw!

Consult Notes

Consult Q

New diagnosis of HIV

One-liner

26 year old previously healthy female with a new diagnosis of HIV

Key Points

Jump to:

HIV Guidelines & Resources
Other references
Goals of initial evaluation
Notes on goals of ART
Key components of history
Lab screening
notes on ART initiation
when to delay ART start
two drug ART regimens
tips for counseling

HIV Guidelines & Resources:

Goals of the initial evaluation for new HIV diagnosis and some tips!

  • Creating a welcoming and safe environment in clinic that is culturally sensitive, nonjudgmental, patient-centered.  Darcy discussed how many of the patients are from underserved and marginalized populations.  Creating this positive relationship can be choices such as: 
      • Wearing pins with the rainbow flag, a button that says “ask me about my pronouns”, posters/resources/flags on the wall
      • Training in culturally-competent and trauma-informed care 
      • Diverse clinic staff with respect to gender, gender identity, sexual orientation, race/ethnicity — so patients can visibly see that people caring for them in clinic are either part of their community or a dedicated ally
  • Confirming the diagnosis of HIV (if haven’t already)
  • Obtaining medical history and comprehensive physical exam
  • Appropriate baseline and historical lab data
  • Assessing patient’s understanding about HIV and transmission of HIV
      • Ask and understand what the patient knows about HIV: where they’re coming from, what they’re hearing about, misconceptions
      • Counseling about life expectancy. When you control for comorbidities, health-related behaviors, and being ART, life expectancy is nearly the same as people without HIV.  Highlighting this is a great way to link discussion to importance of starting ART and maintaining virologic suppression
      • Provide education about HIV basics depending on what the patient knows.  Some phrasing and topics that were mentioned in the episode included:
          • HIV is a chronic disease that can be managed extremely effectively with medication. 
          • There is no cure for HIV currently, although researchers are actively working on this
          • CD4 T-cell count
            • Immune cells targeted and killed by HIV.  Medications prevent HIV from killing these cells.
            • Goal is great than 200 (normal is 500-1800)
            • Count is dynamic and can vary even over the course of day, in the setting of a cold, etc so a change of >30% is when we start to think that this is a significant change.  I also discuss how the CD4 percentage (goal >14%) tends to fluctuate less and so this can be reassuring if a patient’s absolute CD4 cell count drops despite consistently taking their medications
            • Counsel that when the CD4 <200, patients are at risk for other infections and so may need antibiotic prophylaxis to prevent these infections until their immune system is stronger
          • ART medications are highly effective, well-tolerated.   Most patients can be treated with 1 pill once a day that is extremely well tolerated with minimal side effects and very few drug-drug interactions.  Patients no longer have to take handfuls of pills several times a day as was the case 20 years ago.  From a medical standpoint, HIV is similar and often easier to treat than diabetes, hypertension, cardiovascular disease, etc.  It’s often the psychological aspects of HIV that are difficult to address.
          • Undetectable = untransmittable
            • Many years and thousands and thousands of pieces of data demonstrate that when one person is undetectable, they cannot transmit HIV to a person who does not have HIV.  This helps to decrease stigma and self-stigma, guilt, and fear that many patients have about giving HIV to someone else
            • Usually can happen in a month or too once started
  • Initiating medical care and ART
      • Explaining the clinical and psychological benefits to rapid start HIV meds
  • The multidisciplinary approach to care and accessing care — how to understand clinic and approach care.  Some examples:
      • Meeting with financial counselor to learn about programs like Ryan White and ADAP and to help navigate steps required to achieve maximal financial coverage for care
      • Social workers and patient navigators can help with housing resources, access to food and transportation
      • Mental health resources including psychiatrists, psychologists, substance use counselors
      • Clinical pharmacists who can help with ensuring medications are covered, assist with co-pay cards, and help with adherence counseling

We discussed the key components of the history you want to ask about in the initial assessment.  The topics below are a brief summary of the episode discussion and Tables 1-2 from HIVMA Primary Care Guidance.  Darcy emphasized that we are covering all the components of the history we typically think about and learn from medical school — but often she is spending the most time on social and psychiatric history as these are often most important and can create some of the most challenging barriers to care.  One of the primary goals of the baseline evaluation is to assess readiness for ART

  • History of present illness and ascertaining primary reason for visit if not simply to establish care
  • HIV-related history
      • Was patient ever tested for HIV, when last negative test was, what prompted them to get tested now
      • How the patient thinks they may have acquired HIV
      • If known HIV history: prior HIV care, nadir CD4, peak viral load, current and past ART (regimens, duration, reasons for changing, etc)
      • Prior HIV-associated conditions, such as opportunistic infections and/or malignancies. Might start with open-ended question but can often find more information with follow-up detailed questions (e.g. have you ever had meningitis, pneumonia, infection in eye, chronic diarrhea, shingles, TB, lymphoma, etc)
  • Past medical history/Comorbidities, past surgical history, gyn/obstetric history
  • Mental health history
      • Previous or current psychotherapy and medication treatment
      • Anxiety disorders, bipolar disorder, depression, violent behavior
      • Suicidal or homicidal ideation; suicide attempts
      • History of hospitalization due to mental health issues
      • History of trauma, including physical and sexual abuse, intimate partner and other violence, post-traumatic stress disorder
    • Social history
      • Gender identity and sexual orientation; pronouns
      • Birthplace, residence, and travel history
      • Employment history
      • Education history
      • Financial and social support; Access to housing, food, transportation
      • Children, pets
      • Diet and exercise
      • Current or past use of alcohol or other substances
      • Sexual history: type of activities including partners and practices; sexual exposure sites; STI prevention; past STIs; prior PrEP
      • Has patient told people they are living with about their diagnosis
  • Medications & Allergies
  • Immunizations and healthcare maintenance/preventative health screening if appropriate

When obtaining the initial lab screening, pull up the charts from the guidelines!  Here was the general approach that Darcy discussed as well.

*Key Point*: For patients doing same day ART start, you actually don’t need any labs back other than a 4th generation HIV Ag/Ab assay and HIV confirmatory test!

  • Explain to patients the general process for how frequently you will obtain labs and explain that you  initially will be checking labs more frequently (viral load every 1-2 months until the patient is suppressed) but once most patients are stable, labs will space out
  • Use order sets for new patients if available in your EMR, since everyone gets the same set of initial labs for the most part!
  • HIV-specific labs to order:
      • Last confirmation of HIV diagnosis if not done already
      • CD4 cell count and percentage
      • Quantitative plasma HIV RNA viral load
      • HIV genotype (for baseline, but routine baseline resistance testing for INSTIs is not routinely recommended)
      • Usually don’t get tropism or HLA B*5701 testing since I am rarely starting patients on maraviroc or abacavir 
  • Routine/General Labs
      • CBC with diff
      • CMP (basic chemistry and liver function tests)
      • Fasting lipid panel
      • UA to look for proteinuria
      • STI screen (GC/CT NAAT testing from exposed sites and syphilis testing)
      • Viral hepatitis studies: 
        • Hep A total Ab
        • Hep B sAb, sAg, coreAb 
        • HCV Ab with reflex to RNA if positive
      • Varicella IgG and measles titer if no history of chicken pox and/or vaccination history of measles
      • Pregnancy test
      • G6PD if using dapsone
      • M.tuberculosis screening with PPD or IGRA
      • Usually not getting Toxo IgG, CMV IgG, serum CrAg unless CD4 is low

We didn’t discuss these data in the audio podcast much, but a quick note!  All individuals regardless of CD4 count should be started on ART as soon as possible after diagnosis. Initiation of ART soon after diagnosis is particularly important if CD4<200, and delayed ART can lead to suboptimal virologic and immunologic response. Here is a brief summary of the goals of ART and a few key studies:

We’ll have some infographics summarizing first line ART.  A few notes from the discussion with Darcy:

  • Since individuals may fail to engage in care between diagnosis/first clinic visit and time of ART prescription, rapid ART initiation on same day of HIV diagnosis/clinic visit has been a strategy to increase uptake and engagement in care.  This strategy is supported by RCTs from outside the US (South Africa, Haiti) as well as observational trials in US.
  • For same day start (before labs are back), need to use a regimen that has a high genetic barrier to resistance and activity against HBV
      • BIC/TAF/FTC
      • DTG + FTC/TAF 
      • DRV/Cobi/FTC/TAF
  • Usually starting with BIC/FTC/TAF, but if patient has drug-drug interactions (such as taking a rifamycin for TB co-infection), can use DTG alternative (bictegravir can’t be used with rifamycins)
  • HIV medications are difficult to learn!  It takes a some time and practice
    • There are generic names, brand names, 3 letter abbreviations, and fixed dose combination names
    • Some tips we talked about:
      • Having an ART chart (similar to the one here from POZ)
      • You can practice by running through the ART history of your clinic patients and writing out the names/abbreviations
      • Pick one drug each clinic and add to a running table (with mechanism of action, side effects, common resistance mutation) >> build your table over time

What are the clinical scenarios where we might delay therapy?  There is rarely a reason to delay starting ART in the clinic setting

Two-drug ART regimens: how to use, who is the right candidate?Two drug therapy is exciting, but if you are doing rapid starts in clinic, you might not have all of the lab information back yet to start them on 2-drug regimen

  •  

We ended with some tips and advice from Darcy on counseling at the visit.  Here are a few topics:

Other miscellaneous mentions and notes:

Episode Art & Infographics

Goal

Listeners will be able to apply guideline and evidence-based recommendations to provide antiretroviral medication and patient counseling for an initial evaluation after new HIV diagnosis.

Learning Objectives

After listening to this episode, listeners will be able to:

  • Summarize the goals of initial evaluation for new HIV diagnosis and key components of history that should be collected
  • List the recommended baseline laboratory studies
  • State the recommend antiretroviral regimens for treatment-naive individuals for rapid start HIV therapy
  • Identify the only FDA-approved two-drug HIV ARV regimen for treatment-naive patients
  • Describe strategies for optimizing rapport and linkage to care for a patient newly diagnosed with HIV in the US

Disclosures

 

Our guest (Darcy Wooten) as well as Febrile podcast and hosts report no relevant financial disclosures

Citation

Wooten, D., Dong, S. “#13: Fresh stART: The New Diagnosis of HIV”. Febrile: A Cultured Podcast. https://player.captivate.fm/episode/28a53ee9-25d3-45f1-a349-3779cb854a46

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