Working with less experienced clinicians

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Working with less experienced clinicians

• Factors leading to changes in care models
• Trends in the epidemic
• Workforce questions
• Changes in technology and pharmacotherapeutics

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Trends in epidemic

• More persons living with HIV
• Medical stability / longer survival
• Older patients
• The epidemic in African Americans

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Living with HIV infection

• At the end of 2003 the CDC estimated more than
  1,000,000 in the US living with HIV infection

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Older patients

• More elderly patients living with HIV infection
• Other medical issues are becoming pre-eminent
• Maintaining HIV treatment in the face of other
  severe illness
• Alzheimers
• Cancer
• Heart Disease
• Diabetes
• Polypharmacy and polydrug interactions
• Toxicity
• Reduced plasma levels of HIV medications
• Competing economics for patients

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Workforce Questions

• Are we losing HIV physicians in the US?
• Will the workforce match the epidemiologic /
  medical needs
• Cultural competence
• HIV care stablized in contrast to geriatric and
  other health problems
• Obstetrical needs

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Technology and pharmacotherapeutics

• Easier treatment regimens
• Drug interactions with aging populations

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• Communication
• Fatalism
• Division of care
• Responsibility for primary care
• Womens care
• Co-morbid conditions
• HBV, HCV
• Mental health
• Chronic pain
• Patient dependence / expectations

• Appreciation of drug interactions

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How would (will) we restructure care if (when)

• Pressures of patient volume have you reduced to
  15 minutes per visit
• or
• You have 25 of your HIV patient population
  older than 65 years old
• or
• 95 of your patients have been undetectable for
  the past year and are taking one pill daily to
  treat HIV but 5 other prescriptions
• or
• HIV becomes the 5th most pressing health care
  matter on the problem list for your patient
• English is the second language for 60 of your
  patients
• or
• 50 have addiction or mental health problems (or
  both)
• or
• All, part, mixtures of the above

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Where is the balance between HIV care and
clinicians and primary care clinicians?
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Working with Other Clinicians
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Primary Prevention

• Level 1 trainings
• General Public Health Messages

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Working with Other Clinicians
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Case Finding

• Movement Towards Routine Testing for HIV
• Consent and counseling questions
• Local requirements
• Consent and ethical standards
• Prenatal testing
• Office based
• Special settings (treatment, mental health,
  incarceration)
• Emergency Departments
• Rapid testing
• Hospitalized patients
• Targeted emphasis based on epidemiology
• Is this acceptable
• Very low threshold for testing as a part of
  differential diagnosis
• PHI overemphasis compared to routine or
  recognition of established
• Testing technology applications

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General Prevention and Case Finding

• Broad involvement
• Sexual history and risk assessment
• Safe and low risk sexual behavior changes
• IDU treatment and harm reduction

• Counseling and Testing
• Prenatal Testing
• Rapid testing
• Early warning signs of HIV infection
• Primary (acute) HIV infection
• Rapid Testing

This is an old slide from a prior lecture how
obsolete is it for case finding?
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Very Low ThresholdInfections Associated with HIV
Infection

• Coinfections which indicate increased risk for
  HIV
• HBV
• HCV
• Syphilis
• Other STDs

• Common clinical infections more severe or
  recurrent in HIV
• Reactivated TB
• Herpes zoster (shingles)
• Recurrent, severe HSV 1 or HSV 2
• Gastrointestinal parasitosis
• Cutaneous and mucocutaneous candida and fungal
  infections
• Warts, molluscum

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Common Abnormal Findings in HIV Infection

• Lab abnormalities
• Anemia
• Leukopenia (particularly lymphopenia)
• Thrombocytopenia
• Elevated total protein

• Abnormalities on Physical Examination
• Facial seborrhea
• Angular cheilitis
• Thrush, gingivitis, aphthae
• Hairy leukoplakia of the tongue (highly specific)
• Diffuse adenopathy
• Hepatosplenomegaly
• Onychomycosis and other dermatophytoses

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Cooperative Care begins with identified cases
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Working with Other Clinicians
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Cases Intake

• Establishes expectations and division of labor
• Cultural translation (seat of competence)
• Health education
• Correct HIV fatalism
• But most will eventually need treatment
• Resources
• Baseline evaluation and needs
• Some go directly to treatment

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Working with Other Clinicians
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Monitoring Off TreatmentPrior to Indication or
Ability

• Monitoring for early HIV complications
• Some may result in initiation of treatment
• Patient education
• Prevention for Positives
• Stabilization of patient environment and
  situation in preparation for treatment if and
  when necessary
• Understanding that most will eventually require
  treatment
• Good record keeping

• Avoid casual ARV prescribing
• Regular communication with HIV specialist
• To determine if and when to initiate treatment
• To keep up with developments
• Send results of labs
• Reduce visit rate with HIV specialist
• Absolute commitment to regular testing of CD4 and
  HIV VL
• As a rule every 3-4 months
• Accelerated as needed
• Baseline labs and HIV related health maintenance

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Working with Other Clinicians
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Initiation of Treatment

• Patient Factors
• Medical indication
• Psychologic readiness
• Sociologic stability
• Cultural factors

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Initial ARV RegimensInternational AIDS
Society-USA Treatment Guidelines (2006)
Recommended Recommended Recommended
NRTI NNRTI PI
TDF/FTC or ZDV/3TC or ABC/3TC EFV (or NVP) LPV/r SQV/r ATV/r FPV/r
Alternate Alternate Alternate
No specific alternatives listed No specific alternatives listed No specific alternatives listed
In selected patients Triple-NRTI regimens are
no longer recommended as initial therapy because
of insufficient antiretroviral potency compared
with a regimen containing efavirenz. However, for
patients requiring treatment with regimens that
preclude use of NNRTIs or protease inhibitors, a
combination consisting of zidovudine, abacavir,
and lamivudine may be considered. Adapted from
Hammer S, et al. JAMA 2006296827-843.
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Cautionary Notes

• AZT anemia, myopathy
• ABC HSR management
• TDF renal precautions, monitoring, treats HBV
• 3TC / FTC treats HBV, HBV resistance
• NVP hepatotoxicity, induction
• EFV possible teratogenicity
• ATV PPIs
• RTV DRUG INTERACTIONS (Statins,)

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Working with Other Clinicians
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Establishment of viral suppression

• Early management of new regimens
• Adherence assistance
• Sociologic / psychologic stabilization and
  reinforcement
• Resources
• Monitoring of VL / CD4 / early toxicity

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Working with Other Clinicians
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Monitoring Stable on Treatment

• Regular communication with HIV specialist
  regular visits
• Send Labs, notes
• Commitment to regular HIV VL and CD4 monitoring
• Do not underestimate the importance of adherence
• Get help if needed
• Watertight refill systems
• Excellent records
• Patient education
• Prevention for Positives
• Monitoring for residual HIV complications

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• Monitoring for complications of HIV treatments
• Specific medication and class related
• Lipodystrophy (photo examples)
• Liver disease, lactic acidosis, myopathy,
  neuropathy
• CBC, liver, CMP, lipids
• Resist diagnostic nihilism / overreaction based
  on CD4
• Reflex reaction to detectable VL
• Acute illnesses
• Care co-morbid conditions
• Proportional perspective
• Drug interaction checks / resources
• Supportive Operations at HIV Office, ASOs

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Working with Other Clinicians
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Resistance Management and Advanced HIV Care

• Shift back to HIV specialty care

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Working with Other Clinicians
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End of Life Care

• How the decision is achieved
• Fatalism
• Zealousness
• Balanced participation

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Management tools

• Care plans, timetables for monitoring, visits,
  consults
• Regimen specific monitoring plans
• Communication pathways (labs, notes, imaging)
• Drug interaction consultation / tools
• Database / digital photography
• Chart review
• Care at a distance