Start with a free account for 3 free CME credits. Already a subscriber? Sign in.

HIV Care for the Primary Care Clinician

Devang Patel, MD, Neda Frayha, MD, and Mizuho Morrison, DO
00:00
24:39

No me gusta!

The flash player was unable to start. If you have a flash blocker then try unblocking the flash content - it should be visible below.

Can HIV be managed in the primary care setting? With today’s advances in antiretroviral therapy, the answer is yes. Infectious Diseases physician Dr. Devang Patel sits down with Miz and Neda for a conversation about the latest developments in HIV treatment. 

 

Pearls:

  • Regardless of CD4 count, everyone with HIV is being treated to a goal of undetectable viral load.

  • Regimens have become simpler once daily, small single pills that are much better tolerated with the newest option being integrase inhibitors.

 

  • Brief history of HIV treatment:

    • Per 2004 International AIDS Society Guidelines, people weren’t treated until their CD4 count dropped below 200 given the risk/benefits of toxicity, cost, resistance

    • In 2006 DHHS guidelines updates to support treatment between CD4 count of 200-350

      • Data emerged that showed early treatment led to 90% reduction in all-cause mortality

    • In 2012 DHHS guidelines updated to treat regardless of CD4 count

  • Benefits of early initiation of ART:

    • Improve mortality and morbidity

    • Less likely to spread infection

    • Less likely to have immune reconstitution syndrome

  • Drugs target the viral life cycle:

    • Viral attachment to the CD4 receptor

    • Fusion of virus to the cell

    • Reverse transcription (nucleoside and non-nucleoside reverse transcriptase inhibitors - NRTI and NNRTI)

    • Integration of viral DNA into host cells (integrase inhibitors)

      • Integrase inhibitor: raltegravir → dolutegravir → bictegravir

        • Few side effects

        • Low threshold of resistance

        • Once or twice daily administration

    • Maturation and expulsion of virus (protease inhibitors)

  • Treatment:

    • 2 NRTI + integrase inhibitor

      • Abacavir + Lamivudine + dolutegravir = Triumeq (large pill)

    • New NRTI - 

      • Tenofovir Disoproxil Fumarate (TDF) had bone and renal side effects, so Gilead developed Tenofovir Alafenamide (TAF), which is concentrated intracellularly, needed at lower dose and not associated with the bone or renal side effects. Also, the combination pills are smaller.

      • New combination pills have TAF as the main nucleotide analog

    • New integrase inhibitor - 

      • Bictegravir

      • FDA approved 2018

      • Combined with TAF and emtricitabine = Biktarvy (small pill once a day)

    • As of Spring 2019, FDA approved a 2 drug regimen (dolutegravir and lamivudine, Dovato), which is good for patients who are new to ARTs but not ideal for those with Hepatitis B co-infection

  • Testing at initiation (DHHS guidelines)

    • HIV viral load to confirm diagnosis and monitor treatment response

    • Genotype testing

    • Resistance testing

      • Uncommon to have integrase inhibitor testing but with NNRTI’s, up to 20% in certain populations have resistance

    • CD4 counts for staging

    • STI screening: gonorrhea, chlamydia, syphilis

    • CMP

    • CBC

    • Urinalysis to look for renal disease

    • A1c

    • Lipids

    • Hepatitis B and C

    • Quantiferon or PPD

    • HLA-B 5701if starting abacavir regimen

    • If low CD4 count consider:

      • Toxoplasmosis antibody

  • Lab monitoring:

    • Viral load every 4-8 weeks and then once stabilized every 3 months x 2 years, and then every 6 months afterwards

    • Goal is for undetectable viral load

    • CD4 count every 3-6 months for the first couple of years and even less if CD4 is consistently above 300-500

    • If TDF-based regimen: UA every 6 months

    • Annual A1c and lipids

  • Pregnancy:

    • Dolutegravir-based regimens used to be first-line but recent data from Botswana and their association with neural tube defects have been its safety into question.

    • Raltegravir is safe

  • U=U:

    • Undetectable = untransmittable

    • If you have an undetectable viral load you can’t transmit to anyone else

    • Hope is to destigmatize those with HIV to have healthy open relationships

 

REFERENCES: 

  1. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV. Department of Health and Human Services. Available at http://www.aidsinfo.nih.gov/ContentFiles/ AdultandAdolescentGL.pdf. Accessed June 25, 2019.

  2. Saag MS, Benson CA, Gandhi RT, et al. Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2018 Recommendations of the International Antiviral Society–USA Panel. JAMA 2018;320(4):379–396. doi:10.1001/jama.2018.8431

  3. Riddell J. 2018 IAS-USA Recommendations for the Use of Antiretroviral Therapy for HIV: Building on Decades of Progress. JAMA 2018;320(4):347–349. doi:10.1001/jama.2018.9184

FDA News Release: FDA Approves First Two-Drug Complete Regimen for HIV-Infected Patients Who Have Never Received Antiretroviral Treatment, April 2019. https://www.fda.gov/news-events/press-announcements/fda-approves-first-two-drug-complete-regimen-hiv-infected-patients-who-have-never-received

To join the conversation, you need to subscribe.

Sign up today for full access to all episodes and to join the conversation.

To download files, you need to subscribe.

Sign up today for full access to all episodes.
Primary Care Gets Some Love Full episode audio for MD edition 196:25 min - 92 MB - M4AHippo Primary Care RAP - August 2019 Written Summary 659 KB - PDF

To earn CME for this chapter, you need to subscribe.

Sign up today for full access to all episodes and earn CME.

0.25 Free AMA PRA Category 1 Credits™ certified by Hippo Education or 0.25 Free prescribed credits by the American Academy of Family Physicians

  1. Complete Quiz
  2. Complete Evaluation
  3. Print Certificate

3.25 AMA PRA Category 1 Credits™ certified by Hippo Education or 3.25 prescribed credits by the American Academy of Family Physicians

  1. Complete Quiz
  2. Complete Evaluation
  3. Print Certificate