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CCHCS Care Guide: Human Immunodeficiency Virus (HIV)

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CCHCS Care Guide: Human Immunodeficiency Virus (HIV) September 2021 CCHCS Care Guide: Human Immunodeficiency Virus (HIV) SUMMARY DECISION SUPPORT PATIENT EDUCATION/SELF MANAGEMENT ALL HIV INFECTED PATIENTS MUST BE MANAGED BY A CCHCS HIV SPECIALIST GOALS • Offer HIV screening to all • Ensure a sexual history and appropriate risk reduction counseling is performed • Refer all patients with HIV to HIV specialists as by a primary care team member for every patient with HIV at least annually. soon as possible • Initiate antiretroviral therapy (ART) for all patients with HIV as soon as possible • Identify newly diagnosed cases of HIV/Acquired • Screen and evaluate the patients with substance use disorder as a Immunodeficiency Syndrome (AIDS) transmission risk factor (see CCHCS Substance Use Disorder Care Guide) • Identify acute HIV seroconversion ALERTS Inappropriate or suboptimal treatment regimens Red Flags • Patients receiving only one HIV medication rather than a multi-drug ANY CD4 CD4 <200 CD4 <100 combination (note that some co-formulations exist) • New onset fevers • Dyspnea • Headache • Patients on treatment for months with a persistently detectable viral • Weight loss >10% • Cough • Blurry or lost load • Fatigue • Fevers vision • Patients with CD4 <200 cells/mm3 who are not on Pneumocystis • Skin lesions • Diarrhea jiroveci (PCP) prophylaxis (see page 6) • Night sweats DIAGNOSTIC CRITERIA/EVALUATION (SEE PAGE 2 FOR HIV TESTING ALGORITHM) D Consider HIV in the following circumstances: • Patients with known high risk behaviors prior to or during incarceration (tattoos, injection drug use, sexual exposure) • Patients with symptoms suggesting immunocompromised state (e.g., unexplained weight loss (>10%), recurring fevers, rashes, diarrhea, enlarged lymph nodes, recurrent infections, thrush) I E • Date of diagnosis • Current opportunistic infection (OI) • Vaccination history • Transmission risk factors prophylaxis (if applicable) • Smoking/substance use history • History of AIDS related conditions • HIV medication history • Thorough review of systems • Lowest (nadir) CD4 count • HIV resistance history • Transmission and risk reduction • History of opportunistic infections • History of Tuberculosis/Sexually Transmitted strategies Diseases/Rapid Plasma Reagin • Baseline Labs (See page 4) TREATMENT OPTIONS - INITIATING TREATMENT: GUIDELINES FOR WHEN TO START AND WHAT TO USE Do not initiate, change, or discontinue HIV medications without first consulting an HIV specialist WHEN TO START HIV TREATMENT: • ART is recommended for all HIV infected individuals as soon as possible, regardless of CD4 counts. ART should be initiated ONLY in consultation with an HIV specialist. The patients starting ART must be willing to commit to treatment and understand the risks and benefits of treatment and the importance of adherence. The patients and/or providers may elect to defer therapy based on clinical or psychosocial factors. WHAT TO USE: • Monotherapy is NEVER acceptable for HIV treatment. In general, three agents are used in combination. See page 5 for recommended initial HIV combination treatment regimens. See pages 8-11 for treatment precautions and side effects: noting specific contraindications and interactions between HIV medications and the patient’s existing medications. • Ensure a sexual history is performed annually and provide risk reduction counseling and education. Order ART and confirm eligibility in CCHCS’ 340b program as documented in the Electronic Health Record System (EHRS). Education for health care staff on conducting a sexual history can be found on the Center for Disease Control’s website: https://www.cdc.gov/hiv/pdf/clinicians/screening/cdc-hiv-php- discussing-sexual-health.pdf MONITORING (See page 4 for monitoring details) Clinic visits are recommended as clinically indicated during TABLE OF CONTENTS treatment: HIV TESTING ALGORITHM .............................................................. PAGE 2 • Components of the clinical evaluation include: NONOCCUPATIONAL POST‐EXPOSURE PROPHYLAXIS (nPEP) ........ PAGE 3 Review of systems (fever, weight loss, cough, diarrhea, etc.), MONITORING HIV PATIENTS .......................................................... PAGE 4 Physical examination (vitals, oropharynx, lymph nodes, skin, etc.), ANTIRETROVIRAL TX REGIMENS .................................................... PAGE 5 Assessment: date of diagnosis, note CD4, viral load, h/o OI, HIV OPPORTUNISTIC INFECTION PROPHYLAXIS.................................... PAGE 6 medication regimen, previous medications, RECOMMENDED IMMUNIZATIONS ............................................... PAGE 7 Education: discuss risk reduction, adherence. MEDICATIONS ................................................................................ PAGE 8‐12 PATIENT EDUCATION ..................................................................... PE‐1 & 2 Contact the HIV Program mailbox with questions: [email protected] InformaƟon contained in the Care Guide is not a subsƟtute for a health care professional's clinical judgment. EvaluaƟon and treatment should be tailored to the individual paƟent and the clinical circumstances. Furthermore, using this informaƟon will not guarantee a specific outcome for each paƟent. Refer to “Disclaimer Regarding Care Guides” for further clarificaƟon. hp://www.cchcs.ca.gov/clinical‐resources/ 1 September 2021 CCHCS Care Guide: Human Immunodeficiency Virus (HIV) SUMMARY DECISION SUPPORT PATIENT EDUCATION/SELF MANAGEMENT HIV TESTING Clinical Routine HIV testing is offered to new arrivals. See Opt Out* HIV screening policy, Patient reports a presentation Health Care Department Operations Manual (HCDOM) Section 3.1.8, Reception Cen- history of HIV suspicious ter. HIV testing is also available on patient request and should be considered routine- disease, but no for acute ly in patients at high risk for acquiring HIV (persons who inject drugs and their sex documentation of versus chronic partners, persons who exchange sex for money or drugs, sex partners of person with a positive HIV HIV: offer HIV HIV infection, persons or their partners who have had more than one sex partner antibody in the testing since their most recent HIV test, and transgender women). health record Patient agrees to HIV test Patient agrees to HIV test No Yes Document reasons Is Acute HIV suspected? (any of the following for ≥ 6 weeks): for refusal of test • Fevers/Myalgia • Pharyngitis • Diarrhea • Lymphadenopathy • Rash • Headache Yes No Order HIV-1/2 antigen/antibody 4th generation Order HIV-1/2 antigen/antibody 4th generation screening test screening test AND quantitative HIV viral load positive negative Screening test and Screening test and/or viral load negative viral load positive Patient Tests HIV Positive: Patient is HIV Negative: Confirmatory HIV-1 and Consider retesting HIV-2 antibodies performed annually and as automatically clinically indicated Patient is HIV Patient is HIV Positive: Negative: Consider retesting 1. Order baseline labs (Page 4) HIV-1 positive or Both HIV-1 annually and as 2. Perform clinical evaluation (Page 1) HIV-2 positive And HIV-2 clinically indicated 3. Refer to a CCHCS HIV specialist Or both positive negative onsite or via telemedicine. 4. Ensure the patient is transferred out of a restricted-cocci area 1 or 2 in- stitution. Qualitative HIV viral load 3 5. If CD4 <200 cells/mm , start PCP positive (automatically performed) negative prophylaxis (Pages 6, 12) 6. If CD4 <50 cells/mm3, start Mycobacterium avium complex Note: Western Blot is NO longer recommended as (MAC) prophylaxis (Pages 6, 12) a confirmatory HIV screening test 7. Do not attempt to initiate HIV *Patient has the option to decline HIV test. Signed consent/refusal not required. Patient declination HIV Screening Test Result Interpretation recorded in progress notes. HIV-1/2 antigen/ Reflex Qualitative Reflex HIV-1 and HIV-2 antibodies Diagnosis: antibody 4th generation HIV viral load Positive HIV-1 positive and/or HIV-2 positive Not performed HIV Positive Positive HIV-1 and HIV-2 negative Positive HIV Positive; Acute HIV False Positive HIV test. No further Positive HIV-1 and HIV-2 negative Negative workup recommended. HIV Negative; no further testing Negative Not performed Not performed recommended • Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in adults and adolescents living with HIV. Department of Health and Human Services. August 16, 2021. Available at https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv/whats-new-guidelines 2 September 2021 CCHCS Care Guide: Human Immunodeficiency Virus (HIV) SUMMARY DECISION SUPPORT PATIENT EDUCATION/SELF MANAGEMENT PATIENT NONOCCUPATIONAL POST-EXPOSURE PROPHYLAXIS (nPEP) For employee occupational exposures, contact employee’s supervisor (do not use this Care Guide) NOTE: Protocols for the patient occupational and non-occupational exposures are the same. D C/E R L HIGHER LOWER NEGLIGIBLE RISK • Percutaneous injury • Receptive or insertive • Kissing from non-bloody vaginal or anal intercourse • Receptive and insertive • Mouth to mouth Exposure sharps • Bites with blood exposure oral-vaginal, oral-anal, or resuscitation • Mutual masturbation • Needle sharing oral-penile contact • Non bloody human bites without blood or skin • Hollow-bore needle sticks • Solid bore needle sticks breakdown Source HIV Evaluate case-by case: Positive or unknown Any negative, positive or unknown status Yes if: • HIV positive and HIV viral load is elevated* • Mucosa is not intact (gingival disease, oral lesions)
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