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Primary Care in the HIV-positive Individual

This program provides an overview of the initial evaluation and primary care management of individuals with HIV. Topics covered include baseline testing, coinfection and comorbidities, sexually transmitted infections, cancer screening, and PCP prophylaxis.

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Primary Care in the HIV-positive Individual

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  1. Primary Care in the HIV-positive IndividualJessica Yager, MDSTAR ProgramSUNY Downstate Medical CenterJuly 15, 2015

  2. Learning Objectives: • Understand important aspects of the initial evaluation in individuals with HIV • Appreciate similarities and differences in the primary care of HIV-positive and HIV-negative individuals • Be familiar with available resources and guidelines

  3. Initial Evaluation • CBC and CMP • HIV confirmation! • CD4 count and percent • HIV viral load • HIV resistance testing • Co-receptor tropism assay • Glucose-6-Phosphate dehydrogenase • HLA B5701 testing • Fasting lipid panel • Urinalysis and calculated CrCl

  4. Case 1: Baseline testing • A 44-year-old man comes to clinic to establish longitudinal care for his HIV disease. He recently was diagnosed with HIV infection, but believes he likely acquired HIV years at least 5 years earlier from a male sex partner who subsequently developed AIDS. In addition, he injected drugs "on a few occasions" more than 10 years ago while living in Cincinnati, Ohio. Physical examination reveals seborrheic dermatitis and oral candidiasis. As part of the initial evaluation of this patient, you order a complete blood count, comprehensive chemistries (including hepatic aminotransferase levels), CD4 cell count, HIV RNA level, and a tuberculin skin test. To assess exposure to other infectious agents, you perform additional serologic testing. Which one of the following tests is appropriate to order at this initial visit? • anti-Toxoplasma IgG • Hepatitis C genotype • anti-Histoplasma IgG • Serum cryptococcal antigen

  5. Case 1: Answer • anti-ToxoplasmaIgG • Serologic testing to determine previous infection with Toxoplasma gondii is indicated for all patients infected with HIV. Almost all cases of toxoplasmosis involving HIV-infected persons occur as a result of reactivation of latent infection. According to United States guidelines for the prevention and treatment of opportunistic infections, patients who are seropositive for anti-Toxoplasma IgG should initiate primary prophylaxis against Toxoplasma encephalitis when the CD4 count is less than 100 cells/mm3. Patients without evidence of prior Toxoplasma infection can be counseled in ways to prevent infection.

  6. Initial Evaluation Continued: Coinfection and comorbidities • TB screening: TST vs IGRA • Repeat testing in those with negative screens and advanced AIDS • Close contacts of individuals with active TB: treat for LTBI • Toxoplasma gondii screening • Hepatitis • HAV • HBV • HCV • CMV screening

  7. Sexually transmitted infections • Syphilis screening • At initiation of care; periodically thereafter depending on risk • When to refer for LP? • Reactive RPR if ANY neuro/occular s/sx • Serologic treatment failure (failure to reduce titer by 4-fold after appropriate therapy) • Trichomoniasis screening* • All women • Chlamydia • All women ≤25yo • All women and men at initial presentation and annually thereafter (if at ongoing risk for infection) • Gonorrhea • All women and men at initial presentation and annually thereafter (if at ongoing risk for infection) • Follow-up testing in 3 months: GC, CT and trichomonas *Area of discordance between guidelines

  8. Cancer screening: HPV-associated • Cervical cancer • Pap at initiation of care • If normal: again in 6 months, then annually • Refer for colposcopy for any abnormality • Anal cancer • Anal pap smears in: MSM, women with a history of anal receptive intercourse, woman with dysplasia on cervical pap • HPV vaccination in: • Females and males aged 9-26 years

  9. Case 2: PCP Prophylaxis A 38-year-old man presents for care with newly diagnosed HIV infection. In the past 12 months, he has received treatment for three episodes of community-acquired pneumonia. He currently takes no medications, but in the past he has taken azithromycin (Zithromax), penicillin, and trimethoprim-sulfamethoxazole (Bactrim, Septra) without difficulty. He currently has no respiratory symptoms and his physical examination is notable for seborrheic dermatitis, poor dentition, and extensive oral candidiasis. His initial laboratory studies show a CD4 count of 214 cells/mm3 and a positive IgG Toxoplasma antibody. Which of the following is true regarding prophylaxis for Pneumocystis pneumonia?

  10. Case 2, Continued: • This patient should receive Pneumocystis pneumonia prophylaxis, but prior to initiating prophylaxis, a sputum sample should be sent to perform Pneumocystis jiroveci resistance testing. • The patient does not need Pneumocystis pneumonia prophylaxis; he should start prophylaxis if his CD4 count decreases to less than 200 cells/mm3 • The patient should start on Pneumocystis pneumonia prophylaxis using trimethoprim-sulfamethoxazole at a dose of one double strength tablet per day. • The patient should receive Pneumocystis pneumonia prophylaxis, but first should undergo bronchoscopy to rule out active Pneumocystis pneumonia prior to receiving prophylaxis.

  11. Case 2: PCP Prophylaxis A 38-year-old man presents for care with newly diagnosed HIV infection. In the past 12 months, he has received treatment for three episodes of community-acquired pneumonia. He currently takes no medications, but in the past he has taken azithromycin (Zithromax), penicillin, and trimethoprim-sulfamethoxazole (Bactrim, Septra) without difficulty. He currently has no respiratory symptoms and his physical examination is notable for seborrheic dermatitis, poor dentition, and extensive oral candidiasis. His initial laboratory studies show a CD4 count of 214 cells/mm3 and a positive IgG Toxoplasma antibody. Which of the following is true regarding prophylaxis for Pneumocystis pneumonia? • This patient should receive Pneumocystis pneumonia prophylaxis, but prior to initiating prophylaxis, a sputum sample should be sent to perform Pneumocystis jiroveci resistance testing. • The patient does not need Pneumocystis pneumonia prophylaxis; he should start prophylaxis if his CD4 count decreases to less than 200 cells/mm3 • The patient should start on Pneumocystis pneumonia prophylaxis using trimethoprim-sulfamethoxazoleat a dose of one double strength tablet per day. • The patient should receive Pneumocystis pneumonia prophylaxis, but first should undergo bronchoscopy to rule out active Pneumocystis pneumonia prior to receiving prophylaxis.

  12. Case 2, Answer: • The patient should start on Pneumocystis pneumonia prophylaxis using trimethoprim-sulfamethoxazole at a dose of one double strength tablet per day. • This patient has two indications to receive Pneumocystis pneumonia prophylaxis: (1) oral candidiasis, and (2) an AIDS-defining illness (two or more episodes of bacterial pneumonia in a 1-year period is an AIDS-defining illness). Trimethoprim-sulfamethoxazole is the preferred agent for Pneumocystis pneumonia prophylaxis. Furthermore, trimethoprim-sulfamethoxazole provides protection against Toxoplasma encephalitis and may provide some benefit in preventing further episodes of community-acquired pneumonia. Patients with a history of a mild-to-moderate rash caused by trimethoprim-sulfamethoxazole can often undergo successful trimethoprim-sulfamethoxazole desensitization.

  13. Case 3: Toxoplasmosis prophylaxis A 48-year-old HIV-infected woman from Mexico presents to clinic for primary HIV care. She was diagnosed with Pneumocystis pneumonia and HIV infection approximately 3 months prior. At the initial clinical visit, serologic testing detected antibodies to Toxoplasma (IgG) and her most recent CD4 count is 78 cells/mm3. Her only current medications is dapsone; antiretroviral therapy will be started . She has a history of a severe rash when taking trimethoprim-sulfamethoxazole (Bactrim, Septra) approximately 1 year ago. She is not sexually active and her last menstrual period was 2 weeks ago. Which one of the following would you recommend for this patient regarding prophylaxis for Toxoplasma encephalitis?

  14. Case 3, continued: • The patient's positive IgG antibody to Toxoplasma shows evidence of immunity to Toxoplasma and thus she does not need prophylaxis against Toxoplasmaencephalitis. • The patient should receive prophylaxis for Toxoplasma encephalitis and the dapsone she takes for Pneumocystis prophylaxis will provide adequate prophylaxis against Toxoplasmaencephalitis. • The patient should add atovaquone (Mepron) to the dapsone to provide adequate prophylaxis for both Pneumocystis pneumonia and Toxoplasmaencephalitis. • The patient should receive prophylaxis for Toxoplasma encephalitis. Dapsone alone does not provide sufficient protection against reactivation of Toxoplasma; she should take pyrimethamine and leucovorin in addition to dapsone

  15. Case 3: Toxoplasmosis prophylaxis A 48-year-old HIV-infected woman from Mexico presents to clinic for primary HIV care. She was diagnosed with Pneumocystis pneumonia and HIV infection approximately 3 months prior. At the initial clinical visit, serologic testing detected antibodies to Toxoplasma (IgG) and her most recent CD4 count is 78 cells/mm3. Her only current medications is dapsone; antiretroviral therapy will be started . She has a history of a severe rash when taking trimethoprim-sulfamethoxazole (Bactrim, Septra) approximately 1 year ago. She is not sexually active and her last menstrual period was 2 weeks ago. Which one of the following would you recommend for this patient regarding prophylaxis for Toxoplasmaencephalitis? • The patient's positive IgG antibody to Toxoplasma shows evidence of immunity to Toxoplasma and thus she does not need prophylaxis against Toxoplasmaencephalitis. • The patient should receive prophylaxis for Toxoplasma encephalitis and the dapsone she takes for Pneumocystis prophylaxis will provide adequate prophylaxis against Toxoplasmaencephalitis. • The patient should add atovaquone (Mepron) to the dapsone to provide adequate prophylaxis for both Pneumocystis pneumonia and Toxoplasmaencephalitis. • The patient should receive prophylaxis for Toxoplasma encephalitis. Dapsone alone does not provide sufficient protection against reactivation of Toxoplasma; she should take pyrimethamine and leucovorin in addition to dapsone

  16. Case 3, Answer: • The patient should receive prophylaxis for Toxoplasma encephalitis. Dapsone alone does not provide sufficient protection against reactivation of Toxoplasma; she should take pyrimethamine and leucovorin in addition to dapsone. • Trimethoprim-sulfamethoxazoleis the simplest and most effective prophylaxis for both Pneumocystis pneumonia and Toxoplasma encephalitis, but this patient's severe skin rash caused by trimethoprim-sulfamethoxazole necessitates her using an alternative regimen. Dapsone alone is not effective as prophylaxis against Toxoplasma encephalitis—it must be combined with pyrimethamine and this regimen is the preferred alternative to trimethoprim-sulfamethoxazole for prophylaxis against Toxoplasma encephalitis. When pyrimethamine is used, leucovorin should also be added to prevent leukopenia. Pyrimethamine is contraindicated during pregnancy, but this was not a concern in the patient presented.

  17. Primary OI prophylaxis: Initiation

  18. Primary OI prophylaxis: Termination

  19. Case 4: Immunizations A 35-year-old HIV-infected woman presents to clinic with recently diagnosed HIV infection. Her risk factors for acquiring HIV disease consist of injection-drug use and heterosexual sex with a partner known to have HIV. Initial laboratory tests show a CD4 count of 426 cells/mm3, HIV RNA of 32,000 copies/mm3, negative total hepatitis A virus antibody, negative hepatitis B virus surface antigen, positive antibody to hepatitis B surface antigen (anti-HBsAg), positive antibody to hepatitis B core antigen (anti-HBc), and negative hepatitis C virus antibody. The patient reports that she received all required childhood vaccinations and received a tetanus booster 2 years ago, but she does not recall ever having chicken pox or shingles. Which one of the following would you recommended immunizations for this patient?

  20. Case 4: Immunizations • Pneumococcal vaccine should be deferred until the patient’s CD4 count declines to less than 200 cells/mm3. • The patient should receive the hepatitis A virus vaccine series. • Influenza vaccine should not be given to this patient because influenza vaccine is likely to cause a marked increase in HIV RNA levels, a significant decline in CD4 cell count, and an acceleration of HIV disease. • Varicella serology should be checked and, if negative, the zoster vaccine (Zostavax) should be given.

  21. Case 4: Immunizations A 35-year-old HIV-infected woman presents to clinic with recently diagnosed HIV infection. Her risk factors for acquiring HIV disease consist of injection-drug use and heterosexual sex with a partner known to have HIV. Initial laboratory tests show a CD4 count of 426 cells/mm3, HIV RNA of 32,000 copies/mm3, negative total hepatitis A virus antibody, negative hepatitis B virus surface antigen, positive antibody to hepatitis B surface antigen (anti-HBsAg), positive antibody to hepatitis B core antigen (anti-HBc), and negative hepatitis C virus antibody. The patient reports that she received all required childhood vaccinations and received a tetanus booster 2 years ago, but she does not recall ever having chicken pox or shingles. Which one of the following would you recommended immunizations for this patient? • Pneumococcal vaccine should be deferred until the patient’s CD4 count declines to less than 200 cells/mm3. • The patient should receive the hepatitis A virus vaccine series. • Influenza vaccine should not be given to this patient because influenza vaccine is likely to cause a marked increase in HIV RNA levels, a significant decline in CD4 cell count, and an acceleration of HIV disease. • Varicella serology should be checked and, if negative, the zoster vaccine (Zostavax) should be given.

  22. Case 4: Answer • The patient should receive the hepatitis A virus vaccine series. • Hepatitis A vaccine is recommended for all HIV-infected patients at risk of encountering hepatitis A including men who have sex with men and injection drug users. This vaccine does not contain live virus and does not pose any special risk to HIV-infected persons.

  23. Routine Immunizations:

  24. Routine Healthcare Maintenance

  25. Behavioral counseling: • Sexual health, secondary prevention, including PrEP • Substance abuse • Tobacco cessation • Domestic violence • Reproductive health, family planning • Diet and exercise

  26. Resources: • http://www.hivguidelines.org • http://www.hivguidelines.org/wp-content/uploads/2014/01/primary-care-approach-to-the-hiv-infected-patient.pdf • http://cid.oxfordjournals.org/content/early/2013/11/12/cid.cit665.full.pdf • http://www.hivwebstudy.org/

  27. Resources, continued:

  28. Resources, continued:

  29. Resources, continued:

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