The
Role
of
the
Primary
Care
Physician
in
HIV
Management
David M. Forrest, MD, MHSc, FRCPC Infectious Diseases
Infectious Diseases Nanaimo
Disclosures
Disclosures
• No financial disclosures – though I haveNo financial disclosures though I have several dependents
Testing
Testing
• Primary care physicians in an optimal positionPrimary care physicians in an optimal position to test
• Consent needed
• Consent needed
• Counseling required
Testing
Testing
• Opportunistic testingOpportunistic testing
¾On admission to hospital
¾In office (e g at time of pap test ‘flu shot regular
¾In office (e.g., at time of pap test, flu shot, regular
visit)
• Target at least one test per patient in your • Target at least one test per patient in your
practice/yr
T f l if i k b h i
• Test more frequently if risky behaviour
Testing
Testing
• NegativeNegative testtest
¾Review risky behaviour
¾Review means of mitigating risk
¾Review means of mitigating risk
• Positive test
¾
¾Review risk of transmission and precautions to
reduce risk
¾HIV t d th t hil t bl
¾HIV not a death sentence – while not curable, a
Getting Help
Getting
Help
• D Forrest (NRGH)( )¾250‐755‐7691
• Access to HIV clinic and RN (CI/NI) – Positive
W ll NI (PWNI) Wellness NI (PWNI)
¾250‐755‐6233
• REACH (Rapid Expert Advice and Consultation forREACH (Rapid Expert Advice and Consultation for
HIV) at St. Paul’s Hospital ¾1‐800‐665‐7677
• Web resource
Primary Care in HIV: A Primer
Primary
Care
in
HIV:
A
Primer
• BaselineBaseline historyhistory
¾General history
¾Mental/psychosocial health
¾Mental/psychosocial health
¾Behavioral risk assessment (sexual, substance use)
¾Addi ti hi t
¾Addictions history
Primary Care in HIV: A Primer
Primary
Care
in
HIV:
A
Primer
• Basic investigationsBasic investigations
¾General bloodwork, U/A, CXR
¾β β HCG,, Papp smear in females
• Investigate abnormalities • Screening investigationsScreening investigations
¾Hepatitis A, B, C
¾VDRL and Chlamydia/gonorrhea urine PCR
¾VDRL and Chlamydia/gonorrhea urine PCR
¾Toxoplasma, Bartonella serology
¾Tuberculin skin test
Primary Care in HIV: A Primer
Primary
Care
in
HIV:
A
Primer
• HIV specific investigationsHIV specific investigations
¾CD4+ (and %)
¾HIV plasma viral load (PVL)
¾HIV plasma viral load (PVL)
• Ensure immunizations up to date (Public H lth)
Health)
• Contact PWNI (250‐755‐6233) for further investigations and consultation
Primary Care in HIV: A Primer
Primary
Care
in
HIV:
A
Primer
• Prophylaxis of opportunistic infections shouldProphylaxis of opportunistic infections should be given if CD4+ < 200 (or fraction < 14%)
¾CD4+ < 200 Pneumocystis ¾CD4+ < 200 Pneumocystis
¾CD4+ < 100 Toxoplasma (if serology +ve)
¾CD4+ < 50 M avium complex ¾CD4+ < 50 M. avium complex
• All patients with +ve TST should be screened
f ti t b l i d t t d f ti
for active tuberculosis and treated for active or latent disease (PH)
Primary Care in HIV: A Primer
Primary
Care
in
HIV:
A
Primer
• When do I refer?When do I refer?
¾Anytime! • Critical thresholds • Critical thresholds • CD4+ > 500 treatment offered • CD4+ 350‐500 treatment advised • CD4+ 200‐350 treatment needed • CD4+ < 200 treatment critical
Primary Care in HIV: A Primer
Primary
Care
in
HIV:
A
Primer
• Ongoing primary care in HIV not as complex asOngoing primary care in HIV not as complex as you imagine!
• HIV patients still get cuts and injuries and
• HIV patients still get cuts and injuries and colds and mental illness like everyone else
M l h l h d ddi i i d
• Mental health and addictions issues need
Primary Care in HIV: A Primer
Primary
Care
in
HIV:
A
Primer
• More intensive followMore intensive follow up‐up and primary care and primary care interventions needed
¾History and physical exam 2 x / year
¾History and physical exam 2 x / year
¾Pap smear at least 1 x / year (females)
¾CD4+ and HIV PVL Q 3 months
¾CD4+ and HIV PVL Q 3 months
¾HIV bloodwork Q 6 months
If not
followed by
Primary Care in HIV: A Primer
Primary
Care
in
HIV:
A
Primer
• HIV and its treatment (antiretroviral therapy)
cause metabolic dysfunction – even in the young ¾Osteoporosis ¾Di b t llit II ¾Diabetes mellitus II ¾Dyslipidemia ¾Hypertension ¾Hypertension
¾Consequent cardiovascular disease
¾Renal disease
Primary Care in HIV: A Primer
Primary
Care
in
HIV:
A
Primer
• Medications all HIV patients should be taking
¾Multivitamin
¾Vitamin D 1000‐2000 IU / day
¾± Calcium supplementpp
Primary Care in HIV: A Primer
Primary
Care
in
HIV:
A
Primer
• Whatever medications you start, check for
drug interactions, especially with antiretroviral medications
Engagement
Engagement
• Engagement of the patient by the primaryEngagement of the patient by the primary care practitioner is crucial to the success of HIV management
Engagement
Engagement
“It is much more important to know what sort ofIt is much more important to know what sort of patient has a disease than what sort of disease a
patient has” patient has
Engagement
Engagement
• Patient management coordinated by primaryPatient management coordinated by primary care physicians associated with lower costs and lower all‐cause mortality
and lower all cause mortality
Engagement
Engagement
• Why?Why?
¾Care integrated, personalized, prioritized
¾Care continuous and not fragmented
¾Care continuous and not fragmented
¾Preventive services more consistently delivered
¾A t bl di d/t t d li
¾Acute problems diagnosed/treated earlier
¾Greater access
¾B l l d b h lf f
¾Better local advocacy on behalf of
patient/community Sloane 2011
Engagement
Engagement
• Improves quality of HIV care
¾Krentz, 2011; Ulett, 2009; Ding, 2008
• Improves adherence to antiretroviral medications
medications
¾Blackstock, 2012; Schneider, 2004
• Reduces risk of HIV transmission
• Reduces risk of HIV transmission
Engagement
Engagement
• Improves overall health care
¾Zou, 2012; Krentz, 2011
• May have psychosocial benefits (e.g., in
facilitating treatment of addictions issues and facilitating treatment of addictions issues and reducing criminal behaviour)
¾Takizawa 2007; Islam 2011; Lum 2011
l
d
Original
Paradigm
FD FD PP P P P SW Phrm P FD Splst RN AVI P MHd
New
Paradigm
Ph SW RN Phrm P P FD PP P FD FD Splst P FD AVI MHEngagement
Engagement
• The relationship between family physician andThe relationship between family physician and patient is central to providing high quality
comprehensive HIV care – in the best interests comprehensive HIV care in the best interests of the patient and the public
Conclusions
Conclusions
1 The family physician is in the best position to
1. The family physician is in the best position to ensure patients are tested for HIV – critical to the success of Seek and Treat to Optimize
the success of Seek and Treat to Optimize Prevention of AIDS
¾Target at least one test per patient in your
¾Target at least one test per patient in your
Conclusions
Conclusions
2 Get help! There’s lots of good resources in
2. Get help! There s lots of good resources in
BC
3 Primary care of the HIV patient is easier than
3. Primary care of the HIV patient is easier than you think
¾ F i i
¾ Focus on common primary care issues
Conclusions
Conclusions
4 Engage Number One!
4. Engage, Number One!
¾ Patient engagement with his/her primary care
physician is the single most important physician is the single most important
intervention to improve HIV care and general
Issues for Discussion
Issues
for
Discussion
• What role doWhat role do youyou see for the primary caresee for the primary care physician in management of HIV patients?
• How can we help in ensuring a continued and
• How can we help in ensuring a continued and strengthened relationship between HIV
patients and their primary care physician? patients and their primary care physician?