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(1)

The

 

Role

 

of

 

the

 

Primary

 

Care

 

Physician

 

in

 

HIV

 

Management

David M. Forrest, MD, MHSc, FRCPC Infectious Diseases

Infectious Diseases Nanaimo

(2)

Disclosures

Disclosures

• No financial disclosures – though I haveNo financial disclosures  though I have  several dependents

(3)

Testing

Testing

• Primary care physicians in an optimal positionPrimary care physicians in an optimal position  to test

• Consent needed

• Consent needed

• Counseling required

(4)

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 yourTarget 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

(5)

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 

(6)

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

(7)

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

(8)

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

¾ToxoplasmaBartonella serology

¾Tuberculin skin test

(9)

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

(10)

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)

(11)

Primary Care in HIV: A Primer

Primary

 

Care

 

in

 

HIV:

 

A

 

Primer

• When do I refer?When do I refer?

¾Anytime! • Critical thresholdsCritical thresholds • CD4+ > 500 treatment offered • CD4+ 350‐500 treatment advised • CD4+ 200‐350 treatment needed • CD4+ < 200 treatment critical

(12)

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 

(13)

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 

(14)

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

(15)

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

(16)

Primary Care in HIV: A Primer

Primary

 

Care

 

in

 

HIV:

 

A

 

Primer

• Whatever medications you start, check for 

drug interactions, especially with antiretroviral  medications

(17)

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

(18)

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

(19)

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 

(20)

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

(21)

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

(22)

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

(23)
(24)

l

d

Original

 

Paradigm

FD FD PP P P P SW Phrm P FD Splst RN AVI P MH

(25)

d

New

 

Paradigm

Ph SW RN Phrm P P FD PP P FD FD Splst P FD AVI MH

(26)

Engagement

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

(27)

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 

(28)

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

(29)

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 

(30)

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?

(31)

Issues for Discussion

Issues

 

for

 

Discussion

References

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