1. Human Immunodeficiency Virus (HIV)
Part 1
Sindhuri Benjaram
PGY 1

2. HIV now has become a treatable condition but carries with it some psychological and medical issues.
Before going to management of these issues first we will discuss about
Screening
Diagnosis
Prevention

3. You see four patients as the acute care physician in your resident clinic.  Which of the following patients should be offered HIV testing?
a) A 34 year old police officer presenting for bronchitis. He has had 2 sexual partners since his last HIV test a year ago.
 b) A 45-year-old homeless man with former injection drug use and severe psoriasis. He has not received medical care in over 25 years.
 c) A 64-year-old monogamous former social worker without history of injection drug use who presents with headache. She has not had prior HIV testing.
 d) All of the above patients should be offered testing
 e) None of the above should be offered testing in the acute care setting

4. CDC Guidelines The current guidelines reflect on the facts that
Prior risk-based HIV testing programs failed to reduce the incidence of HIV.
To identify and establish care to the estimated 25% of Americans with HIV who are unaware of their status.
Early diagnosis of HIV and treatment has shown to reduce morbidity and mortality.  In addition, treatment of HIV has shown to be an effective form of prevention of new infections.

5. "Opt in" vs. "Opt out"
To make routine screening feasible and reduce barriers to implement testing pretest counseling and written consent requirements were eliminated.
"Opt in" wording approach was previously used. "Do you want an HIV test?“ Which puts the weight on the patient to accept for testing or not
“Opt out" wording approach saying "I test everyone for HIV unless they decline“ creates a default mode of acceptance.
This approach has been used successfully in HIV screening during pregnancy.
Significant increase in testing rates
30% with "opt in" to over 80% with "opt out" phrasing.

6. A 23-year-old man presents to clinic and has been on buprenorphine therapy for the past six months.  In this setting, according to CDC guidelines:
A) an HIV test should be ordered on the patient after verbal consent is obtained
B) an HIV test should be ordered on the patient after written consent is obtained
C) neither verbal nor written consent is required for HIV antibody testing
D) he should be referred to a counselor for pre-test counseling and HIV testing.
Discussion
Although separate written consent for HIV testing is no longer recommended by the CDC, no patient should be tested involuntarily or without their knowledge.  Some states still have laws that mandate written consent.

7. Average patient HIV testing once every 5 years
High risk patients at least annually

8. Clear communication with patients is important
No pretest counselling and written consent are required but the way we approach matters
6R strategy is recommended
Raise the topic;
Reassure the patient that the offer is routine “ not singling him/her out due to a clinical sign or concern that's not being mentioned;
Provide rationale for the test;
Respond to questions the patient has about the test;
Request the test;
Tell the patient when and how they will get results.

9. Screening/Diagnostic

10. Acute infection
‘ Window period’ no antibodies developed yet
3 weeks to several months
If Symptoms they are due to high viral load, hence HIV RNA PCR diagnostic test of choice
Chronic infection
 HIV-1/2 antigen/antibody combination immunoassay is diagnostic test of choice

11. A 24-year-old man presents with sore throat, fever, cervical and axillary lymphadenopathy, and a faint rash on his trunk. He has been having unprotected sex with male partners he has met at a local bar. Which test is the most appropriate to confirm the diagnosis? A) HIV-1/2 antigen/antibody combination immunoassay B) HIV-1/2 antibody differentiation assay C) HIV rapid test D) HIV RNA PCR

12. Discussion
This patient’s presentation is consistent with acute HIV infection. The best test to diagnose acute HIV infection is an HIV RNA PCR (aka "viral load"). 
The HIV-1/2 antigen antibody combination immunoassay, HIV 1/2 differentiation assay and rapid HIV test are antibody tests that may be negative in the first few weeks of infection.
While the p24 antigen is positive earlier in infection, it is not a sensitive enough test for acute retroviral syndrome.  

14. PREVENTION / Transmission
Factors associated with increased risk of HIV sexual transmission include the following:
High viral load
Concurrent STDs
Use of alcohol or drugs
Higher risk sexual behaviors
Being uncircumcised (for heterosexual men only).  
Easy transmission occurs through rectal mucosa and cervical mucosa,
Highest number of CD4 bearing cells
Rectal mucosa are easily traumatized

16. Condom use is still recommended even in patients with undetectable viral loads.
HIV viral load in the serum does not always accurately reflect the viral load in the semen or vaginal fluid. Different antiretroviral medications may have different levels of pharmacologic penetration into these compartments.
Condoms prevent transmission of other STDs, such as syphilis or HSV-2.
Viral load may vary with adherence to medications and may not be durable over time.

18. Pre-exposure prophylaxis (PrEP)
The Iprex study for HIV-negative men who have sex with men found on daily tenofovir DF/emtricitabine (Truvada) reduced the risk of acquiring HIV by 44% with 60% reduction in the most adherent patients. 
High-risk heterosexuals in BOTSWANA - 62%
Serodiscordant couples in Kenya and Uganda- 75%
Bangkok tenofovir DF study showed reduced transmission of 49% in injection drug users. The efficacy was 74% in those with detectable blood levels of tenofovir.
The FDA approved tenofovir DF/emtricitabine (Truvada) for pre-exposure prophylaxis among individuals at high risk of acquiring HIV infection in 2014

19. Assessing risk High risk for HIV infection:
Person in a sexual relationship with an HIV positive partner.
Non-monogamous MSM practicing unprotected anal sex or STDs.
Heterosexuals having unprotected sex with high risk partners.
Person with injection drug use who share needles or equipment or are in drug treatment programs

20. A 22-year-old woman comes to see you for her routine gynecologic care
A 22-year-old woman comes to see you for her routine gynecologic care. She has had three prior male partners including a recent "one night stand" that she met bar hopping with friends. In considering how to reduce her risk of HIV infection: A) negotiate a specific change to be most effective (e.g., "Take condoms when going to the bar") B) recommend a broad change to be most effective (e.g., "Always use condoms") C) preventive counseling is no longer recommended due to ineffectiveness D) preventive counseling is no longer recommended due to stigmatization

21. Discussion
Preventive counseling has been shown to be effective. Specific recommendations are more likely to lead to behavior change than blanket recommendations.

22. Approach
Construct a framework that will help patients understand why you are asking these questions.
Assess a patient's risk for HIV with nonjudgmental questions.  "Many of my patients have difficulty getting their partners to use condoms. Has that ever happened to you?"
Open- ended questions are generally more useful in eliciting informative responses than yes/no questions.  
Address any inconsistencies in behaviors and beliefs like alcohol prior to sex... Smoking cessation, identify attempts at prior risk reduction. 
A concrete plan for risk reduction strategies is more effective than a general blanket recommendation. For example, advise patient to "carry a condom when he/she goes out to the bar" rather than "always use condoms".

24. Renal function to avoid tenofovir induced nephrotoxicity
HIV testing
Hepatitis B status – possible reactivation on discontinuation of prep
Pregnancy
Repeat HIV testing and pregnancy status every 3 months along with adherence and prevention counselling
Creatinine clearance check every 6 months

25. Post Exposure Prophylaxis (PEP)
Occupational exposure to HIV is common.
In 1995, 48% of all graduating medical students recalled being exposed at least once to potentially infectious body fluids during their last two years of medical school
Post Exposure Prophylaxis (PEP)
EXPOSURE
HIV-1/2 antigen/antibody combination 0,1, 4 months
Evaluate for PEP

26. The rate of transmission depends on several factors
The viral load of the source patient,
The type of needle (e.g., Solid vs. Open-bore),
Whether the needle was in a blood vessel,
Visible blood on the needle, and
The depth of penetration of the needle into the exposed individual.

27. The United States Preventive Services task force, with guidance from the CDC and FDA, published updated guidelines on post exposure prophylaxis for health care workers in
The guidelines recommend pep for all health care workers exposed percutaneously or via mucous membrane or non-intact skin to blood, tissue, or other body fluids that are potentially infectious.  Cerebrospinal, pleural, pericardial, peritoneal, synovial and amniotic fluids are all considered potentially infectious.  Saliva, sputum, nasal secretions, vomitus, urine and feces are not considered infectious unless visibly bloody. 
If the source patient has an undetectable viral load, PEP is still recommended.
Begin PEP as soon as possible following exposure. PEP may still be considered in delayed presentations (>72 hours) in high risk cases, but expert consultation is recommended.    
If an occupational exposure occurs and the source patient is of unknown HIV status, experts recommend a rapid HIV test. Rapid testing can determine the source patient's status within 30 minutes

28. PEP therapy- 3 or more antiretroviral agents
Tenofovir, emtricitabine and an integrase inhibitor (Raltegravir or Dolutegravir). 
Alternative regimens are available if the patient has underlying renal insufficiency or other known contraindications to that regimen. 
The optimal duration of therapy is unknown, but current recommendations are to treat for 4 weeks.
Should the unknown source prove to be HIV negative, PEP should be discontinued
No definitive CDC guidelines for PEP for non-occupational exposures such as injection drug use, sexual assault, or consensual sex with an HIV positive partner. However, consensus suggests use of PEP for significant exposures with known HIV positive individuals, or when the exposure occurred with an individual of unknown status likely to be at high risk

29. Thank you