HIV

(This information was provided by Ann Harvey, updated 12.1.16toc

**HIV ("Positive Health") Clinic Providers**

 * **Brentwood:**Chris Farnitano
 * **Pittsburg:** Larry Boly, Chris Farnitano, Anthony Pizzo,
 * **Martinez:** Judy Bliss, Jamie Pehling, Anthony Pizzo, Daniel Moring-Parris
 * **WCHC:** Anthony Pizzo, Jamie Pehling

**Infectious Disease Referrals:**
To arrange an appointment with an infectious disease specialist, you must page the infectious disease specialist on call. Please do not refer non-HIV related ID consults to the Positive Health Clinic.

For **obstetrical questions**, remember that Judy Bliss is also Chair of OB and happy to consult and facilitate.

**__Referral/Consultation guidelines:__**

 * All HIV positive patients should be given the option of being followed in an Positive Health clinic. State law requires that all HMO's offer treatment by a qualified HIV provider. The providers staffing the Positive Health clinics meet the legal qualifications.
 * The HIV clinics also serve as primary care clinics for most patients. However, you are welcome to continue primary care and have us only manage the HIV if you and your patient like.
 * If you and your HIV positive patient decide that you will manage the HIV care, please send the patient to an Positive Health clinic at least once a year to review care. HIV care guidelines change frequently. Antiretroviral therapy is now recommended for all HIV positive patients, regardless of CD4 count or HIV viral load. If you decide against this periodic referral, please review the patient's care with one of us at least annually. This could take the form of a chart check or an in-person or phone consult.

**Logistics of accessing HIV care:**

 * Your nurse can arrange an initial HIV clinic appointment through EPIC. (hiv int, pos int, or aids int all get you to a list, at the bottom of which is Positive Health INT REF (HIV))
 * Any of the HIV social workers can arrange an initial HIV Clinic appointment, including John Sturr as the intake coordinator. If he is not available, please call the main Contra Costa office line 925-313-6771, and ask to speak to the social worker on duty to schedule an appointment. The client will be asked to contact Financial Counseling to be screened for insurance eligibility for CCHP, as well as MediCal.
 * Undocumented immigrants who meet income requirements are eligible for HIV-specific BHC. There may be a wait list. Please contact the social workers as above.
 * Legal residents for less than 5 years with HIV who are at 200-300% of Federal Poverty Level can get BHC. Please contact the social workers as above.

**Labs to order for newly diagnosed HIV-positive patients**:

 * 1) Use the “HIV New Diagnosis Initial Labs” panel:

Includes: T cells, HIV quantitative RNA, comp panel, HLA B5701, chronic hepatitis panel, CBC/d, RPR, toxo IgG, urinalysis, microalbumin/creatinine ratio, quantiferon-TB, HIV genotype). Labs should be drawn before patient takes their first dose of ARVs. ARV initiation can begin before results are available.

**Prescribing for newly diagnosed HIV-positive patients:**
1. When to prescribe: 2. What to prescribe:
 * **PCP Prophylaxis**
 * CD4 count below 200.
 * If CD4 count is not yet known, whenever there is clinical reason to suspect significant immune deficiency. Indicators include oral thrush, significant weight loss, chronic diarrhea, or skin conditions such as prurigo nodularis, severe seborrhea, severe psoriasis, multi-dermatomal Herpes Zoster, mollusca contagiosa.
 * Most effective: trimethoprim-sulfamethoxazole (Septra/Bactrim). Single Strength tablet daily OR DS tab daily OR Double Strength tablet three days per week. Single Strength daily is the simplest and best tolerated.
 * Second-line: dapsone, 100 mg daily


 * **Anti-retrovirals (HAART--"highly active antiretroviral therapy"):** Starting antivirals as soon as possible after diagnosis is now strongly encouraged. Please seek consultation on choice of regimen:
 * [[file:Rapid ART protocol CCHS v1.5 1_20_17.docx|rapid ART protocol for CCHS]]


 * Frequent __lab abnormalities__ that do not need work-up:**


 * High indirect bilirubin in patients on atazanavir (Reyataz) (non-toxic drug effect)
 * High MCV in patients on zidovudine (aka AZT or Retrovir) or stavudine (aka d4T or Zerit)
 * High non-albumin protein (anti-HIV and non-specific antibodies)

> [] are two excellent sources for thorough HIV drug interaction information. You can also use the micromedex or utdol interactions tools.
 * Please check for __drug interactions__ before prescribing anything!**
 * __Especially__:**
 * benzodiazepines
 * simvastatin
 * lovastatin
 * older seizure medications
 * Antacids, calcium preparations
 * H2 blockers
 * PPIs
 * [] and

**__Testing and results reporting__**

 * __Screening__ for HIV Infection: CDC recommendations**
 * **In all health-care settings, screening for HIV infection should be performed routinely for all patients aged 13-64 years. This should be done once for everybody, and repeated depending on their level of risk.**
 * **All patients initiating treatment for TB** should be screened routinely for HIV infection
 * **All patients seeking treatment for STDs**, including all patients attending STD clinics, should be screened for HIV during each visit for a new complaint, regardless of whether the patient is known or suspected to have specific behavior risks for HIV infection

**Repeat screening**

 * Health-care providers should subsequently test all persons likely to be at high risk for HIV at least annually. Persons likely to be at high risk include:
 * Injection-drug users and their partners
 * Persons who exchange sex for money or drugs
 * Sex partners of HIV-infected persons
 * MSM or heterosexual persons who themselves or whose sex partners have had more than one sex partner since their most recent HIV test
 * Health-care providers should encourage patients and their prospective sex partners to be tested before initiating a new sexual relationship
 * Repeat screening of persons not likely to be at high risk for HIV should be performed on the basis of clinical judgment
 * Unless recent HIV tests results are immediately available, any person whose blood or body fluid is the source of an occupational exposure for a health-care provider should be informed of the incident and tested for HIV infection at the time the exposure occurs

A. Ordering providers and the ** AIDS Program ** Social Worker from their respective region will be notified of all positive HIV tests by the lab. The laboratory will page the ordering provider. The ordering provider should arrange to give the patient results in a face to face visit as soon as possible. Telephone notification is discouraged in general, due to potentially severe emotional reactionsto the news and inability to read and respond to the patient's reaction.
 * HIV Antibody results reporting and follow-up protocol**
 * 1. HIV positive results**

 B. ** AIDS Program Social Workers do not give out HIV test results to patients. **

C. After confirming that the provider has disclosed the resluts, the ** AIDS Program ** Social Worker will contact the patient to offer psychosocial support, linkages with case management, and partner notification.

D. Pertinent names and phone numbers will be provided by the ** AIDS Program ** Social Worker to link patient with support systems provided by the AIDS Program and community support services.

E. If the ordering provider of a positive result cannot be contacted by the laboratory the same day, then the following applies:

1. If the ordering provider is not an Emergency Department (ED) Provider, a Positive Health Clinic provider of the pertinent region is contacted by secure email or sealed transmittal envelope and given the results by the lab. 2. If the ordering provider is an Emergency Department (ED) Provider, the ED provider who has been designated by their department head to receive positive test results shall be notified by secure email. The provider is responsible for arranging notification to the patient of their positive HIV test result, whenever possible.

Providers should give negative results to the patient and offer risk reduction counseling. Contra Costa Health Plan Advice Nurses are also authorized to give negative test results to patients.
 * 2. HIV negative results**

All results: All relevant information should be recorded in the patient’s chart. The laboratory staff should record in the electronic medical record when and to which provider the positive test results were communicated. An additional copy of all positive HIV results will be delivered to the Infection Prevention and Control Program Manager.

Post Exposure Prophylaxis (PEP) for HIV
Updated 12/16/2013

The [|new guidelines]have a couple of changes, most notably that medications should be administered "as soon as possible" after the exposure and that **a 3-drug regimen should be used (Truvada qD+ Raltegravir BID)** instead of the 2-drug treatment (Truvada, which is Tenofovir + Emtricitabine).


 * First doses of these pills are now stocked at all our health centers as well as the ED** . Health Center providers are often the first point of contact for an employee with a blood or body fluid exposure and you should be encouraged to have the patient **"swallow first, ask questions later."** A single dose of PEP is extremely non-toxic and at least in theory the effectiveness depends in large part as to how soon it is given after exposure. Raltegravir is dosed bid, so after taking the first dose you and the employee have 12 hours to assess level of risk to decide whether to continue further PEP dosing.

A goal is to have the Source patient tested within 1 hr of exposure when possible, and hopefully have this guide the need for further doses of PEP.

**Consultation**
You are welcome to consult any of the HIV providers listed above as well as Dr. Kuhl and the other ID specialists.

In addition, the National Clinicians' Consultation Center is happy to consult by phone:
 * HIV Warmline** 1-800-933-3413 (6 AM to 5 PM) -- all questions concerning diagnosis and management of HIV and HIV-related conditions
 * Perinatal HIV Hotline** 1-899-448-8765 (24 hours for urgent questions; 6 AM to 5 PM for routine ones) -- questions concerning care of pregnant women and newborns
 * Post-Exposure Prophylaxis Hotline** 1-888-448-4911

**Other Links:**

 * HIV Drug Resistance Database**

HIV Resource Guide: list of community resources to assist people living with HIV/AIDS

HIV Community Testing Site: Mobile Clinics that provide free HIV testing in the community Prevention for POZ toolkit: A link to online training, education and resources for primary care providers on up to date prevention care to people living with HIV. Published by the NY Dept of Public Health.flat