#388 HIV in Primary Care with Dr. Jonathan J. “JJ” Nunez MD

April 3, 2023 | By Beth Garbitelli

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LIVE! Updates in HIV management at Hershey

Highly active, high-yield points on HIV management in Primary Care!  We are joined by Infectious Disease specialist Dr. Jonathan J. “JJ” Nunez MD (of Penn State Health – Hershey) to review basics of management, important comorbidities, and new horizons in HIV care. 

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Show Segments

• Intro
• Establishing HIV Care, Initial History Taking
• Privacy and HIV
• Physical Exam Tips for HIV
• Weight gain, managing cardiometabolic risks
• Initial labs, tracking viral load
• Undetectable = Untransmissible
• Sexual history considerations, PEP, PrEP, 
• Anal paps, cervical cancer screening
• Long-Acting HIV Medications
• Take-home points
• Outro

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HIV In Primary Care Pearls

1. Important components of an HIV history include hospitalizations for HIV complications,  history of opportunistic infections, comorbidities, co-infections (especially hepatitis B, hepatitis C), and former medication regimens, per Dr. Nunez.  
2. Never assume a person in the room with a patient knows of the diagnosis without confirming with the patient themselves. 
3. Take a good sexual history to ensure appropriate intervals for repeat HIV and STD screening. And don’t forget about syphilis screening!
4. Risk for cardiovascular disease is about two times higher in patients living with HIV (Hsue 2018, Hsue 2019)!
5. Undetectable = Untransmittable
6. Dr. Nunez recommends screening HIV patients with anal pap smears, as emerging data supports treatment for high-grade lesions (Palefsky 2022).
7. Antivirals are drugs with a myriad of interactions.  Check out the National HIV Curriculum from University of Washington, UCSF InSite, HIV Drug Interactions from University of Liverpool for interactive tools to help. 

HIV In Primary Care – Show Notes

Establishing Care

Treat managing HIV in your practice like any other chronic issue. Set the stage by building rapport, understanding basic background information about a patient, and staying curious about their story.  Always respect pronouns and sexual identity, while recognizing that these may be fluid for patients. Dr. Nunez recommends documenting the timeline of their HIV care by establishing when and how they were diagnosed as well as learning about their medication regimen. Of note, please remember that the initial diagnosis and circumstances surrounding diagnosis may be traumatic for the patient to recount. 

Important components of an HIV history include hospitalizations for HIV complications, history of opportunistic infections, comorbidities/co-infections (especially hepatitis B, hepatitis C), and former medication regimens, per Dr. Nunez.  

Dr. Nunez also recommends determining social supports, where they live, and how they feel about their current medication regimen.  Side effects of HIV medicines can be prominent (Reust 2011) and asking about this is also important.  Asking about mental health is also a critical part of initial interviews as psychiatric comorbidities are common in HIV (Nedelcovych 2018). 

Protecting Privacy

An important consideration in patients with HIV is privacy regarding the diagnosis.  Dr. Nunez recommends noting who or who does NOT know about the diagnosis very clearly so other providers and caregivers can be aware. Never assume a person in the room with a patient knows of the diagnosis without confirming with the patient themselves. 

HIV Management Pearls

HIV is a full-body disease and requires a head-to-toe exam. In particular, skin and eyes should be assessed (Knight 2022, Rigopoulos 2004). Always assess for fevers, weight loss, lymphadenopathy as these may hint at disease progression (Morgan 2002).  Besides cachexia, weight gain should also be noted. While HIV is a catabolic disease, certain HIV medications, particularly integrase inhibitors, are associated with metabolic syndrome and weight gain (Eckard 2021). 

Risk for cardiovascular disease is about two times higher in patients living with HIV (Hsue 2018, Hsue 2019).  Patients should be screened for high cholesterol, diabetes, high blood pressure, and treated with appropriate medication therapy (Siddiqui 2023). HIV-associated cardiac pathophysiology (Ntsekhe 2023) and primary CV prevention in HIV patients (Grinspoon 2019) are areas of active inquiry.  Of note, protease inhibitors are associated with dyslipidemia (Clotet 2003). Smoking rates are higher in patients with HIV, so cessation is another important health maintenance topic (Ledgerwood 2016, Nansseu 2020). 

Mixing Meds

Antivirals are drugs with myriad interactions. Longer-acting integrase inhibitors can interact with metformin so the dose should be lower (Song 2016).  Also, statins should be chosen carefully.  Check out the National HIV Curriculum from University of Washington, UCSF InSite, HIV Drug Interactions from University of Liverpool for interactive tools to help. 

Cabotegravir (part of the long-acting HIV-1 injection) can increase clearance of methadone so withdrawal symptoms would need to be monitored (Hodge 2021). 

Counting CD4 Count and Going Viral

With initial diagnosis,  it is always recommended to obtain a CD4 count to determine appropriate infectious prophylaxis (Goldschmidt 2016).  In Dr. Nunez’s practice, he checks CD4 every 3-6 months in a new diagnosis and switches to annual monitoring in stable patients with undetectable viral loads (Thompson, 2020). The goal is keeping viral load suppressed and HIV RNA should be routinely checked. When initiating an integrase inhibitor, he expects to see a log reduction and if he does not, he worries about adherence. 

Talking About The Birds & The Bees 

Take a good sexual history! This allows us to target appropriate prophylaxis for partners as well as determine an appropriate interval for repeat testing and STI screening (CDC 2023).  Dr. Nunez recommends asking about their sexual practices, preferences, prior STIs, and number of recent partners in the past 3-6 months. 

STI testing includes gonorrhea, chlamydia, and don’t forget: syphilis (Amerson 2023).  Carefully consider which swabs are needed based on sexual practices, i.e., don’t forget rectal and pharyngeal (Gunn 2008, Rahman 2023)!   HCV should also be checked, given possible increased transmission between men who have sex with men (IDSA 2022). Dr. Nunez also makes it his practice to check HBV. 

Undetectable = Untransmittable

Treatment is more than just treatment, its HIV prevention! Landmark studies (Cohen 2016, Rodger 2019) have shown that treating HIV aggressively makes it much less transmissible in serodiscordant couples.  Over time, Dr. Nunez believes this is part of what has driven the more proactive approach to HIV treatment (SMART Study Group, Coffey 2019).   When thinking about fertility and family planning, Dr. Nunez recommends 6mo of undetectable viral load prior to seeking pregnancy (HIV.gov 2023). 

PrEP/PEP for STI? Not yet. 

Some data indicate doxycycline as a post-exposure prophylaxis (200mg within 24-72 hrs of condomless sexual activity) may decrease STIs (Molina 2018, Luetkemeyer, 2022).  Dr. Nunez recommends keeping in mind that much of the data right now evaluates specifically cis men and trans females but has not shown impact in cisgender women (Stewart 2023). He also reports concerns exist regarding resistance (Luetkemeyer 2023). 

Preventative Measures: Paps and Vaxx

Dr. Nunez recommends screening HIV patients with anal pap smears, as emerging data supports treatment for high-grade lesions (Palefsky 2022). Cervical cancer screening is also critical (ASCCP 2019, WHO 2021). Important vaccines include Hepatitis B, Hepatitis A, Shingles, HPV, Pneumococcal, and Meningococcal vaccination; of note: the meningococcal vaccine should be offered every 5 years as a booster (University of Washington, National HIV Curriculum – Vaccination). 

Long-Acting HIV Medications

There is an exciting new effective tool in the toolkit, injectable HIV medications, with one fully injectable regimen (cabotegravir-rilpivirine) and one injectable PrEP regimen (cabotegravir) now available(Gandhi 2023, Swindells 2020). This type of dosing gives patients more autonomy and removes the barrier of  a daily pill, noting it is dosed in two gluteal injections in an office visit. In his expert opinion, this can sometimes be an issue if a patient no-shows frequently, as missing or delaying doses could promote resistance. Also important to consider that rilpivirine can prolong QTc (Ford 2011), so make sure you get a baseline EKG. 

Links

1. The Wandering Earth (book)
2. Mass Effect (video game)
3. The National HIV Curriculum from the University of Washington
4. HIV Drug Interactions from University of Liverpool
5. Yale Medicine Cervical and Anal Cancer Screening in HIV-infected patients

Goal

Listeners will discuss primary care considerations for patients living with HIV.

Learning objectives

After listening to this episode listeners will…  

1. Outline strategies to maintain retention in care for patients living with HIV.
2. Conduct an effective and sensitive HIV history.
3. Describe the potential metabolic impacts of HIV and ART therapy on long-term outcomes.
4. Perform appropriate health maintenance, including cancer screening, for patients with HIV.
5. Perform appropriate routine laboratory evaluation for patients living with HIV.
6. Described current broad treatment strategies for patients with HIV.

Disclosures

Dr. Nunez  reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Nunez JJ,  Garbitelli BC, Williams PN, Watto MF. “#388 HIV in Primary Care”. The Curbsiders Internal Medicine Podcast. https://thecurbsiders.com/episode-list April 3, 2023