Transfer of HIV Care – What Do You Need to Consider?
**No Longer Available for Credit**
Deborah, a 31-year-old female, has recently moved to your area and she schedules an appointment to establish care. She has no additional medical history. She takes a multivitamin daily. She was diagnosed with HIV at her OB/GYN’s office 10 years ago by routine screening. She was started on coformulated emtricitabine/tenofovir disoproxil fumarate/efavirenz (Sustiva) at that time by her HIV provider and she has been on it since her diagnosis and she has no tolerability issues. She is currently asymptomatic.
Data:
- BP: 120/70 mmHg
- CD4 count: 700 cells/mm3
- HIV RNA by PCR: <20 copies/mL
- Hepatitis A and B: immune
- Hepatitis C antibody: negative
Questions for Discussion:
- What additional information would be important for you to know about Deborah as she transfers into your care?
- Would you recommend updating Deborah’s antiretroviral therapy to an integrase inhibitor based regimen? Why or why not?
- At what point do you approach changing a patient’s regimen who is new to your practice and you are still developing a trusting relationship?
Welcome back everyone. We are presenting a case here that I am sure most of you have seen in your clinic. The questions posted for discussion are a start but you do not have to use them, please feel free to talk about something else you may see as a priority.
This case has so many interesting aspects and I think it should be a lively discussion.
I will start the discussion by saying when I see a patient like this for the first time, I almost never start discussing changing things. I have done it in the pasta nd I feel like it makes the patient uncomfortable. The only time I have done that is when someone presented to me on Stavudine (Zerit)-yes that occurred in 2018 and I started my discussion with has anyone talked to you about the toxicities of that medication.
Thoughts from anyone?
I agree Bill regarding waiting a few visits before approaching the topic of changing ANY regimen as long as the patient is safe. There is definitely a time period where we are developing trust with these patients new to us, but NOT new to the disease. I think that period of time differs in length with each patient and it’s our responsibility to gauge how long a person needs.
Stavudine is a scary drug but one many of us used years ago.
Does anyone else have a medication that they feel is dangerous enough to approach the discussion of “change” during the first visit?
How do other providers bridge the transition for these patients to a new office setting? Do you have a protocol for new patients?
I definitely agree that taking time to establish a trusting relationship with a new patient, whether a new diagnosis or a transfer of care, is essential to the success of the patient’s care moving forward. In terms of this patient’s medications, she is on a regimen that we wouldn’t recommend if we were starting her on therapy for the first time today, but it’s one that she has tolerated well with good efficacy over a number of years. As a result, I don’t think there’s an emergent need to update things to an integrase-based regimen. In other words, you have time to establish a good relationship with the patient before pursuing any ART changes that you may find are necessary as you get to know the her better.
Hello Bill, Eileen & Jason,
My first meeting with a new patient mostly focuses on establishing a rapport with the patient, allowing her to voice any questions or concerns she may have. This visit is usually pretty intimidating for the patient, Giving detailed medical, financial and sexual history, I almost never discuss switching medications during the initial visit but I do have medication charts hanging in the exam rooms so that patients can see the various treatment options available. Patients get to sew hat they are currently taking along with all the others choices of meds available. Being that this patient may be of childbearing childbearing age, I like to discuss her her past and present use of birth control. There will be plenty of upcoming visits to discuss medication changes.
Gwen,
I agree with what you are saying. I am cautious with rushing to discuss switching ART especially now with all of the concern regarding weight gain with TAF vs TDF, integrase vs non-integrase and it may cause her to not trust the system. The only time I rush to a change if there is toxicity that I see.
Given the patient is stable, has no additional history and is not on a toxic med regimen, I would focus on using a sympathetic and nonjudgmental attitude to establish trust. Assessing the patient knowledge of the disease would be a good start. Then, obtaining a baseline and ongoing HIV-related history including sexual history, mental health and substance abuse. The confidential nature of these discussions would be stressed as well as the importance of partner notification. In addition, the patient being a young female of child bearing age I would discuss family planning including risks to the mother and fetus during pregnancy. I would invite her to voice questions and concerns to include her in the decision-making and leave a change in medication regimen for a later visit.
I really like this approach and it would probably make the patient feel comfortable given the transfer to a new clinic.
I agree with the above in terms of not strongly recommending regimen changes at the first visit, although I would make mention of the fact that there are other regimens available that may not have some of the long-term side effects we’ve seen with EFV, and so we could explore further at this visit or in the future when she’s ready. Perhaps the person would actually be interested in having more information, maybe she has already heard there are other “better” drugs out there, and I wouldn’t want to withhold the fact that I have more information about this until a future visit.
Cori,
That is my approach as well. in the past, I would discuss the change at the first visit and it made patients uncomfortable. Unless someone is on Zerit (D4T) I do not feel the urgency. I have had someone referred to me over the last year who was on zerit and had such profound lipoatrophy and he did not even realize it was happening until i asked him to bring in and old picture of himself to compare.
Other questions I have for this person are what are her fertility intentions, what is she doing in terms of contraception or pre-conception care, if anything? Of course I’d like to learn more about her social and family history, get to know her as a person and better understand the context of her life.
Interesting Cori, her fertility intentions should definitely be a discussion point. Suppose she asks your advice regarding long-acting contraception such as an IUD “for a few years”, she didn’t like the pill in the past. She needs a few more years to get settled before planning to have children.
What would your advice be?
Refer to Ob/Gyn?
If she wants an IUD, I would provide her with information about the IUD options (e.g. copper or progestin-containing) – there are great contraception handouts on the RHAP website btw – https://www.reproductiveaccess.org/contraception/
If I could provide the IUD myself, I would, but unfortunately I am out of practice, so I would refer to a colleague in my community health center so she can get one.
We provide primary care, including women’s health in our clinic. I incorporate their HIV follow up visit with their routine women’s health exam where paps or pelvic exams are performed. Discussions can include family planning, birth control methods that are available, sexual health concerns or menopause. We also hold an annual mammogram van day onsite which the women really enjoy. The Fox Chase Mammogram Van offers their services for the day. If there is a need for referral to Ob/GYN that will be done.
Really important points raised by everyone in terms of the patient’s child bearing potential and fertility planning. If the patient was actively trying to conceive at this time, would you recommend a change in her HIV treatment regimen? Why or why not? If you did want to make a change, what would be your regimen of choice?
I think that one of the best places to look when trying to answer this question are the perinatal HIV guidelines published by the NIH: https://aidsinfo.nih.gov/guidelines/html/3/perinatal/224/whats-new-in-the-guidelines. These guidelines are updated frequently and have changed considerably over the years as new data emerges. Perhaps the best quick reference within those guidelines is this table: https://aidsinfo.nih.gov/guidelines/htmltables/3/7444. It essentially takes you through each possible scenario in terms of selecting ART during pregnancy or in those trying to conceive. Using this table, if our patient came to us pregnant and virally suppressed on emtricitabine/tenofovir disoproxil/efavirenz, it would be recommended that we continue this regimen, if possible. Otherwise, if the patient is trying to conceive and on this regimen, we might consider an alternative. If we wanted to know more about the recommendations regarding efavirenz in these settings the teratogenicity section of the guidelines provides extensive reviews of all of the available evidence for each antiretroviral agent: https://aidsinfo.nih.gov/guidelines/html/3/perinatal/170/teratogenicity.
Suppose Deborah was pleased with her first visit and returns for follow-up wishing to discuss her family planning needs. She remains on her EFV regimen ( as we are still developing trust) and has questions regarding “safe and effective” methods of birth control. She used “the pill” in the past but her sister had a Mirena IUD placed and she wants to know if this is safe to use in someone with HIV. Deborah relocated to your area to be close to her fiancé and has not yet found an OB/Gyn provider. She plans to get married and have children in the near future but needs a few years to get established.
How comfortable are you with discussing family planning issues within your practice or do you refer to Ob/Gyn?
Are there drug interactions we need to be concerned with when prescribing hormone-based birth control?
Eileen this topic is so important. There is data that 3/4 of pregnancies among women with HIV are unintended. It is important to discuss this with patients during their routine visits. Most of the patients that I see who are pregnant come in to the OB clinic well after the first trimester when most of the organs are formed.
To answer to Eileen’s question, I would discuss family planning issues to educate the patient about prevention of mother to child HIV transmission. Briefly go over maternal ART, infant prophylaxis etc. However I would definitely refer to OB/GYN for more perinatal transmission prevention education, as well as management during Labor and delivery, infant prophylaxis, post partum management and breastfeeding.
Comments and Question: I have had patients who do not want to switch off of their regimen and I have supported that unless they were on a toxic medication like Stavudine.
One thing I am starting to see is patients who have heard through social media about the TDF effects and actually want to stop ART all together.
Have you seen this or have your patients come in to talk to you about it and what have you done.
I discussed that a small percentage of patients have developed renal and/or bone problems but that is why they get frequent blood work, etc.
I have see patients who came to our ID clinic for prep but were very concerned about the AE of Truvada on renal function and osteopenia. I explained that it is why we do regular blood tests or BMD if needed to prevent any harm.
This is our approach too. Whether it is from social media, adds on television or word of mouth, some patients definitely have concerns about TDF. We try to explain that significant AEs with TDF are rare and that we are constantly evaluating safety of all ART medications with routine blood tests. If we did not feel that a medication was safe, we would not be prescribing it.
I agree with both of you-I see the ads over and over again on social media and I occasionally (not always) read some of the comments attached and they are really unbelievable.
I have patients who have seen ads about the adverse effects of TDF/FTC. Some are concerned enough to join class action lawsuits against Gilead. While I would never pressure a patient especially on her first visit to change her regimen, I would gather more information to inform our discussion should she become open to a regimen switch – such as history of other past agents tried, and any HIV genotype test results.
Gathering a complete ART history is so essential in terms of future treatment decisions. I think that sometimes we get caught up only talking about previous ART failures and subsequent resistance, but including tolerability issues with previous ART agents/classes when taking an ART history can be very informative as well.
When patients bring up the lawsuit, I discuss what it is about and the small percentage of pts who have suffered from these adverse effects (renal failure and osteoporosis with fractures). I also remind them that being in care and getting blood work/urine checked helps providers check and monitor on the toxicity of medication.
I am checking for osteoporosis in my postmenopausal female and male patients over 50 who have been on TDF in the past, according to HIVMA / IDSA guidelines for primary care in HIV. I have been surprised by the degree of bone loss I’ve seen in my male patients, though perhaps I shouldn’t be. This informs my counseling of patients who wish to remain on TDF based regimens.
It is definitely interesting to hear that you have observed considerable bone loss in your patients. Unfortunately, DEXA scanning has not become a routine practice in our clinic, but I bet we would have similar findings in our patients. What has been challenging recently is determining just how clinically relevant the BMD changes and renal function changes are that can occur with TDF vs. TAF. Some recent articles/studies/editorials are really starting to question the overall “benefits” of TAF. Some examples are: https://www.ncbi.nlm.nih.gov/pubmed/30515300, https://www.ncbi.nlm.nih.gov/pubmed/29682298, and https://annals.org/aim/fullarticle/2758848/tenofovir-alafenamide-hiv-preexposure-prophylaxis-what-can-we-discover-about. Curious to hear what other think about the benefits of TAF vs. TDF. Are they clinically relevant or not? In my opinion, there’s probably not a one size fits all answer to this question. Rather, like most therapy decisions we make, it likely depends on the case.
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