The Role of the Primary Care Physician in HIV Management

Transcription

1 The Role of the Primary Care Physician in HIV Management David M. Forrest, MD, MHSc, FRCPC Infectious Diseases Nanaimo

2 Disclosures No financial disclosures though I have several dependents

3 Testing Primary care physicians in an optimal position to test Consent needed Counseling required For positive and negative test

4 Testing Opportunistic testing On admission to hospital In office (e.g., at time of pap test, flu shot, regular visit) Target at least one test per patient in your practice/yr Test more frequently if risky ik bh behaviour Including unprotected heterosexual intercourse

5 Testing Negative test Review risky behaviour Review means of mitigating risk Positive test Review risk of transmission and precautions to reduce risk HIV not a death sentence while not curable, a treatable chronic disease

6 Getting Help D Forrest (NRGH) Access to HIV clinic and RN (CI/NI) Positive Wll Wellness NI (PWNI) REACH (Rapid Expert Advice and Consultation for HIV) at St. Paul s Hospital Web resource

7 Primary Care in HIV: A Primer Baseline history General history Mental/psychosocial health Behavioral risk assessment (sexual, substance use) Addictions history Thorough physical examination

8 Primary Care in HIV: A Primer Basic investigations General bloodwork, U/A, CXR β β HCG, Pap smear in females Investigate abnormalities Screening investigations Hepatitis A, B, C VDRL and Chlamydia/gonorrhea urine PCR Toxoplasma, Bartonella serology Tuberculin skin test

9 Primary Care in HIV: A Primer HIV specific investigations CD4+ (and %) HIV plasma viral load (PVL) Ensure immunizations up to date (Public Health) Contact PWNI ( ) for further investigations and consultation

10 Primary Care in HIV: A Primer Prophylaxis of opportunistic infections should be given if CD4+ < 200 (or fraction < 14%) CD4+< < 200 CD4+ < 100 CD4+ < 50 Pneumocystis Toxoplasma (if serology +ve) M. avium complex All patients with +ve TST should be screened for active tuberculosis and treated t dfor active or latent disease (PH)

11 Primary Care in HIV: A Primer When do I refer? Anytime! Critical thresholds CD4+ > 500 CD CD CD4+ < 200 treatment offered treatment advised treatment needed treatment critical

12 Primary Care in HIV: A Primer Ongoing primary care in HIV not as complex as you imagine! HIV patients still get cuts and injuries and colds and mental illness like everyone else Mental lhealth hand addictions i issues need special attention

13 Primary Care in HIV: A Primer Moreintensive follow up and primary care interventions needed History and physical exam 2 x / year Pap smear at least 1 x / year (females) CD4+ and HIV PVL Q 3 months HIV bloodwork Q 6 months If not followed by HIV specialist

14 Primary Care in HIV: A Primer HIV and its treatment (antiretroviral therapy) cause metabolic dysfunction even in the young Osteoporosis Diabetes b t mellitus II Dyslipidemia Hypertension Consequent cardiovascular disease Renal disease

15 Primary Care in HIV: A Primer Medications all HIV patients should be taking Multivitamin Vitamin D IU / day ±Calcium supplement If cardiovascular risks, ASA 81 mg / day

16 Primary Care in HIV: A Primer Whatever medications you start, check for drug interactions, especially with antiretroviral medications

17 Engagement Engagement of the patient by the primary care practitioner is crucial to the success of HIV management

18 Engagement It is much more important to know what sort of patient has a disease than what sort of disease a patient has Osler, 1904

19 Engagement Patient management coordinated by primary care physicians associated with lower costs and lower all cause mortality Baicker, 2004

20 Engagement Why? Care integrated, personalized, prioritized Carecontinuous and not fragmented Preventive services more consistently delivered Acute t problems diagnosed/treated d/t t d earlier Greater access Better local ladvocacy on bhlf behalf of patient/community Sloane, 2011

21 Engagement Improves quality of HIV care Krentz, 2011; Ulett, 2009; Ding, 2008 Improves adherence to antiretroviral medications Blackstock, 2012; Schneider, 2004 Reduces risk of HIV transmission Metsch, 2008; Johnson, 2008

22 Engagement Improves overall health care Zou, 2012; Krentz, 2011 May have psychosocial benefits (e.g., in facilitating treatment of addictions issues and reducing criminal behaviour) Takizawa, 2007; Islam, 2011; Lum, 2011

23 A Model of Care for CI/NI

24 Original Paradigm FD FD P P P SW Phrm RN Splst AVI P FD MH P

25 New Paradigm Phrm SW RN P FD P P P Splst FD P FD AVI MH

26 Engagement The relationship between family physician and patient is central to providing high quality comprehensive HIV care in the best interests of the patient and the public

27 Conclusions 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 Prevention of AIDS Target at least one test per patient in your Target at least one test per patient in your practice/yr

28 Conclusions 2. Get help! There s lots of good resources in BC 3. Primary care of the HIV patient is easier than you think Focus on common primary care issues Refer for HIV specialty care

29 Conclusions 4. Engage, Number One! Patient engagement with his/her primary care physician is the single most important intervention to improve HIV care and general health of the patient and society

30 Issues for Discussion What role do you see for the primary care physician in management of HIV patients? How can we help in ensuring a continued and strengthened relationship between HIV patients and their primary care physician?

31 Issues for Discussion How can we help you?