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Goals and Objectives

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					  HIV IN PRIMARY CARE
                     Miriam Rabkin, M.D., M.P.H.


There are approximately 900,000 people in the United States infected with the human
immunodeficiency virus (HIV); these patients receive primary care services from both
generalists and subspecialists. Internists also play a vital role in testing, counseling, and
educating both HIV-negative and HIV-positive patients. It has become increasingly clear
that antiretroviral therapy should only be prescribed by those expert in its use, and thus
this chapter will focus on HIV testing, harm-reduction counseling, primary HIV infection
and post-exposure prophylaxis. More detailed discussions can be found in the resources,
references and websites listed at the end of the chapter.

                                       HIV Testing

Testing at-risk people for HIV is essential in order to provide adequate health care and
counseling. With no vaccine expected in the near future, behavior modification and
treatment of infected patients are the only possible ways to stem the epidemic. Risk-
reduction behavior - such as abstinence, condom use and the use of clean needles -
clearly reduces HIV transmission. The use of highly active antiretroviral medications
makes patients live longer and feel better – it may also make them less infectious.
Although testing is increasingly frequent, more than 30 percent of the HIV-infected
people in the U.S. are thought to be unaware of their serostatus, and there are an
estimated 40,000 new infections a year in this country. While HIV testing can be
emotionally challenging for doctor and patient, identifying HIV-infected people has
enormous potential benefit both for the individual and for the community.

"High risk" patients are those who belong to populations known to have a high
prevalence of HIV infection: sexual partners of patients with HIV, injection drug users,
people with multiple sexual partners, men who have sex with men, people with other
sexually transmitted diseases, and children of HIV-positive mothers. Blood products have
been screened for HIV-1 since 1985 and for HIV-2 since 1992; the risk of infection from
blood transfusion subsequent to 1985 is extremely low (estimated at 1/100,000 transfused
units). Of note, screening of blood products in the Dominican Republic is not
standardized and the risk of a transfusion in the DR is currently unknown.

While complete seroprevalence data are lacking, the rates of HIV in New York City are
clearly high. The NYC Department of Health estimates that there are between 100,000
and 140,000 HIV-infected New Yorkers, of whom only 75,000 are aware of their
diagnosis; there were 48,145 New Yorkers known to be living with AIDS at the end of
2001. Some surveys suggest that 15 percent of patients in NYC emergency rooms are
HIV-infected. We practice in an endemic area.

There is a growing sense that the threshold for HIV testing has been unreasonably high.
In addition, generalists fail to recognize common HIV-associated conditions, such as the
pathognomonic oral hairy leukoplakia, and may not realize that others – such as
seborrheic dermatitis, psoriasis, and herpes zoster are indications for HIV testing.
Primary care providers may also fail to identify risk behaviors. Several articles have
urged primary care providers to "think HIV" and to abandon what the authors feel is a
passive approach to HIV testing. Table 1 summarizes testing recommendations:

TABLE 1: Which adult New Yorkers should be tested for HIV?*

Condition/risk group:                                       HIV testing strongly   Consider HIV
                                                            recommended            testing

Injection drug users                                                 4

Men who have sex with men                                            4

Sexual partners of HIV+ persons                                      4

Persons with other STDs                                              4

Pregnant women (and those planning pregnancies)                      4

Recipients of transfusion or blood products prior to 1985            4

Health care workers with occupational exposure to HIV                4

Heterosexuals with multiple sexual partners                          4

Commercial sex workers                                               4

Persons who exchange sex for drugs                                   4

Persons with oral hairy leukoplakia                                  4

Persons who use cocaine                                                                  4

Person with alcohol dependence                                                           4

Persons with herpes zoster                                                               4

Persons with seborrheic dermatitis                                                       4

Persons with psoriasis                                                                   4
Young adults with community-acquired pneumonia                                    4

Persons with pneumococcal bacteremia                                              4

Women with CIN or cervical cancer                                                 4

Women with recurrent vaginal candidiasis                                          4

Adults with unexplained weight loss                                               4

Recipients of transfusions in the Dominican Republic                              4


* adapted from sources 15,16,,. This is not an all-inclusive list.

HIV testing involves important public health and privacy issues which neither patient nor
provider should take lightly. Counseling (pre-test and post-test) is mandated by law in the
state of New York, and the test may not be performed on an adult without written
informed consent. Providers should document that they provided pre-test and post-test
counseling. Table 2 summarizes recommendations for counseling.

Physicians and patients should be aware of the difference between anonymous and
confidential testing. In anonymous testing, samples are given an identifying code and the
test center cannot connect the result with a name. The advantage of this method is that it
ensures patient privacy. The disadvantage is that it cannot be used to guide therapy; a
treating physician must document HIV test results in the medical record. In confidential
testing, privacy is a goal that is not always attainable. Test results are available to anyone
with access to the medical chart, and HIV is a reportable condition in New York City.
Contact tracing and partner notification is also a standard of care – and required by law.
Anonymous testing is not available through New York Presbyterian Hospital, but there
are several centers in the city which provide this service. Patients can call the NYC AIDS
hotline at (800) 825-5448, the New York State AIDS Information Service (800) 541-
2437, Planned Parenthood 274-7200, the Geffen Center 367-1100, or GMHC 807-6655
to ask about sites near them. It is important to establish that patients actually received the
results of their HIV tests; 10 to 15 percent of patients tested do not return for results.

TABLE 2: Guide to HIV pre-test and post-test counseling*

HIV pre-test counseling:

Discuss with patient:

        Prior history of HIV testing and counseling
        The nature of AIDS and HIV-related illness
        The benefits of early diagnosis and medical intervention
        HIV transmission and risk-reduction behaviors
       Possible discrimination resulting from the disclosure of HIV test results and the legal protections
        against discrimination
       Anonymous and confidential testing options
       The patient’s responsibility for partner notification
       The availability of medical, psychological and social work support.



With pregnant women, also explain:

       The benefits of early diagnosis for preventing perinatal transmission and for treatment of the
        newborn
       That testing of the newborn will be conducted even if the mother chooses not to be tested herself
        (there is universal testing of neonates in NY)
       The meaning of the test for both mother and newborn



The patient must be able to provide written informed consent. If the patient does not
have decisional capacity, testing should be deferred.

HIV post-test counseling:

For patients with negative test results:

       Discuss the meaning of the test result
       Discuss the possibility of exposure during the past 6 months and the need to consider retesting
       Emphasize that a negative test does not imply immunity to future infection
       Reinforce personal risk reduction strategies



For patients with positive test results:

       Discuss the meaning of the test result
       Discuss the availability of medical care; provide appropriate referrals
       Encourage partner notification; discuss options
       Encourage referral of partner and children for HIV testing
       Provide counseling re: behavior modification/risk reduction strategies



* New York State Department of Health AIDS Institute Publication 0285.

As noted in Table 2, the essential parts of pre-test counseling are obtaining informed
consent to perform the test and preparing the patient to face the results – whether
negative or positive. Unfortunately, discrimination against HIV-infected persons still
occurs and it can be helpful for patients to think about plans in advance, and to consider
carefully whom they will tell if the test returns positive.

Telling patients that they have a potentially fatal disease is one of the hardest things a
physician must do. Counseling a patient whose HIV test is positive is a complex task, and
one that may take several sessions. While there is no "right way" to do this, the CDC and
the NY State Department of Health have published guidelines for HIV counseling. In
addition to conveying the basic information about a patient’s HIV status, there are several
topics that must be covered in post-test counseling:

   a. Behavior modification: Whether the test is negative or positive, patients should
      be counseled about behaviors that spread HIV. It is important to be specific when
      discussing sexual practices, injection drug use and behavior modification, even
      with patients who have been counseled before. Patients should understand that
      HIV has been isolated from blood, semen, and vaginal secretions, as well as
      breast milk, pre-ejaculate and saliva. The best way to avoid contracting the
      disease or giving it to others is to avoid sharing body fluids with others – e.g. to
      abstain from penetrative sexual intercourse, exchange of secretions or needle-
      sharing. In lieu of this, harm-reduction strategies (see below) can effectively
      reduce the risk of transmission.
   b. Contact tracing: By law, a patient who is HIV-positive is required to inform
      sexual and needle-sharing partners of that fact. In practice, leaving notification up
      to patients is ineffective. Other options include notifying partners yourself, or
      utilizing the NYC Contact Notification Assistance Project (212) 693-1419, which
      provides anonymous partner notification. New York State law explicitly permits a
      physician to violate patient confidentiality and inform patients’ partners of their
      exposure. Initial steps, however, should include encouraging patients to tell their
      partners and offering any assistance they require. If patients refuse to cooperate,
      providers are in a very difficult situation. Informing their partners (if they could
      be found) could help stop the spread of a deadly disease and allow them to be
      treated if infected; it will also likely destroy the patient-physician relationship.
      While partner notification is the responsibility of the primary care provider, as a
      rule this is not a situation that should be handled by housestaff alone.
   c. Pregnancy: It is vital that your patients understand that a pregnant woman
      infected with HIV can pass the virus on to her fetus. Although antiretroviral
      therapy in combination with Caesarian section can dramatically reduce the risk of
      vertical transmission, it does not eliminate it. HIV can be transmitted by breast
      milk, and HIV-infected mothers should be advised not to breast feed their
      children.

                              Risk-reduction Counseling

Recommendations about risk-reduction education and counseling are bounded by two
facts: it is clear that behavior modification can reduce the risk of HIV infection, but it is
not clear that counseling can dependably cause behavior modification. Studies of specific
counseling interventions and meta-analyses of these studies show mixed results.
Characteristics of successful counseling programs include culturally sensitive and
patient-specific counseling, repeated and consistent counseling over time, and promotion
of patient self-efficacy.
As noted in Chapter 19, a careful history is the first step in risk-reduction counseling. Not
only is it not helpful to tell a lesbian patient to use condoms or to assume that an elderly
patient is abstinent, but such missteps will close further avenues of discussion between
patient and provider. A complete sexual history should always be taken, and patient
should be asked directly about high-risk behavior. In a respectful and non-judgmental
manner, providers should ask about frequency of sexual activity, number and gender of
partners, type of penetrative sexual activity and use or non-use of condoms. Patients
should also be asked if they are current or former injection drug users.

A "single dose" of counseling is unlikely to effect long-lasting behavior change.
Providers should routinely and repeatedly discuss safer sex with sexually active patients.
The message should be clear, non-judgmental, patient-specific, explicit and upbeat. The
only ways to eliminate the risk of HIV infection are to be abstinent or to have
monogamous sex with an HIV-negative partner, and all counseling should include this
information. Patients who choose to be sexually active should know that there are
specific acts which are highly risky – receptive anal intercourse with an HIV-infected
partner being the most dangerous. While exact data are elusive, insertive anal intercourse,
"rough sex" (i.e. sex in which mucosa are torn), and sex while genital ulceration is
present are also clearly high-risk. Receptive vaginal intercourse appears to be more
dangerous than insertive vaginal intercourse; it is also possible (although much less
likely) to acquire HIV through oral sex. Prompt treatment of other sexually transmitted
diseases is essential, since these are biological "co-factors," which increase the risk of
HIV transmission.

Sexually active patients should know that correct and consistent use of barrier protection
can dramatically reduce the risk of HIV infection. Latex condoms (male or female), latex
dental dams and non-porous (non-microwaveable) plastic wrap are all effective barriers.
In order to use a condom correctly, a specific sequence of events must occur: recognition
that sexual activity is going to occur, access to a condom, negotiation of condom use with
one’s partner, and technical efficacy (removing the condom from its package, putting it
on correctly, using it during intercourse and removing it correctly). Only water-based
lubricants should be used with latex condoms; oil-based lubricants can weaken the latex.
Medicaid will pay for condoms with a prescription.

Users of injection drugs should be referred to detoxification and rehabilitation programs
and encouraged to stop. As long as a patient is using, s/he should use clean needles or
clean needles and "works" in bleach. Specific guidelines are beyond the scope of this
chapter, but questions can be referred to the social workers and peer educators in the
Harkness 6 Infectious Disease clinic (305-3174).



                                Primary HIV infection

Primary HIV infection (P-HIV) also called the "acute retroviral syndrome," is the
constellation of symptoms and signs that occurs in most patients as they acquire HIV. It
is critically important for generalists in high-prevalence areas to be able to identify this
syndrome for three reasons: symptomatic patients will present to their primary care
providers, patients with primary HIV are extremely infectious, and early treatment may
alter the course of HIV disease.

There are at least 40,000 new cases of HIV in the United States each year, half of which
occur in people under 30 years of age. Both prospective and retrospective studies suggest
that two-thirds of patients are symptomatic at the time of seroconversion and that most
seek medical attention. Symptomatic seroconversion has been documented in all risk
categories, but primary HIV infection is rarely suspected, even among high-risk patients.
While there is a broad spectrum of severity, the classic presentation is an acute-onset self-
limited "flu-like" illness that occurs two to six weeks after exposure and resolves after
one to two weeks. Symptoms are felt to correlate to an initial burst of viremia and the
associated immune response. Clinical features are listed in Table 3, and are
disappointingly nonspecific.

               TABLE 3: Clinical features of primary HIV infection

                  Characteristic                 Percent 31,

                  Fever                          96 %

                  Fatigue                        92 %

                  Myalgia/arthralgia             72 %

                  Adenopathy                     64 %

                  Pharyngitis                    64 %

                  Diarrhea                       46 %

                  Headache                       44 %

                  Rash                           40 %

                  Weight loss                    36 %

                  Nausea/ vomiting               32 %

                  Mucocutaneous                  20 %
                  ulcerations

                  Thrush                         12 %

                  Thrombocytopenia               45 %
                  Leukopenia                    40 %

                  Elevated LFTs                 21 %




Because the signs and symptoms of the acute retroviral syndrome are nonspecific,
patients are often thought to have other viral infections, including mononucleosis,
influenza or viral hepatitis. A morbilloform or maculopapular rash on the trunk, arms or
face is highly suggestive in the right context. A high index of suspicion and a careful risk
history are essential; patients with no exposure to HIV in the past two months do not have
primary HIV infection.

Diagnosis of primary HIV is complicated by the fact that patients will not yet have
antibodies to HIV; standard ELISA and Western Blot tests may be negative for the first
three to six weeks after symptoms occur. If P-HIV is suspected, antigen testing (i.e. RNA
viral load testing) should be performed; this should be done with caution as false-positive
testing has been reported. We strongly recommend subspecialty consultation with the
Infectious Diseases service for patients suspected of having primary HIV infection. If you
are considering the diagnosis of primary HIV, the patient should be aware that s/he is
likely extremely infectious. Viral load during the acute retroviral syndrome can be "off
the chart," and patients should use latex barrier protection or abstain from penetrative
sexual intercourse while symptomatic.

                               Post-exposure prophylaxis

Primary care providers in HIV-endemic areas should be familiar with indications for
post-exposure prophylaxis (PEP). There are excellent websites dedicated to this topic,
and a 24-hour CDC hotline for physicians (888) HIV-4911. One New York City program
that provides free PEP has a 24-hour hotline for patients (212) 358-2400. In brief, there
are four circumstances in which PEP is usually considered: occupational percutaneous
exposure, rape, consensual sexual exposure and exposure through injection drug
use/needle sharing. There are limited data with which to make decisions about the last
three situations, but PEP guidelines have been developed via expert consensus. It is
important to remember that there are not enough data to be dogmatic about PEP, and that
in all four scenarios, there are concerns other than HIV infection, including hepatitis and
pregnancy.

   a. Occupational percutaneous exposure: There is a single case-control study of
      post-exposure prophylaxis among health care workers exposed via needlestick or
      laboratory injury. The authors reviewed 33 cases and 665 controls, looking at risk
      factors for seroconversion and efficacy of zidovudine (AZT) monotherapy. The
      average risk of seroconversion after injury with an HIV-infected needle is about 1
      in 300 (0.3 percent). The study found four independent risk factors for
      seroconversion: deep injury, injury with a device visibly contaminated with the
   patient’s blood, procedures involving a needle placed in the source patient’s vein
   or artery and terminal illness in the source patient. An injury with any one of these
   characteristics is considered to be high risk. The authors also found that the
   adjusted odds ratio of seroconversion after PEP was 0.19 – i.e. that the use of
   zidovudine monotherapy after occupational exposure reduced the risk of HIV
   infection by 80 percent. Based on these data, the recommendations for PEP in this
   setting are outlined in Table 4. Of note, the CDC suggest using four weeks of
   combination antiretroviral therapy (zidovudine + epivir) instead of AZT
   monotherapy. In specific high risk situations, or ones in which the source patient
   is already on antiretroviral therapy, protease inhibitors or other nucleoside
   analogues are recommended. Questions about PEP can be referred to the
   Infectious Diseases service; speed is essential as there are theoretical reasons to
   believe that there is a "window of opportunity" for effective PEP. Ideally, persons
   will take PEP within hours of occupational exposure – the medications are
   available from Employee Health, the Chief Residents’ office and the Emergency
   Department.

   TABLE 4: Post-exposure prophylaxis for percutaneous injuries

   Source status                 Class I            Class 2               Class 3

                                 Asymptomatic;      AIDS; symptomatic     Pre-terminal AIDS;
                                                    infection             acute
                                 known low titer                          seroconversion;
                                                                          known high titer

   Exposure level                Offer              Recommend             Strongly
                                                                          encourage
   I – superficial injury

   II – visibly bloody device;   Recommend          Recommend             Strongly
                                                                          encourage
   device used in artery or
   vein

   III – deep/ IM injury;        Strongly           Strongly              Strongly
                                 encourage          encourage             encourage
   actual injection


b. Injection drug use: There are no trials of PEP in the context of needle-sharing,
   although the pathophysiology of infection is presumably the same as that of
   percutaneous exposure. It is clear that sharing needles with an HIV-infected
   person is one of the highest risk behaviors there is. The probability of HIV
   infection in this setting is estimated to be 0.67 – 1.00, and it is likely that PEP
   would significantly reduce this risk. However, there are no recommendations to
   provide PEP in the context of ongoing behavior and the subject is an extremely
   controversial one. In addition, some experts feel that offering PEP to injection
      drug users sends a mixed message and may promote IDU itself. There are no
      Federal guidelines; the UCSF PEP program recommends PEP in this context only
      if the needle-sharing was an isolated event and the patient intends to abstain from
      drug use or to use clean needles in the future (see Table 5).
   c. Sexual assault: There are scarce data on the risk of HIV-transmission after a
      single sexual exposure, and few human studies of PEP in this context. In animal
      studies, PEP can prevent SIV (simian immunodeficiency virus) infection in
      macaques after mucosal exposure. If the source is HIV-infected, specific sexual
      acts are riskier than others: receptive anal intercourse > insertive anal intercourse
      > receptive vaginal intercourse > insertive vaginal intercourse >>> oral sex. Most
      guidelines recommend offering PEP to survivors of rape.
   d. Consensual sexual exposure: As noted, there are no experimental data regarding
      PEP and sexual exposure to HIV. As with needle sharing, there are those who
      worry that providing PEP in this context will create a "mixed message," that high-
      risk sexual behavior is permissible, or that it will even promote risky sexual
      behaviors. This concern is entirely theoretical, and it should be noted that the
      availability of the "morning after" pill, an analogous intervention, does not seem
      to increase risk behavior with regards to pregnancy. In certain communities, such
      as San Francisco, provision of PEP to patients after (and sometimes even before)
      high-risk sexual behavior is the standard of care. If the exposure is an isolated
      event, it may be worth considering PEP. If the risk behavior is ongoing, however,
      PEP is contraindicated.

TABLE 5: UCSF Guidelines for the use of PEP

    Consider PEP if conditions 1-5 are met:

        1. High risk exposure (in descending order of risk)
        a.   unprotected receptive anal intercourse
        b.   sharing needles or drug paraphernalia
        c.   unprotected receptive vaginal intercourse
        d.   unprotected insertive vaginal intercourse
        e.   unprotected insertive anal intercourse
        f.   unprotected receptive fellatio with ejaculation


        1. Partner is known to be HIV-infected, or in an HIV risk group, or patient was
           raped
        2. Exposure is an isolated event (i.e. broken condom) or patient intends to
           avoid future exposure through abstinence, safer sex or clean needles
        3. Patient presents for care within 72 hours of exposure
        4. Patient desires treatment and agrees to adhere to the treatment regimen



                                                       Resources
While there are many useful textbooks of HIV medicine, the field is a rapidly-changing
one and texts may be out of date by the time they are published. The websites listed here
have more up-to-date information, but may not be peer-reviewed: caveat emptor.

Websites: http://

   1.   www.hopkins-aids.edu
   2.   www.hivatis.org.
   3.   www.cdcnac.org
   4.   www.thebody.com
   5.   www.chp-health.org
   6.   www.aidsnyc.org/network/access/index.html

				
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