Basically, we should test (screen) every patient we see regardless of whether or not they have risk factors for HIV infection according to Dr. Michael Saag, the guest expert on The Curbsiders podcast Episode #121 HIV Care for the Internist
And the reason is because the early diagnosis of HIV infection leads to early treatment.
And early effective treatment of HIV infection will render the patient much less likely to spread the infection and much less likely to die of HIV infection. And early diagnosis and treatment offers the best chance to actually cure HIV infection if (when) a vaccine or curative treatment is developed. [See Resource 3 below about the possibility in the future of a cure for HIV in patients in patients diagnosed early and treated early.]
So my approach based on the Curbsiders will be to test all my patients (when feasible).
I will ask patients a series of questions about whether they have any sexual behaviors that puts them at increased risk of silent HIV infection.
I will explain to them that the reason I’m doing this is because of the information contained in the first three paragraphs above.
Most people will have no increased behavior risks.
I will then say, regardless of whether they have any increased risk of HIV infection:
I’m testing all my patients for silent HIV infection because people with no risk factors can still have a silent HIV infection.
And the earlier we diagnose a silent HIV infection, the better will be your outcome AND the better will be your chance of an ultimate cure. See Resource (3) below.
So I’m going to send you to the lab for a blood test – fourth generation HIV Ab/Ag test. If you have a silent infection this test will find it [99.5 to 99.7% of the time].
Now, our office will not give you the results over the phone regardless of whether or not the test is positive or negative.
This is because if notified by phone that the test was negative, you would know that the test was positive if we didn’t call.
And whether the test is positive or negative, there are many great things that we can do to help you prevent AIDS whether or not your test is positive or negative.
And there will be no charge for this return visit.
And when the patient returns I will use the script for the positive or negative result as appropriate.
The script for a positive HIV test will be very encouraging and hopeful while emphasizing the critical importance of the patient following up on our treatment plan.
The negative script will include the importance of HIV risk reduction behaviors and if indicated the use of PrEP*.
I will refer all patients with a positive HIV test to an HIV clinic for additional laboratory tests and for treatment. I will refer the patient to a Ryan White HIV/AIDS provider in my area. See Find a Ryan White HIV/AIDS Program Medical Provider.
I will treat patients with negative test results who exhibit high risk sexual behviors with PrEP*.
*Here are three resources for learning to use PrEP for HIV prevention the outstanding
Get Comfortable With HIV PrEP in Primary Care
Joseph P. McGowan, MD March 01, 2018
PrEP Safer, More Effective Than Many Physicians Realize
Naveed Saleh, MD, MS December 14, 2017
Choosing Between Daily and Event-Driven Pre-Exposure Prophylaxis
Results of a Belgian PrEP Demonstration Project
Thijs Reyniers, PhD; Christiana Nöstlinger, PhD; Marie Laga, PhD; Irith De Baetselier, MSc; Tania Crucitti, PhD; Kristien Wouters, MD; Bart Smekens, MSc; Jozefien Buyze, PhD; Bea Vuylsteke, PhD. J Acquir Immune Defic Syndr. 2018;79(2):186-194
And for me, the place to start is with the podcast, Episode #121 HIV Care for the Internist [Link is to the podcast and show notes]; OCTOBER 22, 2018 By MATTHEW WATTO, MD, from The Curbsiders. I’ve embedded the podcast below so that I can easily review it:
The show notes for the podcast are outstanding [Note to myself, a quick review of the show notes is always a good idea.]
The discussion of the clinical aspects of HIV infection diagnosis and treatment begins at 8:48 into the podcast. Prior to that time the hosts spend time getting to know the guest expert, Michael Saag MD, Professor of Infectious Diseases at University of Alabama and founder of the 1917 Clinic. Here are some excerpts from the podcast show notes:
Who and when to screen
Dr Saag recommends screening every patient for HIV with a fourth generation HIV Ab/Ag test at the initiation of care. In general, consider screening again every 5-10 years, or every time a new STI is diagnosed. If risk factors are identified, screen every 3-4 months and consider starting PrEP (see episode #41 HIV, PrEP, STI screening).
HIV Test Details
There are two major categories of testing for HIV: 1) the rapid HIV Antibody test and 2) the fourth generation HIV 1&2 Antibody/Antigen test. The rapid HIV antibody test is slightly less sensitive (98% vs. 99.5-99.7%). Dr Saag notes the rapid HIV test is more useful in public health settings or when follow up is uncertain. The fourth-generation antibody/antigen test is used to test for established infection (HIV 1 and 2 Antibodies) and acute phase infection (p24 Antigen: p for protein, 24 for kD -which is where the protein travels on a Western blot). The fourth-generation antibody/antigen test misses infection acquired within the last 10-12 days. Tests become positive at different times following viral infection. On average, the HIV RNA (viral load) is positive at 10 days, HIV Ag at 15-20 days, and HIV Antibody at 30 days. HIV 1 and HIV 2 represent different strains of the virus. In the United States, HIV 1 is far more prevalent than HIV 2. HIV 2 infections primarily occur in West Africa.
HIV Pearls from Dr. Saag
- Dr Saag recommends that clinicians screen every patient for HIV at initiation of care with an HIV 1/2 Antibody/Antigen (Ab/Ag) test and then every 3-4 months if risk factors are identified.
- Screen for HIV anytime you treat someone for a new sexually transmitted infection (STI). -Dr Saag
- The HIV Ab/Ag test will only miss individuals infected within the last 10-12 days. HIV viral load (RNA) is positive about 10 days after infection.
- Follow up a positive HIV Ab/Ag test with an HIV viral load.
- Screen for HLA-B*57:01 allele in each patient at diagnosis, and do not start treatment with abacavir if this is pending or positive due to abacavir hypersensitivity.
- Start treatment for HIV within 2 weeks of diagnosis. -Dr Saag
- Integrase inhibitor regimens are preferred due to potency and low side effect profile.
- Regimens that include the integrase inhibitors, dolutegravir or bictegravir, are first-line because they provide a one pill per day regimen. Raltegravir probably has the least likelihood of drug-drug interactions, but has a higher pill burden.
- The CD4 count is not a measure of immune system function!!! A high viral load CAUSES immune system dysfunction! Immune function returns rapidly once the viral load is suppressed. –Dr Saag
- Dr Saag recommends not following the CD4 count once viral load has been persistently suppressed (Saag JAMA 2018 PMID: 30043070) because it becomes irrelevant to management.
(1) #121 HIV Care for the Internist [Link is to the show notes and podcast].OCTOBER 22, 2018 By MATTHEW WATTO, MD:
HIV care for the internist with author and HIV expert, Michael Saag MD, Professor of Infectious Diseases at University of Alabama and founder of the 1917 Clinic. We discuss the specifics of screening & diagnostic testing in HIV, monitoring CD4 counts and viral loads, first line antiretroviral therapy, harm reduction, and how to provide excellent HIV care in your primary care clinic.
(2) Clinical and public health implications of acute and early HIV detection and treatment: a scoping review [PubMed Abstract] [Full Text HTML] [Full Text PDF]. J Int AIDS Soc. 2017 Jun 28;20(1):21579. doi: 10.7448/IAS.20.1.21579.
(4) The National HIV Curriculum – A free educational web site from the University of Washington and the AETC National Coordinating Resource Center.