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Starting HIV Care

CE / CME

Starting in Care: Ensuring HIV Services Are Inclusive and Equitable

Nurses: 0.75 Nursing contact hour

Pharmacists: 0.75 contact hour (0.075 CEUs)

Physicians: maximum of 0.75 AMA PRA Category 1 Credit™

Released: August 05, 2024

Expiration: August 04, 2025

Ofole Mgbako
Ofole Mgbako, MD
CME/CE Information

Activity

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Standard of Care vs Rapid ART Models

Over the past 5 to 6 years, clinical practice has shifted towards initiating antiretroviral therapy (ART) immediately upon diagnosis. Real-world implementation has shown that this approach is most effective when combined with comprehensive wraparound services.8,12

Prioritizing rapid or immediate ART initiation can shorten the time to achieve virologic suppression in newly diagnosed patients without adverse effects. This faster viral suppression provides clinical benefits to individual patients and prevention benefits to the community.12

Previously, the process involved multiple staged visits: diagnosis, counseling, screening for social determinants of health, insurance verification, lab work, and readiness assessment before starting treatment.

The new standard condenses these steps into a single visit. During this visit, clinicians assess social determinants of health, assist with insurance, draw blood, provide counseling, evaluate readiness, and prescribe medication on the same day.12

Modern medications have a high barrier to resistance. There are multiple single-tablet regimens and new long-acting therapies available.13 Adjustments to the regimen can be made based on bloodwork at a follow-up visit. The benefits of starting treatment immediately are well-established in the literature, and it is crucial to communicate this to people with HIV.14

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Improved Clinical Outcomes With Rapid ART Initiation

The evidence consistently demonstrates that initiating ART within 14 days of HIV diagnosis enhances patient retention in care and increases the likelihood of achieving viral suppression at 12 months. These findings have been statistically significant across multiple studies.15-18

Early initiation of ART is endorsed by local, state, national, and international governing bodies.15-19

Compared to standard of care, same-day ART initiation increases likelihood of ART initiation in first 90 days, patient retention, and viral suppression at 12 months.17,18

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Recommendations for Rapid ART

Recommendations advocating for rapid ART are outlined in various guidelines, spanning from national guidelines by the Department of Health and Human Services (DHHS) to global authorities like the World Health Organization (WHO) and influential medical bodies such as International Antiviral Society‒USA (IAS-USA).

Although nuances exist regarding whether treatment should commence on the same day, as soon as possible, or within 7 days, the consensus is that ART should be initiated promptly.20-23

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Non-HIV Medical History and Preventative Care

Understanding the comorbidities affecting people with HIV through thorough medical history taking is important. Although it is a significant achievement that individuals with HIV are living longer and more fulfilling lives, this longevity increases their susceptibility to conditions such as diabetes, hypertension, and other comorbidities. It is essential to screen for these conditions upon intake and assess the risk factors they face, including mental health and psychological issues.24

Given the stigma associated with mental health and substance use, establishing a streamlined workflow for referrals to psychiatric services is vital for sensitively managing these conditions.23

In addition, ensuring comprehensive vaccine coverage—such as for recent outbreaks like mpox that disproportionately affect those with advanced HIV and people of color—is crucial.25 Regular cancer screenings, such as colonoscopies and pap smears, tailored to age and risk, are also important to mitigate the elevated cancer rates observed in people with HIV.26

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Co-Creating a Treatment and Care Plan

Adopting a shared decision-making approach when caring for people with HIV is essential. It empowers patients by showing that their care is a collaborative journey, not a dictated path.

Setting clear goals between appointments and ensuring regular follow-ups, through means like secure messages or video visits, reinforces this partnership. It is vital for patients to understand that this is the start of a long-term process.27

The initial visit is crucial for HIV care, with studies indicating that early experiences significantly impact long-term retention. Patients with better initial care experiences have significantly greater retention in HIV care.28

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Take-home Points

My points for providing welcoming care?

  • Providers should be aware of the historical, cultural, and epidemiologic aspects of the HIV epidemic.
  • Effective care begins before patients enter the clinic and involves a coordinated team effort.
  • Recognizing the mental health and trauma challenges associated with an HIV diagnosis is crucial. Treat patients as individuals, not just their diagnosis. Understand their sexual health, community, relationships, and aspirations.
  • Collaborate with patients on every decision to foster a strong, supportive relationship.

I am aware of strategies I can use to directly address stigma and other care barriers among people with HIV starting in care.

At every first visit with a person living with HIV, I ask them about their life before their diagnosis.

Do you plan to make any changes in your clinical practice based on what you learned in today’s program?

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