1 Ending the HIV EpidemicKathleen Jacobson MD Medical Director, Los Angeles Region Pacific AIDS Education and Training Center USC, Keck School of Medicine

2 Summary Epidemic Treatment Cascade Diagnostic Testing & GuidelinesAcute HIV Newly Diagnosed PrEP Changing the Epidemic

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4 CDC Estimates of Those Living with HIV in US1.2 million estimated > 13 years old (End of 2012) Includes 156,300 (12.8% undiagnosed) Prevalence of Diagnosed and Undiagnosed HIV Infection — United States, 2008–2012. MMWR 2015; 64:657 662(http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6424a2.htm?s_cid=mm6424a2_e)

5 Rates of Adults and Adolescents Living with Diagnosed HIV Infection, Year-end 2013—United States and 6 Dependent Areas N = 950,811 Total Rate = 355.9 Estimated rates (per 100,000 population) of adults and adolescents living with diagnosed HIV infection at the end of 2013 in the United States and 6 dependent areas are shown in this slide. Areas with the highest estimated rates of persons living with diagnosed HIV infection at the end of 2013 were the District of Columbia (2,695.8), New York (784.1), the U.S. Virgin Islands (705.8), Maryland (641.1), Puerto Rico (610.0), Florida (606.1), Georgia (512.7), New Jersey (505.8), and Louisiana (502.2). The District of Columbia (i.e., Washington, DC) is a city; use caution when comparing the rate of persons living with diagnosed HIV infection in DC with the rates in states. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not for incomplete reporting. Persons living with a diagnosis of HIV infection are classified as adult or adolescent based on age at year-end 2013. Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting.

6 2013 Los Angeles County DataLAC+USC Medical Center >50% of LAC Epidemic lies in the catchment area of LACUSC ED

7 Diagnoses of HIV Infection and Population by Race/Ethnicity, 2014—United StatesThe pie chart on the left illustrates the percentage distribution of diagnoses of HIV infection in 2014 by race/ethnicity in the United States. The pie chart on the right shows the percentage distribution of the population in the United States by race/ethnicity in 2014. In 2014, blacks/African Americans made up approximately 12% of the population of the United States, but accounted for 44% of diagnoses of HIV infection. Whites made up 62% of the population of the United States, but accounted for 27% of diagnoses of HIV infection. Hispanics/Latinos made up 17% of the population of the United States, but accounted for 23% of diagnoses of HIV infection. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not for incomplete reporting.     Hispanics/Latinos can be of any race. More information on the epidemiology of HIV in the United States and HIV prevention among blacks/African Americans and Hispanics/Latinos is available in CDC fact sheets at Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting. a Hispanics/Latinos can be of any race.

8 Ending the Epidemic How do we do it??

9 Skarbinski, et al, JAMA IM 2015Background Recent Article Engaged in care & virally suppressed Estimated to be 94.0% less likely to transmit HIV Than undiagnosed HIV-infected people Skarbinski, et al, JAMA IM 2015

10 Skarbinski, et al, JAMA IM 2015Even if they are not virally suppressed HIV-infected patients prescribed ART Estimated to be 30.3% less likely to transmit HIV Than those retained in care but not prescribed ART Note: Analysis did not account for all transmission risk factors including acute HIV Skarbinski, et al, JAMA IM 2015

11 Risk of Transmission Findings are consistent with.. HPTN 052 studyShowed 96% reduction in sero-discordant partners if the HIV positive partner was on ART and had an undetectable viral load (Cohen et al. NEJM Aug 2011) Rakai study Showed for each 1 log rise in viral load there was a correlated increase risk factor of 2.45 for HIV transmission. (Quinn et al. NEJM 2000) Evidence Supporting the Use of ART to Prevent HIV Transmission Prevention of Sexual Transmission A number of investigations, including biological, ecological, and epidemiological studies and one randomized clinical trial, provide strong evidence that treatment of the HIV-infected individual can significantly reduce sexual transmission of HIV. Lower plasma HIV RNA levels are associated with decreases in the concentration of the virus in genital secretions.42,43 Studies of HIV-serodiscordant heterosexual couples have demonstrated a relationship between level of plasma viremia and risk of HIV transmission—when plasma HIV RNA levels are lower, transmission events are less common.1,44 Most significantly, the multi-continental HPTN 052 trial enrolled 1,763 HIV-serodiscordant couples in which the HIV-infected partner was ART naive with a CD4 count of 350 to 550 cells/mm3 at enrollment to compare the effect of immediate ART versus delayed therapy (not started until CD4 count <250 cells/mm3) on HIV transmission to the HIV-uninfected partner.2 At study entry, 97% of the participants reported to be in a heterosexual monogamous relationship. All study participants were counseled on behavioral modification and condom use. The interim results reported 28 linked HIV transmission events during the study period, with only 1 event in the early therapy arm. This 96% reduction in transmission associated with early ART was statistically significant (HR 0.04; 95% CI, 0.01–0.27; P < 0.001). The final results of this study showed a sustained 93% reduction of HIV transmission within couples when the HIV-infected partner was taking ART as prescribed and viral load was suppressed.45 Notably, there were only eight cases of HIV transmission within couples after the HIV-infected partner started ART; four transmissions occurred before the HIV-infected partner was virologically suppressed and four other transmissions occurred during virologic failure. These results provide evidence that suppressive ART is more effective at preventing transmission of HIV than all other behavioral and biomedical prevention interventions studied. This study, as well as other observational studies and modeling analyses showing a decreased rate of HIV transmission among serodiscordant heterosexual couples following the introduction of ART, demonstrates that suppression of viremia in ART-adherent patients with no concomitant sexually transmitted diseases (STDs) substantially reduces the risk of HIV transmission.3,46-49 HPTN 052 was conducted in heterosexual couples and not in populations at risk of HIV transmission via male-to-male sexual contact or needle sharing. In addition, in this clinical trial, adherence to ART was excellent. However, the prevention benefits of effective ART observed in HPTN 052 can reasonably be presumed to apply broadly. Therefore, the Panel recommends that ART be offered to individuals who are at risk of transmitting HIV to sexual partners (AI). Clinicians should discuss with patients the potential individual and public health benefits of therapy and the need for adherence to the prescribed regimen. Clinicians should also stress that ART is not a substitute for condom use and behavioral modification and that ART does not protect against other STDs (see Preventing Secondary Transmission of HIV).

12 HIV Care Continuum (aka Treatment Cascade, Gardner Cascade)

13 Currently 12.8% UndiagnosedDiagnosis Currently 12.8% Undiagnosed

14 HIV Testing Recommendations2006 CDC Testing Guidelines Routine screening for HIV infection in all healthcare facilities… Including Emergency Departments

15 Why Emergency DepartmentsHIV patients are 3 times more likely to visit an emergency room, be racial minorities and lack insurance than their non-HIV counterparts Rothman, R. E. et al. Academic Emergency Medicine, 14(7), DOI: /j.aem Pitts, S. R. et al. Natl Health Stat Report, 7(7), PMID: Lyons, M. S. et alPublic Health Reports, 120(3), 259. Bozzette SA et al. N Engl J Med. 1998;339(26): EDs are a safety net for HIV-infected individuals Often the sole point of entry into the healthcare system (Hsieh et al Ann Emerg Med. 2015;66:69-78)

16 2013 Los Angeles County DataLAC+USC Medical Center >50% of LAC Epidemic lies in the catchment area of LACUSC ED

17 2014 New CDC HIV Testing AlgorithmHIV Viral Load Testing by RNA PCR Laboratory testing for the Diagnosis of HIV Infection, CDC 2014

18 Primary/Acute HIV Infection

19 HIV Tests Temporal Sero-conversionTime HIV RNA HIV p 24 Ag HIV 1/2 Ab aka Multispot Western Blot - 1-2 weeks -/+ 1.5-3 weeks + 4-6 weeks 2 months 3 months + (2) 6 months + (8) # of Ab +

20 (Branson et al. CDC June 27,2014)Ag/AB Immunoassay Identify acute HIV infections between days post exposure Patients are likely to be symptomatic Possibly seek medical care for the non-specific acute viral illness (Branson et al. CDC June 27,2014)

21 AIDS Kathleen Jacobson MD, Nancy Glick MD, Thomas Giordano MD MPH, Douglas White MD, Priya Mammen MD, Sanjay Arora MD, Mike Menchine MD MPH,Laura Kelly BSN RN, Siavash Pasalar PhD, Nancy Miertschin MPH, Tamara Todorovic BS, Kristi Stanley MD, Johnathon Lam MPH, Bernard Branson MD. 14% overall (range11%-38% )

22 Typical Testing Venues Location  Number Tested  Number (%) of New HIV Diagnoses Number (%) of AHI among new HIV infections Citation Public Health HIV Testing Programs         North Carolina 109,250 666 (0.6%) 23 (3.5%) Pilcher NEJM 2005 Los Angeles 37,012 462 (1.2%) 18 (3.9%) Patel Arch Int Med 2010 Florida 54,948 673 (1.2%) 10 (1.5%) North Carolina 215,528 1,156 (0.5%) 44 (3.8%) Miller AIDS 2009 High-risk, High Prevalence MSM Populations         New York City * 36,617 659 (1.8%) 56 (8.5%) Peters JAMA 2016 San Francisco * 29,335 422 (1.3%) 62 (17%) Raleigh, Durham, Winston-Salem 211 (0.6%) 16 (8.2%)

23 ED Testing The percentage of new HIV infections among ED patients that are in the acute stage was high in all 6 EDs. 14% overall, range 11%-38% Compared with the percentages identified among populations undergoing HIV testing at Public sites (2 -4%) Very high-risk, high-prevalence MSM (8-17%) The disproportionate percentage of AHI is likely attributed to these patients seeking medical care in the ED for symptoms attributable to AHI   ***Opportunity to intervene in AHI***

24 Routine Screen Case 1 35 year old black female comes in for a sore throat, abdominal pain, fever to You tell her that you will be getting some labs today including an HIV test. Results of Routine Screen Antigen/antibody combo: POSITIVE HIV-1/2 antibody differentiation: NEGATIVE HIV viral load: POSITIVE Acute infection

25 Case 1 Results? Based on these lab findings she is?A. Not HIV infected B. Acutely HIV infected C. Chronically HIV infected D. I am not sure

26 Case 1 Results? Based on these lab findings she is?A. Not HIV infected B. Acutely HIV infected C. Chronically HIV infected D. I am not sure, better call VCPH HIV Division

27 Primary/Acute HIV Infection

28 HIV Tests Temporal Sero-conversionTime HIV RNA HIV p 24 Ag HIV 1/2 Ab aka Multispot Western Blot - 1-2 weeks -/+ 1.5-3 weeks + 4-6 weeks 2 months 3 months + (2) 6 months + (8) # of Ab +

29 Acute HIV Infection Time period from HIV acquisition to antibody sero-conversion (Cohen, et al. JID, 2010) Initial -“eclipse phase” Approximately= 10 Days Local tissue invaded (Stacey, et al, J. of Virology , 2008) HIV dissemination is not yet detectable systemically

30 Acute HIV (cont.) HIV invades into the lymphoid tissue and systemic circulation “Ramp up” of viremia- HIV replication doubling time every 20 hours HIV viral load hits a peak 5-10,000,000 (Fiebig, et al , AIDS 2001) VL> 10,000 > p24 antigen ++ Latent viral pool reservoir develops “Cytokine storm” >>intense inflammatory response (Fiebig, et al , AIDS 2001) Irreparably damaging the immune system (Cohen et al. NEJM Aug 2011)

31 Acute HIV Infection Laboratory DefinitionHIV 1-2 Ag/Ab Immunoassay- positive HIV 1-2 Ab- negative HIV RNA Viral Load by PCR –positive 40-90% develop clinical signs and symptoms 2-6 weeks in duration-untreated Fever, rash, HA, fatigue, pharyngitis, diarrhea, myalgias, arthralgia Recent high risk exposure Panel on Antiretroviral Guidelines for Adults and Adolescents. (2016). Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Available at

32 Primary/Acute HIV InfectionTypically has very high viral loads Stacey et al. J Virol 2009 HIV transmission risk likely very high Supported by Primary HIV infection increases the risk of transmission between 11-70%. Brenner et al. JID, 2007, Hollingsworth, et al. JID, 2008, Pilcher, et al. JID, 2004, Gray, et al. JID, 2012

33 Primary/Acute HIV Infection

34 Earlier Intervention in Acute HIV…Decrease viral replication Decreases the size of latent HIV reservoirs Decreased Inflammation- long term health implications Delays viral rebound Possible decreases transmission (Payne et al. #35, Uprety et al. #374, Ghosn et al, #373, Etemad et al. #110 LB) Theoretical Continued Benefit of Early ART Initiation Long After Viral Suppression is Achieved While the START and TEMPRANO studies demonstrated a clear benefit of immediate ART initiation in individuals with CD4 cell counts >500 cells/mm3, it is plausible that the benefits of early ART initiation continue long after viral suppression is achieved. As detailed in the Poor CD4 Cell Recovery and Persistent Inflammation section, persistently low CD4 counts and abnormally high levels of immune activation and inflammation despite suppressive ART predict an increased risk of not only AIDS events, but also non-AIDS events including kidney disease, liver disease, cardiovascular disease, neurologic complications, and malignancies. Earlier ART initiation appears to increase the probability of restoring normal CD4 counts, a normal CD4/CD8 ratio, and lower levels of immune activation and inflammation Individuals initiating ART very early (i.e., during the first 6 months after infection) also appear to achieve lower immune activation levels and better immune function (as assessed by vaccine responsiveness) during ART-mediated viral suppression than those who delay therapy for a few years or more Thus, while these questions have yet to be addressed in definitive randomized controlled trials, earlier ART initiation may result in less residual immune dysfunction during treatment, which theoretically may result in reduced risk of disease for decades to come.

35 Ag/Ab Immunoassay Opportunity to intervene earlier in acute HIVLimits viral replication Potentially decreasing the size of HIV reservoirs Decreases the diffuse inflammation associated with high viremia Possibly interrupt further HIV transmission

36 DHHS Guideline Panels RecommendationsAntiretroviral therapy (ART) is recommended for all individuals with HIV-1 infection (AI) including those with early or acute HIV-1 infection. Once initiated, the goal of ART is to suppress plasma HIV-1 RNA to undetectable levels (AIII). Testing for plasma HIV-1 RNA levels, CD4 T lymphocyte counts, and toxicity monitoring should be performed as recommended for patients with chronic HIV-1 infection (AII). Genotypic drug resistance testing should be performed before initiation of ART to guide the selection of the regimen (AII).

37 DHHS Guideline Panels RecommendationsART can be initiated before drug resistance test results are available. Resistance to pharmacokinetically enhanced protease inhibitors (PIs) emerges slowly Clinically significant transmitted resistance to PIs is uncommon, Darunavir (DRV/r) + (TDF/FTC) is a recommended (AIII) Dolutegravir (DTG) + TDF/FTC is a reasonable but…. Data regarding transmission of integrase strand transfer inhibitor (INSTI)-resistant HIV and the efficacy of this regimen in early HIV infection is limited (AIII). When results of drug resistance testing are available, the treatment regimen can be modified if warranted (AII).

38 Routine Screen Case 2 24 year old H/M comes to your office after being involved in a motor vehicle accident 2 days ago. He is otherwise well. He is advised at your clinic everyone getting labs gets a routine HIV test. He does not refuse routine screen. Routine Screening Results Antigen/antibody combo: POSITIVE HIV-1/2 antibody differentiation: POSITIVE HIV viral load: POSITIVE Chronic Infection

39 Case 2 Results? Based on these lab findings he is? A. Not HIV infectedB. Acutely HIV infected C. Chronically HIV infected D. I am not sure, better call VCPH HIV Division

40 Case 2 Results? Based on these lab findings he is? A. Not HIV infectedB. Acutely HIV infected C. Chronically HIV infected D. I am not sure, better call VCPH HIV Division

41 DHHS Guidelines for Initiating ARTALL PATIENTS should begin ART The following conditions increase the urgency to initiate: Acute/Early HIV Pregnancy AIDS-defining conditions, including HIV-associated dementia (HAD) and AIDS-associated malignancies Acute opportunistic infections (OIs) Lower CD4 counts (e.g., <200 cells/mm3) HIV-associated nephropathy (HIVAN) Hepatitis B virus co-infection Hepatitis C virus co-infection should be guided by the regimen’s efficacy, genetic barrier to resistance, adverse effects profile, and convenience. head-to-head comparisons between boosted PI- and INSTI-containing regimens, the INSTI was better tolerated with fewer treatment discontinuations.8-10 Although the NNRTIs EFV or RPV are optimal choices for some patients, these drugs have low genetic barriers to resistance, especially in patients with suboptimal adherence. EFV has a long track record of widespread use in the United States and globally. Most EFV-based regimens have strong virologic efficacy, including in patients with high HIV RNA (except when EFV is used with ABC/3TC); however, the relatively high rate of central nervous system (CNS)-related side effects makes the EFV-based regimen less tolerable than other regimens. RPV has fewer adverse effects than EFV, is available as one of the smallest coformulated single tablets, and has a favorable lipid profile. However, RPV has lower virologic efficacy in patients with high baseline HIV RNA (>100,000 copies/mL) and low CD4 count (<200 cells/mm3). ATV/r has demonstrated excellent virologic efficacy in clinical trials and has relatively few metabolic adverse effects in comparison to other boosted PI regimens; however, clinical trial data showed that ATV/r had a higher rate of adverse effect-associated drug discontinuation than DRV/r and RAL.8 Thus, despite these favorable attributes, based on the above considerations, EFV-, RPV-, and ATV/r-containing regimens are now listed as Alternative regimens for initial therapy. However, based on individual patient characteristics, some Alternative regimens may actually be the optimal regimen for some patients. Furthermore, patients who are doing well on EFV-, RPV-, and ATV/r-containing regimens should not necessarily be switched to other agents.

42 START Study- All Subgroups Did Better with Early vs Delayed ART

43 Current RecommendationsMove from diagnosis to… Immediate prescription of ART In an effort to reduce HIV transmission (Skarbinski et al. JAMA IM and START)

44 HIV Care Continuum

45 What happens when you give immediate ART?

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50 RAPID Pilot Program San Francisco's "Getting to Zero" InitiativeN=39 patients who participated in the pilot 95% of them started ART within 24 hours Median time to viral suppression (<200 copies/mL) RAPID 1.8 months Historic SOC 4.3 months Retention in care was very high. San Francisco's "Getting to Zero" Initiative Adopted RAPID Program as new SOC

51 TEMPRANO Study Delayed vs Immediate ART with or without 6 months of IPT ART or IPT each independently led to lower rates of severe illness than did deferred ART with or without IPT Regardless of CD4 Funded by the French National Agency for Research on AIDS and Viral Hepatitis; TEMPRANO ANRS ClinicalTrials.gov number, NCT )

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53 AIDS 2016-Immediate ART vs 21 day delayed ART (DMB- stopped study early)12

54 Immediate ART Study The primary outcome measured in the study was the proportion of people in each arm retained in care with viral load below 50 copies/ml at the 12-month study visit. After 12 months, 54% of the same-day ART group remained in care with viral load < 50 copies/ml compared to 42% of the standard-of-care group (p = 0.004), and were around 75% more likely to have a viral load< 50 copies/ml (adjusted odds ratio 1.76, 95% CI , p = 0.002). People in the standard-of-care group were significantly less likely to be alive and in care after 12 months (71% vs 80%, p = 0.007). When the results were compared with a cascade of care reported from South Africa by Sydney Rosen and colleagues in 2011, the effects of the intervention on retention in care were pronounced. Whereas only 59% of people diagnosed ever completed the CD4 count stage in the South African study (receiving the CD4 result), 100% of people in the same-day group received a CD4 result. Similarly, only 68% of those who went through CD4 staging started ART in the South African study, compared to 100% of same-day ART patients in Haiti, and after 12 months only 37% of those originally diagnosed in the South African study were on ART, compared to 80% of the same-day ART patients in Haiti. The study showed that same-day ART initiation is feasible in Haiti and results in improved retention in care and virologic suppression, as well as providing people with a sense of hope, optimism and connectedness to health care providers, Dr Koenig concluded.

55 UNAIDS 90-90-90 Goals 2020 International Country TargetsOf ALL HIV Positive People Target 1= 90% diagnosed Target 2= 90% on ART Target 3= 90% virally sup

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60 Guidance for Starting ART can be initiated before drug resistance test results are available. Treatment regimen can be modified when resistance test available(AII). If no resistance test available use recommended regimens Patients starting ART should be…. Willing and able to commit to treatment Understand the importance of adherence (AIII). Patients may choose to postpone therapy, and providers, on a case-by-case basis, may recommend that patients defer therapy because of clinical and/or psychosocial factors.

61 Recommended Regimen OptionsINSTI plus 2-NRTI Regimen: • DTG/ABC/3TCa (AI)—if HLA-B*5701 negative • DTG plus either TDF/FTCa (AI) or TAF/FTCb (AII) • EVG/c/TAF/FTC (AI) or EVG/c/TDF/FTC (AI) • RAL plus either TDF/FTCa (AI) or TAF/FTCb (AII) Boosted PI plus 2 NRTIs: • DRV/r plus either TDF/FTCa (AI) or TAF/FTCb (AII) should be guided by the regimen’s efficacy, genetic barrier to resistance, adverse effects profile, and convenience. Recommended regimens are those with demonstrated durable virologic efficacy, favorable tolerability and toxicity profiles, and ease of use. head-to-head comparisons between boosted PI- and INSTI-containing regimens, the INSTI was better tolerated with fewer treatment discontinuations.8-10 Although the NNRTIs EFV or RPV are optimal choices for some patients, these drugs have low genetic barriers to resistance, especially in patients with suboptimal adherence. EFV has a long track record of widespread use in the United States and globally. Most EFV-based regimens have strong virologic efficacy, including in patients with high HIV RNA (except when EFV is used with ABC/3TC); however, the relatively high rate of central nervous system (CNS)-related side effects makes the EFV-based regimen less tolerable than other regimens. RPV has fewer adverse effects than EFV, is available as one of the smallest coformulated single tablets, and has a favorable lipid profile. However, RPV has lower virologic efficacy in patients with high baseline HIV RNA (>100,000 copies/mL) and low CD4 count (<200 cells/mm3). ATV/r has demonstrated excellent virologic efficacy in clinical trials and has relatively few metabolic adverse effects in comparison to other boosted PI regimens; however, clinical trial data showed that ATV/r had a higher rate of adverse effect-associated drug discontinuation than DRV/r and RAL.8 Thus, despite these favorable attributes, based on the above considerations, EFV-, RPV-, and ATV/r-containing regimens are now listed as Alternative regimens for initial therapy. However, based on individual patient characteristics, some Alternative regimens may actually be the optimal regimen for some patients. Furthermore, patients who are doing well on EFV-, RPV-, and ATV/r-containing regimens should not necessarily be switched to other agents.

62 Alternative Regimen OptionsNNRTI plus 2 NRTIs: • EFV/TDF/FTCa (BI) • EFV plus TAF/FTCb (BII) • RPV/TDF/FTCa (BI) or RPV/TAF/FTCb (BII)—if HIV RNA <100,000 copies/mL and CD4 >200 cells/mm3 Boosted PI plus 2 NRTIs: • (ATV/c or ATV/r) plus either TDF/FTCa (BI) or TAF/FTCb (BII) • DRV/c (BIII) or DRV/r (BII) plus ABC/3TCa—if HLA-B*5701 negative • DRV/c plus either TDF/FTCa (BII) or TAF/FTCb (BII) Alternative Regimens may be preferred for some patients. Alternative regimens are effective and tolerable, but have potential disadvantages when compared with the Recommended regimens, have limitations for use in certain patient populations, or have less supporting data from randomized clinical trials. However, an

63 Case 3 35 year old w/m presents to the ED complaining of abscess of the right index finger. You tell him that you will be getting some labs today including an HIV test. Results of Routine Screen Antigen/antibody combo: POSITIVE HIV-1/2 antibody differentiation: pending HIV viral load: pending Disclosure yields history of HIV diagnosed 5 years ago, previously LTC but didn’t like the clinic so fell out of care. ART? Acute infection

64 Why Stop w Newly Diagnosed?LACUSC ED 1 newly diagnosis : 2.73 return to care EDs are often the sole point of entry into healthcare system (Hsieh et al Ann Emerg Med. 2015;66:69-78) Marginalized and dis-enfranchized most difficult to reach populations (Rothman, et al. Academic Emergency Medicine, 2007) October “Meeting Them Where They are At”—Re-engagement Project **Opportunity to Intervene**

65 Preliminary LACUSC ED Re-Linkage Data3/1/15 – 9/30/15 (6 mo) 10/1/15- 4/30/16 (7 mo) Tested 10,723 14,918 Tested Positive 272 265 “Out of Care” Positives 219 212 Re-linked to Care 14/ 219 (6%) Primary Care> HIV Clinic 109/212 (51%) Primary Care> ED Second visit 52/109 = (48%) 2nd Primary Care> clinic or ED 42/52 < 60 days 3/52 at days 7/52 > 90 days

66 What about Prevention?

67 PrEP Case 1 A 23 year H/M MSM requested PrEP from his primary care provider. He has a few male partners but always uses condoms. What is PrEP and what are the indications for PrEP?

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69 CDC Indications for PrEPMen who have sex with Men (MSM) Sexual partner with HIV Recent bacterial STD High number of sex partners History of inconsistent or no condom use Commercial sex work

70 CDC Indications for PrEPHeterosexual Men and Women (HSM, HSW) Sexual partner with HIV Recent bacterial STD High number of sex partners History of inconsistent or no condom use Commercial sex work Lives in high-prevalence area or network

71 CDC Indications for PrEPIVDU HIV-positive injecting partner Sharing injection equipment Recent drug treatment (but currently injecting)

72 PrEP Case The provider advised the patient that he was not at high enough risk for HIV and therefore he was not a good candidate for PrEP. https://www.cdc.gov/hiv/risk/prep/

73 PrEP Case 1 Continued Patient presented to an emergency department 2 months later with fevers to 102.5, headache, myalgias for 7 days. HIV Antigen Antibody Immunoassay Test + HIV 1-2 Antibody Differentiation Test – Diagnosis?

74 Diagnosis Acute HIV HIV Antigen Antibody Immunoassay Test +HIV 1-2 Antibody Differentiation Test – Patients HIV Viral Load = >10 million Unfortunately the patient was not using condoms all the time and thus why he wanted PrEP.

75 PrEP Baseline AssessmentNo signs or symptoms of acute HIV Assess for other STIs Baseline labs HIV Antigen Antibody Pregnancy Test Hepatitis B screen and vaccination status Chemistry Panel Urinalysis

76 CDC PrEP Follow Up RecommendationsAt least every 3 months to provide: HIV test Medication adherence counseling Assess for Side effects Behavioral risk reduction STI Assessment Renal function at 3 months and then every 6 months Every 6 months test for bacterial STDs Assess pregnancy intent – Pregnancy test every 3 months Access to clean needles/ syringes and drug treatment services

77 CDC Reminders PrEP is not 100% Use other forms of protectionUsing condoms consistently and correctly- prevents other STIs Get HIV testing with partners. Choosing less risky sexual behaviors, such as oral sex. For people who inject drugs, getting into drug treatment programs and using sterile equipment. PrEP is for people who are at ongoing risk of HIV infection.

78 PEP HIV Prevention after a single high-risk event of potential HIV exposure— such as unprotected sex needle-sharing injection drug use sexual assault PEP should begin within 72 hours of exposure Integrase Inhibitor+ TDF + FTC

79 Decreased Patient VL Decrease Transmissions PrEP/ PEP Prevention Potential to Decrease the Epidemic

80 “We must not squander the opportunity“We must not squander the opportunity. History will judge us harshly if we do” (Fauci, 2016)

81 https://plus.google.com/+HanifNurAssyifa#+HanifNurAssyifa/posts