East Bay Getting to Zero
Clinical Guides, COVID, Data, Epidemiology, HIV treatment, Linkage, PrEP, Rapid ART, Retention, STIs, Youth

The 2021 virtual Ryan White Clinical Conference took place October 3-6, 2021. Here are some materials from the conference:

Key takeaways:

  • New Ryan White resources: HIV care best practices compilation, HIV/AIDS Compass Dashboard.
  • New ART in development include candidates with reduced frequency of dosing: Islatravir for qmonth oral PrEP, Lenacapravir for q6 month ART and for MDR HIV, broadly neutralizing antibody infusions to be used with long-acting CAB or oral regimens.
  • CAB-RPV LA studies have shown non-inferiority with q8 week dosing (CROI 2021), and Europe has approved q8 week dosing. Studies are on-going for direct-to-inject for treatment naïve and without oral lead-in (LATTITUDE study), plus in adolescents (MOCHA study).
  • PLWH and COVID vax: CDC clarified that third Pfizer or Moderna doses are for CD4 <200, hx of AIDS OI without immune recovery, symptomatic HIV, or untreated HIV. Pfizer boosters are permitted for all PLWH but not all may be at higher risk. HIVMA has updated guidance.
  • New ART and weight gain: significant weight gain seen: 3-6 kg for INSTIs and 2-4.5 kg for switching from TDF to TAF, mostly within the first year, and highest for women and Black and African American people. INSTI and TAF combo with highest weight gain. Exercise and caloric restriction can reduce weight gain by 30%. 
  • Drug-drug interactions (DDI): try to reduce polypharmacy and use the Liverpool Drug Checker when starting new meds, especially if using ritonavir, cobicistat, statins, anticoags, antacids.
  • Remember that INSTIs (Biktarvy, dolutegravir/Tivicay, CAB oral) need to be taken 2 hours before or 6 hours after multivitamins and antacids (cations reduce INSTI absorption). 
  • HIV and aging: assess frailty and fall risk with chair-to-stand observation, screen for HIV-associated neuro-cognitive disorder (HAND) using MOCA (PDF in English), and assess loneliness with UCLA loneliness scale.
  • The Friendship hotline provides 24/7 crisis help for elders to talk to someone: 1-888-670-1360.
  • ART panel: Updated data presented in October from the STAT RCT on the DTG/3TC single-pill 2-drug rapid ART regimen showed non-inferiority to other ART regimens at 48 weeks; panelists want to see long-term data around durability of viral load suppression.
  • Young PLWH: “I am more than my viral load!” Feedback from young PLWH is for providers to see them as whole people and more than just their ART and viral loads.
  • INSTIs cause an artificial increase in A1C, so it’s not as reliable for diagnosis for people on INSTI regimens. Use fasting glucose instead to screen for diabetes.
  • Lung cancer rates are 2x higher among PLWH, and viral cancers are 5x higher among PLWH. Remember to screen with low-dose CT for people ages 50-80 who have a 20-pack-year smoking history and currently smoke or quit in the past 15 years. (USPSTF grade B)
  • Hot off the press! Anal cancer screening results from the ANCHOR study show that removing HSIL with electrocautery significantly reduced the rates of progression to anal cancer, compared to active monitoring without treatment. Stay tuned for data to inform our anal pap practices.
  • Depression in PLWH is very common, about 30-40% in HIV clinics. Screen with PHQ2 or 9 with form they fill out themselves or by someone who cares. Distinguish from bipolar. Treatment is trial and error: use usual meds, check for DDI, go up to max dose for 6-8 weeks before switching. With 2 med trials, 2 out of 3 will achieve acute remission. If no remission, refer to psychiatry.
  • Pregnant PLWH: PCPs can continue to take care of them w/o specialty OB! Generally, continue ART if it’s working (except cobi and check if you need to adjust dosages). For newly dx’ed pregnant PLWH, DTG+TDF/FTC is preferred, or DTG/ABC/3TC if HLAB5701 neg (but don’t delay).
  • Breastfeeding for PLWH in the US: guidelines for people who don’t want to formula feed: it’s acceptable to exclusively breastfeed during the first 6 months, then introduce complementary foods and gradually wean from breastfeeding. Avoid rapid weaning due to á viral shedding. 
  • Addressing burnout: recognize the emotional exhaustion, depersonalization (cynicism), and feeling of diminished personal accomplishment. Take time off for self-care. Organizations need to ask “How do we prioritize what really matters? Is what we make people do really necessary?”
  • Re-engaging PLWH in care: when reaching out to people, use intentional messaging: “We missed you. We care about you. We’d love to see you again. Call today and make an appointment or drop by.” Text messaging can be used with patient permission (document it).
  • 2021 CDC STI treatment guidelines: Please download the updated wall chart summary here.
  • Gonorrhea treatment update: The treatment of uncomplicated gonorrhea is now 500 mg of intramuscular ceftriaxone; if chlamydia is present or is not ruled out, add one week of 100 mg of oral doxycycline taken twice daily. Patients with pharyngeal gonorrhea should have a test-of-cure 1-2 weeks later. Everyone with gonorrhea should be re-screened 3 months after treatment.
  • Chlamydia treatment update: Doxycycline 100mg orally twice daily is the preferred option. Asymptomatic or mild infections or proctitis: treat for 7 days. Moderate-severe: 21 days.   
  • PrEP data-free zone: please see Dr. Landovitz’s slides (PDF, PPT), and see Dr. Landovitz’s amazing PrEP RCT effectiveness summary infographic near the end of the slide set.