Could Home Human Immunodeficiency Virus Self-Testing Ever Become a Game Changer?

Could home human immunodeficiency virus (HIV) self-testing make a major difference in identifying persons with undiagnosed HIV in the United States? We argue that approval of new self-test assays for home use would help but must be combined with extensive investment in community outreach and linkage to care to make an impact.

Therapy for HIV-associated cryptococcal meningitis: a case report demonstrating a new treatment approach emphasizing updated treatment guidelines.

Cryptococcal meningitis (CM) remains a significant global health burden, especially for persons living with HIV. Despite effective antiretroviral and antifungal therapy, mortality rates are still approximately 70% in low- and middle-income countries and 20-30% in high-income countries. Central nervous system symptoms range from mild to severe, depending on burden of disease, and prompt and appropriate therapy is critical to reducing mortality. Treatment consists of three phases: induction, consolidation, and maintenance. Although treatment regimens have largely remained unchanged for decades, recent clinical trials have led the World Health Organization to update guidelines to reflect best practices in resource-limited settings. We review the clinical presentation, diagnosis, and standard therapy for CM, present a case with a challenging diagnostic and treatment course complicated by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, and discuss the benefits of a new treatment dosing strategy highlighting potential advantages of adopting this novel dosing option in high-income countries.

Human Immunodeficiency Virus Training Pathways in Residency: A National Survey of Curricula and Outcomes.

BACKGROUND: The Ending the HIV Epidemic initiative, which aims to decrease the annual incidence of HIV infections in the United States (US) by 90% over the next decade, will require growth of a limited HIV provider workforce. Existing HIV training pathways within Family Medicine (FM) and Internal Medicine (IM) residency programs may address the shortage of HIV medical providers, but their curricula and outcomes have not previously been assessed. METHODS: We identified HIV residency pathways via literature review, Internet search, and snowball sampling and designed a cross-sectional study of existing HIV pathways in the US. This survey of pathway directors included 33 quantitative items regarding pathway organization, curricular content, graduate outcomes, and challenges. We used descriptive statistics to summarize responses. RESULTS: Twenty-five residency programs with dedicated HIV pathways in the US were identified (14 FM and 11 IM), with most located in the West and Northeast. All 25 (100%) pathway directors completed the survey. Since 2006, a total of 228 residents (77 FM and 151 IM) have graduated from these HIV pathways. Ninety (39%) of 228 pathway graduates provide primary care to persons with HIV (PWH). CONCLUSIONS: HIV pathways are effective in graduating providers who can care for PWH, but generally are not located in nor do graduates practice in the geographic areas of highest need. Our findings can inform quality improvement for existing programs, development of new pathways, and workforce development strategies. Specifically, expanding pathways in regions of greatest need and incentivizing pathway graduates to work in these regions could augment the HIV workforce.

Advancing Digital Health Equity: A Policy Paper of the Infectious Diseases Society of America and the HIV Medicine Association.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has revolutionized the practice of ambulatory medicine, triggering rapid dissemination of digital healthcare modalities, including synchronous video visits. However, social determinants of health, such as age, race, income, and others, predict readiness for telemedicine and individuals who are not able to connect virtually may become lost to care. This is particularly relevant to the practice of infectious diseases (ID) and human immunodeficiency virus (HIV) medicine, as we care for high proportions of individuals whose health outcomes are affected by such factors. Furthermore, delivering high-quality clinical care in ID and HIV practice necessitates discussion of sensitive topics, which is challenging over video without proper preparation. We describe the "digital divide," emphasize the relevance to ID and HIV practice, underscore the need to study the issue and develop interventions to mitigate its impact, and provide suggestions for optimizing telemedicine in ID and HIV clinics.

The Impact of COVID-19 on HIV Care Provided via Telemedicine-Past, Present, and Future.

PURPOSE OF REVIEW: This review summarizes HIV care delivered via telemedicine before and during the COVID-19 pandemic and highlights areas of study to inform optimal usage of telemedicine in HIV clinical practice in the future. RECENT FINDINGS: To address barriers to care created by the COVID-19 pandemic, regulatory agencies and payors waived longstanding restrictions, which enabled rapid expansion of telemedicine across the country. Preliminary data show that providers and persons with HIV (PWH) view telemedicine favorably. Some data suggest telemedicine has facilitated retention in care, but other studies have found increasing numbers of PWH lost to follow-up and worsened virologic suppression rates despite offering video and/or telephone visits. The COVID-19 pandemic has exacerbated gaps in the HIV care continuum. To help mitigate the impact, most clinics have adopted new virtual care options and are now evaluating usage, impact, and concerns. Further research into the effects of telemedicine on HIV care and continued work towards universal access are needed.

Infectious Diseases Society of America Position Statement on Telehealth and Telemedicine as Applied to the Practice of Infectious Diseases.

Over the last 2 decades, telemedicine has effectively demonstrated its ability to increase access to care. This access has the ability to deliver quality clinical care and offer potential savings to the healthcare system. With increasing frequency, physicians, clinics, and medical centers are harnessing modern telecommunications technologies to manage a multitude of acute and chronic conditions, as well as incorporating telehealth into teaching and research. The technologies spanning telehealth, telemedicine, and mobile health (mHealth) are rapidly evolving, and the Infectious Diseases Society of America (IDSA) has prepared this updated position statement to educate its membership on the use of telemedicine and telehealth technologies. IDSA supports the appropriate and evidence-based use of telehealth technologies to provide up-to-date, timely, cost-effective subspecialty care to resource-limited populations.

A Review of Telehealth Innovations for HIV Pre-Exposure Prophylaxis (PrEP).

PURPOSE OF REVIEW: This review summarizes novel interventions that employ technology to improve HIV pre-exposure prophylaxis (PrEP) availability, uptake, and adherence. RECENT FINDINGS: Several notable technology-based programs are increasing access to PrEP in unique ways. We identified multiple models for using telehealth to bolster PrEP dissemination and adherence, such as mobile applications that offer PrEP prescribing without an in-person visit, longitudinal distance telementoring for community provider PrEP education and clinical guidance, and electronic consults for PrEP specialist support in the primary care setting. Outcomes data for all of these modalities are limited but show promise. Technology-based interventions can address gaps in the PrEP care continuum. Future research should assess and compare outcomes, scalability, cost-effectiveness, and sustainability. Costs associated with the creation of new technological tools slow innovation and the field would benefit from a platform for technology sharing.

Knowledge, Practices, and Barriers to HIV Preexposure Prophylaxis Prescribing Among Washington State Medical Providers.

BACKGROUND: We aimed to assess HIV preexposure prophylaxis (PrEP) awareness and prescribing practices among Washington State medical providers from diverse professional disciplines and practice types. METHODS: In May 2016, we administered an anonymous online survey to licensed medical practitioners who provide primary, longitudinal, walk-in, emergency, obstetric, gynecologic, sexually transmitted infection, or family planning care. RESULTS: Of 735 eligible providers, 64.8% had heard of PrEP. Younger providers and providers with a doctor of medicine degree were more likely to be aware of PrEP compared with older providers (P = 0.0001) and providers of other training backgrounds (advanced registered nurse practitioner, doctor of osteopathic medicine, or physician assistant; P = 0.04). Among providers aware of PrEP, most frequent reported concerns about prescribing were adherence (46.0%) and costs (42.9%). Providers felt very (20.1%) or somewhat (33.8%) comfortable discussing PrEP overall, but very (26.8%) or somewhat (44.7%) uncomfortable discussing cost and insurance issues. The 124 PrEP prescribers reported a median of 2 (range, 1-175; total, 1142) patients prescribed PrEP. Prior authorizations and insurance denials had prevented prescriptions for 28.7% and 12.1% of prescribers, respectively. CONCLUSIONS: Interventions to improve PrEP access should include education to inform medical providers about PrEP, with particular attention to provider types less likely to be aware. Continued efforts to eliminate cost and insurance barriers and educate providers regarding financial resources would help improve PrEP access.

Washington state satellite HIV clinic program: a model for delivering highly effective decentralized care in under-resourced communities.

To improve access to high-quality HIV care in underserved regions of Western Washington (WA) State, we collaborated with the WA State Department of Health (DOH) and community partners to launch four satellite HIV clinics. Here, we describe this innovative clinical care model, present an estimate of costs, and evaluate patient care outcomes, including virologic suppression rates. To accomplish this, we assessed virologic suppression rates 12 months before and 12 months after the satellite clinics opened, comparing people living with HIV (PLWH) who enrolled in the satellite clinics versus all PLWH in the same regions who did not. We also determined virologic suppression rates in 2015 comparing satellite clinic versus non-satellite clinic patients and compared care quality indicators between the satellite clinics and the parent academic clinic. Results demonstrate that the change in virologic suppression rate 12 months before to 12 months after the satellite clinics opened was higher for patients who enrolled in the satellite clinics compared to all those in the same region who did not (18% versus 6%, p < 0.001). Virologic suppression in 2015 was significantly higher for satellite clinic than non-satellite clinic patients at three of four sites. Care quality indicators were met at a high level at the satellite clinics, comparable to the parent academic clinic. Overall, through community partnerships and WA DOH support, the satellite clinic program increased access to best practice HIV care and improved virologic suppression rates in difficult-to-reach areas. This model could be expanded to other regions with inadequate access to HIV practitioners, though financial support is necessary.

Infectious Diseases Society of America Position Statement on Telehealth and Telemedicine as Applied to the Practice of Infectious Diseases.

The use of telehealth and telemedicine offers powerful tools for delivering clinical care, conducting medical research, and enhancing access to infectious diseases physicians. The Infectious Diseases Society of America (IDSA) has prepared a position statement to educate members on the use of telehealth and telemedicine technologies. The development of telehealth and telemedicine programs requires the consideration of several issues such as HIPAA, state and local licensure requirements, credentialing and privileging, scope of care, quality, and responsibility and liability. IDSA supports appropriate use of telehealth and telemedicine to provide timely, cost-effective specialty care to resource-limited populations.

Integrating patient voices into the extraction of social determinants of health from clinical notes: ethical considerations and recommendations.

Identifying patients' social needs is a first critical step to address social determinants of health (SDoH)-the conditions in which people live, learn, work, and play that affect health. Addressing SDoH can improve health outcomes, population health, and health equity. Emerging SDoH reporting requirements call for health systems to implement efficient ways to identify and act on patients' social needs. Automatic extraction of SDoH from clinical notes within the electronic health record through natural language processing offers a promising approach. However, such automated SDoH systems could have unintended consequences for patients, related to stigma, privacy, confidentiality, and mistrust. Using Floridi et al's "AI4People" framework, we describe ethical considerations for system design and implementation that call attention to patient autonomy, beneficence, nonmaleficence, justice, and explicability. Based on our engagement of clinical and community champions in health equity work at University of Washington Medicine, we offer recommendations for integrating patient voices and needs into automated SDoH systems.

Impact of the COVID-19 pandemic on HIV testing rates across four geographically diverse urban centres in the United States: An observational study.

BACKGROUND: Non-emergent clinical services were limited or suspended during the early stages of the coronavirus disease 2019 (COVID-19) pandemic in the United States (U.S.). This could adversely impact epidemics of public health importance, such as HIV, and access to testing, which is a cornerstone of prevention efforts. METHODS: In this observational study, we collected HIV testing and positivity rate clinical data from four geographically diverse U.S. healthcare systems in New Orleans, Louisiana; Minneapolis, Minnesota; Providence, Rhode Island; and, Seattle, Washington. Data from 2019 to 2020 were examined to assess changes in HIV testing in community-based, emergency department, and outpatient settings. Poisson regression was used to explore trends in HIV testing through phases of the COVID-19 pandemic. FINDINGS: In outpatient settings, there was a 68-97% reduction in the number of HIV tests per week during each state's stay-at-home order period, compared to during the pre-stay-at-home order period in early 2020. HIV testing remained reduced 11-54% after states transitioned to advisory phases. The HIV positivity rate increased slightly at outpatient settings, except in New Orleans where it fell. INTERPRETATION: We found a concerning trend of substantially decreased HIV testing across four geographically diverse sites. These findings suggest that new HIV infections within the U.S. may be undiagnosed and not yet linked to clinical care and services, as a consequence of the COVID-19 pandemic. Thus, augmented efforts to identify patients and link them to HIV services will be needed as healthcare settings return to full operation. FUNDING: U.S. National Institute of Mental Health.

Direct and Indirect Effects of a Project ECHO Longitudinal Clinical Tele-Mentoring Program on Viral Suppression for Persons With HIV: A Population-Based Analysis.

BACKGROUND: Project Extension for Community Health Outcomes (ECHO) aims to connect community providers to academic specialists, deliver longitudinal clinical mentorship and case consultations, plus encourage dissemination of knowledge and resources. The impact on outcomes for persons with HIV (PWH) is uncertain. SETTING: PWH in Washington and Oregon outside of the Seattle and Portland metro areas, January 2011 to March 2018. METHODS: Using viral load (VL) surveillance data, we assessed difference in the percentage of PWH who were virally suppressed among PWH whose providers participated versus did not participate in Project ECHO. Analyses included multiple mixed-effects regression models, adjusting for time and for patient, provider, and clinic characteristics. RESULTS: Based on 65,623 VL results, Project ECHO participation was associated with an increase in the percentage of patients with VL suppression (13.7 percentage points greater; P < 0.0001), although the effect varied by estimated provider PWH patient volume. The difference was 14.7 percentage points ( P < 0.0001) among patients of providers who order <20 VL's/quarter and 2.3 and -0.6 percentage points among patients of providers who order 20-40 or >40 VL's/quarter, respectively ( P > 0.5). The magnitude of difference in VL suppression was associated with the number of sessions attended. Among patients of lower-volume providers who did not participate, VL suppression was 6.2 percentage points higher if providers worked in a clinic where another provider did participate ( P < 0.0001). CONCLUSION: Project ECHO is associated with improvement in VL suppression for PWH whose providers participate or work in the same clinic system as a provider who participates, primarily because of benefits for patients of lower-volume providers.

Excess Weight Gain With Integrase Inhibitors and Tenofovir Alafenamide: What Is the Mechanism and Does It Matter?

Numerous studies have detected a greater likelihood of excess weight gain with specific antiretrovirals (ARVs), particularly tenofovir alafenamide and integrase inhibitors, as compared with other agents and classes. The long-term implications and potential reversibility for individuals who have experienced substantial ARV-associated weight accumulation remain poorly understood. Furthermore, the underlying mechanism remains controversial: Is the explanation mitochondrial toxicity and weight suppression from the older agents or direct effects of the newer drugs on appetite, adipocytes, or other unintended targets? This review discusses proposed mechanisms and evidence to date and argues that the question about mechanism is highly clinically relevant because it carries significant implications for ARV management. The existing literature suggests that older ARVs, such as tenofovir disoproxil fumarate and efavirenz, suppress weight gain, but also that integrase inhibitors may stimulate excess weight gain through several plausible biologic pathways. Confirming the mechanisms of ARV-associated excess weight gain should be high priority for future research.

Visit Trends and Factors Associated With Telemedicine Uptake Among Persons With HIV During the COVID-19 Pandemic.

BACKGROUND: In response to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, clinicians in outpatient HIV practices began to routinely offer telemedicine (video and/or phone visits) to replace in-person appointments. Video visits are preferred over phone visits, but determinants of video visit uptake in HIV care settings have not been well described. METHODS: Trends in type of encounter (face-to-face, video, and phone) before and during the pandemic were reviewed for persons with HIV (PWH) at an urban, academic, outpatient HIV clinic in Seattle, Washington. Logistic regression was used to assess factors associated with video visit use including sociodemographic characteristics (age, race, ethnicity, language, insurance status, housing status) and electronic patient portal login. RESULTS: After an initial increase in video visits to 30% of all completed encounters, the proportion declined and plateaued at ~10%. A substantial proportion of face-to-face visits were replaced by phone visits (~50% of all visits were by phone early in the pandemic, now stable at 10%-20%). Logistic regression demonstrated that older age (>50 or >65 years old compared with 18-35 years old), Black, Asian, or Pacific Islander race (compared with White race), and Medicaid insurance (compared with private insurance) were significantly associated with never completing a video visit, whereas history of patient portal login was significantly associated with completing a video visit. CONCLUSIONS: Since the pandemic began, an unexpectedly high proportion of telemedicine visits have been by phone instead of video. Several social determinants of health and patient portal usage are associated with video visit uptake.

Brief Report: Weight Gain Following ART Initiation in ART-Naïve People Living With HIV in the Current Treatment Era.

OBJECTIVES: Evaluate differences in weight change by regimen among people living with HIV (PLWH) initiating antiretroviral therapy (ART) in the current era. METHODS: Between 2012 and 2019, 3232 ART-naïve PLWH initiated ≥3-drug ART regimens in 8 Centers for AIDS Research Network of Integrated Clinical Systems sites. We estimated weight change by regimen for 11 regimens in the immediate (first 6 months) and extended (all follow-up on initial regimen) periods using linear mixed models adjusted for time on regimen, interaction between time and regimen, age, sex, race/ethnicity, hepatitis B/C coinfection, nadir CD4, smoking, diabetes, antipsychotic medication, and site. We included more recently approved regimens [eg, with tenofovir alafenamide fumarate (TAF)] only in the immediate period analyses to ensure comparable follow-up time. RESULTS: Mean follow-up was 1.9 years on initial ART regimen. In comparison to efavirenz/tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC), initiating bictegravir/TAF/FTC {3.9 kg [95% confidence interval (CI): 2.2 to 5.5]} and dolutegravir/TAF/FTC [4.4 kg (95% CI: 2.1 to 6.6)] were associated with the greatest weight gain in the immediate period, followed by darunavir/TDF/FTC [3.7 kg (95% CI: 2.1 to 5.2)] and dolutegravir/TDF/FTC [2.6 kg (95% CI: 1.3 to 3.9)]. In the extended period, compared with efavirenz/TDF/FTC, initiating darunavir/TDF/FTC was associated with a 1.0 kg (95% CI: 0.5 to 1.5) per 6-months greater weight gain, whereas dolutegravir/abacavir/FTC was associated with a 0.6-kg (95% CI: 0.3 to 0.9) and dolutegravir/TDF/FTC was associated with a 0.6-kg (95% CI: 0.1 to 1.1) per 6-months greater gain. Weight gain on dolutegravir/abacavir/FTC and darunavir/TDF/FTC was significantly greater than that for several integrase inhibitor-based regimens. CONCLUSIONS: There is heterogeneity between regimens in weight gain following ART initiation among previously ART-naïve PLWH; we observed greater gain among PLWH taking newer integrase strand transfer inhibitors (DTG, BIC) and DRV-based regimens.

Electronic Consults for Infectious Diseases in a United States Multisite Academic Health System.

We launched Infectious Disease electronic consultations (eConsults) in 2018. During the first 15.5 months, primary care practitioners submitted 328 eConsults; the most frequent reasons were a positive culture or polymerase chain reaction (PCR) result, syphilis, and latent tuberculosis. Practitioners commonly requested advice on antimicrobial choice, clinical evaluation, and indications for treatment. Internal phone consultations decreased after eConsult implementation.

Switching Antiretroviral Therapy in the Setting of Virologic Suppression: A Why and How-To Guide.

This review provides a synopsis of key clinical considerations for switching antiretroviral therapy (ART) for individuals with human immunodeficiency virus who have maintained a routinely suppressed viral load. There may be benefits but also risks involved in every ART regimen change, so strategies for prioritizing individuals for a switch based on the specific antiretroviral agents in the regimen are discussed, along with approaches to ensure maintenance of viral suppression after treatment modifications. Controversial and evolving questions in the area of ART switches and simplifications are also considered.