Transfer of HIV Care – What Do You Need to Consider?

   

Deborah, a 31-year-old female, has recently moved to your area and she schedules an appointment to establish care.  She has no additional medical history.  She takes a multivitamin daily.  She was diagnosed with HIV at her OB/GYN’s office 10 years ago by routine screening.  She was started on coformulated emtricitabine/tenofovir disoproxil fumarate/efavirenz (Sustiva) at that time by her HIV provider and she has been on it since her diagnosis and she has no tolerability issues. She is currently asymptomatic.

Data:

  • BP: 120/70 mmHg
  • CD4 count: 700 cells/mm3
  • HIV RNA by PCR: <20 copies/mL
  • Hepatitis A and B: immune
  • Hepatitis C antibody: negative

Questions for Discussion:

  1. What additional information would be important for you to know about Deborah as she transfers into your care?
  2. Would you recommend updating Deborah’s antiretroviral therapy to an integrase inhibitor based regimen?  Why or why not?
  3. At what point do you approach changing a patient’s regimen who is new to your practice and you are still developing a trusting relationship?

9 thoughts on “Transfer of HIV Care

  1. William Short says:

    Welcome back everyone. We are presenting a case here that I am sure most of you have seen in your clinic. The questions posted for discussion are a start but you do not have to use them, please feel free to talk about something else you may see as a priority.

    This case has so many interesting aspects and I think it should be a lively discussion.

    I will start the discussion by saying when I see a patient like this for the first time, I almost never start discussing changing things. I have done it in the pasta nd I feel like it makes the patient uncomfortable. The only time I have done that is when someone presented to me on Stavudine (Zerit)-yes that occurred in 2018 and I started my discussion with has anyone talked to you about the toxicities of that medication.

    Thoughts from anyone?

    • Eileen Donaghy says:

      I agree Bill regarding waiting a few visits before approaching the topic of changing ANY regimen as long as the patient is safe. There is definitely a time period where we are developing trust with these patients new to us, but NOT new to the disease. I think that period of time differs in length with each patient and it’s our responsibility to gauge how long a person needs.
      Stavudine is a scary drug but one many of us used years ago.
      Does anyone else have a medication that they feel is dangerous enough to approach the discussion of “change” during the first visit?
      How do other providers bridge the transition for these patients to a new office setting? Do you have a protocol for new patients?

    • Jason Schafer says:

      I definitely agree that taking time to establish a trusting relationship with a new patient, whether a new diagnosis or a transfer of care, is essential to the success of the patient’s care moving forward. In terms of this patient’s medications, she is on a regimen that we wouldn’t recommend if we were starting her on therapy for the first time today, but it’s one that she has tolerated well with good efficacy over a number of years. As a result, I don’t think there’s an emergent need to update things to an integrase-based regimen. In other words, you have time to establish a good relationship with the patient before pursuing any ART changes that you may find are necessary as you get to know the her better.

  2. Gwen Verlinghieri says:

    Hello Bill, Eileen & Jason,

    My first meeting with a new patient mostly focuses on establishing a rapport with the patient, allowing her to voice any questions or concerns she may have. This visit is usually pretty intimidating for the patient, Giving detailed medical, financial and sexual history, I almost never discuss switching medications during the initial visit but I do have medication charts hanging in the exam rooms so that patients can see the various treatment options available. Patients get to sew hat they are currently taking along with all the others choices of meds available. Being that this patient may be of childbearing childbearing age, I like to discuss her her past and present use of birth control. There will be plenty of upcoming visits to discuss medication changes.

    • William Short says:

      Gwen,
      I agree with what you are saying. I am cautious with rushing to discuss switching ART especially now with all of the concern regarding weight gain with TAF vs TDF, integrase vs non-integrase and it may cause her to not trust the system. The only time I rush to a change if there is toxicity that I see.

  3. Idalina Afopa says:

    Given the patient is stable, has no additional history and is not on a toxic med regimen, I would focus on using a sympathetic and nonjudgmental attitude to establish trust. Assessing the patient knowledge of the disease would be a good start. Then, obtaining a baseline and ongoing HIV-related history including sexual history, mental health and substance abuse. The confidential nature of these discussions would be stressed as well as the importance of partner notification. In addition, the patient being a young female of child bearing age I would discuss family planning including risks to the mother and fetus during pregnancy. I would invite her to voice questions and concerns to include her in the decision-making and leave a change in medication regimen for a later visit.

  4. Cori Blum says:

    I agree with the above in terms of not strongly recommending regimen changes at the first visit, although I would make mention of the fact that there are other regimens available that may not have some of the long-term side effects we’ve seen with EFV, and so we could explore further at this visit or in the future when she’s ready. Perhaps the person would actually be interested in having more information, maybe she has already heard there are other “better” drugs out there, and I wouldn’t want to withhold the fact that I have more information about this until a future visit.

  5. Cori Blum says:

    Other questions I have for this person are what are her fertility intentions, what is she doing in terms of contraception or pre-conception care, if anything? Of course I’d like to learn more about her social and family history, get to know her as a person and better understand the context of her life.

  6. Jason Schafer says:

    Really important points raised by everyone in terms of the patient’s child bearing potential and fertility planning. If the patient was actively trying to conceive at this time, would you recommend a change in her HIV treatment regimen? Why or why not? If you did want to make a change, what would be your regimen of choice?

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