HIV Update focuses on Rapid ART, pregnancy and transgender health

Faculty from the UNC School of Medicine provided 400 clinicians from around the state best practices and the latest research results during the annual HIV Update conference at the Friday Center on Monday, May 6.

HIV Update focuses on Rapid ART, pregnancy and transgender health click to enlarge Although people aged 45-59 make up the majority of people living with HIV in North Carolina, the majority of new infections are among MSM aged 13-34, said Heidi Swygard, MD, MPH, a professor of medicine within the UNC Division of Infectious Diseases.
HIV Update focuses on Rapid ART, pregnancy and transgender health click to enlarge UNC's Tonia Poteat, PhD, PA-C, MPH, encouraged clinicians to properly address and provide clinical care to the transgender population in their medical practices.

More than 400 clinicians who care for people living with HIV around North Carolina gathered at UNC’s Friday Center on Monday, May 7, for the annual HIV Clinical Update conference. Held for more than 25 years, the day-long event seeks to arm providers with the latest clinical best practices and research data to improve the health of North Carolinians at risk for or living with HIV. It is jointly sponsored by the UNC Institute for Global Health & Infectious Diseases (IGHID), the Greensboro Area Health Education Center (AHEC) and the UNC Eshelman School of Pharmacy.

“We need to engage everyone, from front desk staff to nurses to social workers to physicians, about a person-centered approach to HIV care,” said Heidi Swygard, MD, MPH, a professor in the UNC IGHID and the conference’s organizer. “We receive feedback from attendees each year about how they appreciate this multidisciplinary, educational approach.”

One of those attendees this year was Octavio Cieza, MD, an infectious diseases specialist at UNC Specialty Care at Smithfield, which is southeast of Raleigh.

“This conference is a helpful, general clinical update, but it is also especially appropriate for us in Johnston County because we are seeing many new patients,” Cieza said. “Access to care is our patients’ biggest concern. My colleagues and I need to learn more about what resources are available to patients through the Ryan White Program. This conference allows us to learn more about that, which then allows us to keep our patients in care and healthy.”

Rapid ART
Swygard was one of the morning’s first presenters. She spoke about rapid antiretroviral therapy or ART. Studies over the past few years have shown the benefits of starting patients who test positive for HIV immediately on treatment. This approach ensures the short- and long-term health of the person living with HIV and makes them less likely to transmit the virus to others.

In North Carolina, the majority of new HIV infections are among Black men who have sex with men (MSM) who are 13 – 34-years-old. Hot pockets of infections are seen in urban areas where the population is greater, but also in more rural areas where there is a lack of HIV clinicians. One-third of new HIV infections in NC are diagnosed when a person comes into a county clinic and asks for sexually transmitted diseases (STD) testing, Swygard said.

“We then ask if they would also like HIV testing while they are there and that is how we discover they are living with the virus,” said Swygard, who treats patients at the UNC Infectious Diseases Clinic in Chapel Hill and a clinic in Wake County. “It is very important to offer rapid treatment to keep them healthy. However, we are finding that although we can get the medications to people living with HIV quickly, we are having trouble keeping people engaged in care long-term. We’ve got to do better about removing obstacles to retention. Ideally, we would need to figure out how to afford to have a dedicated room in each clinic with culturally competent staff who can help patients navigate insurance, housing, transportation and other barriers to care.”

Long-acting Treatment
Myron Cohen, MD, director of the UNC Institute for Global Health & Infectious Diseases and co-principal investigator of the National Institutes of Health-funded HIV Prevention Trials Network (HPTN), spoke about alternatives to pills to prevent HIV. The Antibody Mediated Prevention study, or AMP, is investigating long-acting infusions of monoclonal antibodies to prevent HIV infection.

“I really didn’t think people would say yes to these infusions, but I was wrong,” Cohen said. “We’ve enrolled 4,625 patients worldwide and done 30,000 infusions. We’ve had 96 percent retention and 99 percent adherence. It turns out, people love infusions and they are cost affordable.”

AMP is a joint study between the HPTN and the NIH-funded HIV Vaccine Trials Network (HVTN). The antibodies used in these two global studies – one for women and one for men – were harvested from humans. The studies’ results are still pending, but Cohen said pharmaceutical companies like Sanofi are now making their own antibodies in the lab that provide combination antibody therapy as protection against HIV. He told the attendees the future of HIV prevention would most likely be some injectable or implantable long-acting formula, giving people another option to the currently available once, daily pill.

Pregnancy and HIV
Lisa Rahangdale, MD, MPH, an associate professor in the UNC Department of OB/GYN, presented four case studies about HIV and pregnancy. She spoke about giving women living with HIV the information they need to conceive safely. She also spoke about helping women who are in serodiscordant relationships, where their male partner is living with HIV but they are not, become pregnant and prevent HIV transmission to themselves and their baby.

In addition, Rahangdale addressed two guidelines for pregnancy that could be influenced by future research results. The preferred antiretroviral therapy treatment for women living with HIV is dolutegravir. Yet in 2014, a study of 88,000 women in Botswana, in which 22,000 were pregnant and taking dolutegravir to control their HIV, showed a risk of neural tube defects in infants. The neural tube is developed within the first 28 days of pregnancy or within the first trimester. Until results from further studies are released this summer, Rahangdale said it is not recommended that women living with HIV and who want to become pregnant take dolutegravir to control their viral load. Yet, she cautioned that patient-centered care means giving women all the information they need, but also respecting their choice.

“Another study in Uganda found that despite the potential risk to the baby’s neural tube development, the majority of women preferred to stay on dolutegravir,” Rahangdale said. “As providers, we need to discuss family planning with every patient, especially our female patients. We need to develop an overall plan with them for a safe pregnancy and that means screening for STDs, talking about current medications, assessing their mental health, advising against smoking, suppressing their viral load if they are living with HIV, and talking about their partner’s health.”

Rahangdale also spoke about the risk of breastfeeding and HIV transmission. In the United States, breastfeeding is not recommended for women living with HIV because of the risk of transmission to the infant. Rahangdale acknowledged that many women feel external, societal pressures to breastfeed their babies and know their community will suspect they are living with HIV if they are not breastfeeding.

“I directly ask my patients about breastfeeding. We need to validate a woman’s right to breastfeed her child and seek to understand her motivation for wanting to breastfeed,” Rahangdale said. “The field of HIV and pregnancy changes rapidly. We need to be quicker to evolve and take care of our moms and babies.”

Transgender Health  
Tonia Poteat, PhD, PA-C, MPH, is an assistant professor in the UNC Department of Social Medicine. She spoke about transgender health, including HIV prevention and hormone replacement therapy. Poteat said it is estimated that 1.4 million people living in the United States identify as transgender. She said it is difficult to know if this number is accurate due to poorly worded population surveys and fears of violence, and even death, people who identify as transgender face.

In North Carolina, a 2015 survey of 686 people who identified as transgender revealed that 32 percent limited their food or drink intake when they were not at home for fear of not being able to find a restroom that matched their gender identity without a harassing or violent incident. Poteat said these fears of violence and stigma, as well as legal and economic retaliation, are social drivers of health disparities.

“There is a .3 percent incidence of HIV in the general population in the United States, but a 3.5 percent incidence of HIV in the transgender population,” Poteat said. “We know that transgender women are more at risk than transgender men. We also know that once we educate them about pre-exposure prophylaxis (PrEP) to prevent HIV, they are willing to take PrEP, but are not taking it for fear of the drug-drug interaction with their hormone replacement therapy.”

Poteat stressed the importance of healthcare providers staying informed about their patient population and how to properly care for people who identify as transgender. She said one negative experience with a healthcare provider can cause people to drop out of care, which can have negative health effects if the person stops PrEP and/or decides to get hormone replacement therapy from an underground source.

“We need to anticipate the existence of transgender patients in our medical practices and know how to properly care for them,” Poteat said. “This includes calling them by their preferred name and pronoun, deferring unnecessary exams and questions, conducting genital exams sensitively, and advising them on the importance of daily adherence to PrEP.”

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