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Quality of Care of Patients with HIV Infection

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Northeast Florida Medicine, Vol. 68, No. 3, Autumn 2017

Quality of Care of Patients with HIV Infection

Professor & Director, University of Florida Center for HIV/AIDS Research, Education and Service (UF CARES), Chief, Pediatric Infectious Diseases, Wolfson Children’s Hospital

Address Correspondence to:

Mobeen Rathore, MD, CPE, FAAP, FPIDS, FIDSA, FACPE, FSHEA
653-1 West 8th Street, LRC 3rd Floor L-13, Jacksonville, FL 32209
Email: mobeen.rathore@jax.ufl.edu

Date of Release: September 1, 2017
Date Credit Expires: September 1, 2019
Estimated Completion Time: 1 hour
Background:

The Duval County Medical Society (DCMS) is proud to provide its members with free continuing medical education (CME) opportunities in subject areas mandated and suggested by the State of Florida Board of Medicine to obtain and retain medical licensure. The DCMS would like to thank the St. Vincent’s Healthcare Committee on CME for reviewing and accrediting this activity in compliance with the Accreditation Council on Continuing Medical Education (ACCME). This issue of Northeast Florida Medicine includes an article, “Quality of Care of Patients with HIV Infection” authored by Mobeen Rathore, MD, CPE, FAAP, FPIDS, FIDSA, FACPE, FSHEA, which has been approved for 1 AMA PRA Category 1 credit.TM For a full description of CME requirements for Florida physicians, please visit www.dcmsonline.org.

Faculty/Credentials:

Mobeen Rathore, MD, CPE, FAAP, FPIDS, FIDSA, FACPE, FSHEA is the Professor/Director at the University of Florida Center for HIV/AIDS Research, Education and Service (UF CARES) and Chief, Pediatric Infectious Diseases at Wolfson Children’s Hospital in Jacksonville, FL.

Needs Assessment:

With the evolving patient management of patients with HIV and AIDS, it is crucial to educate physicians on epidemiology, prevention, and control. Quality of care for these patients must be measured and improved upon. It is also incredibly important that physicians know the proper precautions to protect themselves and others against transmission.

Objectives:

1. To understand the epidemiology of HIV.
2. To understand prevention of transmission of HIV.
3. To understand principles of infection control in HIV.

CME Credit Eligibility:

A minimum passing grade of 70% must be achieved. Only one re-take opportunity will be granted. If you take your test online, a certificate of credit/completion will be automatically downloaded to your DCMS member profile. If you submit your test by mail, a certificate of credit/completion will be emailed within 4 weeks of submission. If you have any questions, please contact Kristy Williford at 904-355-6561 or kristy@dcmsonline.org. 

Faculty Disclosure:

Mobeen Rathore, MD, CPE, FAAP, FPIDS, FIDSA, FACPE, FSHEA reports no significant relations to disclose, financial or otherwise, with an commercial supporter or product manufacturer associated with this activity.

Disclosure of Conflicts of Interest:

St. Vincent’s Healthcare (SVHC) requires speakers, faculty, CME Committee and other individuals who are in a position to control the content of this educational activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly evaluated by SVHC for fair balance, scientific objectivity of studies mentioned in the presentation and educational materials used as basis for content, and appropriateness of patient care recommendations.

Joint Sponsorship Accreditation Statement:

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of St. Vincent’s Healthcare and the Duval County Medical Society. St. Vincent’s Healthcare designates this educational activity for a maximum of 1 AMA PRA Category 1 credit.TM Physicians should only claim credit commensurate with the extent of their participation in the activity.

The management of HIV infection has improved significantly over the last three decades of the epidemic. The treatment of HIV/AIDS infection has benefited significantly from the progress. National targets and benchmarks are used to determine the quality and extent of HIV care that patients are given in a particular program. In addition, quality of a program can also be gauged by the recognition of a program as a patient centered medical home. Staff can be safe from the potential transmission of HIV if they carefully follow all standard precautions and take blood and body fluid precautions when needed. In addition, the use of safer devices can provide protection against transmission.

Significant advances have been made in the past three decades in diagnosis and management of HIV infection. The newer, fourth generation HIV screening tests are more sensitive and can diagnose HIV infection as early as one to two weeks after an individual is infected. A lot of effort is still needed to reach populations at risk for HIV infection. Outreach programs need to be tailored to specific populations and HIV testing needs to be easy for the tester and individuals wanting to get tested.5

HIV can be transmitted by several mechanisms including sexual contact, intravenous drug abuse, exposure to blood and body fluids (including needles), transfusion of infected blood and blood products (a route that no longer occurs in the United States of America) and MTCT (also referred to as perinatal transmission).10

Since 2010, almost 5000 cases of HIV infections have been diagnosed in Florida.1 According to the Florida Department of Health, the HIV/AIDS surveillance program “plays a vital role in how Florida determines HIV/AIDS resource needs, program planning and evaluation.” Data from each calendar year is finalized on June 30. Figure 1 shows a summary of newly diagnosed HIV infection cases over the last six years. 1 The Department of Health also points out that there is a difference between year of diagnosis and year of report. Year of diagnosis indicates when a person was first diagnosed with HIV/AIDS, while year of report is the year the patient’s case was first reported to the Florida Department of Health and entered into the enhanced HIV/AIDS Reporting System.1

Of all the reported cases in Florida of HIV infection in 1987, 11 percent were in women (ages 13+). This number grew to 29 percent in 2005. In 2014, this figure decreased to 20 percent.2 According to the Florida Department of Health, women are more likely to be infected through high risk heterosexual contact, followed by injection drug use.2 In 2014, Florida statistics showed that HIV was the 5th leading cause of death among women between the ages of 25-44.

It is also important to look at racial statistics regarding HIV/AIDS. National and Florida data show that the survival time from AIDS diagnosis to death is significantly shorter for blacks than other racial/ethnic groups.3 In 2014, statistics showed that blacks accounted for about 47 percent of HIV infection cases in Florida.3 Survival rates for AIDS cases in Florida also differs by race. According to data from 2007-2014, blacks had a median survival rate of 66 months, compared to 67 months for Hispanics, 75 months for American Indians, and 90 months for whites.4

When it comes to states with the highest number of pediatric AIDS cases, the state of Florida, with 1,571 pediatric AIDS cases in 2013, ranks second, after New York, in the number of pediatric AIDS cases.5,6 Through 2013, Florida has reported 2,561 cases of pediatric HIV infection, of which 74 percent were in African Americans and 95 percent were the result of MTCT.5,6 The number of perinatally acquired HIV-infected babies born in Florida (N=1,208 through 2013) has steadily declined (91 percent) from a peak of 110 cases in 1993 to 10 cases in 2013.5,6 Of the 503 babies known to be born to an HIV-infected mother in Florida in 2013, 10 (2 percent) were infected.5,6

The risk factors for these transmissions include:

  1. Mothers who do NOT know their HIV status prior to birth
  2. Inadequate prenatal care (adequate care is defined as: 5 or more visits, starting by month 4 or earlier),  
  3. No prenatal antiretroviral therapies (ART)
  4. No ART at delivery, and/or
  5. Non-caesarean birth
  6. No neonatal ART (within the first 6 weeks of the infant’s life)
  7. Breast feeding
  8. A mother who is a substance abuser during pregnancy
  9. A mother who acquired a STD during pregnancy
  10. Issues associated with poverty and limited access to health care

In Florida, state law requires that healthcare providers must offer HIV testing to all pregnant patients early and late in pregnancy. HIV testing should be offered at the initial visit and then at 36 weeks gestation or after. The use of an “opt-out” HIV testing strategy in Florida has increased HIV testing in pregnant women by making it easier. In Florida, there are many sites where HIV testing can be obtained free of charge. Testing is always confidential and has the same protection under HIPPA laws as any other medical condition.

Tuberculosis (TB) remains a major public health concern in the HIV-infected population. Routine annual screening of all HIV-infected individuals is a quality outcome that must be a major target. Although tuberculin skin testing (TST) has traditionally been the gold standard, interferon gamma release assays (IGRAs) are more specific and a better option to screen for TB in the HIV-infected population. IGRA is now the preferred test for TB screening.

According to the Centers for Diseases Control and Prevention (CDC), people living with HIV are more likely to become infected with tuberculosis.7 Worldwide, TB is a leading cause of death among those with HIV. 2011 statistics from the World Health Organization estimate that of the 8.7 million people who developed incident tuberculosis, 13 percent were co-infected with HIV.8

Physicians can treat both HIV and tuberculosis but there are some challenges including overlapping side effects, drug-drug interactions and immune reconstitution inflammatory syndrome. Despite the challenges, the CDC reports that “providing antiretroviral therapy to HIV-infected adults during tuberculosis treatment, rather than waiting until completion of tuberculosis therapy, reduces mortality, particularly among those with advanced HIV disease.”9

HIV/AIDS Research, Education and Service in Jacksonville

In Jacksonville, there is a system of care for HIV-infected women and children led by the University of Florida Center for HIV/AIDS Research, Education and Service, in collaboration with many community and healthcare partners. As a result, MTCT of HIV remains a rare occurrence and is considered a sentinel event for which UF CARES conducts an intensive route cause analysis. 

One of the measures of high quality of care is recognition as a Patient Centered Medical Home (PCMH) by the National Committee on Quality Assurance (NCQA). Level 3 recognition by NCQA is the highest level of recognition and assures that a program offers care that is accessible, coordinated, culturally appropriate and patient and family-centered. UF CARES has NCQA recognition as a Level 3 PCMH.

Quality of care regionally, statewide or nationally can be determined by the percent of HIV-infected individuals diagnosed, engaged in care, prescribed antiretroviral medications and virally suppressed. A November 2014 study by the Centers for Disease Control and Prevention noted that only one-third of 1.2 million Americans living with HIV had their virus under control.10 Figure 2 takes a closer look at the CDC’s analysis and shows the tremendous need for improvement in each of the categories.10

Such data are lacking locally. Each program in the region is required to have a quality improvement program and some of these outcomes can be determined by using the CareWare database that has all the eligible patients in our region.

Developing an infrastructure and a system of care using the Testing, Engaging and Retain (TEAR) in care methodology is key to identifying HIV-infected individuals and bringing them into care early. In Jacksonville, this is done by offering HIV testing by several state designated HIV testing sites, including UF CARES. Innovative outreach programs are also conducted by UF CARES, including programs such as Targeted Outreach to Women with HIV/AIDS (TOPWA) and the Expanded Testing Initiative (ETI). Once identified, HIV-infected individuals benefit from intensive case management and referral to appropriate service providers. Access to primary care, specialty, mental health and nutritional services, along with many other essential services, is critical for high quality outcomes. Access to the latest innovative and cutting-edge research is an integral part of providing high quality care for the HIV-infected population.

Treatment of Infants

Infants born to HIV-infected mothers need antiretroviral therapy for at least six weeks. It is imperative the mother leaves the hospital with the necessary prescriptions. Follow-up at appropriate intervals is necessary so that diagnosis of HIV infection can be detected as soon as possible. Early treatment with antiretrovirals and prophylaxis for PCP infection in the infant is critical to decrease the morbidity and mortality associated with MTCT of HIV infection. Other opportunistic infections, such as tuberculosis, are fortunately rare in children in the United States, but are still a huge problem in the under resourced parts of the world.  Nevertheless, HIV-infected children are at increased risk for tuberculosis and require appropriate screening for tuberculosis on a regular basis. Early diagnosis of HIV infection in the newborn period and the first 18-24 months of age requires molecular tests, such as HIV DNA or RNA PCR and, in some cases, a NAAT test. The routinely-used antibody-based HIV testing for adults is not accurate in infants, because of the presence of transplacentally acquired maternal HIV antibody.

 

Treatment of Children

Although many antiretroviral treatment options are available for children, the management of HIV-infected children is highly specialized. Such children should be managed by pediatric infectious diseases specialists who are experienced and knowledgeable about the latest treatment guidelines for pediatric HIV infection. Management of HIV is quite fluid and dynamic as the field burgeons and evolves. The latest information can be obtained from living documents at AIDSinfo.org. 

All healthcare providers have a critical role in the prevention of MTCT of HIV. First and foremost, all healthcare providers and institutions should offer HIV testing to their patients annually, as recommended by the CDC in 2006.11 This will identify HIV-infected individuals so that they can receive appropriate treatment. Such treatment would decrease the chance of MTCT if a woman gets pregnant. Testing of HIV-infected men would identify potentially infected women. When appropriately treated and educated, HIV-infected men would be less likely to transmit the infection to their uninfected partners. As a result, a female partner would be less likely to transmit to their infants.

 

Treatment of Adolescents and Adults

HIV-infected adolescents and adults should be cared for by HIV specialists. At UF CARES, special programs for adolescents (13-18 years old) and emerging adults (19-24 years old) focus on their specific needs phased on their maturity and psychosocial development. Perhaps the most challenging group in this age group are those with alternate lifestyles, including the lesbian, gay, bisexual, transgender and questioning (LGBTQ) communities, who are at heightened risk for many life problems, including HIV. Young men who have sex with men are particularly at risk for HIV and especially vulnerable and difficult to reach.

Florida statistics show that in 2014, 16 percent of all new HIV infections occurred in individuals less than 25 years of age.12 Between 2012 and 2014, 548 new cases of HIV infection were reported among those between 13 to 19 years of age and 2,117 cases among those between 20 and 24 years of age.12 As of June 30, 2014, a total of 3,768 adolescents between the ages of 13 and 24 years old were infected.12

The quality of care in a region, state or nationally is best defined by quality indicators and good outcomes. The CDC tracks the “HIV care continuum” to gauge progress towards national goals.13 The HIV care continuum tracks the following:

  •  Diagnosed: The number of people diagnosed with HIV, regardless of AIDS status. 
  • Linked to care: The number of people diagnosed with HIV in a given calendar year that had one or more documented medical visits, viral load or CD4 tests within three months after diagnosis.
  •  Retained in care: The number of diagnosed people who had two or more documented medical visits, viral load tests, or CD4 tests, performed at least three months apart in the measurement year.
  •  Antiretroviral use: The number of people receiving medical care and who have a documented antiretroviral therapy prescription in their medical records in the measurement year.
  •  Viral load suppression: Number of people whose most recent HIV viral load within the measurement year was less than 20 copies/ml.

The National HIV/AIDS Strategy (NHAS) 2020 has set up a five-year plan with annual targets for responding to the HIV epidemic.14 The ten indicators, plus three that considered developmental, are listed in Figure 3.14

 

 

For example, for Indicator 6 the target is to increase the percentage of persons diagnosed HIV infection who are virally suppressed to at least 80 percent. This target was expected to be reached progressively over a period of years. The annual targets for year 2010 through year 2020 are shown in Figure 4.15

 

Prevention of HIV/AIDS

The solution to the HIV epidemic worldwide is a safe and effective vaccine. Unfortunately, the field of HIV vaccinology has been fraught with more failures than successes. Although, each of these failures has guided the path to developing a safe and effective vaccine, progress has been slow and a vaccine remains elusive. Other prevention modalities such as condoms, diaphragms and microbicides have been available for years and offer significant protection for preventing HIV transmission, but they have not been very easy to implement. More recently, there has been success with the use of post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) in the prevention of HIV transmission. None of the discussed modalities are perfect and require the at-risk person to proactively seek these modalities of prevention before or after an at-risk encounter making them less than optimum. A vaccine remains the best hope.

 

Preventing Transmission to Health Care Personnel

Prevention of transmission to health care personnel (HCP) is critically important. Following the recommended infection control policies is key. HCP should follow standard universal precautions for all patients. All blood and body fluids should be considered infectious and handled accordingly. All exposures must be reported and documented. This is important for protection of the HCP who may benefit from preventive antiretroviral protocols.

The most critical factor in patient and HCP safety is the use of standard precautions at all times and blood and body fluid precautions whenever necessary. In addition, the use of safer devices can also increase safety. It is important to remember that there are no completely safe devices, only safer devices. HCP must still use all medical devices especially sharps with utmost care.

High quality HIV care requires developing a system of care with strong processes and aiming for PCMH recognition. Using accepted standard outcome targets, such as those set by NHAS, assures the highest quality care. Every HIV program must have a quality improvement program that establishes a process to reach the desired outcomes. The use of infection prevention and control procedures and safer devices protects HCP from potential exposure to HIV.

1. Florida Department of Health. HIV Data Center [Internet]. 2016 Jun 30 [cited 2017 Jul]. Available from: http://www.floridahealth.gov/%5C/diseases-and-conditions/aids/surveillance/index.html

2. Florida Department of Health. HIV among women [Internet]. 2016 Feb 15 [cited 2017 Jul]. Available from: http://www.floridahealth.gov/diseases-and-conditions/aids/surveillance/_documents/fact-sheet/2015/2015-women-fact-sheet.pdf.

3. Florida Department of Health. HIV among blacks [Internet]. 2016 Feb 15 [cited 2017 Jul]. Available from: http://www.floridahealth.gov/diseases-and-conditions/aids/surveillance/_documents/fact-sheet/2015/2015-black-fact-sheet2.pdf

4. Florida Department of Health. HIV among American Indians [Internet]. 2016 Jan 22 [cited 2017 Jul]. Available from: http://www.floridahealth.gov/diseases-and-conditions/aids/surveillance/_documents/fact-sheet/2015/2015-american-indian-fact-sheet.pdf

5. Florida Department of Health. Epidemiology of HIV Among Pediatric* Cases in Florida through 2012 [Internet]. 2013 June 30 [cited 2017 Jul]. Available from: http://www.floridahealth.gov/diseases-and-conditions/aids/surveillance/_documents/HIV-AIDS-slide%20sets/PEDS_2012.pdf.

6. Florida Department of Health. Pediatric Fact Sheets [Internet]. 2015 [cited 2017 Jul]. Available from: http://www.floridahealth.gov/diseases-and-conditions/aids/surveillance/fact-sheet1.html.

7. Centers for Disease Control and Prevention. TB and HIV Coinfection [Internet]. 2016 Jun 29 [cited 2017 July]. Available from: https://www.cdc.gov/tb/topic/basics/tbhivcoinfection.htm

8. World Health Organization. Global Tuberculosis Report 2012. Geneva (Switzerland): WHO Press; 2012. 100 p.

9. Centers for Disease Control and Prevention. Managing Drug Interactions in the Treatment of HIV-Related Tuberculosis [Internet]. 2013 Dec 9 [cited 2017 Jul]. Available from: https://www.cdc.gov/tb/publications/guidelines/tb_hiv_drugs/introduction.htm.

10. Centers for Disease Control and Prevention. HIV in the United States: The Stages of Care [Internet]. 2014 Nov [cited 2017 Jul]. Available from: https://www.cdc.gov/nchhstp/newsroom/docs/HIV-Stages-of-Care-Factsheet-508.pdf.

11. CDC. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm

12. Florida Department of Health. Adolescent and Young Adult Fact Sheet [Internet]. 2015 [cited 2017 Jul]. Available from: http://www.floridahealth.gov/diseases-and-conditions/aids/surveillance/fact-sheet1.html.

13. Centers for Disease Control and Prevention. Understanding the HIV Care Continuum Fact Sheet [Internet]. 2017 Jul [cited 2017 Jul]. Available from: https://www.cdc.gov/hiv/pdf/library/factsheets/cdc-hiv-care-continuum.pdf.

14. HIV.gov. What is the national HIV/AIDS strategy? [Internet]. [cited 2017 Jul]. Available from: https://www.hiv.gov/federal-response/national-hiv-aids-strategy/overview.

15. National HIV/AIDS Strategy for the United States: Updated to 2020. White House Office of National AIDS Policy; 2016 Jul. 34 p.