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Abbreviations forAntiretroviral Drugs and Dosing InstructionsCommonly Used in This ManualDOSING TERMINOLOGYANTIRETROVIRAL DRUGSBID twice daily3TC lamivudineIM intramuscularABC abacavirIV intravenousAPV amprenavirPO orallyATV atazanavirPRN as neededd4T stavudineQ2H, Q4H, etc every 2 hours,ddC zalcitabineevery 4 hours, etcddI didanosineQAM every morningDLV delavirdineQD once dailyDRV darunavirQH every hourEFV efavirenzQHS every night at bedtimeENF enfuvirtideQID 4 times per dayETR etravirineQOD every other dayFPV fosamprenavirTID 3 times per dayFTC emtricitabineTIW 3 times per weekIDV indinavirLPV/r lopinavir/ritonavirANTIRETROVIRAL TERMINOLOGYMVC maravirocART antiretroviral therapyNFV nelfinavirARV antiretroviralNVP nevirapineFI fusion inhibitorRAL raltegravirNNRTI nonnucleosideRTV ritonavirreverse transcriptase inhibitor/r ritonavir, low doseNRTI nucleoside (or nucleotide)SQV saquinavirreverse transcriptase inhibitorTDF tenofovirPI protease inhibitorTPV tipranavirZDV zidovudinexiiprimary c are of veterans with hiv

Caring for a Veteran with HIV

Caring for a Veteran with HIVWide availability of antiretroviral (ARV) therapy regiments enables most patientsinfected with Human Immunodeficiency Virus (HIV) to enjoy the same lifeexpectancy as the general population. ARV therapy is now recommended forall patients who are HIV-infected, regardless of their CD4 cell count, to reducemortality, morbidity and transmission rate. Upon starting ARV therapy, it isimportant to educate patients about benefits and side effects, and address strate gies to increase adherence.One in 96 Americans will be diagnosed with HIV in their lifetime.The malepopulation has a higher estimated lifetime risk than the female population. Exactstatistics in the Veteran population has not yet been studied.ARV therapy side effects and drug interactions are numerous and complex.Within the infected population, the primary care clinician is the first line ofdefense against poor adherence to the treatment and aggravated side effects. SeeComorbid Conditions, p. 313, for more information about side effects.Impact on Patient PopulationTwo main routes of contracting HIV are having unprotected sex, especially inmen who have sex with men (MSM) population, and IV drug use.Veterans may beespecially unwilling to acknowledge these underlying behaviors.Veterans with anHIV-positive test can be stigmatized by their peers and perceived to have partici pated in these activities. This situation can lead to desperation and alienation. It isimportant to discern the signs of pariah status and provide necessary support tothe impacted patients.There are a few unique issues for the Veteran patient described here. Through out the manual, we will primarily use “patient.” However, when there are issuesspecific to the Veteran population, we will use the term “Veteran”.Patients who are HIV positive are at high risk of suffering mental health issuesthroughout the progression of the disease. Specific episodes can instigate majormental health challenges for patients. These events include but are not limited tothe positive HIV test, the initial onset of physical symptoms, sudden decline in theCD4 count, the first opportunistic infection and the first hospitalization. Depres sion, anxiety and stress are common among older patients who are HIV-positive.Psychological support for patients with HIV and their partners or family memberis an important aspect of holistic HIV management. Counseling for patients withHIV is crucial to understand the patient needs and refer them to the relevantspecialists, including psychologists, social workers or dietitians. Studies suggest acanine companion is an effective treatment to improve the mental well-being ofpatients with HIV.primary c are of veterans with hiv3c ar ing for a ve ter an with hivDealing with a Positive HIV Test

Patients with HIV may also suffer from economic hardship and social isolation.Moreover, patients who are HIV-positive with minority racial/ethnic identity,minority sexual preference, low socioeconomic status and intergenerationalpoverty, and limited social supports report increased challenges in dealing withan HIV diagnosis.It is important for the primary care physician to establish that the patientswho contract the disease can live fulfilling lives and with the advent of the ARVtherapy drug regiments, there is minimal impact on the daily activities of patients.Patients experiencing withdrawal from social activities because of the stigma ofHIV need to be reassured that social activities may be resumed.Stigma and DiscriminationHigh clinical suspicion of disease and regular testing for HIV is helpful for bothpatients and society by improving treatment and decreasing transmission rate inthis contagious period of infection. Primary care clinicians are tasked to over come two significant psychological barriers. Clinicians need to gain acceptancefrom the patient for the necessary HIV test and at the same time they need toensure that the patients with positive HIV tests understand that a full life can belived with ARV therapy regiments.Frequency of Clinical EvaluationFrequent visits may be appropriate for new patients and patients who haverecently started ARV therapy. Side effects of ARV therapy and possible drug inter actions will provide significant challenges in the starting phase of the treatment.Once the viral load has been suppressed and CD4 cell count is increased andstable less frequent monitoring is appropriate. Follow the U.S. Department ofHealth and Human Services guidelines for ARV therapy.Necessary TestsAccording to the Department of Health and Human Services (DHHS) HIV treat ment guidelines and HIV Medicine Association the laboratory tests listed beloware beneficial in caring for patients with HIV infection.c ar ingfor a ve ter an with hiv CD4 count – needs to be checked at the initiation of the care and then ev ery 3-6 months or even yearly, depending on situation. HIV viral load – needs to be measured at the beginning of the care andevery 3-4 months; however, it can be extended to every 6 months in somesituations. CBC, electrolyte panel, liver enzymes, bilirubin level, lipid panel, HIV geno type, and urinalysis – All patients who receive a diagnosis of HIV requirescreening for other sexually transmitted infections, including chlamydia,gonorrhea, and syphilis. Screening for tuberculosis and serologies for toxo plasma and viral hepatitis are also indicated.4primary c are of veterans with hiv

All women need a cervical papanicolaou test, and premenopausal womenshould have a pregnancy test. In a patient with concerning symptoms of hy pogonadism, measuring morning serum total testosterone can be helpful.ImmunizationPreventing patients who are HIV-infected from contracting vaccine-preventableillnesses is an important part of primary care. These vaccines are recommended: H influenza type B vaccine – for asplenic patients and those with history ofrecurrent haemophilus infection Hepatitis A vaccine – for susceptible MSM and those with an indication forhepatitis A vaccine Hepatitis B vaccine – administer to patients without evidence of past orpresent hepatitis B infection Human papillomavirus (HPV) vaccine – administer to all aged 13-26 years ifnot previously vaccinated Influenza vaccine – annually. Inactivated vaccine is recommended Pneumococcal vaccine – it is necessary for all patients with CD4 200 Polio – Inactivated polio vaccine should be given only if indicated Tetanus toxoid – same indication as patients without HIV MMR – administer to all nonimmune persons with CD4 counts of 200 ormore Varicella zoster vaccine (VZV) – consider for HIV-infected,VZV-seronegativepatients with CD4 counts of 200 or more Meningococcal conjugate vaccine – for persons aged 2 months or older withHIV infectionCytochrome P450 system metabolizes multiple HIV medications in the non nucleoside reverse transcriptase inhibitor and protease inhibitor classes. Pos sible drug interactions should be reviewed before administering new medication.Complications with HIV treatment and comorbidities present in patients withHIV leads to common prescriptions for cytochrome P450 metabolized drugsincluding benzodiazepines; cholesterol-lowering, anti-seizure, erectile dysfunctionagents, and warfarin. Additionally, herbal supplements such as St John’s wort andgarlic supplements have demonstrated adverse interaction with HIV medication.Monitoring for ComplicationsSince the start of ARV therapy, mortality of patients with HIV has decreased andcomorbidities have increased and develop at a younger age than in the generalpopulation.primary c are of veterans with hiv5c ar ing for a ve ter an with hivDrug-Drug Interaction

These complications include metabolic complication and some malignancies. As aresult, primary care clinicians have an active role in the management of patientswith HIV. Primary care clinicians with knowledge about prevention and manage ment of chronic diseases can be utilized to manage care for patients with anHIV-positive diagnosis that exhibit chronic illness as they age.OtherCounselling for behavioral risk reduction is an essential part of HIV care. At eachvisit, the practitioner should review the patient’s knowledge of HIV transmissionand his/her sexual and drug-use activities. Patients who are HIV-infected shouldavoid eating high bacterial load food items, including raw eggs, unpasteurizeddairy products, raw seafood and undercooked meat. They should not drink waterfrom untested sources. Other relevant counselling issues for patients who areHIV-infected may include pet and travel safety.Primary care providers (PCPs) are the first line in managing patients infectedwith HIV for chronic illness, psychological issues and drug complications. It isimperative that the necessary resources are provided to ensure best practices.The relevant topics will be discussed with further details in the following chap ters.REFERENCESAIDSinfo. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults andAdolescents. 2016. Accessed May 2017 from https://aidsinfo.nih.gov.Burgess MJ, Kasten MJ. Human immunodeficiency virus: what primary care clinicians needto know. Mayo Clin Proc. 2013 Dec;88(12):1488–74.Chan IWS, Chung, RWY.The basics of HIV medicine: meeting psychosocial needs of HIVpatients. Accessed Jan 2017 from http://www.info.gov.hk/aids/pdf/g190htm/05.htm.c ar ingfor a ve ter an with hivHess K, Hu X, Lansky A, Mermin J, Hall HI. Croi Conference Proceedings. Estimating thelifetime risk of a diagnosis of HIV Infection in the United States. 2016. Accessed May 2017from http://www.croiconference.org.Kruger KS, Stern SL, Anstead G, Finley EP. Perceptions of companion dog benefits on well being of US military veterans with HIV/AIDS. South Med J. 2014 Mar;107(3):188–93.Moore RC, Marquine MJ, Straus E, Depp CA, Moore DJ, et al. Predictors and barriers tomental health treatment utilization among older veterans living with HIV. Prim Care Com panion CNS Disord. 2017 Feb 2;19(1).Moyers VA, on behalf of the U.S. Preventive Services Task Force. Screening for HIV: U.S.Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2013 Jul2;159(1):51–60.Okullcz JF. ed Bronze MS. HIV in Primary Care. Medscape. Accessed May 2017 -overview.6primary c are of veterans with hiv

Pollack TM, Libman H. Primary care of the HIV-infected adult. Accessed May 2017 fromhttp://www.uptodate.com.Remien RH, & Rabkin JG.Topics in review: psychological aspects of living with HIV disease:a primary care perspective.West J Med. 2001;175.5:332.c ar ing for a ve ter an with hivSignoracci GM, Sterns-Yoder KA, Holliman BD, Huggins JA, Janoff EN, et al. Listeningto our patients learning about suicide risk and protective factors. J Hollist Nurs. 2016Dec;34(4):318–328.primary c are of veterans with hiv7

Interactions Tables

Common Medications: ARV InteractionsFor information on potential ARV interactions with the following medications,see the specified chapters:Acid-lowering medications (See Gastroesophageal Reflux Disease (GERD),p. 431)Hormonal contraceptives (See Women’s Health, p. 283)Lipid-lowering medications (See Lipid-Lowering Medications, p. 25)Psychoactive medications: antidepressants, sedatives, antipsychotics(See Psychoactive Medications, p. 41)St. John’s wort (See Food and Supplements, p. 23)Antiepileptic MedicationsCarbamazepine, phenytoin, and phenobarbital may PI and NNRTI levels sub stantially.CarbamazepineCYP450 inducerARV InteractionsPIs: may PI levels ATV: carbamazepinelevels DRV: carbamazepineAUC 45% RTV: carbamazepinelevels LPV/r: carbamazepinelevels Other PIs: may also carbamazepine levels COBI: COBI levelsCommentsShould not be used; usealternative antiepileptics. Contraindicated withATV/c or DRV/cDRV: no significant changeDRV/r: Monitor anticonvul sant level and adjust doseaccordingly.ATV/r, LPV/r: Consideralternative anticonvulsant ormonitor levels of both drugsand assess virologic response.Do not coadministerwith LPV/r QDay.Two-way interactions alsoaffect PI and NNRTI levels.NNRTIs: may levels ofall NNRTIs EFV: carbamazepineAUC 27%; EFV levelsMonitor carbamazepine andEFV/NVP levels, if possible;use alternative antiepileptics.ETR and RPV should notNote: Some medications mentioned in this chapter may not be available on the VHA National .asp). Consult VA pharmacists for alternatives.primary c are of veterans with hiv11common medic ations : arv inter ac tionsMedication

Medication-ARV Interactions36% ETR and NVP: carbam azepine and NNRTI levelsCommentsbe coadministered. RPV: expect RPV levelsNRTIsTAF: TAF possibleConsider alternative anticon vulsant.INSTIsDTG: Consider alternativeanticonvulsant. DTG: DTG levels pos sible EVG/c: carbamazepineAUC 43% EVG AUC 69% and Cmin 99% COBI expectedEVG/c: Contraindicated. Donot coadminister.EVG plus PI/r: Consider alter native anticonvulsant. EVG plus PI/r: EVGPhenobarbitalCYP450 inducerMVC: MVC levelsIf used concurrently without astrong CYP 3A4 inhibitor, giveMVC 600 mg BID or alterna tive antiepileptic agent.PIs: may PI levels DRV: phe

MPH, MSW, PMP . Senior Program Manager Ofice of Specialty Care Ser vice, VHA Bellville TX , Matt Johnston . Project Manager Instructus Media, Ltd . . System and University of Texas Health San Antonio T, exas . Gregory Aung, PharmD, BCPS, AAHIVP VA Loma Linda Healthcare System Loma Linda, California Roger Bedimo, MD, MS,