HIV Training in General Medicine

By: Marcus J. Hopkins, Policy Consultant

HIV in the United States is an issue that isn’t going away, anytime soon, despite the fact that the incidence of new infections has continued to decline annually since 2012 (Centers for Disease Control and Prevention, 2018). Other bright spots exist on the HIV front, as well:

• The majority of HIV treatments released since 2010 have been easy-to-tolerate, single-pill regimens, cutting down on the number of medications patients have to take to achieve and sustain viral suppression;

• Patients no longer have to wait until they are diagnosed as “AIDS” in order to begin treatment (as was the case when I was first diagnosed), initiating treatment immediately upon receiving an HIV diagnosis;

• Fourth- and Fifth-Generation HIV combination testing assays have reduced significantly the time between initial infection and the time when HIV can be detected down to 1 month or 14 days (respectively);

• The reality that treatment will soon be available in once-monthly long-term injectable form; and

• Data indicating that people with undetectable HIV viral loads cannot transmit the disease to others.

These bright spots all point to one thing: the time has come to begin taking HIV out of the realm of specialized medicine, and into the general practice.

When HIV first hit the medical scene in the early-1980s, circumstances required that the disease become the provenance of Infectious Disease (ID) specialists.  As times have progress, however, HIV has become increasingly easier to diagnose, treat, and manage, so much so that conversations need to be had about beginning to shift at least some aspects of treatment off of ID docs, and over to General Practitioners (GPs).

This is particularly true when it comes to prevention – a task which was supposedto be falling to GPs in the form of biannual HIV, STD, and STI testing, but which GPs have been notoriously lax in doing (a topic for another blog, really). That said, we have at our fingertips one of the most effective methods of preventing HIV transmission in the history of the disease: Pre-Exposure Prophylaxis (PrEP).

Photo Source: POZ

PrEP, for the uninitiated, is the medical repurposing of HIV drugs – Truvada (emtricitabine and tenofovir disoproxil fumarate) and, soon, Descovy (emtricitabine and tenofovir alafenamide fumarate) – that, when taken properly, can prevent the spread of HIV via sexual contact by more than 90% and by more than 70% among People Who Inject Drugs (PWIDs). This is an amazingtool that can be used to essentially eliminate the risk of HIV transmission in the U.S. and, potentially, around the world.

The problem? Nobody’s using it.

In 2017, there were a total of 100,282 PrEP users in the United States (AIDSVu, 2019). There were roughly 1,008,929 people living in the United States who are diagnosed with HIV in 2016 (CDC), and the total U.S. population is 327,200,000. If we subtract that 1,008,929, we’re left with approximately 326,191,071 people in the nation who are notinfected with HIV. That means that 0.03% of the non-HIV-infected U.S. population was prescribed PrEP.  Granted, not every single one of those 326,191,071 people face a high risk of HIV infection, particularly if take into account the number of children. That said, the number of PrEP users is astonishingly low.

Among the various barriers to receiving PrEP – financial barriers, social stigma-related barriers, geographic barriers – perhaps the biggest hurdle faced by patients who would like to take advantage of this groundbreaking prevention method is that few medical providers know anything or enough about the drug, its utilization, and HIV to be comfortable prescribing the regimen. This is troubling, because PrEP – the medication – can be prescribed by literallyany prescribing physician (although payor approval may require consultation with or prescribing by a ID specialist).

A recent study published in the Journal of General Internal Medicine found that even though 96% of 229 internal medicine residents surveyed had heard of PrEP, more than half rated their knowledge of the medication and its side effects as only fair or poor (Terndrup, et al., 2019). The authors write, “Residents who rated their knowledge more highly reported a greater likelihood of prescribing PrEP in the future.”

Photo Source: Business Insider

Essentially, the more physicians know about PrEP, the likelier they are to prescribe the regimen – a drum that PrEP advocates and activists have been beating since the regimen first became available in 2012. Seven years after it was first made available for prevention purposes, and only 0.03% of the non-HIV-infected U.S. population is utilizing this tool? That’s simply unacceptable.

With all of these advances in HIV prevention tools and treatment, for proactive patients (like myself), HIV has largely become a “maintenance” disease. I take my meds every night, at Midnight, I see my ID specialist twice a year, and the majority of our conversations are collegial in nature about my work in viral hepatitis. I have my blood drawn, I see my Ryan White caseworker, and I have my prescriptions renewed. I am a low-maintenance patient.

For me, and patients like me, my HIV maintenance is something that could essentially be shifted off onto a GP, allowing my ID specialist to focus his time and efforts onto patients with greater needs and/or challenges. This additional focus could potentially allow those higher-maintenance patients to become better stewards of their own health, eventually allowing them to ideally move their treatment over to a GP, as well. In this ideal scenario, where GPs are better educated, trained, and knowledgeable about HIV and its various treatment regimens, this could potentially open up dozens of new provider options, reducing the need to travel to ID specialists, and instead receive treatment from someone more local.

For patients who are not living with HIV, increased GP training, education, and knowledge about HIV and its prevention via PrEP has the potential to exponentially increase utilization of PrEP and decrease new HIV infections, even among PWIDs – a growing concern in areas of the country hardest hit by the opioid epidemic (i.e. – rural and suburban areas of the country). In areas where ID specialists are rare, the option of being prescribed a preventative medicine to prevent HIV infection by a local GP would be a godsend.

Terndrup’s study indicates that residents are more likely to prescribe if they have more knowledge. This is something that can and should be easily provided to them, and it is incumbent upon those in charge of these residency programs to begin instituting HIV training within their programs.

References:

• AIDSVu. (2019). 2017 PrEP Data – AIDSVu. Atlanta, GA: Emory University: Rollins School of Public Health: AIDSVu: Tools & Resources. Retrieved from: https://aidsvu.org/wp-content/uploads/2019/01/AIDSVu_State_PrEP_2017_2.xlsx
• Centers for Disease Control and Prevention. (2018, November). HIV Surveillance Report, Vol. 29. Atlanta, GA: United States Department of Health and Human Services: Centers for Disease Control and Prevention: National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention: Division of HIV/AIDS Prevention. Retrieved from: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-2017-vol-29.pdf
• Terndrup, C., Streed, Jr., C.G., Tiberio, P., Black, M., Davis, J., Apfel, A., Blackstock, O.J., Edelman, E.J., & Berkenblit, G. (2019, April 24). A Cross-sectional Survey of Internal Medicine Resident Knowledge, Attitudes, Behaviors, and Experiences Regarding Pre-Exposure Prophylaxis for HIV Infection. Journal of General Internal Medicine. DOI: https://doi.org/10.1007/s11606-019-04947-2

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.