2022 MCO Training Michelle Agnoli RN MSN Clinic Nurse University of Illinois Chicago UI Health Community Outreach Network What We Will Be Covering HIV 101 HIV Metrics and Clinical Expectations ID: 934271
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Slide1
Medical Management of Persons Living with HIV
2022 MCO TrainingMichelle Agnoli, RN, MSNClinic NurseUniversity of Illinois, ChicagoUI Health Community Outreach Network
Slide2What We Will Be Covering
HIV 101HIV Metrics and Clinical ExpectationsStrategies to Suppress Viral LoadReporting Procedures
Slide3HIV 101
Slide4Objectives
What is HIV? How is it transmitted?What is the normal progression of the disease?
Slide5What is HIV?
HIV: Human Immunodeficiency VirusDestroys immune system so that it cannot fight infectionsSpecifically our T-helper or CD4 cellsIt is related to the Simian Immunodeficiency VirusThought to jump into humans via the butchering and consummation of monkey meat
PLWH-Person Living with HIV
Slide6Difference between HIV and AIDS
HIV-Human Immunodeficiency VirusVirus that destroys immune systemCan have HIV, but not have AIDSAIDS-Acquired Human Deficiency SyndromeHave HIV
Have progressed to end stage HIV infection
CD4 or T-helper count below 200
AIDS defining infection
Slide7How is HIV transmitted
Condomless intercourseAny kindBlood-bloodBlood transfusionsOrgan transplant
During pregnancy and delivery
Re-use of needles
Sharing of needles
IVDU
Sharing of needle
Contaminated medical equipment
Breast-milk
Slide8Progression of HIV Disease
Once HIV enters the body, through one of the routes of transmission, it selectively attacks the cells in our body responsible for our immunity, our protection from diseaseIf left untreated, HIV will destroy our body’s natural defenses against germs in about 10 years, leading to deathIf we give antiretroviral therapy, we can restore the immune system to near normal function and normal life-expectancy for a person
Slide9Terrible Game of Catch-Up That Never is Won
HIV destroys CD4 cells as it reproduces itselfHIV uses our own cells to reproduce itselfEventually, our bodies cannot produce enough CD4 cells to keep pace with the HIV’s ability to destroy themThat is when our CD4 counts decline and approach zero
Antiretroviral Medications can stop this
Slide10Once HIV has completed its replication cycle, it bursts out of the CD4 cell, rupturing the CD4 cell membrane, destroying the cell.
Slide11Viral Load and Relationship to CD4 Count-Inverse Relationship
Natural Course of Disease
With Antiretroviral treatment
Slide12Undetectable = Untransmittable
Slide13Slide14CD4 Count Response After ARV
Usually anticipate a 50-150 cell rise within several months of initiating therapy
Slide15Getting to Zero U = U
If we can have patients take their medications to suppress viral load, this makes it nearly impossible to transmit HIV to another personUndetectable = Untransmittable
Slide16HIV Metrics & Clinical Expectations
Slide17Definitions
For our conversationMetric will equal a measurementHIV is the Human Immunodeficiency Virus, the virus that infects exposed personsAIDS is the Acquired Immune Deficiency Syndrome, which indicates that a person’s HIV infection has progressed to a point where they are at risk for opportunistic infections
Defined as T-cell or CD4 count under 200 cells/mm
Being diagnosed with an opportunistic infection (examples: KS, PJP, histoplasmosis, Active TB)
Opportunistic Infection-to understand what an Opportunistic Infection, or OI is, we need to understand we have bacteria, viruses and fungi that live in and on our body. When our body is healthy, these don’t cause illness in us. When our immune system is weakened by illness, these germs can then cause illness that normally not be a problem
Slide18Lab Values Monitored
CD4 lymphocyte, T-cell, Helper T-cell, T-lymphocyte: all the same name for a specialized immune cell in our body responsible for helping to coordinate our response to germs, be it a virus, bacteria of fungus. HIV targets and destroys these cells in the bodyViral load or HIV-RNA PCR: the amount of HIV virus in the body-yes, we can measure how many virus copies are in a mL of blood
AIDS-is defined by the level of CD4 lymphocytes, under 500 cells, we see signs of problems with our immune system, thrush, frequent bacterial infections, skin infections. Under 200 CD4 cells, we define as AIDS, or severe immunocompromise. Life-threatening opportunistic infections can happen if your CD4 count is under 200.
Slide19Goals for Labs
CD4-as close to a normal CD4 count as we can getNormal 500-1400 cells/mm3Viral Load-as suppressed as we can get (IL Medicaid quality measure)DHHS Guidelines-maximally and durably suppress
under 200 copies/mL
This is a recommendation not a law
https://clinicalinfo.hiv.gov/en/guidelines
Slide20Other Labs That Will Be Monitored
Slide21What IL Medicaid HIV quality/pay for performance measures?
Viral Load Suppression: The percentage of members living with HIV with an undetectable viral load (less than 200)Health of patient depends on VL suppressionDecreased number HIV Cased depends on VL suppression
Gap in HIV medical visits: Percentage of members living with HIV who did not have a medical visit in the last six months of the measurement year
Members living with HIV should see their provider for HIV care and labs every six months (2x per year)
Patients that aren’t engaged with their medical provider are more likely to not be taking their meds, need more support and may be become sicker
Prescription of HIV antiretroviral therapy: Percentage of members living with HIV who are prescribed HIV medications during the year
Every member with HIV should be taking HIV medications daily
More medication prescribed, better controlled illness, better health, better life!
Slide22Strategies to Suppress Viral Load
Slide23Medications
Antiretroviral Medications (ARVs) are used to suppress the HIV virus to a range we refer to as undetectable (under 200 copies/mL)When do they get started? There are several scenarios:Acute HIVTest and Treat
When client is ready
AIDS diagnosis, with or without OI
Guidelines give suggestions on what medications to start with
Based on latest research
Slide24Viral Load Suppression: Support
Relationship with patient is first key to achieving viral load suppressionMedicationExplaining to patient why medication is neededDispelling myths and fears regarding medications (my friend died from taking “that” medication)
Working with patient to choose a medication that will work for their life-style
Explaining side effects and when they should call the doctor
Insurance system is complicated. This whole world of insurance and prior authorizations is new and baffling to our patients. But nearly all HIV meds are covered by IL Medicaid MCOs.
Understanding
Everything that goes with a diagnosis of HIV. Many cannot share diagnosis for fear of domestic violence, alienation, loss of jobs, family, etc.
Sharing with patient that they can have intimate relationships, U=U, and how medication is the way to physical, mental and sexual health
Slide25Viral Load Suppression: Behavioral Interventions
Pill boxes, pre-filled bubble packs from pharmacyEncourage medication to be taken same time, every dayTimers, phone alarmsMedication adherence studies, MEMS capsA buddyEncourage pill taking/other behaviors (injection use)
Slide26Barriers to Achieving Viral Suppression
Competing prioritiesSometimes health isn’t our patients’ first priorities. Kids, jobs, housing, mental health issues, issues of addiction and sobriety may come first.Social determinants of healthStigma
Toward self
From others
Prior experience with healthcare/insurance systems
Prior bad experiences
Care that doesn’t reflect culture
We are most comfortable in settings that we can see ourselves in, and can trust that we will be accepted
If I am fearful of being insulted or berated in the place I seek help for healthcare, and am likely not going to follow through with recommendations, because, you don’t know and aren’t willing to understand what it is like to experience life and illness as I do. Being able to connect with a patient at that level, to be open, provides an amazing opportunity to partner together for success in the health outcomes that you have together have designed.
Slide27Reporting Procedures
Slide28What is Reportable
The Illinois AIDS Confidentiality Act outlines provisions for testing, disclosure of results and reporting of positive results to the health authority (410 ILCS 305/) AIDS Confidentiality Act.
Executive Order 2019-08 Executive Order Strengthening the States Commitment to Ending the HIV Epidemic
Take action to end HIV epidemic and reduce health disparities
Monitor viral load metrics
Slide29Clinic-MCO Partnership
JG is gentleman, 65 years old, who was in an assisted living facility and left on his own accord because he was afraid of getting COVID-19 in 3/2020. He has been HIV-positive since 1999 and is currently on biktary, Remeron and metformin. He went to his daughter’s home and was taken to the hospital and had a week stay due to COVID-19. He was released into his daughters care. He came to clinic and clinic physician received an alert that his blood sugar was 599. Patient called and counseled to go to ER for treatment, but refused. Clinic contacted patient’s case manager to see what assistance could be gotten for patient for home diabetes education, and medication adherence. Daughter’s home not conducive for client, he was sleeping on a broken couch and grandchildren would steal his food. Patient enrolled in the MCO high-risk client program and was monitored monthly with intradisciplinary team meetings with case manager, clinic nurse and MCO team to determine care needs and intervention for client. Home health nurse reported back to team that pills found on floor and client unable to verbalize how to take or if he had taken meds that day. Neuropsychiatric testing ordered. It was determined client could not make decisions for himself or manage insulin injections or blood sugar monitoring. With the assistance of the MCO team, the client is again placed in an assisted living facility that is supportive to his needs and is now adherent to both HIV and diabetes therapy.
Slide30Summary
HIV is the virus that selectively destroys T-cells (helper T-cells, CD4 cells are all other names for T-cells)AIDS is when HIV-infection has progressed to a point where the T-cell count is below 200, or a patient has been diagnosed with an opportunistic infectionAntiretroviral medication used to treat HIV-infection can prevent the progression to AIDS and allow a person living with HIV to live a normal life
Partnering with patients to empower their understanding of their disease, the medications and providing a safe and understanding, supportive environment is key to viral suppression
MCO-patient partnership also key in keeping our patients healthy
Slide31Summary (continued)
All members with HIV should: Be taking HIV medications daily (quality measure – prescription of ARVs)Visit their provider for HIV-related care (labs and other care) twice a year, more often if needed (quality measure - gap in medical visits)Try to become virally suppressed (quality measure – HIV viral load suppression)
Slide32Resourses
HIV Guidelineshttps://clinicalinfo.hiv.gov/en/guidelineshttps://www.cdc.gov/hiv/guidelines/index.htmlHow Antiretroviral Medications Work
https://www.youtube.com/watch?v=9aDNwlRaJqw
How to Explain What Undetectable Means to Your Patients
https://www.helpstoptheviruspro.com/hiv-patient-support/undetectable-viral-load
Slide33Contact Info:
Michelle Agnoli, RN, MSNUI Health Community Clinic NetworkUniversity of Illinois at Chicago
magnoli@uic.edu
312-519-2668