The 1-2-3s of HIV (Human Immunodeficiency Virus)
This is the second installment article following up from the status neutral model approach. This article will include information on 4th generation testing, basic HIV disease progression, U=U, and PrEP/nPEP options available. There is also a link included that has a document crafted for primary care providers and providers who treat substance use disorders regarding prescribing, labs, and monitoring individuals on PrEP. While extensive, this document has easy to follow flowsheets, tables, billing/coding and clinical hotline information for PrEP and nPEP.Did you know that the HIV epidemic has been around for over 40 years? Luckily, with the knowledge obtained, testing availability, and medication advancements HIV is now akin to any other chronic disease (like hypertension or diabetes).
HIV is a bloodborne pathogen (meaning that there must be an exposure to infectious blood to be transmitted). The virus in the blood attacks a type of white blood cell called a T cell changing the structure of the cell and then using that cell to replicate other altered cells. It is for this reason that HIV can go undetected by the body's immune system (in some instances there can be 10-12 years between exposure and symptom development). There are three stages to the HIV disease progression.
Stage 1 is the acute stage. There is a 2-week window period that the virus builds in the body. Stage 1 occurs approximately 2 weeks after initial exposure. During this stage someone is very contagious. Some people will present with flu-like symptoms (fever, chills, muscle aches, sore throats, fatigue, etc.), others will have no symptoms at all. Stage 2 is the chronic phase of disease development. It is a latent period that allows the disease to progress. This means that while the viral level is increasing, the T cell count is decreasing. Since there are no symptoms, HIV often goes unnoticed allowing the virus to spread through communities. Testing is incredibly important and depending on the lifestyle of individuals ongoing testing is vital. The gold star of testing is the 4th generation test that can recognize HIV antigens and HIV antibodies approximately 30 days post exposure (remembering that there is a 2-week window period). Detection allows for earlier linkage to care and healthier outcomes. Once an individual has been on antiretroviral (ART) medications, they can achieve an undetectable viral load. This status means that they cannot transmit HIV to other people (U=U or undetectable equals untransmittable). Stage 3 is Acquired Immunodeficiency Syndrome (AIDS). This stage is now called advanced HIV because of the stigma that surrounds the virus. During this stage, a person will have a high viral load and be very infectious. Diagnosis of stage 3 occurs when the T cell count is below 200/mm or there is a development of one of the opportunistic infections identified by the CDC. Without treatment at this stage, it will lead to a diminished life expectancy.
Recently, I had written a short article on the status neutral approach. It is a new twist on an old idea. Each person who comes through a clinic door is tested for HIV and with those results the provider explains either the HIV prevention path or the HIV treatment path. I like to think it comes down to three simple questions and depending on the answer it will let you know which path you are on, and the additional information needed to move forward. Question 1-- have you ever had sex, injected substances or gotten a tattoo from an unregulated source? Question 2—is the total number of sexual partners more than one in your lifetime? Question 3—did you use a barrier (condom/dental dam, etc.) during the sexual contact or share syringes/works (cooker, tourniquet, water, cotton/filter, straw, etc.)? Easy right? The prevention path includes things like education, condoms, harm reduction and PrEP/nPEP medications. The treatment path includes linkage to care to obtain medication, Ryan White services, partner services/supports, and viral suppression (U=U).
Taking Pre-Exposure Prophylaxis (PrEP)/nonoccupational Post-Exposure Prophylaxis (nPEP) is like having insurance. You question why you need it when you pay the monthly premiums, but you are glad you have it in place when things happen. Let's start at the beginning, in 2012 the oral PrEP pill Truvada (TDF/FTC) was approved by the FDA to prevent people (adults and adolescences weighing at least 77lbs) from contracting HIV despite their participation in sexual behaviors without a barrier and people who engage in injection practices. This medication has been proven effective in male and female (cis and transgender) individuals. Since then, the FDA has approved the oral pill Descovy (TAF/FTC in 2019) to be utilized in cis gender men and transgender women populations and the intramuscular injectable Cabotegravir (Apretude in 2021) that can be given to male and female (cis and transgender) individuals every 2 months. This eliminates the barrier of taking a pill every day. nPep is any medication that is provided after an exposure to prevent or decrease the disease response. This is not a new idea in medication, historically it had been useful in incidences of Tetanus, Rabies, Anthrax and recently COVID. In the case of HIV, within 72 hours after an exposure a 28-day regiment of medications should be dispensed. For more in depth information specifically crafted for primary care providers and providers who treat substance use disorders, I have included a link regarding prescribing, labs, and monitoring individuals on PrEP US Public Health Service: PREEXPOSURE PROPHYLAXIS FOR THE PREVENTION OF HIV INFECTION IN THE UNITED STATES – 2021 UPDATE, A CLINICAL PRACTICE GUIDELINE (cdc.gov). While extensive, this document has easy to follow flowsheets, tables, billing/coding and clinical hotline information for PrEP and nPEP (855-448-7737).
If you would like to discuss this or other related topics. Don't hesitate to reach out to me.
Center for Disease Control and Prevention (CDC). 2019, April 26. Comprehensive HIV Prevention Services. Retrieved from Comprehensive HIV Prevention Services | THRIVE |Research | HIV/AIDS | CDC
Center for Disease Control and Prevention (CDC). 2022, December 1. HIV Basics. Retrieved from HIV Basics | HIV/AIDS | CDC
Centers for Disease Control and Prevention (CDC). 2021. US Public Health Service: Preexposure prophylaxis for the prevention of HIV infection in the United States—2021 Update: a clinical practice guideline. Retrieved from https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2021.pdf.
Medical News Today. 2019, March 1. What is 4th Generation HIV test?. Retrieved from https://www.medicalnewstoday.com/articles/323901
Written by Chera H. Mattox, MPH