Ellis Frazier MD

Family Healthcare Inc. 1049 Western Avenue

Chillicothe, Ohio 45601mrdatafrazier@yahoo.com

&Portsmouth City Health Department Primary Care Clinic

605 Washington Street, 2nd FloorPortsmouth, Ohio 45662740-353-8863, Ext. 241efrazier@odh.ohio.gov

Exercise Adequate Sleep Stress Reduction Stopping Smoking Limited Alcohol Drinking No Recreational Drugs Eating right Having supportive family/friends/pets Adherence to Antiretroviral Regimen

I have no specific affiliation with any pharmaceutical company.

I am a primary care FP with almost 2 decades of experience of treating individuals living with HIV and/or AIDS

I am here to provide some education and insight to the issues of routine health care of individuals with HIV disease. Please try to listen, ask questions and remember to do the same with anyone who is providing care to you (infectious disease clinician, internist, nurse, pharmacist, mental health counselor and case manager). After listening ask questions to make sure you understand what was discussed and to ensure you are involved actively in you health care plan. Remember “It’s all about the patient/client/customer”.

I am not Carey Dodrill’s or Julie Carver’s lesser half– We’ve decided I am the good looking one

I will not be showing any nude photos of Kevin Sullivan or Michael McDonald in this presentation . The individuals we will discuss are fictitious characters.

Participant will understand the role of several routine health screening.

Participant will understand the importance of bilateral communication with their healthcare provider(s).

The role of self-management will be reviewed. This is different than “Self-Medicate”.

The importance of mental health care and dental health care for HIV infected individuals.

Provide universal HIV screening

Counsel patients on prevention of HIV transmission

Counsel on risk reduction measures

Provide basic monitoring of labs and routine healthcare services including health screening, immunizations, and prophylaxis along with other primary care support services that all patients should be entitled to based on age appropriate guidelines of care.

Do your providers even know each other?

Do your providers send letters to each other or fax notes from office visits?

Do they send copies of laboratory studies to each other?

Do they even know that you are seeing another specialist?

Whose responsibility is it to coordinate this?? Case manager? Patient? Primary Care Provider? Husband? Wife? Significant other?

The CDC has called for routine, voluntary HIV screening of all patients aged 13-64 in all health care settings. The agency issued:

“Revised Recommendations for HIV Testing of Adults, Adolescents and Pregnant Women in Health Care Settings"in the Sept. 22, 2006 issue of Morbidity and Mortality Weekly Report.

With 40,000 people becoming infected each year and with HIV+ patients living longer, there is definitely a need for more physicians to assume the primary care and specialty care of these patients.

About One half of the HIV sub specialists in the US have been trained in family or internal medicine.

HIV/AIDS is now considered “A chronic, manageable disease”, perhaps not unlike diabetes, hypertension, or hyperlipidemia.

Jeffery Kirschner, D.O.

Medical director of the Comprehensive Care Clinic at Lancaster General Hospital, Lancaster, Pennsylvania—Editorial “Who should care for Patients with HIV/AIDS?”

Exam Timeline

Complete history Update annually

Risk Assessment– smoking,ETOH, illicit drug use, sexualactivity, domestic violence,support systems

Update annually & brief riskassessment at each visit for ongoingappropriate screening & riskreduction counseling

Complete physical exam Annually

Vision Annually by eye care specialist,every 6 months with CD4 <100

Dental Exam Every 6 months

Coronary Heart Disease Screen1 If applicable

Breast/Testicular Exam Annually with physical

Mammogram Annually after 40 y/o

Pap Smear/Pelvic Exam2 Every 6 months (annually after 2consecutive negative Pap smears)

Discussion regarding HRT3 Perimenopausal women

Digital Rectal Exam/ PSA Annually after 50 y/o, 45 y/o withrisks

Exam Timeline

Anal Pap Smear Consider annually with h/o analreceptive sex or HPV

Colon Cancer Screening5 Annually after 50 y/o

Screening for Osteoporosis Consider in all patients on long-termARV especially in postmenopausalwomen and men withhypogonadism

STD /Hepatitis C Screen Annually & as needed

Fasting Lipids Annually after 35 y/o if not on ART,every 6 months on ART

PPD Annually, every 6 months for highrisk

Immunizations (Hepatitis A & B,Pneumovax, Td, influenza,Varicella)

See CDC guidelines

Depression Screen Annually & as needed

Diet & Exercise Every 6 months

Advanced directives Annually

Vaccine Type Recommendation

Pneumococcal (polysaccharide) Recommended for all; consider revaccination every 5 years. If CD4 count is <200 cells/µL, may be less effective; revaccinate when

CD4 count increases in response to ART.

Hepatitis A Virus (HAV) Recommended, for persons with chronic hepatitis C or hepatitis B, injection drug users, men who have sex with men, international travelers, and hemophiliacs. Consider for all, unless there is serologic evidence of previous disease. 2 doses (0, 6-12 months)

Hepatitis B Virus (HBV) Recommended, unless there is evidence of immunity (HBV surface Ab+) or active hepatitis B infection (HBV surface Ag+, or HBV core Ab+ and evidence of HBV activity). 3 doses (0, 1-2, 4-6 months)

Influenza (inactivated vaccine) Recommended (yearly) Vaccination is most effective among persons with CD4 count >100

cells/µL and HIV RNA <30,000 copies/mL. In patients with advanced disease and low CD4 cell count, inactivated

vaccine may not produce protective antibodies. Live, attenuated cold-adapted vaccine (LAIV, FluMist) is

contraindicated in patients with HIV infection.

Tetanus-Diphtheria Recommended (booster is recommended every 10 years in adults; or, if injured, after 5 years)

Measles, Mumps, Rubella (MMR) Recommended if indicated (eg, if contact with measles is likely through travel or other exposures). For live vaccine, use caution in those with low CD4 counts. Consider for all susceptible people who are not severely

immunosupressed.* Contraindicated in severe immunosuppression.

Varicella Zoster (VZV)** Consider for asymptomatic patients with relatively high CD4 counts, if they have no history of chickenpox and no evidence of immunity or significant exposure. Avoid in patients with advanced immunosuppression. Avoid exposure to VZV, if possible. If someone without immunity to

VZV is exposed to VZV, administer VZIG as soon as possible, at least within 96 hours.

Replacement approach. The average urine output for adults is 1.5 liters a day. You lose close to an additional liter of water a day through breathing, sweating and bowel movements. Food usually accounts for 20 percent of your total fluid intake, so if you consume 2 liters of water or other beverages a day (a little more than 8 cups) along with your normal diet, you will typically replace the lost fluids.

Dietary recommendations. The Institute of Medicine advises that men consume roughly 3.0 liters (about 13 cups) of total beverages a day and women consume 2.2 liters (about 9 cups) of total beverages a day.

Even apart from the above approaches, it is generally the case that if you drink enough fluid so that you rarely feel thirsty and produce between one and two liters of colorless or slightly yellow urine a day, your fluid intake is probably adequate.

Mayo Clinic Report

Drinking a reasonable amount of diet soda a day, such as a can or two, isn't likely to hurt you. The artificial sweeteners and other chemicals used in diet soda are safe for most people, and there's no evidence that these ingredients cause cancer. Some types of diet soda are even fortified with vitamins and minerals. But diet soda isn't a health drink or a cure for weight loss. Although switching from regular soda to diet soda will save you calories, some studies suggest that drinking soda of any type leads to obesity and other health problems. And healthier choices abound. Start your day with a small glass of 100-percent fruit juice. Drink skim milk with meals. Sip water throughout the day. For variety, try sparkling water or enjoy a squirt of lemon or cranberry juice in your water. Save diet soda for an occasional treat.

Mayo Clinic dietitian Katherine Zeratsky, R.D., L.D.,

there is "no magic number" for your sleep. There are two different factors that researchers are

learning about: a person’s basal sleep need – the amount of sleep our bodies need on a regular basis for optimal performance – and sleep debt, the accumulated sleep that is lost to poor sleep habits, sickness, awakenings due to environmental factors or other causes.

one thing sleep research certainly has shown is that sleeping too little can not only inhibit your productivity and ability to remember and consolidate information, but lack of sleep can also lead to serious health consequences and jeopardize your safety and the safety of individuals around you.

For example, short sleep duration is linked with: * Increased risk of motor vehicle accidents * Increase in body mass index – a greater likelihood of obesity due

to an increased appetite caused by sleep deprivation * Increased risk of diabetes and heart problems * Increased risk for psychiatric conditions including depression and

substance abuse * Decreased ability to pay attention, react to signals or remember

new information. National Sleep Foundation

PS is a 55 year old HIV+ female who recently lost her job as a school teacher . She worked for nearly 30 years in the same school district . She began having problems with increasing fatigue, weakness, irritability. She has missed several weeks of work due to her symptoms. She was asked to resign from her job using.

She comes to see you and she reports these same symptoms. She denies any recent exposure to health hazards. She has been HIV+ for 12 years and had been seeing her regular ID doctor on a routine basis and reports that she has had no change in her medication regimen and that her CD4 levels have been over 500 for over 4 years and her Viral load has been undetectable for just as long. She does state she has missed the last couple of appointments due to not wanting to miss any other days of work.

She has not traveled outside the US in a long time.

She does report tearfulness and problems with sleeping yet she always feels tired. She attributes this to having gained 40 pounds over the last six months She is concerned that her periods have been heavier than usual and have been occurring more frequently (every month and lasting 3 weeks). She has been drinking 2-3 beer at night to help her get to sleep

Ask more questions

Last GYN exam

Last time she actually did do blood work

Last hemoglobin

Ask about Diet

Ask about Family History

Thyroid Disease

Anemia

Depression

Cancer

Diabetes

Heart Disease

The PS reports that she has not had a PAP smear in 5 years because she hated the fact that she always has to have a repeat because they have been abnormal due to previous infection with HPV. She was told also she may need to have surgery. She didn’t want this. She admits to being upset and depressed about because she missed the appointment that her ID doctor ‘s staff made for her to see the GYN they told her she may need to have an endometrial biopsy.

Her hemoglobin was 8.0 which is low and her iron levels were low. Thyroid testing was normal.

Anemia--fatigue

Thyroid Disease--fatigue

Depression--fatigue

Substance Use--fatigue

26 year old single father of 2 construction worker who has been HIV+ for 2 years reports to you he has been doing well except for family problems due to finances. He is adherent to medications 100% of the time yet is frequently ill due to allergies, recurrent sinus infections and headaches, problems with sleep and fatigue. He has not had time or money to do the annual eye exam or semi-annual dental exam that his ID doctor wanted him to keep up with.

He works hard his only vice is his smoking habit of 1-2 packs of cigarettes per day and drinks ½ pot of coffee each day to get started with his day.

BJ has had several days when he worked in pain due to congestion, headache and even having a fever. It’s Sunday (no work today) so his ID doctor office is closed and he doesn’t want to go to the ER because he is afraid that his medications might be adjusted and he doesn’t want this. Nor does he want to be admitted to the hospital and have testing done because he cannot afford this. His children guilt him into going to the Urgent care where he has a temp. of 99.9, he has treated and released being told to complete the antibiotics, allergy medications, and to get more rest. He was strongly urged to stop smoking, decrease his caffeine intake and to see a dentist.

So what are the issues here with BJ

Acute illness

Sinuses

Allergies

Fatigue

Chronic Problems

Sinus infection

Fatigue

Stressors- financial, being ill, responsibilities

Caffeine

Nicotine

Dental Disease

65 year old HIV+ female scheduled for her routine visit yet says she has to cancel because she has been very ill. She has been doing well with her HIV medications (antiretroviral), has not kept track of her sugars like we wanted because she would then have to use the Insulin more and she just wants to keep on the pills. If she feels really bad she will give herself a random dose of Insulin to keep from having a high “sugar attack”

She did not get the last set of blood work that was asked for because her HIV labs have been okay and she felt that I was just trying to put her on more medications because she not been adhering to her diet and she knows her cholesterol will be higher than the 325 level it was 6 months ago.

She denies diarrhea but is having night sweats. She missed the mammogram appointment and also did not get her bone density study done. She did get her flu shot last fall. She did promise to reschedule. Her main concern is that she is getting more fatigued, short of breath and feels she needs some vitamins because she cannot even vacuum her floors without getting short winded. She know that her 1 ½ -2 ppd cigarette habit contributes to this shortness of breath.

The DAD trial 23,437 HIV-infected patients, most of whom were treated in Europe, 345 developed myocardial infarction (MI) during 94,469 person-years of observation. Overall, in a multivariate model, potent combination antiretroviral therapy increased the risk for MI by 16% per year of exposure, compared with no treatment.

Although these findings certainly point to HIV treatment — and PI use in particular — as risk factors for MI, we as clinicians must not infer that a "silent epidemic" of cardiovascular disease exists that somehow negates the hugely beneficial effect of HIV treatment overall. As nicely summarized by editorialists, the overall effect of antiretroviral therapy on MI risk was quite small.

The surprising results from the SMART study, showing an increase in cardiovascular events related to treatment interruption (ACC Nov 29 2006), suggest that the most dangerous clinical state for the overall health of our patients is being off treatment entirely — and, of course, smoking cigarettes!

Total Cholesterol Level Category Less than 200 mg/dL

Desirable level that puts you at lower risk for coronary heart disease. A cholesterol level of 200 mg/dL or higher raises your risk. 200 to 239 mg/dL Borderline high 240 mg/dL and above

High blood cholesterol. A person with this level has more than twice the risk of coronary heart disease as someone whose cholesterol is below 200 mg/d

HDL Cholesterol LevelCategory Less than 40 mg/dL (for men) Less than 50 mg/dL (for women)

Low HDL cholesterol.

A major risk factor for heart disease. 60 mg/dL and above

High HDL cholesterol.

An HDL of 60 mg/dL and above is considered protective against heart disease.

LDL Cholesterol Level Category Less than 100 mg/dL Optimal

100 to 129 mg/dL

Near or above optimal 130 to 159 mg/dL

Borderline high 160 to 189 mg/dL

High 190 mg/dL and above Very high

The American Diabetes Association acknowledges these as normal blood sugar for healthy people who do not have diabetes: fasting/before eating < 100 mg/dl

bedtime 120 mg/dl

A1c blood sugar test (3 month blood sugar indicator)      <6%

What does the American Diabetes Association recommend for those with diabetes?

The American Diabetes Association recommends the following blood sugar goals for those with diabetes:

before eating (pre-prandial plasma glucose)  90-130 mg/dl

1-2 hours after the beginning of eating (peak post-prandial plasma glucose) <180 mg/dl

A1c blood sugar test (3 month blood sugar indicator)     <7%

What do other organizations recommend for blood sugar goals?

The American Association of Clinical Endocrinologists (endocrinologists are medical doctors specializing in disorders including diabetes) recommends the following blood sugar goals for those with diabetes: before eating (pre-prandial) 110 mg/dl

2 hours after eating (post-prandial) 140 mg/dl

A1c blood sugar test (3 month blood sugar indicator)     <6.5%

HIVANHIV associated nephropathy

STD Testing

Depression The great mimicker

Triglyceride Level Category Less than 150 mg/dL Normal

150–199 mg/dL Borderline high

200–499 mg/dL High

500 mg/dL and above Very high

“Cigarette smoking is the most important modifiable cardiovascular risk factor among HIV-infected patients.”

Marion is a 46 year old HIV+ male with bipolar disorder who is brought in to see you by his partner and ex-wife who both don’t know what to do with him he has stopped taking his medications for his HIV and for his bipolar disorder. He has just spent $32,000 of his recent disability settlement (on an internet investment project– a High rise condominium complex in Wellston Ohio).

He has not slept in days and despite their lack of caring for each other the partner and ex-wife want to know what to do to get him on his medications. They are both worried that he will develop resistance to his medications and that he will need to change to another regimen.

The patient is insisting on writing down details of “how you can improve your patient flow efficiency and suggests you let him be your office manager”

What do you do??? What’s the problem here??

Resourceswww.aahiv.orgwww.aidsinfonet.orgwww.aidsinfo.nih.govwww.iasociety.orgwww.nrharural.orgwww.aids-ed.orgwww.aids.govwww.aidsetc.orgwww.aidsmeds.comwww.thebody.com

AIDS Education and Training Center

Clinical Manual for Management of the HIV-Infected Adult

www.aids-ed.org

Research suggests that primary care physicians do not routinely perform risk assessments for HIV infection, often missing clinically important risk behaviors and failing to include HIV infection in the differential diagnosis.