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COVID-19: Special Considerations for People Living with HIV
Covid 19 VirusThis document on COVID-19 considerations for people living with HIV (PLWH) is intended as a resource for clinicians and public health officials. The information is based on best practices in areas that have been heavily impacted by COVID-19 and will be updated as new information and data become available. This information is not intended to supersede existing clinical practice guidelines, nor should it be construed as a care directive. For HIV treatment, refer to the HHS Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV and the HHS HIV/AIDS Guidelines Panels Interim Guidance for COVID-19 and Persons with HIV. Email HIVMA with suggestions or questions and visit the IDSA COVID-19 Resource Center for additional resources.

Patients with HIV Hospitalized with COVID-19

  • PLWH on treatment have a normal life expectancy. Therefore, HIV status should not be a factor in medical decision-making regarding the triaging of potentially lifesaving interventions or enrollment into clinical trials. Since HIV is eminently treatable, whether HIV is currently controlled or not should also not be factor in triaging clinical care interventions for COVID-19.
  • Care and treatment for COVID-19 in PLWH should follow the same protocols advised for patients without HIV. See IDSA Guidelines on the Treatment and Management of Patients with COVID-19.
  • As noted in the HHS Interim Guidance for COVID-19 and Persons with HIV, there are no data indicating that PLWH will get sicker than people without HIV or will have worse outcomes. However, >50% of PLWH in the U.S. are older than 50, and many have comorbid conditions such as cardiovascular disease, hypertension and diabetes that confer risk for more severe illness and death.
  • Until more data are available heightened awareness for severe disease should be considered for persons with HIV, particularly those with CD4+ T cells <200/mm3 or viral loads > 5000/ml (see Interim Guidance).
  • Consultation with an HIV or infectious diseases (ID) specialist is strongly recommended for people with HIV who are hospitalized for the treatment of COVID-19.
  • If HIV or ID expertise is not available locally, the national Clinician Consultation Center maintains an HIV management warmline Monday to Friday from 9 am ET to 8 pm ET. HIV treatment consultation is available by leaving a voicemail message at (800) 933-3413 or submitting a case online (registration required). The service responds to voicemail messages as soon as possible with the average response time being 30 to 60 minutes during their business hours. Cases submitted online are responded to within one business day.
  • For pregnant women with HIV, the Perinatal HIV/AIDS Hotline -- (888) 448-8765 provides 24 hour/7 day week consultation services.
  • Antiretroviral therapy should be continued during hospitalization without interruption and changes in therapy are generally not recommended.
  • For patients who have not initiated antiretroviral therapy or have been off therapy for > 2 weeks prior to hospitalization, consult with an HIV or ID specialist about a safe plan for initiating antiretroviral therapy.
  • If a patient is on a COVID-19 clinical trial with a drug active against HIV, an HIV or ID specialist should be consulted to ensure their HIV therapy remains appropriate and that a complete HIV antiretroviral regimen is maintained.
  • Medications used for treatment of COVID-19 may interact with some HIV medications. The Liverpool Drug Interaction Group is maintaining prescribing resources for experimental COVID-19 treatments including drug interaction information.
  • For patients who are not able to swallow, consult an HIV or ID specialist. Also refer to a resource like this one from the Toronto General Hospital on Oral Antiretroviral/HCV DAA Administration: Information On Crushing And Liquid Drug Formulations.

Diagnostic Testing

Due to high rates of cardiovascular disease, lung disease and diabetes in addition to a high prevalence of smoking, people with HIV who are experiencing fever or signs/symptoms of a lower respiratory tract illness should be prioritized for diagnostic testing (see IDSA’s COVID-19 Prioritization of Diagnostic Testing) regardless of their viral load status or CD4+ T cell count. We have insufficient data in people living with HIV at this time to suggest what laboratory parameters comprise increased immunologic risk for severe COVID-19 disease.

Issues for Ambulatory HIV Care Management

Social and Physical Distancing

It is important to educate all patients on the importance of following the CDC guidelines to promote physical distancing and to wear cloth face coverings in public to reduce spread of the virus. Clinic and clinical protocols should be adjusted to support social distancing through telehealth and home delivery of medication when possible. Additional support for persons experiencing housing insecurity is warranted. Share with your patients this resource maintained by HIVMA and allies COVID-19 and People Living with HIV – Frequently Asked Questions.

HIV Treatment

Changes in antiretroviral therapy to prevent or treat COVID-19 are generally not recommended, except in the context of a clinical trial and in consultation with an ID or HIV specialist. Please refer to the HHS Interim Guidance for COVID-19 and Persons with HIV.

HIV Viral Load Monitoring

For patients presently with suppressed HIV and no adherence concerns, consider delaying routine viral load monitoring for up to an additional six months. Patients who have recently initiated antiretroviral treatment and are not yet virally suppressed and patients with adherence or drug resistance concerns should be prioritized for viral load testing. By deferring RNA testing in people who are virologically suppressed on antiretroviral therapy, we can lessen the burden on clinical virology laboratories and the health-care workforce while avoiding additional exposure to our patients. Deferring other safety labs (blood counts, kidney function) can also be considered in patients for whom these results have previously been stable.

Routine Office Visits

For stable patients, or patients with non-urgent appointments, schedule a telephone or telehealth encounter if that is an option. Check with your patients to see if they have COVID-19 questions. For patients with non-respiratory urgent concerns, consider keeping the appointment or offering a telehealth or telephone visit. The American Society of Addiction Medicine has guidance on maintaining access to buprenorphine by leveraging telehealth.

HRSA’s HIV/AIDS Bureau is encouraging the use of telehealth in Ryan White clinical settings to support social distancing and refers to PCN #16-02 in support of the policy. The Center for Connected Health Policy is a resource for updates on state telehealth policies. ACGME has issued guidance regarding residents and fellows participation in telehealth visits. For protocols for telehealth and in person appointments, please see the Clinical Policies & Protocols section of the resource center. Also see IDSA’s Medicare Telehealth: What You Need to Know.

Prescription Drug Refills

Patients should maintain at least a supplemental 30-day supply of their medications to prevent the possibility of treatment interruptions. A number of health insurers and state AIDS Drug Assistance Programs are allowing early medication refills and lifting quantity limits in addition to making other changes to their coverage policies. Information on the policies of large health insurers is available in the IDSA COVID-Resource Center. Many health insurers require patients to have a new prescription to obtain a 90-day supply and/or switch to mail order. Please check with your patients to see if they need a new prescription.

Ryan White HIV/AIDS Program

The HIV/AIDS Bureau maintains an online Frequently Asked Questions resource that is regularly updated with questions raised by Ryan White Program grantees.

The National Alliance of State and Territorial AIDS Directors maintains a COVID-19 Updates & Resources with information on antiretroviral supply chain issues, state ADAP policies and other public health updates.

Source: https://www.idsociety.org/globalassets/covid-19-special-considerations

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