sc-COVID19-Update-for-PWH_Section-3_040320.pptx

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Section 3: Routine HIV Primary Care, COVID-19 Risk Reduction, Management of Patients & Staff with COVID-19

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COVID-19 Updatefor Patients with HIV
Section 3:
Routine HIV Primary Care, COVID-19 Risk Reduction,
Management of Patients & Staff with COVID-19

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V_04032020
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Slide Set Contributors
Avenue 360, Houston: C.Mark Nichols, DDS
Baylor College of Medicine: Shital Patel, MD; Melanie Goebel, MD
Gallup IHS: Jonathan Iralu, MD, FACP
LSUHSC: Paula Seal, MD MPH
PHNT: Deborah Morris-Harris, MD, EMBA
UNMHSC: Carly Floyd, Pharm D PhC AAHIVM; Nestor Sosa, MD; Meghan Brett, MD; Michelle Iandiorio, MD
Valley AIDS Council: Pedro Coronado

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Learning Objectives
Recognize the current pandemic and how it is effecting the nation and region.

Recognize the risk factors for severe COVID-19.

Identify strategies to reduce risk of COVID-19.

Identify strategies to stay healthy during COVID-19 pandemic that People with HIV (PWH) should consider.

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PLWH now PWH per HRSA guidance
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GUIDANCE FOR PROVIDING CARE FOR PEOPLE WITH HIV IN THE SETTING OF COVID-19
Melanie Goebel, MD; Infectious Disease Fellow, BCM
Shital M. Patel, MD;
Assistant Professor, Infectious Disease; Clinical Director BCM AETC
Baylor College of Medicine
Pedro Coronado; Valley AIDS Council
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Guidance for all PWH
Maintain adequate (> 30-day, ideally > 90-day) supply of ART and other chronic medications
Mail order delivery if possible
Delay switching ART regimens if feasible

Keep vaccinations (influenza, pneumococcal) up to date

Follow CDC recommendations for travel recommendations, social distancing and hand hygiene

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Routine Care
Patients should check with their healthcare provider to see if they should reschedule their visit, convert it to a telephone visit, or come for an in-person check

May be safe to delay HIV viral load monitoring by 6 months in those with good adherence and current viral suppression

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Consider telephone or virtual visits for routine or non-urgent care
Weigh risks versus benefits of face-to-face encounters
Telehealth options: Telephone visits, TeleMedicine visits, TeleECHO consultation
Postpone medical and laboratory visits for patients with stable health and well-controlled HIV
Patient self-collection of swabs [STI self-swab posters http://uwptc.org/]
Develop plan for evaluating patients with symptoms of COVID-19

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Patient Care Jumping in Uncharted Waters
Telemedicine
Zoom Health
Healow eCW's
Phone Visits
Phone Triage
Routine Visits Rescheduled if Possible; usually when telemedicine is not an option

Linkage to Care / Retention to Care
Ryan White Eligibility
Intakes (Phone, Zoom Health)
Documentation
Assessments
Transportation
Safety Measures

Case Management RW Part D Model
Tele-Case Management
Zoom
Medication Assistance
Support Services
Food Cards
Transportation Vouchers
Referrals for Health Care Services
Health Insurance Assistance

Safety Measures
Sanitation Stations
Front Desk Triage

Safety Measures
Department leaders in constant contact
With each other
With Staff
Skeleton Crew Implemented

Zoom for:
Interviews
Meetings
Morning Huddles
All hands on deck to sanitize
Your area
Common areas
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COVID-19 AND ORAL HEALTH CARE
C.Mark Nichols, DDS
Director of Dental Services, Avenue 360 Health and Wellness, Houston
Dental Director, South Central AETC
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COVID-19 and Oral Health Care
On March 19, 2020 the American Dental Association issued guidelines for the practice of dentistry during the COVID 19 pandemic. These guidelines recommend that dental healthcare workers postpone elective dental care but continue to provide emergency and urgent dental care to patients.

These guidelines were established to protect the public as well as dental healthcare workers, to conserve the availability of PPE, and to reduce the need of patients to access the hospital systems for dental related issues.

These guidelines can be found at ADA website's Coronavirus Center (https://success.ada.org/en/practice-management/patients/infectious-disea...)
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Dental Emergencies
Potentially life threatening and require immediate treatment to stop tissue bleeding, alleviate severe pain or infection, and include
Uncontrolled bleeding
Cellulitis or a diffuse soft tissue bacterial infection with intra-oral or extra-oral swelling that potentially compromise the patient's airway.
Trauma involving facial bones, potentially compromising the patient's airway

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American Dental Association ada.org
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Urgent Dental Care
Focuses on the management of conditions that require immediate attention to relieve severe pain and/or risk of infection and to alleviate the burden on hospital emergency departments

Should be treated as minimally invasively as possible
Severe dental pain from pulpal inflammation
Pericornitis or third molar pain (wisdom teeth)
Surgical post-operative osteitis, dry socket dressing changes
Abscess, or localized bacterial infection resulting in localized pain and swelling
Tooth fracture resulting in pain or causing soft tissue trauma
Dental trauma with avulsion/luxation
Dental treatment required prior to critical medical procedures
Final crown/bridge cementation if the temporary restoration is lost, broken or causing gingival irritation
Biopsy of abnormal tissue

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American Dental Association ada.org

Other Urgent Dental Care
Extensive dental caries or defective restorations causing pain (Manage with interim restorative techniques when possible)
Suture removal
Denture adjustments on radiation/oncology patients
Denture adjustments or repairs when function impeded
Replacing temporary filling on root canal access openings in patients experiencing pain.
Snipping or adjustment of an orthodontic wire or appliance piercing or ulcerating the oral mucosa
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American Dental Association ada.org

Routine or Non-Urgent Dental Procedures
Initial or periodic oral examinations and recall visits, including routine radiographs
Routine dental cleaning and preventive therapies
Orthodontic procedures other than those to address acute issues (e.g. pain, infection, trauma)
Extraction of asymptomatic teeth
Restorative dentistry including treatment of asymptomatic carious lesions.
Aesthetic dental procedures
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List not inclusive. American Dental Association ada.org

PREVENTION OF COVID-19
Michelle Iandiorio, MD
Associate Professor, UNMHSC DOIM, Division of Infectious Diseases
Clinical Director, SCAETC
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Preventing COVID-19
Social Distancing
Avoid groups > 10
Keep distance > 6 feet
Stay at home
Reduce errands
Stay home if sick

Clean & disinfect
Clean frequently touched surfaces

Hand hygiene
Wash hands frequently

Cover coughs & sneezes

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https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/preventio...
Avoid groups 5 in NM
There is no FDA-approved vaccine available at this time but studies on ongoing

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Preventing Illness
Eat a healthy diet
Fruits, vegetables
Balanced meals

Get 7-9 hours sleep/night

Exercise

Reduce toxins
Smoking, alcohol
Illicit substances

Reduce stress
Limit exposure to news
Mindfulness
Make time to unwind
Stay connected
Online communities
Social media
Video chats
Get help
SAMHSA's Disaster Distress Helpline: 1-800-985-5990; text: TalkWithUs to 66746

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https://emergency.cdc.gov/coping/selfcare.asp
Jobin, K et al. High-salt diet compromises antibacterial neutrophil responses through hormonal perturbation. Science Translational Medicine. 25 Mar 2020; 12(536).
Stay connected
"Physical distancing, Social solidarity"
For LGBTQIA+ communities, Fierce Pride is hosting or linking folks to online gatherings for social support, and is compiling an online resource list for covid-19-related community resources. mailing list at fiercepride.org or on facebook here https://www.facebook.com/FiercePrideNM/
resource list here https://drive.google.com/file/d/1Wtf64PfU2geObOMyO3EvTl4suGm-Ldgy/view

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Preventing Illness for People Who Use Drugs
Minimize need to share supplies
Don't share e-cigs/cigarettes, pipes, bongs, joints, nasal tubes
If sharing needed, wipe down mouthpieces with alcohol swab or use separate mouthpieces
Stock up on supplies, work with syringe services program

Prepare drugs themselves
Minimize close contact with others
Wash hands x 20 seconds with soap & water
Wipe down packaging
Keep surfaces clean (alcohol at least 70%, microbial wipes, or bleach)
Do not lick needle

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https://harmreduction.org/miscellaneous/covid-19-guidance-for-people-who...

Risk Reduction in Setting of COVID-19 for Providers
Prioritize staff & participant safety
Send sick staff home
Plan for employee absence (i.e. cross-training)
Immunize to prevent other illnesses
Promote hand hygiene
Sanitize surfaces frequently
Consider limiting access for non-essential visitors
Offer extra supplies
In case of service closure
Take inventory of stock & discuss with all staff what is maximum allowance per person for each item
Latex gloves, safe masks, hand sanitizer
Consider one-month Rx of buprenorphine, with possible refill by phone or telehealth

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https://harmreduction.org/miscellaneous/covid-19-guidance-for-people-who...

Risk Reduction in Setting of COVID-19 for PWUD
Prepare for drug shortage
May lose access to drug of choice
Consider buying OTC to minimize withdrawal symptoms (Pepto-Bismol, loperamide, ibuprofen)
Enroll in MAT program for buprenorphine or methadone

Plan & prepare for overdose
911 services may be stretched
Avoid using alone but maintain distance >6 feet
Create overdose safety plan with someone who knows you're going to use
Ensure adequate naloxone rescue kits
Store a breathing mask in case rescue breathing needed
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https://harmreduction.org/miscellaneous/covid-19-guidance-for-people-who...
PWUD= people who use drugs

Sex and COVID-19
Safe sex without risk of COVID-19: masturbation, sexting, video dates, chat rooms

Next safest partner is someone you live with

Avoid close contact, including sex, with people outside your household

Reduce number of partners

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https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-sex-guidance.pdf

Awareness of Stigma & Isolation
Many patient already face stigma: HIV-status, gender, sexual orientation, race/ethnicity, mental health, substance use disorder

Recent compounded stigma in era of COVID-19 pandemic

Stigma affects mental health & compounds isolation

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https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/reducing-sti...
http://eqnm.org/#covid19-statement

Fear and anxiety can lead to social stigma
Some groups currently experiencing stigma: persons of Asian descent, people who have traveled, emergency responders and healthcare workers
Stigmatized groups may be subject to social avoidance/rejection, denials of healthcare/education/housing/employment, physical violence

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Care for PWH with Suspected COVID-19
Daily telephone check ins with healthcare team
Symptom monitoring, temperature

Avoid urgent care/emergency department unless severe illness

Patient should wear surgical/procedure mask if leaving home/coming to clinic

Staff should wear droplet+contact precautions when caring for person with confirmed/suspected COVID-19
Airborne precautions if nebulizer treatment or NP swab
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Aerosol half life about 1 hour so if not in negative airflow room, after nebulizer or other aerosolizing procedure, leave room empty for 1 hour
Ibuprofen
"At this time, FDA is not aware of scientific evidence connecting the use of NSAIDs, like ibuprofen, with worsening COVID-19 symptoms" (3/19/20)
NSAIDS may mask fever

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ART Drug Interactions with Potential COVID-19 Treatments
Check for potential drug-drug interactions https://www.covid19-druginteractions.org

Some complementary therapies or over-the-counter remedies may interact with ART
i.e. zinc avoid within 3-6 hours of INSTIs
Natural Medicines Interaction Checker at www.naturalmedicines.therapeuticresearch.com

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Liverpool now has a dedicated page for COVID-19 drug interactions with HIV medications. This is not a searchable database, but there are documents with tables of interactions and current evidence.
Chloroquine/Hydroxychloroquine: moderate inhibitors of CYP2D6 & P-gp

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Criteria for Healthcare Worker with COVID-19 Return to Work
Back to work criteria
7 days since symptom onset or 3 days since symptoms improved, whichever is longer.

HCW must wear a surgical mask for 14 days after symptom onset or until symptoms completely gone, whichever is longer

No contact with severely immunocompromised pts: oncology, transplant, etc

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Follow your organization's guidance for specific recommendations
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Resources
Clinical Consultation Center http://nccc.ucsf.edu/
HIV Management
Perinatal HIV
HIV PrEP
HIV PEP line
HCV Management
Substance Use Management

Present case on ECHO http://echo.unm.edu [email protected]
AETC National HIV Curriculum https://aidsetc.org/nhc

AETC National Coordinating Resource Center https://targethiv.org/library/aetc-national-coordinating-resource-center-0

Additional trainings [email protected]
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Find an HIV TeleECHO clinic in your area: https://echo.unm.edu/locations-2/echo-hubs-superhubs-united-states/
Additional Local Trainings in NM: includes preceptorships, telephone/email consultation, on-site trainings, HIV TeleECHO; [email protected]
AETC National HIV Curriculum: 6 core modules for self study; regularly updated; CME, CNE

Clinical Consultation Center HIV PrEP line: 888-448-7737 (9am-8pm ET M-F); https://nccc.ucsf.edu/clinician-consultation/prep-pre-exposure-prophylaxis/
AETC National HIV Curriculum, module on PrEP. https://www.hiv.uw.edu/go/prevention/preexposure-prophylaxis-prep
Clinical Consultation Center HIV PEP line: 888-448-4911 (9am-8pm ET M_F, 11am-8pm ET weekends & holidays); PEP Quick Guide: nccc.ucsf.edu/clinical-resources/pep-resources/pep-quick-guide-for-occupational-exposures/
AETC National HIV Curriculum, module on Non-occupational PEP. https://www.hiv.uw.edu/go/prevention/nonoccupational-postexposure-prophy...

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References
AAHIVM:https://aahivm.org/hiv-care-covid-19/
CDC:https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/hiv.htm...
DHHS:https://aidsinfo.nih.gov/guidelines/html/8/covid-19-and-persons-with-hiv...
IDSA, HIVMA COVID-19: Special Considerations for People with HIV https://www.hivma.org/globalassets/covid-19-special-considerations_v5.pdf
WHO:https://www.who.int/news-room/q-a-detail/q-a-on-covid-19-hiv-and-antiret...
AETC NCRC COVID-19 Resources for HIV providers https://aidsetc.org/resource/covid-19-resources-hiv-providers
HRSA COVID-19 Frequently Asked Questions https://bphc.hrsa.gov/emergency-response/coronavirus-frequently-asked-qu...

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References
Cao B, et al. 2020. A Trial of Lopinavir-Ritonavir in Adults Hospitalized with Severe Covid-19. N Engl J Med doi:10.1056/NEJMoa2001282.
Zhu F, Cao Y, Xu S, Zhou M. Co-infection of SARS-CoV-2 and HIV in a patient in Wuhan city, China. J Med Virol 2020.
www.hiv-druginteractions.org
COVID-19 drug interactions website: www.covid19-druginteractions.org
Natural Medicines Interaction Checker at www.naturalmedicines.therapeuticresearch.com
https://www.healthline.com/nutrition/immune-boosting-supplements
https://www.discovermagazine.com/health/can-natural-remedies-really-help...
https://www.pharmacytimes.com/news/what-are-drug-prevention-and-treatmen...

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References
Harm Reduction Coalition. Syringe Services and Harm Reduction Provider Operations During the COVID-19 Outbreak.
https://harmreduction.org/miscellaneous/covid-19-guidance-for-people-who...
Sex and COVID-19 https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-sex-guidance.pdf
CDC: Coronavirus Disease 2019: Information for Healthcare Professionals https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html
POZ:https://www.poz.com/article/people-hiv-need-know-new-coronavirus
https://www.nytimes.com/2020/03/28/nyregion/coronavirus-larry-kramer-aid...

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Resources
American Dental Association Coronavirus Center https://success.ada.org/en/practice-management/patients/infectious-disea...

Organization for Safety Asepsis and Prevention https://www.osap.org/page/COVID-19

Centers for Disease Control and Prevention https://www.cdc.gov/coronavirus/2019-ncov/hcp/index.html
Harm Reduction Coalition. Syringe Services and Harm Reduction Provider Operations During the COVID-19 Outbreak.
https://harmreduction.org/miscellaneous/covid-19-guidance-for-people-who...
Sex and COVID-19 https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-sex-guidance.pdf
CDC: Coronavirus Disease 2019: Information for Healthcare Professionals
https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html
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Resources
Medicaid
https://www.medicaid.gov/medicaid/benefits/telemedicine/index.html
HIV and COVID 19 (The Body)
https://www.thebody.com/article/new-coronavirus-and-hiv
CDC
https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/hiv.html
HIV Care and Testing Services in Mexico
https://www.gob.mx/cms/uploads/attachment/file/332406/Responsables_CAPAS...
HHS & Telehealth
https://www.hhs.gov/about/news/2020/03/17/ocr-announces-notification-of-...

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