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HIV and COVID-19: Practical Considerations for Care

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HIV and COVID-19 - Practical Considerations for Care Disclosures This program is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $3,879,101 with zero percent financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government. 2 Disclosures John J. Faragon, PharmD discloses the following: Speakers Bureau Gilead Janssen Merck Advisory ViiV 3 The following planning members have no financial relationships to disclose: Cynthia Miller, MD, Sarah Walker, MS and Jennifer Price. 5 SAVE-THE-DATE HIV Clinical Care Mini-Symposium* Live Webinar via Zoom Wednesday, October 14, 2020 8:00 am-12:30 pm Details and Agenda Available in Late August * Formerly the HIV & HCV Clinical Care Conference for North Country Providers Questions? 518-262-6864 Or [email protected] No registration Fee HIV - HCV - PrEP - PEP Clinical Consultations For Providers in Upstate NY Call or E-mail for a consultation: 518-262-6864 Monday Friday 8:00 a.m. 4:30 p.m. [email protected] If you have experienced an occupational exposure such as a needle stick, please call 518-262-4043. You will be given an opportunity on the telephone menu to speak to a physician 24 hours a day. www.amc.edu/hiv HIV Mini-Residencies forLicensed Healthcare Providers in Upstate NY Are you interested in learning more about HIV diagnosis and treatment? Free training Train for as little as 1 day, or up to 5 We will work with your schedule! Transportation, lodging and food are covered Basic and advanced trainings are available Education credits are available CANDIDATES FOR THIS PROGRAM MUST BE PRACTICING IN NEW YORK AS A LICENSED MD, DO, PA, or NP. Please contact our Mini-residency Coordinator: John Prokop Albany Medical College 518-262-6864 [email protected] www.amc.edu/hiv HIV Grand Rounds Breakfast SeriesLive Webinars via Zoom Investigational Treatments for COVID-19 Presented by Roy M. Gulick, MD, MPH Friday, September 11, 2020 8:15-9:15 am Anticoagulation Medication Update: A Focus on Patients Living with HIV Presented by Erica Maceira, PharmD Friday, October 2, 2020 8:15-9:15 am 8 Registration Questions? Contact Lejla Stocevic at 518-262-4674 or [email protected] Learning Objectives Review recent recommendations from DHHS regarding patients with HIV during the COVID-19 epidemic. List potential therapeutic options for COVID-19, recognizing current data and guideline limitations. Describe examples of practical considerations in outpatient HIV care during the COVID-19 epidemic. 4 Sections COVID-19 Epidemiology and Overview COVID-19 Treatment Select options with data, protocols, guidelines COVID-19 HIV Specific Information DHHS Guidelines, ICU HIV Medication Management, Select Drug Interactions COVID-19 Resources for Providers COVID-19 EPIDEMIOLOGY https://coronavirus.jhu.edu/ - Accessed 8.3.20 https://coronavirus.jhu.edu/ - Accessed 8.3.20 https://coronavirus.jhu.edu/ - Accessed 8.3.20 https://coronavirus.jhu.edu/ - Accessed 8.3.20 https://coronavirus.jhu.edu/ - Accessed 8.3.20 Transmission, Symptoms and Complications COVID-19 Wiersinga, WJ, et al. JAMA, doi:10.1001/jama.2020.12839 Transmission Primarily via respiratory droplets from face-to-face contact Aerosol spread may occur, but remains unclear 48% to 62% of transmission via pre-symptomatic carriers Common symptoms, hospitalized patients Fever (70%-90%), Dry cough (60%-86%), Shortness of breath (53%- 80%) Fatigue (38%)Myalgias (15%-44%) Nausea/vomiting or diarrhea (15%-39%) Headache, Weakness (25%), and rhinorrhea (7%) Anosmia or ageusia may be the sole presenting symptom in approximately 3% of individuals with COVID-19 Common laboratory abnormalities, hospitalized patients Lymphopenia (83%), elevated inflammatory markers (eg, erythrocyte sedimentation rate, C-reactive protein, ferritin, tumor necrosis factor-, IL-1, IL-6) Abnormal coagulation parameters (eg, prolonged prothrombin time, thrombocytopenia, elevated D-dimer [46% of patients], low fibrinogen) Transmission, Symptoms and Complications COVID-19 Wiersinga, WJ, et al. JAMA, doi:10.1001/jama.2020.12839 Common radiographic findings Bilateral, lower-lobe predominate infiltrates on chest radiographic imaging and bilateral, peripheral, lower-lobe ground-glass opacities and/or consolidation on CT imaging Common complications among hospitalized patients pneumonia (75%); acute respiratory distress syndrome (15%) acute liver injury (19%) cardiac injury (7%-17%) VTE (10%-25%) AKI (9%) Neurologic manifestations, impaired consciousness (8%) Shock (6%) Cerebrovascular disease (3%) Rare complications among critically ill patients cytokine storm and macrophage activation syndrome CDC Clinical Tips for HCP CDC. Available athttps://www.cdc.gov/coronavirus. Accessed 8/3/20 Post COVID-19 Data from Italy evaluating Post-COVID-19 Symptoms 143 patients Data collected April 21 May 29, 2020 On 12.6% COVID-19 symptom free Fatigue, dypsnea, joint pain, chest pain most common Carfi A, et al. JAMA, doi:10.1001/jama.2020.12603 20 COVID-19 TREATMENT "The health of individual patients and the public at large will be best served by remaining true to our time-tested approach to clinical trial evidence and drug evaluation, rather than cutting corners and resorting to appealing yet risky quick fixes." Rome, BN, Avorn, J. N Engl J Med. 2020:382;24:2282-2284. ACE2 ALVEOLUS HOST CELL SARS-CoV-2 S-Protein TMPRSS2 Arbidol Camostat mesylate Uncoating Translation Polypeptides RNA RNA-dependent RNA polymerase RNA Non Structural Proteins Assembly Structural Proteins Translation Ribavirin Remdesivir Favipiravir Macrophage IL-6 Tocilizumab Sarilumab COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. Available athttps://www.covid19treatmentguidelines.nih.gov/. Accessed 8/3/20 Remdesivir Mild or Moderate COVID-19 There are insufficient data for the Panel to recommend either for or against the usein patients with mild or moderate COVID-19. Patients with COVID-19 Who Are on Supplemental Oxygen but Who Do Not Require High-Flow Oxygen, Noninvasive or Invasive Mechanical Ventilation, or ECMO The Panel recommends usingremdesivirfor 5 days or until hospital discharge, whichever comes first(AI) Patients with COVID-19 Who Require High-Flow Oxygen, Noninvasive Ventilation, Mechanical Ventilation, or ECMO Because there is uncertainty regarding whether starting remdesivir confers clinical benefit in these groups of patients, the Panel cannot make a recommendation either for or against starting remdesivir. Duration of Therapy There are insufficient data on the optimal duration ofremdesivirtherapy for patients with COVID-19 who have not shown clinical improvement after 5 days of therapy, some experts extend the duration to up to 10 days(CIII) COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. Available athttps://www.covid19treatmentguidelines.nih.gov/. Accessed 8/3/20 Adaptive Covid-19 Treatment Trial (ACTT-1) Remdesivir IV versus placebo Enrollment started February 21, 2020, ended on April 19, 2020. 60 trial sites in US, Denmark, UK, Greece, Germany, Korea, Mexico, Spain, Japan, Singapore Randomized 1:1 to get remdesivir or placebo Beigel. NEJM. 2020;[Epub]. NCT04280705. NIAID ACTT-1: Efficacy and Safety Preliminary results from 1059 patients with data available after randomization Serious AEs: 21.1% (114/541) with remdesivir and 27.0% (141/522) with placebo Outcome Remdesivir (n = 538) Placebo (n = 521) HR (95% CI) P Value Median recovery time, days 11 15 1.32 (1.12-1.55) < .001 Mortality by 14 days, % 7.1 11.9 0.70 (0.47-1.04) NS Beigel. NEJM. 2020;[Epub]. Slide credit: clinicaloptions.com AE, adverse event; NS, not significant. 28 Characteristic All Remdesivir Placebo Age 58.9 +/- 15 58.6 +/- 14.6 59.2 +/- 15.4 Male Sex 684 (64.3) 352 (65.1) 332 (63.6) American Indian 7 (0.7) 4 (0.7) 3 (0.6) Asian 134 (12.6) 77 (14.2) 57 (10.9) Black, AA 219 (20.6) 108 (20) 111 (21.3) White 565 (23.4) 279 (51.6) 286 (54.8) Hispanic/Latino 249 (23.4) 132 (24.4) 117 (22.4) Median time, Symptoms to randomization 9 (6-12) 9 (6-12) 9 (7-13) Zero comorbid conditions 193/920 (21) 91/467 (19.5) 102/453 (22.5) One comorbid conditions 248/920 (27) 131/467 (28.1) 117/453 (25.8) Two or more comorbid conditions 479/920 (52.1) 245/467 (52.5) 234/453 (51.7) Cancer 71 (7.7) 39 (8.3) 32 (7.0) Immunodeficiency (innate or acquired) 64 (6.9) 28 (6.0) 36 (7.9) HTN 460/928 (49.6) 231/469 (49.3) 229/459 (49.9) Obesity 342/925 (37) 177/469 (37.7) 165/456 (36.2) Type 2 DM 275/927 (29.7) 144/470 (30.6) 131/457 (28.7) Hospitalized, no O2 127 (11.9) 67 (12.4) 60 (11.5) Hospitalized, on O2 421 (39.6) 222 (41.0) 199 (38.1) Hospitalized, non-invasive ventilation, High-Flow 197 (18.5) 98 (18.1) 99 (19.0) Hospitalized, mechanical ventilation or ECMO 272 (25.6) 125 (23.1) 147 (28.2) Baseline Score Missing 46 (4.3) 29 (5.4) 17 (3.3) Beigel. NEJM. 2020;[Epub]. Remdesivir.com/us/ - EUA Other Drugs Recommends againstthe use of chloroquine orhydroxychloroquinefor the treatment of COVID-19, except in a clinical trial(AII) Also recommends againsthigh-dose chloroquine(600 mg twice daily for 10 days) for the treatment of COVID-19(AI) Recommends againstusing the following drugs to treat COVID-19, except in a clinical trial: The combination ofhydroxychloroquine plus azithromycin (AIII), because of the potential for toxicities. Lopinavir/ritonavir (AI)orother HIV protease inhibitors (AIII), because of unfavorable pharmacodynamics and because clinical trials have not demonstrated a clinical benefit in patients with COVID-19. COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. Available athttps://www.covid19treatmentguidelines.nih.gov/. Accessed 8/3/20 Lopinavir/ritonavir 199 patients randomized to LPV/r 400/100 BID for 14 days versus standard of care alone Mortality at 28 days similar (19.2% for LPV/r, 25% for standard) Modified ITT, LPV/r had a shorter time to clinical improvement by 1 day GI events more common in LPV/r arm Serious ADRS similar in both arms 14% of patients stopped LPV/r due to ADRs Cao B, et al. NEJM. DOI:10.1056/NEJMoa2001282 Immunomodulators for COVID-19 Dexamethasone Based on preliminary report from the Randomised Evaluation of COVID-19 Therapy (RECOVERY) trial, the Panel recommends usingdexamethasone6 mg per day for up to 10 days for the treatment of COVID-19 in patients who are mechanically ventilated(AI)and in patients who require supplemental oxygen but who are not mechanically ventilated(BI). The Panelrecommends againstusingdexamethasonefor the treatment of COVID-19 in patients who do not require supplemental oxygen(AI) If dexamethasone is not available, the Panel recommends using alternative glucocorticoids, ie: prednisone,methylprednisolone, orhydrocortisone (AIII) COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. Available athttps://www.covid19treatmentguidelines.nih.gov/. Accessed 8/3/20 Dexamethasone 28 day mortality RECOVERY Collaborative Group. NEJM. DOI:10.1056/NEJMoa2021436 Immunomodulators for COVID-19 Insufficient data to recommend either for or against the use of the following immunomodulators for the treatment of COVID-19: Interleukin-1 inhibitors(e.g.,anakinra) Interleukin-6 inhibitors(e.g.,sarilumab, siltuximab, tocilizumab) Interferon-betafor the treatment of early (i.e., <7 days from symptom onset) mild and moderate COVID-19. Recommends againstthe use of the following immunomodulators for the treatment of COVID-19, except in a clinical trial: Interferons (alfa or beta)(AIII) Bruton's tyrosine kinase inhibitors(e.g.,acalabrutinib, ibrutinib, zanubrutinib) andJanus kinase inhibitors(e.g.,baricitinib, ruxolitinib, tofacitinib)(AIII) COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. Available athttps://www.covid19treatmentguidelines.nih.gov/. Accessed 8/3/20 Convalescent Plasma Insufficient data for the COVID-19 Treatment Guidelines Panel to recommend either for or against the use of the following blood-derived products for the treatment of COVID-19: COVID-19 convalescent plasma Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immunoglobulins COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. Available athttps://www.covid19treatmentguidelines.nih.gov/. Accessed 8/3/20 Anticoagulation Venous Thromboembolism Prophylaxis and Screening: Hospitalized adults with COVID-19 should receive VTE prophylaxis per the standard of care for other hospitalized adults(AIII) Treatment: Patients with COVID-19 who experience an incident thromboembolic event or who are highly suspected to have thromboembolic disease at a time when imaging is not possible should be managed with therapeutic doses of anticoagulant therapy as per the standard of care for patients without COVID-19(AIII) Patients with COVID-19 who require extracorporeal membrane oxygenation or continuous renal replacement therapy or who have thrombosis of catheters or extracorporeal filters should be treated with antithrombotic therapy per the standard institutional protocols for those without COVID-19(AIII) COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. Available athttps://www.covid19treatmentguidelines.nih.gov/. Accessed 8/3/20 Miscellaneous Medications Angiotensin-Converting Enzyme (ACE) Inhibitors and Angiotensin Receptor Blockers (ARBs) Persons with COVID-19 who are prescribed ACE inhibitors or ARBs for cardiovascular disease (or other indications) should continue these medications(AIII). The COVID-19 Treatment Guidelines Panel (the Panel)recommends againstthe use of ACE inhibitors or ARBs for the treatment of COVID-19, except in a clinical trial(AIII). HMG-CoA Reductase Inhibitors (Statins) Persons with COVID-19 who are prescribed statin therapy for the treatment or prevention of cardiovascular disease should continue these medications(AIII). The Panelrecommends againstthe use of statins for the treatment of COVID-19, except in a clinical trial(AIII). Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) Persons with COVID-19 who are taking NSAIDs for a comorbid condition should continue therapy as previously directed by their physician(AIII). The Panel recommends that there be no difference in the use of antipyretic strategies (e.g., with acetaminophen or NSAIDs) between patients with or without COVID-19(AIII). COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. Available athttps://www.covid19treatmentguidelines.nih.gov/. Accessed 8/3/20 AMC COVID-19 Protocol, NOT Recommended HYDROXYCHLOROQUINE and AZITHROMYCIN use is currently not recommended due to lack of efficacy by the NIH or IDSA LOPINAVIR/RITONAVIR Did not reduce mortality or time to clinical improvement SARILUMAB and SILTUXIMAB No evidence of efficacy ECULIZUMAB No evidence of efficacy FLUOROQUINE ANTIBIOTICS: AVOID ANAKINRA No evidence of efficacy Science17 Jul 2020:Vol. 369, Issue 6501, pp. 238-239DOI: 10.1126/science.369.6501.238 Select Vaccine Data, July 2020 COVID-19 HIV SPECIFIC INFORMATION Veterans Aging Cohort Study Persons with HIV VACS is an open cohort of all Veterans with HIV and age-, race/ethnicity-, sex-, and site-matched uninfected Veterans. ExtractedCOVID-19 laboratory testing results and diagnoses reported through May 17, 2020 Among VACS participants alive in 2020 (30,948 PWH, 76,618 uninfected), 4.8% of PWH and 3.6% of uninfected engaged inCOVID-19-related VA care Over 78-day period, 189 PWH (12.7% of tested) and 380 uninfected (13.9%) were diagnosed withCOVID-19 (adjusted odds ratio [OR]: 1.04, 95% CI: 0.85-1.26). PWH and uninfectedCOVID-19+ patients had similar distributions of baseline characteristics. Elevated risk for non-Hispanic black (OR: 1.87, 95% CI:1.49-2.36) and Hispanic (OR: 1.57, 95% CI: 1.11-2.22) patients compared to non-Hispanic white was similar for PWH and uninfected Risk of severeCOVID-19 outcomes was similar by HIV status PWH had higher testing rates, but no evidence of increased burden of positivity among those tested, nor an increased risk of severeCOVID-19 outcomes by HIV status Park LS, Rentsch CT, Sigel K, et al. AIDS 2020:July 6-10, 2020. Abstract LBPEC23. Park LS, Rentsch CT, Sigel K, et al. AIDS 2020:July 6-10, 2020. Abstract LBPEC23. COVID and HIV VA Data Park LS, Rentsch CT, Sigel K, et al. AIDS 2020:July 6-10, 2020. Abstract LBPEC23. COVID-19 and The Bronx Patel VV, et al. 23rd International AIDS Conference Virtual. July 6-10, 2020. Abstract OABLB0102. COVID-19 and HIV in The Bronx Compared COVID-19 outcomes for patients with and without HIV diagnosis from the Montefiore Health System Patients 18 years or older admitted to the hospital from March 10 to May 11, 2020, RNA PCR positive for SARS-CoV-2 100 persons with HIV compared to 4,513 without HIV No difference in time to death or time to hospital discharge HIV status did not affect risk of acute kidney injury. No one with a detectable HIV viral load was intubated or died in the hospital 21 people (26%) with an undetectable HIV viral load were intubated (p=0.04) 22 people (27%) with an undetectable HIV viral load died in the hospital (p=0.02). Every 100-cell higher CD4 count before admission significantly raised the risk of intubation 14% (adjusted HR 1.14, 95%CI 1.04 to 1.25, p=0.005) CD4 count not associated with death or length of stay Patel VV, et al. 23rd International AIDS Conference Virtual. July 6-10, 2020. Abstract OABLB0102. COVID-19 and HIV in the Bronx Patel VV, et al. 23rd International AIDS Conference Virtual. July 6-10, 2020. Abstract OABLB0102. Patel VV, et al. 23rd International AIDS Conference Virtual. July 6-10, 2020. Abstract OABLB0102. COVID-19 and HIV in the Bronx DHHS Interim Guidance, COVID-19 for Persons with HIV June 19, 2020 Individuals aged >60 years and those with diabetes, hypertension, cardiovascular disease, pulmonary disease, or obesity are at highest risk of life-threatening COVID-19 The limited data do not indicate that the disease course of COVID-19 in persons with HIV differs from that in persons without HIV. Before the advent of effective combination antiretroviral therapy (ART), advanced HIV infection (i.e., CD4 cell count <200/mm3) was a risk factor for complications of other respiratory infections. Whether this is also true for COVID-19 is yet unknown. Some people with HIV have other comorbidities (e.g., cardiovascular disease, lung disease) that increase the risk for a more severe course of COVID-19 illness. Chronic smokers are also at risk of more severe disease. Additional caution for all persons with HIV, especially those with advanced HIV or poorly controlled HIV DHHS. Interim Guidance on HIV and COVID-19. June 19, 2020. DHHS Interim Guidance, COVID-19 for Persons with HIV June 19, 2020 Every effort should be made to help persons with HIV maintain an adequate supply of ART and all other concomitant medications. Influenza and pneumococcal vaccinations should be kept up to date. Persons with HIV should follow all applicablerecommendations of the U.S. Centers for Disease Control and Prevention (CDC) to prevent COVID-19, such as social distancing and proper hand hygiene. These recommendations are regularly updated. Information on COVID-19 prevention in children with HIV forpediatric health care providersand thegeneral publicis available from CDC. DHHS. Interim Guidance on HIV and COVID-19. June 19, 2020. DHHS Interim Guidance, COVID-19 for Persons with HIV June 19, 2020 Persons with HIV Should: Maintain on-hand at least a 30-day supplyand ideally a 90-day supplyof antiretroviral (ARV) drugs and other medications. Talk to their pharmacists and/or health care providers about changing to mail order delivery of medications when possible. Persons for whom a regimen switch is planned should consider delaying the switch until close follow-up and monitoring are possible. Some ARV agents (e.g., lopinavir/ritonavir, boosted darunavir, tenofovir disoproxil fumarate/emtricitabine), are being evaluated in clinical trials or are prescribed for off label use for the treatment or prevention of COVID-19 Persons with HIV should not switch their ARV regimens or add ARV drugs to their regimens for the purpose of preventing or treating SARS-CoV-2 infection. DHHS. Interim Guidance on HIV and COVID-19. June 19, 2020. DHHS Interim Guidance, COVID-19 for Persons with HIV June 19, 2020 Clinic or Laboratory Monitoring Visits Related to HIV Care: Together with their health care providers, weigh the risks and benefits of attending, versus not attending in-person, HIV-related clinic appointments at this time Factors to consider include the extent of local COVID-19 transmission, the health needs that will be addressed during the appointment, and the person's HIV status (e.g., CD4 cell count, HIV viral load) and overall health. Telephone or virtual visits for routine or non-urgent care and adherence counseling may replace face-to-face encounters. For persons who have a suppressed HIV viral load and are in stable health, routine medical and laboratory visits should be postponed to the extent possible. Persons with HIV and in Opioid Treatment Programs: Clinicians caring for persons with HIV who are enrolled in opioid treatment programs (OTPs) should refer to theSubstance Abuse and Mental Health Service Administration (SAMHSA) websitefor updated guidance on avoiding treatment interruptions. State methadone agencies are also responsible for regulating OTPs in their jurisdictions and may provide additional guidance. DHHS. Interim Guidance on HIV and COVID-19. June 19, 2020. DHHS Interim Guidance, COVID-19 for Persons with HIV June 19, 2020 Guidance for Persons with HIV in Self-Isolation or Quarantine Due to SARS-CoV-2 Exposure Health Care Workers Should: Verify that patients have adequate supplies of all medications and expedite additional drug refills as needed. Devise a plan to evaluate patients if they develop COVID-19-related symptoms, including for possible transfer to a health care facility for COVID-19-related care. Persons with HIV Should: Contact their health care provider to report that they are self-isolating or in quarantine. Specifically, inform their health care provider how much ARV medications and other essential medications they have on hand. DHHS. Interim Guidance on HIV and COVID-19. June 19, 2020. DHHS Interim Guidance, COVID-19 for Persons with HIV June 19, 2020 Guidance for Persons with HIV who have Fever or Respiratory Symptoms and are Seeking Evaluation and Care Health Care Workers Should: FollowCDC recommendations, as well as state and local health department guidance on infection control, triage, diagnosis, and management. DHHS. Interim Guidance on HIV and COVID-19. June 19, 2020. DHHS Interim Guidance, COVID-19 for Persons with HIV June 19, 2020 Guidance for Persons with HIV who have Fever or Respiratory Symptoms and are Seeking Evaluation and Care Persons with HIV Should: FollowCDC recommendations regarding symptoms. If they develop a fever and symptoms (e.g., cough, difficulty breathing), they should call their health care provider for medical advice. Call the clinic in advance before presenting to the care providers. Use respiratory and hand hygiene and cough etiquette when presenting to the health care facility and request a face mask as soon as they arrive. If they present to a clinic or an emergency facility without calling in advance, they should alert registration staff immediately upon arrival of their symptoms so that measures can be taken to prevent COVID-19 transmission in the health care setting. Specific actions include placing a mask on the patient and rapidly putting the patient in a room or other space separated from other people. DHHS. Interim Guidance on HIV and COVID-19. June 19, 2020. DHHS Interim Guidance, COVID-19 for Persons with HIV June 19, 2020 When Hospitalization is Not Necessary, the Person with HIV Should: Manage symptoms at home with supportive care for symptomatic relief. Maintain close communication with their health care provider and report if symptoms progress (e.g., sustained fever for >2 days, new shortness of breath). Continue their ARV therapy and other medications, as prescribed. DHHS. Interim Guidance on HIV and COVID-19. June 19, 2020. DHHS Interim Guidance, COVID-19 for Persons with HIV June 19, 2020 When the Person with HIV is Hospitalized: ART should be continued. If the ARV drugs are not on the hospital's formulary, administer medications from the patients' home supplies. ARV drug substitutionsshould be avoided. If necessary, clinicians may refer torecommendations on ARV drugs that can be switchedin the U.S. Department of Health and Human Services (HHS) guidelines for caring for persons with HIV in disaster areas. DHHS. Interim Guidance on HIV and COVID-19. June 19, 2020. DHHS Interim Guidance, COVID-19 for Persons with HIV June 19, 2020 When the Person with HIV is Hospitalized: For patients who receive ibalizumab (IBA) intravenous (IV) infusion every 2 weeks as part of their ARV regimen, clinicians should arrange with the patient's hospital provider to continue administer of this medication without interruption. For patients who are taking an investigational ARV medication as part of their regimen, arrangements should be made with the investigational study team to continue the medication if possible. For critically ill patients who require tube feeding, some ARV medications are available in liquid formulations and some, but not all, pills may be crushed. Clinicians should consult an HIV specialist and/or pharmacist to assess the best way for a patient with a feeding tube to continue an effective ARV regimen. DHHS. Interim Guidance on HIV and COVID-19. June 19, 2020. DHHS Interim Guidance, COVID-19 for Persons with HIV June 19, 2020 When Receiving Investigational or Off-Label Treatment for COVID-19: There is currently no approved treatment for COVID-19. Several investigational and marketed drugs are being evaluated in clinical trials to treat COVID-19 or may also be available via compassionate use or off-label use. For patients receiving COVID-19 treatment, clinicians must assess the potential for drug interactions between the COVID-19 treatment and the patient's ARV therapy and other medications. Information on potential drug interactions may be found in product labels, drug interaction resources, clinical trial protocols, or investigator brochures. When available, clinicians may consider enrolling patients in a clinical trial evaluating the safety and efficacy of experimental treatment for COVID-19. Persons with HIV should not be excluded from these trials.ClinicalTrials.govis a useful resource to find studies investigating potential treatments for COVID-19. DHHS. Interim Guidance on HIV and COVID-19. June 19, 2020. DHHS Interim Guidance, COVID-19 for Persons with HIV June 19, 2020 Additional Guidance for HIV Clinicians Some Medicaid and Medicare programs, commercial health insurers, and AIDS Drug Assistance Programs (ADAPs) have restrictions that prevent patients from obtaining a 90-day supply of ARV drugs and other medications. During the COVID-19 outbreak, clinicians should ask providers to waive drug-supply quantity restrictions. ADAPs should also provide patients with a 90-day supply of medications. Persons with HIV may need additional assistance with food, housing, transportation, and childcare during times of crisis and economic fragility. DHHS. Interim Guidance on HIV and COVID-19. June 19, 2020. DHHS Interim Guidance, COVID-19 for Persons with HIV June 19, 2020 Additional Guidance for HIV Clinicians During this crisis, social distancing and isolation may exacerbate mental health and substance use issues for some persons with HIV. Telehealth options, including phone calls, should be considered for routine visits and to triage visits for patients who are ill. There are reports that measures designed to control the spread of COVID-19 may increase the risk of gender-based violence against women and girls, as well as limit their ability to distance themselves from abusers or to access external support. During the COVD-19 outbreak, reproductive desires and pregnancy planning should be discussed with all women of childbearing potential. DHHS. Interim Guidance on HIV and COVID-19. June 19, 2020. COVID-19 and Sex, NYC Guidance Virus can be spread via direct contact with saliva Unknown if Coronavirus is passed through sex Avoid sex with people who are not close contacts (ie those outside your household) Washing hands before and after sex Avoid sex if partner is not feeling well Prevent HIV with PrEP and condoms Sex and Coronavirus Disease 2019 (CVOID-19). Located at https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-sex-guidance.pdf Accessed April 16, 2020. NYC DOH Sex and COVID-19 COVID-19 RESOURCES Sanders JM, et al. JAMA Review Sanders JM, et al. JAMA. Doi:10.1001/jama.2020.6019. Published online April 13, 2020. What the Review Includes Excellent diagram of potential viral targets Systematic review of common medications under evaluation for COVID-19 management Azithromycin Chloroquine, Hydroxychloroquine Umifenovir Remdesivir Favipiravir Corticosteroids IL-6 inhibitors Convalescent plasma Sanders JM, et al. JAMA. Doi:10.1001/jama.2020.6019. Published online April 13, 2020. What the Review Includes Tables Overview/Summary of Early Clinical Trials Helpful Resources Select Clinical Guidance on Management Clinical Trial Registries Drug-Drug Interaction Resources Special Populations FAQs on Treatment, Clinical Management Sanders JM, et al. JAMA. Doi:10.1001/jama.2020.6019. Published online April 13, 2020. Wiersinga, WJ, et al. JAMA, doi:10.1001/jama.2020.12839 Berlin DA, Gulick RM, Martinez FJ. N Engl J Med. DOI: 10.1056/NEJMcp2009575 COVID-19 and Drug Interactions Select National and International Resources for COVID-19 CDC Cases and Latest Updates www.cdc.gov/coronavirus/2019-ncov/cases-updates/index.html CDC Situation Summary www.cdc.gov/coronavirus/2019-ncov/cases-updates/summary.html CDC Healthcare Professionals Information www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html CDC Interim Guidelines for Clinical Specimens www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html CDC Emergency Preparedness and Response, Clinician Outreach and Community Activity (COCA) www.emergency.cdc.gov/coca/ WHO Coronavirus Website www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-h... HRSA COVID-19 FAQs www.bphc.hrsa.gov/emergency-response/coronavirus-frequently-asked-questi... Local Resources for COVID-19 NY, NJ, PR, USVI NYSDOH Coronavirus Website www.health.ny.gov/diseases/communicable/coronavirus/ NYSDOH Coronavirus Website Information for Providers www.health.ny.gov/diseases/communicable/coronavirus/providers.htm NJDOH Coronavirus Website www.nj.gov/health/cd/topics/ncov.shtml Puerto Rico Coronavirus Website www.salud.gov.pr/Pages/coronavirus.aspx USVI Coronavirus Website https://www.covid19usvi.com/ COVID-19 Patient Care and Management Resources CDC Mental Health and COVID-19 www.cdc.gov/coronavirus/2019-ncov/prepare/managing-stress-anxiety.html CDC Patient Management www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patie... Clinical Trials Portal (search COVID19) http://www.clinicaltrials.gov/ Toronto Information on Crushing/PT HIV Medication Use https://www.hivclinic.ca/main/drugs_extra_files/Crushing%20and%20Liquid%... Liverpool Drug Interaction Guide for Treatment http://www.covid19-druginteractions.org/ Liverpool Guide for Patients with Swallowing Difficulties http://www.covid19-druginteractions.org/ www.aidsetc.org www.necaaetc.org National HIV Curriculum hiv.uw.edu