Guidance for Non-HIV-Specialized Providers Caring for Persons with HIV Displaced by Disasters

Guidance for Non-HIV-Specialized Providers Caring for Persons with HIV Displaced by Disasters

Last Updated: August 31, 2017; Last Reviewed: August 31, 2017

Introduction

The following information provides guidance to health care providers attending to the medical needs of adults and children with HIV displaced from disaster areas who have not yet secured HIV care in the areas where they have relocated.

If possible, management of antiretroviral therapy should be done with the assistance of clinicians with experience in HIV care. Medical consultation may also be available at specific local or regional HIV clinics. After the initial assessment of a patient’s immediate medical needs, the patient should be referred to the care of an HIV clinician in the area if at all possible.

The recommendations in this guidance are based on the current standard of care for persons with HIV infection, which emphasize antiretroviral therapy for all patients regardless of CD4 T lymphocyte (CD4) cell count. Interruptions of antiretroviral therapy should be avoided or kept to a minimum period of time. If patients report successful treatment without side effects from their ongoing therapy, that treatment regimen should be continued or reinstituted as soon as possible.

Initial Assessment

  1. Assess the patient’s general health and need for immediate medical intervention. Acute illnesses should be diagnosed and attended to promptly.
  2. Obtain the following information from the patient (see Appendix A for an Intake Form clinicians can use when evaluating a patient):
    1. Name, location, phone number, pager number, and e-mail address of the primary HIV care provider/clinic and research staff (if the patient is participating in a research study, such as a clinical trial).
    2. The name, location, and phone number of the pharmacy where the patient obtained medications.
    3. Pertinent medical history (including whether the patient is currently on treatment for opportunistic infections [OIs], including hepatitis B virus [HBV] or hepatitis C virus [HCV] infection, malignancies, and other conditions such as pregnancy, hypertension, and diabetes mellitus).
    4. Latest known CD4 cell count and HIV viral load, with the approximate date when they were obtained.
    5. A list of current medications, including:
      1. Antiretroviral drugs. Images of Food and Drug Administration (FDA)-approved antiretroviral medications can be found at https://aidsinfo.nih.gov/contentfiles/upload/HIV_Pill_Brochure.pdf.
      2. Any investigational medication. If the patient is participating in a clinical trial, obtain information about the clinical trial site and contact information, if available.
      3. Medications for treatment of OIs.
      4. Medications for prevention of OIs.
      5. Other medications.
    6. History of drug allergies and type of reactions, especially if there is any history of serious reactions to antiretroviral medications (such as abacavir) or drugs used for treatment or prevention of OIs (such as trimethoprim-sulfamethoxazole). Patients who have had positive genetic tests for the HLA-B* 5701 allele should not be given abacavir (Ziagen™) or fixed-dose combinations containing abacavir (Epzicom™, Trizivir™, or Triumeq™) because HLA-B* 5701 predisposes patients to life-threatening hypersensitivity reactions.
    7. History of intolerance to antiretroviral medications and other medications.

Useful Web-Based Resources

A number of web-based resources may be useful for clinicians and other healthcare professionals when providing care for displaced persons with HIV infection (see Appendix B at the end of this document).

Medication Management Strategies

Patients who had their antiretroviral therapy, prophylaxis, and/or treatment for OIs interrupted by disaster-related displacement should restart these medications as soon as possible.

  1. Antiretroviral Therapy Management for Patients Who Were Receiving Treatment Prior to Displacement

    1. All antiretroviral drugs should be continued or restarted as soon as possible.
    2. Similar to HIV, treatment interruption of HBV and/or HCV infection is not recommended. For most patients who have both HIV and HBV infection, HBV treatments are part of the antiretroviral regimen due to dual activity for some nucleoside reverse transcriptase inhibitors, including tenofovir disoproxil fumarate (or tenofovir alafenamide), emtricitabine, and lamivudine. These medications should remain as part of their antiretroviral regimen.
    3. Treatment interruptions due to disaster displacement should not prompt an attempt to modify a regimen; rather, the priority should be to resume therapy as soon as possible, as long as the patient reports tolerating the regimen.
    4. In general, the patient should be on a combination regimen consisting of at least two to three different antiretroviral drugs. Many antiretroviral drugs are now available in fixed-dose formulations where two or more drugs are coformulated into one pill.
    5. If combination pills are not available, some antiretroviral medications are interchangeable if needed. See Appendix C for a list of these products. Clinicians should consult HIV specialists if there are additional questions regarding switching antiretroviral medications due to supply shortages.
    6. Pediatric patients may be taking liquid, granules, or powder formulations, some of which may need to be refrigerated or may need clean water for reconstitution. Special attention should be paid to appropriate weight- or surface area-based dosing for pediatric patients.
    7. If patients cannot recall drug dosages or cannot recall their regimens, use pill posters to assist them with recall (e.g., https://aidsinfo.nih.gov/contentfiles/upload/HIV_Pill_Brochure.pdf), consult an HIV care specialist or consultation service for recommendations, or contact the pharmacy or affiliated local pharmacy chain store where they most recently obtained their medications.
    8. Antiretroviral medications may interact with each other and with many other drugs. Please consult product labels, an HIV care specialist, or a pharmacist when concerned about drug-drug interactions, especially if new medications will be prescribed for any reason. Tables with common antiretroviral drug interactions can also be found in the latest adult and pediatric antiretroviral guidelines at https://aidsinfo.nih.gov/guidelines/.
    9. These guidelines also include information regarding dosing and adverse effects of antiretroviral drugs. The guidelines also discuss special considerations for treatment in certain patient populations, such as patients with HBV, HCV, or tuberculosis coinfections, and antiretroviral dosing for patients with renal or hepatic impairment.
    10. If possible, obtain blood samples for general safety laboratory tests (such as complete blood count and chemistry panel, including assessment of renal and hepatic functions). Additionally, if feasible, CD4 cell count and HIV viral load tests should also be done and reported to the patient’s primary HIV clinician or referral physician. However, resumption or continuation of antiretroviral therapy should not be delayed while these results are pending.
  2. Caring for the Pregnant Woman with HIV

    1. All pregnant women with HIV should enter into standard prenatal/obstetric care as soon as possible. When feasible, pregnant women with HIV should be referred to specialists with expertise in both obstetric and HIV management.
    2. The National Perinatal HIV Hotline service provides 24-hour access to consultations with experts on treating pregnant women with HIV and infants exposed to HIV: 888-448-8765. The hotline also serves as a clinicians’ network and can assist providers with identifying clinicians nationwide who have experience in the management of pregnant women with HIV and infants exposed to HIV.
    3. Pregnant women with HIV who discontinued antiretroviral drugs during displacement that were used for treatment and for prevention of mother-to-child transmission of HIV should urgently restart therapy.
    4. All pregnant women with HIV should receive antiretroviral therapy regardless of their CD4 count.
    5. Elective cesarean delivery is recommended for women who have HIV RNA >1,000 copies/mL in the late third trimester (i.e., >36 weeks’ gestation), regardless of whether they are receiving antiretroviral drugs (see the Perinatal Guidelines, available at: https://aidsinfo.nih.gov/contentfiles/PerinatalGL.pdf.
    6. Women with HIV who are in labor should receive their usual oral antiretroviral regimen. Women with HIV RNA >1,000 copies/mL or with unknown HIV RNA should also receive intravenous zidovudine (abbreviated as AZT or ZDV). For dosing, see Table 8 in the Perinatal Guidelines, available at: https://aidsinfo.nih.gov/contentfiles/PerinatalGL.pdf.
    7. Infants should receive zidovudine prophylaxis for 4 to 6 weeks (see the Perinatal Guidelines at https://aidsinfo.nih.gov/contentfiles/PerinatalGL.pdf for more detailed discussion).
    8. Women with HIV in the United States should not breastfeed their infants.
    9. Treatment and prophylaxis for OIs should also be restarted. A section on “Special Considerations During Pregnancy” is available under each OI in the most current guidelines for treatment and prevention of OIs (https://aidsinfo.nih.gov/guidelines/html/4/adult-and-adolescent-oi-prevention-and-treatment-guidelines/0).
  3. Treatment and Prevention of Opportunistic Infections

    Persons with HIV receiving therapy for treatment or prevention of OIs should continue or be restarted on treatment as soon as possible. For more detailed information and recommendations regarding prevention and treatment of OIs in adults, including pregnant women, and pediatric patients, please refer to the guidelines at https://aidsinfo.nih.gov/guidelines/.

  4. Vaccinations

    General Recommendations:
    1. Practitioners should refer to the Centers for Disease Control and Prevention (CDC) website (https://www.cdc.gov/disasters/immunizations.html) for updated general recommendations for individuals displaced by disasters.
    2. Inactivated influenza vaccine, when available, is recommended for all persons with HIV who are >6 months of age, including pregnant women. This is especially important if the residents continue to reside in crowded areas.
    3. All patients who received immunization at temporary medical care facilities should be given written documentation of the date and types of such immunization as records for their primary care providers. If available, immunization administration can be submitted to a local/area immunization registry.
    4. Adult formulation of the tetanus/diphtheria toxoids/acellular pertussis (Tdap) vaccine should be given to adult and adolescent persons with HIV if it has been at least 10 years since last vaccination or the vaccination date is unknown.
    5. Tdap should be given to all pregnant women with each pregnancy.

    Specific Recommendations for Children with HIV:

    Children with HIV should be vaccinated according to routine childhood immunization schedules (https://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html). The complete recommendations on immunization for children with HIV can be found in the Pediatric OI Guidelines, available at: https://aidsinfo.nih.gov/contentfiles/lvguidelines/oi_guidelines_pediatrics.pdf.

    More information regarding antiretroviral management in adult, pregnant, and pediatric patients, as well as recommendations for prophylaxis and treatment of specific OIs, can be found at https://aidsinfo.nih.gov/guidelines/.

 


These guidelines were prepared by:

  • HHS Panel on Antiretroviral Guidelines for Adults and Adolescents
  • HHS Panel on Antiretroviral Therapy and Medical Management of Children Living with HIV
  • HHS Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission
  • HHS Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents
  • HHS Panel on Opportunistic Infections in HIV-Exposed and HIV-Infected Children

For more detailed information regarding treatment and care for patients with HIV, visit the federally approved medical practice guidelines for HIV/AIDS at https://aidsinfo.nih.gov/guidelines.

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