Episode Transcript
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Welcome back to the Curbsiders. I'm Dr. Matthew Otto,
1:39
here with my great friend, Dr. Paul Nelson
1:41
Williams. Today we're gonna be talking about
1:44
HIV.
1:44
You know, what should we be, what
1:46
should we know about this as generalists
1:49
in primary care? And we have a great
1:51
guest, Dr. JJ Nunez. Paul,
1:53
before we introduce our wonderful guests, would
1:55
you tell people what is it that we do
1:56
on the curbsiders? Yeah, I often
1:59
ask myself, but thank you. Thank you, Matt. And also, by the way, thank
2:01
you, John, for that nice introduction. I have never
2:03
been introduced first in my entire life, by the way, so that was
2:05
a real thrill for me. That's nice that
2:07
I recorded for posterity. We are the
2:09
internal medicine podcast. We use expert interviews
2:12
to bring you clinical pearls and practice-changing knowledge. And
2:14
what an expert we have for you. I can say on a personal
2:17
note, I've known Dr. Nunez for
2:19
years, and he is one of those people who is, like,
2:21
annoyingly good. I don't
2:23
know if you know people like that, but, like, he's nice and then also
2:25
competent and takes good care of patients and is smart. And the type
2:28
of person who makes you feel bad about yourself if you're me at least.
2:30
So we're thrilled to have him, but I'll give a more formal bio now.
2:33
So Dr. Nunez received his medical degree from the University
2:35
of Connecticut School of Medicine, and what I want to
2:38
do is internal medicine residency at Yale New Haven Medical
2:40
Center and completed his fellowship in infectious disease
2:42
at the University of Pennsylvania with Penn Medicine.
2:44
Dr. Nunez is interested in health equity and medical
2:46
education. In addition, he has an interest
2:48
in improving access to medications for opioid use disorder,
2:53
medical and resident education, medical student and resident education,
2:55
that was probably as opposed to P, HIV primary
2:57
care and HIV-prevented medicine. So
2:59
without further ado, let's bring up Dr. Nunez. JJ. J.J.,
3:02
we're gonna tell you about Mr. Jones.
3:05
He is a 24-year-old gentleman, a self-identifying
3:07
male who presents to your
3:10
primary
3:10
care office for the establishment of care. He is transferring
3:12
care to your office after
3:14
moving to your city from out of state. Medical records are not available at
3:16
this time. So let's bring up Dr. Nunez.
3:18
JJ. All right, let's get right to a case,
3:20
right down to business. All right. JJ, we're
3:22
gonna tell you about Mr. Jones. He is a 24-year-old gentleman,
3:24
a self-identifying male, this visit. He's without
3:26
specific somatic concerns and
3:30
he reports a medical history significant for HIV
3:32
for which he takes Bictegrifir, Entercitabine,
3:35
and Tenofivir, otherwise known as Bictarvi. For
3:37
the purposes of this case, you're not an expert,
3:40
you are me, which means you are well-meaning
3:42
and you don't have a lot of experience in care of HIV, but you have
3:46
ready access to competent colleagues like yourself who are able
3:48
to do so. I feel like one
3:50
of the reasons I chose this case is this comes up in
3:52
my practice on Novacchiwado a lot where I have someone
3:54
who say their HIV is well managed by an
3:57
ID doc, but they still want somebody else for their primary care.
4:00
It's the lines get kind of blurred, and I feel like I need
4:02
a little bit of help. But for you, at a
4:04
first visit like this, where you're meeting this patient for the first time,
4:06
what are your goals, and what does this first conversation
4:08
look like for you? Yeah, so I think usually
4:11
when I'm first seeing any new patient, I
4:13
kind of always try to break the ice. I kind of introduce
4:16
myself. Mostly I try to tell them two things. I'm
4:18
slow, so I'm like molasses.
4:21
So I usually tell them probably don't
4:23
want to schedule an appointment after that, mostly
4:25
because it gives me time to really dive into a little
4:27
bit of the psychosocial stuff that's necessarily
4:30
going on. Second thing
4:32
I always tell them, I'm like Colombo. So I tend
4:34
to repeat myself a lot. And mostly I
4:36
feel like it's mostly just to pick up things that might not
4:38
have come up the first time, or maybe I
4:40
did not actually pick up when they were talking.
4:43
So I think from the first visit,
4:45
I really tried to get a sense of what brought them here
4:47
today. If they're transferring their care,
4:50
what was the reason that they're transferring care? Was
4:52
there barriers to the last practice that they're
4:54
necessarily at?
4:57
I think the other things, They're moving from a different
4:59
state. What brought them to the state?
5:01
Is it work? Is it employment?
5:04
I feel like starting off with some of those questions gives me
5:06
a little bit more about the social support as I
5:08
try to ask these questions overall.
5:12
Then during the actual visit, I think focusing
5:15
a little bit more on the HPI, mostly
5:17
of HIV, the big things I'm looking for mostly
5:20
is time of diagnosis. How
5:23
long have they been diagnosed? Are they actually
5:25
on medication? Are they taking their medication? Are they
5:27
struggling with adherence? Those are
5:29
the kind of the questions I'm necessarily asking
5:31
overall, mostly to kind of think about barriers
5:33
to care. I think we do an excellent
5:36
job of screening patients for HIV,
5:38
it's just retain patients in care, where
5:40
it's a little bit more difficult.
5:43
I noticed you mentioned Colombo. I'm 40
5:46
years old and I barely get that reference, so I'm sure
5:48
your patients really appreciate it. Yeah,
5:51
but
5:51
I wanted to ask about,
5:54
you mentioned psychosocial things is
5:56
like.
6:00
Like how, now I threw myself
6:02
off here, Paul. It's a solid joke though,
6:04
it's worth it. I just really
6:06
wanted to make the Colombo joke. No, but
6:09
at that first visit, how
6:12
much time are you getting and how much detail
6:14
are you getting into about like, you mentioned
6:16
the psychosocial stuff, so can you give an example of
6:18
like where you might spend the time on those, like
6:21
which specific issues? Sure, I think usually
6:23
I start off with just asking about the social history in the beginning,
6:26
really getting a chance to learn my patience. It makes
6:29
it easier for me to remember
6:30
who they are, especially when they're calling. So
6:32
I can really remember one or two special facts
6:34
necessarily about them. But I think the things I'm really
6:37
focusing on is in
6:39
a living situation,
6:41
things about how they interpret and
6:44
look at their disease, how do they feel
6:46
about their disease, how
6:48
do they feel about their medication management? These
6:51
are, are there things where they feel that they're empowered?
6:53
Are they feel like they're being listened to? Those
6:56
are some of the things I'm actually necessarily going through
6:58
as well. As I focus on that,
7:00
I'm also just trying to figure out if there's
7:02
issues with housing,
7:04
or if there's issues with changing
7:06
insurance, or making sure that there's coverage for the
7:08
medications. Are they having trouble
7:10
with side effects, or any reportable side effects
7:12
that I don't know about medications? So as
7:15
I go through with that, I also try to focus a little
7:17
bit more on mental health, just
7:19
to try to see where they're necessarily at. Have
7:22
they been treated before in the past for any mental
7:24
health? Are they having any barriers right now? So
7:27
a lot of times I think of it as more like a biopsychosocial
7:29
assessment than necessarily like a true
7:32
social history, actually. And then
7:34
that's where I kind of segue and make that
7:37
introduction to kind of the more
7:39
personal questions. I don't usually like to start off
7:41
with just the HIV questions, because sometimes they can
7:43
be a little bit more personable or intrusive.
7:45
So then I kind of move into the history of
7:48
like when they were diagnosed, where they've been diagnosed.
7:50
Couple questions I might focus on for that
7:52
is, have they been on medications
7:54
that worked for them, Have they been on medications that
7:57
hadn't worked for them? Are there any side effects
7:59
for me to know about?
8:00
So, you know,
8:01
what do they look for in a
8:03
provider? Those are the things I kind of focus on during
8:06
the visit. Usually I
8:08
have about 40 to 60 minutes for new patients, which
8:10
is lovely. It also
8:12
runs slow, so it's going to be a little bit longer than that. In
8:15
my practice, you know, there's days I
8:18
have social worker and case managers, so I
8:20
think we're all working together as
8:22
they work with the patients. And I think at the
8:24
end, we try to debrief and see if there's
8:27
any issues that we might have missed. is
8:29
I'm just by myself, I
8:31
feel like the first visit is really a job interview.
8:34
That's really what it is for me. I
8:36
got to make sure that this patient feels comfortable to come back.
8:39
No one really wants to go to the doctor. I don't want to go to the doctor.
8:41
The only thing I'm more popular than, maybe
8:43
the dentist, okay. But I
8:45
feel like
8:46
how much I try to focus on that visit, you
8:48
know, I might have my expectations, but
8:50
it's really measuring what expectations my patient
8:53
have. If there's an ongoing issue or
8:55
medical concern that they have, I'm gonna push
8:57
some of that aside and really just focus on that
9:00
because I think one of the big things is trying to retain
9:02
them and cares making sure that we're taking care
9:04
of the issues that they have.
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Other than being your usual charming excellent doctor
10:24
Lee self Is there any sort of systemic
10:26
or sort of like clinic level stuff that you can do to encourage
10:28
retention and care? And I guess, what can we
10:30
do to keep these people engaged in treatment? Because I know that there's
10:32
going to be a challenge at times. I
10:34
feel like
10:36
jumping around a lot in the sense that
10:38
I mentioned what I do. I think the first thing I
10:41
also make sure is just making sure that we're using
10:43
right pronouns. So for some of my
10:45
patients, it might be fluid. So I might
10:47
ask during each particular visit. So
10:50
I think that might be one part where
10:52
I would start. I think one of the big things that
10:54
I try to make sure during the visit is ways I can
10:56
contact my patient. There was a study that
10:58
was done at one of the Ryan Wright conferences, I wanna
11:00
say like years ago, that was one
11:02
of the biggest predictors was change in full number in
11:05
a year. So I think for me, trying to focus
11:07
out where they're at, where I can contact them,
11:09
how I can contact them, recognizing especially
11:12
for my younger adolescent or
11:15
young adult patient population, cell
11:17
phone calling them is archaic. No
11:20
one calls them, right? So it's like usually through text. So
11:22
I try to find other ways in theirs as
11:25
well. I think the other thing systemically I try
11:27
to do just see them without medical
11:29
records. If I have it, lovely, awesome. If
11:31
it's not, that's fine too. I don't find
11:33
that they're overall super helpful. You get 200 pages
11:36
of stuff that you don't necessarily need. Right?
11:39
Yeah, it's more helpful if you have a specific
11:41
question when you get that 200 page document dump
11:44
of prior records. But
11:46
I wanted to point out to the audience, because I think about
11:48
this a lot. I'm a doctor,
11:50
but I try to read and listen to
11:53
stuff that's way outside of medicine and try to apply
11:55
it to medicine. But I think if you're in the audience
11:58
and you don't see anyone who has age. I
12:00
think a lot of what you talked about is just good doctoring,
12:02
where you're just like, I start off, I want to get
12:05
details about the person so I remember who they are.
12:07
I remember their story. You're building your memory
12:10
palace of who is this person. I
12:13
think that's great. So I think people
12:15
can apply that to whatever they're doing, even
12:18
if they're not seeing any HIV in their
12:20
clinic.
12:23
And you mentioned some of the things, but
12:25
I wonder if you could just sort of role model for us
12:27
what your specific HIV history looks like. once you
12:29
have the patient comfortable with you in terms of things
12:31
like date of diagnosis
12:34
and acquisition, are there any, and
12:36
I think you touched on most of those points, but you just sort of bullet
12:38
point out what you kind of ask about when you're asking about the HIV
12:40
history specifically.
12:42
Yeah, sure. So I try to figure out where
12:44
they're necessarily coming from, when they were diagnosed,
12:47
if they've ever been hospitalized or non-hospitalized,
12:49
this gives me an idea if there's been complications. Usually
12:52
I go back to see if they've been on history of
12:54
any opportunistic infections, so can kind of
12:56
give me an idea what stage of HIV or AIDS
12:59
or complications they might have had before
13:01
in the past.
13:02
You know, medications we talk about, I really
13:04
want to make sure that we're aware of resistance,
13:07
which most patients may not necessarily know.
13:10
They just may remember, hey, this medication I was told
13:12
does not work for me overall.
13:14
I want to get a sense if they have an understanding
13:17
of what the name of their medication is. Realistically,
13:19
they're probably going to know more about their medication than
13:21
some of the providers. We just don't see
13:23
it as often. And then what pharmacy that we've been
13:26
using it, how have they been getting it, have they
13:28
had any issues for the barriers for the pharmacy?
13:30
Because sometimes if it's smaller mom and pop
13:32
shops, the medication
13:35
can sometimes be delayed for getting it compared
13:37
to some of the bigger institutions. As
13:40
for additional HIV
13:42
history, you know, other things I try to get a sense
13:45
of as well as any other co-infections, mostly
13:48
thinking about hepatitis B and hepatitis C
13:50
because it's going to determine what I do for treatment. And
13:52
then want to make sure that we really treat hep C very
13:55
early on because with co-infection, progression
13:57
to liver disease is much higher.
14:00
I also want to make sure there's social support,
14:02
actually, so just making sure, like, as we're
14:04
working about things, you know, are
14:06
there people are aware of their diagnosis, are they not
14:09
aware of their diagnosis, are they secretive about
14:11
their diagnosis, stigma. The way I ask
14:13
that's mostly like, what's been barriers for you about, you
14:15
know, taking care of your medical condition, actually.
14:19
Paul
14:19
and I were talking about this on the
14:21
drive up, up here. I mean, it, I
14:24
feel like that it's, it's a chronic disease,
14:26
we have such good treatment for it, but the
14:28
stigma and people just remember the 80s
14:31
and the 90s when everyone was dying from it and
14:33
people are still just so secretive
14:35
about it or I've still had patients tell
14:37
me, please don't test me for HIV. I'm like, what are
14:39
you worried about getting tested? And they're like, I
14:42
just don't want to, I don't even want to go there. I'm like, well, it's
14:44
a chronic disease. Like you can get treated. And so
14:47
I think there's still a lot of like misinformed
14:49
patients. You know, you brought up an excellent point, Matt,
14:52
because like
14:52
how how I
14:54
always mention is it's a chronic disease that's
14:56
easy to treat, it is in diabetes. That
14:58
may be true for me as the provider, but
15:01
it may not be the truth for the patient. I
15:03
think a couple of times I always touch base with them is
15:05
just that they can tell you the exact date that
15:07
they were diagnosed. They can tell you the exact
15:09
situation that they were in when they were diagnosed.
15:11
And for many, it was really, really traumatic, actually.
15:15
It was in a very awkward situation,
15:18
or the other thing was the involvement with the
15:20
healthcare system at that time, or
15:22
it was a complete shock. So
15:24
it's very easy for me to say, hey, it's easy to take
15:26
a pill every day. For some, it's really not.
15:29
So that's why I really try to get a sense of what
15:31
is their understanding of the disease and how do
15:33
they view themselves overall
15:35
during the visit.
15:37
And this is fairly granular. But
15:40
I wonder, how do you
15:42
document
15:44
in the record who knows about the diagnosis
15:46
and who it can be disclosed to? I feel like I don't know about
15:48
you all, but I've been involved in teams where
15:50
there's been catastrophic disclosure of diagnoses, the
15:52
family members who didn't know or that kind of thing. So is there a
15:54
way to sort of safely
15:57
sort of share that information so that you're protecting the patient the way
15:59
they need. we
16:00
were protected. Yeah, I try to keep it in
16:02
my note. I think I
16:04
try to forward with every part of my note, part
16:07
of the HIV initial history, so
16:09
that if anyone's pulling up the chart. I also try
16:11
to use stickies if we can. So
16:14
by previous medical records, you can actually put it. So
16:16
it comes up as a pop-up
16:18
that you can make sure that they're not aware of the diagnosis.
16:21
I know our medical
16:23
record here has that option too. I
16:26
just assume that no one knows, and you
16:28
shouldn't assume that anyone does. And I think
16:31
also when you're seeing patients in the hospitalized
16:33
setting, you just assume that someone in the room does not
16:35
know, actually. Because I've
16:37
had similar instances where they were accidentally
16:40
disclosed in front of people that didn't
16:42
know.
16:43
Thank you for not mentioning the medical record by
16:45
name. We bleeped that on the show. Actually,
16:47
a past guest complained to Paul and I because we
16:50
bleeped them because they said the medical record name
16:52
so many times that their colleagues
16:54
were like, why are you swearing so much on curbside?
16:57
And he's like, I wasn't swearing. I was saying the name of
16:59
a medical record. Yeah, listen, until they sponsor us. Anyway,
17:01
yeah. They're not getting free press from us. All right, Paul, should
17:03
we move on with the case? We should probably move on with the case.
17:08
All right, so Mr. Jones, in terms of getting
17:10
your excellent history, he tells you that he was diagnosed with HIV
17:12
three years ago. He states that his viral load is
17:15
undetectable. He believes his CD4 count was,
17:17
quote, pretty good at last check approximately
17:19
six months ago. He is without any other
17:21
medical issues other than occasional seasonal allergies.
17:23
He states that his parents are in good health. He reports
17:26
occasional alcohol use, smokes cannabis daily
17:28
and denies other substance use. He
17:30
is sexually active with two male partners and engages in
17:32
receptive and penetrative anal and oral sex, endorsing
17:35
routine barrier protection. He reports
17:37
a prior history of chlamydia infection about
17:39
nine months ago, and then again two years prior
17:41
to that, works as a graphic designer currently
17:44
and lives alone. We'll
17:46
get into some of the social history and some of the management
17:48
stuff, but I do want to give a space
17:50
to at least talk about your initial physical examination,
17:53
if this diagnosis changes anything that you would do, or
17:55
if it's just your routine bread and butter.
17:56
Sure. I think a lot of it's visualization actually
17:59
just like. looking at the patient if they seem anxious,
18:02
you know, overall that gives me some kind of things to kind
18:04
of look for. Also, the things I'm
18:06
looking for during my history, even though it's part
18:08
of the physical, you know, I always do
18:11
like a full review of symptoms because it might kind
18:13
of gears me if there's issues with adherence. Things
18:15
I'm looking for really is if
18:17
there's been any weight loss, any night sweats, any
18:20
fevers, you know, have they noticed any lymphadenopathy
18:24
overall because it might gear to me on what I'm going
18:26
to focus on on my necessarily exam
18:28
as well. And then thinking about the sexual history,
18:31
actually, which I'll talk about in a little bit, but
18:33
I think one of the big things is if they're having any active
18:35
symptoms, because again, you know, one of the big
18:37
things I try to do on the exam is make sure that,
18:40
you know, we're not missing anything on the diagnosis. And
18:42
then for the physical exam, you know,
18:44
really just like I tell the residents, it's
18:46
really just head to toe. But you know, a couple things for
18:48
me to kind of keep an eye on is if there's weight
18:51
loss, if the patient looks cactic.
18:54
I think other things, if there's visual field deficits,
18:56
you know, the rooms have a thaumascopes, We can use them
18:59
for reminding them that they're there, other than paper weights.
19:02
I do a good full skin exam, lymphadenopathy.
19:05
And then depending on patient preference and reading
19:07
the room, unless there's an active symptom that's
19:09
concerning for me for an STD, I also
19:12
make sure that I try to do a
19:15
sexual health exam as well. But that might
19:17
also be determined by patient comfort.
19:20
And you mentioned looking for a catexia
19:22
and everything. But one thing that I was, I guess,
19:25
not as aware of, like people
19:27
with screening for metabolic syndrome or just
19:29
like weight gain on medications, can you speak to that
19:31
a little bit? That wasn't really on my radar. Totally,
19:34
so like also part of my exam is looking
19:36
through the vitals and then also looking for like anything
19:38
that suggests of metabolic syndrome. So
19:41
why is that? Because I think, you know,
19:43
patients had mentioned that there has been weight
19:45
gain with certain HIV medications and I
19:48
think a lot of times back in my
19:50
day, as a trainee and as a
19:52
student and as a fellow, we used to always mention
19:54
that, you know, HIV is this catabolic state. You're
19:57
undetectable, you lose fat deposits.
20:00
You're on medications, that's why you're gaining
20:02
weight. Although, since
20:04
there's been newer treatment options,
20:06
which is awesome in the sense that they're
20:09
easier to take, has less reportable side
20:11
effects, they suppress the virus really well, we're
20:13
learning a lot about our patients on these new medications.
20:16
And I think there's been a lot of association with
20:18
weight gain as well. And when we
20:20
look at that, it's also not necessarily
20:23
equal actually. So I remember reading
20:25
something where about one in six patients within the next
20:27
two years will gain 10% of their body weight. actually
20:30
starting on antiretrovirals. And when you
20:32
split that even more, the weight gain's even
20:34
higher in African-Americans, and especially
20:36
African-American women, so nearly 20%
20:38
of patients. And some of these
20:40
studies, I think the one I remember is like the advanced
20:43
trial, noticed that there was a weight
20:45
gain about up to 6.4 kilos. So,
20:49
is it part of the medications? It could be. I
20:51
think some of the newer formulations, when
20:54
we used to use a lot of Tenofovir disaproxyl,
20:57
We kind of advanced to tenofovir alifinamide.
21:00
We're noticing that there is some weight gain, and there
21:02
might be even more concurrent weight gain with some of the integrase
21:04
inhibitors. So when we're thinking of dolatagravir
21:06
or bactagravir. So it's something to kind
21:09
of think of consul. So as exam wise,
21:11
it's important to note, to keep an eye on that,
21:13
because there is gonna be some weight
21:15
gain. And I think preparing patients for that, if you
21:18
wanna talk about adherence is important.
21:21
What do you do in terms of mitigation
21:23
strategies for that? I mean, I know this is not the episode
21:25
for initiation of therapy, I guess if you were at that point,
21:27
is it just an anticipatory guidance? Is there, how
21:30
do you talk to that with patients? I
21:32
think I've changed my focus on a couple
21:34
things. I think one, I really think
21:36
about talking about diet and nutrition very
21:39
early on. And then again, it's really not just that.
21:41
It's really checking if there's access
21:43
to healthy food. So I think if there's
21:45
an issue with that with patients, I might tie that in with my case
21:48
manager or local resources to kind of focus on that.
21:50
I think
21:51
three, try to really form and talk
21:53
about physical activity. When I talk
21:55
about physical activity, That's another kind of sneaky way
21:57
to kind of find out safety of the neighborhood because like there
21:59
are some neighborhoods where it's not super safe to go
22:02
exercise outside. It also has
22:04
made me rethink sometimes med switches. So
22:07
a lot of times, you know, the thought processes and your medication
22:09
comes out
22:11
super great,
22:12
less side effects, you know,
22:14
but if my patient haven't had issues to change
22:16
them, you know, sometimes it's conversations now that
22:18
I initiate, hey, there's this new option, but
22:21
let's sit down if this is the right option for you. So
22:23
I've been like rethinking some of the initiations
22:26
and switches overall. Or if
22:28
I do switch, mentioning that this
22:31
may be something that note that we will know,
22:35
actually. For the patients that
22:37
I've had some patients recently tell me that they
22:40
started doing like YouTube workouts, because you know,
22:42
like Peloton, all those things are expensive,
22:45
unattainable for a lot of patients. But like,
22:48
there's free workouts on YouTube and things. And
22:50
same thing, patients are like, my neighborhood's too dangerous.
22:52
So I don't, I don't walk around or during
22:55
the pandemic, people weren't comfortable going
22:57
outside so now they're doing that. I
23:00
did want to ask you, is it okay
23:02
to talk about labs now, Paul? Are we moving into
23:04
the initial labs or do we have something else? I can save
23:06
my question. Well, I guess while we're here in sort
23:09
of metabolic land, I guess there are any other considerations.
23:11
I know that I hear some rumblings about sort of screening
23:13
and diagnosing
23:14
diabetes and
23:16
sort of choosing labs for that and timing of the initiation
23:18
of ART and that kind of stuff. Is there anything that might
23:21
be a little bit more nuanced than we need here? But from a primary care
23:23
standpoint, is there anything that we should know about specifically between
23:25
HIV as treatments and diabetes? Yeah,
23:27
I think as part of the
23:30
one thing that's really interesting, and
23:32
I'm happy to have patients that are living longer
23:34
lives, I'm happy for the day they're cured, and I lose
23:36
my job. I tell them I'll cry tears of joy with
23:38
that. But there is a risk
23:42
for cardiovascular disease about two times
23:44
higher in patients living with HIV, even being
23:46
undetectable, and in higher
23:48
CD4 counts. So I think as we look back
23:50
at that, there's some kind of big focus
23:53
points for metabolic syndrome. You
23:55
know, I think one of the things is really being aggressive
23:57
to screen for diabetes. I
23:59
think all making sure that lipid profiles
24:01
that we're not just checking them, we're actually treating them
24:04
actually. So as we're thinking about things, you know, I have
24:06
many patients who are super well
24:08
controlled for
24:11
the HIV, their diabetes needs a
24:13
little bit of help actually. And I think
24:15
one of the big things as I focus on that is highlighting
24:17
that that's probably just as important or even
24:19
more important for mortality overall
24:22
than necessarily just treating your HIV. So
24:24
I think I tend to do a lot more
24:26
screening and then as I'm thinking about my antiretrovirals,
24:30
as we talk about switches, it's important to
24:32
think of what medication interactions there might be. I
24:35
think one of the big things is making sure that if a patient
24:37
needs to be on a statin medication to really
24:39
think about that. And you can't just go by the ACCVD
24:42
risk factor in our patients who are living with HIV
24:45
because we're not actually part of the calculation.
24:47
We know there's a risk. So as
24:50
I discuss with my patients why I'm doing
24:52
stuff. And I think one of the big things for my
24:54
patients is I feel a lot of times
24:56
overall, both non-HIV, more
24:58
meds, I'm always pushing meds, right? They want
25:00
less meds, but I try to really focus
25:02
that, hey, if you have a heart attack, there's gonna be about three
25:05
or four meds I'm gonna add onto your med list that probably won't
25:07
go off. And I think that's if
25:09
you have a minor heart attack
25:10
with no dysfunction after.
25:13
And then for, so for us, for
25:15
mostly taking off the patients for boosters for cholesterol
25:18
medications, if we can, some
25:20
of the protease inhibitors can cause dyslipidemia.
25:23
The newer ones, not as much, but compared
25:25
to the integrase inhibitors, they tend to be pretty
25:27
lipid neutral. But my dosing
25:30
for the statins can be contraindication.
25:32
I have to start with a lower dose and make sure that they're
25:34
not having any side effects. And the statins
25:37
we tend to use is Resuva statin or Torvastatin
25:39
overall. For diabetes
25:42
management, some of the longer-acting
25:44
integrase inhibitors actually do interact
25:46
with metformin. So the dosing should probably be a
25:48
little bit lower. So thinking about Della Tigrvir
25:51
and Bic Tigrvir. But
25:53
I think one of the big things is just making sure that as
25:56
a provider, we're doing just as updated
25:58
care for HIV for the... primary care. So like if
26:01
they really are indicated to get a GOP
26:03
one for diabetes really thinking about that if they
26:05
need the statin really thinking about that overall
26:08
so I tend to be pretty aggressive on that and same thing for blood
26:10
pressure control. Do you have any
26:12
preferred resources for the statin interactions or do
26:15
you just know these off the top of your head at this point? I
26:18
always double-check you know I think I
26:20
always double-check you know there's a couple great
26:22
resources I think University of Washington
26:24
has this like self-study module for HIV
26:27
and also HIV and primary care. It's
26:29
free, it's amazing. They also have one for Hep C.
26:32
UCSF also has one where I think they're
26:35
just revamping the website because it's been off for
26:37
about a year and it's called the Knowledge Link
26:39
and it's great because it's all topics necessarily
26:41
all towards there. Those are my kind of
26:45
go to ones and then I know I'm digressing
26:47
a little bit but I think as I talk about my patients
26:49
is really focused on smoking
26:52
because there's a much higher the prevalence of smoking
26:54
in patients living with HIV. And I describe
26:57
it as, you know, a couple years ago, our
26:59
journal, Clinical Infectious Disease, had a article
27:02
on smoking and smoking conversations
27:05
to have with patients, reviewing their treatments for patients,
27:07
you know, pretty much a primary care
27:10
article in a infectious disease journal.
27:12
And I think it just shows that the prevalence of smoking
27:14
is much, much higher. Yeah.
27:17
The quit line in
27:19
the state of Pennsylvania is great. They give five
27:21
free coaching sessions and they'll send patients
27:24
patches and then either gum or lozenges for
27:26
free. So it's a fantastic
27:28
resource. And I think it's a national resource. I
27:30
think if you call, you actually get a person
27:33
too. So I would recommend people
27:35
just even call it yourself just to see like what
27:37
experience the patient's got. I've done it and
27:39
it is very
27:42
helpful.
27:43
I wanted to ask a little
27:45
bit about,
27:47
or no, I'm sorry, I wanted to note the Liverpool calculator,
27:49
isn't that the one that like all the ID docs, I
27:52
think it's been mentioned on the show before. I think
27:54
they have one for hep C, for HIV, and for
27:57
the COVID medications, I think. Yeah, and thank you for bringing
27:59
that back.
28:00
because that one's also a very helpful source. I've
28:02
used it a lot during COVID, especially just
28:04
a magic check for the Pax Levitt interactions.
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29:18
All right Paul, where to next? Well
29:20
it's Valentine's Day. I mean we should probably why
29:23
she is Valentine's Day. Happy Valentine's
29:25
Day. Thanks to you too, buddy.
29:27
So actually, let's talk about, because I do want to
29:30
make space for this too, about the conversations
29:32
about transmissibility in relation
29:34
to, say, viral load in CD4 counts. Or what's
29:37
the current thinking, the current counseling? Can we, I just
29:39
want to make sure that we talk about the u equals u before we move
29:41
past it into the other screenings. Yeah,
29:43
so I think this was big when this
29:46
came out with CDC. I think there was many
29:48
studies that were already super suggestive
29:50
of this. there is a study which I
29:52
can't remember all. I think it was HPTN052.
29:56
You might quote me on that one. I should know that
29:57
one, but I think overall, I was looking at zero discord.
30:00
couples and what they noticed in serial-descorbent
30:02
couple one living with HIV, one without is that
30:05
the patient, as long as the patient was undetectable,
30:07
actually did not contract, was unable
30:10
to transmit HIV. And there's been several
30:12
iterations of it from different parts. There's the partner
30:14
studies and the partner two studies that looked at more
30:16
diversified patient populations
30:19
and same thing. So when we're looking at
30:22
patients that are MSM or gay, bisexual,
30:25
they were able to extrapolate that
30:27
as well, that U equals U. So really
30:30
thinking about treatment is not just treatment.
30:32
It's also preventive. So that's why I think
30:34
a lot of our Treatment options have
30:37
really focusing on starting medications very early
30:39
on. It's crazy like ten years ago I would
30:41
wait till they're a defining illness just talking about this.
30:43
Yeah, yeah, and I was a when I was a resident I
30:46
think the smart trial came out. So it was like CD4
30:49
come up 500. Yeah, and you
30:51
know really talking about the rapid initiation
30:53
and really bringing down that viral load as
30:55
quick as often And there's a lot of stuff from UCSF
30:58
also looking at bringing down that viral load
31:00
very quickly with same day initiation. You just got to
31:02
remember there's some patients that you may want
31:04
to do that too. There might be others that you want
31:06
to be careful on actually.
31:09
Yeah. And
31:10
I wanted to, you know, this is something I do
31:13
on the show from time to time. So I maybe
31:15
I'll tell me if I'm wrong. I might be wrong. Feel
31:17
free to shoot this down. He's going to be wrong, by the way. We
31:20
should just check the CD4 account. That's still most
31:22
important. and we should just check it like every
31:25
month or so for just the entire time
31:27
the person has HIV. What's the current
31:29
thinking on that? Am I up to date? So,
31:32
you know, we'll check a CD4 count initially
31:34
as a baseline when we're thinking of treatment
31:38
naive, mostly to give us an idea
31:40
of,
31:40
you know, if there's issues with us to think about
31:43
for opportunistic infections prophylaxis.
31:46
You know, the absolute number is what my patients are so
31:49
on and remember, but to me, just
31:51
as important as the CD4 count the percent because
31:53
the absolute number can change. Someone can be
31:56
ill, hospitalized with a pneumonia, come in with a colitis,
31:58
that absolute number can come down.
32:00
the percent tends to be less
32:02
variable. For how often we check it,
32:04
so I usually will check it within
32:07
three to six months, in the initial
32:09
part. As patients who've been undetectable
32:12
for greater than two years, I've sometimes just switched
32:14
to once yearly, actually. It
32:16
also is patient driven. There are some patients that
32:18
are really, that is super important for
32:21
them to know. So I think
32:23
that's
32:24
something that I keep in until my thought as well. It probably
32:26
depends on when they were diagnosed too, right? Yeah, I
32:28
mean we had talked years ago with Michael
32:32
Sagg and he was just like, yeah, viral load is what's
32:34
important now, suppressing that. Once someone's
32:36
viral load's suppressed and their CD4's greater
32:39
than 500 and stable for years, like
32:42
checking it has minimal value at that point
32:44
if they're staying
32:45
on their meds. I would agree with that. I
32:47
think some reporting that some funding comes
32:50
from different states for like our Ryan Wright program
32:52
still are on that. They still want that. I still want
32:54
that. But I think I agree with that. To me,
32:56
the bigger thing is making sure at the viral load. And
32:58
that's what I'm going to be checking more often, especially
33:00
I want to make sure that's dropping within a log, actually.
33:03
And with the introduction in integrase inhibitors, it does.
33:06
Where I get worried is if it's not. And that's
33:08
when you've got to start thinking about, hey, were
33:10
there barriers for adherence? Is
33:12
there some underlying resistance that I might
33:14
see? And that's where I might focus on. But
33:17
one thing I forgot to mention, even as I'm having
33:19
this discussion with this patient, too, is
33:23
taking a really good sexual history. Because
33:25
one of the big things I want to make sure is that
33:28
if their patient partners get offered PrEP
33:31
or discussions about HIV PrEP. And I know these
33:33
guys have done talks on HIV PrEP. I won't
33:35
focus so much on that. And then
33:38
also take a really good sexual history as
33:40
well. Yeah.
33:41
So before I actually, I would like to hear what
33:43
your sexual history sounds like before we get there and
33:45
before we leave this slide. Is there a recommended
33:48
duration of time for someone to be undetectable
33:50
before you can say with confidence, OK, equals you? Is
33:52
there guidance, recommendation for that? Is one lab sufficient?
33:55
How was the timing about that? So
33:59
back what I always.
34:00
remember when I'm talking about family planning, I would like
34:02
to make sure that they're undetectable for at least six months.
34:04
But I think honestly, the data suggests that if
34:06
they're been undetectable with viral loads
34:09
less than being
34:11
detectable, it reduces the chance.
34:13
Perfect. OK. And I know that you wanted to talk
34:15
about your sexual health history. This
34:18
feels like the right time. So I would say
34:20
that the greatest thing I've ever
34:22
had, honestly, was working with
34:24
a young patient population. Because they really
34:26
broke me down in the sense of like terms,
34:29
lingo, like everything. And I still learn so
34:31
much from them. I have a, it's a joy
34:33
taking care of them. I always think
34:35
of, there's actually an insert from like the CDC
34:38
and it's really thinking about like the five P's. Now
34:41
I don't always remember all the P's, but it's still good. So
34:44
I think one is like looking at practice. So
34:46
like, you know, what is their practice? So I usually
34:48
will go in, like, I always start off with like, I have no assumptions,
34:51
just tell me like, you know, what preference
34:53
of partners do you have? trans be female
34:55
by, you
34:57
know, overall how do you practice, top,
34:59
bottom, verse. Usually I preface
35:01
this by, this is important for me to think about for testing.
35:04
So like I usually will preface that from that. Sometimes
35:06
I'll even ask them, you know, have they been tested in that
35:09
modality before overall. I
35:12
think the next thing I kind of get to is number of partners
35:14
within the last three to six months. So again,
35:16
it gives me an idea of how often to do STD screening, making
35:19
sure that that's offered. thinking about
35:22
HIV prep if there's like also partners that
35:24
they're necessarily having that might be interested in
35:26
that as
35:27
well. You know, I think
35:30
also prior history,
35:32
so again, knowing if they had previous histories
35:34
of STDs, mostly to make sure that they get tested
35:37
more frequently, and then also to make sure that
35:39
they're getting tested correctly. A lot of times I see
35:41
the primary care providers, amazing, they'll do a good job
35:43
of screening. They forget the check syphilis. So
35:45
like a lot of times I'll see like the urine and the
35:48
swab, but I won't see the RPR
35:50
actually. So just there's higher rates of syphilis
35:54
as expected. And then one other thing that might be
35:56
a little bit different in my patient population is hep C. So
35:59
there's.
36:00
There's been some
36:01
data looking at sexual
36:03
transmission, mostly in MSM. So
36:06
there's been thoughts that screen hep C might
36:08
want to have a discussion with patients to screen yearly,
36:11
actually. So that might be something else in my practice. And
36:13
making sure they're immune for hep B is also
36:15
a part of my practice. So like looking through all
36:18
these is making sure that if we do have the
36:20
swabs to do recto-infringial testing,
36:22
that should be included as well,
36:24
because we'll catch more cases that way. Yeah. We
36:28
did a STI episode years
36:30
ago and I
36:31
again was embarrassed to not know that. I
36:34
was just like, oh,
36:34
do the urine nucleic acid amplification
36:37
test
36:37
and I'm good to go. And our guest is like, no, you
36:39
miss a ton if you do that. Like you have to ask them
36:41
like, how are you having sex? You know, if and
36:44
then you have to do rectal swabs or pharyngeal
36:46
swabs, as you just said, as well if
36:49
that's happening. So I think that's,
36:51
we can't say that enough so that people remember to
36:54
do that. What
36:55
else, Paul? I wanted
36:57
to ask about, well,
36:59
actually, I guess, let's get into the labs first. So
37:02
we have some of these up here. Hopefully, they're
37:04
reasonably accurate. But I guess, let
37:08
me go back to my original question. I heard
37:11
rumblings about doxycycline for
37:13
STI prep. Can you talk me where are we
37:15
at with that? How should we be thinking about that? Is that something that
37:17
is commonly used? Sure. When I was in
37:19
Philadelphia, there was an arm of the hypergase
37:22
study that looked at doxycycline to
37:24
look at reducing the cases
37:26
of syphilis and chlamydia.
37:29
As the advent of HIV prep, great
37:32
in preventing HIV expectations
37:34
that there's been higher cases of STD, especially
37:36
in certain patient populations where there's just
37:38
much, much higher cases overall. The
37:41
thought process is that it's really thinking
37:45
about post-exposure prophylaxis, because
37:47
what they're looking at is providing doxycycline,
37:49
which is 200 milligrams within. You want to do
37:52
it within 24 hours, but up to 72 hours after
37:54
condomless sexual activity. And
37:56
what they noticed is that it actually decreased syphilis
37:59
case. and chlamydia cases, UCSF
38:02
and their state health department, I thought, had just
38:04
come out with a study, because it was kind of mentioned
38:07
in the International AIDS Conference from last summer,
38:10
actually looking at doxycycline, and they were
38:12
only looking at it for MSM. So it's only really,
38:14
MSM, it's cis
38:17
men or trans females, to think about when we're
38:19
talking about doxy prep, actually, and
38:21
what their, although there's ongoing studies looking
38:24
at it for cis females as well. But
38:27
what they noticed was that reduced STDs, but
38:29
up to 66%. And as
38:32
a former, before ID
38:34
fellowship, I was an epidemiologist, and
38:36
I can tell you, I've never done syphilis contact tracing,
38:38
but I've done other contact tracing. Takes up
38:40
a lot of time and resources to really
38:42
find patient zero. So when you're trying to find
38:45
and track cases of syphilis, how
38:48
much resources are spent, thinking
38:50
about conversations about doxypep might
38:53
be something to actually talk about. And
38:55
this is a daily doxy dose
38:57
to prevent? It's two different ways. So
39:00
most ways I've used it is mostly as
39:02
post-exposure prophylaxis. So 200 milligrams
39:04
within the 72 hours, really
39:06
try to put it 24 hours. There's other studies that are
39:08
coming from Canada and Australia that are
39:11
both looking at both PEP and Doxy
39:13
Prep as well. So there might
39:15
be stuff coming about because next week is our
39:17
big retrovirus and opportunistic
39:19
conference, which is a mouthful. So we just call it CROI.
39:22
So CROI. So there might be some updates. By the time
39:24
this airs, we might have to update the show. You'll let
39:27
us know if you need to update the show notes by the time
39:29
this airs. But the question comes
39:31
on who to think about it. So when I was
39:33
in Philadelphia, I remember the health department meeting
39:35
with us and just talking about
39:37
how much resources they use for syphilis testing.
39:40
And there had been discussions and reflections on should
39:43
we be thinking about doxypeps. So it's a conversation
39:45
that I've had for my patients. I think of any
39:47
patients that had more than one or two STDs actually
39:50
within a year, especially if it
39:52
was syphilis, actually. So it's like one
39:54
of the big things have had discussions with
39:57
the controversy or the part did not know in that
39:59
study. the most recent one was there was more
40:01
resistance to gonorrhea. Like it reduced it,
40:03
I think by 50%. Yeah, we don't want super gonorrhea
40:06
to get any more prevalent than it. But the
40:08
caveat is that we don't really use tetracycline
40:11
for gonorrhea treatment. But
40:13
the question is, well, will it change the biome
40:15
or resistance for other stuff that we use doxycycline
40:18
for, right? So when we think about staph infections
40:20
and stuff like that. So I think there's still a lot of data. So
40:22
like CDC's inputs like,
40:24
hey, it can be used off-label,
40:27
but there's still need a lot of data. Well,
40:30
I wanted to ask, because
40:32
we do want to leave time
40:33
for audience questions. I know we have
40:36
a lot of other stuff to test for. I did want
40:39
to ask about anal cancer screening,
40:41
because that's, I think probably most primary care
40:43
docs are less familiar with that. And
40:45
talking about doing digital rectal exams and
40:48
anal PAPs, are you doing those in the
40:50
off? Like who's doing those? Should primary
40:52
carers be doing those? if their patient's
40:54
not seeing an HIV specialist, really?
40:56
Sure, yeah, I've been doing
40:59
anal pap screening.
41:02
I did a lot of it before coming
41:03
to Penn State Hershey. The
41:06
issue sometimes I worry is that the costs of
41:08
the testing for patients prior, but I
41:11
think a lot of things have swayed in the last couple
41:13
years. Last year at CROI, the anchor study
41:15
kind of gave out some preliminary results looking
41:17
at anal cancer screening. So I'm
41:20
trying to remember what the anchor study stands for, things like
41:22
anal cancer, high-grade
41:25
squamous intraepithelial lesions.
41:28
Oh, that's great. Yeah, it's probably a cardiology
41:30
trial. That's not bad. Yeah, yeah. But
41:33
what they were looking at was they were screening patients over the
41:35
age of 35. They had both men and women, trans-female, trans-males
41:38
as well. And they were looking through and
41:41
seeing if a patient tested
41:43
positive for a high-grade lesion, should
41:45
they just take it out or should they just monitor
41:48
it? And the study actually had closed early. It
41:50
was between 15 different sites overall
41:52
in the U.S. and just because
41:54
there was clear benefit necessarily from it.
41:57
So it's something that I've been doing a lot
41:59
more in my patients. and practice and having that discussion
42:02
overall. And
42:04
I've caught a lot of high grade lesions. And then
42:07
after that, really tying them for the anoscopy
42:09
or colorectal to take a look to make sure if there's any
42:11
suspicious lesions. And then after that, follow
42:13
up with colorectal. And any resources
42:16
for people? I mean, I don't
42:18
think I did not learn how to do that. I know I
42:20
did not learn how to do that in training. So what resources
42:22
are there for people if they have to learn
42:24
how to do anal path? Yeah, so there's what
42:27
we call, there's a wonderful iteration
42:29
and stuff from some of the health departments overall.
42:33
It sounds more difficult than it is. It's
42:36
just a brush, actually, overall. And
42:38
you're trying to get around the z-line and putting pressure
42:40
as you go in, put pressure as you go in, and then
42:42
just spin as you go out. It's
42:45
been, you can Google it. There's many
42:47
different things in PDF. And patients can't
42:49
self-swab for that. That's one where we don't
42:51
recommend necessarily self-swabbing. And then
42:53
sometimes also thinking recto
42:55
exam, digital exam, just making sure you're not missing the
42:57
lesion from the brush. So those are things
43:00
I've had discussions with my patients
43:02
and recognized that overall,
43:04
they may not want to do that at the moment. Or
43:06
I don't save it for the first visit. It might be stuff as
43:08
we develop rapport. OK, great.
43:11
And along those lines for cervical cancer screening,
43:14
I know things are a little bit different for patients living with HIV.
43:17
You don't have to go too, too granular, but
43:19
any big differences between anything
43:22
that you would do differently for someone who is living with HIV
43:24
than someone who is not? Yeah, so I think
43:27
if I remember correctly from the primary
43:29
care guidelines, usually age 65, you
43:31
would necessarily stop for cervical cancer
43:34
screening in patients not living with HIV. In
43:36
persons living with HIV, actually
43:38
it goes on past that. So overall,
43:42
also depends, we try
43:44
to do it within the first time of diagnosis,
43:46
but still go by the guidelines, so nothing
43:48
earlier than necessarily 21. And
43:50
then I always have to look at the flowchart
43:52
overall to make sure that I remember, but
43:55
excellent chart up there that you're
43:57
showing.
43:59
So Paul, I
44:01
think we should leave a
44:03
few minutes for audience questions. We have some time left. But
44:05
what else do you definitely want to get to? I know we've got
44:07
into a lot of the stuff on here already. I think the
44:09
things I want to hit for sure, any differences in vaccines.
44:12
And then I think
44:13
we should probably finish up with the future is the injectable
44:15
stuff, because I feel like that's an important conversation to have. So why don't
44:17
we, any difference
44:19
in terms of vaccine considerations for someone with a diagnosis
44:22
of HIV? Yeah, I think as I think
44:24
about
44:26
necessarily vaccines, making
44:28
sure that they're definitely screened for
44:31
hep A and hep B. So making sure that
44:33
they're hep A and hep B immune.
44:35
Actually, again, for prevention
44:38
as an STD, but also co-infection, there's
44:40
worse liver with co-infection. Strep
44:43
the caucus pneumonia. So really thinking
44:45
about strep pneumo vaccinations actually
44:47
indicated there's higher rates. Which ones? Right.
44:50
I always, yeah, same thing. So usually I start
44:52
off with the PCV 15 and then 23. No.
44:58
I got to look at it again. It's changed so much
45:00
recently. It's what it's a day before. It's usually 23.
45:02
Yeah. Yeah. And then the other things to think about meningococcal
45:05
will vaccinate every five years for
45:08
meningococcal. And then even when I was
45:10
looking at the ACIP guidelines,
45:12
thinking about recombinant zoster
45:14
as well.
45:16
Yeah, I know they're trying to simplify. They tried to simplify
45:18
the pneumococcal guidelines, but I still think
45:21
it's still, because there's been so many
45:23
changes in quick succession and there's two new
45:25
vaccines, the two new PREVNARS, I feel
45:27
it's still confused and people are still confused.
45:30
Patients are like, didn't I already have two pneumonia vaccines?
45:32
So anyway, I'm on your side about, I'm on team JJ
45:35
for this one. I'm genuinely angry
45:37
about the pneumococcal vaccinations, which is not great for my patients.
45:39
Well, you know, I think like there's still some tables that
45:41
I have where I usually sit in my pod in clinic
45:43
and I'm like, yes, I'm still up to date on that one. Yeah,
45:46
all right. Well, let's talk about, I
45:48
was excited, I think the first I heard about
45:50
this
45:50
was last year at probably
45:52
ACP talking about the injectable
45:55
medicine, both for prep and for just like
45:57
once, once every eight weeks injectable.
46:00
and they don't have to take a daily pill. Can
46:02
you talk about this? Is this, are
46:05
there any barriers to this? Any downsides to
46:07
this?
46:08
So I think this has been really exciting. A
46:10
lot of patients had been hearing rumblings
46:12
for quite a while. As I mentioned
46:15
to you, it's very easy for me to come in and go, hey, take your
46:17
medication every day. Easy, but
46:19
I have patients that, it's a constant reminder
46:22
of their diagnosis necessarily. I have patients
46:24
that hide their pills or their transitional
46:27
housing in between, So like not making sure
46:29
that they don't want anyone to know that they necessarily
46:31
have HIV. And then I have other patients
46:33
that have just trouble taking pills. So when
46:35
this came out, it was really awesome to kind
46:37
of really talk about different treatment
46:39
options overall. One of the big
46:41
things is it can't be used with Hep B. So they have
46:43
to be hepatitis B, can't
46:47
have chronic hepatitis B, as we tend to
46:49
use tenofovir a lot for heptie
46:53
infections. But I think it's been really
46:55
revolutionary and really giving some of the
46:57
autonomy back to the patient that they don't
46:59
have to take a daily pill. When they were looking at the studies,
47:02
there's two, actually one that we're looking at it monthly,
47:04
the other looked at higher dosing and providing the
47:06
first shot, then the second shot, and then after that, every
47:08
two months. And patients did well.
47:10
There was not
47:12
as many breakthroughs overall from becoming
47:15
detectable. So I think it's a really effective
47:17
tool in our toolbox. Couple of caveats
47:20
to it is that it has to be done in a medical
47:22
visit. So because it's a gluteal
47:25
injection, actually it has to be
47:27
done. And I always tell it is that commercial is awesome.
47:30
I love the commercials. Commercial doesn't tell you that's
47:32
actually two shots. So like
47:34
actually as you're selling it with
47:37
the patients overall. So like the- Wait,
47:39
two shots on the same day? Yeah, so one
47:41
per
47:43
gluteal cheek. So
47:45
like as I just- I think you started with gluteal and then someone with
47:47
cheek at the end. Like you started out medical and then just
47:49
kind of- Sorry. You know, that's how I talk about it with my
47:51
patients. But I think one of the big things to really
47:53
highlight overall from it is from
47:56
the patients that have had transition,
47:58
they've absolutely loved it. I mean. And I think one
48:00
of the big things that I really
48:02
want to try to make sure is I need to
48:04
have a way to find our patient. And
48:06
I think that's the hard part sometimes is like, you
48:08
know, you have to remember to come
48:11
back to get that second shot.
48:13
You know, we have a little bit of a window or wiggle room,
48:16
but the always concerning part is if you pass
48:18
that window and the levels are starting to come down and
48:20
we're promoting resistance actually. So
48:23
you know, I've been having my patients do it.
48:25
We try to track it as best as we can, but I
48:27
think sometimes it's just that might be a
48:29
barrier to think about as implementing is really
48:31
the patient follow-up and retention.
48:34
And then the other thing I mentioned is that injectable
48:37
repivirin, so I also do a lot of methadone,
48:39
so like injectable repivirin can actually prolong
48:41
QTC. So like one thing to remember
48:43
is that if there's other QTC prolonging agents
48:46
to make sure there's a baseline EKG, and
48:48
cabbatagravir can actually interact with methadone. So
48:51
it can actually lower the dose. So it's something to think about
48:53
when you're discussing if they're getting methadone
48:56
with their site to make sure that they're
48:58
mentoring for any withdrawal symptoms overall.
49:01
And logistically with these, do you do an oral
49:03
run-in period for tolerance? Like are the
49:05
oral medications first and then transition to the injections?
49:08
So what does this look like? I know probably more than I need
49:10
to know specifically. No, no. So it's a great question.
49:12
For some patients, you know, if I
49:15
haven't done an oral lead-in, you don't necessarily
49:17
have to do the oral lead-in. And if you're doing
49:19
a switch, actually, and they're undetectable, they
49:21
tolerate it well. For patients where I've had
49:23
a lot of issue with medication side effects, I'll still
49:26
do an oral lead in just to make sure that
49:28
they're not having any side effects. So I've had patients
49:30
where we cycled through many different
49:31
antiretrovirals overall,
49:34
and that might be the time that I'll talk about it. The
49:36
other thing is just remembering that they can't
49:38
have NNRTI resistance. So if
49:40
they have resistance to ripivirine,
49:42
it's not an option. If there's a lot of integrase-inhabitore
49:45
resistance, it's not an option. But
49:47
I think it's a good discussion to have with
49:49
our patients overall. overall. And then the exciting
49:51
part of Cabotagravir as well is thinking at
49:54
it as an option for prep.
49:56
All right, well, should we take, I think we should
49:58
probably take questions from. the audience. We
50:01
might probably only have time for maybe like one or so,
50:03
but we'll just call on you and
50:05
we'll repeat it for the people in the audience.
50:08
So does anybody have any questions?
50:11
If not, that's okay. We're happy to just
50:13
get some take home points and get you all out of here. So
50:16
the question was, is there a PAP equivalent for
50:19
HPV related cancer screening?
50:21
I believe so.
50:23
I think... Yeah,
50:27
it's okay. If the answer is we're not sure... I
50:29
would say I'm not as sure for that, so I wouldn't feel comfortable mentioning
50:31
it. But that is a great question. Yeah, I know
50:33
people, I have had patients ask me that question.
50:35
They're worried about it. I think some celebrity has,
50:38
you know, head and neck cancer from HPV
50:40
and people are now aware that
50:42
that could be a thing. Any other questions
50:45
from the audience?
50:49
Okay. It feels like a question.
50:51
Just the furious avoidance of eye contact is my favorite thing
50:53
about medical education. All right. But we could, we could end
50:55
on time. Let's get some take home points. Like people,
50:57
we've talked about a
50:58
lot today. I mean, we've done hero's work as
51:01
always. As always. But
51:02
if there was like maybe a couple of things,
51:05
one, two, three things you wanted the audience to remember,
51:07
what would those be? You
51:09
know, I think just making sure that
51:12
we're
51:12
balancing patient expectations
51:14
and what they're looking for in primary
51:16
care, recognizing that barriers that they may have experienced,
51:19
I think that's something to kind of really think about
51:22
as we work with our patient populations. The second
51:24
thing that drives me crazy is the expectation
51:26
that if patients are late, we just reschedule.
51:29
We have no clue how our
51:31
patient's journey to come to our clinic or
51:34
practice that day. And you don't know the competing factors
51:36
that they're necessarily having. So I think one
51:38
of the big things is just being slightly flexible. And
51:41
I think one of the big things is recognizing that when
51:43
a patient has questions that if you don't know the answer,
51:46
just making sure that you can either refer or touch base
51:48
with much smarter colleagues overall
51:51
and not ignoring that. And I bring that up because a lot of
51:53
times, we've always talked about patients mentioning, hey,
51:55
I'm gaining weight, I'm gaining weight, I'm gaining weight, and
51:57
then now there's like a lot data suggesting that hey it's
51:59
true.
52:00
you gained weight on your medication. So I think listening to
52:02
the patients overall. And
52:05
we will be back with our lightning round.
52:09
All right, so before JJ, these
52:11
people know you, but maybe they don't have a
52:13
time to talk to you about like, some
52:15
of the more fun stuff. So maybe
52:18
give them a pick of the week. What are you
52:20
enjoying these days? And that you would recommend
52:22
to them and to the audience at home listening to
52:24
this after the fact. So if I
52:27
kind of want to seem like I'm sophisticated, So
52:29
I probably might start off with an actual book. I
52:31
do love to read. I wish I could say something
52:34
like, memoirs or biographies
52:36
or like stuff, but it's usually sci-fi. So
52:38
I think right now I'm reading The Wandering Earth, which is
52:40
really good. It's about moving this planet
52:42
as our sun is dying. It's very depressing,
52:44
but very good. Sounds right up my alley. Depression
52:47
sci-fi is like my specific niche, so I'll have to check it out.
52:49
And then realistically, probably playing
52:51
video games is my, you know, my stress
52:54
reliever and mass effect. I'm really
52:56
enjoying that. Okay, is
52:58
that available on Switch? Not,
53:00
not the moment. Yeah, I probably won't check
53:02
that out then because, yeah,
53:05
PS5's still hard to come by, maybe, I don't
53:07
know. It's fine.
53:10
This has been another episode of The Curbsiders,
53:12
bringing you a little knowledge food for your brain hole. Yummy?
53:15
I mean, it could have been your chance to shine. Do you want to say, do you want to
53:18
yummy? I'm okay. In front of your colleagues? I mean,
53:20
you can, right here. I'm okay. Great.
53:23
All right, missed opportunity buddy. All right, get your shout outs to thecurbsiders.com
53:25
and while you're there signing for a mailing list to get our weekly show notes in your inbox.
53:28
Plus, twice each month, you'll get our curbsiders digest, recapping
53:31
the latest practice changing articles, guidelines, and news
53:33
in internal medicine. And we're committed
53:35
to high value practice changing knowledge.
53:37
And we'd also like your feedback. Please subscribe,
53:39
rate, and review the show. You can find us
53:41
on YouTube, Spotify, or Apple Podcasts.
53:44
You can also email us at askcurbsiders at
53:46
gmail.com.
53:47
And I wanted to give a special thanks to the great Dr.
53:50
Paul Nelson Williams, America's primary care
53:52
doctor, and to
53:55
Dr. Beth Garbz-Garbatelli for helping
53:57
to write this episode. the curbsiders tech
54:00
is done by the team at Podpaste, Elizabeth Proto, and
54:03
Jen Watto run our social media, and Stuart Brigham composed
54:05
our theme music. And with
54:07
all that, until next time, I've been Dr. Matthew
54:09
Frank Watto. I do want to throw in a quick thanks
54:11
for Dr. Ellen Todaldi, who actually is one of my
54:14
legit heroes, who's at Temple right now, who actually looked
54:16
over the script and gave me some ideas. So I just
54:18
wanted to say thank you to her. And then also just ask for
54:20
another round of applause to the great Dr. Níngez
54:22
before they say hi. I'm Paul Williams. Thanks,
54:25
guys. Thanks guys.
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