infection also has a negative impact on the immune response to HIV, accelerating the progression from HIV infection to AIDS. 35 TB treatment in patients with HIV infection follows the same principles as in people who do not have HIV. However, caution is advised because of interactions between anti-TB drugs and ART drugs, such as protease inhibitors and rifamycins, in particular rifampicin, as well as the potential for immune reconstitution inflammatory syndrome (IRIS). IRIS refers to the rapid drop in viral load and subsequent rapid rise in CD4 cell counts following introduction or ART. IRIS is associated with an enhanced immune response to co-infecting pathogens and is associated with an “unmasking of latent TB.” 35 The clinical management of HIV-associated TB includes the careful integration and timing of effective anti-TB treatment, followed by initiation of ART, prevention of HIV-related comorbidities, management of drug toxicity, and prevention/ treatment of immune IRIS. 35 COVID-19 The coronavirus disease 2019 (COVID-19) pandemic has significantly impacted persons with HIV or at risk of HIV. 36 The pandemic has had a negative effect on the availability of HIV testing, linkage to care, and access to initiation or continuation of ART.
It is speculated that the disruption of these and other services, including treatment of opportunistic infections, availability of PrEP, and other prevention strategies has already led to increased HIV incidence, morbidity, and mortality. 36 As discussed, Black/African American and Hispanic/ Latinx populations are disproportionately at risk for HIV acquisition. These same populations and other minority ethnic groups (Native Americans) are at increased risk of acquiring COVID-19 infection and have worse clinical outcomes (eg, hospitalizations, admissions to intensive care units and mortality), compared with white individuals. 36 However, when comorbidities are removed from the calculation, HIV infection itself does not appear to be a risk factor for acquiring SARS-CoV-2 infection or progressing to severe COVID-19. There is little clear evidence that SARS-CoV-2/HIV coinfected individuals have a different risk of severe COVID-19 disease than individuals with only COVID-19. 36 According to a recent article co-authored by Dr. Fauci, although the totality of the data is somewhat contradictory, it is clear that the COVID-19 pandemic has had a negative impact on persons with HIV. 36 The most consistent finding is that the severity of COVID-19 in persons with HIV is related strongly to the presence of comorbidities that increase the risk of severe disease in COVID-19 patients in the absence of HIV. 36
STIGMA AS A BARRIER TO OPTIMAL CARE
National strategies to prevent new HIV infections and effectively engage people diagnosed with HIV in the care they need, have consistently identified stigma as a primary barrier. To successfully reach national HIV prevention goals, reducing stigma (real and perceived by patients) by healthcare providers is vital. 37 People seeking services encounter HIV-related stigma from healthcare providers in both traditional (clinical) and nontraditional (community-based) settings. HIV-related stigma is associated with decreased HIV testing, condom use, PrEP uptake and persistence, medication adherence, linkage to care, and retention in care, which are all essential components of the HIV care continuum. 37 One review showed that stigma can be manifested through inadvertent behaviors and ideologies, such as homophobia, transphobia, racism, and negative views of people who inject drugs. These attitudes can create uncomfortable environments that act as a barrier to HIV prevention, treatment, and care. 37 In the Southern US, where HIV is impacting many rural communities, cultural conservatism, and policies such as abstinence-based sex education have contributed to high levels of HIV-related stigma. 38 Conclusion As summarized in this learning activity, the management of patients with HIV/AIDS remains a significant challenge in the US in 2021, forty years after the start of the HIV epidemic. Much of the success in achieving the goals of the HHS Plan for
Awareness of the ways stigma can impact safety within the healthcare encounter requires an understanding about how these structural factors impact the care provided. 39 Compassionate, culturally competent healthcare providers are an essential component of the support systems for people with HIV. Nonjudgmental attitudes from healthcare workers are fundamental to creating a safe space for people with HIV. Supportive attitudes facilitate care- seeking behaviors, motivate adherence, encourage communication, and decrease social isolation and exclusion. Creating culturally safe environments, through self-reflection and self-humility at the institutional level, can disrupt these experiences of stigma within the healthcare system. 39 Online assessments, such as the Teach Tolerance survey, “Test Yourself for Hidden Bias,” allow providers to privately examine themselves for implicit biases and then begin the process of understanding their personal context even as they try to improve as providers. 37 Other strategies to address stigma include hiring a diversified workforce and reorganizing the staff structure to effectively meet the needs of the care setting. 37 America will fall upon primary care providers in the coming years. Primary care providers need to be prepared to manage HIV patients in a comprehensive and compassionate way as outlined in this activity.
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Book Code: CT24CME
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