CAPT. Chad Garrett 0:25 I got just a little Under a minute left. Mr. Smith, go ahead and take it away. Unknown Speaker 0:56 Morning, everybody. Just Christopher Smith, NPA 0:57 a key technical note for those of you out there, if you intend to talk, you should take yourself out of mute. CAPT. Chad Garrett 1:05 How's everybody doing today? Christopher Smith, NPA 1:09 Oh, hello, and welcome to our fifth installment of our NIC clinical pearls webinar series. My name is Chris Smith, and I'm a national program advisor with the National Institute of Corrections. We are thrilled to have you join us for this information. Informative nine part series exploring the integration of the clinical pharmacist into primary care and highlighting proven approaches for correctional team medicine. Before we begin today's session, I would like to cover a few important housekeeping items. Each webinar in this series is scheduled to last approximately one hour, the sessions will be recorded, and once captured and made, 508 compliant will be available on the NIC website. This is a Listen Only event, meaning participants microphones are muted. However, we strongly encourage engagement through the WebEx chat function. Please use the chat to share your thoughts, ask questions or request technical support. I will address as many questions as possible during the Q A portion at the end of the webinar by presenting the questions to our experts to practice the chat function. Everyone, please type into their chat what their favorite springtime events are. It could be fishing or hiking, gardening, reading mystery novels, but whatever it is, go ahead and type in the chat feature what your favorite springtime events are. All right, Benjamin's in the gardening Thank you. CAPT. Chad Garrett 2:43 Christine says anything outside? Christopher Smith, NPA 2:54 We got a few rolling in. Thanks, everybody. I appreciate just keep putting in your answers. I appreciate it. All right, so throughout Alright, if you experience any audio difficulties, we recommend connecting to the webinar audio via telephone using the number provided on your registration confirmation email. Throughout this series, we want to hear from you. You can always email the Health Programs Manager, Chad Garrett at ca garrett.vop.gov with any comments, questions or ideas for future events, I and my team for Nic, including some great staff from the NIC library, will be posting information in the chat during the presentation. Again, if you have any questions, please feel free to type them into the chat, and we will answer as many as we can at the end of the webinar. Thank you again for joining our webinar, and now I give you captain Chad Garrett, CAPT. Chad Garrett 4:02 Chad, I think you're on mute. Hey, you know what I learned that lesson that if you take yourself off mute, it does sound better. Christopher Smith, NPA 4:11 It sounds, in fact, sound much better off mute. Welcome CAPT. Chad Garrett 4:13 everybody once again today we are diving deep into a topic that demands both precision and compassion, HIV screening, management and treatment in the correctional environment. So this is just not about antiretrovirals. It's about access, advocacy and accountability behind the wall to guide us through this mission critical material, we have two standout professionals whose credentials are as impressive as their commitment. We have Lieutenant Commander Miranda Thomas LePage, a clinical pharmacist as FCC Buttner, who has spent the past 11 years turning pharmacy practice into a platform for public health impact with roots in the Navy and advanced degrees in microbiology, immunology and pharmacy, she brings both the. Molecular mindset and the operational expertise to tackle infectious diseases head on. She is a she is board certified in infectious disease pharmacotherapy and a hivp certified expert. So when she speaks HIV care, it's both with authority and action off duty. She is also fluent in compassion, learning Spanish and American Sign Language, caring for creatures, and even roller skating her way through life. Joining her today is Commander, Drew swinger, a pharmacist whose clinical scope is as broad as his commitment is deep, after launching his career in retail, he traded the CVS counter for the correctional corridors and never looked back. Currently stationed at USP Lewisburg, the manager serves not only his institution but the entire system as one of the Bureau's regional clinical consultants for HIV with board certification and ambulatory care and advanced credentials his HIV pharmacotherapy, he is redefining what it means to be a pharmacist in correctional medicine. So together, these two do not just fill prescription, they shape protocols, build systems and elevate care for our most vulnerable populations. Remember, Correctional Health is public health, so I want you all to lean in, take lots of notes and get ready to rethink what HIV care can and should look like in corrections. And with that, let's all welcome our presenters. Commanders, the floor is yours. Thank you. Applause. You, Speaker 1 6:44 welcome and thank you for attending this program entitled HIV screening, treatment and prevention in the correctional setting. Next slide, Speaker 1 7:02 there are no financial disclosures or conflicts of interest. Next slide today, we'll be focusing on three points, identify strategies for appropriate HIV screening and the correctional setting, apply guidelines for selection of first line antiretroviral therapy, AR T regimens for incarcerated adults, and summarize the multidisciplinary roles and functions that are involved in the treatment of HIV in the correctional setting, with an emphasis on the unique contributions made by pharmacists to the care team. Unknown Speaker 7:40 Next slide, sorry, Speaker 1 7:43 so we're starting with the case, and we're meeting with Mr. Turner. He is newly incarcerated in the federal bop custody, and arrives at a bop institution. Next slide, he is evaluated on intake by an advanced practice provider, either a nurse practitioner or a physician. And he is a 42 year old male with past medical history of hypertension, diagnosed in May of 2022 and he provides social history of two tattoos, three female partners in past five years. Admits to some condom use, he denies IV drug use, and he reports being treated for a past syphilis infection. Next slide, labs are ordered on intake, including the HIV, one, two antigen antibody test, since Mr. Turner agreed to have the test done next slide. Hi Speaker 2 8:47 everyone. So commander swagger here, I'm going to take this portion now and just talk to you a little bit about why HIV screening is important in the BOP environment, and to give you an idea of the community situation, of the patients that we are taking in when we do have somebody that comes into our custody, almost one in seven people on in the community don't even know that they have an HIV diagnosis. And of those, as you see on the second bullet point here, those that do know they have the diagnosis, there are still about 35% of those that do not have suppressed viral loads, and their treatment is not where it needs to be. So as we take in new patients, there is a fair chance that we actually may be taking a new, undiagnosed or even uncontrolled HIV patients. And so also, the type of patient that we have in our incarcerated population tends to have a lifestyle that lends itself more to HIV infection, such that we see a prevalence in the Bureau of Prisons of almost 2.5 times that in the general community. So it's certainly something that we want to be very cognizant of and very active in checking for. So the screening process in the BOP, it can actually be just. Separated into three different categories. As you see here, there's a voluntary screening system that we will use, there's mandatory screening, and there's also involuntary screening, and we're going to go through each of those right now. So again, just like Mr. Turner, who came into our custody when somebody arrives, we go through a process that's called an opt out voluntary system. So upon intake, that patient is ordered an HIV screen along with the hepatitis C screen as well, unless that patient specifically decides they want to refuse it, or if there's information in the chart that would indicate it's not necessary because we already know their status. That's the case for every new intake that we have, and also a case if somebody has been previously in the VOP but then left and it's been over 30 days, that test will automatically be ordered unless there's an indication to actually remove it. We also offer our inmates to request a testing once a year if they desire so. That would be the other voluntary process that we would use if a patient believes there's a reason they want to be checked, they can ask for that voluntarily once a year. Outside of the voluntary reasons that we would test, there's several mandatory reasons that we would test as well. The first that you see here is risk factors. If a patient has risky injection practices, perhaps the known IV drug user or have a lot of tattoos, that would be a risk factor that we may want to mandatorily test. Or if there was some type of significant sexual exposure the person had on the outside, that would also be, of course, a risk factor. So once those things are known, that would be a mandatory situation, and in those situations, we do not need the patient's consent to do the test, although they still do have the authority to refuse it on their own. In that case, it would be considered refusing an order. And in the BOP we would follow our normal processes for writing an instant report for refusing an order, but some other reasons that we might mandatory test a patient would be if it's clinically indicated, so perhaps there's signs or symptoms of acute HIV, something like the patient has some fever or lymphadenopathy. Maybe develops a rash. Those symptoms would warrant a look into the patient's case farther, and in that case, we would want to mandatory test them also. Perhaps they have a symptom that's that's related to some kind of opportunistic infection, perhaps they have oral thrush. So those health related conditions would make us decide that we want to make sure that this patient either does or does not have HIV. In this case, it would be a mandatory test as well. But there is also an involuntary situation, and this would happen in the case of an exposure incident, if there was a blood borne pathogen exposure, especially if it's a patient who's known HIV positive, then this would be an involuntary testing situation where the the inmate in question would not have the ability to refuse again. There's no written consent required, but there would also be the need to use a use of force if this patient would not cooperate. Those are the three scenarios, and now I want to talk a little bit about the actual HIV test itself. It's a little confusing. The BAP uses a fourth generation test. So this is an antigen antibody combination immunoassay test, and it actually checks for HIV one and HIV two, the two different strains of HIV. This test will check for the presence of either HIV, one antibodies, HIV two antibodies, or what's called the HIV 1p 24 antigen. And the reason that P 24 antigen is important for this test is because it allows us to detect HIV infection before that seroconversion happens and those antibodies are developed that will allow us to detect HIV as early as 15 days after the initial exposure. To give you an idea of how this test actually runs again when they take the blood sample, this test will look for the presence of either the HIV one antibody, the HIV two antibody, or that P 24 antigen, if either one of those is detected, that test will automatically do another test on that sample where it's looking to do a confirmation test or a differentiation assay. Essentially, this second part of the test is going to identify whether or not it is, in fact, HIV one, HIV two, or perhaps a co infection of HIV one and HIV two. If the first test is positive, the second test will run. If it's positive, then you have your confirmation that there is an HIV infection present, but there's also a chance that that second test could come out negative. In that case, we get what's called an indeterminate result. I'm going to run through two scenarios here to help explain that situation a little better as well. But first, let's consider a scenario where the first test was done again, checking for either HIV one, HIV two, or that P 24 antigen. When that test was positive, it reflexes to the second test, and this time again, it was positive. So in this case, we have a confirmed H. HIV, one infection, and what would the next step be? Well, the next step would be you would want to order an HIV viral load. This will confirm the test even farther as presence of HIV virus in the blood sample will essentially completely confirm that you do have that infection present in the patient. But consider a different scenario. This would be the indeterminate one. In this case, the first test was reactive, the test auto reflexes to the confirmatory test, but again, here it became negative. So what do you do in this scenario? Again, this would be that indeterminate. The same scenario, the same next step applies where you would order an HIV one viral load, if you happen to get a positive result on the viral load, that would indicate that this is probably an early or acute infection. The reason that that second confirmatory test was negative was because you've detected this HIV infection prior to that seroconversion where those antibodies had developed. So that would be the result of this scenario. But again, there's a chance that if you do that HIV viral load, maybe you won't find any virus, and you would get a result like this. In that case, it is more than likely a false positive test. And there's many reasons you could get a false positive different infections can cause that, like tuberculosis, hepatitis and COVID, some vaccinations influenza. And there's also the chance that maybe it was just a lab error, or perhaps it's going to be something that's unknown completely, and you'll never get to the bottom of it. There are some things that are actually intrinsic to the patient, and that patient will always have a false positive test. But there's also things that are transient, like those infections or a recent vaccination, that once enough time has gone by, then the patient's false positive tendency will wane and you can have accurate results after that. So then I hope that explained a little bit about how you would test and screen for HIV and what you do when you get those results. Now we're going to return back to our patient, Mr. Turner, Hi. Speaker 1 17:03 Mr. Turner has called in for follow up appointment to discuss his lab results with his primary care provider. Could be either an AP or a physician, and as we discussed earlier in the slide, previous slides, the HIV, one two antigen antibody was done, which reflects to the one, two antibody and there was a follow up, HIV, one viral load done, and all these tests confirmed HIV, one infection Department of Health is notified as done through infection control, and an HIV diagnosis is made by the provider who will fall, who will forward the results to an HIV pharmacist consultant for further recommendations. Next slide, Speaker 1 17:50 clinical pharmacist consultant can review the labs already performed and then order HIV, one genotype and other baseline labs in order to determine the most appropriate first line AR T regimen to initiate next slide. Okay, so this is our first poll question and our presentation, and I'll read it and choices based on the current national HIV guidelines. What is the most appropriate first line art regimen to initiate choice A, dolutegravir plus Lama lutine, B, bacterevir, intricitine tenofovir AF, C, dolutegravir plus abacavir plus Lama lutine or D, the runover COVID, cyst at plus interested in to know for ver AI, give a few seconds to answer that. CAPT. Chad Garrett 18:46 So we do have our polls open. If you guys want to go ahead and answer via the poll, it looks like we've got about 37 folks yet. Let's just give them another couple seconds. It looks like we do have a few people who are choosing a a few people who most people it looks like are choosing B, and a few people are choosing C. Speaker 1 19:30 Okay, next slide. So the most appropriate answer would be B, the category of your anticipating tenofovir, AF, which is brand name of the party one tablet once a day, has three different antiretroviral medications in it. Choice A can be given as first line. However. Don't have all the labs available right now for this patient, and it's a two drug regimen and if by chance, this patient has hepatitis B, infection then there are not enough medications in that AR T, regimen to cover that hep B, infection, choice C with dietary Rebecca bear plus Lim alluding also has the same idea as choosing a as far as if the patient had a hep B infection, we wouldn't be covering that hep B infection with our AR two regimen and the other issue with C is We would have to have done a specific test, which we will discuss later, the FLA HLA B 5701 screening to make sure there would be no hyper sensitivity to the back of the air Unknown Speaker 20:54 Next slide, a Speaker 1 21:00 lab is included in the baseline testing, arson, CD four, CD account we mentioned earlier, doing an HIV genotype to check for resistance, complete blood count, CDC, complete metabolic panel, samp, liquid profiling and a 1c urinalysis. I kind of alluded to the right side of this with some of the poll questions, with the poll question rather than the answer. So the HLA B 5701 screening would be done if we were considering the back of the air in our patient, and the CO receptor. Tropism assay is another test that we could do if we were considering miragal Rock as part of our AR T regimen, the glucose six phosphate dehydrogenase test could be done if we were thinking about having to cover for opportunistic infections in our patient. And we need a sulfa drug allergy, because the two of the primary opportunistic infections that tend to be covered for primary prevention include sofa methoxazole trimethoprim as the agent to provide that primary prevention. Prophylaxis and so if you have a sulfur allergy already, the alternative would be dat set, but if you have glucose six phosphate dehydrate dehydrogenase deficiency then you wouldn't use Babson because you would be at an increased risk of Hemolytic Anemia Unknown Speaker 22:32 next slide, Speaker 1 22:36 additionally some other baseline testing just more geared to co infection screening. Have hepatitis A, antibody, hepatitis B, serology, hepatitis C antibody, toxic PLAs plasma, gondii, mycoplasma, tuberculosis which was done with a tuberculin skin test or TST, syphilis we already know that he report the power patient reported having a previous syphilis infection that he was treated for. So we kind of know we're going to see some positive with that test, Chlamydia, Neisseria, Trichomoniasis and HIV, positive women only, varicella IgG, or a history of chickenpox, shingles or MMR IgG. So going back to the Hepatitis B serology, if we have a hep B surface antigen that is reactive, that's going to let us know that there is a hep B infection. Also with that, we would have a hep B core antibody which is also reactive. That core antibody is the total one. So then it would reflux to IgM or IgG. If the IgM is reactive, then that slit was known as an acute hep B infection. If it is just the IgG that's positive, so the IgM is more reactive, then this is a chronic he infection going a little bit further, if you had a surface antigen that was non reactive, but an isolated core antibody that was reactive, you'd still want to go ahead and do a viral load, just to ensure that there is no hep B infection here, because there are instances where The Surface antigen is non reactive. Core antibody is reactive, and then the viral load results in, you know, some copies here. So then we would have to cover we have to basically say this patient is CO infecting HIV and hep B, and we'd have to make sure that the antiretroviral regimen that is used will cover our HIV infection, as well as our hep B infection for the MMR IgG, if it comes back, and although one of the three is recognized as being deficient on low levels that doesn't color doesn't provide immunity, then we would offer an MMR vaccine. 18. However, we can't do that until we get the result for a CD four count. Next slide. Lab results are now in for our patient and viral load of 60,000 copies has a CD four count of 450 with a percent of 32 bn, serum creatinine and GFR, renal function is normal, AST Alt and T billiver event show normal liver function to the right side, as I mentioned earlier, we are seeing our RPR and our T palladium antibody, which we are tests that are associated with syphilis. The T by palladium antibody is reactive, or the RPR is non reactive, and this is what we would expect to see for someone who had a successful treatment of a prior syphilis infection. And the test that we use here, it's a syphilis antibody cascading reflux. And if you get a reactive with the teeth, palate and antibody, it's going to reflux the RPR, and then it's in this situation with it being non reactive, since that is kind of like a critical result, it's going to reflux to a TPPA, which is a specific trepone antibody, so, or rather a specific trepone confirmatory test, and it's basically an agglutination assay for a patient who has a antibodies reactive. So he's immune hepatitis B, surface antibodies reactive, hepatitis four antibodies non reactive, and he has a non reactive surface antigen. So this will lead us to believe that he has been previously vaccinated for hepatitis B, and this hepatitis C antibody is non reactive. Next slide, here's our HIV genotype report, and you can see that for the various classes, the NRTI, the NRTI pi, as well as integrase inhibitors, there's no predicted resistance. But if you look further, you'll see that they're at the bottom, you'll see some mutations for the reverse transcriptase and praise inhibitor classes, but those are, for the most part, mutations that are not expected to cause resistance. Unknown Speaker 27:20 Next slide. Speaker 2 27:25 Okay, so after seeing those results for our patient, Mr. Turner, I'm going to now talk a little bit about how we decide what AR T or antiretrothy antiretroviral therapy to initiate. And on that last slide, with the genotype you saw there was four different main classes of of drugs that we use for HIV. So this slide will summarize a little bit of how we combine those. On the left you see that typically we use two nucleoside reverse transcriptase inhibitors as our backbone. We call it. So that was that very first section of the genotype on Mr. Turner's last labs. With that, we will either add an integrase inhibitor, a protease inhibitor or a non nucleoside reverse transcriptase inhibitor. A typical HIV regimen consists of three medications, like I said, usually two nucleosides that form the backbone and then one of the others in combination, and you'll see with that little asterisk beside the insti, which stands for Integrated strand inhibitor, the NS or integrate strain inhibitors, are typically the ones that we want to choose. They're the best choice for most individuals because they're very tolerable and they have a high barrier to resistance. So without a reason not to choose one of those, that will typically be the route that we'll take. And CAPT. Chad Garrett 28:43 now I'm going to look at the guidelines. Speaker 2 28:45 This table summarizes the guidelines for the Department of Health and Human Services, guidelines on HIV management. And there is a lot, a lot going on here, but I want to break it down, and you'll see it's actually pretty simple. This table shows you what would be a first line treatment recommendation, as long as the patient did not have previous exposure to cabotegravir for PrEP or pre exposure prophylaxis. If that patient did have pre exposure prophylaxis treatment with cabotegravir and he still became HIV positive, we would want to go to a table that I'll show you next. But in the absence of that which is the most common, these will be the medications you want to consider. So the very first row shows you bictarby, and in the rows of the columns to the right, the orange columns represent the different integrase inhibitors that you could potentially use for these first line regimens. And as you'll see in the first row, bactegravir is what is in bictar V. It is the only medicine that actually contains big Tiger beer, and the only way you can get big Tegra beer with that. Bactegravir in bictar V is the nucleoside backbone of tenofovir, alafenamide and M tricyta being that is a one tablet once a day regimen. It is probably the most common because it is very simple. But if for some reason, the patient was not able to take the tegravir with the rows below, you'll see that each of those regimens include dolutegravir and dolutegravir, which is known as, typically, is available as a one medication, one tablet, so you would have to add something to the tivocay to use those first four regimens that are listed underneath bigtarby, again with that typically and discovery option you see in the second row, we again have tenofovir, alfenamide and M tri city, and the exact same as bigtarby. But then if we move one row below it, there is a option to use tivoca and Truvada. And there you'll see that the only difference between that and the second one is that now the tenofovir is called tenofovir disapproxyl, fumarate. It may seem a little confusing as to why we have two different tenofovirs, but if you look at that footnote that has a one next to it, T, A, F and TDF are two separate forms of tenofovir. The advantage of TAF is that there's fewer bone and kidney toxicities associated with it. So if there was a concern for any kind of osteopenia or osteoporosis or perhaps the patient's renal function is a concern the TAF version would be the one that you would want to go with. While TDF does have an advantage in that it's associated with lower lipid levels. So if everything is considered the same, but perhaps the patient has a higher concern for high lipids. Maybe the TDF would be the appropriate choice in that case, if you look again at that table, as you go down, the regimens do become more complicated, where, instead of a two drug regimen then you get into a three drug regimen where you may want to substitute lamivine for the M tricyta Being again, that would be a decision based on what was available patient preference. But in reality, choosing a three drug regimen over either a two or one drug regimen would be more complicated for the patient. So even though these are first line recommendations, I think your best choice is either going to be victarbi, if Victoria is your option, or the tivocay and either discovery or Truvada, if dolutegravir would be the choice. You do see at the very bottom a medication called dovato. And as that asterisk shows, that is a two drug regimen of dolutegravir, lamivudine. And just like as the answer was explained by Lieutenant Commander, Thomas LePage, if a patient has either a high viral load greater than 500,000 copies or has hepatitis B Co infection, that would not be an appropriate choice. And so in our patient, Mr. Turner, where we were starting medications without knowing the status of either those his viral load or his Hepatitis B status, we could not choose that. That's only an option if you do know both of those things and they're appropriate. Moving on to the next table, again, if the patient happened to be previously treated with cabotegravir for pre pre exposure, prophylaxis we would not want to use an integrase inhibitor as part of this HIV. Regimen because cabotegravir is an H as an integrase inhibitor in that case, as you see in the middle orange column here, we would substitute arunavir, which is a protease, inhibitor for those integrase inhibitors that were listed in the last table. The very first row shows syntuza, which is a one tablet once a day medication. So that may be an appropriate option if a patient has this scenario, that symptoza has the same 10 off of your alfeni that bictar V had. And as you continue down the call the table, you'll see that the other rows again become progressively more complicated, where now you don't have a single tablet, regimen you're either mixing 123, medications together to come up with your three drug regimen but again, there's more options, depending on if the perhaps the resistance genotype would show that there was a certain resistance available, that you have other options you can choose from. And what makes a successful treatment what are we looking for Why are those medications first line well first we want to pick things that have no to low or tolerable adverse effects as I mentioned before those integrase inhibitors are very well tolerated. That's why they are our first line Medications also low pill burden so those tables, previously showed several one tablet once a day, options that helps with adherence for the patient, if it's only one tablet to take and usually cost as well, we want something that's going to be a robust medication to improve CD four cell count, perhaps the patient, when he starts his CD four is relatively low, and it may take a while For it to rebound but we know that those first line treatments that were recommended in those tables, they have been shown to be some of our robust agents for improving CD four cell count so we want to get them on board and improve that immune function as soon as we can we know that a regimen is effective by checking a viral load again, at four to eight weeks out. After the treatment was started. And what we're looking for at that four to eight week check is to have a more greater than, or equal to one log reduction in the viral load. Usually this equates to at least a halfing of the quantity. And also, we want to get the viral load down below the detectable limit within 12 to 24 weeks of treatment. Current labs usually can detect viral loads down to 20 copies per milliliter. So within the first 12 to 24 weeks, when we do a lab check, we want to know that that medication is effective and it gets it down below that limit of detection. In that time frame, Speaker 1 35:37 the HIV consultant pharmacist has received all lab results and determine the most appropriate regimen. The consultant pharmacist can meet with the provider and the patient via telehealth to discuss the results in the most appropriate first line AR T regimen, or can make and send a recommendation through a chart review to the provider. The pharmacist, consultant has selected victory. It's a three and one tablet taken once daily, as we've discussed in previous slides, next slide, lab monitoring, and is very necessary while on AGR T regimen. So the usually when your AR T is initiated, and at any modification, you're going to check your labs in four to eight weeks, and the lab staff are going to be checked at that point will be the viral load and basic metabolic panel, AST, Alt and total bilirubin. Usually, I will do the viral load in a cmp that complete metabolic panel includes your BNP, astlt and total bilirubin, and the viral load, along with the CMP, will be checked every four weeks until suppress that less than 50 copies every three to six months, until consistently undetectable For two years, and then every six months, as long as it remains undetectable. So anytime that you are ordering the viral load, you do want to order that CNP and the CD four account is paired with our CDC with differential, and that's ordered every three months if the CD four count is less than 300 every six months during the first two years when the CD for account is greater than 300 now, after two years of having a consistently suppressed viral load, if the CD for account is greater than 500 you can opt to not even follow that CD for account any longer. But if it's in the range of 300 to 500 you want to check it every 12 months again, along with the CDC with differential Unknown Speaker 37:45 next slide, so Speaker 1 37:47 several months later, Mr. Turner is transferred to another institution in the bop. We have clinical dashboards, and we have one that is developed to for HIV to help track those HIV patients. In this slide, you can see some of the important information that's included. Is a last name of the inmate, Reg number. We have the these diagnosis, we have these last viral load result and date, which on the slide we can see it's less than 20. So it's, you know, within that suppressed copy a number that we want rather and we have our last CD four result and the date. Also, you can see that it shows medications and Vaccine Information. And on the dashboard here, unfortunately, Mr. Turner had expired, so it doesn't show up as an active medication on this dashboard. And so therefore, when he is transferring to another institution, it's just not it's not there. So there's a problem when he gets them direct. Next slide, okay, so in the Pharm, in the BOP, rather, pharmacists have a unique and fortunate experience to work as clinical pharmacists using a collaborative practice agreement a CPA. As a result, the pharmacists are able to work clinically in several disease states, including HIV. And on the slide, you can see in 2014 there are only eight HIV pharmacists, but grew to 46 and 2023 next slide, at Mr. Turner's new institution, there is an HIV clinical pharmacist that's locally at that facility, so the pharmacist can look at the HIV dashboard, which we showed a couple of slides ago to discover new HIV patients like Mr. Turner, who arrives at the facility. Unfortunately, his pictar V expired at his previous institution, so there was no current AOT. Regimen listed for him, and the HIV, pharmacist is able to actually look through the patient's medical chart and the Bureau electronic medical record known as Beamer. As a result, the pharmacist is able to find that Mr. Turner had been on victory, and that's the agent that had provided a less than 20 bar load, and it he's able to talk to him about that when he sees the NIC clinic again, because it expired when he arrived at the new facility, when the medication reconciliation was performed at intake, it was not included because it had actually expired. So on this slide, we see that the only active medication you had is for thalido, for his hypertension. So the conversation is had regarding the big target being expired, the pharmacist is going to want to know, was this kind of like intended, you know, because you having problems with the medication and you just stopped taking it, or have you? And Mr. Turner reports that he had no adverse effects to taking mctarney. He it fell off. His profile expired. He just never got around to contacting the provider or nursing staff or what have you to try to get it back on. He felt fine. Things were great. He was working and doing his thing, and just never bothered to reach out to have it, add it back on. So that's discussed. Lab left that need to be ordered are discussed. So a viral load is going to be ordered, a genocide is going to be ordered. Because with that lap, we kind of figured that he has a viral load now, CD for account, CNP, CDC, with dif during our conversation, there's some immunizations that need to be updated or given, and we have proven our 20 down here listed. However, there's an update of 21 that's out now. So that's probably what we'd be giving, because Prevnar 20 can be given for certain situations. We have meningococcal acwi vaccine, Tdap, the MMR and sugars, the MMR vaccine would not be given right now, if he, even if he agreed to all of these vaccines, we would not give the MMR vaccine right now, because we don't know what his CD four count is, and it has to be greater than 200 in order to administer the MMR Unknown Speaker 42:33 vaccine. Next slide. Speaker 1 42:37 Okay, so we have our second poll question, what is the most appropriate plan for HIV management at the end of this encounter? CAPT. Chad Garrett 42:46 So our schools just quit on me. We're going to go ahead and answer this question in the chat. So if you want to put your answers in the chat, that would be awesome. Thank you, as Speaker 1 42:57 you can see, the choices. But just in case, people are, you know, listening and they just want to kind of hear the choices or read them. A, restart tegreav intricitine or AF. B, give MMR and Tdap vaccines. C, start Stefan methoxyzolme for prophylaxis against PJP and toxin plasmosis. Or D, start the COVID assist at plus interest setting to nofair af Looks CAPT. Chad Garrett 43:36 like we're getting a lot of A's. Speaker 1 43:42 Okay? So the answer to this question is to restart big tardy CAPT. Chad Garrett 43:48 next slide, Speaker 1 43:53 since our patient had a lapse in his art regimen, having a conversation about opportunistic infection would be pretty important. Those opportunistic infections and primary prevention for them are indicated when the CD four count is less than 200 so as you can see on this slide, pneumocystis JIRA vishi pneumonia would be indicated the CD four is less than 200 and the preferred agent is supplemental trimethoprim either one double strength tablet daily, or one single strength tablet daily. Toxoplasma gondii encephalitis is indicated with a CD for less than 100 and the preferred regimen there is so from a toxic trimethoprim one double string tablet daily. So if you had a CD four count of less than 100 and you didn't have sulfur allergy, then the agent that would be preferred would be sulfamethoxazole, trimethoprim at one double strait tablet once daily. Our third opportunistic infection here of importance, and it's more common than some of. Other things, mycobacterium, Avium, complex disease, or Mac in the CD four count, it's only indicated if the CD four count is less than 50, and they're not on an nirt, regimen or they remain viremic on that antiretroviral. Regimen and the preferred regimen for that would be azithromycin, 1200 milligrams once weekly or 600 milligrams twice weekly or as you can say through my son 500 milligrams beyond but we tend to lean forward to using azithromycin because there's less frequency of having to take it next slide. Speaker 1 45:41 So this slide kind of goes into some of the recommended immunizations per our HIV guidelines, national guidelines. And you can see that the flu and COVID vaccines, as annual vaccines are recommended. We have the pneumococcal vaccine, I said earlier, to be pro Noah 21 versus 20. And right now that's a one time administration of that vaccine, meaning local AC, W, y, vaccine two dose series, one month apart, and you have boosters every five years. Hepatitis A an activated vaccine is a two dose series at least six months apart. Think depending on the product you have all the weights for you have until 18 months, depending on the product that you select, hepatitis B, recombinant vaccine, we have two products that we tend to use in generics B, we use it at a double dose and it's four times so 012, and six months in HIV patients heplisav B is a two dose series one month apart, and that is pretty much the same in our HIV patients or non HIV patients. And our MMR vaccine is a live vaccine two dose series one month apart. And again, as I mentioned earlier, we wouldn't want to give that unless the CD four counts were even 200 we have the option between Tdap or TD vaccine, and the difference between those two, products is we have pertussis and Tdap version, and that's every 10 years. And then it's also recombinant vaccine. Brand name shingrix is a two dose series given two to six months apart. Unknown Speaker 47:23 Next slide, Speaker 1 47:28 our patients, lab results are in, and he has a bar load of 25,000 copies. The genotype does not predict any resistance, so that's good. A CD four count is 287, and his BU and serum creatinine, GFR is normal, within normal limits. His AST and LTV and hematocrit are normal. And his lymphocyte, absolute lymphocyte, is at 1900 but it's also normal. Next slide, and here are the lab results. Eight weeks after restarting, victory he has a not detective bar load his CD four count has increased to 405 and his renal function and liver function remain within normal limit hemoglobin hematocrit also and his absolute lymphocytes have increased to 2650 next slide. Speaker 2 48:25 Okay, so thankfully, Mr. Turner is back to being well controlled and managed, and just like 95% of all the patients we have in custody, he eventually is going to be released back to the community he came from. So the healthier we can keep our patients in custody, the healthier the community becomes in response and in preparation for his release. There's some things that we would want to discuss with him, as far as HIV prevention, first, in the realm of safe sex practices, we want to educate him and anybody else who would be releasing back to the street to use condoms when engaging in sexual behavior. Certainly, even though a person could be protected from HIV by taking pre exposure, prophylaxis that does not protect them from all the other sexually transmitted infections. So by by stressing condom use, we can not only prevent HIV spread, but also the spread of other sexually transmitted infections. Also instruct him to limit the number of sexual partners he has or choose less risky sexual behaviors and if he does have behaviors like that, or exposures he should be instructed to test regularly and treat for any kind of sexually transmitted infection that he would receive as far as injecting injectable drug usage if This patient has that tendency he should be referred to Pro to resources that would allow for safe needle exchanges so that he would not have to reuse syringes or share needles. And if, in the case of a patient like Mr. Turner, because he's returning the community HIV positive already, we want to inform him that he needs to continue to take. His medications regularly, as long as he can continue to maintain a viral load that is less than 200 copies per ml, that would be what we call untrans undetectable, equals untransmittable. So by keeping his viral load down, even if there was an exposure, he would not transmit that virus. If a patient is leaving us, and they have not yet not become HIV positive, but they express to us that they have practices and tendencies on the outside that concerns them, that they might be exposed to the HIV virus, then we could have a conversation about pre exposure prophylaxis or PrEP. And I'm not going to go into a lot of detail about this, because prep will actually be covered in another harm reduction PowerPoint. But like I mentioned, 95% of the patients that we serve in our BOP facilities will return to the community at some point, and so when there is a patient who expresses concern that he may be exposed, we do have processes and programs in place where we will initiate them on a prep regimen just prior to their release. We would want to start that about 30 days before they leave, because it's been shown that they need to have the medication in their system for at least 21 days for them to be completely protected. So after doing some labs that are required, that could be initiated and then when he leaves, we would supply him with a 90 day supply of medications to allow him to be cared for until he can get connected to resources on the outside. But in summary, here is the what we have covered throughout this presentation, and some high points. Screening is important and a priority in the Bureau of Prisons, and we do so for all of our inmates, we test all those with risk factors on a mandatory basis, but it's outside of those factors. It is a voluntary process. But again, we do place a high priority on screening upon intake, and so that is an opt out process upon intake. In the BOP we use medications that are shown to be effective and first line according to guidelines, those are part of our national formulary. And the pharmacists that are in the Bureau of Prisons, through their use of collaborative practice agreements and through their training and ability to work as clinical regional consultants, they contribute in a unique way to the collaborative health care team that helps to manage HIV within our walls, here are some references that were used in the preparation of today's presentation. And with that, I think we have some time that we could take a few questions. Christopher Smith, NPA 52:38 Oh, sorry, Chad, go ahead. CAPT. Chad Garrett 52:39 You go right ahead. Chris, alright, Christopher Smith, NPA 52:41 I've been watching the chat as we go along, and there's not been any questions keyed into the chat. So if you have a question, if you want to go and key it in real quick, I would greatly appreciate it, and we can forward the question along. Okay, looks like we have our first one from Katie has the B, o, p, s, use of pharmacies, pharmacists managing HIV through collaborative practice agreements and as regional consultants led to improve patient outcomes. Speaker 2 53:11 I can take that one, yes, I would say so. If let me think about this. So 2004 where we began using pharmacists in a consultant fashion, that we would train specific pharmacists and have them review all the patients throughout the BOP and then make adjustments to their medications. In 2004 when that was initiated, the viral suppression rate was around 32% now, since then, in 2009 I think it was up to around 66% and today, according to the dashboards, we're up to 91% so I can certainly say that since 2004 there's been a significant improvement in our ability to maintain suppressed viral loads. But I don't know that's entirely due to the pharmacist. Just because we have seen a lot of newer, more effective treatments become available, that has definitely changed the management of HIV. But as I mentioned in one of my initial slides, in the community, there's still about 35% of people who know they have HIV and they don't have suppressed viral loads. So if you compare that to our numbers, around 91% I think that we show that by far, our ability to stay on top of these patients is showing that we've made remarkable improvements to what The community standard is. Unknown Speaker 54:36 I think you're on mute. You CAPT. Chad Garrett 54:45 Hey, Chris, I think you're on mute again. I Christopher Smith, NPA 54:48 was testing. Everybody. Great. Thank you. I have a question from Kennedy. It's I have concerns about mandatory HIV testing, especially when you support. Maybe present is this? Implement? And in all federal facilities. Can you elaborate on the reasoning behind this policy? I don't know how in depth you want to get on this question, but Speaker 2 55:08 yeah, well, I'll speak to it. I don't know how often it becomes a reality. I can only tell you that that is what is in our practice guidelines, as far as if we had an exposure and made on inmate and made on staff that they do need to get that sample and test for it. That is what our policy is. I can't speak to it any more than just the fact that that's what our policy says. Again, I don't know that, especially in my time, everybody that has ever been involved in such a scenario was cooperative. So I don't know that that has even come to be an issue, but I can only speak to what our policy currently says. Speaker 1 55:50 I agree with that comment that he made as well. I've not noticed it being a something done with any frequency, so I believe that most of the inmates agree to have that testing done, and it's not forced, and they're not very many cases of use of force for that. Speaker 2 56:10 And that would not be the only test that an inmate would not be allowed to refuse. They're not allowed to refuse PPDs, to my knowledge, for tuberculin skin tests and even some certain DNA tests that are ordered by the court. So, you know, I'm not saying this is not certainly anything that is completely left field. There are other scenarios that would be similar to it in our policy. If Christopher Smith, NPA 56:35 I can answer it from the unit team, former unit team perspective and custody perspective, I've never heard of anyone mandatorily forcing it to take a test for HIV. I imagine there would be a lot of interventional steps before they would push that issue. Well, unless somebody else is working on another question and frantically typing, we've come to the end of the question, so maybe another second or two for somebody to hit enter well CAPT. Chad Garrett 57:05 outstanding. So matters. On behalf of the National Institute of Corrections, thank you so much for your time and your insight and your commitment to advancing HIV in the correctional setting. Really, we recognize the demands of your role, and we truly appreciate your dedication to improving patient care in this very complex environment. With that, I would like to invite everyone to next week's clinical Pearl, engaging with opioid use disorder, everyone's favorite topic. As the opioid epidemic continues to pose a significant public health challenge with opioid use disorder. We into corrections continue to work to help these folks. So until then, continue challenging the status quo, champion best practices and striving for excellence. Thank you again for your engagement. Stay curious, stay committed, and we are looking forward to seeing you next time you. Transcribed by https://otter.ai