PHAN’s Resource for Health Care Providers

This resource is meant to serve as a guide for family physicians in Peel in order to provide support for their care of patients with HIV. As patients are living longer and longer with HIV, long-term primary care has become an essential aspect of the management of this disease. In this light, it is important for physicians to have the supports available to provide care for these patients. While this list is not exhaustive regarding resources available in the community, it is meant to provide a clear list of first resources to try in order to provide complete care for patients. This current list reflects the resources available as of 2015-2016.

For physicians new to the management of patients with HIV/AIDS, and even for well-established practitioners, working with these patients can be a daunting experience. The Peel HIV/AIDS Network draws on a diverse network of experts dedicated to managing all aspects of the lived experience of people living with HIV/AIDS. In the interest of optimal patient care, we recommend that family physicians take full advantage of the combined experience of PHAN and other local organizations. Communicating early and often with PHAN regarding your patients with HIV/AIDS will help you uncover resources to allow these patients to manage their illness and live up to their full potential.

Newly Diagnosed

Children, Families, and Pregnancy
Treatment

Social Services
HIV Testing Options
Prevention

Newly Diagnosed

There are many types of resources that might be helpful in working with newly diagnosed patients. Here we have collected some key location-specific patient resources (though there are many more available). It is incredibly important to provide counseling and support to this patient population. Community organizations such as PHAN and the Bloom Clinic (905.451.6959) are well-suited to assist with this and many other aspects of living with HIV/AIDS. It is recommended that all people who are newly diagnosed with HIV be referred to PHAN for counseling and to introduced to the community services available to them. While patients will be able to receive specialist medical care, HIV treatment, and case management through PHAN, you are encouraged to stay on as their family physician to provide primary care. For HIV-specific treatment, many of these patients can be seen by infectious disease specialists; in particular, Dr. David Richardson david.richardson@williamoslerhs.ca, can provide specialized care.

Information on post-test counseling is available below under “HIV Testing”. Kindly refer to the PHAC / CATIE document. For additional information on post-test recommendations and patient plan development, consult the BC centre for disease control. Well-described flow-charts explain next steps following positive or indeterminate test results. Note that we have included Peel and Ontario-specific resources to supplement their BC recommendations below.

Typically, after diagnosis, an HIV baseline evaluation is necessary. This includes a series of laboratory tests: CD4 count, viral load (HIV RNA), resistance test (HIV genotype), CBC, blood chemistry tests and fasting lipids, and screening for TB, Hepatitis, and STIs. Typically, CD4 counts should be repeated every 3-6 months as treatment is initiated to monitor response. If CD4 counts reach normal levels and viral load remains suppressed, CD4 counts do not require following unless viral load changes.

Patient Resources

  1. CATIE patient guide for new diagnosis of HIV: Newly Diagnosed Resource
  2. PHAN offers positive self-management programs, 7 week courses on living with HIV/AIDS. For these programs and more see their Upcoming Events
  3. “Managing Your Health”: CATIE’s in-depth guide to living with HIV/AIDS. This comprehensive package should be required reading for newly-diagnosed patients and their family doctors.
  4. AIDS hotline: 1-800-668-2437
    • Provides information and counseling to Ontarians
  5. Asian Community AIDS Services
    • Prevention and supports for East / Southeast Asian communities
  6. Teresa Group: support groups for families and children, including for new moms
  7. Alliance for South Asian AIDS Prevention
    • Prevention and support for South Asian communities in the GTA

Resource Network

  1. HIV 411
    • GIS-based service (similar to Google Earth) providing location-based information about patient resources including HIV treatment, counseling, financial support, food assistance, harm reduction, sexual health, health and wellness, HIV/AIDS service organizations, housing, legal services, and testing.
  2. Ontario HIV Treatment Network: provides information and program evaluation across the province related to HIV programs.
    • Includes the HIV Outpatient Clinic Network, a coalition of 18 HIV outpatient clinics across Ontario. Provides services and a network of physicians, nurses, social workers, nutritionists and clinical coordinators.
  3. The Ontario HIV Epidemiology and Surveillance Initiative (OHESI) is a new collaboration between the Ontario Ministry of Health and Long-Term Care, Public Health Ontario, the OHTN and the Public Health Agency of Canada. OHESI will monitor the epidemiology of HIV in Ontario to help:
    • Understand challenges along the prevention, engagement and care cascade
    • Provide the information needed to develop and evaluate strategies and interventions, and integrate evidence into practice
    • Inform local and provincial policies and programs so that services can adjust to changing needs.
    • If you have questions, please contact Dr. Mark Gilbert, the OHTN’s Director of Applied Epidemiology at mgilbert@ohtn.on.ca.
  4. The CPSO Public Register
    • Provides contact information for physicians in Ontario organized by specialty and location, allowing you to contact colleagues for consultation and referral.

Children, Families, and Pregnancy

In Canada, HIV is a rare disease in children. HIV+ mothers can successful have children without HIV. However, there are numerous resources that can be used to support families with HIV+ children or children exposed to HIV. It is important for these children to be followed, especially for surveillance purposes. Family physicians should continue to provide primary care, including well baby visits, and to be aware of potential long-term challenges for children exposed to in-utero ARTs, including developmental issues, potential for immune dysfunction, and long-term carcinogenicity. It is also important for physicians to be aware of concerns surrounding stigma, and to discuss disclosure and confidentiality with families.

  1. Under the age of 18, all children should be referred to The Hospital for Sick Children (SickKids) to the HIV Comprehensive Care Program. All HIV exposed babies should be seen by SickKids, including those who are not HIV+ at birth. These patients will be followed until school-age, at which point monitoring will continue through their family doctor. For more information, please contact Georgina MacDougall, macdougall@sickkids.ca and Dr. Ari Bitnun, ari.bitnun@sickkids.ca from the HIV clinic. PHAN can also be contacted for assistance.
  2. The Motherisk counseling line (from SickKids) (416) 813-6780 or 1-877-439-2744 will answer questions pertaining HIV medications and pregnancy.
  3. The Society of Obstetricians and Gynecologists of Canada provides updated guidelines on HIV in pregnancy
  4. For those closer to Hamilton, there is a pediatric clinic at McMaster Children’s Hospital that can provide care. Please contact Dr. Sandra Seigel, at seigels@mcmaster.ca.
  5. SickKids About Kids Health website has 4 relevant info sheets: HIV and AIDS; HIV and Pregnancy; HIV and Your Baby; HIV and Your Child. They are found under Health A-Z, under H. They are available in 8 different languages: Arabic, Chinese, Portuguese, Punjab, Spanish, Swahili, Tamil, Urdu and Vietnamese.
  6. Teresa group’s Family Support Program
    • The Teresa group provides a whole host of programs to help provide care for children, including:
      • Free formula program for pregnant women diagnosed with HIV
      • Diapers up until child’s 3rd birthday
      • Clothing bank and Get Ready for Winter program
      • Family food program for healthy meals
      • Back to school program for school supplies
      • TTC tokens
      • Financial assistance
      • Birthday gifts
    • Can also be reached at 416-596-7703
  7. Child tax benefit
    • A tax-free monthly payment made to eligible families to help them with the cost of raising children under age 18.
    • 1-800-622-6232
  8. Universal Child Care Benefit: 1-800-387-1193
    • Taxable benefit providing direct financial support for child care/ daycare services

Treatment

Therapeutic guidelines provide a valuable framework to begin developing an effective approach to care for people with HIV/AIDS. It is important to remember that HIV is now managed as a chronic condition.

For management of patients, it is encouraged for family physicians to work with their patients’ specialist to develop a treatment plan. Current treatment plans can be found below. It is important to remember that new regimens are not as complicated as past treatments, nor do they necessarily have many side effects. While drug-drug interactions and opportunistic infections must be kept in mind, patients usually do quite well. PHAN and Wellfort can help find treatment solutions for patients not under OHIP, such as refugees.

Therapeutic Guidelines

American guidelines

  • Regularly updated guidelines for adult antiretroviral treatment, complication management, primary care guidelines, and others
  • Suggested by specialists as treatment guidelines for managing your patients

BC Guidelines

  • Includes therapeutic guidelines (adult and pediatric, opportunistic infections, accidental exposure, sexual assault), pre-exposure prophylaxis, information on drug dosage and safety, and more.
  • Primary care guidelines
  • Includes flow sheets for adult male and adult female specifically aimed at directing the primary care visit.

A very comprehensive document from the U.S. Department of Health and Human Services can be found here

  • Includes complete information on history and physical examination for initial visit and follow-ups
  • Includes guidelines for initial laboratory tests in addition to continual monitoring in summary tables
  • Includes information on managing common complaints, complications, coinfections, and comorbidities
  • Includes significant information on ART treatment and adverse effects

Preventing vertical HIV transmission in pregnancy from Pediatric Infectious Diseases Notes and CATIE

Clinical Care Options

  • Database for diverse topics in HIV care including comorbidities, ARV management, epidemiology, clinical course and natural history, opportunistic disease and co-infection, special populations, resistance, and viral tropism, with coverage of relevant conferences on HIV management and decision-tree models for drug management (requires registration).

Pre-Exposure Prophylaxis (PrEP): CATIE fact sheet

  • Pre-exposure prophylaxis to reduce the risk of transmission for high-risk individuals. It was approved for use by Health Canada in February, 2016 via daily use of Truvada.

Drugs

  1. Ontario Public Drug Formulary and related resources
  2. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents from the US Department of Health and Human Services
  3. Antiretroviral therapy decision support tools (requires registration)
  4. Patient-directed primer on alternative therapies for HIV/AIDS from Healthline

Social Services

There are many options for working with patients to access affordable medications. For support in managing your patient’s case file, we encourage you to work with PHAN to help your patient access the care they need.

Patients can apply for ODSP immediately once they are deemed financially eligible; HIV is considered a disability for ODSP.

If ill health is preventing patients from working, they can apply for CPPD.

Legal information from the HIV & AIDS Legal Clinic Ontario (HALCO):

  • Resource list including links to information regarding legal counsel, ODSP/OW, drug and health information, registered disability savings plan, disclosure for individuals, families and children, and other useful government services and programs.
  • HALCO provides free legal services to people with HIV/AIDS in Toronto.
  • More information on HALCO from PHAN

Poverty Support: A practical tool for primary care:

  • A resource list covering food and housing supports, medication and child financial benefits, legal and immigration counseling, and emergency shelter services.

Ontario Works:

  • Financial and employment assistance to cover basic needs like food and shelter, as well as health benefits. Also provides employment assistance to help clients find and keep a job, and emergency/crisis assistance:

Trillium Drug Program:

  • Drug benefit program for people whose drug costs are high relative to their household income. Covers all drugs on the Ontario Drug Benefit formulary. Includes a link to the Exceptional Access Program, which facilitates patient access to drugs not funded by the ODB formulary.

HIV Testing Options

If a patient asks for an HIV test, it is important to understand the patient’s history, perform a risk assessment, and provide appropriate counseling around the test. Testing can be done anonymously or not; if not, it can be done nominally (under the patient’s name) or non-nominally (a code replaces the patient’s name in reporting; Public Health is only notified of the patient’s identity if the test is positive). If patients opt for anonymous testing they must use one of Peel Public Health’s clinics (link below). All doctors can order the test using either patient name or code. If you provide the patient with their testing, ensure that proper pre- and post-test counseling is performed. We encourage physicians to refer to the CATIE HIV Screening and Testing Guide (see below), which includes checklists to ensure all topics are covered. Peel Public Health will contact you, as the physician, with results. The MHLTC resource is a good place to start for resources on providing counseling and testing to patients. We also recommend consulting the Ontario guidelines which provides specific resources for counseling on positive, negative and indeterminate test results, in addition to disclosure information. They also provide useful pre-test checklists and risk stratification information.

  1. MHLTC
    • Ministry of Health and Long-Term Care document outlining prenatal HIV screening guidelines, as well as resources for communicating the importance of HIV testing to pregnant women and women expecting to become pregnant.
    • Includes pre-test counselling checklist, quick guides for testing, and info sheets in many different languages
    • Complete resource from 2008: http://www.health.gov.on.ca/en/pro/programs/hivaids/docs/sayyes_brochure.pdf
  2. Sexuality Clinics: https://www.peelregion.ca/health/sexuality/clinics/cli-locations.htm
    • Locations for anonymous HIV testing in Peel Region.
  3. PHAN on testing
    • Patient resource discussing the testing process, interpreting test results, and common patient concerns, including accessing anonymous testing in Peel Region.
  4. Ontario HIV Testing Frequency Guidelines (CATIE)
    • Provides a risk assessment based on behaviours and past tests to determine suggested frequency of testing, including follow-up from a first test.
  5. HIV Screening and Testing Guide (CATIE / PHAC)
    • Includes clinical indications for HIV testing, pre-test and post-test checklists.
  6. Ontario HIV Counseling and Testing Guidelines
  7. Additional information for healthcare providers on HIV testing (CATIE)
    • Further information on nominal, non-nominal and anonymous testing and the legal requirements for notification and disclosure
  8. HIV Laboratory Guidelines Physician Resources (BC CDC)
    • Detailed information on the type of testing conducted and lab test interpretation
    • http://www.bccdc.ca/resource-gallery/Documents/Communicable-Disease-Manual/Chapter%205%20-%20STI/HIVTestinginBCResourceDocumentforHealthProfessionalsJune2010.pdf
  9. WHO Consolidated Guidelines on HIV Testing Services: http://www.who.int/hiv/pub/guidelines/hiv-testing-services/en/
    • “A public health approach to strengthening and expanding [HIV Testing Services]. They present and discuss a new recommendation to allow trained lay providers to perform HTS, and they compile a range of existing WHO guidelines into one consolidated document”.

Prevention

For patients at higher risk of contracting HIV, there are many resources available to help reduce risk.

  1. Pre-Exposure Prophylaxis (PrEP) fact sheet for high-risk patients
  2. Post-Exposure Prophylaxis (PEP) fact sheet for occupational and non-occupational exposures
  3. PHAN harm reduction and targeted work with higher-risk populations: Programs
    • Focus populations include African, Caribbean and Black; gay, bisexual, Men who have Sex with Men (MSM) and transgender men; and women’s health
  4. Canadian AIDS Treatment Information Exchange (CATIE) provides excellent information on HIV prevention
    • This includes information on both HIV and Hepatitis C
    • Information available regarding pre-exposure prophylaxis for prevention of sexually-transmitted HIV
    • Educational information is available regarding HIV (and Hepatitis C) transmission (pathophysiology, communicating HIV risk, relation to STIs, exposure risk, etc.)
  5. Peel needle exchange program
    • Information on location of clinics, mobile van, nursing services, and further links on harm reduction and methadone treatment centres
  6. Peel Public Health Sexuality clinics
    • Offer anonymous testing, pre- and post- test counseling, referrals for seeking HIV services
    • Provide counseling support to physicians and their clients in person and over the phone (call 905-799-7700 for more information)
  7. Hope 24/7 crisis hotline, for those who have experienced sexual violence:
    • 24 hours/toll free: 1-800-810-0180
  8. Black Coalition for AIDS Prevention
    • Community-based organization targeting reduction of HIV rates among the black community
  9. Pregnancy and HIV (Vertical transmission) – for additional information for patient counseling, the Motherisk program out of SickKids provides useful information, as well as a hotline
    • Includes information about medications, anonymous testing sites, and FAQs