Transcript Related Guidelines

Managing HIV Patients in the Era of COVID-19

Richard A. Elion, MD · George Washington University

Disclosures

July 20, 2020

This transcript has been edited for clarity.

The era of COVID-19 has presented some unique challenges for HIV-positive patients. It has presented challenges for every patient, whether they are HIV-positive or HIV-negative. The sense of living through a pandemic, the sense of isolation, the sense of fear of contagion – those things are already familiar to HIV-positive people.[1] The sense of stigmatization – it is certainly less so for COVID-19 than HIV. All of these are issues that have become part of the terrain that HIV-positive patients have lived with. 

For providers, I think the biggest change for us is that we've shifted ambulatory practices into a telemedicine model. For many practices, this has been an enormous amount of work and transition.[2] And some of that is based on the logistics. Let me go through some of the changes that are necessary. 

First of all, with telemedicine, there are state and local rules that apply. Most of those rules have been waived. The Centers for Medicare & Medicaid Services (CMS) has waived the rules for Medicare and, for the most part, Medicaid, to allow for the substitution of telemedicine visits for in-person visits.[3,4] But the corollary is, what's happened to reimbursement? Has reimbursement kept up with that? 

I'd say that, in the last month to six weeks, there's been movement in that regard. And insurers who understand that most of our ambulatory care has to occur in a telemedicine format have started to equalize the payments for those people who are doing this via telemedicine, as well as regular medicine, provided-- and this is an important distinction-- that video is part of the visit and it's not just a telephone consultation.[3,4,5] 

Telemedicine is a broad term, and I think it's important to try and integrate the video piece into the audio piece because it makes for a more immersive experience. And I think, in some ways, it is a more effective model to conduct clinical care that requires both exchange of information, but more importantly, I think some listening and empathic approach to patients.[6] 

So, I think the issues then go into your electronic medical record (EMR). How does your EMR link to a video feed? There are some EMRs that have an attached video feed. The key piece on the video feed is that it must be Health Insurance Portability and Accountability Act (HIPAA)-certified.[7] For those of you who are using this media Zoom, there is a HIPAA certification component, but it's not the free one. It's something that you pay extra for.[8] 

And there are other programs that exist like that. And I won't go through some of the different names to not do any commercial endorsements. But there are HIPAA-available video feeds that can be used for clinical care. Which then, when used and documented in the electronic record, provide the composite record of a telemedicine visit, embodying both the clinical care given through the conversation back and forth, as well as the interaction of the patient and the physician. 

Finally, we get to two other issues. One is the relationship to insurance and malpractice. Many of the malpractice policies now allow for telemedicine, but there are different requirements.[9] Some require that the care be given only to people who live within the same state. Others give you all the states that border your state. And other states give you a national ability to talk. Some of them make a distinction between a consultative visit for coverage for your malpractice versus when you're doing a regular primary care that is not seen as consultative, which could have different jurisdictional limitations based on how far the patient lives from you. All of these individual questions-- and I know, by this point, you're thinking, oh my god, another set of headaches in the midst of all this COVID-19-- they're all things that you can deal with and dispatch with, but they should be dealt with.

Finally, often, it's necessary to have an informed consent for a telemedicine visit.[10] All new rules of the trade, if you will. But this is a very simple form. There are various forms that are downloadable. You can get them signed either through various online signatures, and there are a variety of programs that you can use to do that. And then once they're established, it's a one-time deal. And then that is part of the patient's record. 

We haven't gotten into the practice of medicine yet. We've only talked about the operationalization of telemedicine. But these steps are important because I think they provide a certain kind of an emotional message to patients, which is, we are here for you. We are not leaving you because you're not coming into the visit, or you're worried about catching things. We'll talk about what are appropriate steps for when patients should come in.

But we are here for you and we're going to make the mechanism by which we're going to conduct our visits stable, reproducible, solid, and with the same rigor you've come to expect of what it's like to be with us in person. I think that establishes telemedicine as a legitimate option. And I'm positive that when COVID-19 has come and gone, there'll be a higher percentage of our visits that we'll do through telemedicine.[11] And we've learned that there are certain advantages to this approach, not just the disadvantages that I've described in the transition to get used to it. 

So meanwhile, once we've set up these forums to do telemedicine, the question then becomes, what's going to be different? Well, what's different really depends on how detailed you'd like to make a telemedicine visit. There are tools available that patients can wear that measure their heart rate, measure their home blood pressure. You can establish their vitals by looking at their respiratory rate and have all of that done. 

There are rashes, there are bumps, there are things you can see by focusing the camera differently with different things that you can often mimic a lot of what we do in a clinical visit in a telemedicine visit. So, some of the conduct of the visit in a telemedicine format is as varied as the conduct of a visit in an in-person format. It just depends on what the nature of the complaint is. 

If it's a regular HIV visit that's not for an episodic problem or a symptom-based problem, but a review, then I think it's really quite straightforward. There are issues around getting labs done. Either you can get the labs done ahead of time by doing either virtual encounter or sending the patient a prescription or arranging through your own in-house lab in your office, if your lab is open in your office, for the patient to come in and get their labs. Or the alternative is you get the labs at the end of the visit and have the patient come in that way. 

Therefore, the blood labs are not having interruptions. I think, in the beginning, everybody was very nervous about coming into any facility. But at this point, most clinical practices that I'm aware of have either kept their visits to a minimum, developed COVID-19 precautions and various screens that occur before the patients even get into the building, let alone the office, and then have laboratory services done by a phlebotomist in the office. That is one option. 

Option two is to use the drawing station of the commercial laboratory or the hospital where you work. Almost all of these places have remained open. And with the patient having a prescription that can either be mailed or sent in electronically to whomever you're working with, all the labs can be conducted in a normal fashion. 

In terms of the delivery of medications, these days, it's simple enough to mask up, glove up, and go out to the pharmacy to pick that up if you wish. But probably over half the patients  already get their prescriptions through mail order or some delivery service. So the basic contract of HIV care-- consultation, appropriate lab consultation, and then provision, maintenance or even initiation of medication-- shouldn't really be impacted. 

I think the only challenges that I've seen are the usual ones. Prior authorizations. How do you get the message for prior authorization? Can you reach the health benefits manager or the pharmacy benefit manager (PBM) in an appropriate timeframe to address concerns and then get things straightened out for the patient? 

The usual slow down on my androgen prescriptions that require prior authorizations, or some of the antivirals, are all the normal speed bumps which may seem more irritating because of the extra irritation of COVID-19, but, in fact, were the customary irritations you had before COVID-19. I think when put together in those areas, these roadblocks are quite navigable and easy to fix. 

Another area that comes up a lot for those of you who are involved in HIV practices is the question of pre-exposure prophylaxis or post-exposure prophylaxis. Most of those can also be done in a telemedicine format.[12] Perhaps, in PrEP, you might delay your visit which had been every three months to every six months. But I would be cautious about that. 

One of the things we're seeing is that, despite our requests for social distancing, people listen with their brains, but libidos don't necessarily pay attention to social distancing. And people, god forbid to even say it, are still having sexual relations in the era of COVID-19 and not necessarily obeying social distancing. So, the need may not be there for all the patients to have every three-month STI testing, but there will be for some. 

And I think for a patient who would feel somewhat remiss in saying they broke social distancing, it's incumbent upon physicians to still offer that opportunity to patients to be truthful. And to say, listen, from the beginning I'm not here to judge your behavior. I'm here to help you stay HIV-negative. So, if you've had any exposure that puts you at risk, let's work together to mitigate that. 

In those situations, self-swab is certainly an acceptable way for three location STI testing for gonorrhea and chlamydia.[13] So, you can either send those swabs to the patient-- have them mail the samples into the lab-- or they can come in and get them done. So STI testing can continue. The issue about how often you need creatinine might be different if they're on a TDF-based TAF-based preparation, but you could increase the interval for that as well. 

And then if somebody needs the bloodwork for an rapid plasma regain (RPR) or hepatitis B or C tests, or HIV PCR if you're worried about acute HIV, then appropriate arrangements can be made, just as we discussed previously with arranging lab services. 

All in all, I think the biggest impact of COVID-19 has been on the shift to telemedicine. There are some offices that are still doing visits in-person, and our office has one provider that is there for people who need to be seen for various reasons. But for the most part, for me personally, I've shifted almost all of my visits into a telemedicine model. 

And I have not found, once I got that working, that's been impossible, or even difficult, to achieve. In fact, there's actually been another side of it that's been surprising to me. And that is, as we're all in this era of increased isolation-- and to some degree, increased vulnerability-- it allows sometimes for a deepening of our relationship with our patients. 

I had a patient talk to me about his partner's substance abuse yesterday, and how that was so scary for him. I had two patients today in another session talk about issues of abuse when they were teenagers. And these would have never come across in a visit when we were rushed and in the office. 

So, like every other crisis that comes, we can all think of all the ways that this has been terrible. But let us all work together to find the underside of this crisis, the moments where we all feel a little more vulnerable, where we feel a little more tender. And we can talk to our patients about stuff that's a little more intimate, and maybe improve the model of care from what we were doing before to something even better.

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