Guidance for Providers Treating HIV-Positive People Displaced by Disasters

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Hurricane Harvey was the worst storm to reach landfall in the United States in more than a decade, leaving a path of destruction over southern Texas that killed at least 60 people and displaced tens of thousands.

Many residents fleeing their homes were forced to leave everything behind, including personal items and medication. For those with HIV, interrupting treatment can be life-threatening, and may lead to a resurgence of viral load and treatment resistance.

In response to this crisis, the federal government's AIDS working group has released an updated how-to manual designed for nurses, doctors and community health workers treating displaced people with HIV. Aimed at health workers in evacuation shelters, many of whom have not been specifically trained to care for adults and children with HIV, the formal guidance was developed by the Department of Health and Human Services (HHS) Panel on Antiretroviral Guidelines for Adults and Adolescents, a working group of the Office of AIDS Research Advisory Council.

First and foremost, the guidance emphasizes antiretroviral care for any person with HIV, regardless of viral load, and it cautions providers to avoid treatment interruptions whenever possible. Also, the guidance encourages providers to avoid switching from a patient's current antiretroviral treatment unless there is a drug shortage.

According to the panel co-chairs -- who include Roy M. Gulick, M.D., of Weill Medical College of Cornell University, Martin S. Hirsch, M.D., of Massachusetts General Hospital/Harvard Medical School and H. Clifford Lane, M.D., National Institutes of Health -- the guidance was initially designed in 2005 after Hurricane Katrina slammed Louisiana and Mississippi, leading to the displacement of large number of people.

"Many of these residents fled their homes without their belongings including their medications. Persons with HIV found themselves losing contact with their home clinics and providers," said the panel co-chairs, who elaborated on the need for an HIV-specific guidance via a joint email statement.

"Most large shelters provided medical assistance to individuals requiring immediate care or medication refills. Often, the clinic providers were not practitioners with experience for treatment of persons with HIV and, thus, we published guidance to provide links to key electronic resources for management and to define some key management principles," continued the written statement from the co-chairs.

The guidance document includes guidelines for providers on basic medical assessment, antiretroviral therapy management, caring for pregnant women with HIV, preventing and treating opportunistic infections and providing vaccinations.

The document was first updated in 2011, after Hurricane Irene left a wake of destruction that stretched from the Bahamas to the Northeast coast of the United States. However, since 2011, experts have started recommendation antiretroviral therapy for everyone with HIV (regardless of viral load), many pills have been combined into single tablet regimens and it is now considered safe for pregnant women to take efavirenz, a non-nucleoside reverse transcriptase inhibitor sold under the brand names Sustiva and Stocrin.

The newly updated guidance document also includes three tools designed specifically to help providers working in shelters or emergency displacement zones. The first is a short intake form that will help clinicians determine critical information about an HIV-positive person's condition and treatment history. The second tool is a list of websites that provide useful information related to HIV management. Finally, the guidance includes a list of medications that can be swapped for others in the event of a drug shortage.

The panel co-chairs recommend that providers consult with an HIV specialists "when needed, especially when one needs to prescribe a different regimen for a patient." If issues arise, they recommend calling the National HIV Consultations Center's Clinicians' Warmline (1-800-933-3413) or the Texas HIV Medication Program (1-800-255-1090).

In addition, they caution that all pregnant women who may have experienced treatment interruption should re-initiate treatment and be referred to obstetric care as soon as possible.

The full guidance document can be found here.