Guidance for Non-HIV-Specialized Providers Caring for People With HIV Who Have Been Displaced by Disasters (Such as a Hurricane)

Introduction

The following information provides guidance to health care providers attending to the medical needs of adults, adolescents, and children with HIV who have been affected by disasters or displaced from disaster areas and who have not yet secured HIV care in the areas where they have relocated. Because disasters and their consequences may occur with little or no notice, health care providers are encouraged to plan for contingencies in advance.

After the initial assessment of immediate medical needs, if at all possible, the person with HIV should be referred to the care of a clinical provider with expertise in HIV in the local area. Medical consultation may also be available at specific local or regional HIV clinics.

The recommendations in this guidance are based on the current standard of care for people with HIV, which emphasize the following points:

• Antiretroviral therapy (ART) is recommended for all people with HIV.
• Interruptions of ART should be avoided, and any unavoidable interruption of ART should be kept to a minimum duration.
• If people with HIV report successful treatment without side effects from their currently prescribed ART, that regimen should be continued or reinstituted as soon as possible.

Initial Assessment

1. Assess the person’s general health and need for immediate medical intervention. Acute illnesses should be diagnosed and attended to promptly.
2. Obtain the following information (see Appendix A for an intake form that clinicians can use when evaluating people with HIV):
   1. Name, location, phone number, pager number, and email address of the person’s primary HIV care provider/clinic and/or research staff (if the person is participating in a research study, such as a clinical trial)
   2. Name, location, and phone number of the pharmacy where the person obtained medications
   3. Pertinent medical history. This includes whether the person is currently being treated for opportunistic infections (OIs), hepatitis B virus (HBV) or hepatitis C virus (HCV) infection, malignancies, or other medical conditions. A medical history should also include whether the person is taking medications to treat opioid use disorder (OUD), such as buprenorphine or methadone.
   4. Latest known CD4 T lymphocyte (CD4) cell count and HIV viral load, including the approximate date when the measurements were obtained
   5. List of current medications (with doses and dosing frequencies), including the following:
      1. Antiretroviral (ARV) drugs, including both oral and long-acting (LA) injectable medications. Images of U.S. Food and Drug Administration (FDA)–approved ARV medications can be found in the National Institute of Allergies and Infectious Diseases (NIAID)’s guide on Drugs That Fight HIV.
      2. Medications for the prevention or treatment of OIs
      3. Any investigational medications. If the person is participating in a clinical trial, obtain information about the clinical trial site and contact information, if available.
      4. Medications for treating other conditions, including over-the-counter and herbal medications
   6. History of drug allergies and the types of reactions experienced, especially if there is any history of serious reactions to ARV medications (such as abacavir) or drugs used to treat or prevent OIs (such as trimethoprim-sulfamethoxazole). People with HIV who have had positive genetic tests for the HLA-B* 5701 allele should not be given abacavir (Ziagen) or fixed-dose combinations containing abacavir, because HLA-B* 5701 predisposes people to life-threatening hypersensitivity reactions.
   7. History of intolerance to ARV medications and other medications
   8. If the person is pregnant
   9. Existence of accessible electronic health record resources (e.g., access to patient portal of health care institutions or pharmacies, health apps on smartphones)

Useful Web-Based Resources

A number of web-based resources may be useful for clinicians and other health care professionals when providing care for people with HIV who have been affected or displaced by a disaster (see Appendix B at the end of this document).

Medication Management Strategies

People with HIV who experienced interruptions in ARV drugs and/or OI prophylaxis or treatment due to disaster-related displacement should restart these medications as soon as possible. More information regarding ARV management in adults, pregnant people, and children with HIV, as well as recommendations for prophylaxis and treatment of specific OIs, can be found in the HHS Clinical Practice Guidelines for HIV.

1. Antiretroviral Therapy Management for People With HIV Who Were Receiving Treatment Prior to Disruption or Displacement

1. People with HIV should be on a combination regimen consisting of at least two different ARV drugs. Many ARV drugs are now available in fixed-dose formulations where two or more drugs are coformulated into one pill.
2. All ARV drugs should be continued or restarted as soon as possible.
3. Interruption of treatment for HBV and/or HCV infection is not recommended. For most people who have both HIV and HBV, HBV treatments are part of the ARV regimen due to dual activity for some nucleoside reverse transcriptase inhibitors, including tenofovir disoproxil fumarate or tenofovir alafenamide, emtricitabine, or lamivudine. These medications should remain as part of the person’s ARV regimen.
4. Treatment interruptions due to disaster or displacement should not prompt an attempt to modify a regimen; rather, the priority should be to resume the person’s original regimen as soon as possible, as long as the person reports tolerating the regimen.
5. If a person cannot recall drug dosages or the medications in a regimen, use pill posters to assist the person with recall (e.g., NIAID’s reference guide to HIV medications), consult an HIV care specialist or consultation service for recommendations, or contact the pharmacy or affiliated local pharmacy chain store where the person most recently obtained medications.
6. If combination pills are not available, some ARV medications are interchangeable if needed. See Appendix C for a list of these products. Clinicians should consult an HIV specialist if there are additional questions regarding switching ARV medications due to supply shortages.
7. ARV medications may interact with each other and with many other drugs. Please consult product labels, an HIV care specialist, or a pharmacist when concerned about drug–drug interactions, especially if new medications will be prescribed for any reason. Common ARV drug interactions can be found in the Adult and Adolescent Antiretroviral Guidelines (see Tables 24a to 25b) and the HIV Drug Interaction Checker.
8. Clinicians should note that not all ARV medications are given as daily oral medications. Several LA injectable ARV drugs are now available and may not be on a person’s daily medication list. These medications include the following:
   • Cabotegravir plus rilpivirine (CAB/RPV, or Cabenuva), given as two separate intramuscular injections every 1 or 2 months
   • Ibalizumab (Trogarzo), given as one intravenous infusion every 2 weeks
   • Lenacapavir (Sunlenca), given as two subcutaneous injections every 6 months
9. For a person with HIV who is using one or more LA injectable medications as part of an ARV regimen and who is expected to be affected or displaced at the time of the next scheduled dose, every effort should be made to procure and administer these drugs no longer than 1 week after the originally scheduled dosing date.
   • If the person is taking LA CAB/RPV and it is not possible to procure the next dose of these drugs, daily dosing with either oral CAB or dolutegravir plus RPV can be prescribed until LA injectable CAB/RPV can be resumed. If neither of these drug options is available in a disaster, clinicians should consult with an HIV specialist for an appropriate alternative ART regimen.
   • If the person is on ibalizumab or lenacapavir and it is not possible to procure the drug, consult an HIV specialist with expertise in HIV drug resistance to determine the course of action.
10. Children with HIV may be taking liquid ARV drugs that need to be refrigerated or dispersible tablets or powder formulations that require clean water for reconstitution. Special attention should be paid to ensure appropriate weight-based dosing for children.
11. The Adult and Adolescent Antiretroviral Guidelines and Pediatric Antiretroviral Guidelines also include information regarding dosing and adverse effects of ARV drugs. The guidelines also discuss special considerations for treatment in certain populations—such as people with HBV, HCV, or tuberculosis coinfections—and ARV dosing for people with renal or hepatic impairment.
12. If possible, obtain blood samples for general safety laboratory tests (such as a complete blood count and chemistry panel, including an assessment of renal and hepatic functions). Additionally, if feasible, CD4 count and HIV viral load tests should also be done and reported to the person’s primary HIV clinician or referring physician. However, resumption or continuation of ARV drugs should not be delayed while these results are pending.
13. If the person with HIV is a participant in a clinical trial, contact the clinical trial staff to discuss what, if any, measures to take while the participant is affected by or displaced due to a disaster.
14. If the person with HIV is a state or territorial AIDS Drug Assistance Program (ADAP) client in their primary state or U.S. territory of residence, the ADAP should be contacted as soon as possible to identify prescription drug coverage while the person is affected by or displaced due to a disaster.

2. Caring for People With HIV Who Are Pregnant or Postpartum

1. All pregnant people with HIV should enter into standard prenatal/obstetric care as soon as possible. When feasible, they should be referred to specialists with expertise in both obstetrics and HIV management.
2. The National Perinatal HIV Hotline provides 24-hour access to experts on managing HIV in pregnancy and caring for infants exposed to HIV: 1-888‑448‑8765. The hotline also serves as a clinicians’ network and can assist providers with identifying clinicians nationwide who have experience in managing HIV in pregnancy and caring for infants exposed to HIV.
3. All pregnant people with HIV should receive ART.
4. If ART is discontinued during disaster or displacement, the regimen should be restarted as soon as possible.
5. Elective cesarean delivery is recommended for those who have HIV RNA >1,000copies/mL in the late third trimester (i.e., at 38 weeks gestation), regardless of whether they are receiving ARV drugs (see the Perinatal Guidelines).
6. Individuals with HIV who are in labor should receive their usual oral ARV regimen. Those with HIV RNA >1,000 copies/mL or with unknown HIV RNA levels should also receive intravenous zidovudine (abbreviated as AZT or ZDV). For dosing, see Table 9 in the Perinatal Guidelines.
7. Infants should receive zidovudine prophylaxis for 2 to 6 weeks. Infants at higher risk for perinatal HIV transmission will require two additional ARV medications in the postpartum period (see the Perinatal Guidelines for a more detailed discussion).
8. People with HIV may decide to breastfeed/chestfeed. Guidance about infant feeding is available (see Infant Feeding for Individuals With HIV in the United States for a detailed discussion).
9. Treatment and prophylaxis for OIs should also be restarted. A section on “Special Considerations During Pregnancy” is available under each OI in the Adult and Adolescent Opportunistic Infection Guidelines.

3. Treatment and Prevention of Opportunistic Infections

People with HIV who are receiving therapy for the treatment or prevention of OIs should continue treatment or restart treatment as soon as possible. If these medications are not readily available, clinicians should refer to Tables 1 and 2 of the Adult and Adolescent Opportunistic Infection Guidelines or to the Pediatric Opportunistic Infection Guidelines for alternative options. Consultation with specialists who have expertise in managing HIV-associated OIs is advised.

For more detailed information and recommendations, see the Adult and Adolescent Opportunistic Infection Guidelines and Pediatric Opportunistic Infection Guidelines.

4. Caring for People on Medications for Opioid Use Disorder

Disasters can disrupt other medical services that are important to people with HIV, including methadone maintenance therapy (MMT) for OUD. Methadone clinics may close for unknown periods of time during weather-related disasters, leading to an interruption of MMT services. This may lead to an increase in drug-seeking activity and drug use or opioid withdrawal in the absence of MMT availability. Federal law prohibits physicians from prescribing methadone for the treatment of OUD outside of a methadone clinic. Increasing access to buprenorphine replacement therapy, which can be prescribed by health care providers outside of a licensed methadone clinic, can help to preserve access to medication-assisted treatment for OUDs until MMT clinics reopen.

Providers should consider the following issues when caring for people on MMT:

1. All health care providers with a U.S. Drug Enforcement Administration (DEA) license may prescribe buprenorphine for the treatment of OUD (an X waiver is no longer required). This includes treatment for withdrawal symptoms.
2. If a provider is unable to prescribe buprenorphine, or if buprenorphine is not available in a specific area, other medications can be prescribed to lessen withdrawal symptoms. For example, lofexidine is FDA approved to treat opioid withdrawal symptoms. The dose is 0.18 mg four times daily at 5- to 6-hour intervals for up to 14 days. Barriers to lofexidine use may include cost and availability. Other medications—including clonidine, hydroxyzine, and loperamide—have been used off label to support people in opioid withdrawal. Consultation with a specialist is optimal to aid in dosing.
3. Providers should prescribe naloxone to all people with OUD. Providers should also make sure that the person with OUD has naloxone on hand to reverse an overdose should they relapse, use unknown quantities of illicit methadone, or attempt to self-medicate with other substances.
4. Tips for locating substance use and mental health services can be found on the Substance Abuse and Mental Health Services Administration (SAMHSA) website.

5. Vaccinations

General Recommendations

1. Inactivated influenza vaccine and COVID-19 vaccine are recommended for all people with HIV who are ≥6 months of age, including pregnant people. Vaccination status should be assessed in a person with HIV >6 months of age to determine if initial or additional vaccines are needed. This is especially important if the person continues to reside in crowded areas.
2. All people who received immunizations at temporary medical care facilities should be given written documentation of the date and types of immunizations administered for their primary care providers. If available, immunization administration can be submitted to a local/area immunization registry.
3. Adult formulation of the tetanus/diphtheria toxoids/acellular pertussis vaccine (Tdap) should be given to adults and adolescents with HIV if it has been at least 10 years since the last vaccination or if the vaccination date is unknown.
4. Tdap should be given to all pregnant people during each pregnancy.

Specific Recommendations for Children With HIV

Children with HIV should generally be vaccinated according to routine childhood immunization schedules, with the exception of live vaccines, which are contraindicated in children with severe immune suppression. The complete recommendations on immunization for children with HIV can be found in the Recommended Immunization Schedule section of the Pediatric Opportunistic Infection Guidelines.

The Guidance for People With HIV Displaced by Disasters was collectively prepared by five panels of HIV experts from the Department of Health and Human Services (HHS):

• Panel on Antiretroviral Guidelines for Adults and Adolescents
• Panel on Antiretroviral Therapy and Medical Management of Children Living With HIV
• Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission
• Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents With HIV
• Panel on Opportunistic Infections in Children With and Exposed to HIV

To view or download the guidelines, go to the Guidance for People With HIV Displaced by Disasters section of the Clinicalinfo website.