Evidence of Success - National Clinicians' Consultation Center

HIV Telephone Consultation Service (Warmline)

The National Clinicians' Consultation Center (NCCC) operates the National HIV Telephone Consultation Service (Warmline) to provide distance-based consultation and education. The Warmline is a free resource, providing clinicians with opportunities to discuss challenging issues in HIV care. The Warmline is staffed by University of California at San Francisco (UCSF) physicians and clinical pharmacists experienced in HIV care. Clinical pharmacist consultation can be especially useful for answering difficult drug dosing questions, screening for drug-drug interactions, and evaluating possible drug toxicities.

The Warmline can be reached from 8 a.m. - 8 p.m. Eastern Time at 800/933-3413. The Warmline is based at UCSF San Francisco General Hospital and is funded by the AETC Program in the Health Resources and Services Administration (HRSA). More than 34,000 calls have been received since the Warmline began 10 years ago.

Illustration: Warmline Consultation Call

As an example, the Warmline recently received a call from an internal medicine physician at a correctional facility in Ohio who asked about antiretroviral (ARV) therapy for a 49 year-old HIV-infected man. Three years previously, when the patient's CD4+count was 280 cells/mL and viral load was 9500 copies/ml, ARV treatment was initiated with didanosine (ddI), stavudine (d4T), and nelfinavir (NFV). Eight months ago, medications were discontinued because he developed pancreatitis. The antiretroviral regimen was then changed to zidovudine (AZT, ZVD), tenofovir (TDF), and nevirapine (NVP). The viral load was undetectable until two months ago, but had increased to 8080 copies/mL. The patient's CD4+ count was 410 cells/mL. Viral resistance testing showed sensitivity to all protease inhibitors except nelfinavir and resistance to all non-nucleoside reverse transcriptase inhibitors (NNRTIs).

The physician asked the Warmline consultant about the most appropriate management and received a recommendation for lopinavir/ritonavir (Kaletra?) plus zidovudine (AZT) and lamivudine (3TC), and abacavir, available as Trizivir?. In addition, the Warmline clinical pharmacist suggested changing from simvastatin to pravastatin to avoid a drug interaction with lopinavir/ritonavir. Two months later, the physician called to report the viral load had become undetectable for this patient. She then used the call to ask a question about another patient regarding opportunistic infection prophylaxis.

Outcomes

Immediate/Short-term:

	Addressed decisions about patient care issues.
	Increased patient confidence when clinicians have access to expert consultation and state-of-the-art information.
	Provided education to inform future patient care.

Mid-term/Long-term:

	Developed process for better decision-making, especially in complicated areas such as antiretroviral drug use.
	Increased confidence in ability to manage HIV disease with knowledge that expert consultation is readily available.
	Established system wherein successful consultation can lead to follow-up questions and consultations in other areas.
	Improve patient care for all HIV-infected patients.

National Clinicians' Post-Exposure Prophylaxis Hotline (PEPline)

The National Clinicians' Consultation Center (NCCC), located at San Francisco General Hospital, operates the National Clinicians' Post-Exposure Prophylaxis Hotline (PEPline). The PEPline provides 24-hour toll-free telephone consultation for clinicians managing healthcare workers exposed to blood-borne pathogens and for exposed healthcare workers.

Expert consultants at the PEPline are available to discuss the entire range of exposures (e.g., needlesticks, splashes, etc.) and possible exposures in the occupational setting. Dialogue with PEPline faculty or other expert clinicians trained in post-exposure management helps providers evaluate actual exposure risk, relative benefits and risks of PEP, and best PEP strategies. Consultation can also address special issues such as antiretroviral resistance, PEP in pregnancy, and PEP for exposures to source patients of unknown HIV/hepatitis status. Discussion with knowledgeable colleagues is a key to providing excellent post-exposure care.

The PEPline, funded by the Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC), is a toll-free service that can be reached at (800) 448-4911, 24-hours a day. PEPline consultants include physicians and clinical pharmacists based at UCSF San Francisco General Hospital. The PEPline has consulted on more than 36,000 exposure-related calls in the past five years.

Illustration: PEPline Consultation

In one call, a physician from Florida called the PEPline regarding an occupational exposure to blood. In the course of drawing blood on an HIV-infected patient, the clinic's phlebotomist pierced her finger with a bloody needle. She immediately washed the site with soap and water and reported to the clinic physician. The physician called the PEPline to ask what the best management strategy would be.

The PEPline consultant recommended initiating HIV post-exposure prophylaxis with zidovudine (AZT), lamivudine (3TC), and nelfinavir (NFV) immediately. The PEPline also recommended obtaining baseline HIV, hepatitis B, and hepatitis C antibody testing on the exposed phlebotomist as well as hepatitis testing of the source patient. The physician was advised on ways to counsel and reassure the phlebotomist regarding this exposure. Follow-up counseling and testing with Employee Health was strongly advised.

The following day, Employee Health called the PEPline to report that the source patient's hepatitis B surface antigen had come back positive. The phlebotomist had hepatitis B antibodies from immunization. PEPline reconfirmed with Employee Health that hepatitis B immunity was adequate without the need for hepatitis B immune globulin. The exposed phlebotomist was tolerating PEP, but was experiencing headaches from the AZT. The PEPline recommended acetaminophen with reassurance that headache was usually a self-limiting side effect that would resolve within a week.

Outcomes

Immediate/Short-term:

	Addressed decisions about post-exposure prophylaxis.
	Provided appropriate support to the exposed worker.
	Increased confidence of exposed health care workers when clinicians have access to expert consultation and state-of-the-art information.
	Assured that post-exposure prophylaxis can be given in an appropriate and timely manner when indicated and unnecessary drug toxicity is avoided.

Mid-term/Long-term:

	Enhanced ability to make better clinical decisions, especially in managing complicated exposures.
	Improved patient care for all exposed healthcare workers.
	Decreased number of cases of HIV disease transmitted via occupational exposure.