Transcription:
Current Trends in Pediatric HIV

Trisha Williams (Host):  Hi guys. Welcome to the Advanced Practice Perspectives. I'm Trisha Williams.

Tobie O'Brien (Host): And I'm Tobie O'Brien. This is a podcast created by Advanced Practice Providers for Advanced Practice Providers. We will be highlighting our amazing APPs here at Children's Mercy and do some education along the way.

Trisha: We are so glad that you're joining us today. So, sit back, tune in and let's get started.

Tobie: April 10th is National Youth HIV and AIDS Awareness Day. We have invited our friend, Diane Petrie to talk more about this topic. Diane is a Family Nurse Practitioner in the Infectious Disease Clinic at Children's Mercy. She specializes in HIV and other sexually transmitted illnesses. Diane, thank you so much for joining us today. I know life has been busy. You have a new baby, and so I appreciate you taking the time today to be with us.

Diane Petrie, RN, APRN, FNP (Guest): Yeah, no problem. I'm glad to be here.

Trisha: We are so excited to have you on our podcast today. Super excited. So, tell us a little bit about yourself.

Diane: No, thank you so much, Trisha and Tobie for having me, I am excited to be a part of this. Like you said, my name is Diane Petrie. My husband, Sean and I have three kiddos. Jack is four, Emory is two and a half and Levi will be four months this week. So, we are staying pretty busy. I actually grew up around Kansas City, in Raytown. And so I love calling this city home. I left just briefly to go to college and finished my bachelor's in nursing, a little school called Cedarville University in Ohio. Right after that, I worked for about nine months in adult bedside nursing and then came to a job at Children's Mercy as a nurse on what used to be three Hinson. I actually applied to work there because it was listed online as the infectious diseases floor.

So, that has always kind of piqued my interest. And then a couple of years later, I started nurse practitioner school and I moved to the emergency department to work as a nurse there while I was in school. And I loved being right there, meeting patients and their families where they were in a moment of great need. And so after a nurse practitioner school and I graduated, I started as a Nurse Practitioner in the Emergency Department here at Children's Mercy where I worked until just last year.

Trisha: That's kind of where we met. You are my Preceptor in the Emergency Department when I was in grad school.

Diane Petrie, RN, APRN, FNP (Guest): Yes.

Diane: Lots of friends come through that way.

Tobie: Well, Diane, tell us a little bit more about how you became so passionate about HIV.

Diane: Well, my passion kind of started way back when I decided to be a nurse then in nursing school discovered I had a passion for public health for global health and for really working with underserved patient populations. I was working on my BSN, and I really, at that time had wanted to be a nurse so I could move overseas and do like international or medical mission type work.

looking back, I think HIV was always kind of wrapped up in that, you know, growing up in the eighties and nineties, we kind of had a front row seat to the HIV pandemic. It was on the forefront of everything we did, it was on TV commercials. It was in school programming. So, I kinda got my nursing degree intending on doing that type of work, but marriage and life shifted a little bit for me.

So, as I mentioned, I was working at Children's Mercy as a Nurse Practitioner in the Emergency Department. And in 2015, I had the opportunity to take a short hiatus from the ED there and worked at a place called well it used to be called the KC Free Health Clinic. It's now called the KC Care Health Center and it's in Midtown, Kansas City and they do great work just helping people who don't have a connection to healthcare, be able to get that care. And the opportunity really aligned my passions with an opportunity to care for those who were in great need. And so while I was working there, I actually got the opportunity to care for some HIV patients through their HIV Primary Care Clinics. So, at their clinic, HIV care is like the whole kit and caboodle. You can get a mental health, case management, your HIV care, your primary care visits, all wrapped up into one thing. So, it was really cool and I really loved it. And while I was there, I was actually selected as an HIV Clinician Scholar.

So, they have a program that while you're working in practice, for those people who are doing clinical work, you can spend a year doing extra coursework, extra clinical and shadowing opportunities just to improve your knowledge of caring for HIV. And just to really do your best at that, because it's a lot to learn and it changes so fast.

So, just even getting a bearing on the resources you need to keep up with it. And during that rotation, one of those, I was actually connected to the Children's Mercy Infectious Diseases Clinic through a colleague here because I wanted to get some experience with pediatric and adolescent HIV since I was working at Children's Mercy. And so ultimately my connections with them led me to get a part-time job in ID starting in 2016. And then just this last year, I was able to come to ID full-time.

Trisha: So, do we have something like that similar at Children's Mercy to where it's mental health, physical health, kind of an all encompassing clinic for our HIV patients

Diane: And we don't have that yet. That's one of my dreams, especially for our adolescent patients who have a lot of barriers to their care. We do what we have, we have what we call a special immunology kind of multidisciplinary clinic. So, a couple of times a month we have a clinic here at Children's Mercy, where physicians, nurse practitioners, nurses, a social worker, a clinical psychologist, and a pharmacist are all together and available to help make sure that our children and young people who are living with HIV can receive the best care possible.

So, we have access to kind of resources to connect to all those things. We're still missing that primary care piece, which I think is key for our adolescents and working on what that might look like in the future. Hopefully to partner with our teen and adolescent specialty friends.

Trisha: Yeah. Sounds like a good goal. like a good goal.

Tobie: Yeah. So, tell us a little bit more then about your specific role then in the special immunology clinic. It sounds like it's twice a month for HIV patients, but I'm assuming there's other things that you're doing then than HIV. So, tell us a little bit more about what your role is.

Diane: Yeah. So right now I do, I lead that special immunology team. So, we meet up once a month to talk through all the patients. We have our clinic days, and then other kinds of behind the scenes work, some of my other HIV work right now is we actually just got finished with an HIV Care Process Model. It's kind of like a care algorithm, but it's kind of a best practice at our facility for how to do HIV testing, which is really a neat thing to do.

I also spend some time keeping our other ID providers up to date on all the changes that happen with HIV. For all of the different patients we see and our ID physicians take a lot of calls from community physicians and providers all across the region. So, working to make sure we have updated plans of cares, processes, things like that to help them.

I also do some clinic time, so I see our HIV patients. I also see some general ID patients. And one of, a couple of those populations that still have to do with HIV, is we see most of the region's infants who were born to mothers living with HIV. So, after a mom who has HIV delivers an infant, we see them here for a period of time.

And we also follow up on patients from the emergency department or the scan clinic, following a sexual assault. I get a couple of other fun kind of things on the side, little breaks from HIV, but I get to see patients and families for pre-travel consultations and counseling, which is awesome cause I have that passion for global health and travel. So, it's fun helping our families prepare, to get to go abroad and all the things they need to stay safe and healthy. And then my newest role is actually kind of interesting, is finding a new way to tie into STIs with the new guidelines that are coming out, but it's in our antibiotic allergy de labeling clinic.

So, I work with one of our physicians here to do oral and skin antibiotic challenges to try to de label a patient's allergy profile from penicillin type antibiotics. So, we try to determine whether their reaction was like a delayed skin rash or other non-anaphylactic type reaction. And then we work to see if they have a true allergy. And then it's fun to be a part of getting to take that allergy off if they successfully pass the challenge. Antibiotic stewardship is kind of a big deal here at Children's Mercy. So, it's fun to be a part of helping patients be able to take the best medicine to treat their infection.

Tobie: Oh, that sounds really fun. I didn't know that you got to do that as well. So, it does sound like you get to do a variety of things that probably helps sometimes take away from the heaviness that comes with HIV.

Diane: Yeah, for sure.

Tobie: Yeah. Tell us more about the education that you do for families that are traveling abroad, especially since I know that you have traveled abroad. And so maybe you could share a little bit about your experience of traveling and also how that helps you when you are communicating with those families that are getting ready to travel.

Diane: Yeah. So, we have a really comprehensive and great Clinic here. It's a great thing that we offer for families. And thankfully I'm actually a Family Nurse Practitioner, so I can see the kiddos and their parents, which is nice. And then we also see some, prior to COVID, of our employees here at Children's Mercy, our Global Health Residents and people like that who are doing work abroad for Children's Mercy.

So, that is fun too. But I've had a couple of different opportunities internationally. I, right after I graduated from Nurse Practitioner school, I spent five weeks in Northern Ghana at a hospital doing a little bit of a Global Health Immersion, kind of learning about some of the different tropical diseases, that I wasn't as familiar with from going to school and living here. And just kind of broadening my horizons with that a little bit. It was a part of a different program that I did at that time, to improve that. So, it was it's called a Diploma in Public Health and International Medicine. And so it's something I did through an organization in Kansas City called INMED and that rotation was kind of the end of some coursework and stuff that I did related to learning about those diseases.

And then, so through that passion and knowing that already, it was a natural fit when I started to work here to do HIV, but thankfully we don't have a huge enough HIV population to keep me busy in clinic every day of the week. And so this was the perfect other fit to do. And so I had that travel experience, a few other mission trips through like churches and 2019, I actually went to go do like a week encouraging a friend who was a nurse at a hospital in Subsaharan Africa. And I took my daughter with me who was almost a year old at the time. So, I got to come through our clinic as a parent and as a patient to kind of see what that experience was, but having traveled with my daughter, it really makes the visits where I talk and share with the patients kind of come alive. Like, hey, we tried this insect repellent and it worked like a dream with an infant, you know, and we this on the plane and so it's really been great to be able to apply those experiences to that.

But it's a comprehensive educational deal with all of the like checking their vaccines, their medical history, preventative medicines for malaria and traveler's diarrhea and altitude sickness and, making sure they have all the education on insect repellents and food and beverages and traveling and how to take a car seat and how to take food and drink for your infants through security and all of those kinds of things, just to make sure they are perfectly prepared to be able to travel wherever they're going.

Tobie: Oh, I love that. I think we are so lucky and fortunate to have that at Children's Mercy.

Trisha: Yeah, it sounds like you could write a book.

Tobie: Yeah. Yeah. for

For sure.

Trisha: I would read that. That is amazing.

Tobie: I know, instead of me Googling, I'm just gonna call up Diane.

Let

Trisha: her write a book for

us

Diane Petrie, RN, APRN, FNP (Guest): Yeah.

Tobie O'Brien (Host): Yeah.

Trisha: us. I want to loop back around. You have so many buckets, I think your work, we can kind of put in little buckets. But I want to loop back around to the HIV bucket and you said thankfully, we don't have a very large population of HIV patients to keep you working full-time, which is fantastic. can you kind of shed some light on how many new HIV cases and diagnoses we have each year? And are those diagnoses mainly for infants born to mothers with HIV, or are we seeing teenagers? Can you shed some light on that for us?

Diane: Sure. So, I did a little bit of digging and went back. So, the CDC, I think is a little bit behind because of COVID and I understand why, so is the last that they had some really solid full year statistics done. And it looks like the US about 37,968 new HIV infections in 2018. And I'm going to throw out a guess that's probably been pretty consistent for 19 and 20.

the past several years, it's been pretty close to the same. so what's very encouraging, is that number is dramatically less than it was 25 years ago at the height of the pandemic. a lot of that is because kind of in the early two thousands with CDC and other ACOG and other organizations implemented recommendations for opt-out HIV testing for all pregnant women as part of routine prenatal care.

And so when that started happening, moms who were living with HIV were identified much earlier. They were able to be started on treatment. And we found that if moms are on treatment and their viral load is not detectable, then they have a very low chance of passing HIV to their baby. And so getting moms on treatment, testing every woman who is pregnant has made as huge decrease in infant and child acquisition of HIV over the past couple of decades. So, as an example, I found some stats that between 2014 and 2018, there were only 645 children diagnosed with HIV. And they consider that anyone less than 13 years of age. So, it's

Trisha Williams (Host): Wow.

Diane: what that's done.

Trisha: Absolutely. Now do you collaborate with any of our surrounding OB-GYN clinics or maternal health clinics to help facilitate that testing, to get the infants into your clinic sooner? Anything like that?

Diane: We do. So, we work with case managers at Truman and at KU and at Research all who know that they can send these infants to us right after they are born. And we've kind of worked with them, to line out, the typical process of hey, here's what medicine they should get right after birth, depending on if mom's viral load is which number and kind of have that all lined out. And then they can call our on-call physician provider who can get them as in a referral into our clinic to be seen. And we see them, we test them pretty frequently in the first month or so of life. And then it spaces out and we see them one last time when they're older than four months of age to do kind of one final test to say it's negative and you don't have to worry from here on out.

Tobie: Now, what is life like these days for those that test positive and what is their treatment like and sort of what life is like for them and how you guys care for them?

Diane: Sure. So, looping back some more of the numbers of that almost 38,000 people who were diagnosed with HIV in 2018. We know that about 21% of those or approximately 7,900 people across the country were aged 13 to 24 years old. So, looking at our perspective as a pediatric center, we've done great at preventing that vertical or perinatal acquired HIV, but our teenage and adolescent population, is still having a fairly frequent amount of HIV acquisition. And so one thing that we do for that, the way that we measure kind of success in HIV treatment is a thing called the HIV Treatment Cascade. And it's kind of how we move people from diagnosis to linkage to care. And then it moves to retention and care, starting antiretrovirals and then ultimately leads to viral suppression.

So, our goal with every patient is to work through that, starting with just testing, to know, have every teen who is sexually active, know their HIV status, know their partners status, et cetera. So, we have teenagers who test positive. Now they come to our clinic kind of for a consultation. We do some confirmatory lab testing. We have rapid tests and antibody tests, and then we do a little bit more blood work just to ensure that we certainly will confirm or either way, we'll confirm that it is truly positive or negative with some of our more specific lab results that we can get. And then it's really the beginning of a partnership to work with that patient and family or whoever they have as a support person, make sure that we can work as quickly as we can to get them on treatment.

And to help them kind of adjust to this new life, which is hard for a lot of teenagers, because they do have to have medicine that they take at the same time every day. Thankfully, most of the antiretroviral treatment today, is very easy to take. Most of our otherwise healthy teenagers who get diagnosed with HIV can start by taking just one or two pills once a day. The medicines have very low side effects. They have very low interactions with other medicines. And so it's a lot easier for our teen patients. Even a lot of them, you don't even have to take it with food, which is something that, you know, those little things we think of to find the best fit for our patients.

There's a wide variety of treatment options anymore. And so we work together to say, hey, this we think is going to be the best fit for you because we let them speak into it. No, I can't take, I can't eat the same time every day, so maybe I need a different option and together to really help get them buy-in to wanting to be able to take ownership of their health and take medicine every day.

Trisha: Yeah, and teenagers are opinionated, I'm raising two of them. And they have to have buy-in to be able to be compliant, right?

Diane: Yeah.

Trisha Williams (Host): Fantastic work.

Tobie: Do many of these patients get referred to you from our teen clinic or how are they sort of identified? Just when they become sexually active, their pediatrician maybe recommends testing? Can you kind of shed a little bit of light on how they are really referred to you? Or how do you think they're getting picked up?

Diane: Sure. So, we rely heavily on our partnerships in the community, whether it's local pediatricians, local STI treatment clinics, or other facilities like KC Care does a lot of good testing work at events and things. We also rely on our Teen and Adolescent clinics, our EDS our urgent cares to really be the frontline of doing that basic test that, you know, rapid HIV test or that HIV antibody test, that's going to get kind of a quick yes or maybe not answer. And then it's, once they're in the process of saying that test is either positive or inconclusive, that they come to us and we do a little bit more digging into some more specific and expensive and kind of other workup to make sure yes, this person has HIV or no, this was just a false positive or things like that. So, we don't do much of that frontline testing right now in our clinic per se, but we work to help empower the people around us and other people at Children's Mercy to feel comfortable and competent in doing that testing.

Trisha: Yeah, I just saw your Care Process Model get displayed on our internal website today and I was super excited. I was like, ooh, look at that. So, that was amazing work. Is there other work that still needs to be done on the HIV front for this population of patients? Do you feel like there is improvements to be had?

Diane: Yeah, so there is always improvement to be had. And I think that kind of looking at our HIV Treatment Cascade, where Children's Mercy can really step into the gap of that is to start improving our processes for HIV testing. Just like with all of the pregnant mothers, they got this opt out HIV testing. I think that really we could be at a place where we could move towards doing opt out testing for our adolescents. Historically adolescents have been some of the hardest patients to connect into that continuum. And at every step of that HIV Cascade, we see that they are, there's less adolescents engaged in each step of that as there are adults.

And so we want to work to improve that. One way is just education. There's a lot of healthcare providers that don't know that the CDC and the American Academy of Pediatrics have been recommending opt-out testing for adolescents since about 2013. And that includes annual screenings at their PCP as well as HIV testing as part of comprehensive STI screening and part of that HIV Care Process Model was step one to say we need to be doing more testing.

And the question I always got, well, I don't know what to do. I don't know how to give test results. I don't know where to send them if it's positive. So, I said, why don't we fix this side of it first? And then we can start working on trying to find ways that we can do more testing inside of our facility, now that we've ironed out kind of the details of what happens once a patient has been tested.

Trisha: Now. Moving mountains.

Trisha Williams (Host): Okay.

Tobie: Thank you for doing all of that work.

Diane: It was really fun. It was a collaborative team of people from adolescent specialty and lab. And made a lot of friends along the way of people who also have a passion about wanting to do this and do it well. So, it's actually been a really great way to connect with more people in the hospital.

Tobie: Absolutely. Well, you are certainly a wealth of knowledge on many fronts. So, thank you for sharing your expertise with us today, Diane. We would love to finish this little recording with the question that we ask everyone this same year in 2021, we want to know if you could go back to your old, like new nurse practitioner-self, fresh out of school 2013, what advice would you give yourself? If you could go back and tell yourself something, what would you give yourself?

Diane: Oh, sure. And that is because I wouldn't have seen myself here necessarily but I would tell myself I'm

Tobie O'Brien (Host): Yeah.

Diane: afraid to try new things, to keep my eyes open and kind of jump head first in any opportunities to connect my career with my passions. I think one of the best things about being an Advanced Practice Provider is that the sky's the limit, and I've been able to, in the last couple of years, be involved in some of the different leadership and self-improvement things that we have at Children's Mercy.

And I would have told myself to jump into that way sooner. It's just been great to see the different ways that so many Advanced Practice Providers are doing awesome work just here at Children's Mercy, you know, let alone the whole country and making a huge difference. And so I think I would've wanted to jump into some of that stuff a lot sooner than I did.

Tobie: Great. That is great advice. That's where I met you at Academy, actually. And it was really cool to see all the wonderful things that people were doing and how many of them had such amazing dreams of what they wanted to do and ideas. So, yes, that's definitely where I heard first from you and realized how brilliant you are. So, thank you so for joining us today.

Diane: Yes. Thank you guys so much for having me. This has been fun.

Trisha: Yeah, thank you much for joining us. To be able to do this podcast and highlight all of the amazing Advanced Practice Providers is a true blessing for Tobie and I and we have really enjoyed listening to your story and how you give back to Children's Mercy and the patients of our community. So, thank you so much for that. And listeners, thank you for tuning in today. Our next episode will feature one of our amazing Advanced Practice Providers that works in GI to discuss EOE.  

Tobie: If you have a topic that you would like to hear about, or you are interested in being a guest, please email us at Tdo'brien@cmh.edu or twilliams@cmh.edu. Thanks again to Diane and thank you all for listening to the Advanced Practice Perspectives podcast.