Dr. Loveless will be writing a quarterly article on various topics in Infectious Disease.
We hope you find "Our Blog", not only interesting, but informative.


Thomas J. Loveless, MSN, CRNP, PhD graduated from Thomas Jefferson University College of Nursing in 2002, where he completed his BSN and MSN. He completed his post-masters in Nursing Education and Curriculum design from Thomas Jefferson University College of Nursing in 2006.

He completed his PhD in Nursing from the University of Wisconsin-Milwaukee in 2013.


He is Board Certified as an Adult Primary Care Nurse Practitioner through the American Academy of Nurse Practitioners and has an active practice in caring for and counseling HIV patients.


  

 Happy June- One and All!


Since last writing, I’m pretty sure we can say farewell to insane temperature swings – and snow and ice.  The rain however, and tropical humidity now another story.  But welcome June!  Now that summer is here, there are some interesting updates to share with you all – along with some exciting plans for the summer.


Let’s begin with this idea:

“You must go on adventures to find out where you truly belong”


Sue Fitzmaurice


Let’s start with HIV screening.  Did you know that it is estimated that 1.2 million Americans are affected by HIV and about 162,500 people who are unaware of their status.   More than a decade has passed from the time the Centers for Disease Control  and Prevention (CDC) recommended standardized screening be completed routinely for all people between the ages of 13 and 64, no matter one’s sexual preference, gender, or comorbidities- and the literature still suggest this is not being done.


This idea of routine screening is called “opt-out” where HIV screening is recommended for patients in all health-care settings after the patient is notified that testing will be performed unless the patient declines.  In other words, unless you tell your health care provider that you absolutely do not want to ever be routinely screened for HIV without your knowledge, then this cannot be done routinely.  Opt-out specifically says performing HIV screening after notifying the patient that 1) the test will be performed and 2) the patient may elect to decline or defer testing.  Assent is inferred unless the patient declines testing.


It’s simple actually - routine voluntary HIV screening can be a normal part of medical practice, no different from other treatable conditions like diabetes or thyroid disease. The advantage by making this all routine is supporting public health initiatives used to identify unrecognized health conditions so treatment can be offered before symptoms develop and, for communicable diseases, so interventions can be implemented to reduce the likelihood of continued transmission


The bottom line – treat all humans the same and consistently embark on standardized, run-of-the-mill annual HIV screening.   By the way, the CDC wasn’t the only professional body to promote this idea. Seven years after this CDC recommendation was mobilized, the United States Preventative Services Task Force (USPSTF), further recommended routine screening.  However barriers have been identified, and many primary care offices are not adhering to current CDC guidelines to routinely screen patients aged 13-64 for HIV- it’s a conundrum.  Because many people live with HIV for years before they know their diagnosis, and it is estimated that a quarter of people living with HIV have been positive for 7 or more years. It is these folks, with no symptoms whatsoever, that we should not miss, and instead welcome you into our fold of care.


It’s a muddy quagmire that finds a persistence of failed HIV screening – but we can change that! To raise awareness about the importance of HIV testing and early diagnosis of HIV your devoted clinicians at IDA have decided to buddy up with Family Services of Bucks County.  Together we encourage HIV testing on National HIV Testing Day – June 27th - to ensure people get tested for HIV, know their status, and get linked to care and treatment services.  So, on June 27th – a team of counselors, and clinicians are launching our first annual HIV Screening Day in our Southampton office.  We look forward to being here when and if you need us!  Our overarching goal is to remove barriers to HIV testing by simply offering a special consent form for all patients no matter why you see us – and screen everyone who we treat.


We have also embarked on an intentional screenings for Hepatitis C – especially for our Baby-Boomer population.  Did you know that HCV infection is the most common chronic blood borne infection in the United States, with an estimated 2.7 million persons living with chronic infection an estimated 3.5 million people in the United States have chronic hepatitis C and most people with chronic HCV infection are asymptomatic?  So as one place to start - everyone born from 1945 through 1965 should be screened for HCV.  You will be asked about your most recent screening, and if you have not been screened – it certainly is recommended.


Another new initiative underway is offering Gardasil vaccinations.   Gardasil is a vaccine for use in the prevention of certain strains of human papillomavirus.   Street slang – better known as venereal warts or genital warts.  HPV infection is very common and HPV infection causes cervical, vaginal, and vulvar cancers in women; penile cancers in men; and oropharyngeal and anal cancers as well as genital warts in both men and women. Most people—about 9 in 10—will get an HPV infection at some point in their lives. HPV infections can cause health problems, including several kinds of cancer in both women and men.  Even though there are as many as 150 types of HPV - the majority of all HPV-associated cancers are caused by HPV 16 or 18.  In fact, HPV types 16 and 18 cause an estimated 70% of cervical cancers and are responsible for most HPV induced anal, vulvar, vaginal, and penile cancer cases.   Some other important facts - all 11-12 year olds should get a 2-shot series of HPV vaccine at least 6 months apart- we sure hope your pediatrician is having this candid discussion with you about your children; routine vaccination at age 11 or 12 years has been recommended by the Advisory Committee on Immunization Practices (ACIP) since 2006 for females and since 2011 for males.


More aligned with our adult practice – let’s keep in mind, a 3-shot series is needed for those with weakened immune systems and those age 15 or older.   Also keep in mind, HPV is a clinical diagnosis – which means a visual inspection.  There is no blood test to screen for this.  HPV is a point-contact virus – it is not spread in the air, or toilet seats. It is transmitted only by direct skin-to-skin contact. So – the bottom line – where do you fit in? The vaccines are all are noninfectious- they cannot cause the growth of HPV.

The vaccine we have is licensed for use in females and males aged 9 through 26 years.  HPV vaccines are highly effective and safe, and a powerful prevention tool for reducing HPV infections and HPV-associated cancers.  So, if you fit into any of these populations please consider calling us – or on your next appointment talk to us about this – we can help save you worsened illness.  For men who have sex with men,  the ACIP recommends routine HPV vaccination as for all males, and vaccination through age 26 years for those who were not adequately vaccinated previously.


For transgender persons, ACIP recommends routine HPV vaccination as for all adolescents, and vaccination through age 26 years for those who were not adequately vaccinated previously.  So no matter which population you fall – please make certain you consider Gardasil vaccination- it can protect you for up to 10 years, and, can prevent spread of a curable virus- seems a ‘no-brainer’.

 

While we are talking about the birds-and-the-bees, here is one more area of clinical significance we should remind you. First – we are certain you understand our commitment to all folks and recognize the need for a practice devoted to sexually transmitted infections.  We know it can be embarrassing which often keeps people out of care – we are great at keeping of secrets – and promise we can fix things if only you come to see us. We have clinicians as stewards of this initiative, and devote many hours to this population. You can see us specifically for any concern related to a sexually transmitted infection.  Just ask! The tricky and dangerous issue with some sexually transmitted infections, is their clandestine presentation, often confused with many other diagnosis.  In fact, syphilis for example, is called the Great Masquerader because if looks like a million other things.  But- another bottom line- because the incidence of some sexually transmitted infections, notably syphilis has increased in our area, the use of client-centered sexually transmitted infections counseling has received strong emphasis from public health agencies and organizations- and we are happy to mobilize services to reach and treat anyone in need. Just ask!


One other area- even though data are insufficient to recommend routine anal cancer screening with anal cytology in persons with HIV infection, MSM without HIV infection, and the general population- a discussion is warranted. An annual digital anorectal examination may be useful to detect masses on palpation that could be anal cancer in persons with HIV infection and possibly HIV-negative MSM with a history of receptive anal intercourse. Clinically we are still learning about the natural history of anal intraepithelial neoplasia (AKA- anal cancer), the best screening methods and target populations, the safety and response to treatments, and other programmatic considerations (e.g. your insurances companies opinion), nevertheless, while the learning continues,  we are capable of performing anal cytology to screen for anal cancer among high-risk populations (e.g., persons with HIV infection, MSM, and history of receptive anal intercourse).  Of course referrals will follow a true diagnosis, for example for a high-resolution anoscopy (HRA) for those with abnormal cytologic results (e.g., ASC-US or worse).  Another bottom line – don’t ignore this – get screened, and empowered and in charge of your health.


 And here’s our newest and most fun initiative- The Infectious Diseases Associate Travel Medicine Clinic.  We are really excited to mobilize this initiative, and can’t wait to help you. The timing is perfect given summer has finally arrived.  For all you folks traveling to lands far away and exciting – don’t let the trip of a lifetime land you a hospital in a third-world country.   The CDC Health Information for International Travel (commonly called the Yellow Book) is in our procession.  We now have a devoted staff with clinical interest and expertise for you.  We have a devoted examination room, and clinical travel day to protect you from the bazaar diseases from lands far-away.


Things you need to consider - The 2018 Yellow Book - but leave the worry to us.  We’ll manage the pre-travel council.  We’ll talk about peak exposure times, and places. We’ll talk about your perception of the risks and how to prioritize your wellness while you travel.  There are host of things for us to worry about – for example, water and food dangers, sun exposure, those nasty critters called mosquitoes and ticks, if you are pregnant, or if you are traveling with kids- see, the list seems endless. 


So that’s our job – let’s meet and provide appropriate vaccination and treatment.  All we ask is you enjoy your trip, and to send us pictures from that trip of a lifetime.  Did you know that there are new cholera vaccine recommendations?  Did you also know there are updated guidelines on the use of antibiotics in the treatment of travelers' diarrhea? 


So no matter your destination, let’s start with the basics first.  Let’s be sure to talk about those special considerations for unique types of travel, such as wilderness expeditions, work-related travel, and study abroad. 


We are here for you to provide destination-specific recommendations for popular itineraries, including new sections for travelers to Cuba and Burma. Worry less, and let us council you about the vacation you have dreamed of for many years. It should also be our job to worry about the latest information about emerging infectious disease threats such as Zika, Ebola, and Middle East Respiratory Syndrome (MERS) - that’s why you have us.  Your job is to meet us first – than enjoy the best trip ever!


So as you can see – it’s been busy lately.  We are excited to share all this new learning.  We wish you the best of summers. We are here for you to keep you well and empowered. 


We look forward to seeing many of you over the summer.  Don’t forget about the importance of keeping regularly scheduled appointments and labs – that surveillance is critical to your overall wellness.  While your prescriptions are life-savers, things can go awry too – which is why we need to see you and have current labs to make certain things are keeping you well.  The risks are high and too dangerous for you to be taking prescriptions without knowing how healthy your liver and kidneys are – these are just two considerations.  But you know this already – right?   


Call us – we look forward to hearing from you and seeing you soon. I leave you with this:


All journeys have secret destinations of which the traveler is unaware.”


Martin Buber (1878–1965)


Dr. Thomas J. Loveless