Primary care of the HIV-infected adult
- Todd M Pollack, MD
Todd M Pollack, MD
- Instructor in Medicine, Part-time
- Harvard Medical School
- Howard Libman, MD
Howard Libman, MD
- Deputy Editor — Primary Care (Adult)
- Professor of Medicine, Emeritus
- Harvard Medical School
Over the past two decades, antiretroviral therapy (ART) has radically altered the natural history of HIV infection . Opportunistic diseases have become less common, and mortality has declined such that most treated HIV-infected patients now have a near normal life expectancy [2,3]. More than 50 percent of deaths in HIV-infected patients receiving ART are now related to conditions other than AIDS . HIV infection appears to increase the risk of non-AIDS-related cardiovascular disease, renal disease, liver disease, and malignancies . In addition, a variety of long-term complications associated with ART have been described.
The emergence of non-AIDS-related conditions highlights the important role of the primary care physician. Based on experience from other chronic medical conditions, general practitioners are well suited to oversee and coordinate a multidisciplinary approach to HIV care. One survey of 102 internal medicine physicians and 75 infectious disease specialists found that generalists with extensive experience in HIV management provided high-quality care to these complex patients . In the United States, there will be a future need for increased involvement of primary practitioners in HIV care given the growing prevalence of persons living with HIV .
The role of the primary physician in the care of the HIV-infected adult will be discussed here, with particular attention to clinical monitoring and health care maintenance. The initial evaluation of the HIV-infected adult is addressed elsewhere. (See "Initial evaluation of the HIV-infected adult".)
In the United States, the HIV Medicine Association of the Infectious Diseases Society of America has published guidelines on the primary care of HIV-infected individuals, which were last updated in 2013 . The recommendations provided in this topic are generally consistent with these guidelines. Other expert groups that have released recommendations on the ongoing evaluation and management of HIV-infected individuals include the European AIDS Clinical Society .
The initial evaluation of an HIV-infected patient includes assessment of disease stage and evaluation for comorbidities, prior exposures, and risk factors in order to inform appropriate management. This issue is discussed in detail elsewhere. (See "Initial evaluation of the HIV-infected adult".)
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- INITIAL EVALUATION
- FREQUENCY OF CLINICAL EVALUATION
- MANAGEMENT OF ANTIRETROVIRAL THERAPY
- MONITORING FOR COMPLICATIONS
- Hematologic, renal, and hepatic toxicity
- Cardiovascular disease
- - Dyslipidemia
- - Glucose intolerance/diabetes mellitus
- - Hypertension
- - Tobacco use
- Chronic lung disease
- Premature bone loss
- Neuropsychiatric disorders
- Cancer and precancerous lesions
- - Cervical cancer
- - Anal cancer
- - Other cancers
- Sexually transmitted infections
- Viral hepatitis
- Less common HIV-specific toxicities
- CONSIDERATIONS FOR SPECIFIC POPULATIONS
- Patients with low CD4 cell counts
- Men who have sex with men
- Older adults
- Long-term nonprogressors
- OTHER PRIMARY CARE ISSUES
- Behavioral risk reduction counseling
- Food safety
- Pet safety
- Travel safety
- Clinical trials
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS