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
- Professor of Medicine
- 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".)
- Bhaskaran K, Hamouda O, Sannes M, et al. Changes in the risk of death after HIV seroconversion compared with mortality in the general population. JAMA 2008; 300:51.
- Samji H, Cescon A, Hogg RS, et al. Closing the gap: increases in life expectancy among treated HIV-positive individuals in the United States and Canada. PLoS One 2013; 8:e81355.
- Antiretroviral Therapy Cohort Collaboration, Zwahlen M, Harris R, et al. Mortality of HIV-infected patients starting potent antiretroviral therapy: comparison with the general population in nine industrialized countries. Int J Epidemiol 2009; 38:1624.
- Smith CJ, Ryom L, Weber R, et al. Trends in underlying causes of death in people with HIV from 1999 to 2011 (D:A:D): a multicohort collaboration. Lancet 2014; 384:241.
- Neuhaus J, Angus B, Kowalska JD, et al. Risk of all-cause mortality associated with nonfatal AIDS and serious non-AIDS events among adults infected with HIV. AIDS 2010; 24:697.
- Landon BE, Wilson IB, McInnes K, et al. Physician specialization and the quality of care for human immunodeficiency virus infection. Arch Intern Med 2005; 165:1133.
- Institute of Medicine. HIV screening and access to care: Health care system capacity for increased HIV testing and provision of care. Washington, DC: The National Academies Press, 2011.
- Aberg JA, Gallant JE, Ghanem KG, et al. Primary care guidelines for the management of persons infected with HIV: 2013 update by the HIV medicine association of the Infectious Diseases Society of America. Clin Infect Dis 2014; 58:e1.
- European AIDS Clinical Society Guidelines. Updated yearly. http://www.eacsociety.org/Guidelines.aspx.
- Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf (Accessed on April 08, 2015).
- INSIGHT START Study Group, Lundgren JD, Babiker AG, et al. Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection. N Engl J Med 2015; 373:795.
- Antiretroviral Therapy Cohort Collaboration. Causes of death in HIV-1-infected patients treated with antiretroviral therapy, 1996-2006: collaborative analysis of 13 HIV cohort studies. Clin Infect Dis 2010; 50:1387.
- Schambelan M, Benson CA, Carr A, et al. Management of metabolic complications associated with antiretroviral therapy for HIV-1 infection: recommendations of an International AIDS Society-USA panel. J Acquir Immune Defic Syndr 2002; 31:257.
- Dubé MP, Stein JH, Aberg JA, et al. Guidelines for the evaluation and management of dyslipidemia in human immunodeficiency virus (HIV)-infected adults receiving antiretroviral therapy: recommendations of the HIV Medical Association of the Infectious Disease Society of America and the Adult AIDS Clinical Trials Group. Clin Infect Dis 2003; 37:613.
- Triant VA, Lee H, Hadigan C, Grinspoon SK. Increased acute myocardial infarction rates and cardiovascular risk factors among patients with human immunodeficiency virus disease. J Clin Endocrinol Metab 2007; 92:2506.
- Seaberg EC, Muñoz A, Lu M, et al. Association between highly active antiretroviral therapy and hypertension in a large cohort of men followed from 1984 to 2003. AIDS 2005; 19:953.
- Helleberg M, Afzal S, Kronborg G, et al. Mortality attributable to smoking among HIV-1-infected individuals: a nationwide, population-based cohort study. Clin Infect Dis 2013; 56:727.
- Mdodo R, Frazier EL, Dube SR, et al. Cigarette smoking prevalence among adults with HIV compared with the general adult population in the United States: cross-sectional surveys. Ann Intern Med 2015; 162:335.
- Crothers K, Huang L, Goulet JL, et al. HIV infection and risk for incident pulmonary diseases in the combination antiretroviral therapy era. Am J Respir Crit Care Med 2011; 183:388.
- Fernández-Rivera J, García R, Lozano F, et al. Relationship between low bone mineral density and highly active antiretroviral therapy including protease inhibitors in HIV-infected patients. HIV Clin Trials 2003; 4:337.
- Bedimo R, Maalouf NM, Zhang S, et al. Osteoporotic fracture risk associated with cumulative exposure to tenofovir and other antiretroviral agents. AIDS 2012; 26:825.
- Cazanave C, Dupon M, Lavignolle-Aurillac V, et al. Reduced bone mineral density in HIV-infected patients: prevalence and associated factors. AIDS 2008; 22:395.
- Shiels MS, Pfeiffer RM, Engels EA. Age at cancer diagnosis among persons with AIDS in the United States. Ann Intern Med 2010; 153:452.
- Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: Recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf (Accessed on October 20, 2015).
- Piketty C, Selinger-Leneman H, Grabar S, et al. Marked increase in the incidence of invasive anal cancer among HIV-infected patients despite treatment with combination antiretroviral therapy. AIDS 2008; 22:1203.
- Williams AB, Darragh TM, Vranizan K, et al. Anal and cervical human papillomavirus infection and risk of anal and cervical epithelial abnormalities in human immunodeficiency virus-infected women. Obstet Gynecol 1994; 83:205.
- Goldie SJ, Kuntz KM, Weinstein MC, et al. The clinical effectiveness and cost-effectiveness of screening for anal squamous intraepithelial lesions in homosexual and bisexual HIV-positive men. JAMA 1999; 281:1822.
- Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64:1.
- Engsig FN, Zangerle R, Katsarou O, et al. Long-term mortality in HIV-positive individuals virally suppressed for >3 years with incomplete CD4 recovery. Clin Infect Dis 2014; 58:1312.
- Centers for Disease Control and Prevention. Estimated HIV incidence in the United States, 2007–2010. HIV Surveillance Supplemental Report 2012;17(No. 4). Published December 2012 http://www.cdc.gov/hiv/topics/surveillance/resources/reports/#supplemental (Accessed on January 08, 2015).
- Centers for Disease Control and Prevention (CDC). HIV prevalence estimates--United States, 2006. MMWR Morb Mortal Wkly Rep 2008; 57:1073.
- Hess K, Hu X, Lansky A, Mermin J, Hall HI. Estimating the lifetime risk of a diagnosis of HIV infection in the United States. Conference on Retroviruses and Opportunistic Infections (CROI), February 22-25, 2016, Boston. Abstract 52.
- Frosch D, Shoptaw S, Huber A, et al. Sexual HIV risk among gay and bisexual male methamphetamine abusers. J Subst Abuse Treat 1996; 13:483.
- Makadon HJ, Mayer KH, Garofalo R. Optimizing primary care for men who have sex with men. JAMA 2006; 296:2362.
- Libman H. Will You Still Treat Me When I'm 64? Care of the Older Adult With HIV Infection. Top Antivir Med 2015; 23:97.
- Migueles SA, Connors M. Long-term nonprogressive disease among untreated HIV-infected individuals: clinical implications of understanding immune control of HIV. JAMA 2010; 304:194.
- Hsue PY, Hunt PW, Schnell A, et al. Role of viral replication, antiretroviral therapy, and immunodeficiency in HIV-associated atherosclerosis. AIDS 2009; 23:1059.
- Pereyra F, Lo J, Triant VA, et al. Increased coronary atherosclerosis and immune activation in HIV-1 elite controllers. AIDS 2012; 26:2409.
- Crowell TA, Gebo KA, Blankson JN, et al. HIV elite controllers are hospitalized more often than persons with medically controlled HIV. Presented at the 21st Conference on Retroviruses and Opportunistic Infections, Boston, MA, March 3-6, 2014. Abstract #108.
- Crowell TA, Gebo KA, Blankson JN, et al. Hospitalization Rates and Reasons Among HIV Elite Controllers and Persons With Medically Controlled HIV Infection. J Infect Dis 2015; 211:1692.
- Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011; 365:493.
- 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