Primary Care Guidelines Updated for Management of HIV

Laurie Barclay, MD

August 14, 2009

August 14, 2009 — Updated, evidence-based, primary care guidelines have been issued for treatment of those infected with HIV and published in the September 1 issue of Clinical Infectious Diseases.

The new recommendations were developed by an expert panel from the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA) to assist primary care providers who care for HIV-infected patients or patients who may be at risk for acquiring HIV infection.

“While improvements in antiretroviral therapy have improved the prognosis for many HIV patients, data from recent studies suggest those living with HIV are at higher risk for developing common health problems, such as heart disease, diabetes, or cancer,” lead author Judith A. Aberg, MD, FIDSA, from New York University School of Medicine and Bellevue Hospital Center in New York City, said in a news release. “Now more than ever, it’s imperative that HIV care providers be aware of the primary care needs of their patients, and that includes routine screening for these kinds of conditions.”

Since the advent of new antiretroviral drugs and classes offering better outcomes, fewer complications and increased survival, persons infected with HIV are more likely to develop chronic health conditions that become more frequent with aging. In addition, HIV infection itself and its treatment may predispose to some of these chronic conditions commonly affecting the general population. Therefore, persons infected with HIV should be monitored for all relevant age- and sex-specific health problems and treated appropriately.

The guidelines suggest specific screening tests for these common health problems that are tailored to persons with HIV infection, as well as recommendations for immunizations and antiretroviral pharmacotherapy dosages and regimens.

Comprehensive Care Plan Best for HIV Patients

New evidence based on literature published from the period 2003 through 2008 has been incorporated into the updated recommendations. In comparison with the previous update in 2004, the new guidelines highlight the need for HIV-infected patients to adhere to a comprehensive care program rather than just an antiretroviral medication regimen.

“For people living with HIV, it’s not just about adherence to medication, it’s also about adherence to care,” Dr. Aberg said. “These patients must have access to a range of services to help them stay engaged in their medical care and should receive the regular monitoring and medical attention this chronic infection demands.”

The updated guidelines were designed to fit the medical home model of care, in which a multidisciplinary team of health providers with specific roles coordinates a comprehensive, personalized, patient-centered approach.

“Many HIV programs are effectively using the medical home model today to manage the complex needs of HIV patients,” said HIVMA chair-elect Michael S. Saag, MD, FIDSA, “This successful track record offers a valuable lesson, not only for HIV care but for all patients, as lawmakers finalize health care reforms.”

Updates to Previous Guidelines

Changes to the latest guidelines from the previous update in 2004 include formatting to highlight the recommendations; a specific question addressed in each section, followed by numbered recommendations and an evidence-based summary; and new tables on immunizations and routine healthcare maintenance issues. In addition, the list of diagnostic HIV tests is expanded.

Specific changes and/or additions to the updated guidelines (and their accompanying level of evidence rating) since the previous 2004 update are as follows:

• Regardless of whether antiretroviral therapy will be started, all HIV-infected patients should have a genotypic resistance test at baseline (A-III).

• As soon as possible (within 96 hours) after exposure to a person with chickenpox or shingles, patients who are seronegative for varicella zoster virus (VZV) or with no history of chickenpox or shingles should receive postexposure prophylaxis with VZV immune globulin (VariZIG; A-III).

• Clinicians may consider varicella primary vaccination for HIV-infected, VZV-seronegative persons older than 8 years who have CD4 cell counts higher than 200 cells/mm3 (C-III) and in HIV-infected children aged 1 to 8 years who have CD4 cell percentages at least 15% (B-II).

• Cerebrospinal analysis is recommended for persons with syphilis who have neurologic or ocular signs or symptoms, active tertiary syphilis, syphilis treatment failure, or late-latent syphilis, including those with syphilis of unknown duration (A-II).

• To decrease the risk for a hypersensitivity reaction, human leukocyte antigen (HLA)-B*5701 testing is recommended before starting treatment with abacavir (A-I). Abacavir therapy should not be given to patients who are positive for the HLA B*5701 haplotype (A-II).

• Baseline urinalysis and calculated creatinine clearance may be helpful, particularly in black patients, because of greater risk for HIV-associated nephropathy (B-II).

• Before starting treatment with potentially nephrotoxic drugs such as tenofovir or indinavir, urinalysis and calculated creatinine clearance are recommended (B-II).

• Before starting treatment with a chemokine receptor 5 (CCR5)-antagonist antiretroviral drug, tropism testing is recommended (A-II).

• Women aged 40 to 49 years should periodically undergo individualized evaluation of risk for breast cancer and be informed regarding the potential benefits and risks of screening mammography (B-II).

• Routine use of hormone replacement therapy is not currently recommended because of slightly increased risk for breast cancer, cardiovascular disease, and thromboembolic disease (A-I). If hormone replacement is considered in women who experience vasomotor symptoms, vaginal dryness, or other severe menopausal symptoms, it should generally be used only for a limited period and at the lowest effective doses (B-II).

• The importance of adherence to care should be emphasized, rather than just adherence to medications (B-II).

“As we seek to make each patient comfortable and promote his or her engagement in primary care, it is important to keep in mind that HIV/AIDS affects a diverse group of persons in terms of race/ethnicity, culture, gender, and lifestyle,” the study authors conclude. “Each patient should be treated as an individual, and HIV treatment sites should provide culturally competent and appropriate care to the community of patients being served. A broad range of components, from having staff of the same race, culture, or lifestyle to having art and reading material in the clinic that reflects the culture of the local community, may be useful in facilitating this goal.”

IDSA supported development of these guidelines. Some of the guidelines authors have disclosed relevant financial relationships with Abbott Laboratories, Boehringer Ingelheim, Bristol Myers Squib, Gilead Sciences, GlaxoSmithKline, Merck, Pfizer, Schering-Plough, Tibotec Therapeutics, Achillion, Koronnis, Theratechnologies, the American Academy of Pediatrics, and/or Monogram Biosciences.

Clin Infect Dis. 2009;49:651-681.

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