November 11, 2009 — A review published in the November 1 issue of American Family Physician describes the role of primary care clinicians in the treatment of patients with HIV infection.
"Prevention and treatment of...HIV infection have changed considerably in the past few years," write Frank Romanelli, PharmD, MPH, and Samuel C. Matheny, MD, MPH, from the University of Kentucky College of Pharmacy and the University of Kentucky College of Medicine in Lexington. "Updated screening recommendations give family physicians an important role in assessing patients at risk of HIV infection, detecting those who are infected, and recommending treatment options. Although family physicians may elect to refer some patients to an HIV subspecialist for therapeutic interventions, they may continue to provide intermittent or chronic care for these patients."
Since HIV infection was first reported in the United States in 1981, there has been dramatic progress in prevention and management. Because screening for HIV is essential to detect early infection, this testing is now incorporated into routine primary care.
HIV may be diagnosed at any stage of HIV infection. The constitutional symptoms associated with acute retroviral syndrome occurring soon after infection are nonspecific, hindering distinguishing early HIV infection from infection with prevalent community-acquired viruses.
Monitoring patients with HIV infection is also an important role assumed by primary care providers. Patients with newly diagnosed HIV infection should undergo a thorough history and physical examination and be offered counseling, baseline testing, and appropriate immunizations. Although patients with HIV infection may receive killed or inactivated vaccines, those with severe immune compromise (CD4 cell count < 100 cells/mm3 [100 × 109 per L]) or uncontrolled viremia may not mount an appropriate immune response. When CD4 cell counts increase, revaccination may be indicated.
These patients should also be evaluated for the risk for opportunistic infections, such as Pneumocystis jiroveci pneumonia, toxoplasmosis, and Mycobacterium avium complex disease. Specifically, patients with CD4 cell counts of less than 200 cells/mm3 require antimicrobial prophylaxis against various opportunistic infections.
Combination antiretroviral therapy and other aspects of appropriate HIV infection management have improved patient survival duration, sometimes by many years. Genotypic or phenotypic resistance testing is important in choosing the optimal pharmacotherapy regimen for each patient. Early in the disease course, genotypic assays are recommended, whereas patients with more complicated disease should undergo phenotypic assay testing.
Patients with HIV infection must be treated for the duration of their lifetime, resulting in the need for primary care clinicians to help manage pill burden, cost, adverse effects of treatment, and drug interactions. Drugs that have recently become available for HIV treatment have allowed lower pill burdens, better tolerability, and fewer drug interactions.
"Not all patients with HIV infection are candidates for antiretroviral treatment," the review authors write. "Decisions about the best time to initiate drug therapy should consider drug cost, psychosocial factors, comorbid diagnoses, implications of drug-induced resistance, and the potential toxicity of antiretrovirals....Treatment is generally initiated when the CD4 cell count falls to less than 350 cells per mm3 (350 × 109 per L)."
Key Practice Recommendations
Key clinical recommendations for practice, and their accompanying level of evidence rating, are as follows:
For patients aged 13 to 64 years and for pregnant women, routine HIV screening should be considered. This is especially recommended when the prevalence of undiagnosed infection in the clinician's patient population is 0.1% or more (level of evidence, C).
Before selection of appropriate antiretroviral pharmacotherapy, patients with HIV infection and CD4 cell count of less than 350 cells/mm3 (350 × 109 per L) should have genotypic or phenotypic resistance testing (level of evidence, B).
For HIV infection, initial antiretroviral regimens should include a combination of 3 agents. Usually the regimen should include 2 nucleoside reverse transcriptase inhibitors, plus 1 nonnucleoside reverse transcriptase inhibitor or 1 protease inhibitor. Achieving an undetectable viral load (plasma HIV RNA < 48 copies per mL) should be the primary goal of antiretroviral therapy (level of evidence, A).
In patients with HIV infection, CD4 cell count thresholds should be used when considering the need for antimicrobial prophylaxis against opportunistic infections. Prophylaxis is required for patients with CD4 cell counts of less than 200 cells/mm3 (200 × 109 per L) (level of evidence, B).
Patients with newly diagnosed HIV infection should undergo screening in their primary care medical setting for opportunistic diseases and sexually transmitted infections. They should also have yearly tuberculin testing, and vaccination histories should be updated at each office visit (level of evidence, C).
Recently available combination therapies, such as emtricitabine/tenofovir and efavirenz/emtricitabine/tenofovir, facilitate patient adherence to combination regimens. HIV pharmacotherapy now commonly uses ritonavir to boost the effectiveness of antiretroviral therapies.
Other classes of antiretroviral therapy, such as fusion inhibitors, integrase inhibitors, or coreceptor antagonists, are usually given only to more treatment-experienced patients with a higher probability of acquired resistance.
"After the initiation of a new antiretroviral regimen, follow-up and monitoring usually occur every 30 days, and every 90 days after the patient is stable [then] extended to every six months in patients with slowly progressing disease," the review authors conclude. "The addition of pharmacotherapy in patients with HIV infection warrants close attention to potential drug interactions because they may compromise antiretroviral effectiveness, or lead to resistance or deleterious adverse effects. Physicians should consult appropriate resources or subspecialists to evaluate the potential for drug interactions when additions or deletions are made to drug regimens."
Additional Resources
More information on HIV management is available from the Infectious Diseases Society of America <Hyperlink: https://www.idsociety.org/Content.aspx?id=1922 >
The review authors have disclosed no relevant financial relationships.
Am Fam Physician 2009;80:946-952. Abstract
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Cite this: Role of Primary Care Clinicians in HIV Management Reviewed - Medscape - Nov 11, 2009.
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