HIV: Guidelines Stress Role of Primary Care in Management

Laurie Barclay, MD

November 14, 2013

As a result of longer survival and fewer complications, HIV-infected persons are increasingly developing common health problems that also affect the general population and that require management and monitoring. Updated guidelines by the HIV Medicine Association of the Infectious Diseases Society of America stress these primary care interventions. The guidelines were published online November 14 in Clinical Infectious Diseases.

"In many HIV practices now, 80 percent of patients with HIV infection have the virus under control and live long, full lives, [which] means that HIV specialists need to provide the full spectrum of primary care to these patients, and primary care physicians need a better grasp of the impact HIV care has on routine healthcare," lead author Judith A. Aberg, MD, director of the Division of Infectious Diseases and Immunology at the New York University School of Medicine in New York City, said in a news release. "Doctors need to tell their HIV-infected patients, 'Your HIV disease is controlled and we need to think about the rest of you.' As with primary care in general, it's about prevention."

Annual US incidence of HIV infection is approximately 50,000, and prevalence is currently 1.2 million, according to the Centers for Disease Control and Prevention. In this group, focus on health problems affecting the general population is increasingly important.

Based on new evidence published since the previous guidelines were released in 2009, the updated recommendations target healthcare providers who care for HIV-infected patients, including those in primary care. Persons infected with HIV should be managed and monitored for all relevant age- and sex-specific health problems, including those related to HIV infection itself or to its treatment.

Because persons infected with HIV are typically seen by an HIV specialist and/or a primary care physician, HIV specialists need to be familiar with primary care issues and primary care physicians need to be familiar with HIV care recommendations. The new guidelines are intended to bridge both gaps.

"Patients whose HIV is under control might feel they don't need to see a doctor regularly, but adherence is about more than just taking [antiretroviral therapy] (ART) regularly; it's also about receiving regular primary care," Dr. Aberg said in the release. "These guidelines are designed to help ensure patients with HIV infection live long and healthy lives."

Specific Primary Care Recommendations

HIV-infected persons should be appropriately screened for diabetes, osteoporosis, and colon cancer and vaccinated against pneumococcal infection, influenza, varicella, and hepatitis A and B.

HIV-infected persons are at increased risk for cardiovascular disease, high cholesterol and high triglycerides, and some other common conditions because of the infection itself, ART, or traditional risk factors such as smoking and an unhealthy diet. Lipid monitoring and management, as well as control of other cardiovascular risk factors, is important. The guidelines include a table outlining interactions between specific antiretrovirals and statins.

Clinicians should consistently and nonjudgmentally discuss these issues with patients and counsel them on their current and past sexual history and any other high-risk behaviors, including the use of illicit drugs. They should assess how patients are coping with living with HIV infection and determine whether they have a sufficient support network.

Changes since the 2009 guidelines include the following:

  • Patients with well-controlled HIV infection should undergo blood monitoring for viral levels every 6 to 12 months, rather than every 3 to 4 months, as previously recommended.

  • Using the Grading of Recommendations Assessment, Development and Evaluation system, the authors grade recommendations as either strong or weak and the quality of the evidence as high, moderate, low, or very low.

  • The authors have expanded recommendations on initial evaluation and immediate follow-up and have included user-friendly tables.

  • The new guidelines no longer include recommendations for long-term complications.

  • A new section on metabolic comorbidities eliminates the need for separate guidelines on dyslipidemia.

  • The updated guidelines contain a more robust section and table on sexually transmitted diseases. Women should undergo annual trichomoniasis screening, and all who may be at risk should undergo yearly screening for gonorrhea and chlamydia.

The Infectious Diseases Society of America supported development of this guideline. Some of the guidelines authors reported various financial disclosures with Abbvie, Janssen (Tibotec), Merck, ViiV, the National Institutes of Health, Kowa, Gilead, Wyeth/Pfizer, Bristol-Myers Squibb, Vertex Pharmaceuticals, GlaxoSmithKline, the US Department of Health and Human Services, and/or Siemens.

Clin Infect Dis. Posted online November 14, 2013.

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