COMMENTARY

A Framework for Comprehensive
HIV Primary Care

Christine A. Kerr, MD, and Rachel Lastra, New York State Department of Health AIDS Institute

May 19, 2021

HIV care has long had an identity crisis — Does it belong in the realm of primary care, specialty care, or both? Should patients with HIV receive their care in multiple settings? HIV care can be complex, particularly in patients who are long-term survivors and have been treated with multiple generations of antiretroviral medications or have multiple comorbidities.

Once viral suppression is achieved, the focus of primary care for people with HIV is in many ways the same as for those who don't have HIV, which increasingly includes the problems associated with aging. The recently updated guideline "Comprehensive Primary Care for Adults With HIV" from the New York State Department of Health AIDS Institute (NYSDOH AI) addresses key issues in healthcare for adults with HIV. Designed for use in multiple clinical settings and areas of practice, this framework for comprehensive primary care addresses the following:

  • Elements of an HIV history, including assessment, screening, and prevention for comorbidities that occur more often or at a younger age in people with HIV, and monitoring for long-term effects of treatment with antiretroviral medications.

  • Health maintenance and prevention across the lifespan, including immunizations.

  • Screening and harm reduction for patients who engage in high- or higher-risk behaviors.

  • Addressing the effects of HIV-related stigma, trauma, and healthcare disparities.

Taking an HIV-Specific Medical History

In addition to a general medical history and physical examination, a baseline HIV-specific medical history is the framework on which a patient's HIV care is built. An HIV-specific medical history combines elements standard to primary care with those specific to people with HIV, such as:

  • Viral load and CD4 cell count

  • Antiretroviral therapy (ART) history, including regimen changes (and why), adverse effects, and adherence issues

  • Resistance testing results

  • History of opportunistic infections (OIs)

  • History of HIV-related hospitalizations

  • Housing, employment, food security, and relationship status

  • HIV disclosure status and partner notification

  • History of other sexually transmitted infection (STIs) with shared risk factors, including hepatitis B and C viruses

  • Ongoing high-risk behaviors, including injection drug use

  • Experience of stigma and social support

The guideline offers a step-by-step, detailed checklist for taking the HIV-specific medical history, assessing psychosocial, behavioral, and sexual health, and performing recommended laboratory testing, including frequency.

Making a Plan for Prevention and Protecting Against Opportunistic Infections

Equally important to the baseline medical history are routine screening and primary prevention, which are largely the same for people with and without HIV, although some comorbidities may occur more frequently, at younger ages, or with atypical presentations in people with HIV.

Routine screening for patients with HIV includes checking for breast, colon, cervical, anal, lung, and prostate cancers; measuring bone density; checking for abdominal aortic aneurysm; and performing routine vision tests.

Primary prevention includes screening for tobacco, alcohol, and drug use; cardiovascular disease risk; depression; domestic violence; STIs; breast and skin cancers; and falls in older adults.

Although related incidence and mortality have decreased, OIs are still a concern for people with HIV [Masur 2015], and in particular, in patients with low CD4 cell counts at HIV diagnosis [Ransome, et al. 2015; Tominski, et al. 2017]. It is important that clinicians who provide medical care for people with HIV are able to identify common OIs and initiate or discontinue OI prophylaxis depending on specific patient needs.

Addressing Aging-Associated Concerns in Patients With HIV

Patients who have lived with HIV for a long time, and especially those diagnosed before the era of effective ART, often exhibit characteristics of advanced aging, such as increased or earlier onset of comorbidities and frailty. Advanced aging may also be observed in people newly diagnosed with HIV who are aged 50 years and older with a delayed diagnosis, low CD4 count, or AIDS [Tavoschi, et al. 2017]. In 2017, more than 49% of people diagnosed with HIV in the United States were aged 50 years or older [CDC 2020].

New to the NYSDOH AI guideline is a dedicated section on aging in patients with HIV. To help clinicians assess the specific health needs and priorities of aging patients with HIV, this section outlines an approach based on recognizing and discussing with patients the effects of HIV-associated aging by:

  • Using the "5Ms" — Mind, Mobility, Multimorbidity, Medications, and Matters Most [Tinetti M, et al. 2017] — for assessment

  • Being vigilant in identifying and reducing the negative effects of polypharmacy

  • Becoming familiar with screening tools, resources, and local services

Supporting HIV Care Clinicians

The NYSDOH AI guideline is a tool to guide clinicians in providing comprehensive HIV primary care that also includes links to resources and national standards of care for clinicians who wish to learn more. One important resource is the centralized guide to immunizations for adults with HIV, recommendations which can be hard to find in standard sources.

Because there is a national shortage of both HIV-specialty clinicians and primary care physicians, healthcare professionals without HIV experience may increasingly be called on to provide care for adults with HIV [Mathematica 2016; Bono, et al. 2021]. A comprehensive framework for HIV primary care across the adult lifespan will support them in providing sustainable, high-quality, and engaging HIV care regardless of the setting. With effective support and tools, clinicians in any setting will be able to support their adult patients with HIV in meeting the goals of effective HIV management and the primary care goals of health maintenance and prevention.

References:

Bono RS, Dahman B, Sabik LM, Yerkes LE, Deng Y, Belgrave FZ, Nixon DE, Rhodes AG, Kimmel AD. Human immunodeficiency virus-experienced clinician workforce capacity: urban-rural disparities in the Southern United States. Clin Infect Dis. 2021;72(9):1615-1622. [PMID: 32211757]

CDC. Centers for Disease Control and Prevention. HIV surveillance report 2018. 2020 May. https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html [accessed 2021 May 5]

Masur H. HIV-related opportunistic infections are still relevant in 2015. Top Antivir Med 2015;23(3):116-119. [PMID: 26518395]

Mathematica. Gap in supply of HIV clinicians expected to increase. https://www.mathematica.org/news/hiv-specialist [accessed 2021 May 5]

Ransome Y, Terzian A, Addison D, et al. Expanded HIV testing coverage is associated with decreases in late HIV diagnoses. AIDS 2015;29(11):1369-1378. [PMID: 26091296

Tavoschi L, Gomes Dias J, Pharris A. New HIV diagnoses among adults aged 50 years or older in 31 European countries, 2004-15: an analysis of surveillance data. Lancet HIV 2017;4(11):e514-e521. [PMID: 28967582]

Tinetti ME, Naik AD, Dindo L, et al. Association of patient priorities-aligned decision-making with patient outcomes and ambulatory health care burden among older adults with multiple chronic conditions: A nonrandomized clinical trial. JAMA Intern Med 2019. [PMID: 31589281]

Tominski D, Katchanov J, Driesch D, et al. The late-presenting HIV-infected patient 30 years after the introduction of HIV testing: spectrum of opportunistic diseases and missed opportunities for early diagnosis. HIV Med 2017;18(2):125-132. [PMID: 27478058

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