Initial Management of Patients with HIV Infection

 


FREE PREVIEW. AAFP members and paid subscribers: Log in to get free access. All others: Purchase online access.


FREE PREVIEW. Purchase online access to read the full version of this article.

Human immunodeficiency virus (HIV) infection has become a treatable chronic disease with near-normal life expectancy when patients receive antiretroviral therapy (ART). Family physicians and other primary care clinicians commonly provide long-term comprehensive care for persons with HIV infection. This article describes the scope of initial care, including obtaining a thorough history; physical examination for HIV-associated manifestations; attention to HIV-specific immunization schedules; routine and HIV-specific laboratory evaluation; and ensuring standard health care maintenance to prevent HIV- and non–HIV-related morbidity and mortality. Clinicians should encourage combination ART as early as possible, although careful assessment of patient readiness and ability to sustain lifelong treatment must be weighed. After ART initiation, monitoring viral load and CD4 lymphocyte response is essential to ensure viral suppression and evaluate immune system restoration. Opportunistic infections are now less common than in the past because ART usually prevents or markedly delays progression to advanced HIV disease. The most important reasons for consultation or comanagement with an HIV expert include management of antiretroviral drug resistance or drug toxicities, as well as special circumstances such as viral hepatitis coinfection or pregnancy.

Remarkable advancements in anti-retroviral therapy (ART) over the past 35 years have resulted in human immunodeficiency virus (HIV) infection becoming a manageable chronic disease.1 Patients receiving early suppressive ART now have near-normal life expectancies,2,3 reduced HIV-induced inflammation and chronic immune activation,4,5 decreased progression to advanced HIV disease,6 and markedly reduced risk of transmission.7

WHAT IS NEW ON THIS TOPIC: MANAGEMENT OF PATIENTS WITH HIV INFECTION

Management of patients with HIV infection, often in consultation with experts for selection or change of the ART regimen, is in the domain of primary care clinicians.

Current recommendations are to start ART as early as possible. Once-daily pill regimens are now available.

Effective ART markedly reduces the risk of HIV transmission.


ART = antiretroviral therapy; HIV = human immunodeficiency virus.

View/Print Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Combination ART should be initiated early to delay progression of HIV infection.

A

4, 5

Combination ART can prevent HIV transmission.

A

7

Patients with HIV infection who have substantial immunosuppression should receive prophylaxis to prevent or delay opportunistic infections.

C

14

After ART-induced immunologic improvement (as measured by increased CD4 lymphocyte counts), it is safe to discontinue prophylaxis for opportunistic infections.

C

14

Non–HIV-specific primary care should be provided for all persons with HIV infection.

C

11, 12, 25


ART = antiretroviral therapy; HIV = human immunodeficiency virus.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Combination ART should be initiated early to delay progression of HIV infection.

A

4, 5

Combination ART can prevent HIV transmission.

A

7

Patients with HIV infection who have substantial immunosuppression should receive prophylaxis to prevent or delay opportunistic infections.

C

14

After ART-induced immunologic improvement (as measured by increased CD4 lymphocyte counts), it is safe to discontinue prophylaxis for opportunistic infections.

C

14

Non–HIV-specific primary care should be provided for all persons with HIV infection.

C

11, 12, 25


ART = antiretroviral therapy; HIV = human immunodeficiency virus.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

The HIV continuum of care illustrates falloff points in care, but also shows opportunities for intervention by primary care clinicians (Figure 1).8,9 There are 1.2 million persons infected with HIV in the United States, and as many as 70% are not receiving optimal care.9,10 Patients who are HIV-positive are often seen in the primary care setting because of a new HIV diagnosis or changes in health care coverage. This article, targeted toward primary care clinicians, describes the scope of initial care, including obtaining a thorough history and physical examination for HIV-associated manifestations; attention to HIV-specific immunization schedules; routine and HIV-specific laboratory evaluation; and ensuring standard health care maintenance to prevent HIV- and non

The Authors

show all author info

RONALD H. GOLDSCHMIDT, MD, is a professor in the Department of Family and Community Medicine at the University of California–San Francisco, and director of the National Clinician Consultation Center at Zuckerberg San Francisco General Hospital....

CAROLYN CHU, MD, MSc, is an associate professor in the Department of Family and Community Medicine at the University of California–San Francisco, and clinical director of the National Clinician Consultation Center at Zuckerberg San Francisco General Hospital.

BETTY J. DONG, PharmD, is a professor in the Departments of Clinical Pharmacy and Family and Community Medicine at the University of California–San Francisco, and senior pharmacy consultant at the National Clinician Consultation Center at Zuckerberg San Francisco General Hospital.

Address correspondence to Ronald H. Goldschmidt, MD, Zuckerberg San Francisco General Hospital, 1001 Potrero Ave., San Francisco, CA 94110 (e-mail: rgoldschmidt@nccc.ucsf.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Deeks SG, Lewin SR, Havlir DV. The end of AIDS: HIV infection as a chronic disease. Lancet. 2013;382(9903):1525–1533....

2. Nakagawa F, May M, Phillips A. Life expectancy living with HIV: recent estimates and future implications. Curr Opin Infect Dis. 2013;26(1):17–25.

3. Samji H, Cescon A, Hogg RS, et al.; North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) of IeDEA. Closing the gap: increases in life expectancy among treated HIV-positive individuals in the United States and Canada. PLoS One. 2013;8(12):e81355.

4. Lundgren JD, Babiker AG, Gordin F, et al.; INSIGHT START Study Group. Initiation of antiretroviral therapy in early asymptomatic HIV infection. N Engl J Med. 2015;373(9):795–807.

5. Danel C, Moh R, Gabillard D, et al.; TEMPRANO ANRS 12136 Study Group. A trial of early antiretrovirals and isoniazid preventive therapy in Africa. N Engl J Med. 2015;373(9):808–822.

6. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Dept. of Health and Human Services AIDS Info clinical guidelines portal. https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-treatment-guidelines/0. Accessed February 10, 2016.

7. Cohen MS, Chen YQ, McCauley M, et al.; HPTN 052 Study Team. Anti-retroviral therapy for the prevention of HIV-1 transmission. N Engl J Med. 2016;375(9):830–839.

8. Gardner EM, McLees MP, Steiner JF, Del Rio C, Burman WJ. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011;52(6):793–800.

9. Bradley H, Hall HI, Wolitski RJ, et al. Vital signs: HIV diagnosis, care, and treatment among persons living with HIV—United States, 2011. MMWR Morb Mortal Wkly Rep. 2014;63(47):1113–1117.

10. Doshi RK, Matthews T, Isenberg D, et al. Continuum of HIV care among Ryan White HIV/AIDS program clients: United States, 2010 [abstract]. Conference on Retroviruses and Opportunistic Infections, 2013. Atlanta, Ga., March 3–6, 2013. https://blog.aids.gov/wp-content/uploads/Continuum-of-HIV-Care-among-RW-Clients-20101.pdf. Accessed August 8, 2016.

11. Chu C, Selwyn PA. Complications of HIV infection: a systems-based approach. Am Fam Physician. 2011;83(4):395–406.

12. Aberg JA, Gallant JE, Ghanem KG, Emmanuel P, Zingman BS, Horberg MA. 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(1):e1–e34.

13. Centers for Disease Control and Prevention. Immunization schedules: adult immunization schedule, United States, 2016. http://www.cdc.gov/vaccines/schedules/hcp/adult.html. Accessed February 10, 2016.

14. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. Dept. of Health and Human Services AIDS Info clinical guidelines portal. https://aidsinfo.nih.gov/guidelines/html/4/adult-and-adolescent-oi-prevention-and-treatment-guidelines/0. Accessed February 10, 2016.

15. Recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States. Dept. of Health and Human Services AIDS Info clinical guidelines portal. https://aidsinfo.nih.gov/guidelines/html/3/perinatal-guidelines/0#. Accessed February 10, 2016.

16. Pantaleo G, Graziosi C, Fauci AS. New concepts in the immunopathogenesis of human immunodeficiency virus infection. N Engl J Med. 1993;328(5):327–335.

17. Thompson M. Challenges of improving adherence to HIV therapy. Am Fam Physician. 2011;83(4):375, 379.

18. Gandhi M, Gandhi RT. Single-pill combination regimens for treatment of HIV-1 infection. N Engl J Med. 2014;371(3):248–259.

19. Knight DA, Jarrett D. Preventive health care for men who have sex with men. Am Fam Physician. 2015;91(12):844–851.

20. Machtinger EL, Wilson TC, Haberer JE, Weiss DS. Psychological trauma and PTSD in HIV-positive women: a meta-analysis. AIDS Behav. 2012;16(8):2091–2100.

21. Greene M, Justice AC, Lampiris HW, Valcour V. Management of human immunodeficiency virus infection in advanced age. JAMA. 2013;309(13):1397–1405.

22. Shapiro B, Coffa D, McCance-Katz EF. A primary care approach to substance misuse. Am Fam Physician. 2013;88(2):113–121.

23. Centers for Disease Control and Prevention; U.S. Dept. of Health and Human Services. Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupational exposure to HIV—United States, 2016. http://www.cdc.gov/hiv/pdf/programresources/cdc-hiv-npep-guidelines.pdf. Accessed August 8, 2016.

24. Hogben M, McNally T, McPheeters M, Hutchinson AB. The effectiveness of HIV partner counseling and referral services in increasing identification of HIV-positive individuals: a systematic review. Am J Prev Med. 2007;33(2 suppl):S89–S100.

25. Gallant JE, Adimora AA, Carmichael JK, et al. Essential components of effective HIV care: a policy paper of the HIV Medicine Association of the Infectious Diseases Society of America and the Ryan White Medical Providers Coalition. Clin Infect Dis. 2011;53(11):1043–1050.

26. Khalsa AM. Preventive counseling, screening, and therapy for the patient with newly diagnosed HIV infection [published correction appears in Am Fam Physician. 2006;73(10):1704]. Am Fam Physician. 2006;73(2):271–280.

27. Romanelli F, Matheny SC. HIV infection: the role of primary care. Am Fam Physician. 2009;80(9):946–952.



 

Copyright © 2016 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP


Editor's Collections


Related Content


MOST RECENT ISSUE


Dec 1, 2016

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article