HIV-Associated Complications: A Systems-Based Approach

 

Am Fam Physician. 2017 Aug 1;96(3):161-169.

  Patient information: See related handout on common side effects of HIV medicine, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Persons with human immunodeficiency virus (HIV) infection often develop complications related directly to the infection, as well as to treatment. Aging, lifestyle factors, and comorbidities increase the risk of developing chronic conditions such as diabetes mellitus and chronic kidney disease. HIV-associated neurologic complications encompass a wide spectrum of pathophysiology and symptomatology. Cardiovascular and pulmonary conditions are common among persons with HIV infection. Although some specific antiretroviral medications have been linked to disease development, traditional risk factors (e.g., smoking) have major roles. Prevention and management of viral hepatitis coinfection are important to reduce morbidity and mortality, and new anti–hepatitis C agents produce high rates of sustained virologic response. Antiretroviral-associated metabolic complications include dyslipidemia, hyperglycemia, and loss of bone mineral density. Newer options generally pose less risk of significant systemic toxicity and are better tolerated. Family physicians who care for patients with HIV infection have a key role in identifying and managing many of these chronic complications.

Current U.S. treatment guidelines support antiretroviral therapy (ART) for all patients with human immunodeficiency virus (HIV) infection.1 However, most HIV-associated complications arise directly from chronic infection that results in immunologic impairment and inflammation, and indirectly through aging, ART, and lifestyle factors such as smoking and diet.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Patients should be evaluated for potential interactions between antiretrovirals and concurrent medications (including over-the-counter agents).

C

1

Patients should be screened for kidney disease when HIV infection is diagnosed, then twice yearly in stable patients, and more frequently in high-risk patients.

C

1, 15, 50

Cervical cancer screening in women with HIV infection should begin within one year of the onset of sexual activity regardless of the mode of HIV transmission, but no later than 21 years of age. (See Table 4 for specific screening recommendations.)

C

53

Patients should be screened for lipid and glucose disorders when HIV infection is diagnosed, then monitored regularly.

C

1, 15

Clinicians should consider switching antiretroviral combinations to more lipid- and/or glucose-neutral regimens if specific agents are suspected of causing or worsening significant hyperlipidemia or hyperglycemia.

C

1, 55

Baseline bone mineral density should be measured in postmenopausal women, men 50 years and older, and other patients at high risk of osteoporotic fracture.

C

58


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

Patients should be evaluated for potential interactions between antiretrovirals and concurrent medications (including over-the-counter agents).

C

1

Patients should be screened for kidney disease when HIV infection is diagnosed, then twice yearly in stable patients, and more frequently in high-risk patients.

C

1, 15, 50

Cervical cancer screening in women with HIV infection should begin within one year of the onset of sexual activity regardless of the mode of HIV transmission, but no later than 21 years of age. (See Table 4 for specific screening recommendations.)

C

53

Patients should be screened for lipid and glucose disorders when HIV infection is diagnosed, then monitored regularly.

C

1, 15

Clinicians should consider switching antiretroviral combinations to more lipid- and/or glucose-neutral regimens if specific agents are suspected of causing or worsening significant hyperlipidemia or hyperglycemia.

C

1, 55

Baseline bone mineral density should be measured in postmenopausal women, men 50 years and older, and other patients at high risk of osteoporotic fracture.

C

58


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.

This article updates a previous review 2 of key HIV- and ART-related complications; opportunistic infections and other AIDS-defining conditions are not discussed. Major neurologic, cardiopulmonary, hepatic, renal, and metabolic complications of HIV infection are emphasized because of their prevalence and contributions to morbidity and mortality.36 Except where noted, complications

The Authors

show all author info

CAROLYN CHU, MD, MSc, is an associate professor in the Department of Family and Community Medicine at the University of California at San Francisco School of Medicine....

LEALAH C. POLLOCK, MD, MS, is an assistant professor in the Department of Family and Community Medicine at the University of California at San Francisco School of Medicine.

PETER A. SELWYN, MD, MPH, is chairman of the Department of Family and Social Medicine at Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.

Address correspondence to Carolyn Chu, MD, MSc, University of Cali-fornia at San Francisco, 1001 Potrero Ave., Bldg. 20, Rm. 2203, San Francisco, CA 94110 (e-mail: carolyn.chu@ucsf.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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