HIV Infection in Adults: Initial Management

 

Am Fam Physician. 2021 Apr 1;103(7):407-416.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/hiv.

  Related letter: Management of Syphilis in People with HIV Infection

Author disclosure: No relevant financial affiliations.

The HIV epidemic is an important public health priority. Transmissions continue to occur despite effective therapies that make HIV preventable and treatable. Approximately one-half of people with HIV are not receiving suppressive antiretroviral therapy (ART). Starting ART early, followed by continuous lifetime treatment, most effectively achieves durable virologic suppression and restoration of immune function that can improve clinical outcomes and prevent transmission to partners who are seronegative. National treatment guidelines include ART options that can be offered immediately after diagnosis, even before the results of baseline HIV drug-resistance testing are available. Initial ART selection should be guided by co-occurring conditions, including viral hepatitis, medications, and other factors such as pregnancy. Identifying and addressing psychosocial barriers to care is a key element of ensuring long-term adherence to treatment. The initial physical examination typically reveals no clinical manifestations of HIV in the absence of advanced disease. A comprehensive laboratory evaluation, including HIV viral load and CD4 lymphocyte monitoring, is necessary to guide decision-making for treatment, opportunistic infection prophylaxis, and vaccinations. The initial management of people with HIV presents a unique opportunity for family physicians to improve patients' long-term health care and reduce HIV transmissions.

One-half of the estimated 1.1 million people in the United States with HIV infection are not receiving antiretroviral therapy (ART) or are receiving ART that is not sufficiently effective to achieve key clinical outcomes. Key outcomes include preventing clinical progression to advanced HIV disease, allowing near-normal life expectancy, and reducing transmission risk (i.e., treatment as prevention).18 HIV disproportionately affects people of color and people with limited access to continuous, comprehensive health care.9,10 Family physicians are uniquely positioned to diagnose HIV early and ensure long-term quality care for patients.

WHAT'S NEW ON THIS TOPIC

HIV Infection in Adults

Nearly one-half of the estimated 1.1 million people with HIV infection in the United States are not receiving antiretroviral therapy or are receiving antiretroviral therapy that is not sufficiently effective to achieve the key clinical outcomes.

Approximately 38% of new transmissions are from people with HIV who do not know their HIV status.

Clinicians should identify and address potential barriers to treatment and adherence, including concerns for unintended disclosure of HIV status, housing and food instability, transportation challenges or conflicting priorities, and lack of patient readiness or motivation.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

All people 15 to 65 years of age should be screened for HIV at least once; all people who are pregnant should be screened for HIV.12

A

U.S. Preventive Services Task Force recommendations based on systematic review of high-quality patient-oriented evidence

Combination antiretroviral therapy should be initiated as soon as possible after HIV diagnosis.4,20

C

Department of Health and Human Services guidelines based on epidemiologic and modeling studies; consensus guidelines from the International Antiviral Society–USA Panel

Combination antiretroviral therapy with durable viral load suppression is recommended for people with HIV to reduce the risk of sexual transmission to seronegative partners.48,20

C

Department of Health and Human Services guidelines based on randomized controlled trials of serodiscordant couples; consensus guidelines from the International Antiviral Society-USA Panel

If the CD4 count is less than 200 cells per μL (0.20 × 109 per L), prophylaxis against Pneumocystis jiroveci should be initiated.23

C

Department of Health and Human Services guidelines based on retrospective studies

If the CD4 count is less than 100 cells per μL (0.10 × 109 per L) and Toxoplasma antibodies are positive, prophylaxis against Toxoplasma gondii should be initiated.23

C

Department of Health and Human Services guidelines based on retrospective studies

Most vaccinations can be administered according to standard adult vaccination schedules; live vaccines should be avoided in people with a CD4 count less than 200 cells per μL.23,24

C

Department of Health and Human Services guidelines based on expert opinion


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 https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

All people 15 to 65 years of age should be screened for HIV at least

The Authors

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

Address correspondence to Ronald Goldschmidt, MD, San Francisco General Hospital, 1001 Potrero Ave., San Francisco, CA 94110 (email: ronald.goldschmidt@ucsf.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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1. Centers for Disease Control and Prevention. HIV in the United States and dependent areas. Accessed July 20, 2020. https://www.cdc.gov/hiv/statistics/overview/ataglance.html...

2. Li Z, Purcell DW, Sansom SL, et al. Vital signs: HIV transmission along the continuum of care—United States, 2016. MMWR Morb Mortal Wkly Rep. 2019;68(11):267–272.

3. Fauci AS, Redfield RR, Sigounas G, et al. Ending the HIV epidemic: a plan for the United States. JAMA. 2019;321(9):844–845.

4. U.S. Department of Health and Human Services. Guidelines for the use of antiretroviral agents in adults and adolescents living with HIV. Accessed February 23, 2021. https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv/whats-new-guidelines

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

6. Rodger AJ, Cambiano V, Bruun T, et al.; PARTNER Study Group. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy [published corrections appear in JAMA. 2016;316(6):667, and JAMA. 2016;316(19):2048]. JAMA. 2016;316(2):171–181.

7. Rodger AJ, Cambiano V, Bruun T, et al.; PARTNER Study Group. Risk of HIV transmission through condomless sex in serodifferent gay couples with the HIV-positive partner taking suppressive antiretroviral therapy (PARTNER): final results of a multicentre, prospective, observational study. Lancet. 2019;393(10189):2428–2438.

8. Bavinton BR, Pinto AN, Phanuphak N, et al.; Opposites Attract Study Group. Viral suppression and HIV transmission in serodiscordant male couples: an international, prospective, observational, cohort study [published correction appears in Lancet HIV. 2018;5(10):e545]. Lancet HIV. 2018;5(8):e438–e447.

9. Centers for Disease Control and Prevention. HIV and African American people. Accessed July 20, 2020. https://www.cdc.gov/hiv/group/racialethnic/africanamericans/index.html

10. Centers for Disease Control and Prevention. HIV and Hispanics/Latinos. Accessed July 20, 2020. https://www.cdc.gov/hiv/group/racialethnic/hispaniclatinos/index.html

11. Centers for Disease Control and Prevention. Laboratory testing for the diagnosis of HIV infection: updated recommendations. June 27, 2014. Accessed October 29, 2020. http://dx.doi.org/10.15620/cdc.23447

12. Owens DK, Davidson KW, Krist AH, et al.; U.S. Preventive Services Task Force. Screening for HIV infection: US Preventive Services Task Force recommendation statement. JAMA. 2019;321(23):2326–2336.

13. Chou R, Dana T, Grusing S, et al. Screening for HIV infection in asymptomatic, nonpregnant adolescents and adults: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2019;321(23):2337–2348.

14. Selph SS, Bougatsos C, Dana T, et al. Screening for HIV infection in pregnant women: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2019;321(23):2349–2360.

15. Centers for Disease Control and Prevention. US Public Health Service. Preexposure prophylaxis for the prevention of HIV infection in the United States—2017 update. March 2018. Accessed July 20, 2020. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf

16. Owens DK, Davidson KW, Krist AH, et al.; U.S. Preventive Services Task Force. Preexposure prophylaxis for the prevention of HIV infection: US Preventive Services Task Force recommendation statement. JAMA. 2019;321(22):2203–2213.

17. Chou R, Evans C, Hoverman A, et al. Preexposure prophylaxis for the prevention of HIV infection: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2019;321(22):2214–2230.

18. Centers for Disease Control and Prevention. Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupational exposure to HIV—United States, 2016. Accessed September 24, 2020. http://stacks.cdc.gov/view/cdc/38856

19. Chu C, Selwyn PA. Diagnosis and initial management of acute HIV infection. Am Fam Physician. 2010;81(10):1239–1244. Accessed February 12, 2021. https://www.aafp.org/afp/2010/0515/p1239.html

20. Saag MS, Gandhi RT, Hoy JF, et al. Antiretroviral drugs for treatment and prevention of HIV infection in adults: 2020 recommendations of the International Antiviral Society–USA Panel. JAMA. 2020;324(16):1651–1669.

21. McCluskey SM, Siedner MJ, Marconi VC. Management of virologic failure and HIV drug resistance. Infect Dis Clin North Am. 2019;33(3):707–742.

22. Coffey S, Bacchetti P, Sachdev D, et al. RAPID antiretroviral therapy: high virologic suppression rates with immediate antiretroviral therapy initiation in a vulnerable urban clinic population [published correction appears in AIDS. 2019;33(13):2113]. AIDS. 2019;33(5):825–832.

23. Centers for Disease Control and Prevention. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV. Updated August 18, 2020. Accessed October 28, 2020. https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/whats-new-guidelines

24. Centers for Disease Control and Prevention. Recommended adult immunization schedule for ages 19 years or older, United States, 2021. Accessed February 23, 2021. https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html

25. Chu C, Pollock LC, Selwyn PA. HIV-associated complications: a systems-based approach. Am Fam Physician. 2017;96(3):161–169. Accessed February 12, 2021. https://www.aafp.org/afp/2017/0801/p161.html

26. Knight DA, Jarrett D. Preventive health care for men who have sex with men [published correction appears in Am Fam Physician. 2016;94(2):84]. Am Fam Physician. 2015;91(12):844–851. Accessed February 12, 2021. https://www.aafp.org/afp/2015/0615/p844.html

27. Rueda S, Mitra S, Chen S, et al. Examining the associations between HIV-related stigma and health outcomes in people living with HIV/AIDS: a series of meta-analyses. BMJ Open. 2016;6(7):e011453.

28. Terrault NA, Bzowej NH, Chang KM, et al.; American Association for the Study of Liver Diseases. AASLD guidelines for treatment of chronic hepatitis B. Hepatology. 2016;63(1):261–283.

29. American Association for the Study of Liver Diseases; Infectious Diseases Society of America. HCV guidance: recommendations for testing, managing, and treating hepatitis C. Accessed July 20, 2020. https://www.hcvguidelines.org/

30. Marrero JA, Kulik LM, Sirlin CB, et al. Diagnosis, staging, and management of hepatocellular carcinoma: 2018 practice guidance by the American Association for the Study of Liver Diseases. Hepatology. 2018;68(2):723–750.

31. Lerner AM, Eisinger RW, Fauci AS. Comorbidities in persons with HIV: the lingering challenge. JAMA. 2020;323(1):19–20.

32. Centers for Disease Control and Prevention. Recommendations for the use of antiretroviral drugs in pregnant women with HIV infection and interventions to reduce perinatal HIV transmission in the United States. Updated February 10, 2021. Accessed February 23, 2021. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new-guidelines

33. Momplaisir FM, Storm DS, Nkwihoreze H, et al. Improving postpartum retention in care for women living with HIV in the United States. AIDS. 2018;32(2):133–142.

34. Chen JS, Pence BW, Rahangdale L, et al. Postpartum HIV care continuum outcomes in the southeastern USA. AIDS. 2019;33(4):637–644.

35. Althoff KN, Smit M, Reiss P, et al. HIV and ageing: improving quantity and quality of life. Curr Opin HIV AIDS. 2016;11(5):527–536.

36. Parker CM, Hirsch JS, Hansen HB, et al. Facing opioids in the shadow of the HIV epidemic [published correction appears in N Engl J Med. 2019; 380(4):402]. N Engl J Med. 2019;380(1):1–3.

37. Reddon H, Marshall BDL, Milloy M-J. Elimination of HIV transmission through novel and established prevention strategies among people who inject drugs. Lancet HIV. 2019;6(2):e128–e136.

38. Shoptaw S, Montgomery B, Williams CT, et al. Not just the needle: the state of HIV prevention science among substance users and future directions. J Acquir Immune Defic Syndr. 2013;63(suppl 2[02]):S174–S178.

39. Khalsa AM. Preventing 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. Accessed January 29, 2021. https://www.aafp.org/afp/2006/0115/p271.html

40. Romanelli F, Matheny SC. HIV infection: the role of primary care. Am Fam Physician. 2009;80(9):946–952. Accessed January 29, 2021. https://www.aafp.org/afp/2009/1101/p946.html

41. Goldschmidt RH, Chu C, Dong BJ. Initial management of patients with HIV infection. Am Fam Physician. 2016;94(9):708–716. Accessed January 29, 2021. https://www.aafp.org/afp/2016/1101/p708.html

 

 

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