HIV remains a significant public health challenge despite highly effective prevention and treatment strategies. Screening for HIV infection is recommended for individuals ages 15 to 65 years. The status neutral approach to care includes preexposure prophylaxis for HIV-negative patients and antiretroviral therapy for patients with HIV. The preexposure prophylaxis options approved by the US Food and Drug Administration include oral and injectable formulations, which reduce HIV acquisition risk by 99% when taken consistently. Same-day antiretroviral therapy initiation is the standard of care for patients diagnosed with HIV infection, with integrase strand transfer inhibitor–based regimens preferred for treatment-naive patients. Key clinical considerations in primary care require modified management approaches for patients with HIV. All patients 40 to 75 years of age with HIV infection and 10-year atherosclerotic cardiovascular disease risk scores between 5% and less than 20% should be prescribed a moderate-intensity statin, and those with risk scores of 20% or greater should receive a high-intensity statin. In addition to standard age-appropriate vaccines, adults with HIV should receive hepatitis A and B (if not immune), meningococcal, pneumococcal, and herpes zoster vaccines. Cancer screening for patients with HIV includes lifelong cervical cancer screening. Anal cancer screening should start at age 35 for men who have sex with men and transgender women, and at age 45 for all other patients. Family physicians are uniquely positioned to deliver comprehensive care that addresses HIV-specific needs and whole person primary care.
Despite significant advances in prevention and treatment, approximately 1.2 million Americans live with HIV infection, with nearly 32,000 new infections occurring annually.1 Populations disproportionately affected include men who have sex with men (MSM), racial minorities, transgender individuals, and people who inject drugs.
WHAT’S NEW ON THIS TOPIC
| Doxycycline postexposure prophylaxis has been shown to reduce the incidence of bacterial STI by 66% in men who have sex with men and transgender women with recent bacterial STI when administered within 72 hours of unprotected sex. |
| The REPRIEVE trial showed that moderate-intensity statins reduced the rate of major adverse cardiovascular events by 35% in patients with well-controlled HIV infection and low to intermediate atherosclerotic cardiovascular disease risk (10-year risk score less than 15% and low-density lipoprotein cholesterol level below risk-specific thresholds). |
STI = sexually transmitted infection.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
| HIV screening/testing | ||
| Screen adolescents and adults ages 15 to 65 years for HIV. Also screen those in other age groups who are at increased risk.6 | A | USPSTF recommendations based on systematic review of high-quality patient-oriented evidence |
| Screen pregnant women for HIV during each pregnancy, including those presenting in labor without prior testing.7 Retest high-risk women in the third trimester, preferably before 36 weeks. This includes those who inject drugs, have STIs, have multiple or new partners, or have HIV-positive partners, and those who receive care in high-prevalence settings, are incarcerated, or show signs of acute HIV infection.6–8 | A | USPSTF and CDC recommendations based on systematic review of high-quality patient-oriented evidence |
| Fourth-generation antigen-antibody immunoassays should be used to test for HIV infection.15,16 | C | CDC/APHL guidelines based on expert opinion |
| Results of point-of-care and self-testing should be confirmed with laboratory-based HIV testing.15,16 | C | CDC/APHL guidelines based on expert opinion |
| PrEP and PEP | ||
| Prescribe PrEP for individuals at increased risk of acquiring HIV.27 | A | USPSTF grade A recommendation based on systematic review |
| For PEP after substantial-risk exposures, prescribe either (1) bictegravir/emtricitabine/tenofovir alafenamide (Biktarvy) or (2) dolutegravir (Tivicay) plus either tenofovir alafenamide or tenofovir disoproxil fumarate plus either emtricitabine or lamivudine.31 | C | CDC expert opinion |
| For MSM and transgender women with a bacterial STI (ie, chlamydia, gonorrhea, or syphilis) in the previous 12 months, counsel about and offer doxycycline PEP through shared decision-making.11 | A | CDC recommendation based on review of randomized controlled trials |
| Treatment | ||
| Antiretroviral therapy should be initiated in all patients diagnosed with HIV as soon as possible, ideally on the same day or within 7 days of diagnosis, provided the patient is ready and no opportunistic infection is suspected.29,34 | C | Expert opinion from the International Antiviral Society-USA, guidelines from Panel on Antiretroviral Guidelines for Adults and Adolescents |
| Patients with HIV should be treated with antiretroviral therapy to an undetectable viral load level to prevent transmitting the virus to sex partners. This strategy is known as Undetectable = Untransmittable.20 | A | Large multicenter randomized controlled trial |
| Screening and prevention | ||
| Prescribe a moderate-intensity statin for patients 40 to 75 years of age with HIV and 10-year ASCVD risk scores between 5% and less than 20%, with a high-intensity statin recommended for those at higher risk.41,42 | B | Large international randomized, double-blinded trial and guidelines from Panel on Antiretroviral Guidelines for Adults and Adolescents |
| Adults with HIV infection should receive standard age-appropriate vaccinations plus hepatitis A and B (if not immune), meningococcal, pneumococcal, and herpes zoster vaccines.43 | C | Advisory Committee on Immunization Practices guidelines |
| Cervical cancer screening should be continued after age 65 years for patients with HIV.46 | C | Expert opinion from the CDC, HIVMA, and NIH |
| All patients with HIV should be screened for anal cancer, with screening modality and interval adjusted based on age, risk factors, and availability of more specific follow-up testing. Anal Pap screening is preferred if referral for HRA is available for MSM and transgender women starting at age 35.46 | B | NIH/HIVMA/Infectious Diseases Society of America guidelines |
APHL = Association of Public Health Laboratories; ASCVD = atherosclerotic cardiovascular disease; CDC = Centers for Disease Control and Prevention; HIVMA = HIV Medicine Association; HRA = high-resolution anoscopy; MSM = men who have sex with men; NIH = National Institutes of Health; Pap = Papanicolaou; PEP = postexposure prophylaxis; PrEP = preexposure prophylaxis; STI = sexually transmitted infection; USPSTF = US Preventive Services Task Force.
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.
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