ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Primary care of adults with HIV

Primary care of adults with HIV
Literature review current through: Aug 2023.
This topic last updated: Jun 23, 2023.

INTRODUCTION — Over the past two and a half decades, antiretroviral therapy (ART) has radically altered the natural history of HIV infection [1]. Opportunistic diseases have become less common, and mortality has declined such that most treated patients with HIV now have a near-normal life expectancy [2-4]. Most deaths in patients with HIV receiving ART are now related to conditions other than AIDS [5,6]. HIV infection appears to increase the risk of non-AIDS-related conditions, including cardiovascular disease, renal disease, liver disease, and malignancies [7]. These and other common age-related diseases may occur more frequently and at a younger age than in uninfected persons [8,9]. In addition, a variety of long-term complications mostly associated with older antiretroviral drugs has been described.

The emergence of non-AIDS-related conditions highlights the important role of the primary care clinician. Based on experience from other chronic medical conditions, general practitioners are well suited to oversee and coordinate a multidisciplinary approach to HIV care. One survey of 102 internal medicine physicians and 75 infectious diseases specialists found that generalists with extensive experience in HIV management provided high-quality care to these complex patients [10]. In the United States, there will be a future need for increased involvement of primary practitioners in HIV care given the growing prevalence of persons living with HIV [11].

The role of the primary clinician in the care of the adult with HIV will be discussed here, with particular attention to clinical monitoring and health care maintenance. The initial evaluation of the adult with HIV is addressed elsewhere. (See "Initial evaluation of adults with HIV".)

GUIDELINES — In the United States, the HIV Medicine Association of the Infectious Diseases Society of America has published guidelines on the primary care of individuals with HIV, which were last updated in 2020 [12]. The recommendations provided in this topic are generally consistent with these guidelines.

Links to recommendations by other expert groups, including the European AIDS Clinical Society [13], can be found in the society guideline links topic. (See 'Society guideline links' below.)

INITIAL EVALUATION — The initial evaluation of a patient with HIV includes assessment of disease stage and evaluation for comorbidities, prior exposures, and risk factors in order to inform appropriate management. This issue is discussed in detail elsewhere. (See "Initial evaluation of adults with HIV".)

Primary care clinicians need to understand that HIV-related stigma is common and associated with lost follow up, worse health outcomes, and lower quality of life [14]. It is important that all clinic staff communicate in a nonjudgmental manner, use preferred words and phrases, and avoid stigmatizing language in order to increase patient comfort and build positive rapport.

FREQUENCY OF CLINICAL EVALUATION — The appropriate frequency of medical visits for an adult with HIV depends on many factors, including the stage of HIV infection, the use of antiretroviral therapy (ART), and the presence of other medical or social comorbidities and complications. As an example, frequent visits may be appropriate for patients who are recently diagnosed or newly linked to care. Frequent visits are also warranted after the initiation of ART to evaluate efficacy and tolerability. However, once the viral load has been suppressed and the CD4 cell count has normalized, less frequent monitoring is appropriate [15]. (See "Patient monitoring during HIV antiretroviral therapy".)

MANAGEMENT OF ANTIRETROVIRAL THERAPY — The goals of antiretroviral therapy (ART) are to prolong life and improve its quality, restore and preserve immunologic function (as measured by CD4 count), maximally and durably suppress the HIV viral load, and prevent HIV transmission [15]. Although cure of HIV infection is not achievable with current management approaches, ART has resulted in significant reductions in HIV-related morbidity and mortality. Such benefits have been reported even in patients with normal CD4 cell counts [16]. Thus, initiation of ART for all patients with HIV, regardless of CD4 cell count, is recommended [15,17].

Initiation, management, and monitoring the efficacy of ART are fundamental components in the care of the adult with HIV. Detailed discussion of these issues is found elsewhere:

(See "When to initiate antiretroviral therapy in persons with HIV".)

(See "Selecting antiretroviral regimens for treatment-naïve persons with HIV-1: General approach".)

(See "Selecting an antiretroviral regimen for treatment-experienced patients with HIV who are failing therapy".)

(See "Patient monitoring during HIV antiretroviral therapy".)

MONITORING FOR COMPLICATIONS AND PREVENTIVE CARE — Among patients with HIV who are receiving effective antiretroviral therapy (ART), most deaths are now related to conditions other than AIDS [5,6]. Patients with HIV appear to have a higher risk of certain medical conditions, including metabolic complications and some malignancies, compared with the general population. These may be associated with HIV infection itself, risk factors prevalent in populations with HIV, or the use of ART. Optimal care of the patient with HIV requires knowledge about and evaluation for such potential complications (table 1).

Routine preventive care is also important in the care of patients with HIV. Data from a large cohort collaborative, the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD), suggested that traditional risk factors (eg, smoking, hypertension) contributed more to the risk of myocardial infarction, non-AIDS-defining cancers, end-stage liver disease, and end-stage kidney disease than HIV-related risk factors (eg, CD4 count or HIV RNA level) [18]. The analysis also suggested that primary prevention of traditional risk factors alone could decrease development of a large proportion of these diseases.

Preventive care in the general population is outlined elsewhere (see "Overview of preventive care in adults"). The following subsections outline specific complications prevalent among populations with HIV.

Hematologic, renal, and hepatic toxicity — HIV has been associated with abnormalities of bone marrow, kidney, and liver function, either directly or secondary to comorbid conditions. Evaluation for such underlying abnormalities should be done at the initial presentation. (See "Initial evaluation of adults with HIV", section on 'General blood and urine testing'.)

For patients who have not yet initiated ART, routine monitoring for these abnormalities is warranted, for example with a complete blood count (CBC) with differential every three to six months and a chemistry panel including blood urea nitrogen (BUN) and creatinine, serum transaminases, and bilirubin level every 6 to 12 months [15].

For patients who are on ART, monitoring is generally more frequent, particularly when ART is initiated, because of the potential for drug-associated toxicity. Specifically, in the United States, the Department of Health and Human Services recommends routine performance of the following basic laboratory tests [15]:

CBC with differential every three to six months when monitoring CD4 count and every year once the CD4 count is no longer monitored. (See "Patient monitoring during HIV antiretroviral therapy", section on 'CD4 count'.)

Basic chemistry, including BUN and creatinine, four to eight weeks following ART initiation and every six months thereafter.

Urinalysis following ART initiation or change and every 12 months thereafter (or every six months while on a tenofovir disoproxil fumarate [TDF]-containing regimen).

Alanine and aspartate aminotransferases and total bilirubin four to eight weeks following ART initiation and every six months thereafter.

More frequent monitoring may be warranted in patients who have baseline abnormalities in hepatic, renal, and bone marrow function and with the use of certain agents. (See "Patient monitoring during HIV antiretroviral therapy", section on 'ART-associated toxicity'.)

Cardiovascular disease — With more effective and widespread treatment of HIV, cardiovascular disease has emerged as an important cause of death in patients with HIV relative to the decreasing incidence of opportunistic infections [7,19]. The degree to which HIV infection itself, traditional cardiovascular risk factors, and ART (eg, protease inhibitors, abacavir) each contribute to the increased risk of cardiovascular disease in the population with HIV is unknown. It is of paramount importance that clinicians identify and initiate appropriate preventive interventions for cardiovascular risk factors in patients with HIV. Assessment and management of cardiovascular risk and disease in adults with HIV are discussed elsewhere. (See "Management of cardiovascular risk (including dyslipidemia) in patients with HIV" and "Epidemiology of cardiovascular disease and risk factors in patients with HIV".)

Dyslipidemia — Studies have consistently shown a high prevalence of dyslipidemia among patients with HIV, with and without ART. Certain agents, such as earlier generation protease inhibitors, have been associated with a greater risk of unfavorable lipid changes. Thus, patients with HIV should undergo lipid testing routinely throughout care (table 1) [12,20,21].

Management of dyslipidemia consists of lifestyle modification, consideration of switching to a more "lipid-friendly" ART regimen if appropriate, and pharmacologic treatment with statins when appropriate for cardiovascular risk reduction. Standard cardiovascular risk calculators do not incorporate the presence of HIV infection. When starting lipid-lowering agents, it is important to be aware of potential drug-drug interactions. Depending upon the ART regimen, some drugs are contraindicated, and others should be administered in lower dosages initially with monitoring for drug toxicity. The use of lipid-lowering agents in persons with HIV is discussed in detail in a separate topic review. (See "Epidemiology of cardiovascular disease and risk factors in patients with HIV" and "Management of cardiovascular risk (including dyslipidemia) in patients with HIV".)

Glucose intolerance/diabetes mellitus — Glucose intolerance/diabetes mellitus is another important toxicity associated with ART, especially with earlier generation protease inhibitors. Thus, patients with HIV should be screened for diabetes mellitus at baseline and after initiation of ART.

We agree with expert groups in the United States that recommend a blood glucose and/or glycated hemoglobin (A1C) at baseline before starting ART. After ART has been initiated, serum glucose should be used to screen for diabetes mellitus annually [12,15,20]. Some experts also check glucose within one to three months of starting a new regimen [12]. Glycated hemoglobin should not be routinely used to diagnose diabetes mellitus after ART has been initiated as HbA1c may underestimate glycemia in patients with HIV. Fasting glucose >125 mg/dL or abnormal glucose tolerance test can be used as alternatives in this setting.

Management of glucose intolerance/diabetes mellitus includes weight loss through diet and exercise and pharmacologic treatment with oral hypoglycemic drugs and/or insulin as needed. (See "Epidemiology of cardiovascular disease and risk factors in patients with HIV", section on 'Insulin resistance and diabetes mellitus' and "Management of cardiovascular risk (including dyslipidemia) in patients with HIV", section on 'Recognizing and managing diabetes mellitus'.)

Hypertension — Patients with HIV may have higher rates of hypertension compared with uninfected patients [22,23]. A blood pressure check should be performed at least annually [12]. Definition and management of hypertension in the patient with HIV are the same as those for the general population. These issues are discussed in detail elsewhere. (See "Overview of hypertension in adults" and "Epidemiology of cardiovascular disease and risk factors in patients with HIV", section on 'Hypertension'.)

Tobacco use — Smoking is common in patients with HIV and a major contributor to cardiovascular and lung cancer risk. One study from Denmark suggested that smokers with HIV lose more life-years to smoking than to HIV [24]. Another study suggested that smokers with HIV who are taking ART are much more likely to die from lung cancer than from AIDS-related conditions [25]. All patients with HIV should be evaluated for ongoing cigarette smoking, and those who smoke should be advised of the benefits of quitting. Smoking cessation may be more difficult to achieve in this population [26]. (See "Management of cardiovascular risk (including dyslipidemia) in patients with HIV", section on 'Smoking cessation'.)

Chronic lung disease — Chronic obstructive pulmonary disease, lung cancer, pulmonary hypertension, and pulmonary fibrosis appear to be more common in persons with HIV compared with uninfected controls [27]. Some of these findings are likely related to the increased prevalence of smoking in this population.

Premature bone loss — Osteopenia, osteoporosis, and fracture rate have been reported in higher frequency in patients with HIV compared with age- and sex-matched controls. Some studies have suggested a possible link between ART (specifically, TDF and protease inhibitors) and bone loss [28-30].

Although supporting data are limited, baseline bone densitometry screening for osteoporosis in patients with HIV is recommended in postmenopausal women and men aged 50 years of age or older [12]. For those who do not have osteoporosis at baseline, repeat testing is the same as for patients without HIV and dependent on the extent of bone density loss, if any. (See "Screening for osteoporosis in postmenopausal women and men", section on 'Follow-up to screening'.)

In patients with osteoporosis or other risk factors for premature bone loss, TDF should be avoided since tenofovir alafenamide (TAF) and abacavir are associated with smaller declines in bone mineral density [15]. In some patients, a two-drug regimen (eg, dolutegravir-lamivudine) may be reasonable. (See "Selecting antiretroviral regimens for treatment-naive persons with HIV-1: Patients with comorbid conditions", section on 'Osteoporosis' and "Switching antiretroviral therapy for adults with HIV-1 and a suppressed viral load", section on 'Eligibility for two-drug regimens'.)

Management of osteoporosis includes ruling out secondary causes (eg, hypogonadism, vitamin D deficiency, hyperparathyroidism, and thyroid disease), initiating lifestyle changes (eg, increased physical activity, smoking cessation), calcium and vitamin D supplementation, and bisphosphonate therapy. (See "Bone and calcium disorders in patients with HIV".)

Neuropsychiatric disorders — Both psychiatric conditions and neurocognitive problems are common among adults with HIV.

Clinicians should screen patients annually for depression and anxiety using validated instruments (eg, PHQ-9, GAD-7) and inquire about ongoing substance abuse. Aggressive treatment of psychiatric comorbidities is important for the successful management of HIV infection. However, clinicians should be aware that psychological symptoms may also be manifestations of HIV-associated neurocognitive disorder (HAND).

Certain antiretroviral drugs (eg, efavirenz and, occasionally, rilpivirine and integrase inhibitors) have been associated with adverse neuropsychiatric effects. Close monitoring is recommended for patients with pre-existing psychiatric disorders who are on these agents [15]. In some cases, the regimen may need to be changed. (See "Switching antiretroviral therapy for adults with HIV-1 and a suppressed viral load", section on 'Neuropsychiatric side effects'.)

Assessing for the presence of symptoms of neurocognitive impairment can be performed during a clinical visit to identify patients who may be affected by HAND. The Montreal Cognitive Assessment (MoCA) instrument appears useful in this population [31]. Those who have abnormalities on initial evaluation can be referred for more formal assessment. This issue is discussed in detail elsewhere. (See "HIV-associated neurocognitive disorders: Epidemiology, clinical manifestations, and diagnosis", section on 'Screening for deficits'.)

Cancer and precancerous lesions — Although the use of ART has been associated with decreases in the incidence of AIDS-defining malignancies, certain other malignancies may occur more frequently and present at an earlier age among patients with HIV compared with the general population. Data from observational studies have suggested that lung, hepatic, and anal cancers occur at younger ages in adults with HIV than in those without HIV [32]. (See "HIV infection and malignancy: Management considerations".)

Except for human papillomavirus (HPV)-associated neoplasia, formal recommendations for cancer screening are the same in patients with and without HIV. (See "Overview of preventive care in adults", section on 'Cancer screening'.)

Cervical cancer — All women with HIV should be screened for cervical cancer with a Pap test as part of the initial evaluation [33]. Women 30 years of age or older can be screened with Pap alone or Pap plus HPV testing. Detailed recommendations on cervical cancer screening are presented in a separate topic review. (See "Screening for cervical cancer in patients with HIV infection and other immunocompromised states".)

Screening intervals after normal tests depend on whether Pap alone or Pap plus HPV testing was used. Management in women with abnormal Pap tests is based on cytologic findings. Colposcopy is not recommended for screening. These issues are discussed in detail elsewhere. (See "Screening for cervical cancer in patients with HIV infection and other immunocompromised states" and "HIV and women", section on 'Screening and prevention'.)

Anal cancer — HIV infection is associated with an increased risk for anal neoplasia in men and women regardless of sexual orientation [34,35].

Indications for screening for anal intraepithelial abnormalities with anal Pap on initial evaluation of a patient with HIV are discussed elsewhere. (See "Anal squamous intraepithelial lesions: Epidemiology, clinical presentation, diagnosis, screening, prevention, and treatment", section on 'Who should be screened for anal SIL?' and "Initial evaluation of adults with HIV", section on 'Screening for HPV-associated neoplasia'.)

There are few data to inform an appropriate screening interval. In men who have sex with men (MSM) with HIV, annual screening appears cost-effective [36].

Other cancers — Age-appropriate screening for breast, colon, prostate, lung, and other cancers should be performed in patients with HIV according to recommendations used for the general population. (See "Overview of preventive care in adults", section on 'Cancer screening'.)

Sexually transmitted infections — Patients with HIV should be screened for other sexually transmitted infections (STIs) (eg, syphilis, Chlamydia trachomatis, Neisseria gonorrhoeae, and, in women, Trichomonas vaginalis) at the initial evaluation. This issue and methods for screening are discussed elsewhere. (See "Initial evaluation of adults with HIV", section on 'Sexually transmitted infections'.)

Discussion of sexual practices along with prevention counseling should be incorporated regularly into visits. In addition, periodic screening for STIs should be performed in persons at continued risk. As an example, annual screening for syphilis, C. trachomatis, N. gonorrhoeae, and, in persons having vaginal sex, Trichomonas, is recommended for all asymptomatic sexually active patients with HIV [12,37]. More frequent screening (eg, every three to six months) may be warranted for MSM with HIV who have multiple or anonymous partners, as well as in patients who exchange sex for money, drugs, or basic needs. (See "Screening for sexually transmitted infections", section on 'Patients with HIV infection'.)

Viral hepatitis — After screening for hepatitis A and B viruses on initial evaluation, vaccination should be administered to those who are not immune. (See "Immunizations in persons with HIV", section on 'Hepatitis A vaccine' and "Immunizations in persons with HIV", section on 'Hepatitis B vaccine'.)

Ongoing screening for hepatitis C virus (HCV) is warranted for certain patients with HIV whose initial screening for HCV was negative. Annual screening is recommended for people who inject drugs, as well as for MSM and transgender women with HIV, in whom there is accumulating evidence of sexual transmission [12,37]. More frequent screening may be warranted depending on risk factors and potential for HCV exposure. HCV screening is performed with an HCV antibody test. HCV RNA testing may be useful in those with negative HCV antibody but a high suspicion for HCV infection (eg, recent HCV exposures or abnormal transaminases) because HCV antibody is not sensitive in acute infection and is falsely negative in some HIV/HCV coinfected individuals. HCV RNA screening to diagnose reinfection is also indicated in persons who have been successfully treated for HCV or who spontaneously cleared prior infection [15]. (See "Screening and diagnosis of chronic hepatitis C virus infection", section on 'HCV RNA assays'.)

Patients with detectable HCV RNA should be evaluated for HCV antiviral therapy. (See "Treatment of chronic hepatitis C virus infection in the patient with HIV".)

Tuberculosis — Patients with HIV should be screened for latent tuberculosis with tuberculin skin testing or an interferon gamma release assay at initial presentation. (See "Initial evaluation of adults with HIV", section on 'Tuberculosis'.)

Subsequently, for those who tested negative, further screening is warranted annually when there are ongoing risk factors for tuberculosis (eg, incarceration, living in communal settings, active drug use). Additionally, for patients who initially tested negative in the setting of a CD4 cell count <200 cells/microL, repeat testing should be performed once the CD4 cell count has increased above this threshold because of the possibility of false-negative results in the setting of immunosuppression. Testing should not be repeated in patients who have previously had a positive test.

The diagnosis and treatment of latent tuberculosis is discussed in detail elsewhere. (See "Treatment of tuberculosis infection (latent tuberculosis) in nonpregnant adults with HIV infection" and "Tuberculosis infection (latent tuberculosis) in adults: Approach to diagnosis (screening)".)

Weight gain — Many patients gain weight following initiation of ART. Patients on ART should be counseled about the potential for weight gain and the importance of healthy eating and exercise.

A few patients gain substantial weight (more than 10 percent of baseline body weight), primarily in the first one to two years after treatment initiation or switching to a new regimen. For such patients, a change in regimen can be considered, although it is unclear if this change will lead to reversal of the weight gain. (See "Switching antiretroviral therapy for adults with HIV-1 and a suppressed viral load", section on 'Weight gain'.)

The cause of weight gain is likely multifactorial, with some weight gain attributable to improved health following HIV viral suppression. However, some antiretroviral drugs have been associated with weight gain. As an example, integrase inhibitors are associated with more weight gain than protease inhibitors or non-nucleoside reverse transcriptase inhibitors (NNRTIs), and TAF is associated with more weight gain than TDF, abacavir, or zidovudine [38].

Less common HIV-specific toxicities — Older antiretroviral agents that are now rarely used have traditionally been associated with certain toxicities that required special attention, such as peripheral neuropathy, lipodystrophy, and lactic acidosis. With the use of newer agents, these toxicities are less frequently encountered but may still be relevant for certain patients who have had substantial exposure to older drugs. Additionally, some of these abnormalities have also been associated with HIV infection itself, regardless of antiretroviral regimen, or other common comorbidities. More detailed information on these rare toxicities is found in separate topic reviews. (See "Epidemiology, clinical manifestations, diagnosis, and treatment of HIV-associated distal symmetric polyneuropathy (HIV-DSPN)" and "Epidemiology, clinical manifestations, and diagnosis of HIV-associated lipodystrophy" and "Treatment of HIV-associated lipodystrophy" and "Mitochondrial toxicity of HIV nucleoside reverse transcriptase inhibitors".)

IMMUNIZATIONS — Immunizations are an important part of preventive care for patients with HIV (figure 1). Inactivated vaccines are generally safe and acceptable in individuals with HIV. Certain live vaccines have sufficient safety data and are thus appropriate if indicated for individuals with HIV and CD4 cell counts >200 cells/microL. HIV infection is an indication for certain vaccines that might not otherwise be given routinely, and the recommendations on formulations, dosing, or schedules for specific immunizations may differ from those for the general population in an effort to optimize the vaccine response and because of different risks. These issues are discussed in detail elsewhere. (See "Immunizations in persons with HIV".)

CONSIDERATIONS FOR SPECIFIC POPULATIONS

Patients with low CD4 cell counts — Risk for opportunistic infections can be stratified by CD4 cell count; thus additional consideration about the presence and prevention of opportunistic infections is needed for patients with CD4 cell counts <200 cells/microL. Clinicians should have heightened suspicion of symptoms or signs which might be suggestive of an opportunistic infection in this population. We generally see patients with low CD4 cell counts at least every three months.

Patients with HIV viral suppression but persistent low CD4 cell counts (<200 cells/microL) appear to have increased long-term mortality compared with those who have achieved CD4 cell count >200 cells/microL [39]. However, the risk of opportunistic infections is low in people with sustained viral suppression even if the CD4 cell count remains low [40-42].

Prophylactic antibiotics for primary prevention of opportunistic infections are given to patients with CD4 cell counts <200 cells/microL. Antimicrobials may also be continued for secondary prevention in patients who have had certain opportunistic infections. Complete information on dosing regimens and alternative therapeutic agents is discussed elsewhere. (See "Overview of prevention of opportunistic infections in patients with HIV" and "Mycobacterium avium complex (MAC) infections in persons with HIV", section on 'Prevention of MAC disease' and "Treatment and prevention of Pneumocystis infection in patients with HIV".)

Additionally, for severely immunocompromised patients with CD4 cell counts <50 cells/microL, routine funduscopic examination (eg, every 12 months) is reasonable to evaluate for cytomegalovirus retinitis or other complications. However, the clinical benefit of this practice in asymptomatic patients has not been established.

Men who have sex with men — Men who have sex with men (MSM) represent about 4 percent of the male population in the United States, but account for nearly two-thirds (63 percent) of all new HIV infections each year and more than half (52 percent) of people living with HIV [43]. MSM is the only group in the United States. in which new HIV infections have been increasing since the early 1990s [44], and African American and Latino MSM are disproportionally affected [45].

Care of the MSM with HIV, therefore, requires particular attention to HIV prevention messages and risk reduction counseling. Because of increased risk, screening for anal cancer, sexually transmitted infections (STIs), and hepatitis C virus (HCV) is particularly important for MSM. (See 'Anal cancer' above and 'Sexually transmitted infections' above and 'Viral hepatitis' above.)

In addition, clinicians should inquire about methamphetamines and other "club drugs," as their use has been associated with high-risk sexual behaviors [46]. Particular attention should also be given to issues of alcohol and tobacco use, psychological health, domestic violence, and stigma [47]. (See "Primary care of gay men and men who have sex with men".)

Women — Primary care women with HIV requires special attention to issues such as sex-specific drug toxicities, contraception, and family planning. This issue is discussed in detail elsewhere. (See "HIV and women", section on 'Choice of contraception'.)

Older adults — The prevalence and incidence of HIV in patients over the age of 50 is increasing because of the success of potent antiretroviral therapy (ART), as well as the occurrence of new primary infections. Treatment of HIV in this population is as effective as in younger patients but often complicated by comorbidities and an increased potential for drug toxicity and drug-drug interactions. Given the evidence that HIV infection may increase the risk of cardiovascular disease, non-AIDS-related malignancies, and metabolic bone disease, it is important to ensure that cancer screening and other health maintenance issues are kept up to date in older patients [48]. Polypharmacy and drug–drug interactions become more common in older adults living with HIV [49,50]. Inclusion of pharmacists with HIV expertise in the care team may be useful in this setting. (See "HIV infection in older adults".)

Long-term nonprogressors — Some patients with long-standing HIV who are not on ART do not develop clinical progression and have stable CD4 cell counts and low levels of detectable viremia; a subset of these patients are referred to as "elite controllers" because they have no detectable viremia (eg, the viral load is <20 to 50 copies/mL on commercial assays). (See "The natural history and clinical features of HIV infection in adults and adolescents", section on 'HIV controllers'.)

The risks and benefits of ART should be discussed with all long-term nonprogressors. Despite lower levels of viral replication, long-term nonprogressors, including elite controllers, remain at increased risk for noninfectious complications of HIV, such as cardiovascular disease, compared with the uninfected population [51-54]. This is discussed in a separate topic review. (See "When to initiate antiretroviral therapy in persons with HIV", section on 'HIV controllers'.)

OTHER PRIMARY CARE ISSUES

Behavioral risk reduction counseling — Behavioral risk reduction counseling is an important part of the management of patients with HIV. At each visit, practitioners should review the patient's understanding of HIV transmission and his/her sexual and drug-use activities. The discussion should focus on risk reduction interventions tailored to the individual's behaviors. Viral load suppression with antiretroviral therapy substantially reduces the risk of transmission [55,56]. (See "When to initiate antiretroviral therapy in persons with HIV", section on 'Universal treatment'.)

Patients should be informed that people living with HIV on antiretroviral therapy (ART) who have a stable, undetectable viral load have no risk of transmitting HIV to their uninfected sexual partners (undetectable = untransmittable [U = U]) [57]. Recognition of "U = U" can reduce stigma and increase motivation to become virally suppressed. (See "HIV infection: Risk factors and prevention strategies", section on 'Individuals living with HIV'.)

Patients should be advised to limit their number of sexual partners, engage in lower-risk sexual activities, and use latex condoms consistently during sexual intercourse to reduce the risk of acquiring new sexually transmitted infections (STIs). Additionally, they should be counseled regarding the potential for superinfection with a second strain of HIV that may be more resistant to treatment.

Patients who use injection drugs should be counseled about the risks of continued use, including acquisition of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, a drug-resistant HIV strain, and other bloodborne pathogens. Patients should be advised to enter a substance abuse treatment program. Opiate substitution therapy has been associated with improved antiretroviral uptake and adherence and viral suppression [58]. Those who continue to inject drugs should be counseled not to reuse or share needles, syringes, or other drug preparation equipment. Education about overdose and the importance of having access to naloxone at home should be provided. (See "Primary care management of adults with opioid use disorder".)

Patients should be strongly encouraged to disclose their serostatus to all sexual and needle-sharing partners; in the United States, recommendations and/or regulations on this issue vary among states. Providers can notify the local health department of individuals at risk for infection so that they can be contacted and tested.

Food safety — Patients with HIV, particularly those with low CD4 counts, should be advised to avoid eating raw eggs, unpasteurized dairy products, raw seafood, and undercooked meat. Care should be taken not to allow uncooked meat or poultry to come into contact with other foods. Hands, cutting boards, counters, and knives and other utensils should be washed thoroughly after contact with uncooked meat or poultry. Patients should not drink water directly from lakes, rivers, or other untested sources.

More information is available at the US Food and Drug Administration website.

Pet safety — Patients with HIV and CD4 cell counts <200 cells/microL should take precautions regarding contact with certain animals that are associated with infections that may be problematic in the setting of HIV infection.

Primary infection with Toxoplasma gondii occurs after eating undercooked meat containing tissue cysts or ingesting oocysts that have been shed in cat feces. However, most cases of Toxoplasma encephalitis occur due to reactivation of latent disease in a severely immunosuppressed host. The minority of patients who are Toxoplasma seronegative should be counseled to avoid eating undercooked meats (eg, lamb, beef, pork) and to use gloves or use hand hygiene when cleaning cat litter boxes. (See "Toxoplasmosis in patients with HIV".)

The risk of Bartonella infection has been associated with a history of cat exposure or ownership. Cat scratches and bites should be avoided if possible, and any scratch or bite sites should be washed immediately. Patients who wish to obtain a new cat should be advised to adopt or purchase an animal that is more than one year old and in good health. (See "Bartonella infections in people with HIV" and "Zoonoses: Cats".)

Contact with reptiles should be avoided to reduce the risk of salmonellosis. (See "Zoonoses: Animals other than dogs and cats".)

For patients with fish, gloves should be worn while cleaning the aquarium to reduce the risk of Mycobacterium marinum infection. (See "Zoonoses: Animals other than dogs and cats".)

Travel safety — Patients with HIV should discuss travel plans with their health care practitioners in advance. Travel to resource-limited countries may carry substantial infectious risk, especially for those with advanced immune dysfunction. In addition, ensuring that their supply of antiretroviral therapy (ART) will last them through the trip is an important step to prevent interruptions in therapy.

Patients should be advised to avoid tap water, ice made with tap water, raw fruits and vegetables, raw or undercooked seafood or meat, unpasteurized milk and dairy products, and foods and beverages from street vendors.

Antimicrobial prophylaxis for traveler's diarrhea is not recommended, but patients should be given appropriate antibiotics (eg, azithromycin or a fluoroquinolone, depending upon local resistance patterns) to have with them in case they develop it. (See "Travelers' diarrhea: Treatment and prevention", section on 'Limited role for antibiotics'.)

Travelers should also be advised about the need for other preventive measures, such as malaria prophylaxis or specific vaccinations, when indicated. (See "Travel advice" and "Immunizations for travel".)

Clinical trials — Patients should be offered participation in clinical trials when optimal management is unknown. Information about HIV clinical trials can be found at the DHHS website.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Immunizations in patients with HIV" and "Society guideline links: Primary care of adults with HIV".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: HIV/AIDS (The Basics)" and "Patient education: Starting treatment for HIV (The Basics)" and "Patient education: Tests to monitor HIV (The Basics)")

Beyond the Basics topics (see "Patient education: Testing for HIV (Beyond the Basics)" and "Patient education: Initial treatment of HIV (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Frequency of visits – The appropriate frequency of medical visits for an adult with HIV depends on many factors, including the stage of HIV infection, the use of antiretroviral therapy (ART), and the presence of other medical or social comorbidities and complications. Frequent visits may be appropriate for patients who are recently diagnosed or newly linked to care or for those with advanced HIV, whereas individuals who are stable on ART can be monitored less frequently. Discussion of the initiation, management, and monitoring ART efficacy is found elsewhere. (See 'Frequency of clinical evaluation' above and 'Management of antiretroviral therapy' above.)

Monitoring response to antiretroviral therapy – Monitoring the efficacy of ART is fundamental in the care of the adult with HIV. This is discussed in detail in a separate topic review. (See "Patient monitoring during HIV antiretroviral therapy".)

Monitoring and managing other conditions – Patients with HIV appear to have a higher risk of certain medical conditions compared to the general population. These include cardiovascular disease, dyslipidemia, diabetes mellitus, hypertension, tobacco use, premature bone loss, neuropsychiatric disorders, certain malignancies (eg, lung, hepatic, anal, and cervical cancers), and coinfections (eg, sexually transmitted infections [STIs], viral hepatitis, tuberculosis). Some of these may be associated with HIV infection itself, risk factors prevalent in populations with HIV, and/or the use of ART. Optimal care of the patient with HIV requires knowledge about and evaluation for such potential complications (table 1). (See 'Monitoring for complications and preventive care' above.)

Immunizations – Immunizations are an important part of preventive care for patients with HIV (figure 1). Inactivated vaccines are generally safe and acceptable in individuals with HIV. Certain live vaccines have sufficient safety data and are thus appropriate if indicated for individuals with HIV and CD4 cell counts >200 cells/microL. (See "Immunizations in persons with HIV".)

Patient counseling – Behavioral risk reduction counseling is an important part of the management of patients with HIV. At each visit, practitioners should review the patient's understanding of HIV transmission and his/her sexual and drug-use activities. Other relevant counseling issues for patients with HIV may include food, pet, and travel safety. (See 'Other primary care issues' above.)

  1. Bhaskaran K, Hamouda O, Sannes M, et al. Changes in the risk of death after HIV seroconversion compared with mortality in the general population. JAMA 2008; 300:51.
  2. Samji H, Cescon A, Hogg RS, et al. Closing the gap: increases in life expectancy among treated HIV-positive individuals in the United States and Canada. PLoS One 2013; 8:e81355.
  3. Antiretroviral Therapy Cohort Collaboration, Zwahlen M, Harris R, et al. Mortality of HIV-infected patients starting potent antiretroviral therapy: comparison with the general population in nine industrialized countries. Int J Epidemiol 2009; 38:1624.
  4. Wandeler G, Johnson LF, Egger M. Trends in life expectancy of HIV-positive adults on antiretroviral therapy across the globe: comparisons with general population. Curr Opin HIV AIDS 2016; 11:492.
  5. Smith CJ, Ryom L, Weber R, et al. Trends in underlying causes of death in people with HIV from 1999 to 2011 (D:A:D): a multicohort collaboration. Lancet 2014; 384:241.
  6. Burchell AN, Raboud J, Donelle J, et al. Cause-specific mortality among HIV-infected people in Ontario, 1995-2014: a population-based retrospective cohort study. CMAJ Open 2019; 7:E1.
  7. Neuhaus J, Angus B, Kowalska JD, et al. Risk of all-cause mortality associated with nonfatal AIDS and serious non-AIDS events among adults infected with HIV. AIDS 2010; 24:697.
  8. Guaraldi G, Orlando G, Zona S, et al. Premature age-related comorbidities among HIV-infected persons compared with the general population. Clin Infect Dis 2011; 53:1120.
  9. Schouten J, Wit FW, Stolte IG, et al. Cross-sectional comparison of the prevalence of age-associated comorbidities and their risk factors between HIV-infected and uninfected individuals: the AGEhIV cohort study. Clin Infect Dis 2014; 59:1787.
  10. Landon BE, Wilson IB, McInnes K, et al. Physician specialization and the quality of care for human immunodeficiency virus infection. Arch Intern Med 2005; 165:1133.
  11. Institute of Medicine. HIV screening and access to care: Health care system capacity for increased HIV testing and provision of care. Washington, DC: The National Academies Press, 2011.
  12. Thompson MA, Horberg MA, Agwu AL, et al. Primary Care Guidance for Persons With Human Immunodeficiency Virus: 2020 Update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 2021; 73:e3572.
  13. European AIDS Clinical Society Guidelines. Updated yearly. http://www.eacsociety.org/Guidelines.aspx.
  14. 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:e011453.
  15. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf (Accessed on March 01, 2020).
  16. INSIGHT START Study Group, Lundgren JD, Babiker AG, et al. Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection. N Engl J Med 2015; 373:795.
  17. Gandhi RT, Bedimo R, Hoy JF, et al. Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2022 Recommendations of the International Antiviral Society-USA Panel. JAMA 2023; 329:63.
  18. Althoff KN, Gebo KA, Moore RD, et al. Contributions of traditional and HIV-related risk factors on non-AIDS-defining cancer, myocardial infarction, and end-stage liver and renal diseases in adults with HIV in the USA and Canada: a collaboration of cohort studies. Lancet HIV 2019; 6:e93.
  19. Antiretroviral Therapy Cohort Collaboration. Causes of death in HIV-1-infected patients treated with antiretroviral therapy, 1996-2006: collaborative analysis of 13 HIV cohort studies. Clin Infect Dis 2010; 50:1387.
  20. Schambelan M, Benson CA, Carr A, et al. Management of metabolic complications associated with antiretroviral therapy for HIV-1 infection: recommendations of an International AIDS Society-USA panel. J Acquir Immune Defic Syndr 2002; 31:257.
  21. Dubé MP, Stein JH, Aberg JA, et al. Guidelines for the evaluation and management of dyslipidemia in human immunodeficiency virus (HIV)-infected adults receiving antiretroviral therapy: recommendations of the HIV Medical Association of the Infectious Disease Society of America and the Adult AIDS Clinical Trials Group. Clin Infect Dis 2003; 37:613.
  22. Triant VA, Lee H, Hadigan C, Grinspoon SK. Increased acute myocardial infarction rates and cardiovascular risk factors among patients with human immunodeficiency virus disease. J Clin Endocrinol Metab 2007; 92:2506.
  23. Seaberg EC, Muñoz A, Lu M, et al. Association between highly active antiretroviral therapy and hypertension in a large cohort of men followed from 1984 to 2003. AIDS 2005; 19:953.
  24. Helleberg M, Afzal S, Kronborg G, et al. Mortality attributable to smoking among HIV-1-infected individuals: a nationwide, population-based cohort study. Clin Infect Dis 2013; 56:727.
  25. Reddy KP, Kong CY, Hyle EP, et al. Lung Cancer Mortality Associated With Smoking and Smoking Cessation Among People Living With HIV in the United States. JAMA Intern Med 2017; 177:1613.
  26. Mdodo R, Frazier EL, Dube SR, et al. Cigarette smoking prevalence among adults with HIV compared with the general adult population in the United States: cross-sectional surveys. Ann Intern Med 2015; 162:335.
  27. Crothers K, Huang L, Goulet JL, et al. HIV infection and risk for incident pulmonary diseases in the combination antiretroviral therapy era. Am J Respir Crit Care Med 2011; 183:388.
  28. Fernández-Rivera J, García R, Lozano F, et al. Relationship between low bone mineral density and highly active antiretroviral therapy including protease inhibitors in HIV-infected patients. HIV Clin Trials 2003; 4:337.
  29. Bedimo R, Maalouf NM, Zhang S, et al. Osteoporotic fracture risk associated with cumulative exposure to tenofovir and other antiretroviral agents. AIDS 2012; 26:825.
  30. Cazanave C, Dupon M, Lavignolle-Aurillac V, et al. Reduced bone mineral density in HIV-infected patients: prevalence and associated factors. AIDS 2008; 22:395.
  31. Rosca EC, Albarqouni L, Simu M. Montreal Cognitive Assessment (MoCA) for HIV-Associated Neurocognitive Disorders. Neuropsychol Rev 2019; 29:313.
  32. Shiels MS, Pfeiffer RM, Engels EA. Age at cancer diagnosis among persons with AIDS in the United States. Ann Intern Med 2010; 153:452.
  33. Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV. https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/whats-new (Accessed on February 10, 2023).
  34. Piketty C, Selinger-Leneman H, Grabar S, et al. Marked increase in the incidence of invasive anal cancer among HIV-infected patients despite treatment with combination antiretroviral therapy. AIDS 2008; 22:1203.
  35. Williams AB, Darragh TM, Vranizan K, et al. Anal and cervical human papillomavirus infection and risk of anal and cervical epithelial abnormalities in human immunodeficiency virus-infected women. Obstet Gynecol 1994; 83:205.
  36. Goldie SJ, Kuntz KM, Weinstein MC, et al. The clinical effectiveness and cost-effectiveness of screening for anal squamous intraepithelial lesions in homosexual and bisexual HIV-positive men. JAMA 1999; 281:1822.
  37. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021; 70:1.
  38. Sax PE, Erlandson KM, Lake JE, et al. Weight Gain Following Initiation of Antiretroviral Therapy: Risk Factors in Randomized Comparative Clinical Trials. Clin Infect Dis 2020; 71:1379.
  39. Engsig FN, Zangerle R, Katsarou O, et al. Long-term mortality in HIV-positive individuals virally suppressed for >3 years with incomplete CD4 recovery. Clin Infect Dis 2014; 58:1312.
  40. Opportunistic Infections Project Team of the Collaboration of Observational HIV Epidemiological Research in Europe (COHERE), Mocroft A, Reiss P, et al. Is it safe to discontinue primary Pneumocystis jiroveci pneumonia prophylaxis in patients with virologically suppressed HIV infection and a CD4 cell count <200 cells/microL? Clin Infect Dis 2010; 51:611.
  41. D'Egidio GE, Kravcik S, Cooper CL, et al. Pneumocystis jiroveci pneumonia prophylaxis is not required with a CD4+ T-cell count < 200 cells/microl when viral replication is suppressed. AIDS 2007; 21:1711.
  42. Miro J, Esteve A, Furror H, et al. Safety of stopping primary T. gondii prophylaxis with suppressed viremia and CD4>100/mm3. CROI 2016, Boston, Massachusetts. http://www.croiconference.org/sites/default/files/posters-2016/765.pdf (Accessed on January 29, 2019).
  43. Centers for Disease Control and Prevention. Estimated HIV incidence in the United States, 2007–2010. HIV Surveillance Supplemental Report 2012;17(No. 4). Published December 2012 http://www.cdc.gov/hiv/topics/surveillance/resources/reports/#supplemental (Accessed on January 08, 2015).
  44. Centers for Disease Control and Prevention (CDC). HIV prevalence estimates--United States, 2006. MMWR Morb Mortal Wkly Rep 2008; 57:1073.
  45. Hess K, Hu X, Lansky A, Mermin J, Hall HI. Estimating the lifetime risk of a diagnosis of HIV infection in the United States. Conference on Retroviruses and Opportunistic Infections (CROI), February 22-25, 2016, Boston. Abstract 52.
  46. Frosch D, Shoptaw S, Huber A, et al. Sexual HIV risk among gay and bisexual male methamphetamine abusers. J Subst Abuse Treat 1996; 13:483.
  47. Makadon HJ, Mayer KH, Garofalo R. Optimizing primary care for men who have sex with men. JAMA 2006; 296:2362.
  48. Libman H. Will You Still Treat Me When I'm 64? Care of the Older Adult With HIV Infection. Top Antivir Med 2015; 23:97.
  49. Marzolini C, Back D, Weber R, et al. Ageing with HIV: medication use and risk for potential drug-drug interactions. J Antimicrob Chemother 2011; 66:2107.
  50. Deutschmann E, Bucher HC, Jaeckel S, et al. Prevalence of Potential Drug-Drug Interactions in Patients of the Swiss HIV Cohort Study in the Era of HIV Integrase Inhibitors. Clin Infect Dis 2021; 73:e2145.
  51. Hsue PY, Hunt PW, Schnell A, et al. Role of viral replication, antiretroviral therapy, and immunodeficiency in HIV-associated atherosclerosis. AIDS 2009; 23:1059.
  52. Pereyra F, Lo J, Triant VA, et al. Increased coronary atherosclerosis and immune activation in HIV-1 elite controllers. AIDS 2012; 26:2409.
  53. Crowell TA, Gebo KA, Blankson JN, et al. HIV elite controllers are hospitalized more often than persons with medically controlled HIV. Presented at the 21st Conference on Retroviruses and Opportunistic Infections, Boston, MA, March 3-6, 2014. Abstract #108.
  54. Crowell TA, Gebo KA, Blankson JN, et al. Hospitalization Rates and Reasons Among HIV Elite Controllers and Persons With Medically Controlled HIV Infection. J Infect Dis 2015; 211:1692.
  55. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011; 365:493.
  56. Rodger AJ, Cambiano V, Bruun T, et al. Sexual Activity Without Condoms and Risk of HIV Transmission in Serodifferent Couples When the HIV-Positive Partner Is Using Suppressive Antiretroviral Therapy. JAMA 2016; 316:171.
  57. UNAIDS. Undetectable = Untransmittable: Public health and HIV viral load suppression. UNAIDS Explainer, 2018. http://www.unaids.org/sites/default/files/media_asset/undetectable-untransmittable_en.pdf (Accessed on August 17, 2018).
  58. Low AJ, Mburu G, Welton NJ, et al. Impact of Opioid Substitution Therapy on Antiretroviral Therapy Outcomes: A Systematic Review and Meta-Analysis. Clin Infect Dis 2016; 63:1094.
Topic 3745 Version 57.0

References

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟