For physicians of patients living with HIV, the emphasis on treatment is important, hence all the myriad treatment guidelines. However, primary care is equally as important, albeit sometimes overlooked. To provide a better sense of how to provide primary care for patients living with HIV, Judith Aberg, M.D., chair of the HIVMA/IDSA Primary Care Guidelines, provided a walk-through of the guidelines, along with two case studies. This walk-through was part of a presentation Aberg gave at IDWeek 2014.
The first patient is a 25-year-old male who was HIV negative just last year. Now that he knows he has HIV, he wants to start treatment quickly because his cousin died of AIDS-related complications many years ago. Aberg goes over what steps to take in this case, while providing additional information relevant to all patients.
Prognosis and Reassurance
Aberg emphasizes that having HIV is no longer "the end of the world," and that sitting down with someone and talking about the future is vital.
It is very important to remind patients that they "still have a full life ahead of them," Aberg says. A sub-analysis of the ATHENA cohort shows that someone who seroconverts at 25 today has almost the same life expectancy as someone without HIV.
While talking with patients for the first time, Aberg suggests a thorough medical history, including possible infection date, prior STIs (sexually transmitted infections), hepatitis, TB (tuberculosis) exposure, TST (tuberculin skin test) results, history of chicken pox or shingles, vaccinations status, and their travel history for possible exposure to endemic pathogens.
The physician should also get all pertinent history as with any primary care patient: family history of diabetes, cardiovascular history, malignancies, and social history, things like employment and occupational history, tobacco, alcohol, illicit drug use, sexual history, allergies, adverse reactions to medications, and medication history including alternative meds.
The physical exam should be thorough, including: a skin exam; a fundoscopic exam (schedule with an ophthalmologist if the patients' CD4+ cell count is below 50); checking the oropharynx; checking the lymph nodes (consider a biopsy if they are "dominant, focal node or of rapid enlargement"); an anogenital exam; a cervical pap smear; a rectal exam; an anal pap smear; as well as a prostate exam.
Moreover, although Kaposi's sarcoma (KS) should be looked for, much more common now is seborrheic dermatitis (dry skin that can be controlled by moisturizing regularly), according to Aberg. Pruritic papular eruption (PPE) of HIV can be reduced by antiretrovirals; however, be aware that rashes may be a sign of syphilis.
Varicella zoster virus (VZV), cytomegalovirus (CMV) and candidiasis may also occur, all of which require extra special care.
Harsh dental emergencies like oral hairy leukoplakia can happen, Aberg says, adding that some cases of gingivitis may require treatment with penicillin. Oral warts often arise upon starting treatment but will go away over time; however, they may transition to squamous cell carcinoma, so be thorough, Aberg advises.
Most of these tests are very routine, including: blood chemistry, liver function tests, BUN-to-creatinine ratio, lipid levels, glucose levels and urinalysis.
Screening Tests for Infection
Most of these tests are also routine, including: TST, interferon-gamma release assay (IGRA), STI screening and serologic testing for infections that can reactivate, like CMV. If a patient is negative and has a CD4+ cell count below 200, repeat TST and IGRA after immune reconstitution, Aberg says.
For HIV-positive patients, along with documenting CD4+ cell count and percentage, viral load and resistance tests should be conducted, and treatment should be started if needed. In addition, testing for hepatitis is especially important.