For women, administer a cervical pap smear, and again at six months, followed by every year if normal, Aberg says. If CD4+ cell counts are above 300, a pap smear can be done every three years.
Anal cytology is recommended for gay men, women with a history of receptive anal intercourse or abnormal cervical pap smears and all patients with a history of genital warts. If abnormal, administer a high-resolution anoscopy, along with a biopsy of visible lesions, Aberg says.
Lipid management is important for cardiovascular disease prevention. Good lipid management includes important drug interactions between statins and antiretroviral therapy, Aberg says. For the general population, statins should be started when LDL-C (low-density lipoprotein cholesterol) levels are above 190, in the presence of diabetes, or if there is a 7.5% or greater risk of atherosclerotic cardiovascular disease. However, how to apply the lipid guidelines to an HIV population is not clear, Aberg cautions.
Vaccines are recommended for the following: influenza; pneumococcus; hepatitis A; hepatitis B; tetanus; human papillomavirus (HPV) for those under 26 who do not have HPV; meningococcal disease, particularly for men who have sex with men (MSM); and VZV for those with CD4+ cell counts over 200.
For live vaccines, VZV vaccination is recommended for those older than 60 (although the U.S. Centers for Disease Control and Prevention recommends over 50) and measles, mumps, and rubella (MMR) vaccination for those with CD4+ cell counts over 200. Haemophilus influenzae type B (Hib) vaccine is no longer recommended.
A bone density scan is recommended in post-menopausal women and men over 50. A fasting blood glucose or glycated hemoglobin (HbA1c) test is also recommended (an HbA1c cutoff of 5.8% may improve sensitivity for diabetes diagnosis in those on antiretroviral therapy). For males with fatigue, weight loss, loss of libido, erectile dysfunction or reduced bone mineral density, measure free testosterone before 10 a.m.
For transgender people, hormone replacement therapy should happen under the care of a professional with transgender experience. The Center of Excellence for Transgender Health maintains the Transgender Health Learning Center as a resource to help primary care physicians care for their transgender patients.
Finally, Aberg discusses a second patient, a 66-year-old gay man, with gastroesophageal reflux disease (GERD) and allergies, who is on omeprazole (Prilosec) and fluticasone (Flonase). His blood pressure is 126/81 and his body mass index (BMI) is 31. His total cholesterol is 210, his LDL is 165 and his HDL (high-density lipoprotein) is 35.
His CD4+ cell count is 181 and his viral load is 178,000. He has no drug resistance based on genotype testing, but he is HLA-B*5701 positive, so he can't take abacavir (Ziagen). He wants a single-pill, once-daily regimen.
He smokes, and has a Framingham risk score of 18%, and a 10-year atherosclerotic risk of 25%. At a minimum, even when there are no HIV-specific guidelines, the general population recommendations should be followed, according to Aberg.
Therefore, he is offered elvitegravir/cobicistat/emtricitabine/tenofovir (Stribild). He changes fluticasone to beclomethasone (Beclovent, QVAR, Vanceril). He gets a flu shot, two pneumococcal shots, hepatitis A and B vaccines and the meningococcal vaccine. He is counseled to lose some weight, stop smoking, eat better and take a statin that works for him. He gets a colonoscopy, a bone density scan and an AAA (abdominal aortic aneurisms) screen.
Rob Camp is a treatment activist based in Barcelona, Spain.
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