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.
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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