Primary Care for People With HIV Should Encompass More Than Viral Suppression
Ideally, primary care for people living with HIV should include management of the virus, comorbidities (such as cardiovascular diseases or mental health issues), and common health conditions (such as hypertension), as well as counseling on risk reduction and transmission prevention. However, the non-HIV components of care may be neglected during health care visits because the focus is on HIV, said Steven C. Johnson, M.D., of the University of Colorado, in a recent webinar. His clinic therefore includes not only infectious disease specialists but also a family care practitioner and a primary care intern.
While mortality rates for people living with HIV declined from 1996-2011, their life expectancy remained 12 years lower than that of the general population in 2011, according to a Kaiser Permanente study cited by Johnson. Much of this discrepancy is due to comorbidities, rather than HIV itself. Johnson referred to University of Colorado HIV clinic data that revealed an overall 1% mortality rate among people living with HIV, but most of these deaths were from non-AIDS-related complications. Today, people die from AIDS-related illness mainly when they see a health care professional late in their disease, he noted.
One of the common comorbidities common among people living with HIV is cardiovascular disease (CVD). HIV does exacerbate the condition, but much of the higher CVD rate among this population is driven by traditional risk factors. For example, tobacco use is much more common among HIV-positive people compared with the general population. Smoking cessation counseling, along with aspirin for CVD prevention and prescribing statins at lower cholesterol levels than one would for the general population, can help manage this risk. An ongoing clinical trial, REPRIEVE, is assessing CVD prevention among people living with HIV.
Non-AIDS cancers are another significant cause of death among people living with HIV. Lung cancer is the most common among these -- another reason for emphasizing smoking cessation during health care visits. Coinfection with hepatitis C or B also plays a role here, and so does anal cancer. However, Johnson only recommended performing an anal cytology if the patient can be referred for a high-resolution anoscopy, if necessary. Another ongoing study, ANCHOR, is evaluating immediate treatment versus ongoing monitoring for pre-cancerous anal lesions.
Vaccination against common diseases helps to prevent complications in people with lower immune system function, such as people living with HIV. Currently, there are three influenza vaccine versions: standard dose, high dose, and a live attenuated vaccine. The U.S. Centers for Disease Control and Prevention (CDC) does not recommend the live version for people living with HIV. A study among older HIV-positive people showed better results when the higher dose was used.
The live attenuated zoster vaccine against shingles is now considered safe in people living with HIV whose virus is suppressed. However, the new recombinant version of the vaccine is preferred in this population because of its higher efficacy and safety profile, even at detectable viral loads. Johnson noted that because the vaccine is so new, some health insurance plans might not cover it. Other recommended vaccinations include meningitis, hepatitis B, and human papillomavirus. The webinar included his immunization schedule for people living with HIV, by vaccine and age group.
If you are caring for someone who is HIV positive, screen for and manage comorbidities, advise on life-style changes (such as smoking cessation), watch for hypertension and other common conditions, and recommend vaccinations based on age and HIV status, Johnson recommended.