Treating HIV infection in primary care

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Serology is indicated when documentation of HIV status is inadequate.
Serology is indicated when documentation of HIV status is inadequate.

At a glance

  • HIV status must be taken into account in addressing health-maintenance concerns in the general population.
  • Consider urinalysis and creatinine clearance before starting treatment with potentially nephrotoxic drugs.
  • When patients report high-risk behavior, provide brief counseling and refer for more extensive intervention.
  • Perform a fasting lipid profile every six to 12 months in patients with HIV.

Effective antiretroviral therapy has made HIV infection a chronic disease. Patients now look forward to a normal life expectancy, which gives their primary-care needs increased importance.

The Infectious Diseases Society of America addresses these needs in Primary Care Guidelines for the Management of Persons Infected with Human Immunodeficiency Virus. Recommendations are adjusted to keep pace with advances in HIV therapy and changes in general medical practice standards since the last revision in 2004.

"The guidelines should serve as a reminder that you cannot think just about HIV. You must consider comorbidities and the person as a whole," says Judith A. Aberg, MD, associate professor of medicine at New York University, chair-elect of the HIV Medical Association, and lead author of the update.

The role of the primary-care practitioner (PCP) in HIV management "depends on [his or her] knowledge," notes Dr. Aberg. "Some are HIV experts and will manage everything," while others may attend to the patient's general medical needs, allowing a specialist to oversee issues relating directly to HIV.

In either case, the PCP must take HIV status into account in addressing health-maintenance concerns that arise in the general population as well as those unique to this group.

Initial evaluation

The updated guidelines expand the number of HIV-related tests recommended at initiation of care. Serology—rapid HIV test or enzyme-linked immunosorbent assay (ELISA), confirmed by Western blot or indirect immunofluorescence assay—is indicated when documentation of HIV status is inadequate.

Baseline CD4 cell count and estimate of viral load by quantitative HIV RNA determination are also indicated at this time; the update has added HIV genotyping to ascertain drug resistance, whether or not antiretroviral therapy is imminently contemplated.

Other additions are related to specific treatments: coreceptor tropism testing before CC chemokine receptor 5 (CCR5) antiretroviral drug therapy (e.g. maraviroc [Selzentry]); HLA-B*5701 screening to detect hypersensitivity to abacavir (Ziagen) prior to therapy; screening for glucose-6-phosphate dehydrogenase (G6PD) deficiency before oxidant therapy in black men and women and in men of Mediterranean, Indian, and Southeast Asian background.

The importance of standard testing is heightened in people with HIV. In light of widespread kidney function abnormalities (up to 30% of patients), clinicians should consider urinalysis and calculated creatinine clearance—especially in black patients and in those with advanced disease—initially and before starting treatment with such potentially nephrotoxic drugs as tenofovir (Viread) or indinavir (Crixivan).

Because HIV infection and some treatments are linked to elevated cholesterol and triglycerides, obtaining a fasting lipid profile of the patient is essential. The prominence of anemia, leukopenia, and thrombocytopenia necessitates a complete blood count; a standard blood chemistry panel will help assess renal and hepatic function and nutritional status.

HIV-positive individuals are at increased risk of diabetes, and the guidelines recommend fasting-glucose screening.

A thorough HIV history should include date of diagnosis and (when possible) approximate date of infection as well as the patient's recollection of his lowest CD4 cell counts and highest viral load. Antiretroviral drug history should include prior drug regimens and responses to each, toxicities, adherence issues, and the results of drug-resistance testing.

A more general medical history should pay particular attention to HIV-associated complications and comorbidities (e.g., opportunistic infections, malignancies, cardiovascular disease), and chronic conditions (e.g., peripheral neuropathy, GI disease, diabetes, renal insufficiency) that might influence choice of therapy.

Knowing where the patient has traveled and lived could suggest infections at risk of reactivation (e.g., coccidioidomycosis is endemic in the southwestern deserts).

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