Overview
Current data indicate that approximately 50,000 people are newly diagnosed with HIV infection in the United States each year,[1] and a substantial number of them present to primary care practitioners for management.
The care of HIV-infected patients has undergone dramatic changes over the past 2 decades from the advent of combination antiretroviral therapy and the introduction of plasma HIV RNA testing and resistance testing in clinical practice. Patients receiving antiretroviral therapy are hospitalized less frequently with opportunistic infections (OIs) and are living longer. Despite these improvements, only 40% of HIV-infected patients are engaged in care, 37% of patients are prescribed antiretroviral drugs, and viral suppression has been achieved in only 30% of HIV-infected patients.[2]
For health care practitioners, keeping up with a changing but still incomplete knowledge base and addressing potentially complicated outpatient issues within time constraints remain important challenges.
The management of HIV disease lends itself to a primary care approach. Most successful models are multidisciplinary. In addition to history and physical examination, the initial evaluation of HIV-infected patients should include assessment of their emotional state and their knowledge of the disease. Baseline laboratory tests are performed to screen for occult medical conditions and guide drug usage, determine HIV disease status, and look for evidence of concurrent infections. The CD4+ cell count, HIV RNA level, and HIV genotype test are important for staging HIV disease and informing therapeutic decisions.
Antiretroviral therapy is recommended in all HIV-infected patients regardless of their clinical status or CD4+ cell count.[3] There are both individual (decreased morbidity and mortality) and public health (decreased sexual transmission) benefits of such treatment. The strength of antiretroviral therapy recommendations and evidence supporting them are greater in patients with lower CD4+ cell counts.[3]
The recommended initial regimen is generally 2 nucleos(t)ide analogue reverse transcriptase inhibitors (nRTIs) plus a ritonavir-boosted protease inhibitor (PI) or integrase strand transfer inhibitor (InSTI).[3] Modern effective drug combinations consist of fewer pills, are dosed less frequently, and are associated with fewer adverse effects and long-term toxicities. Medication adherence remains essential to treatment success, and factors that may have a negative impact on adherence should be reviewed and addressed before initiation of therapy. About three-quarters of patients will achieve maximal viral suppression with their initial regimen, and the majority of these will continue to have undetectable virus on a long-term basis. The treatment success rate diminishes progressively with subsequent regimens. All HIV-infected patients, regardless of whether they are receiving antiretroviral therapy, should be monitored with laboratory tests, including a CD4+ cell count and an HIV viral load every 3 to 6 months. HIV resistance testing is indicated when the viral load is not maximally suppressed in patients on antiretroviral therapy.
Substantial complications have been associated with earlier antiretroviral regimens, although they are less commonly seen with newer regimens.[4,5] These include: (1) lipodystrophy syndrome (abnormal body fat distribution, hyperlipidemia, glucose intolerance); (2) lactic acidemia or acidosis; (3) premature osteopenia and osteoporosis; (4) avascular necrosis of hips; (5) peripheral neuropathy; and (6) possibly an increased risk of atherosclerotic disease.
Prophylaxis for Pneumocystis jiroveci (formerly Pneumocystis carinii) pneumonia (PCP) is indicated if the patient’s CD4+ cell count is below 200/µL and trimethoprim-sulfamethoxazole is the treatment of choice.[5] Prophylaxis for toxoplasmosis is indicated in patients with a positive toxoplasmosis serology and a CD4+ cell count below 100/µL; trimethoprim-sulfamethoxazole is also the treatment of choice.[5] Prophylaxis for Mycobacterium avium complex (MAC) infection is indicated if CD4+ cell count is below 50/µL; azithromycin is the drug of choice.[5] Prophylaxis for OIs can often be safely discontinued for many infections following immune reconstitution with effective antiretroviral therapy.
Routine health maintenance issues in HIV-infected patients include immunizations (eg, pneumococcal, meningococcal, hepatitis B virus [HBV], hepatitis A virus [HAV], and influenza vaccines), periodic screening for concurrent infections (eg, syphilis, gonorrhea, chlaymydia, hepatitis C virus [HCV], and tuberculosis [TB]), regular Papanicolaou (Pap) tests in women (and anal Pap tests in men who have sex with men or those with a history of anal warts), and other age- and sex-appropriate interventions.