HIV Management and Primary Care

The past two decades has seen the clinical management of people with human immunodeficiency virus (HIV) change dramatically. While the population has remained the same, the age of people with HIV has increased; people with HIV are living longer, with a life expectancy of approximately 72 years compared with 79 in the normal population. "Disease management has also changed radically because the comorbidities that people never used to live long enough to experience are now defining a lot of what we do in HIV care," said Peter A. Selwyn, MD, MHP, Department of Family Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, during his presentation at the 48th annual meeting of the IDSA in Vancouver.

Consequently, the role of the primary care physician is increasingly important in HIV management. "There is a long list of issues that are clinically relevant to primary care," Selwyn said. Chief among them is monitoring for comorbidities. "CD4 cell counts and percentages at all stages of HIV certainly remains the best predictor of risk for complications at different levels of immunosuppression," Selwyn said. "Generally, a CD4 percent of about 12 or 14 correlates with a CD4 count of about 200, but this is not absolute." Viral load also estimates risk of disease progression. And resistance testing is now standard for initiation of care and all points along the spectrum, Selwyn said.

Basic screening that should be done in patients presenting with HIV includes complete blood counts, and glucose-6-phosphate dehydrogenase to screen for dapsone or other oxidant drugs. Because of the metabolic and glycemic complications seen in HIV, fasting blood glucose should also be done, as well creatinine clearance, urine analysis, and lipid profiles. Additionally, the relatively new HLA-B*5701 pharmacogenomic test can be used to identify the risk of abacavir hypersensitivity and should be done on initial presentation, as should tuberculosis screening.

Issues related to the continuous care of patients with HIV include routine screening for heart disease using the Framingham Risk Factors, and cancer, as malignancies, both AIDS-defining and non-AIDS defining, occur at higher rates in HIV.

Vaccine prophylaxis for opportunistic infections including hepatitis B, influenza, pneumococcus and tetanus can be done in patients whose CD4 cell counts are greater than 200. With respect to the timing of vaccinations, HIV-positive patients with CD4 reconstitution of greater than 500 cells demonstrate similar immunogenic responses to those in the general population. Sharon Lee, MD, FAAFP, Clinical Professor of Medicine, University of Kansas, said that "live-attenuated vaccines, should generally be avoided in people with low CD4 levels.”

Periodic prevention measures should include:

• Annual influenza vaccines
• A pneumococcal vaccine every 3-5 years
• Hepatitis A vaccination given as two doses 6 months apart
• Hepatitis B vaccination in three doses
• Tetanus booster every 5-10 years

Periodic screening should include:

• Pap smears and pelvic exams with gonorrhoea and chlamydia evaluations every six months than annually if normal
• Rectal Pap smear — although this is not yet standard or care
• Purified protein derivative (annually if no prior BCG was given)

Additionally, subclinical abnormalities of adrenal, gonadal, and thyroid levels occur more frequently in people with HIV, particularly in those with advanced disease. As there are no current screening recommendations with respect to these endocrine abnormalities, physicians should be alert for associated symptoms. Finally, patients should also be screened for osteoporosis at baseline and every two years if other risk factors are present.