The HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA) has updated its HIV care guidelines to reflect the fact that people with HIV are now living normal life spans, and their physicians need to focus on preventive care, including screening for High cholesterol, diabetes and osteoporosis.
“In many HIV practices now, 80 percent of patients with HIV infection have the virus under control and live long, full lives. This means that HIV specialists need to provide the full spectrum of primary care to these patients, and primary care physicians need a better grasp of the impact HIV care has on routine healthcare,” said Judith A. Aberg, MD, lead author of the guidelines and director of the Division of Infectious Diseases and Immunology at the New York University School of Medicine. “Doctors need to tell their HIV-infected patients, ‘Your HIV disease is controlled and we need to think about the rest of you.’ As with primary care in general, it’s about prevention.”
“Primary Care Guidelines for the Management of Persons Infected with Human Immunodeficiency Virus,” an update on HIVMA’s 2009 guidelines, will appear in print in January in Clinical Infectious Diseases. Reflecting changes in the HIV landscape, the guidelines note patients whose HIV is under control should have their blood monitored for levels of the virus every six to 12 months, rather than every three to four months as previously recommended.
People with HIV are at increased risk for common health conditions, such as High cholesterol and triglycerides, due to the infection itself, ART or traditional risk factors such as smoking and eating unhealthy foods, and doctors must be vigilant about monitoring those levels.
The guidelines include new recommendations for screening for diabetes, osteoporosis and colon cancer, and suggest patients with HIV infection should be vaccinated against pneumococcal infection, influenza, varicella and hepatitis A and B. A table outlining interactions between specific antiretrovirals and statins (the medications commonly used for lipid management) is also included. There also is a more robust section on sexually transmitted diseases, including a recommendation for annual screening of trichomoniasis in women and yearly screening for gonorrhea and chlamydia for all who may be at risk.
Effective antiretroviral therapy (ART) for people living with HIV has resulted in a life expectancy that approaches that of the general population. Both urgent and elective surgical procedures are a common part of HIV medical care. Although the relative risk of surgery in HIV-infected patients has been debated in the literature, retrospective studies have indicated favorable outcomes despite HIV serostatus and regardless of extent or duration of surgery.
Overall health, particularly the presence or absence of organ failure, and nutritional state (albumin <2.5g/dL) have been found to be more reliable predictors of surgical outcome than CD4 count or viral load in HIV-infected patients. Some studies have shown poorer surgical outcomes for individuals with low CD4 counts, although this has not been a consistent finding. Viral suppression also has not been conclusively shown to improve surgical outcomes; however, in the setting of elective surgery, it is still recommended that ART be optimized preoperatively.
The guidelines authors note that doctors should consistently discuss and counsel patients on their sexual history (current and past) and any risky behaviors, such as the use of illicit drugs, in a nonjudgmental manner and determine how patients are coping with living with HIV infection and if they have a sufficient support network.
Definitive AIDS Diagnosis
(With or without laboratory evidence of HIV infection.)
Candidiasis of esophagus, trachea, bronchi, or lungs.
Cryptosporidiosis with diarrhea persisting for more than 1 month.
Cytomegalovirus infection of an organ other than the liver, spleen, or lymph nodes.
Herpes simplex virus infection causing a mucocutaneous ulcer that persists more than 1 month, or bronchitis, pneumonia, or esophagitis of any duration.
Kaposi sarcoma in a patient less than 60 years of age.
Lymphoma of the brain (primary) in a patient less than 60 years of age.
Mycobacterium avium complex or Mycobacterium kansasii infection, disseminated (at a site other than or in addition to the lungs, skin, or cervical or hilar lymph nodes).
Pneumocystis jiroveci pneumonia.
Progressive multifocal leukoencephalopathy.
Toxoplasmosis of the brain.
HIV-infected patients typically are seen by an HIV specialist or a primary care physician. HIV specialists need to be familiar with primary care issues, and primary care physicians need to be familiar with HIV care recommendations and these guidelines are designed to bridge both gaps, said Dr. Aberg.
“Patients whose HIV is under control might feel they don’t need to see a doctor regularly, but adherence is about more than just taking ART regularly; it’s also about receiving regular primary care,” she said. “These guidelines are designed to help ensure patients with HIV infection live long and healthy lives.”
Definitive AIDS Diagnosis
(With laboratory evidence of HIV infection.)
Coccidioidomycosis, disseminated (at a site other than or in addition to the lungs or cervical or hilar lymph nodes).
Histoplasmosis, disseminated (at a site other than or in addition to the lungs or cervical or hilar lymph nodes).
Isosporiasis with diarrhea persisting more than 1 month.
Kaposi sarcoma at any age.
Lymphoma of the brain (primary) at any age.
Other non-Hodgkin lymphoma of B cell or unknown immunologic phenotype.
Any mycobacterial disease caused by mycobacteria other than Mycobacterium tuberculosis, disseminated (at a site other than or in addition to the lungs, skin, or cervical or hilar lymph nodes).
Disease caused by extrapulmonary M. tuberculosis.
Salmonella (nontyphoid) septicemia, recurrent.
HIV wasting syndrome.
CD4 cell count less than 200/uL or a CD4 lymphocyte percentage below 14 percent.
Invasive cervical cancer.
Nearly 1.2 million Americans are living with HIV and approximately 50,000 people are infected each year, according to the Centers for Disease Control and Prevention.
The six-member HIV guidelines update panel includes specialists in internal medicine, pediatrics and infectious diseases. In addition to Dr. Aberg, the panel includes: Joel E. Gallant, MD, Khalil G. Ghanem, MD, Patricia Emmanuel, MD, Barry S. Zingman, MD, and Michael A. Horberg, MD. As with other IDSA guidelines, the HIV guidelines update will be available in mobile device and pocket-sized quick-reference editions. These and other guideline related products will be made available on the IDSA website at http://www.idsociety.org
. The guidelines are embargoed until 12:01 a.m. EDT on Nov. 14.
Founded in 1979, Clinical Infectious Diseases publishes clinical articles twice monthly in a variety of areas of infectious disease, and is one of the most highly regarded journals in this specialty.
The HIV Medicine Association (HIVMA) is the professional home for more than 5,000 physicians, scientists, and other health care professionals dedicated to the field of HIV/AIDS. Nested within the Infectious Diseases Society of America (IDSA), HIVMA promotes quality in HIV care and advocates policies that ensure a comprehensive and humane response to the AIDS pandemic informed by science and social justice.
The Infectious Diseases Society of America (IDSA) is an organization of physicians, scientists, and other health care professionals dedicated to promoting health through excellence in infectious diseases research, education, patient care, prevention, and public health. The Society, which has nearly 10,000 members, was founded in 1963 and is based in Arlington, Va.
Infectious Diseases Society of America
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