Primary care key to management of patients with HIV infection

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.