According to the U.S. Preventive Services Task Force, 1.2 million Americans are living with human immunodeficiency virus infection, and there are 50,000 new cases per year. In 20%-25% of those new cases, patients are unaware of having HIV infection. The recommendation for HIV screening by the USPSTF in 2013 is that all patients between 15 and 65 years of age should receive screening. The HIV Medicine Association of the Infectious Diseases Society of America released updated evidence-based guidelines for primary care management of persons infected with HIV.
Initial assessment
The new guidelines emphasize that all new patients who present to the office with an existing HIV infection undergo a comprehensive assessment, including a complete history, physical, and specific testing. The history must include the date of HIV diagnosis and approximate date of infection. Review the patient’s highest viral load, lowest CD4 count, and past and current treatment regimens; and document any history of opportunistic infections or HIV-related comorbidities. Note any chronic medical conditions, such as cardiovascular disease, diabetes mellitus, and/or renal or liver dysfunction that may impact future treatment regimens for HIV. A general discussion of the person’s understanding of their HIV infection may uncover any mental illness, economic burdens, and lack of social support that may present barriers to treatment adherence.
Testing
The guidelines recommend specific testing that should be performed on initial visit and subsequent further monitoring. It is suggested that the CD4 count be documented and the HIV viral load be quantified in patients who already have the diagnosis of HIV infection. In newly diagnosed patients with HIV infection, it is recommended that you get a CD4 cell count, viral load, and HIV genotype/resistance testing to help choose future antiretroviral therapies. The initial assessment should include testing for possible coexisting conditions, including other sexually transmitted infections: gonorrhea, chlamydia, and syphilis. The patient should be screened for hepatitis A, B, and C; toxoplasmosis; CMV; and tuberculosis. TB screening can be done with either the tuberculin skin test or interferon-gamma release assay.
It is also important to establish a baseline fasting comprehensive metabolic panel, complete blood count, urinalysis, creatinine clearance, and fasting lipid panel because HIV infection and certain antiretroviral therapy (ART) can have a negative effect on a range of organ systems.
Immunization and preventive health screening
Immunization should be routine for all patients with HIV infection. In addition to standard recommendations for all adults, the recommendations for patients with HIV include:
• Hepatitis A and hepatitis B vaccines series. Note that for hepatitis B vaccine, the dose is the 40-mcg dose that is used for immunocompromised patients. Patients should be tested for hepatitis A total, or IgG antibody, 1-2 months after the second dose of the HAV vaccine and HBsAb response 1-2 months after the third dose of the HBV vaccine.
• Pneumococcal vaccine. Patients should receive a dose of PCV13 (Prevnar 13), followed by a dose of PPV23 (Pneumovax) at least 8 weeks later. If a patient was previously vaccinated with PPV23, give PCV13 at least 1 year after PPV23.
• Influenza. Annual flu shot should be given.
• Varicella. Administer to HIV-infected persons with a CD4 count greater than 200 cells/mcL who do not have evidence of immunity to varicella.
• HPV. Indicated for females aged 9-26 years and males aged 9-26 years.
Ongoing monitoring
The main tests to follow in a patient with HIV infection to determine if treatment is successful are viral loads and CD4 counts. The viral load should be checked every 3-4 months after initial diagnosis or more frequently when beginning a new regimen. After 2-3 years of being treated and having their viral load successfully suppressed, a patient is considered stable, and the interval of time to test can be extended to every 6 months.
CD4 counts are a useful tool to assess for the need to start ART urgently as well as the effectiveness of ART. If the count drops below certain numbers, the CD4 count can determine the need for prophylactic therapy against opportunistic infections. For CD4 counts in a stable patient who has a suppressed viral load and an adequate CD4 response, the interval of time between monitoring can be extended to every 6-12 months. There are certain metabolic concerns that need frequent monitoring that are associated with the HIV infection itself and the different side effects of specific treatments. Renal function, complete blood count, lipid panel, fasting glucose, hemoglobin A1c, and liver function studies all require frequent monitoring.
Cervical cancer screening is important, and HIV patients are an exception to the newer lengthened screening interval recommendations. Women with HIV infection should have a pap smear at the time of HIV infection diagnosis, repeated at 6 months, then annually thereafter.