Abstract & Commentary

HIV primary care: You've come a long way, baby

'I honestly can tell them that they won't die of AIDS'

By Dean L. Winslow, MD, FACP, FIDSA, Chief, Division of AIDS Medicine, Santa Clara Valley Medical Center; Clinical Professor, Stanford University School of Medicine. Winslow serves as a consultant for Siemens Diagnostics, and is on the speaker's bureau for Boehringer-Ingelheim and GSK.

Synopsis: Updated evidence-based guidelines for HIV primary care have been released that update those published in 2004. Due to improved survival of HIV-infected patients related to newer antiretroviral agents, attention to primary care/health maintenance is more important now than in the past.

Source: Aberg JA, et al. Primary care guidelines for the management of persons infected with human immunodeficiency virus: 2009 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis. 2009;49:651-681.

The 2009 update of HIV primary care guidelines make several new recommendations, and the evidence basis for these is documented in the paper. The following changes are present in the 2009 guidelines:

  • Formatting changes have been incorporated to help readers more easily track recommendations and see the brief evidence-based summary pertaining to the specific recommendation.
  • Tables on immunizations and routine health care maintenance have been added (and make useful handouts for med students and residents doing brief HIV outpatient rotations).
  • An expanded list of diagnostic tests (to be done at baseline and at periodic intervals) is presented.
  • All patients should have a genotypic resistance test performed at baseline whether or not antiretroviral (ARV) therapy will be initiated.
  • Patients who are seronegative for varicella zoster virus (VZV) or who do not have a history of chickenpox or zoster should receive post-exposure prophylaxis with VZV immune globulin (VariZIG) within 96 hours after exposure to a patient with chickenpox or zoster.
  • Varicella primary immunization may be considered for VZV-negative adults with CD4 > 200/uL and children with CD4% > = 15%.
  • Guidelines for CSF examination in patients with syphilis are clarified, including recommending lumbar puncture in those with late-latent syphilis and those with syphilis of unknown duration.
  • HLA-B*5701 testing should be performed prior to initiating abacavir (ABC) therapy to reduce the risk of hypersensitivity reaction.
  • Urinalysis and calculated creatinine clearance should be obtained prior to initiating therapy with drugs with potential for nephrotoxicity such as tenofovir.
  • Tropism testing should be performed prior to initiating CCR5-antagonist agents such as maraviroc.
  • Providers should assess breast cancer risk for female patients 40-49 years old and inform patients in this age group of the benefits and risks of mammography.
  • Hormone replacement therapy (due to its use being associated with increased risk of breast cancer, cardiovascular and thromboembolic disease) is not generally recommended and should only be used for a limited time and in lowest possible dose for women with severe menopausal symptoms.
  • Emphasis is to be placed on general adherence to care, rather than just adherence to medications.

Commentary

It has been an interesting journey caring for patients with HIV/AIDS since I finished my ID fellowship training in 1981. Three wonderful nurse colleagues of mine (Arlene Bincsik, Pat Lincoln, and the late Helen Smolka) and I started Delaware's multidisciplinary HIV clinic in Delaware in 1985 with the simple vision that it was the right thing to do. All of us basically did this as volunteers. While I do believe we were able to prolong our patients' lives and improve the quality of their lives, the inexorable tide of this terrible disease eventually washed these patients away, although we remember them all. We attended a lot of memorial services in those bad old days. The early nucleoside analogue reverse transcriptase inhibitors definitely improved survival and delayed progression of AIDS, but for generally less than two years. Even the first HIV protease inhibitors (while dramatically altering the natural history of HIV disease) were often limited by significant side effects.

It is truly wonderful to have the 28 or so effective antiretroviral agents we have in 2009. They are all effective, are generally tolerated extremely well, and allow patients to live normal lives. In my HIV clinic patients who take their ARVs religiously, I honestly can tell them that they won't die of AIDS. However, since they can be expected to live almost normal life-spans, I spend an increasing percentage of time trying to persuade patients to stop smoking, trying to get them to maintain ideal body weight, exercise, abstain from drugs, and to practice safe sex, all the while managing an increasing burden of Hepatitis C virus co-infection, type 2 diabetes, hypertension, hyperlipidemia, and cardiovascular disease, etc.

These latest guidelines should provide an excellent reference to the practicing clinician on evidence-based primary care recommendations for HIV-infected patients.