Updated HIV Primary Care Guidelines

Persons with HIV are living longer thanks to antiretroviral therapies (ART) and therefore updated primary care recommendations are needed as the HIV population ages, according to updated clinical guidelines published in Clinical Infectious Diseases.

Investigators from around the United States outlined optimal medical care and desired medical outcomes for persons with HIV, so that they can live to a near expected lifespan. Advances in ART have made this possible, they said, leading to an update of the 2013 HIV Primary Care Guidelines from the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA).

The authors noted they made an effort to use people-first language that uses the person before the disease and also to use gender-neutral language when appropriate. The guidelines were developed after a review of the current literature which identified advancement in the field.

First, the authors said all persons with HIV should have access to routine and urgent primary medical care to optimize care engagement, medication adherence, and viral suppression. In addition, to achieve these goals, HIV care sites should make efforts to: provide linguistically and culturally appropriate language; implement programs that incorporate proven interventions to improve HIV care engagement and viral suppression; and use a multidisciplinary model but still have a primary care physician for each patient to support the development of a trusting long-term patient/clinician relationship.

The authors also suggested that patients should undergo an initial evaluation and follow-up that includes HIV-related information, information about medication, social, and family history, a view of systems, and a physical examination. A clinician may also experience a scenario where a patient is unable to recall details of prior treatments or lab results, so medical records should be requested and reviewed, and added to the current medical record, the authors said.

There are also routine health care maintenance considerations for persons with HIV, the authors said, in addition to HIV monitoring and HIV RNA viral load testing. HIV RNA should be rechecked after 2 to 4 weeks of initiation of ART, they suggested, but no later than 8 weeks until suppression is achieved. After suppression, it should be monitored every 3 to 4 months, they recommended. CD4 cell count should also be monitored, they said, in order to determine the need for prophylaxis against infection.

The study authors noted that about half of the global population with HIV has aged over 50 years. As such, they wrote there is heightened concern about increased rates of common age-related comorbidities, including cardiovascular morbidity. The benefits of ART outweigh the risks of cardiovascular disease, though, they said, and they pointed to existing guidelines for providers about managing lipid abnormalities, diabetes, and other comorbidities. They cautioned that persons with HIV are also at risk for loss of bone mineral density (BMD), hypogonadism, and neurocognitive disorders.

There are also special considerations to be made for persons with HIV with childbearing potential, such as cisgender women and transgender men, and the prevention of perinatal HIV transmission. The authors suggested that the need for routine gynecological care has increased as the lives of persons with HIV are lengthened.

“They have the same reproductive health needs and concerns as those not living with HIV infection,” the authors said, noting that the initial assessment should include comprehensive gynecologic and obstetrical history, menstrual history, sexual practices, contraception history and use, condom use and consistency, previous STIs, Pap test results, any relevant surgeries, and history of gynecologic conditions.

Children and adolescents are also considered in the updated guidelines. The authors recommend that infants diagnosed with HIV should undergo resistance testing prior to ART administration and be managed by a specialist. Adolescents should also be provided with a coordinated and deliberate transition to adult care, the authors wrote.

“Transgender and gender-diverse persons with HIV should have access to gender-affirming, nondiscriminatory, nonstigmatizing, and culturally sensitive care,” the authors also added, noting that intake forms and medical records should use gender-neutral language and include gender identity options beyond those assigned at birth.

The authors also made considerations for the ongoing novel coronavirus (COVID-19) pandemic, including acknowledging that there is limited knowledge about how it interacts with HVI. There may be challenges to HIV care including access to testing, care linkage, access to medication, and psychosocial stress and stigma, the authors said.

“While telemedicine cannot replicate some elements of the office visit, many aspects of the asymptomatic patient visit, including providing medical and HIV-related history, reviewing systems, ordering and reviewing laboratory results, renewing and reviewing medication side effects, and many other aspects of physical and behavioral health, can be accomplished with a telemedicine visit,” the authors concluded, regarding HIV and the coronavirus.