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Primary Care for HIV-Infected Patients — New IDSA Guidelines

The recommendations encompass both HIV-specific care and overall health maintenance.

For those receiving care in the U.S., HIV infection is now considered a chronic condition, with most patients surviving for decades after their initial diagnosis. As the HIV-infected population ages, patients require not only HIV-specific care but also more-general health management, including cancer screening and care for conditions associated with aging. To help clinicians meet these needs, the Infectious Diseases Society of America (IDSA) has updated its primary care guidelines for managing HIV-infected patients. The key changes to the guidelines since the last iteration (in 2004) are as follows.

• Initial evaluation of newly diagnosed HIV-infected persons should always include genotypic testing for HIV drug resistance.
  
• Attention should be given to preventing varicella-zoster virus infection, including consideration of vaccination in HIV-infected patients with CD4 counts >200 cells/mm³.
  
• In HIV-infected persons with syphilis, indications for cerebrospinal fluid examination include neurological or ocular symptoms, serologic treatment failure, and late latent syphilis.
  
• Because of the risk for renal complications in HIV-infected persons, monitoring of creatinine clearance and urinalysis are recommended, particularly in black patients (who are at increased risk for HIV nephropathy). Such monitoring should also be routine when prescribing drugs with nephrotoxic potential (such as tenofovir and indinavir).
  
• HLA-B*5701 testing is recommended for patients considering abacavir use; those who test positive should not receive abacavir.
  
• Viral coreceptor tropism testing is recommended when prescribing maraviroc.
  
• Management of HIV-infected women should include age-appropriate mammography screening for breast cancer. Postmenopausal hormone therapy is not routinely recommended because it is associated with an increased risk for breast cancer, thromboembolic disease, and cardiovascular disease.
  
• Emphasis should be placed on adherence to care, not just adherence to antiretroviral therapy.
  

Comment: Overall, these recommendations reflect the fact that HIV care has become simpler (given the higher proportion of patients who achieve and sustain virologic suppression) but also more difficult (as individuals survive longer and encounter the inevitable diseases of aging). Although none of the specific recommendations are surprising, these guidelines remind HIV treatment providers that managing patients requires more than just selection of a well-considered antiretroviral regimen. These new primary care guidelines map the way to good health and longevity.

— Charles B. Hicks, MD

Published in Journal Watch HIV/AIDS Clinical Care August 24, 2009

Citation(s):

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 Sep 1; 49:651.

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