The HIV Medicine Association (HIVMA) of the Infectious Diseases Society of American have published a 2020 update of their primary care guidance for persons with HIV. The update, published in Clinical Infectious Diseases, offers evidence-based recommendations on optimizing care engagement and medication adherence, initial evaluation and follow-up assessments, routine healthcare maintenance, and more.
Development of the Guideline Update
Panel members of the HIVMA who developed the guideline update are experts in the care of patients with HIV and volunteered to participate in the update. Recommendations were added to the guideline based on a literature review that included studies published since the date of the last guideline publication in 2013.
Optimizing Healthcare Engagement and Medication Adherence
The panel recommends timely access to routine and urgent primary care for all persons with HIV. Access to care could be improved by extending clinic hours or providing weekend hours and increasing the use of telehealth, which may help expand access to patients in rural populations.
Sites providing HIV care are also urged to implement programs that include a multidisciplinary approach to care; however, sites should use a primary clinician for each patient. HIV care sites should focus on implementing programs that use evidence-based interventions that improve HIV treatment engagement and viral suppression.
Initial Evaluation and Follow Up
In the initial evaluation and at initiation of care, clinicians and HIV care centers should conduct a comprehensive past and present medical history that includes:
- HIV-related information
- Medication, social, and family history
- Review of symptoms
- Physical examination
The panel recommends truncating parts of the comprehensive history and physical in settings of rapid antiretroviral therapy (ART) initiation and instead offer a targeted exam with close follow-up. Additionally, clinicians may wish to reference medical record data, especially for patients who are unable to recall prior treatment details and/or laboratory results. These records should be updated accordingly.
Follow-up testing for persons with HIV could include HIV resistance testing, CD4 cell counts and percentages, as well as screening for co-infections.
Following initiation of ART, clinicians should focus on rechecking HIV RNA after 2 to 4 weeks, but no later than 8 weeks. The HIV RNA should then be rechecked every 4 to 8 weeks until there is evidence of viral suppression. Viral load should be monitored every 3 to 4 months after viral suppression is achieved in an effort to confirm maintenance of suppression. In adherent patients who have a viral load that has been suppressed for greater than 2 years and have stable clinical and immunologic status, this monitoring interval could be prolonged to every 6 months.
In contrast, viral load should be monitored frequently following the initiation or change in ART, with preference given to 2 to 4 weeks of the initiation or change. Likewise, clinicians should perform repeat testing every 4 to 8 weeks until viral load is undetectable.
The HIVMA panel recommends monitoring CD4 cell count to determine whether the patient requires prophylaxis against opportunistic infections. Generally, CD4 cell counts should be monitored every 3 to 6 months in the first 2 years, particularly if the virus has not been suppressed.
Consideration of Metabolic Comorbidities
More than half of the global population living with HIV are 50 years of age or older, and many of people in this age are at risk of developing metabolic comorbidities. The HIVMA panel recommends evaluating lipid levels before and within 1 to 3 months following the initiation of ART. Additionally, clinicians should test for and monitor fasting blood glucose and hemoglobin A1c, and perform bone densitometry screening for osteoporosis.
Considerations for Adolescents
Adolescents living with HIV, whether acquired perinatally or nonperinatally, often face stigma surrounding the infection. As such, the HIVMA expert panel recommends an individual approach to care for adolescents with HIV, with reliance on an HIV specialist who has direct experience with this specific patient population. Additionally, clinicians should develop a coordinated game plan for adolescents with HIV for a seamless transition to adult care. Also, vaccinations should be administered based on the Advisory Committee on Immunization Practices schedules for children with HIV.
Recommendations for the Pandemic Era
Patients with HIV may be at risk for opportunistic infections and may also have a greater risk of infection with severe acute respiratory syndrome coronavirus 2, the novel coronavirus responsible for coronavirus disease 2019 (COVID-19). Currently, however, there is not enough evidence to provide a conclusive statement on how COVID-19 affects patients with HIV. There is some concern that poorly-controlled HIV may increase the risk of worse COVID-19-related outcomes, especially if a patient with HIV also has other comorbidities that make them more susceptible to the effects of COVID-19. The HIVMA guideline update recommends telemedicine visits whenever possible for patients with HIV during the COVID-19 pandemic as a means of reducing potential exposure to the novel coronavirus.
Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.
Thompson MA, Horberg MA, Agwu AL, et al. Primary care guidance for persons with human immunodeficiency virus: 2020 update by the HIV Medicine Association of the Infectious Diseases Society of America. Published online November 6, 2020. Clin Infect Dis. doi:10.1093/cid/ciaa1391