www.hivandhepatitis.com

HIV Medicine Association Guidelines Emphasize Primary Care Needs of People with HIV on ART

The HIV Medicine Association (HIVMA) of the Infectious Disease Society of America (IDSA) this week released new Primary Care Guidelines for the Management of Persons Infected with Human Immunodeficiency Virus, focusing on primary care and prevention for HIV positive people on effective antiretroviral therapy (ART). The new guidelines, published in the November 13, 2013, online edition of Clinical Infectious Diseases (in print January 2014) "reflect the fact that people with HIV are now living normal life spans," according to an HIVMA/IDSA press release.

Now that a majority of people receiving modern combination ART are able to maintain viral suppression, the guidelines now recommend viral load and CD4 T-cell monitoring every 6-12 months; the recommendation is still every 3-4 months for HIV patients not on ART.

The revised guidelines include new recommendations for screening for high cholesterol, diabetes, osteoporosis, and colon cancer, as well as updated vaccine recommendations. There is also an expanded section on sexually transmitted infection screening and management.

"In many HIV practices now, 80% of patients with HIV infection have the virus under control and live long, full lives," said lead author Judith Aberg from New York University School of Medicine. "This means that HIV specialists need to provide the full spectrum of primary care to these patients, and primary care physicians need a better grasp of the impact HIV care has on routine healthcare. Doctors need to tell their HIV-infected patients, 'Your HIV disease is controlled and we need to think about the rest of you'."

Since the previous edition of the guidelines was published in 2009, new antiretroviral drugs and classes have become available and the prognosis of people with HIV continues to improve, according to the authors. "However, with fewer complications and increased survival, HIV-infected persons are increasingly developing common health problems that also affect the general population," they write. "HIV-infected persons should be managed and monitored for all relevant age- and sex-specific health problems."

The guidelines include the recommendation that all people with HIV should be screened for hepatitis B and C. Those who remain susceptible to hepatitis B should receive the HBV vaccine series, with a second series for those who do not respond adequately to the first. People who test positive for hepatitis C antibodies should receive HCV RNA testing to assess whether they have active disease. At-risk individuals should also be vaccinated against hepatitis A.

Women with HIV should receive a cervical Pap test at entry into care, 6 months later, and then annually thereafter if results are normal. Noting that HIV positive men and women with human papillomavirus (HPV) are at increased risk for anal dysplasia and cancer, the authors recommend that men who have sex with men, women who have had anal sex or who have abnormal cervical Pap test results, and all HIV positive people with genital warts should receive anal Pap tests, though they acknowledge this is a weak recommendation supported by moderate evidence. HPV vaccination, however, is strongly recommended for women/girls and men/boys age 9-26 years.    

People with HIV are at increased risk for common health conditions such as elevated cholesterol and triglycerides, whether due to the infection itself, ART, or traditional risk factors such as smoking and unhealthy diet, according to the authors.

Accordingly, a new section on metabolic comorbidities was added, replacing separate guidelines for managing dyslipidemia, or abnormal blood fat levels. HIV positive people should have their blood glucose and lipid levels measured prior to ART initiation and again within 1-3 month after starting treatment. Those with abnormal levels should be managed according to American Diabetes Association and National Cholesterol Education Program Guidelines developed for the general population. The revision also includes atable outlining interactions between specific antiretrovirals drugs and statins.

The HIVMA guidelines come a day after new general population guidelines from the American College of Cardiology and the American Heart Association (published online in advance of the November 2013 Journal of the American College of Cardiology) calling for expanded use of statins to manage abnormal blood cholesterol for prevention of heart disease and stroke due to atherosclerosis. The new guidance recommends therapy for specific at-risk groups rather than target levels of LDL cholesterol. The ACC/AHA guidelines -- like the HIVMA/IDSA update -- also emphasize the importance of a healthy lifestyle including a heart-healthy diet, regular exercise, avoiding tobacco, and maintaining a healthy weight.

"Patients whose HIV is under control might feel they don’t need to see a doctor regularly, but adherence is about more than just taking ART regularly; it's also about receiving regular primary care," she Aberg. "These guidelines are designed to help ensure patients with HIV infection live long and healthy lives."

11/14/13

References

JA Aberg, JE Gallant, KG Ghanem, et al. Primary Care Guidelines for the Management of Persons Infected With HIV: 2013 Update by the HIV Medicine Association of the Infectious Diseases Society of America. Clinical Infectious Diseases. November 13, 2013 (Epub ahead of print).

NJ Stone, J Robinson, AH Lichtenstein, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Journal of the American College of Cardiology. November 2013.

Other Sources

HIV Medicine Association/IDSA. Primary Care Key to Management of Patients with HIV Infection. Press release. November 14, 2013.

American College of Cardiology and American Heart Association. ACC/AHA Publish New Guideline for Management of Blood Cholesterol. Press release. November 12, 2013.