Primary care of the hiv infected adult

11/10/2014 Primarycare of the HIV-infected adult
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Official reprint from UpToDate
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Authors
Todd M Pollack, MD
Howard Libman, MD
Section Editor
John G Bartlett, MD
Deputy Editor
Allyson Bloom, MD
Primary care of the HIV-infected adult
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Oct 2014. | This topic last updated: Sep 24, 2014.
INTRODUCTION — Over the past two decades, antiretroviral therapy (ART) has radically altered the natural history of HIV
infection [1]. Opportunistic diseases have become less common, and mortality has declined to the point that treated HIV-
infected patients now have a near normal life expectancy [2]. More than 50 percent of deaths in HIV-infected patients
receiving ART are now related to conditions other than AIDS [3,4]. HIV infection appears to increase the risk of non-AIDS-
related cardiovascular disease, renal disease, liver disease, and malignancies [5]. In addition, a variety of long-term
complications associated with ART have been described.
The emergence of non-AIDS-related conditions highlights the important role of the primary care physician. Based on
experience from other chronic medical conditions, general practitioners are well suited to oversee and coordinate a
multidisciplinary approach to HIV care. One survey of 102 internal medicine physicians and 75 infectious disease
specialists found that generalists with extensive experience in HIV management provided high-quality care to these
complex patients [6]. In the United States, some anticipate a future need for increased involvement of primary practitioners
in HIV care given the growing prevalence of individuals living with HIV [7].
The role of the primary physician in the care of the HIV-infected adult will be discussed here, with particular attention to
clinical monitoring and health care maintenance.
The initial evaluation of the HIV-infected adult is addressed elsewhere. (See "Initial evaluation of the HIV-infected adult".)
GUIDELINES — In the United States, the HIV Medicine Association of the Infectious Diseases Society of America has
published guidelines on the primary care of HIV-infected individuals, which were last updated in 2013 [8]. The
recommendations discussed in this topic are generally consistent with these guidelines.
Other expert groups that have released recommendations on the ongoing evaluation and management of HIV-infected
individuals include the European AIDS Clinical Society [9].
INITIAL EVALUATION — The initial evaluation of an HIV-infected patient includes assessment of disease stage and
virologic parameters and in-depth evaluation for comorbidities, prior exposures, and risk factors in order to inform
appropriate preventive measures. This issue is discussed in detail elsewhere. (See "Initial evaluation of the HIV-infected
adult".)
FREQUENCY OF CLINICAL EVALUATION — The appropriate frequency of medical visits for an HIV-infected adult
depends on many factors, including the stage of HIV infection, the use of antiretroviral therapy (ART), and the presence of
other medical or social comorbidities and complications. As an example, frequent visits may be appropriate for patients
who are recently diagnosed or newly linked to care. Frequent visits are also warranted after the initiation of ART to evaluate
efficacy and tolerability. However, once the viral load has been suppressed and the CD4 cell count is increased and stable,
less frequent monitoring is appropriate. (See "Patient monitoring during HIV antiretroviral therapy".)
MANAGEMENT OF ANTIRETROVIRAL THERAPY — The goals of antiretroviral therapy (ART) are to prolong life and
improve its quality, restore and preserve immunologic function (as measured by CD4 count), and maximally and durably
suppress the HIV viral load [10]. Although eradication of HIV infection is not achievable with current management
approaches, ART has resulted in significant reductions in HIV-related morbidity and mortality. Initiation, management, and
monitoring the efficacy of ART are fundamental components in the care of the HIV-infected adult. Detailed discussion of
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these issues is found elsewhere:
(See "When to initiate antiretroviral therapy in HIV-infected patients".)
(See "Considerations prior to initiating antiretroviral therapy".)
(See "Selecting antiretroviral regimens for the treatment-naïve HIV-infected patient".)
(See "Selection of antiretroviral therapy for the treatment-experienced patient with drug-resistant HIV infection".)
(See "Patient monitoring during HIV antiretroviral therapy".)
MONITORING FOR COMPLICATIONS — HIV-infected patients appear to have a higher risk of certain medical conditions,
including metabolic complications and some malignancies, compared to the general population. Some of these may be
associated with HIV-infection itself, risk factors prevalent in HIV-infected populations, or the use of antiretroviral therapy
(ART). Optimal care of the HIV-infected patient requires knowledge about and evaluation for such potential complications
(table 1).
Hematologic, renal, and hepatic toxicity — HIV infection has been associated with abnormalities of bone marrow,
kidney, and liver function, either directly or because of comorbid conditions. Evaluation for such underlying abnormalities
should be done at the initial presentation. (See "Initial evaluation of the HIV-infected adult", section on 'General blood and
urine testing'.)
For patients who have not yet initiated ART, routine monitoring for these abnormalities is warranted, for example with a
complete blood count (CBC) with differential every three to six months and a chemistry panel including BUN and
creatinine, serum transaminases, and bilirubin level every 6 to 12 months [11].
For patients who have started ART, monitoring should be more frequent, because of the potential for drug-associated
toxicity. Specifically, in the United States, the Department of Health and Human Services recommends routine
performance of the following basic laboratory tests [11]:
Even more frequent monitoring may be warranted in patients who have baseline abnormalities in hepatic, renal, and bone
marrow function and with the use of certain agents. (See "Patient monitoring during HIV antiretroviral therapy", section on
'General laboratory monitoring'.)
Cardiovascular disease — With more effective and widespread treatment of HIV in resource-rich settings, cardiovascular
disease has emerged as an important cause of death in HIV-infected patients relative to the decreasing incidence of
opportunistic infections. The degrees to which HIV infection itself, traditional cardiovascular risk factors, and ART (eg,
protease inhibitors) each contribute to the increased risk of cardiovascular disease in the HIV-infected population are
unknown. It is of paramount importance that clinicians identify and initiate appropriate preventive interventions for
cardiovascular risk factors in HIV infected patients. Assessment and management of cardiovascular risk and disease in
HIV-infected adults are discussed elsewhere. (See "Management of cardiovascular risk (including dyslipidemia) in the HIV-
infected patient" and "Epidemiology of cardiovascular disease and risk factors in HIV-infected patients".)
Dyslipidemia — Studies have consistently shown a high prevalence of dyslipidemia among HIV-infected patients, with
and without ART. Certain agents, such as earlier generation protease inhibitors, have been associated with a greater risk of
unfavorable lipid changes. Thus, HIV-infected patients should undergo lipid testing routinely throughout care. As an
example, several expert groups in the United States recommend screening for dyslipidemia at baseline, annually if not on
ART, prior to initiating ART, within one to three months after starting a new ART regimen, and every 6 to 12 months
thereafter [8,12,13].
Management of dyslipidemia consists of lifestyle modification, consideration of switching to a more "lipid-friendly" ART
CBC with differential every three to six months●
Basic chemistry, including BUN and creatinine, two to eight weeks following ART initiation and every three to six
months thereafter
●
Urinalysis every six months while on a tenofovir-containing regimen●
Alanine and aspartate aminotransferases and total bilirubin two to eight weeks following ART initiation and every three
to six months thereafter
●

regimen if appropriate, and pharmacologic treatment with statins when appropriate for cardiovascular risk reduction. It
remains uncertain whether the indications for statin initiation should be the same as those for the general uninfected
population or should be more aggressive for HIV-infected patients. When starting lipid-lowering agents, it is important to be
aware of potential drug-drug interactions. (See "Epidemiology of cardiovascular disease and risk factors in HIV-infected
patients" and "Management of cardiovascular risk (including dyslipidemia) in the HIV-infected patient".)
Glucose intolerance/diabetes mellitus — Glucose intolerance/diabetes mellitus is another important toxicity
associated with ART, especially with earlier generation protease inhibitors. Thus, HIV-infected patients should be screened
for diabetes at baseline and after initiation of ART. As an example, several expert groups in the United States recommend
checking fasting blood glucose and/or glycated hemoglobin (A1C) at baseline, annually if not on ART, prior to initiating
ART, within one to three months after starting a new regimen, and every three to six months thereafter while on ART
[8,11,12].
Management of glucose intolerance/diabetes mellitus includes weight loss through diet and exercise and pharmacologic
treatment with oral hypoglycemic drugs and/or insulin as needed. (See "Epidemiology of cardiovascular disease and risk
factors in HIV-infected patients", section on 'Insulin resistance and diabetes' and "Management of cardiovascular risk
(including dyslipidemia) in the HIV-infected patient", section on 'Recognizing and managing diabetes mellitus'.)
Hypertension — HIV-infected patients may have higher rates of hypertension compared with uninfected patients
[14,15]. A blood pressure check should be performed at least annually [8]. Definition and management of hypertension in
the HIV-infected patient are the same as those for the general population. These issues are discussed in detail elsewhere.
(See "Overview of hypertension in adults" and "Epidemiology of cardiovascular disease and risk factors in HIV-infected
patients", section on 'Hypertension'.)
Tobacco use — Smoking is common in HIV-infected patients and a major contributor to cardiovascular risk. All HIV-
infected patients should be evaluated for ongoing cigarette smoking, and those who smoke should be advised of the
benefits of quitting. (See "Management of cardiovascular risk (including dyslipidemia) in the HIV-infected patient", section
on 'Smoking cessation'.)
Bone disorders — Osteopenia, osteoporosis, and fracture rate have been reported in higher frequency in HIV-infected
patients compared with age- and sex-matched controls. Some studies have suggested a possible link between ART
(specifically, protease inhibitors and/or tenofovir) and bone loss [16,17], but this has not been a consistent finding [18].
Although supporting data are limited, baseline bone densitometry screening for osteoporosis in HIV-infected patients is
recommended in postmenopausal women and men aged 50 years of age or older [8]. For those who do not have
osteoporosis at baseline, repeat testing is the same as for HIV-uninfected patients and dependent on the extent of bone
density loss, if any. (See "Screening for osteoporosis", section on 'Follow-up to screening'.)
Management of osteoporosis includes ruling out secondary causes (eg, hypogonadism, vitamin D deficiency,
hyperparathyroidism, and thyroid disease), initiating lifestyle changes (eg, increased physical activity, smoking cessation),
calcium and vitamin D supplementation, and bisphosphonate therapy. (See "Bone and calcium disorders in HIV-infected
patients".)
Neuropsychiatric disorders — Both psychiatric conditions and neurocognitive problems are common among HIV-infected
adults.
Clinicians should look for symptoms or signs of depression and anxiety and inquire about ongoing substance abuse.
Aggressive treatment of psychiatric comorbidities is important for the successful management of HIV infection. However,
clinicians should be aware that psychological symptoms may also be manifestations of HIV-associated neurocognitive
disorder (HAND).
Assessing for the presence of symptoms of neurocognitive impairment can be easily performed during a clinical visit to
quickly identify patients who may be affected by HAND. Various strategies for screening exist. Those who have
abnormalities on initial evaluation can be referred for more formal assessment. This issue is discussed in detail elsewhere.
(See "HIV-associated neurocognitive disorders", section on 'Screening for deficits'.)
Cancer and precancerous lesions — HIV-infected individuals have an increased incidence of a wide range of
malignancies. Although the widespread use of ART has been associated with decreases in the incidence of AIDS-defining

malignancies, other malignancies occur slightly more frequently among HIV-infected patients compared with the general
population (table 2). (See "HIV infection and malignancy: Management considerations".)
Except for human papillomavirus (HPV)-associated neoplasia, formal recommendations for cancer screening are the same
in HIV-infected and uninfected patients.
Cervical cancer — All HIV-infected women should be screened for cervical cancer with a Pap test as part of the initial
evaluation in all HIV-infected women (see "Initial evaluation of the HIV-infected adult", section on 'Screening for HPV-
associated neoplasia'). Screening should be repeated six months later and annually thereafter if no abnormalities are
found. Management in women with abnormal Pap tests is based on cytologic findings. The role of human HPV testing in
determining screening interval in HIV-infected women is emerging [8]. Colposcopy is not recommended as a screening
test. Cervical cancer screening in HIV-infected women is discussed in detail elsewhere. (See "Screening for cervical
cancer in HIV-infected women" and "HIV and women".)
Anal cancer — HIV infection is associated with an increased risk for anal neoplasia in men and women regardless of
sexual orientation [19,20].
Indications for screening for anal intraepithelial abnormalities with anal Pap on initial evaluation of an HIV-infected patient
are discussed elsewhere. (See "Anal squamous intraepithelial lesions: Diagnosis, screening, prevention, and treatment",
section on 'Who should be screened for anal SIL?' and "Initial evaluation of the HIV-infected adult", section on 'Screening
for HPV-associated neoplasia'.)
There are few data to inform an appropriate screening interval. In HIV-infected men who have sex with men, annual
screening appears cost-effective [21]. For patients who have indications for anal Pap, we generally perform this yearly.
Other cancers — Age-appropriate screening for breast, colon, prostate, and other cancers should be performed in HIV-
infected patients according to recommendations used for the general population. (See "Overview of preventive medicine in
adults", section on 'Cancer'.)
Sexually transmitted infections — Patients with HIV infection should be screened for other sexually transmitted
infections (STIs) (eg, syphilis, Chlamydia trachomatis, Neisseria gonorrhoeae, and, in women, Trichomonas vaginalis) at
the initial evaluation. This issue and methods for screening are discussed elsewhere. (See "Initial evaluation of the HIV-
infected adult", section on 'Sexually transmitted infections'.)
Discussion of sexual practices along with prevention counseling should be incorporated regularly into visits. Subsequent
periodic screening for STIs should be performed in persons at continued risk. As an example, annual screening for
syphilis, C. trachomatis, N. gonorrhoeae, and, in women, Trichomonas, has been recommended for all sexually-active HIV-
infected patients [22]. More frequent screening (eg, every three to six months) may be warranted for HIV-infected MSM
who have multiple or anonymous partners, as well as in patients who exchange sex for money, drugs, or basic needs.
(See "Screening for sexually transmitted infections", section on 'HIV-infected patients'.)
Viral hepatitis — After screening for hepatitis A and B viruses on initial evaluation, vaccination should be administered to
those who are not immune. (See "Immunizations in HIV-infected patients", section on 'Hepatitis A vaccine' and
"Immunizations in HIV-infected patients", section on 'Hepatitis B vaccine'.)
Ongoing screening for hepatitis C virus (HCV) may be warranted for certain HIV-infected patients whose initial screening for
HCV was negative. Annual screening is recommended for patients who have continued risk for exposure (eg, injection drug
use). In addition, because of the evidence of substantial sexual transmission of HCV among HIV-infected men who have
sex with men (MSM), screening for acute HCV infection among sexually active MSM may be warranted. In a cost-
effectiveness analysis, a screening strategy with yearly HCV antibody testing and twice yearly liver function tests (LFTs)
with reflex HCV RNA testing if abnormal was cost effective when the incidence of hepatitis C is below 1.25 percent [23].
When the incidence is above 1.25 percent, screening with LFTs every three months was most cost effective.
Tuberculosis — HIV-infected patients should be screened for latent tuberculosis with tuberculin skin testing (TST) or an
interferon gamma release assay at initial presentation. (See "Initial evaluation of the HIV-infected adult", section on
'Tuberculosis'.)
Subsequently, for those who tested negative, further screening is warranted annually when there are ongoing risk factors
for tuberculosis (eg, incarceration, living in communal settings, active drug use). Additionally, for patients who initially

tested negative in the setting of a CD4 cell count <200 cells/microL, repeat testing should be performed once the CD4 cell
count has increased above this threshold because of the possibility of false negative results in the setting of
immunosuppression. Testing should not be repeated in patients who have previously had a positive test.
The diagnosis and treatment of latent tuberculosis is discussed in detail elsewhere. (See "Diagnosis of latent tuberculosis
infection in HIV-infected patients" and "Treatment of latent tuberculosis infection in HIV-infected patients".)
Less common HIV-specific toxicities — Older antiretroviral agents that are now rarely used had traditionally been
associated with certain toxicities that required special attention, such as peripheral neuropathy, lipodystrophy, and lactic
acidosis. With the use of newer agents, these toxicities are less frequently encountered, but may still be relevant for
certain patients who have had substantial exposure to older drugs. Additionally, some of these abnormalities have also
been associated with HIV infection itself, regardless of antiretroviral regimen, or other common co-morbidities.
IMMUNIZATIONS — Immunizations are an important part of preventive care for HIV-infected patients (figure 1). Inactivated
vaccines are generally safe and acceptable in HIV infected individuals. Certain live vaccines have sufficient safety data and
are thus appropriate if indicated for HIV-infected individuals with CD4 cell counts >200 cells/microL. HIV infection is an
indication for certain vaccines that might not otherwise be given routinely, and the recommendations on formulations,
dosing, or schedules for specific immunizations may differ from those for the general population in an effort to optimize the
vaccine response and because of different risks. These issues are discussed in detail elsewhere. (See "Immunizations in
HIV-infected patients".)
CONSIDERATIONS FOR SPECIFIC POPULATIONS
Patients with low CD4 cell counts — Risk for opportunistic infections can be stratified by CD4 cell count; thus additional
consideration about the presence and prevention of opportunistic infections is needed for patients with CD4 cell counts
<200 cells/microL. Clinicians should have heightened suspicion of symptoms or signs which might be suggestive of an
opportunistic infection in this population. We generally see patients with low CD4 cell counts at least every three months.
Patients with HIV viral suppression but persistent low CD4 cell counts (<200 cells/microL) appear to have increased long-
Peripheral neuropathy — A predominantly sensory peripheral neuropathy that involve the lower extremities has
been associated with HIV infection itself. It has also been associated with didanosine and stavudine, although these
agents are rarely used. Other causes of peripheral neuropathy (eg, diabetes mellitus, vitamin B12 deficiency, thyroid
disease, syphilis, other drugs) should be considered in the differential diagnosis.
●
HIV-associated peripheral neuropathy is discussed in detail elsewhere. (See "Epidemiology, clinical manifestations,
diagnosis, and treatment of HIV-associated peripheral neuropathy".)
Lipodystrophy — Fat maldistribution can manifest as a loss of peripheral fat (lipoatrophy: facial, extremity, and
buttocks thinning), increase in central adiposity (lipohypertrophy: prominent cervicodorsal fat pad, increased
abdominal girth), or both. Stavudine is most commonly implicated in lipoatrophy.
●
Management consists of modifying the antiretroviral drug regimen, although reversal of the process may be gradual.
Other potential treatments include liposuction or a recombinant growth hormone releasing hormone analogue for
lipohypertrophy and injectable fillers for lipoatrophy. However, clinicians should be aware that most medical insurers
have been reluctant to cover the cost of these interventions. (See "Epidemiology, clinical manifestations, and
diagnosis of HIV-associated lipodystrophy" and "Treatment of HIV-associated lipodystrophy".)
Lactic acidosis — Mitochondrial toxicity has been described in association with nucleoside reverse transcriptase
inhibitors (NRTIs) as a result of their interference with the function of DNA-polymerase. The risk of mitochondrial
toxicity is greatest for didanosine and stavudine, followed by zidovudine, all of which are now rarely used.
●
The clinical manifestations of mitochondrial toxicity include lactic acidosis, pancreatitis, myopathy, and hepatic
steatosis. Asymptomatic mild-to-moderate lactic acidemia is common in patients on regimens that include NRTIs but
does not predict the occurrence of severe lactic acidosis. Routine monitoring of serum lactic acid is not
recommended in the absence of symptoms. However, a venous lactate level should be obtained in a patient on NRTIs
who presents with unexplained weight loss, nausea, vomiting, or abdominal discomfort. (See "Mitochondrial toxicity
of HIV nucleoside reverse transcriptase inhibitors" and "Treatment and prevention of mitochondrial toxicity in HIV-
infected patients".)

term mortality compared with those who have achieved CD4 cell count >200 cells/microL [24]. (See "The impact of
antiretroviral therapy on morbidity and mortality of HIV infection in resource-rich countries", section on 'Impact of
suboptimal CD4 cell recovery'.)
Prophylactic antibiotics for primary prevention of opportunistic infections are given to patients with CD4 cell counts <200
cells/microL. Antibiotics may also be continued for secondary prevention in patients who have had certain opportunistic
infections. Complete information on dosing regimens and alternative therapeutic agents is discussed elsewhere. (See
"Primary prevention of opportunistic infections in HIV-infected patients" and "Prophylaxis against Pneumocystis infection in
HIV-infected patients" and "Mycobacterium avium complex (MAC) infections in HIV-infected patients", section on
'Prevention of MAC disease'.)
Additionally, for severely immunocompromised patients with CD4 cell counts <50 cells/microL, routine funduscopic
examination (every 6 to 12 months) is warranted to evaluate for CMV retinitis or other complications [8].
Men who have sex with men — Men who have sex with men (MSM) account for more than half (53 percent) of all new
HIV infections in the United States each year and nearly half (48 percent) of people living with HIV. MSM is the only group
in the U.S. in which new HIV infections have been increasing since the early 1990s [25].
Care of the HIV-infected MSM, therefore, requires particular attention to HIV prevention messages and risk reduction
counseling. Because of increased risk, screening for anal cancer, sexually transmitted infections (STIs), and HCV are
particularly important for MSM. (See 'Anal cancer' above and 'Sexually transmitted infections' above and 'Viral hepatitis'
above.)
In addition, physicians should inquire about methamphetamines and other "club drugs," as their use has been associated
with high-risk sexual behaviors [26]. Particular attention should also be given to issues of alcohol and tobacco use,
psychological health, domestic violence, and stigma [27]. (See "Primary care of gay men".)
Women — Primary care of the HIV-infected woman requires special attention to issues such as gender-specific drug
toxicities, contraception, and family planning. This issue is discussed in detail elsewhere. (See "HIV and women", section
on 'Primary care' and "HIV and women", section on 'Choice of contraception'.)
Older adults — The prevalence and incidence of HIV infection in patients over the age of 50 is increasing because of the
success of potent ART, as well as the occurrence of new primary infections. Treatment of HIV infection in this population is
as effective as in younger patients but often complicated by comorbidities and an increased potential for drug toxicity and
drug-drug interactions. Given the evidence that HIV infection may increase the risk of cardiovascular disease, non-AIDS-
related malignancies, and metabolic bone disease, it is important to ensure that cancer screening and other health
maintenance issues are kept up to date in older patients. (See "HIV and the older patient".)
Long-term nonprogressors — Some patients with long-standing HIV infection who are not on ART do not develop clinical
progression and have stable CD4 cell counts and low levels of detectable viremia (<10,000 copies/mL); a subset of these
patients are referred to as "elite controllers" because they have no detectable viremia, even on ultrasensitive diagnostic
testing (<1 copy/mL). All long-term nonprogressors should have follow-up testing at three to six month intervals to be
certain that they have not progressed immunologically [28] Additionally, despite lower levels of viral replication, long-term
nonprogressors remain at increased risk for noninfectious complications of HIV, such as cardiovascular disease, compared
to the uninfected population [29-31].
OTHER PRIMARY CARE ISSUES
Behavioral risk reduction counseling — Behavioral risk reduction counseling is an important part of the management of
HIV-infected patients. At each visit, practitioners should review the patient's understanding of HIV transmission and his/her
sexual and drug-use activities. The discussion should focus on risk reduction interventions tailored to the individual's
behaviors. Viral load suppression with antiretroviral therapy substantially reduces the risk of transmission. (See "When to
initiate antiretroviral therapy in HIV-infected patients", section on 'Impact of ART on HIV transmission'.)
Patients should be advised to limit their number of sexual partners, engage in lower-risk sexual activities, and use latex
condoms consistently during sexual intercourse to reduce the risk of acquiring new sexually transmitted infections (STIs).
Additionally, they should be counseled regarding the potential for superinfection with a second strain of HIV that may be
more resistant to treatment.

Patients who use injection drugs should be counseled about the risks of continued use, including acquisition of HBV and
HCV infections, a drug-resistant HIV strain, and other bloodborne pathogens. Patients should be advised to enter a
substance abuse treatment program. Those who continue to inject drugs should be counseled not to reuse or share
needles, syringes, or other drug preparation equipment.
Patients should be strongly encouraged to disclose their serostatus to all sexual and needle-sharing partners; in the
United States, recommendations and/or regulations on this issue vary among states. Providers can notify the local health
department of individuals at risk for infection so that they can be contacted and tested.
Food safety — HIV-infected patients should be advised to avoid eating raw eggs, unpasteurized dairy products, raw
seafood, and undercooked meat. Care should be taken not to allow uncooked meat or poultry to come into contact with
other foods. Hands, cutting boards, counters, and knives and other utensils should be washed thoroughly after contact with
uncooked meat or poultry. Patients should not drink water directly from lakes, rivers, or other untested sources. More
information is available at the US Food and Drug Administration Web site
http://www.fda.gov/ForConsumers/ByAudience/ForPatientAdvocates/HIVandAIDSActivities/ucm135844.htm.
Pet safety — HIV-infected patients with CD4 cell counts <200 cells/microL should take precautions regarding contact with
certain animals that are associated with infections that may be problematic in the setting of HIV infection.
Primary infection with Toxoplasma gondii occurs after eating undercooked meat containing tissue cysts or ingesting
oocysts that have been shed in cat feces. However, most cases of Toxoplasma encephalitis occur due to reactivation of
latent disease in a severely immunosuppressed host. The minority of patients who are Toxoplasma seronegative should be
counseled to avoid eating undercooked meats (eg, lamb, beef, pork) and to use gloves or use hand hygiene when cleaning
cat litter boxes. (See "Toxoplasmosis in HIV-infected patients".)
The risk of Bartonella infection has been associated with a history of cat exposure or ownership. Cat scratches and bites
should be avoided if possible, and any scratch or bite sites should be washed immediately. Patients who wish to obtain a
new cat should be advised to adopt or purchase an animal that is more than one year old and in good health. (See
"Epidemiology and clinical manifestations of Bartonella infections in HIV-infected patients" and "Zoonoses from cats".)
Contact with reptiles should be avoided to reduce the risk of salmonellosis. (See "Zoonoses from pets other than dogs and
cats".)
For patients with fish, gloves should be worn while cleaning the aquarium to reduce the risk of Mycobacterium marinum
infection. (See "Zoonoses from pets other than dogs and cats".)
Travel safety — HIV-infected patients should discuss travel plans with their health care practitioners in advance. Travel to
developing countries may carry substantial infectious risk, especially for those with advanced immune dysfunction. In
addition, ensuring that their supply of antiretroviral treatment (ART) will last them through the trip is an important step to
prevent interruptions in therapy.
Patients should be advised to avoid tap water, ice made with tap water, raw fruits and vegetables, raw or undercooked
seafood or meat, unpasteurized milk and dairy products, and foods and beverages from street vendors.
Antimicrobial prophylaxis for traveler's diarrhea is not recommended, but patients should be given a quinolone antibiotic
such as ciprofloxacin to have with them in case they develop it.
Travelers should also be advised about the need for other preventive measures, such as malaria prophylaxis or specific
vaccinations, when indicated. (See "Travel advice" and "Immunizations for travel".)
Clinical trials — Patients should be offered participation in clinical trials when optimal management is unknown.
Information about HIV clinical trials can be found at the DHHS Web site
http://www.aidsinfo.nih.gov/ClinicalTrials/Default.aspx?MenuItem=ClinicalTrials.
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th th
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Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to
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Topic 3745 Version 16.0
Basics topics (see "Patient information: HIV/AIDS (The Basics)" and "Patient information: Starting treatment for HIV
(The Basics)" and "Patient information: Tests to monitor HIV (The Basics)")
●
Beyond the Basics topics (see "Patient information: Testing for HIV (Beyond the Basics)" and "Patient information:
Initial treatment of HIV (Beyond the Basics)")
●
The appropriate frequency of medical visits for an HIV-infected adult depends on many factors, including the stage of
HIV infection, the use of antiretroviral therapy (ART), and the presence of other medical or social comorbidities and
complications. Frequent visits may be appropriate for patients who are recently diagnosed or newly linked to care or
for those with advanced HIV infection, whereas individuals who are stable on ART can be monitored less frequently.
Discussion of the initiation, management, and monitoring ART efficacy is found elsewhere. (See 'Frequency of clinical
evaluation' above and 'Management of antiretroviral therapy' above.)
●
HIV-infected patients appear to have a higher risk of certain medical conditions, including metabolic complications
and some malignancies, compared to the general population. These include metabolic complications (eg,
dyslipidemia, diabetes mellitus, bone disease), neuropsychiatric disorders, certain malignancies, and certain co-
infections. Some of these may be associated with HIV-infection itself, risk factors prevalent in HIV-infected
populations, or the use of ART. Optimal care of the HIV-infected patient requires knowledge about and evaluation for
such potential complications (table 1). (See 'Monitoring for complications' above.)
●
Immunizations are an important part of preventive care for HIV-infected patients (figure 1). Inactivated vaccines are
generally safe and acceptable in HIV infected individuals. Certain live vaccines have sufficient safety data and are
thus appropriate if indicated for HIV-infected individuals with CD4 cell counts >200 cells/microL. (See "Immunizations
in HIV-infected patients".)
●
Behavioral risk reduction counseling is an important part of the management of HIV-infected patients. At each visit,
practitioners should review the patient's understanding of HIV transmission and his/her sexual and drug-use activities.
Other relevant counseling issues for HIV-infected patients may include food, pet, and travel safety. (See 'Other
primary care issues' above.)
●

GRAPHICS
Evaluation and monitoring for complications in HIV-infected individuals
Test Interval
HIV-related testing HIV serology At baseline if there is no laboratory
documentation of infection
CD4 cell count At baseline
Every 3 to 6 months (or every 6 to 12
months in clinically stable patients)
HIV viral load* At baseline
2 to 8 weeks after ART initiation and
every 3 to 6 months thereafter
Genotypic resistance testing At baseline
Prior to initiation of ART (recommended
in pregnant women, otherwise
optional)
HLA-B5701 testing If considering use of abacavir
Tropism testing If considering use of CCR5 antagonist
Cardiovascular risk factors Blood pressure check At baseline and annually
Fasting glucose and/or
hemoglobin A1c
At baseline and every 6 to 12 months
1 to 3 months following ART initiation
or modification
Fasting lipid profile At baseline and every 6 to 12 months
1 to 3 months following ART initiation
or modification
Weight assessment At baseline and routinely
Tobacco use assessment At baseline and routinely
Other metabolic
complications
Bone densitometry At baseline in postmenopausal women
and men ≥50 years old
Subsequent testing depends on
findings on baseline exam
Aortic aneurysm screening
(abdominal
ultrasonography)
Once in men 65 to 75 year old who
have ever smoked
Neuropsychiatric disorders Depression screening At baseline and annually
Screening for cognitive
deficits
At baseline and annually
Cancers

http://www.uptodate.com/contents/primary-care-of-the-hiv-infected-adult?topicKey=ID%2F3745&elapsedTimeMs=0&source=search_result&searchTerm=HIV… 10/16
Colonoscopy At 50 years old in asymptomatic
patients at average risk
Earlier screening may be warranted
for those with strong family history of
colon cancer
Subsequent testing depends on
findings on baseline exam
Mammography Annually in all women 50 to 74 years
old
Cervical Pap smear Twice during the first year after HIV
diagnosis, then annually in all women
More frequent or additional testing
may be warranted for those with
abnormal results
Anal Pap smear Consider at baseline and annually
More frequent or additional testing
may be warranted for those with
abnormal results
Other infections Syphilis serology At baseline
Annually for sexually active individuals
(or more frequently if at high-risk)
Chlamydia and gonorrhea
testing
At baseline
Annually for sexually active individuals
(or more frequently if at high-risk)
Trichomonas At baseline for women
Annually for sexually active women
Tuberculosis testing (TST or
IGRA)
At baseline unless there is a history of
a prior positive test
Annually in patients at risk for TB
unless there is a history of a prior
positive test
HAV, HBV serology At baseline, with vaccination if not
immune
HCV serology, with reflex
viral level for positive result
At baseline
Annually in patients at risk (ie,
injection drug users, men who have
sex with men)
Medication toxicity Complete blood count with
differential
At baseline and every 3 to 6 months
BUN and creatinine At baseline and every 6 to 12 months•Δ

prior to ART initiation
ALT, AST, and total bilirubin At baseline and every 6 to 12 months
prior to ART initiation
Urinalysis At baseline
Every 6 months while on tenofovir-
containing regimen
Dilated fundoscopic exam Every 6 to 12 months in patients with
CD4 cell count <50 cells/microL
(optional)
ALT: alanine aminotransferase; ART: antiretroviral therapy; AST: aspartate aminotranserase; CBC:
complete blood count; CrCl: creatinine clearance; HAV: hepatitis A virus; HBV: hepatitis B virus; MDRD:
modification of diet in renal disease.
* If HIV RNA is detectable at 2 to 8 weeks, repeat every 4 to 8 weeks until suppression to <200
copies/mL, then every 3 to 6 months. Viral load typically is measured every 3 to 4 months in patients on
ART. However, for adherent patients with suppressed viral load and stable immunologic status for more
than 2 to 3 years, monitoring at 6-month intervals may be considered.
• Determination of renal function should include estimation of CrCl using Cockcroft-Gault equation or
estimation of glomerular filtration rate based on MDRD equation. More frequent monitoring may be
indicated for patients with evidence of kidney disease (eg, proteinuria, decreased glomerular dysfunction)
or increased risk of renal insufficiency (eg, patients with diabetes, hypertension).
Δ Some experts also suggest monitoring the phosphorus levels of patients on tenofovir.
Adapted from: Aberg JA, Gallant JE, Ghanem KG, 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.
Clin Infect Dis 2014; 58:e1 and Panel on antiretroviral guidelines for adults and adolescents. Guidelines for the
use of antiretroviral agents in HIV-1 infected adults and adolescents. Department of Health and Human
Services. Available at: http://aidsinfo.nih.gov/contentfiles/adultandadolescentgl.pdf (accessed on April 2, 2014).
Graphic 96776 Version 1.0

Incidence of cancer in immunosuppressed patients compared with the
general population
Cancer
SIR in people with
HIV/AIDS
SIR in transplant
recipients
Lymphoproliferative and hematologic malignancies
Non-Hodgkin lymphoma 22.6-353.5 5.5-9.9
Hodgkin lymphoma 3.6-18.0 2.2-8.0
Multiple myeloma 2.2-5.0 2.7-3.8
Leukemia 1.8-5.3 2.3-2.5
Cutaneous malignancies
Kaposi sarcoma 3640 208
Skin carcinoma 1.5-19.6 10.7-56.2
Melanoma 0.2-1.3 1.4-2.5
Eye cancer 1.7-2.0 2.0-7.6
Genitourinary malignancies
Cervical cancer 1.0-22.0 1.5-2.5
Vulvar/vaginal cancer 4.4-6.8 22.2-23.9
Ovarian cancer 0.3-4.4 1.2-2.0
Uterine cancer 0.5-0.9 0.9-1.7
Breast cancer 0.7-1.4 1.0-1.5
Penile cancer 3.9-8.0 15.8
Testicular cancer 0.7-1.8 1.3-2.3
Prostate cancer 0.5-1.4 0.9-1.1
Renal cancer 0.8-2.0 4.1-8.0
Bladder cancer 0.4-4.2 1.6-3.3
Gastrointestinal malignancies
Anal cancer 19.6-50.0 2.8-10.3
Liver cancer 1.9-22.2 1.1-3.2
Small intestine cancer 1.3-3.4 1.1-11.8
Stomach cancer 0.4-2.9 1.8-2.3
Pancreatic cancer 0.7-2.9 0.9-1.2
Colorectal cancer 0.9-1.4 1.4-2.1
Esophageal cancer 0.5-2.1 1.6-3.8
Respiratory tract tumors
Respiratory tract (lower)
cancer
1.4-4.5 1.7-2.1
Oropharyngeal cancer 1.1-2.9 2.8-5.3
Laryngeal cancer 0.6-2.8 1.7-2.5

Lip cancer 2.3-3.1 13.0-53.3
Miscellaneous
Thyroid cancer 0.4-3.0 0.9-8.1
Brain cancer 0.5-4.4 0.6-1.4
SIR: standardized incidence ratio compared with general population.
Modified from: Grulich AE, van Leeuwen MT, Falster MO, Vajdic CM. Incidence of cancers in people with
HIV/AIDS compared with immunosuppressed transplant recipients: a meta-analysis. Lancet 2007; 370:59.

Recommendations for vaccination in HIV-infected adults
A summary of the adult immunization schedule vaccines and their primary indications, adverse events,
and contraindications can be found at: http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-
combined-schedule.pdf. For additional information on these and other vaccines (tetanus, diphtheria,
pertusis, measles, mumps, rubella, and meningococcal disease), refer to recommendations of the
Advisory Committee on Immunization Practices (ACIP): www.cdc.gov/vaccines/pubs/acip-list.htm. For
more detailed information on immunization of persons with HIV infection against influenza, pneumoccocal
disease, hepatitis B, human papillomavirus, varicella, and hepatitis A, see disease-specific sections in the
topic on Immunizations in HIV-infected individuals.
* Covered by the Vaccine Injury Compensation Program.
Δ Influenza vaccination
IIV: inactivated influenza vaccine. LAIV (live attenuated influenza vacccine) is not recommended for HIV-
infected persons.
◊ Varicella vaccination

All adults without immunosuppression and without evidence of immunity to varicella (as defined below)
should receive two doses of single-antigen varicella vaccine or a second dose if they have received only
one dose.
Vaccination should be emphasized for those who have close contact with persons at high risk for severe
disease (eg, healthcare personnel and family contacts of persons with immunocompromising conditions)
or are at high risk for exposure or transmission (eg, teachers; child care employees; residents and staff
members of institutional settings, including correctional institutions; college students; military personnel;
adolescents and adults living in households with children; nonpregnant women of childbearing age; and
international travelers).
Pregnant women should be assessed for evidence of varicella immunity. Women who do not have
evidence of immunity should receive the first dose of varicella vaccine upon completion or termination of
pregnancy and before discharge from the healthcare facility. The second dose should be administered
four to eight weeks after the first dose.
Evidence of immunity to varicella in adults includes any of the following:
Documentation of two doses of varicella vaccine at least four weeks apart;
US-born before 1980, except healthcare personnel and pregnant women;
History of varicella based on diagnosis or verification of varicella disease by a healthcare provider;
History of herpes zoster based on diagnosis or verification of herpes zoster disease by a healthcare
provider; or
Laboratory evidence of immunity or laboratory confirmation of disease.
§ Zoster vaccination
A single dose of zoster vaccine is recommended for immunocompetent adults aged 60 years or older
regardless of whether they report a prior episode of herpes zoster. Although the vaccine is licensed by
the US Food and Drug Administration (FDA) for use among and can be administered to persons aged 50
years or older, ACIP recommends that vaccination begin at age 60 years. The ACIP has not made any
recommendations regarding zoster vaccination in HIV-infected individuals with CD4 cell counts ≥200
cells/microL.
Persons aged 60 years or older with chronic medical conditions may be vaccinated unless their condition
constitutes a contraindication, such as pregnancy or severe immunodeficiency.
¥ Measles-mumps-rubella (MMR) vaccination
Adults born before 1957 are generally considered immune to measles and mumps. All adults born in 1957 or
later should have documentation of one or more doses of MMR vaccine unless they have a medical
contraindication to the vaccine or laboratory evidence of immunity to each of the three diseases.
Documentation of provider-diagnosed disease is not considered acceptable evidence of immunity for measles,
mumps, or rubella.
Measles component:
A routine second dose of MMR vaccine, administered a minimum of 28 days after the first dose, is
recommended for adults who:
Are students in postsecondary educational institutions;
Work in a healthcare facility; or
Plan to travel internationally.
Persons who received inactivated (killed) measles vaccine or measles vaccine of unknown type during
1963 to 1967 should be revaccinated with two doses of MMR vaccine.
Mumps component:
A routine second dose of MMR vaccine, administered a minimum of 28 days after the first dose, is
recommended for adults who:
Are students in a postsecondary educational institution;
Work in a healthcare facility; or
Plan to travel internationally.
Persons vaccinated before 1979 with either killed mumps vaccine or mumps vaccine of unknown type who
are at high risk for mumps infection (eg, persons who are working in a healthcare facility) should be
considered for revaccination with two doses of MMR vaccine.
Rubella component:
For women of childbearing age, regardless of birth year, rubella immunity should be determined. If there

is no evidence of immunity, women who are not pregnant should be vaccinated. Pregnant women who do
not have evidence of immunity should receive MMR vaccine upon completion or termination of pregnancy
and before discharge from the healthcare facility.
Healthcare personnel born before 1957:
For unvaccinated healthcare personnel born before 1957 who lack laboratory evidence of measles,
mumps, and/or rubella immunity or laboratory confirmation of disease, healthcare facilities should
consider vaccinating personnel with two doses of MMR vaccine at the appropriate interval for measles and
mumps or one dose of MMR vaccine for rubella.
‡ Pneumococcal vaccination
HIV-infected adults aged 19 years or older who have not previously received PCV13 or PPSV23 should
receive a single dose of PCV13 followed by a dose of PPSV23 at least eight weeks later.
HIV-infected adults aged 19 years or older who have previously received one or more doses of PPSV23
should receive a dose of PCV13 one or more years after the last PPSV23 dose was received. For adults
who require additional doses of PPSV23, the first such dose should be given no sooner than eight weeks
after PCV13 and at least five years after the most recent dose of PPSV23.
When indicated, PCV13 should be administered to patients who are uncertain of their vaccination status
history and have no record of previous vaccination.
Although PCV13 is licensed by the US Food and Drug Administration for use among and can be
administered to persons aged 50 years or older, ACIP recommends PCV13 for adults aged 19 years or
older with HIV infection.
† Haemophilus influenzae type b (Hib) vaccination
One dose of Hib vaccine should be administered to persons who have functional or anatomic asplenia or
sickle cell disease or are undergoing elective splenectomy if they have not previously received Hib
vaccine. Hib vaccination 14 or more days before splenectomy is suggested.
Recipients of a hematopoietic stem cell transplant should be vaccinated with a three-dose regimen 6 to
12 months after a successful transplant, regardless of vaccination history; at least four weeks should
separate doses.
Hib vaccine is not recommended for adults with HIV infection without other indication (as listed above)
since their risk for Hib infection is low.
Reproduced from: Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the
prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from
the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association
of the Infectious Diseases Society of America. Available at:
http://www.aidsinfo.nih.gov/contentfiles/lvguidelines/glchunk/glchunk_365.pdf. Accessed on February 4, 2014.

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