Management of HIV in the Primary Care Setting, from the Internal Medicine Perspective. Focused review.

1. HIV in the Primary Care
Setting
Esteban Toro Velez, MD
Internal Medicine, PGY-3
UT Health San Antonio

2. Importance
● Life expectancy of individuals with HIV has increased with potent antiretroviral therapy
● Less AIDS related complications
● Non-AIDS illnesses: Cardiovascular disease and non-AIDS-defining malignancies
● Be able to manage primary care conditions and to implement evidence-based prevention
measures

3. Cancer
● Increased risk and younger presentation
○ Mechanism of immune dysregulation and decreased immune surveillance
○ Low CD4 cell count increases the risk of malignancy
● AIDS-defining malignancies shifting to non-AIDS-defining malignancies since 2003
● Current most frequents: Kaposi’s Sarcoma, Non-Hodgkin, Lung

4. N Engl J Med 2018; 378:1029-1041DOI: 10.1056/NEJMra1615896

5. General Cancer Screening
Breast
● Most common cancer in women
● Prevalence not increased in HIV
● American cancer society: Begin at age 40
Lung
● 3rd most common cancer
● Higher rates and poor outcomes
● 50 to 80 years who have a greater than or
equal to 20 pack-year smoking history if
they are currently smoking or have quit
smoking within the past 15 years.
Colon
● 4th most common cancer
● HIV may have a higher risk, should follow
same guidelines
● USPSTF recommends screening adults
between the ages of 45 and 75 years
Prostate
● 55 to 69 years of age
● PSA as screening test
● For men 70 years of age and older, the
USPSTF guidelines recommend against
routine screening

6. HIV Specific Screening
Anal Cancer
● Controversial
● Higher prevalence in MSM
● Anal Pap smear screening for individuals
with HIV who have genital warts or an
abnormal cervical Pap test
● Abnormal anal Pap testing (ASC-US or
worse) requires follow-up with high-
resolution anoscopy and possible biopsy
and treatment
Cervical Cancer
● 11 times more common among cisgender
women
● Start at age 21
● Opposed to Non-HIV, doesn’t stop at age 65
● Less than 30
○ 1,1,1→3 year interval of cervical Pap
● Older than 30
○ Pap testing alone or co-testing.
○ If Pap: 1,1,1→3
○ If co-testing: every 3 years
https://www.hiv.uw.edu/custom/primary-care/primary-care-medical-management/2

7. N Engl J Med 2018; 378:1029-1041DOI: 10.1056/NEJMra1615896

8. Cardiovascular
● 1.5- to 2-fold greater risk of CVD in people
with HIV
● Heart failure, stroke, pulmonary
hypertension, and sudden cardiac death
● Strategies for Management of
Antiretroviral Therapy (SMART) trial,
continuous antiretroviral therapy
decreased all-cause mortality, including
death from cardiovascular disease.
Aspirin
● Secondary prevention: Based on
indications
● Primary: USPSTF, 40-59 with an ACVD
greater than 10%
AAA
● 65-75 if ever smoker and men
● Higher risk of progression if CD4 below
200 and increased viral load
https://www.hiv.uw.edu/custom/primary-care/primary-care-medical-management/3

9. HIV Infection and the Risk of Acute Myocardial Infarction
JAMA Intern Med. 2013;173(8):614-622. doi:10.1001/jamainternmed.2013.3728

10. SMART Trial

11. Diabetes
● Prevalence of diabetes mellitus in persons with HIV is estimated at 2 to 14%
● Initial management→Lifestyle changes +/- Metformin
● Goals: A1c <7, glucose readings 70% in 70-180mg/dl range
● Annual screening for neuropathy, retinopathy, nephropathy is the same
https://www.hiv.uw.edu/custom/primary-care/primary-care-medical-management/4

12. Diabetes Screening
Not on antiretrovirals
● IDSA recommends screening with a blood
glucose (random or fasting) level and
HbA1c
● ADA Guidelines recommend screening for
diabetes with a fasting glucose test before
starting antiretroviral therapy
On antiretrovirals
● Only evaluation of plasma glucose
(random or fasting) should be used for
diabetes screening
● The use of HbA1c is not recommended,
may underestimate glycemia
● ADA: Screening at the time of switching
antiretroviral therapy and 3 to 6 months
after starting/switching therapy
● Repeat screening should be performed
annually.
https://www.hiv.uw.edu/custom/primary-care/primary-care-medical-management/3

13. Koethe, J.R., Lagathu, C., Lake, J.E. et al. HIV and antiretroviral therapy-related fat alterations. Nat Rev Dis Primers 6, 48 (2020). https://doi.org/10.1038/s41572-020-0181-1

14. Hypertension
● Hypertension and HIV are cardiovascular risk factors
● Follow the recommendations in the 2017 ACC/AHA Hypertension Guideline
● Important to check and monitor drug interactions
https://www.hiv.uw.edu/custom/primary-care/primary-care-medical-management/5

16. Dyslipidemias
● The pathophysiology of dyslipidemia in HIV is multifactorial
● Effective antiretroviral therapy does not completely eliminate the adverse cardiovascular
impact from HIV
● Can lead to abnormalities in lipid levels, vascular stiffness, inflammation, and immune
activation, even with effective antiretroviral therapy and virologic suppression
● Atorvastatin, Rosuvastatin, Pravastatin, Pitavastatin
https://www.hiv.uw.edu/custom/primary-care/primary-care-medical-management/6

17. Monitoring of Lipid Profiles
● Time of entry
● Antiretroviral Initiation or Modification
● After Initiation or Modification of
Antiretroviral Therapy: 4 to 8 weeks after
initiating or modifying antiretroviral
therapy.
● Routine Monitoring:
○ Repeat yearly if lipid panel is
abnormal or cardiovascular risk
○ Repeat every 5 years, if normal and
no cardiovascular risk
https://www.hiv.uw.edu/custom/primary-care/primary-care-medical-management/6

18. Osteoporosis
● Lower bone density is more prevalent among persons with HIV
○ Inflammation, altered bone metabolism, and toxicities from antiretrovirals (tenofovir DF
and boosted protease inhibitors)
● Ensure vitamin D levels are adequate
● Bisphosphonates are preferred
● Calcium supplementation
○ In the form of calcium carbonate, as polyvalent cations, can interfere with the absorption
of atazanavir, bictegravir, dolutegravir, elvitegravir, and rilpivirine
https://www.hiv.uw.edu/custom/primary-care/primary-care-medical-management/7

19. Screening for Osteoporosis
DEXA
● Postmenopausal women with HIV and
men 50 years of age and older
● Major risk factor for fragility fracture
○ Fragility fracture, chronic
glucocorticoid treatment (greater
than or equal to 5 mg of
prednisone daily for at least 3
months), or high risk of falls
● If FRAX greater than 10%
FRAX
● Men 40 to 49 years of age and
premenopausal women with HIV 40 years
of age and older without a major risk factor
for osteoporotic fracture
● Performed every 2 to 3 years or when a
new clinical risk factor develops.
https://www.hiv.uw.edu/custom/primary-care/primary-care-medical-management/7

20. https://frax.shef.ac.uk/FRAX/tool.aspx?country=9

21. Chronic Kidney Disease
● Higher risk: in older, females, or black, CD4 counts less than 200 cells/mm3, elevated HIV
RNA levels, or comorbid conditions such as diabetes, hypertension, and hepatitis C.
● HIV-associated nephropathy (HIVAN) or immune complex disease; these disorders most
often occurred in persons with untreated HIV, particularly those with a low CD4 cell count.
● Tenofovir DF, can play a role in causing chronic kidney disease in persons with HIV.
https://www.hiv.uw.edu/custom/primary-care/primary-care-medical-management/8

22. Testosterone Deficiency
● Workup only signs or symptoms
○ Gynecomastia, loss of pubic hair, loss of
muscle mass, incomplete sexual
development
○ Decrease libido, decrease erections,
fatigue, depression
● Ideally fasting and in the morning
(8AM to 10AM)
● Lab should be confirmed
○ Low level + signs/symptoms
○ LH and FSH, distinguish primary vs
secondary
○ PSA in older than 40
Contraindications
● Breast or prostate cancer
● A palpable prostate nodule or induration
● PSA greater than 4 ng/mL, or a PSA level greater
than 3 ng/mL in men at increased risk of prostate
cancer who have not undergone urological evaluation
● Elevated hematocrit greater than 48% (greater than
50% for those living at high altitude)
● Untreated severe obstructive sleep apnea
● Severe obstructive lower urinary tract symptoms
● Uncontrolled heart failure
● Myocardial infarction or stroke within the last 6
months
● Thrombophilia
● Those planning fertility in the near term
https://www.hiv.uw.edu/custom/primary-care/primary-care-medical-management/9

23. Follow-Up
● Monitoring response should take place 3 to 12 months, then annually
● Laboratory monitoring of testosterone concentrations should take place 3 to 6 months after
initiation, aiming for testosterone concentrations in the mid-normal range.
● Check hematocrit and hemoglobin levels 3 to 6 months after starting treatment and then
annually.
● Monitor for prostate cancer risk during the first year after initiating testosterone replacement
therapy (including checking a PSA level 3 to 12 months after starting testosterone and
continuing with routine prostate cancer screening after 1 year).
https://www.hiv.uw.edu/custom/primary-care/primary-care-medical-management/9

24. Smoking
● The tobacco cessation
guidelines do not address
smoking cessation in
persons with HIV
● The HIVMA/IDSA Primary
Care Guidance does not
provide
recommendations for
specific interventions
related to smoking
cessation.
https://www.hiv.uw.edu/custom/primary-care/primary-care-medical-management/10