The Basics of HIV Care in 2016

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The annual incidence of new cases of HIV in the United States is around 50,000. The prevalence (total cases) continues to increase-- both as the number of new cases have remained steady for at least 10 years and as advances in antiretroviral therapy have resulted in “near normal” life expectancies for those infected. Most new cases of HIV continue to be diagnosed either in the primary care setting or in the emergency room. 

What follows, then, is a “how to” guide for the initial and subsequent management of HIV in an era in which once-daily, one-pill, co-formulated antiretroviral products predominate, and guidelines for the initial selection of these products are readily available.

• Incorporate HIV testing into routine care, whether in the primary care setting, emergency room, or in the gynecology clinic. Emphasize to all patients, ages 15 through 80, the importance of being tested for HIV (voluntary consent). Even in states such as Michigan, with laws that make HIV testing unnecessarily cumbersome, it takes only about 5 to 10 minutes during the initial encounter with each patient to discuss thoroughly the issues related to HIV risk and testing.
• Become comfortable taking a thorough sexual history, including asking questions related to partner preference (ie, male/female/both), specific sexual activity, and condom use (or lack of use).  Recommend annual repeat HIV testing for those at high risk of HIV acquisition.
• Perform a thorough physical examination, including blood pressure determination, oral exam (looking for thrush and/or oral hairy leukoplakia), and genital/rectal exam (looking especially for venereal warts or other lesions).
• Initiate a thorough conversation about adherence to all medications, including antiretrovirals, and, when appropriate, lipid lowering drugs, diabetic medications, and antihypertensives.
• For those found to be HIV-positive, the following tests should be ordered before antiretroviral therapy is initiated:
• HIV genotype resistance test. Consider ordering both the “standard” test (for resistance in reverse transcriptase and protease) as well as the test for resistance in integrase.
• HIV RNA assay.
• CD4+ cell count determination, which includes (typically) CD4+ percent determination using flow cytometry, and a concomitant CBC with differential to allow for determination of the CD4+ cell “count”.  The CD4+ cell count is determined by multiplying the total WBC count by the percent of white cells that are lymphocyte and multiplying that number by the percent of lymphocytes that are CD4+ lymphocytes.
• Routine chemistry panel, including liver and kidney function tests (ie, serum creatinine, AST, ALT).
• Lipid panel. While not absolutely critical prior to initiating therapy, those individuals found to have elevated LDL, for instance, would benefit from the addition of a statin to their medication regimen. This recommendation is especially important for those individuals known to be, or found to be, hypertensive.
• Base the selection of antiretrovirals both on the presence of any underlying drug-limiting resistance mutations discovered on genotyping, as well as a thorough understanding of the benefits versus limitations of specific classes of antiretrovirals.
• Laboratory tests to order within the first 1 to 3 follow up visits:
• HIV RNA level, which should be obtained 4 to 6 weeks after initiation of therapy. While the HIV RNA level may not be < 50 copies/mL or even < 400 copies/mL so quickly, early HIV RNA testing is a great (indirect) way of determining adherence to antiretroviral therapy.
• HBV, HCV, and especially for men who have sex with men, HAV antibody determination. Note that the CDC recommends “age-based” HCV testing on all persons born between 1945 through 1965.
• CD4+ cell count determination (including CBC with differential).
• Routine chemistry panel.
• While the frequency of follow up visits is based, in part, on underlying comorbidities and level of CD4+ cell count, in general, plan on seeing patients initially every 4 to 6 months. After about 2 to 3 years, those found to be repeatedly “undetectable” can be seen every 6 to 12 months. 
• HIV RNA testing should be performed at each follow up visit.  CD4+ cell count determination can be done once or twice per year.
• Test for syphilis, gonorrhea, and chlamydia when appropriate, based on risk behavior (eg, men who have sex with men) and information obtained from the sexual history.
• Some experienced HIV treaters test annually for these infections, although others advocate for a more individualized approach, which can be as frequently as every visit.
• When testing for gonorrhea and chlamydia, realize that there are 3 potential sites of infection: urethral, oral, anal. In men who have sex with men, 2/3 of all gonococcal infections are oral or anal.
• Make sure that all appropriate vaccinations, including HBV, HAV, pneumococcal, TDaP, VZV, HPV are up to date. Vaccinate for influenza yearly.
• Quantiferon gold testing for TB, once, especially in areas of moderate-to-high TB prevalence. There are no definitive guidelines on the frequency of repeat testing. Quantiferon gold testing has the advantages of being easier to store the results in the EMR and being less “subjective” than skin testing. There is no advantage to performing both tests.
• For HIV-infected women, the CDC still recommends annual PAP smears.  There is no consensus yet on doing initial or subsequent anal PAP smears on HIV-infected men or women.
• Follow well-established guidelines for screening mammography and colonoscopy.
• Actively emphasize cigarette smoking cessation and risk reduction (eg, more consistent use of condoms) at each visit.
• Consider referring patients to an experienced HIV treater, especially if the initial diagnosis was made in the emergency room or in a gynecology clinic, or if the initial resistance test reveals the presence of drug-limiting mutations.