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HIV prevention, management in primary care: What you need to know

PHILADELPHIA — The primary care setting provides an opportunity to prevent, identify and treat patients with HIV, according to a presentation at the ACP Internal Medicine Meeting.

“HIV is a very common disease worldwide,” Carrie Horwitch, MD, MPH, from the department of general internal medicine at Virginia Mason Medical Center, said during her presentation. “It is also common in the United States, with well over 1 million people affected.”

Almost 40,000 new patients are infected with HIV every year and 1 in 7 people living with HIV are unaware of their infection, she said.

“The primary care internist is an essential part of a patient’s health care team and can evaluate, initiate and manage patients with HIV,” Horwitch said.

For more than 10 years the CDC has recommended that clinicians test everyone for HIV and repeat testing as the risks continue, she said.

PrEP

Research has shown that if pre-exposure prophylaxis (PrEP) is taken consistently, it is successful at reducing the risk of HIV, according to Horwitch. Only tenofovir disoproxil/emtricitabine is approved for preexposure prevention of HIV currently, she said.

Individuals who are at risk and eligible for PrEP include HIV-negative adults who report that they have had two or more sexual contacts, inconsistent use of condoms, history of syphilis or gonorrhea or a partner with HIV in past 6 months, she said. IV drug users, women and commercial sex workers are also eligible for PrEP, she added.

Before initiating PrEP, clinicians should test for HIV to ensure that the patient is negative; as well as testing for active hepatitis B; STDs, such as gonorrhea, chlamydia and syphilis; and pregnancy if applicable, according to Horwitch.

Many patients on PrEP think that they do not need to use condoms; however, these patients are having high risk sexual contact and clinicians should advise them to still use condoms to prevent against STDs, Horwitch emphasized.

PEP

Individuals who may have been exposed to HIV via infectious body fluid either by percutaneous or mucous membrane contact or cutaneous contact on nonintact skin are eligible for postexposure prophylaxis (PEP), she said.

The recommended treatment for these patients is combined tenofovir disoproxil/emtricitabine and dolutegravir once daily for 28 days, Horwitch said. This regimen should be initiated as soon as possible after exposure but within 72 hours, she said.

HIV management

Clinicians should test for HIV with an HIV Ab/Ag combination assay and confirm positive test results with HIV viral load, according to Horwitch.

Highly active antiretroviral therapy (HAART) should be initiated early in patients with a confirmed diagnosis of HIV, she said. Initial treatment should include three active medications. Recommended regimens include bictegravir/tenofovir alafenamide/emtricitabine, dolutegravir/abacavir/lamivudine or dolutegravir plus tenofovir alafenamide/emtricitabine, she said. Treatment decisions should be tailored based on patient preference, underlying medical conditions, resistance profile, tolerance, renal function, side effects, other medications and insurance coverage, according to Horwitch.

Clinicians should monitor for adherence, efficacy and toxicity, neurological symptoms and weight gain, she noted.

Important drug interactions

“Drug interactions are common with many of the antiretrovirals,” Horwitch said. “It is important to always check for drug-drug interactions.”

Many HIV drugs interact with statins, but vary by degree, she said. Rosuvastatin has fewer interactions, while simvastatin and lovastatin have the most interactions and should be avoided in HIV-positive individuals, she said.

Women who are pregnant or will become pregnant should not use dolutegravir due to the risk of neural tube defect abnormalities, according to Horwitch.

Additionally, several antiretrovirals can lead to increased weight and obesity, she said.

“Primary care clinicians should be able to identify patients at risk for HIV, counsel them on safe sex and be able to initiate preexposure prophylaxis with tenofovir disoproxil/emtricitabine in appropriate individuals,” Horwitch said. – by Alaina Tedesco

Reference:

Horwitch CA. HIV: Longterm complications, preexposure prophylaxis, and postexposure prophylaxis. Presented at: ACP Internal Medicine Annual Meeting. April 11-13, 2019; Philadelphia.

Disclosure: Horwitch reports no relevant financial disclosures.