Q&A: IDSA updates guidance on HIV management in primary care

The Infectious Diseases Society of America recently published updated guidance in Clinical Infectious Diseases on providing evidence-based primary care to patients with HIV.

The guidance, an update to the group’s previous 2013 recommendations, was made in recognition of the complex primary care needs of patients in the HIV population who are living longer due to the availability of effective, less toxic treatments.

The guidance includes new sections on the care of transgender and gender diverse patients with HIV, and considerations for patients with HIV who become infected with COVID-19.

Additionally, the new guidance provides physicians with updated recommendations on optimizing care engagement; medication adherence and viral suppression; initial evaluations and routine health care maintenance; how to manage metabolic and other comorbidities associated with antiretroviral therapy; and HIV care management in children and adolescents.

To learn more about the guidance and the importance of these updates, Healio Primary Care spoke with Michael A. Horberg, MD, MAS, FACP, FIDSA, of the Mid-Atlantic Permanente Research Institute and director of the HIV/AIDS and STD program at Kaiser Permanente and Care Management Institute.

Q: Is this guidance part of an effort to shift responsibility for the treatment of HIV to primary care? If so, are primary care physicians being asked to take on too much specialized medicine?

A: No it’s not; this is actually an update and revision on previous guidance that is considered by many as one of the three main sets of guidance for HIV care in the United States, the others of course being from HHS and the International Antiviral Society – USA. This really deals with the elements of comprehensive HIV patient care, and while that does fall into primary care, a lot of the time primary care is being delivered by the HIV specialist, ID specialist or in collaboration with a primary care physician. So, while a lot of this [guidance] looks very strenuous and comprehensive, it’s often not just done by one person. And of course, as we stress in the guidelines, multidisciplinary care is the key to quality HIV care.

Q: What updates have been made to guidance on initial evaluation and routine health care maintenance in patients with HIV?

A: First and foremost, we now recognize that this all just doesn’t happen on the first visit — those long in-person visits are just not pragmatic in this world today, especially in the case of COVID-19. But there are still so many elements of it that are important, including complete prior history. For many of your patients who come in with an HIV diagnosis, this isn’t a completely new diagnosis. For insurance reasons, mobility, et cetera, they may already have an established HIV diagnosis but haven’t had established care, or they may have fallen out of care. So, the full complete history is one of the things we stress here. Additionally, we also stress which laboratory exams are important to include and which ones that were commonly used in the past but aren’t necessarily recommended now. As patients are now more likely asymptomatic and often presenting with higher CD4 counts than before — likely due to better, earlier testing — some of those tests in the past may not be needed. Also, we’ve really emphasized now the importance of the non-HIV-related, but very important, primary care health screening — including screening for many cancers — as patients are aging, as well as looking closely for any comorbidities, including things like hepatitis and diabetes, which was stressed before but also now includes weight management. In the past, we weren’t as concerned about weight gain, but as our patients are living longer, it’s a far greater concern. Finally, I would also add we’ve updated guidance on vaccinations and really stressed the importance of stopping smoking and depression and substance use screening.

Q: What is the importance of updates to recommendations for managing metabolic and other noncommunicable conditions in patients with HIV, and what should PCPs know about these changes?

A: This is really one of the unintended consequences of the great successes of HIV. We have so much more effective therapy to treat the HIV, and with high adherence, patients are living longer. The other side of that is that there does seem to be a higher risk of comorbidities, some of them related to the medications and some of them related to HIV itself, including diabetes. Certainly, some cancers related to other infectious causes seem to heighten this issue in HIV, including HPV and anal cancer. It’s important that physicians have a heightened awareness for this and screen regularly and appropriately, as well appropriate vaccinations, including hepatitis B and HPV.

Q: How has the guidance for managing children and adolescents with HIV changed?

A: It’s changed a little bit in that there is greater recognition now that more parents with HIV who can be successfully managed prenatally and are going to have more and more children. The incidence of vertical transmission from mother to child is low, but there is greater recognition that children are living longer and will have very complex issues, including greater issues with viral control and some potential developmental issues. For adolescents, there is a greater sense of the fact that adolescents can be sexually active and can acquire HIV that way and will have unique developmental issues compared with many of their peers because they have an added issue of a chronic medical condition. Further, there needs to be purposeful transitioning from pediatric care to adult care. The essence of the care is very different. There are other family dynamics that have to be managed in adolescents, and they are not going to be the same family dynamics in adult care.

Q: The guidance includes new recommendations for managing HIV in transgender and gender diverse populations. What should PCPs know about these recommendations?

A: We need to create a welcoming space and make sure we’re using the correct names and pronouns. Understand that transgender care is a continuum, and we’re placing self-determination along that continuum that will require you to be open and welcoming of the patients. Additionally, as patients go down many other routes, including hormonal therapies, there are some potential drug interactions that the primary care physician, the HIV specialist, the person providing transgender care and endocrinologists may need to be aware of. Again, this is a multidisciplinary care approach.

Q: What considerations should PCPs make for patients with HIV who become infected with COVID-19?

A: At this point, there are no unique recommendations for patients with HIV who get COVID-19. However, it’s really imperative that the viral load be under good control and that the CD4 count be maximized. Again, that really helps in almost every comorbidity among patients with HIV. The other thing is, obviously, there may be less opportunity for in-person care for a variety of public health safety issues, including social distancing and masking. So, the use of video visits and telephone follow-ups may become even more important. If you have patients who have been isolated or have already had a history of isolation, substance use or depression, it is really important to check on these patients much more regularly because these are also co-conditions that could affect both COVID-19 and their HIV care.

References:

IDSA. IDSA and HIVMA Release New Comprehensive Primary Care Guidance for People with HIV. https://www.idsociety.org/news--publications-new/articles/2020/idsa-and-hivma-release-new-comprehensive-primary-care-guidance-for-people-with-hiv/. Accessed November 12, 2020.

Thompson MA, et al. Clin Infect Dis. 2020;doi:10.1093/cid/ciaa1391.