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• Most patients with HIV have no symptoms.
• Test all pregnant women.
• Regularly test patients who engage in risky behaviors or have a new sexually transmitted disease.
• The best screening approach is a serum antibody test.
• HIV has become a chronic disease and primary care providers have an important role to play in management.
• Antiretroviral (ARV) drugs have many drug interactions and side effects. Primary care providers may be the first to recognize and manage these complications.
• For people potentially exposed to HIV, offer a standard PEP regimen.
• PEP should be initiated immediately following exposure, and no more than 72 hours later.
Epidemiology of HIV in the US
• With improved treatment regimens, HIV-positive people are living longer and the prevalence of HIV is thus increasing steadily.
• Unfortunately, the number of new infections each year has remained relatively unchanged since the early 1990s.
• Most cases of HIV in the US occur in whites. However, there are proportionally more cases among blacks and Hispanics.
• The majority of new cases occur in men who have sex with men (MSM). It is important to keep in mind that not all MSM identify themselves as gay men.
• Women are more likely to contract HIV heterosexually than men.
• IV drug abuse accounts for about 10% of new cases.
According to the Center for Disease Control (CDC), an area has a high-prevalence HIV epidemic if more than 1% of the population is infected. At the end of 2009, about 3.2% of the adult population in Washington, D.C. were living with HIV/AIDS.
In most states including D.C., testing is done on an “opt-out” basis; that is, the patient is notified that HIV testing will be performed, and he or she has the option to decline.
• Universal testing can help identify the 20% of infected Americans who do not know they are infected.
• Neither written consent nor prevention counseling is required to test for HIV in most areas.
• Those who opt out should be counseled on the benefits of early diagnosis.
Test all pregnant women in the 1st trimester.
• Repeat screening in the 3rd trimester in high-prevalence areas, which includes D.C.
• Timely diagnosis during pregnancy can prevent perinatal HIV infection of the baby.
Test all patients with a sexually transmitted infection or active TB.
Several conditions are more common in HIV-positive patients, and should prompt HIV testing.
• Herpes zoster;
• seborrheic dermatitis;
• thrush;
• recurrent vaginal candidiasis.
Serum antibody testing is first line.
• If the antibody test is positive, the lab will confirm with a Western blot.
• An “indeterminate” Western blot result may mean:
— the antibody test was a false positive;
— the patient has acute HIV infection and has not yet seroconverted, or
— HIV-2 infection is present (very rare in the U.S.).
• Rapid HIV antibody testing is widely used; it is fast, convenient, and accurate.
— Results can be received within 30 minutes.
Undiagnosed chronic HIV infection usually presents with opportunistic infections. The most common include the following:
• bronchitis;
• tracheitis;
• esophagitis;
• chronic diarrhea (>1 month);
• retinitis;
• chronic lip ulcers;
• pneumonia;
• brain lesions, and
• bloodstream infections.
Other HIV-associated complications include:
• cancers (invasive cervical cancer, Kaposi sarcoma, some lymphomas);
• HIV encephalopathy, and
• HIV wasting syndrome.
After the initial HIV diagnosis, take a thorough history with specific focus on:
• medication history, including over-the-counter medicines, to determine potential drug interactions;
• sexual practices to assess potential for risk reduction and notification of sexual partners;
• alcohol and substance abuse, depression/anxiety, and social support, all of which can affect adherence to HIV therapy.
Drug treatment is generally recommended for patients with CD4 counts under 500 cells/mm3. Initiating treatment in patients with counts >500 cells/mm3 can be considered.
Populations that should be treated regardless of CD4 count include:
• pregnant women;
• those with a history of any AIDS-defining illness;
• patients with HIV nephropathy, and
• hepatitis B co-infection requiring treatment for Hepatitis B.
Once treatment is started, it should not be stopped unless there is a compelling reason. The main goal is reduction of the viral load. CD4 count and viral load will be monitored.
HIV treatment regimens work in several different ways:
1. Preventing the virus from entering (or “fusing” with) the human cell (fusion inhibitors and co-receptor antagonists).
2. Preventing the virus from replicating inside the cell (nucleoside/nucleotide reverse transcriptase inhibitors [NRTIs] and non-nucleoside reverse transcriptase inhibitors [NNRTIs]).
3. Preventing integration of viral DNA into host DNA (integrase strand transfer inhibitors, INSTIs).
4. Terminating viral protein assembly (protease inhibitors, PIs).
At least 3 agents are usually started together, most commonly:
2 NRTIs + 1 NNRTI/PI/integrase inhibitor
Once-daily combination pills can enhance compliance:
2 NRTIs (tenofovir + emtricitabine) = Truvada
2 NRTIs (tenofovir + emtricitabine) + 1 NNRTI (efavirenz) = Atripla
2 NRTIs (tenofovir + emtricitabine) + 1 NNRTI (rilpivarine) = Complera
Medication adherence is especially important for antiretroviral therapy because inconsistent use can lead to the development of a drug-resistant strain of HIV. The following strategies can be used to improve adherence:
• use a multidiscipinary approach through an accessible health care team;
• establish a trusting relationship with the patient;
• establish readiness to start antiretroviral therapy;
• identify potential barriers to adherence prior to starting therapy;
• provide resources for the patient;
• involve the patient in ARV regimen selection;
• assess adherence at every visit;
• identify the type of nonadherence;
• identify the reasons for nonadherence, and
• assess and simplify regimen, if possible.
After a needlestick exposure, the use of PEP can reduce the risk of HIV acquisition by ~ 80%.8 Administer PEP as soon as possible, and definitely within 72 hours of exposure, and continue it for 28 days.
The CDC recommends PEP for people exposed to HIV by:
•a percutaneous injury (e.g., needle-stick or cut);
•contact with blood, tissue, or potentially infected fluid* on mucous membranes/non-intact skin.
The precise regimen depends on the nature of the exposure, and the status of the patient.
• It generally consists of 2 nucleoside reverse transcriptase inhibitors (NRTIs) such as the combination pill, Truvada, and
• a protease inhibitor (PI), such as Kaletra, may be added for severe exposures.
If a patient seeks care after possible exposure through sexual contact (consensual or forced), drug use, or another source of exposure, the intervention needs to be immediate.
1) Initiate ARV treatment.
2) Contact an infectious disease specialist, but do not allow this to delay treatment initiation.
3) Send patient to the emergency room if contacted outside of office hours.
• Test for HIV and other sexually transmitted diseases (including hepatitis B and C);
• Counsel on risk reduction and emergency contraception if appropriate;
• Follow up at 1, 3, and 6 months for repeat HIV, syphilis, hepatitis B and hepatitis C serologies.
HIV transmission between partners can be prevented by early antiretroviral therapy in the infected partner.7 Successful antiretroviral therapy (e.g., that achieves very low viral loads) can sharply reduce the risk of infecting a sexual partner.
Pre-exposure prophylaxis (PrEP) of daily emtricitabine and tenofovir can reduce HIV acquisition by 44 to 78%. For more information: www.cdc.gov/hiv/prep.
Male circumcision reduces the risk of heterosexually acquired HIV infection in men. For more information: www.malecircumcision.org.
If an HIV-positive patient wants to participate in a vaccine trial, refer to the HIV Vaccine Trials Network (HVTN) at www.hvtn.org.
Syringe exchange programs reduce HIV transmission in injectable drug users by providing a way to safely dispose of used syringes and obtain sterile syringes at no cost.