HIV care has made leaps and bounds over the past few years. New guidance for primary care physicians addresses these changes and acknowledges the diversity and complexity of individuals with HIV.
Advances in HIV care, along with new complexities about who contracts the disease and issues specific to these patient populations, have spurred the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA) to issue new guidelines for primary care practitioners. The new guidelines supplant the previous guidelines, which were released in 2013.
The recent guidelines emphasize the need for a comprehensive, sensitive, patient-centered approach to HIV care that acknowledges the complexities involved and the barriers faced by many people with HIV. “[The guidelines] discuss initial care, as well as ongoing care, and reflect preventive health care, comorbidity care, as well as the course of HIV throughout the life cycle of the person with HIV,” said Michael Horberg, MD, MAS, FACP, FIDSA, director of HIV/AIDS program-wide for Kaiser Permanente in Washington, DC and an author of the new guidelines, told Contagion®.
HIV specialists are increasingly functioning as primary care physicians for their patients, according to Horberg, although they may retain their role as specialists depending on the healthcare systems in which they practice and what their patients prefer. The COVID-19 pandemic has put particular stress on infectious disease clinicians, who no longer have the time to devote to people with HIV. Because of this, many aspects of HIV care are now being performed by primary care physicians--meaning these revised guidelines are particularly timely.
One section of the new guidelines is on the treatment of people with HIV who have comorbidities such as cardiovascular disease, diabetes, and kidney disorders. Because adherence to antiretroviral therapy (ART) enables people with HIV to live near-normal lifespans, many of them must deal with conditions that commonly occur in an aging populace. Some of them experience comorbidities that arise as a result of having HIV or taking ART. The guidelines stress the importance of monitoring people with HIV for other diseases and incorporating care for these conditions into HIV treatment.
Children and adolescents get a new focus in the updated guidelines. According to the guidelines, children who were infected with HIV in utero are now likely to be in their teens or early adulthood. Along with the typical stresses of these years, youth with HIV are grappling with the demands of the condition and the emotional burdens it bestows. Careful attention to mental health, potential substance issues, risk-reduction behavior and proper dosing of ART by a multidisciplinary team can help these young patients transition to adulthood as easily as possible.
Another addition is information on care for transgender and gender diverse people with HIV, who “should have access to gender-affirming, nondiscriminatory, nonstigmatizing, and culturally sensitive care,” according to the guidelines, including the use of gender-neutral language. This is important because, worldwide, HIV occurs in about 19.1% of transgender women, a 49-fold increase compared with the general population. It’s estimated that up to 1 out of 10 transgender men also may have HIV.
The HIVMA team is particularly proud of the inclusion of care for transgender patients in the updated guidelines, Horberg said, highlighting the fact that potential interactions between HIV drugs and the hormone medications upon which many transgender people rely make such attention necessary.
The considerations of pregnancy or pre-pregnancy planning in people with HIV also are outlined in the new guidelines. “This is one of the great advancements in HIV care,” Horberg said. “Knowing that ‘Undetectable = Untransmissible,’ i.e., if the person with HIV is on effective ART and has an undetectable HIV viral load, then the possibility of transmission HIV to the uninfected partner is exceedingly low. As well, if the uninfected partner also is on HIV pre-exposure prophylaxis (PrEP), safe conception is extremely likely. What this means is that pregnancy and fertility options for all persons and couples with HIV can be a happy conversation and has multiple possibilities, including assisted reproduction technology if need be.”