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Guideline Update for HIV Management in Primary Care

Guideline Watch |
December 9, 2013

Guideline Update for HIV Management in Primary Care

  1. Christin Price, MD and
  2. Paul E. Sax, MD

These guidelines, replacing the 2009 version, have a broader focus and introduce some new recommendations.

  1. Christin Price, MD and
  2. Paul E. Sax, MD

Sponsoring Organization: HIV Medicine Association of the Infectious Diseases Society of America

Target Population: Clinicians who provide primary care to HIV-infected people

Background and Objective

As HIV-related complications decline, people with HIV infection are increasingly at risk for the age-related health problems of the general population. The goal of these guidelines is to offer an overview of initial evaluation and preventive care for clinicians who provide primary care to HIV-infected patients.

Key Points

  • New antiretroviral drugs have become available since the last guideline update in 2009, and the prognosis of people with HIV infection continues to improve.

  • Nevertheless, providers must remain vigilant about health conditions related to HIV infection itself and to HIV treatments.

  • The overall focus of the guidelines has shifted toward preventive measures for HIV-infected patients, including monitoring for age- and sex-specific health problems.

What's Changed

  • The GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system is now being used. Recommendations are graded as strong or weak, and the quality of evidence is categorized as high, moderate, low, or very low.

  • Recommendations on initial evaluation and follow-up for HIV-infected patients, as well as on other sexually transmitted diseases, have been expanded.

  • A new section on metabolic complications replaces the previously separate guidelines on dyslipidemia.

  • Bone densitometry is now recommended for HIV-infected men older than age 50 and for HIV-infected postmenopausal women older than age 50.

  • Anal Pap smears are now recommended for men who have sex with men, women with a history of receptive anal intercourse or an abnormal cervical Pap smear, and all HIV-infected patients who have genital warts.

Comment

The same group that developed the 2009 guidelines has crafted this extensive, well-referenced document, which wisely omits the section on HIV diagnosis and focuses instead on initial evaluation and preventive care for HIV-infected patients. We don't yet know how closely some of the new recommendations, such as anal Pap smears for a very broad range of patients and bone densitometry for HIV-infected men older than age 50, will be followed in general practice — currently, there is widespread variability in how widely they are done. In addition, the guidelines lack recommendations on the frequency of such screening.

One potential modification to future guidelines would be to distinguish practices that are specific to HIV-infected patients (given their higher rates of particular complications), such as screening for sexually transmitted infections and providing pneumococcal immunization, from those that are recommended to certain patients regardless of HIV status. Screening practices in the latter category would include mammography for women older than age 40, colonoscopy at age 50, and ultrasonography to detect abdominal aortic aneurysm for men age 65 to 75 who have ever smoked. Those last three examples are interventions listed without distinction in the new guidelines even though they pertain to conditions known not to be HIV-related. Conceivably, the HIV guidelines could emphasize that screening and preventive strategies for the general population are applicable to those with HIV, omitting specific mention of these non-HIV related individual interventions entirely.

Dr. Price is a Clinical and Research Fellow in Infectious Diseases at Brigham and Women's Hospital in Boston.

  • Disclosures for Paul E. Sax, MD at time of publication Consultant / Advisory board Bristol-Myers Squibb; Gilead; GlaxoSmithKline; Janssen; Merck Grant / research support NIH; Bristol-Myers Squibb; Gilead; GlaxoSmithKline; Merck Editorial boards Medscape; UpToDate Leadership positions in professional societies Mass ID Society (Vice President)

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