Over the decades, HIV infection has transitioned from an almost universally deadly infection to a chronic, manageable disease. Increased survival, along with improved access to health care and screening, has allowed far more patients to live relatively normal lives. But primary care providers need to stay up to date on all aspects of the disease in order to provide the best possible care to those affected and aid efforts to stem the spread of disease.
Patients with HIV infection whose disease is well controlled can now live a normal lifespan. Because of this increase in lifespan, along with increased health care coverage through the Affordable Care Act, primary care clinicians will be increasingly responsible for the care of patients with HIV. In order to offer optimal treatment, however, clinicians must remain current on HIV screening, initial treatment, and ongoing management. New therapies and simplified regimens have improved HIV care, but diligence in monitoring for complications of HIV and its treatment is needed in order to optimize care.
Consider, for example, a 19-year-old man who comes into your primary care office complaining of a sore throat, malaise, and a generalized rash. On exam, you note cervical adenopathy and a widely scattered rash, mainly on his trunk. His throat is mildly erythematous without exudates. You do a rapid test for strep and for mononucleosis, both of which are negative. A viral syndrome seems the most likely diagnosis, but if you neglect to get a sexual and drug history, you might not think of HIV as the virus in question. And even if routine HIV antibody screening is done as recommended, HIV antibodies have likely not yet developed. This is a classic presentation of acute retroviral syndrome, easily confused with a myriad of less consequential infections. Most cases of HIV are not detected at this stage, although it is estimated that between 50% and 90% of patients with acute HIV infection seek medical care.1-4 The patient with acute HIV and potentially many others can be spared significant harm if HIV is part of your differential diagnosis.
Primary care clinicians play a key role in all aspects of HIV care, starting with HIV prevention through screening, helping HIV-negative patients reduce the risk for infection, and helping to assure that HIV-positive patients are less likely to spread the disease because their own infection is fully suppressed. Primary care providers will also become increasingly involved in the care of patients who are living with HIV. Just as with diabetes or hypertension, patients already HIV infected can be largely managed by knowledgeable primary care clinicians. The required knowledge includes an understanding of the latest recommendations for screening, both pre-exposure and postexposure prophylaxis, and the initial work-up and ongoing management of patients diagnosed with HIV. Expert consultation is often helpful and will be critical in many cases, but all providers should have a working knowledge of HIV care.
On the next page: Screening and prevention >>