HIV/AIDS treatment guidelines

HIV/AIDS Treatment Guidelines for Clinicians

In 2021, the Centers for Disease Control and Prevention (CDC) estimated that over 1.2 million people are living with HIV in the United States. Although the number of new HIV diagnoses per year has decreased by 7% between 2017–2021, the US Department of Health and Human Services has set a goal of at least a 90% reduction by 2030. A robust workforce of clinicians with expertise in managing HIV and preventing transmission is required to achieve this goal.  

Recommended course: HIV/AIDS Update for Clinicians 

Unfortunately, fewer physicians are choosing to specialize in the field of HIV medicine. Current estimates predict the supply of providers will be unable to meet the increasing demand for HIV services. To address the provider shortage, more primary care providers (PCPs), including mid-level providers (i.e. PAs and NPs), should receive additional training about HIV/AIDS treatment guidelines and procedures. 

Emerging role of primary care in HIV 

The use of primary care provider teams, consisting of combinations of physicians and mid-level practitioners, can improve access and achieve similar outcomes to physician-only teams. These multi-provider teams combine quality care with cost-effectiveness. A lingering question is whether primary care providers are ready to step into their new role. 

A survey in 2020 set out to provide some insight into this question. Of the 347 physician respondents, 70.6% agreed that PCPs should take care of HIV patients and the majority (59.7%) felt they were ready to care for HIV patients with some training around HIV/AIDS treatment guidelines. 

These encouraging findings are welcomed in the ever-changing landscape of HIV medicine. With PCPs treating HIV patients, these patients receive comprehensive care to manage their chronic diseases and HIV needs.  

Modes of HIV transmission 

Direct contact with bodily fluids of a person with HIV and a detectable viral load can result in transmission of the infection. With rigorous testing procedures, transfusions, organ donation, and allograft tissues are extremely rare causes of transmission. The most common modes of transmission include anal and vaginal sex, needle/syringe sharing, perinatal transmission, and the rare healthcare setting workplace transmission. 

Sexual contact 

Male-to-male sexual contact without the use of barrier protection (i.e. condoms) or pharmacologic barriers (i.e. antiretroviral medications) is the leading mode of HIV transmission. In 2021, 67% of all transmissions were a result of male-to-male sexual contact, while 22% occurred during heterosexual contact. 

Needle/syringe sharing 

The sharing of needles, syringes, and other drug injection equipment can contain blood from an HIV patient resulting in transmission. This mode accounted for 7% of all transmissions in 2021. 

Perinatal transmission 

Mother-to-child transmission can occur during pregnancy, birth, and breastfeeding and accounts for the most common modes of transmission in children. Advances in antiretroviral therapies and preventative strategies have significantly reduced perinatal transmission rates to less than 1%. 

Healthcare workplace transmission 

Universal precautions help to protect healthcare workers from potential transmissions leading to this mode being extremely rare. Even with exposures (ie. needlesticks and splashes), the seroconversion rate is estimated to occur in approximately one in 200 contaminated needlestick injuries. 

Importance of universal precautions in HIV/AIDS treatment 

The introduction of universal precautions in 1987 by the CDC helped to reduce transmission of HIV and other blood-borne pathogens, such as Hepatitis B and C. Treating blood and certain bodily fluids as potentially infected with a blood-borne pathogen is a central premise to universal precautions. These protective measures include: 

  • Wearing gloves, masks, and eye protection to prevent potential exposures 
  • Practicing safe sharps handling (needles, scalpels, etc.) to prevent accidental injuries 
  • Immediately and thoroughly washing hands after contamination with bodily fluids 

Prevention, diagnosis, and management of HIV: Primary care guidelines 

Approximately 40% of new HIV infections are the result of transmission from a person who is unaware they have the virus. Routine screening can help prevent the transmission by identifying those at risk of transmission. Currently, the CDC endorses the following screening guidelines: 

  • Everyone between the ages of 13 and 64 should be tested at least once as part of routine healthcare 
  • Individuals with certain risk factors (male-to-male sexual contact, injection drug use, etc.) should test annually 
  • Clinicians should use an “opt-out” approach by informing patients of routine testing and informing them they can decline testing 
  • Pre-exposure prophylaxis use in those at risk of acquiring an HIV infection 

Diagnosis 

Technological improvements have increased the number of tests capable of detecting and diagnosing an HIV infection. The “window period” is the time from which the exposure occurs and the time when the test can accurately detect HIV. Each test has a specific window period that can help guide the testing timeline after an exposure. 

Currently, testing is performed using one of three types of tests: 

  • Nucleic acid tests (NATs): Detect RNA of the HIV, shortest window period 
  • Antigen/Antibody combination tests: Detect the HIV antigen p24 and IgM and IgG antibodies produced by the body in response to the virus 
  • Antibody tests: Detect IgM and IgG antibodies to the virus. 

The CDC recommends laboratories use the antigen/antibody combo tests for the initial testing modality. If abnormal, confirmation tests should be performed using HIV-1/HIV-2 antibody differentiation immunoassays. 

Management 

An HIV diagnosis has social, psychiatric, and medical implications. Therefore, initial management requires a multidisciplinary approach to ensure the impact on the social and psychiatric well-being of the patient is being addressed. 

Initial medical management requires the assessment of the patient’s readiness to begin antiretroviral (ART) medications and high-risk behaviors, comorbidities, social support, medical insurance, and other factors impacting medication compliance. Initial ART medications for a treatment-naive patient consist of one or two NRTIs, plus a drug from one of the three other drug classes: an INSTI, an NNRTI, or a boosted PI. 

HIV/AIDS treatment guidelines: Barriers to optimal care 

Access to HIV treatment is the most important factor in reducing mortality and morbidity. Unfortunately, there are many factors that can impede appropriate, long-term care. Financial barriers, lack of transportation, and the lack of quality care can prevent patients from seeking appropriate treatment. It may also lead to interruptions in therapy. Mental health issues and lack of support play significant roles in treatment compliance, which is vital to preventing resistance. 

The stigma of HIV and implicit biases surrounding patients with HIV are substantial barriers to appropriate care. This can lead to patients hiding the diagnosis for fear of rejection, social isolation, or judgment. The negative stigma can lead patients to internalize their diagnosis to signify a moral failure or deviance leading to them feeling as if they do not deserve help. 

The engagement of primary care providers can help improve access to quality medical care and enhance screening and preventative measures. Through education and multidisciplinary care, PCPs can reduce the burden on HIV patients and encourage long-term, appropriate therapy.