INTRODUCTION

There are many models for the delivery of good HIV care. Likewise, there are many interpretations of these models. What most providers agree on is that patients deserve good primary care and education as well as expert HIV management. Whether these services are delivered in one practice, usually by an infectious disease specialist or AIDS expert, or by multiple or dual providers separating the HIV care from the primary care, is not an issue. What is important is that each patient is carefully managed to ensure care that is competent, thoughtful and state-of-the art for his or her specific issues.

Antiretroviral therapy (ART) is the best-known and most critical component of HIV management. However, HIV care does not stop with prescribing and monitoring ART. Episodically, most patients will need referrals to specialists for special needs which could include but not be limited to care related to pregnancy, surgical issues, psychiatric illness, substance abuse, dental and subspecialist procedures. Imperative is the element of collegial communication and cooperation in providing these services.

Models of care may include HIV clinics in academic medical centers, infectious disease practices, federally qualified health centers; some are multi-specialty and others require referrals to specialists through ongoing agreements.

HAART*, ARV†, ART‡…whatever you call it, be sure you call upon it with every patient. Patients often just call it – the cocktail or meds or my pills. In this article, we call it ART.

* HAART: Highly Active Antiretroviral Therapy
† ARV: Antiretroviral Therapy
‡ ART Antiretroviral Therapy

HIV Medical Care

Management of the Viral Infection

What characterizes the care of the HIV infected person is that they are HIV positive. The provider must be comfortable with the disease, but more importantly, with the person who is living with the disease. While HIV is just a viral infection, the emotional overlay and stigma make it more than just another infection. This being said, the most important element for most HIV providers is to achieve an intact immune system with a normal CD4+ count and to seek “nirvana,” otherwise known as an undetectable viral load. There are many ways to achieve this, especially in a patient who is newly diagnosed and who has a pansensitive virus. In fact, most patients will quickly and easily have a favorable response to ART. The problem is maintaining treatment adherence and an undetectable viral load in the long term.

HIV Treatment Guidelines, frequently updated by HIV clinical experts, are a framework to help the practitioner know when to start ART and what regimens to start. The standard of care requires obtaining the patient’s CD4+ count, viral load, and genotype to determine the baseline status. The follow-up laboratory management is likewise carefully detailed to ensure appropriate monitoring of the CD4+, viral load, and viral sensititivity to the ART. The most recent HIV Treatment Guidelines may be found at http://www.aidsinfo.nih.gov/Guidelines.¹

Although this is the most expensive part of the treatment, it is perhaps the easiest to manage. The provider is basically a midwife, delivering the treatment. If HIV medication was the totality of treatment, it would be a routine chronic illness.

Avoidance of Treatment Toxicity

Although most breaks in treatment are due to nonadherence, drug toxicity and intolerance also play an important role. While deciding when to start ART and what to start can be fairly straightforward from the laboratory point of view, when dealing with a unique individual, one must have other concerns. Each ART has its own toxicity profile. It is important to match patient preference (and dread) with potentially successful regimens. If a patient tells you that he or she could stand any side effect except nausea, it will be incumbent on the provider to select an ART regimen that will avoid this issue. It is understood that the provider will have a good grasp of the patient’s current medical history as well as past to avoid toxicity.

In the female patient, it is important to assess the potential for pregnancy, which the clinician should assume in any woman of childbearing age unless she has had a hysterectomy, menopause, tubal ligation, or sexual practices that do not involve heterosexual intercourse. It is important to avoid efavirenz for any children of childbearing potential and to be vigilant in screening for pregnancy. The clinician should recommend two forms of contraception including a barrier method.¹

Pre-existing conditions require careful selection of ART to avoid toxicity include renal disease due to heroin use, diabetes, hypertension, or polycystic kidney disease. Clinicians will need to avoid known nephrotoxins for patients with abnormal creatinine clearance, or dose appropriately and monitor closely.

Drugs used to treat opportunistic and other infections that are known to be nephrotoxic include amphotericin B and TMP/SMX (trimethoprim and sulfamethoxazole), also known as Cotrimoxazole, sold as Bactrim, Septra, or Septrim). These may be used as treatment or prophylaxis for pneumocystis jirovecii pneumonia (PCP) and other infections. Additional medications of concern include acyclovir, adefovir, aminoglycosides, cidofovir, famcyclovir, foscarnet, gancyclovir, sulfadiazine, valganciclovir, valacyclovir, and vancomycin.

HIV antiretroviral medications with nephrotoxic effects include nucleoside/ nucleotide reverse transcriptase inhibitors (NRTIs) emtricitabine, lamivudine, tenofovir, and zidovudine; and indinavir, a protease inhibitor. Combination medications containing nephrotoxic NRTIs also require close patient monitoring. These include Combivir (zidovudine + lamivudine), Epzicom (abacavir + lamivudine), Trizivir (zidovudine + lamivudine + abacavir), and Truvada (emtricitabine + tenofovir).^1,2

Patients with liver disease, including hepatitis or cirrhosis, often due to alcohol abuse, may not be able to tolerate medications metabolized through the liver. Patients may be unable to take zidovudine due to a history of hematologic disease such as anemia, or menorrhagia, fibroid, amenorrhea, or sickle cell. Most ART is cleared via the liver and may exacerbate hepatic disease. Likewise, antituberculosis drugs may also present issues with hepatic toxicity.

HIV medical providers should test patients for HLA-B*5701 prior to prescribing abacavir to assess their risk for hypersensitive reaction. Similarly, only patients who are resistant to multiple antiretroviral agents should be tested for CCR5-tropism to determine if they are suitable candidates for maraviroc. Certain combinations and agents are notorious for toxicity, including the combination of didanosine (ddI) and stavudine. Nevirapine can cause lactic acidosis especially in obese women with higher CD4+ counts. Stevens-Johnson Syndrome can also be a toxicity associated with this non-nucleoside reverse transcriptase inhibitor (NNRTI), especially if dose escalation is not used for the first 2 weeks of treatment. Patients with depression may be adversely affected by efavirenz, and this agent also can cause teratogenicity in first-trimester pregnancy by affecting the formation of neural tube defects in the fetus.^1,2

Pancreatitis is a risk when ddI is given to alcoholics and patients with a history of gall bladder disease.

Protease inhibitors are usually very effective but are fraught with GI symptoms including diarrhea and bloating, and may be implicated in lipodystropy.^1,2