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Management Recommendations > Preventive Management

Ward 86 Management Recommendations

Ward 86 Approach to Preventive Management for HIV Patients

Contributors: Prasanna Jagannathan, MD
Mark A. Jacobson, MD

Effective antiretroviral therapy (ART) usually prevents the mortality and complications of AIDS, but HIV-infected patients on ART continue to experience higher rates of cardiovascular, kidney, liver, and bone disease, in addition to an increased incidence of certain malignancies and invasive pneumococcal infections, compared with the general population. The greater risk of "non-AIDS-defining" complications is thought to be caused by the systemic inflammatory state and T-cell activation that often persists despite ART. Incomplete immune reconstitution, concomitant substance abuse (in particular, tobacco and amphetamine use), and adverse effects of antiretroviral drugs also may have a role in increasing risk of these "non-AIDS" complications. However, risks of these complications can be reduced by rigorous screening, vaccination, appropriate prophylaxis, and behavioral interventions. Although preventative management in HIV-infected patients is complex, it can greatly benefit this population.

This piece will give our perspective on the following topics:

  • Monitoring of absolute CD4 T-cell count and HIV viral load
  • Opportunistic infection screening and prophylaxis
  • Vaccinations
  • Surveillance for sexually transmitted diseases (STDs)
  • Cancer screening
  • Preventing cardiovascular disease
  • Preventing chronic kidney disease

Monitoring of absolute CD4 T-cell count and HIV viral load

Repeat CD4 cell count monitoring is of essentially no clinical utility for adherent patients who have demonstrated undetectable HIV viral loads on ART for at least 1 year and whose absolute CD4 count has consistently been >200 cells/µL. Even long-term virologically suppressed patients whose absolute CD4 count is in the 100-200 cells/µL range appear to be at minimal risk of opportunistic infections. On the other hand, we have seen that patients with sustained virologic suppression on ART who have absolute CD4 counts plateauing at <100 cells/µL may develop opportunistic infections. Therefore, for patients whose CD4 cell counts are low despite suppressed HIV RNA, checking the CD4 count every 6 months may impact clinical management decisions (eg, when to institute and discontinue prophylaxis for Mycobacterium avium complex).

For ART-adherent patients who have had an undetectable HIV viral load on ART for at least 1 year and whose absolute CD4 count is >200 cells/µL, we do continue to monitor HIV viral loads at 6-month intervals to confirm ongoing virologic suppression.

Opportunistic infection screening and prophylaxis

  • Pneumocystis pneumonia: Patients with an absolute CD4 count of <200 cells/µL should receive prophylaxis for Pneumocystis pneumonia. The need for prophylaxis in patients who have durable virologic suppression on ART and a CD4 count that has plateaued in the 100-200 cells/µL range is questionable. See Prophylaxis section of Pneumocystis topic for regimen details.
  • Toxoplasmosis: We obtain a serum Toxoplasma gondii IgG for all patients who enter care with an absolute CD4 count of <200 cells/µL (or higher CD4 counts if they decline to initiate ART). Patients who have an absolute CD4 count of <100 cells/µL and a positive Toxoplasma gondii IgG titer should receive prophylaxis for toxoplasmosis. See Prophylaxis section of Pneumocystis topic for details on Toxoplasma prophylaxis.
  • Disseminated M avium complex: Patients with an absolute CD4 count of <50 cells/µL should receive prophylaxis for M avium complex, See section 7 in Disseminated M avium Complex topic for regimen details.
  • Tuberculosis (TB): We recommend yearly screening of all HIV-infected patients not already known to have latent tuberculous infection by skin testing or a blood interferon-gamma release assay (IGRA). See TB (Diagnosis) topic for details. All patients with positive test results should be ruled out for active TB and treated for latent tuberculous infection (LTBI), unless they have already been treated. See TB (Treatment) topic, Table 1, for recommended regimens.

Vaccinations

  • Hepatitis A: All patients who test seronegative for hepatitis A total antibodies should receive the standard prime/boost regimen of hepatitis A vaccine.
  • Hepatitis B: All patients who test seronegative for hepatitis B surface antigen and antihepatitis B surface antibody, whether antihepatitis B core antibody positive or not, should receive the standard prime/boost regimen of hepatitis B vaccine. (Of note, in our clinic, we give HIV-infected patients the "double dose" of hepatitis B vaccine; ie, the 40 mcg dose for the prime and booster shots.) For patients with isolated hepatitis B core antibody (ie, surface antigen and antibody negative) who have otherwise unexplained transaminitis, we check for occult active hepatitis B infection with the serum hepatitis B DNA assay. Some of us check HBV DNA in everyone who will initiate ART with a regimen containing tenofovir (TDF), emtricitabine, or lamivudine so that the presence or absence of chronic hepatitis B infection is completely clear before the effect of these drugs with antiviral activity against hepatitis B makes that difficult to determine.
  • Streptococcus pneumoniae: All patients should receive the prime/boost regimen of 13-valent pneumococcal vaccine followed 2-6 months later by the 23-valent vaccine. (See Community-Acquired Pneumonia topic for more details.)
  • Influenza: All patients should receive influenza vaccine, preferably the injectable inactivated form, yearly.
  • Tetanus/diphtheria/pertussis (Tdap): Tdap vaccine should be administered once every 10 years. Tetanus/diphtheria is a reasonable alternative for subsequent vaccines after initial vaccination with Tdap.
  • Varicella/zoster: Patients with no history of chickenpox or zoster should be tested for varicella-zoster virus (VZV) IgG. Those with a negative result should receive live attenuated varicella vaccine once their HIV viral load has been suppressed.

    We consider the herpes zoster (shingles) vaccine in patients who are ≥60 years of age who have a CD4 count of ≥200 cells/µL with virologic suppression on ART and a positive VZV IgG titer or a history of chickenpox.

  • Other necessary live attenuated vaccines (eg, measles, mumps, and rubella [MMR], polio) should be deferred until the patient has an undetectable HIV viral load and the CD4 count is >200 cells/µL.

Surveillance for sexually transmitted diseases (STDs)

We regularly screen all patients for STDs according to their possible risks and sites of exposure.

For asymptomatic men who have sex with men (MSM) who have unprotected sex with multiple partners, we obtain throat and rectal swabs for gonorrhea and chlamydia nucleic acid amplification testing (NAAT) as well as a serum rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL) test at least every 6 months. We also obtain tests at the sites of contact whenever an MSM is symptomatic or tells us he has had a high-risk exposure. We treat empirically for a particular STD if a patient's partner has informed the patient he has been diagnosed with it.

We regularly screen women as needed if they have risk factors for gonorrhea, chlamydia, and syphilis. We also screen women annually for trichomonas with a NAAT of a vaginal swab or urine specimen, with treatment for both the patient and her partner if indicated.

Cancer screening

Certain malignancies occur at higher rates in HIV-infected persons. Based on recent data from the United States,(1) anal cancer occurs 38 times more frequently in HIV-infected people than in those who are not infected. Cervical cancer occurs 3 times more frequently. Among the non-AIDS-defining solid tumors, liver cancer occurs 3 times more frequently and lung cancer twice as frequently among HIV-infected people.

  1. Anal cancer: We recommend performing an anal Papanicolaou (Pap) test and digital examination upon initiation of care for both women and men. If the result is normal, we repeat the Pap and digital exam yearly. We refer patients with an abnormal digital anal exam result or a Pap revealing high-grade squamous intraepithelial lesions (HSIL), atypical squamous cells-cannot rule out HSIL (ASC-H), or more advanced premalignant or malignant cells for colposcopy and biopsy.
  2. Cervical cancer: A cervical Pap test should be performed upon initiation of care, repeated at 6 months, and then performed annually as long as results are normal. HIV-infected women should not be screened less frequently than annually, even if they are monogamous. Patients with abnormal results should have colposcopy and biopsy.
  3. Liver cancer: Most liver malignancies in HIV-infected patients are hepatocellular carcinoma resulting from chronic hepatitis C (HCV) or B (HBV) infection or chronic alcohol abuse. All these underlying conditions are more prevalent among HIV-infected patients than in the general population. Prevention of hepatocellular carcinoma (as well as end-stage liver disease) can best be achieved by:
    1. Early diagnosis and treatment of HCV infection. We routinely perform a serum HCV antibody test yearly in patients not known to have HCV infection who inject drugs or have unprotected sex.
    2. Appropriate HBV vaccination (see Vaccinations, above).
    3. Treatment of HBV for patients known to be hepatitis B surface antigen-positive or HBV DNA-positive in blood. We typically use combined TDF plus emtricitabine or lamivudine as part of the ART regimen to co-treat HBV and HIV; if TDF is contraindicated, we will add another medication for the hepatitis B (eg, entecavir).
    4. Treatment for alcoholism.
    5. Evaluation of unexplained transaminitis: In patients who have either chronic HCV or HBV, we will check for occult infection by the other hepatitis virus with a HCV RNA or HBV DNA assay. Occult HCV and HBV infection each have been reported to occur in up to 10% of HIV patients who have transaminitis but are HCV antibody negative or HBV core antibody positive but HBV surface antigen and surface antibody negative.
    6. Yearly surveillance using liver ultrasound for all patients with chronic HBV infection and for those with chronic HCV plus cirrhosis.
  4. Lung cancer:
    1. Tobacco cessation is essential for lung cancer prevention. Effective medical interventions (ideally combined with some form of cessation counseling) include:
      1. Daily nicotine replacement patches for patients who smoke >10 cigarettes per day with a tapering regimen of 21 mg/day for 6 weeks, then 14 mg/day for 2 weeks, then 7 mg/day for 2 weeks.
      2. Bupropion SR 150 mg/day for 3 days, then 150 mg BID for 7-12 weeks. This regimen should be initiated 1-2 weeks before the quit date.
      3. Varenicline 0.5 mg daily for 3 days, then 0.5 mg BID for 4 days, then 1 mg BID for 12-24 weeks. Use with caution in patients with psychiatric illness, and dosage reduce in patients whose estimated creatinine clearance is <30 mL/min.
    2. The U.S. Preventive Services Task Force has given a Grade B recommendation to annual screening with a low-dose helical chest CT scan for patients 55-80 years of age who have a >30 pack-year smoking history. We consider this appropriate.
  5. Colon and breast cancer: Although these solid tumors have not been reported to be more frequent in HIV-infected than in HIV-uninfected patients, there is emerging evidence suggesting these two cancers may occur at younger ages and be more aggressive in the HIV population. Thus, standard-of-care surveillance is important.
    1. Yearly stool occult blood or fecal immunochemical testing, or colonoscopy at 10-year intervals, for all adults over 50 years of age.
    2. Biennial screening mammography for women 50-74 years of age.

Preventing cardiovascular disease

Because of the well-documented increased incidence of myocardial infarction and stroke among ART-treated HIV patients compared with matched HIV-negative controls in cohort studies, we recommend every 6- to 12-month monitoring of blood pressure, fasting lipids, and blood glucose (fasting glucose or hemoglobin A1c), as well as tobacco cessation intervention for smokers (see Lung cancer, above). We recommend diet changes, weight loss, and exercise as appropriate. See the Vaccinations topic for specific management recommendations.

Preventing chronic kidney disease

Kidney disease occurs with increased frequency in HIV-infected people and is associated with increased morbidity and mortality. We recommend checking serum creatinine/GFR and urine protein on entering care and every 6 (creatinine/GFR) or 12 months (urine protein), with an increased frequency of monitoring for patients who have hypertension or chronic HCV infection, or receive TDF in their ART regimen. We avoid TDF in patients with a GFR of <60 mL/min and stop TDF in patients with a GFR decline of >25% or a drop to <60 mL/min.

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Preventing osteoporosis: A separate topic addressing osteoporosis will be posted soon.

References

  1. Robbins HA, Pfeiffer RM, Shiels MS, et al. Excess cancers among HIV-infected people in the United States. J Natl Cancer Inst. 2015 Feb 6;107(4).
  2. Aberg JA, Gallant JE, Ghanem KG, et al; Infectious Diseases Society of America. Primary care guidelines for the management of persons infected with HIV: 2013 update by the HIV medicine association of the Infectious Diseases Society of America. Clin Infect Dis. 2014 Jan;58(1):1-10.