University of California, San Francisco Logo

University of California, San Francisco | About UCSF | Search UCSF | UCSF Medical Center

Home > Management Recommendations > Preventive Management

Ward 86 Management Recommendations

Ward 86 Approach to Preventive Management for HIV Patients

updated August 2017

Contributors: Elizabeth Imbert, MD
Paula Lum, MD
Mark A. Jacobson, MD

While effective antiretroviral therapy (ART) can prevent nearly all the mortality and morbidity caused by AIDS-defining opportunistic infections and malignancies, HIV-infected patients with undetectable viral loads on ART continue to experience higher rates of cardiovascular, kidney, liver, and bone disease, in addition to an increased incidence of certain non-AIDS-defining malignancies as well as invasive pneumococcal infections, compared with the general population. This greater risk of "non-AIDS-defining" complications appears to be caused by the systemic inflammatory state and T-cell activation that often persists despite effecctive ART. Incomplete immune reconstitution, concomitant substance abuse (in particular, tobacco and amphetamine use), and adverse effects of antiretroviral drugs may also have a role in increasing risk of these "non-AIDS" complications. However, the risk of these complications can be reduced by rigorous screening, vaccination, appropriate prophylaxis, and behavioral interventions. Although preventive management in HIV-infected patients is complex, it can greatly benefit this population.(1)

This topic will give our perspective on:

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 observed patients with sustained virologic suppression on ART and absolute CD4 counts plateauing at <100 cells/µL develop opportunistic infections. Therefore, for patients whose CD4 cell counts are this 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 8 of Diagnosis and Management of Disseminated Mycobacterium avium Complex Infection 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. Of note, in 2016-17, an unusual increase in cases of hepatitis A affecting mainly men who have sex with men (MSM) has been reported by low-endemicity countries, including the United States.
  • 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 disoproxil fumarate (TDF), tenofovir alafenamide (TAF), 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--the rationale being that patients who have virologically suppressed chronic hepatitis B infection remain at increased risk of developing hepatocellular carcinoma and should be monitored yearly by liver sonogram for this complication.
  • 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.
  • Meningococcal disease: Clusters of serogroup C meningococcal disease among MSM have been reported in recent years. In May 2017, the CDC published results of an analysis of all 527 cases of confirmed meningococcal disease known to have occurred in the United States between January 2012 and June 2015.(2) The relative risk for MSM was 4-fold higher than for non-MSM, and among MSM the relative risk was 10-fold higher for those who were HIV-infected. We now offer routine vaccination with the quadrivalent meningococcal conjugate vaccine to all HIV-infected MSM patients.
  • 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 obtain a history of recent sexual activity and screen all patients for STDs according to their possible risks and sites of exposure.

For asymptomatic MSM who have unprotected oral sex and/or insertive and/or receptive anal intercourse, we obtain throat and/or urine and/or rectal swabs for gonorrhea and chlamydia nucleic acid amplification testing (NAAT) at least every 6 months. For asymptomatic MSM who have any mode of unprotected sex, we obtain a serum rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL) test at least every 6 months. We always 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,(3) 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 anal examination upon initiation of care for both women and men who have sex with men. If the result is normal, we repeat the Pap and digital exam of the anus yearly. We refer patients with an abnormal digital exam result or a Pap revealing low-grade squamous intraepithelial lesions (LSIL) or more advanced premalignant (eg, HSIL) or malignant cells for high-resolution anoscopy (HRA) and biopsy of suspicious lesions. Some us also refer patients whose Pap reveals atypical squamous cells of undetermined significance (ASCUS) for HRA.
  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 or TAF 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/HBV surface antigen and surface antibody negative.
    6. Yearly surveillance using liver ultrasound for all patients with chronic HBV infection, even if HBV DNA is undetectable on antiviral therapy, 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 may 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 Management of Hyperlipidemia in HIV-Infected Patients 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. Many of us now substitute TAF, which has a lower risk of nephrotoxicity, for TDF in all patients.

Preventing osteoporosis

See Osteoporosis topic for specific management recommendations.

Approaching medication adherence and improving retention in care

See Adherence and Retention topic.

Addressing substance use

Substance use can hasten disease progression, affect adherence to ART, and worsen overall consequences.(4) We endorse a harm reduction approach to substance abuse and encourage the use of nonjudgmental language that respects the worth and dignity of all persons and avoids perpetuating stigma.(5,6) Harm reduction is a public health philosophy that directly involves patients in setting their own goals, which often focus initially on incremental reductions in substance use and unsafe practices. Relapse or periods of return to unsafe health practices are not conceptualized as "failure of treatment." Specific approaches to substance abuse treatment in HIV-infected patients are discussed below in Table 1.

Table 1. Approaches to Substance Abuse Treatment in HIV-Infected Patients

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an approach applicable to any substance use problem.

  • This involves asking permission to discuss alcohol and drugs and normalizing this discussion. For alcohol use, we recommend a prescreen question: "Do you sometimes drink beer, wine, or other alcoholic beverages?" followed by a screen: "How many times in the past year have you had 5 (for men, 4 for women) or more standard drinks in a day?" For drug use, we recommend asking, "How many times in the past year have you used an illegal drug or a prescription medication for nonmedical reasons?"
  • If the patient answers anything greater than 0 for the alcohol screen or drug use question, proceed with an assessment of the quantity and pattern of use as well as assess for substance use disorder (SUD) and other consequences.
  • Summarize for the patient your assessment of substance use, its complications and consequences.
  • Ask permission to share information about health effects of drinking/drug use.
  • Provide feedback using the "elicit, provide, elicit" model.
  • Assess readiness. If low, enhance motivation using open-ended questions, affirmations, reflections, and summaries. If high, proceed to action planning. If above-safe drinking limits or illicit drug use with consequences or mild SUD, provide brief intervention during the office visit. If moderate to severe SUD, provide medical management and/or referral to treatment (ie, detoxification, outpatient or residential treatment).

Alcohol use

  • In addition to SBIRT, the Alcohol Use Disorders Identification Test (see AUDIT) is a 10-item screening tool developed by the World Health Organization to assess alcohol consumption, drinking behaviors, and alcohol-related problems.
  • We recommend offering a full range of effective treatments including medications, counseling, mutual help groups, detoxification, and rehabilitation. Naltrexone, which blocks opioid receptors that are involved in the rewarding effects of drinking alcohol and the craving for alcohol, can reduce relapses to heavy drinking. A minimum initial period of 3 months of pharmacotherapy is recommended, although an optimal treatment duration has not been established. In one study, HIV viral load decreased from pre- to post-naltrexone prescription.(7) Pharmacotherapy for alcohol dependence is most effective when combined with some behavioral support that supports recovery. (See Helping Patients Who Drink Too Much and Medication for the Treatment of Alcohol Use Disorder for more information).

Opioid use

  • Treating opioid use disorder includes access to clean needles, safe storage and disposal of sharps, and safer injection techniques.
  • In addition, opioid use disorder can be treated with medication-assisted treatment including: methadone, buprenorphine or naltrexone. All medications for the treatment of the opioid use disorder should be prescribed as part of a comprehensive individualized treatment plan that includes counseling and other psychosocial therapies, as well as social support and other mutual-help programs. Buprenorphine in HIV patients has been associated with increased ARV use, improved quality of life, and decreased opioid use.(8) Methadone in HIV patients has been associated with virologic suppression and CD4 count increase.(9)
  • Providers should prescribe naloxone to patients with opioid use disorder as an available emergency treatment to counter the effects of opioid overdose (see Medication-Assisted Treatment of Opioid Use Disorder for more information).

Methamphetamine use

  • For more information on management of HIV-infected patients who use methamphetamine, see Methamphetamine topic.

References

  1. 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.
  2. Folaranmi TA, Kretz CB, Kamiya H, et al. Increased risk for meningococcal disease among men who have sex with men in the United States, 2012-2015. Clin Infect Dis. 2017 May 13. [Epub ahead of print]
  3. 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).
  4. Centers for Disease Control and Prevention. HIV and Substance Use in the United States. October 25, 2016.
  5. Broyles LM, Binswanger IA, Jenkins JA, et al. Confronting inadvertent stigma and pejorative language in addiction scholarship: a recognition and response. Subst Abus. 2014;35(3):217-21.
  6. Kelly JF, Wakeman SE, Saitz R. Stop talking 'dirty': clinicians, language, and quality of care for the leading cause of preventable death in the United States. Am J Med. 2015 Jan;128(1):8-9.
  7. Tetrault JM, Tate JP, McGinnis KA, et al; Veterans Aging Cohort Study Team. Hepatic safety and antiretroviral effectiveness in HIV-infected patients receiving naltrexone. Alcohol Clin Exp Res. 2012 Feb;36(2):318-24.
  8. Korthuis PT, Fiellin DA, Fu R, et al; BHIVES Collaborative. Improving adherence to HIV quality of care indicators in persons with opioid dependence: the role of buprenorphine. J Acquir Immune Defic Syndr. 2011 Mar;56 Suppl 1:S83-90.
  9. Palepu A, Tyndall MW, Joy R, et al. Antiretroviral adherence and HIV treatment outcomes among HIV/HCV co-infected injection drug users: the role of methadone maintenance therapy. Drug Alcohol Depend. 2006 Sep 15;84:188-94.