One in five people living with HIV in the U.S. doesn't know he or she is infected.
Unfortunately, physicians aren't doing enough to change that statistic, according to Stacey Rizza, MD, chair of HIV and outpatient infectious disease at Mayo Clinic in Rochester, Minn., who gave two talks on HIV at Internal Medicine 2013 in April.
Institutions that receive funding through the Ryan White HIV/AIDS Program screen an average of 60% of their patients for HIV, while non-Ryan White institutions have only a 20% screening rate, she said.
“As doctors, if we miss one person with diabetes or heart disease, that one person may die. If we miss one person with HIV, it could be that person, plus his or her partners, and their partners, and so on, that eventually die from HIV,” said Dr. Rizza, who is an associate professor of medicine at Mayo.
All doctors, whether inpatient, outpatient or specialist, should screen all patients age 13 through 64 for HIV, per Centers for Disease Control and Prevention guidelines, Dr. Rizza said.
“This applies to the 63-year-old woman coming in for the hip replacement, as well as the 21-year-old man with a cold,” Dr. Rizza said. “The initial test isn't based on risk.”
People with known risk should have repeat HIV testing at least annually, she added. For everyone else, the current recommendation is once in a lifetime “because this has been found to be cost-effective. The numbers are not yet available to advocate for or against more frequent testing.”
Though the guidelines recommend that physicians tell patients before screening them for HIV, the screening is an “opt-out test,” so general consent for medical care is all that's required, she said. The screenings are reimbursed by private insurers, Medicare and Medicaid, she added.
When results are positive
When breaking the news to a patient about HIV in the hospital, it's important to counsel and comfort, Dr. Rizza noted. “Remember this person has found out while alone in the hospital, without family and friends nearby, and with strangers coming in and out of the room.”
Be sure to dig down into the reasons your patient may have contracted the disease. Inquire about the possible date of infection by determining if there have been recent new sexual partners or intravenous drug use, and when (if at all) the patient's last negative HIV test result was. Also determine if there are other medical conditions, and screen for signs and symptoms of prior opportunistic infections like shingles, chicken pox, jaundice, hepatitis and other sexually transmitted diseases, she said.
Ask, too, about potential exposure history for other infections, such as from traveling or volunteering at a homeless shelter, vaccination history and social environment, Dr. Rizza said.
After a positive HIV result, order serologies for hepatitis A, B, C, cytomegalovirus (CMV) and varicella-zoster virus (VZV). Also, as part of the baseline laboratory evaluation, get a CD4 T cell count and percentage, an HIV viral load, and do a screening for other sexually transmitted diseases, Dr. Rizza said.
Both men and women also should have an anal Pap smear, since HIV brings a higher incidence of squamous cell carcinoma of the anus, she said.
Starting HIV treatment immediately is usually not necessary. “There's almost never an urgent need to leap into HIV treatment,” Dr. Rizza said. “You may need to treat opportunistic infections of HIV in the hospital, however.”
If you do plan to start anti-retrovirals in the hospital, be sure you know the nature of the patient's medical coverage and what kind of care she or he will have once discharged.
“A patient's social situation is the most important part. Look at whether the person comes from a stable home environment, has stable employment, insurance or other ability to pay for medications, any chemical dependencies or mental health issues,” she said.
The most common cause of hospitalization for HIV patients is a lung infection, including bacterial pneumonia such as pneumococcal pneumonia, pneumocystis jiroveci pneumonia, and tuberculosis. “These infections are an important cause of morbidity and mortality among HIV-infected individuals,” Dr. Rizza said.
Central nervous system infections are also typical, and can include cryptococcal meningitis, toxoplasma encephalitis, primary central nervous system lymphoma, and progressive multifocal leukoencephalopathy, she said.
Patients with HIV may also have thrush, which warrants HIV treatment, Dr. Rizza said.
Co-morbidities that are common with HIV, especially if the patient is already on treatment, include osteoporosis, cardiovascular disease and kidney disease. “Look for end-organ disease in your patients with HIV,” Dr. Rizza said.
One piece of good news you can tell your patients is that, while there is no widely accepted cure for HIV, good treatment exists, she said.
Treatment for HIV
There are many drug options for treating HIV, but the basic formula for antiretroviral therapy is to use three active drugs from at least two different classes of anti-retroviral medications. The classes include nucleoside analogue reverse transcriptase inhibitors (NRTIs or “nucs”), non-nucleoside reverse transcriptase inhibitors (NNRTIs), protease inhibitors, entry inhibitors, and integrase inhibitors.
“Usually, it's two nucs and one drug from one of the other classes,” Dr. Rizza said.
Common side effects of nucs include renal dysfunction and osteoporosis (with tenofovir), hypersensitivity reaction and increased risk of heart disease (with abacavir), macrocytic anemia (with zidovudine), and lipoatrophy and lactic acidosis (with lamivudine and stayudine), she noted.
For NNRTIs, common side effects include rash, vivid dreams and exacerbation of underlying psychiatric disorders (with efavirenz), and hepatoxicity and rash (with nevirpaine). Rilpivirine is likely to cause fewer psychiatric effects than efavirenz, Dr. Rizza said.
As for the protease inhibitors, hyperlipidemia, lipodystrophy and/or hyperglycemia may result from taking lopinavir, ritonavir or nelfinavir, while those on atazaniavir may experience hyperbilirubinemia. Entry inhibitors may cause rash (maravoc) and local site reactions (T20 subcutaneous injections), while integrase inhibitors may cause nausea and myositis (raltegravir) or diarrhea (elvitegravir).
Regardless of which specific drugs are chosen, it's extremely important that a patient be able to commit to taking all three of the active drugs every single day; otherwise, he or she may experience viral resistance. The rule is “all pills or no pills,” meaning it's better to take no pills at all than to only take some of them, Dr. Rizza said.
“You have to carefully assess the patient's likelihood of compliance,” she said.
Patients who faithfully take their medication can substantially reduce the risk of disease transmission to partners, she added. In 2011, the National Institutes of Health announced it had halted a five-year study after two years, because the study found transmission to partners was reduced by 96% in patients who used effective antiretroviral therapy.
“If we identify all the people who have HIV, and we treat them, we can virtually wipe out transmission,” Dr. Rizza said.