Key Points

• Managing HIV/AIDS in the primary care setting helps decrease stigma and patient anxiety.

• Health promotion and disease prevention are becoming as important as managing chronic symptoms.

• A nonjudgmental attitude and strict confidentiality promote trust in the physician-patient relationship.

• Different aspects of the history and physical examination may need to be stressed with certain patients, including safer sex practices.

• HIV-specific history, physical examination, and laboratory tests must be obtained as indicated at each visit.

Family physicians are often the portal of entry into medical care, so they can be instrumental in assessing behaviors that put patients at risk for infection, diagnosing infection, and monitoring and treating the infected patient, even if the patient is referred to a specialist. Although controlling chronic symptoms and treating acute infectious episodes remain vital components of HIV care, health promotion and disease prevention are gaining equal prominence, now that novel and effective treatments are available, making the process of HIV care delivery analogous to that of such chronic illnesses as diabetes and hypertension. Also, managing HIV infection in the primary care setting serves to reduce social stigma and reduce patient anxiety.

The essential components of a successful long-term physician-patient relationship are trust that the physician will act in the patient's best interests, respect their wishes, be non-judgmental about their lifestyle and behaviors, and maintain the highest degree of confidentiality. The physician or other health care professional is responsible for providing a safe space for the patient to discuss sensitive information. Patients may avoid disclosing behaviors they think may be viewed disapprovingly by the professional. It is vitally important that patients are assured of confidentiality and questioned non-judgmentally and respectfully. Culturally sensitive literature addressing the needs of local populations must be readily available, with pictures and posters showing familiar faces.

The first visit is crucial to establishing the tone of subsequent encounters. Aspects of the history that must be stressed may depend on time since diagnosis and the presence of symptoms. Recently diagnosed and asymptomatic patients need reassurance and accurate knowledge about the availability of current treatments. Life-threatening opportunistic infections

Table 17-2 HIV-Specific Patient History

Area of Questioning

Relevance

Date of diagnosis and mode of transmission

Prior HIV-related illnesses and ART treatment history (reasons for discontinuation, side effects experienced)

CD4+ counts and viral loads at diagnosis, nadir point, and most recently HIV-associated symptoms such as fever, night sweats, unintentional weight loss, generalized lymphadenopathy, diarrhea, and oral candidiasis History of travel to areas endemic for histoplasmosis, blastomycosis, and coccidioidomycosis

Assessing risk for other STDs, staging of illness, determination of HAART treatment options; assessing risk of immune suppression and disease progression

Documentation and assessment of need for further testing and treatment

Detailed drug abuse history

History of hepatitides and tuberculosis, including duration and adherence to chemoprophylaxis

Assessment of ability to adhere to treatment

Documentation of herbal and complementary medications

Determination of potential interactions with HAART

Number of pregnancies and HIV status during pregnancy

Determination of children at risk

Status of immunizations

Risk of infection in an immunocompromised patient

Psychiatric diagnoses

Ability to adhere to medication regimen

Living situation, employment, social support, pets. and daily diet

Ability to afford medications, risk of infections, nutritional status

Number of sexual partners and condom use, method of contraception, survival sex, persons to whom the patient has disclosed HIV status

Behaviors likely to increase reinfection and put partners at risk

ART, Antiretroviral therapy; HAART, highly active ART; STDs, sexually transmitted diseases.

(OIs) must be ruled out in symptomatic patients. A detailed treatment history, side effects experienced, and reasons for discontinuation of medications must be obtained from treatment-experienced patients. Screening for substance abuse and STDs must be addressed routinely. Behaviors that put others at risk for infection must be assessed (Table 17-2).

The physical examination must focus on organ systems most likely to be affected by HIV-related OIs and cancers. The examination may also reveal clues to potential complications and aid in staging the illness. Vital signs, including the presence of pain, are documented at every visit (Table 17-3).

Laboratory testing is important to monitor disease progress and the effects of HAART and to delineate treatment side effects, such as lipid, glucose, and renal abnormalities (Table 17-4).

Clinically stable patients need only be seen every 3 to 4 months. Recently diagnosed patients, those with acute illnesses, and those who are failing or have recently changed antiretroviral therapy may need to be seen more frequently. The 2009 guidelines allow follow-up visits to be extended to every 6 months, if the patient is virologically suppressed for more than 2 to 3 years (level 2).

Because 95% adherence maximizes the potential for long-term viral load suppression, adherence to therapy must be confirmed. Asking about doses missed in the prior 48 hours or 2 weeks may yield more accurate answers than inquiring in general about whether or not the patient is taking medications. Younger age, lack of social support, and chronic symptoms, including depression, are negative predictors of adherence. Race, ethnicity, gender, and inactive substance abuse do not predict adherence. Statistical risk factors for poor adherence should not lead to the decision to withhold treatment. Instead, the clinician must explore ways to counter the effects of these predictors.

Safer sex practices and specific instances of unprotected sex must be discussed. Interim problems and the status of previously discussed problems are also monitored.

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