HIV management in general practice

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chapter 60 HIV management in general practice

INTRODUCTION AND OVERVIEW

Human immunodeficiency virus (HIV) infection has had, since the early 1980s, a global impact of unprecedented scale, including the decimation of some populations and the retardation of some nations’ development. There have also been revolutions in our understanding of immunology and the pharmacology of anti-retroviral treatments. Researchers in all the sciences have had to change the way they investigate and communicate with affected communities. There have been changes, too, in the way communities are harnessed to prevent and to care, but also in how they can be stigmatised and blamed.

Globally, in 2007, it was estimated that 30–36 million people were living with HIV infection, with a death toll to that point of 1.8–2.3 million.1

General practitioners have always had a central role in the delivery of healthcare to communities (especially marginalised groups) and they have played a key role here as well. Their skills in chronic disease management, their teamwork, their holistic view of health and their long-term relationships with patients and communities all contribute to the care they can bring to the HIV-infected patient.

The HIV epidemic continues to grow and change around the world, influenced by many factors, including but not confined to:

• patterns of behaviour (especially sexual and IV drug use)
• the prevalence of sexually transmitted infections (STIs) in communities—these are important because they aid the transmission of HIV
• politically driven responses that can help or hinder infection rates
• the burgeoning number of new antiviral medications of increasing effectiveness and safety
• the continuing paucity of resources in those very countries with the highest prevalence rates
• the inability so far to develop an effective vaccine.2

How many HIV-infected patients are managed in general practice? The BEACH study in Australia counted 80 consultations per 100,000 and this low figure would probably be seen in other similar developed countries, where it is a predominantly gay male population that is affected.3

However, within all capital cities there are general practice clinics that have a special interest in sexual health and which would see a vastly greater number of HIV-infected patients. In countries where the prevalence of HIV is much higher and health resources are much more scarce, the GP will be seeing many cases of HIV every day. In those countries HIV is high on the differential diagnosis for any chronic health complaint.

For the GP, therefore, different roles are possible, from sole management, through shared care, to early referral. The role chosen will depend on the setting, the interest of the doctor and the resources available.

In resource-poor communities where there are limited antiviral agents available there will be a higher involvement of primary care / general practice and more reliance on traditional healing and so on. However, even here the number of people with HIV who are taking antiviral medications is growing, with the primary care being delivered in a variety of ways.4

In resource-rich communities there is greater complexity of choices and an interest in complementary/integrative measures. Here there will be more centralisation of care to specialist doctors and clinics. Yet even so there is a large burden of poverty within the HIV-affected community and consequent difficulties in gaining access to best care.5

Other important aspects of this disease are:

• the importance of guarding confidentiality and of working with risk groups
• the importance of harm minimisation principles
• the importance of a holistic approach—despite a burgeoning ‘HIV industry’, the GP has to also manage the rest of the patient’s biopsychosocial issues
• the importance of research that can be done at primary care level—this also includes research into psychosocial aspects. Many anti-retrovirals have been trialled with the help of primary care, as this is where the majority of potential participants can be recruited.

HIV AND THE IMMUNE SYSTEM

This disease has a long lead-time, with decline of immunity as the central but not the only aspect. Many comorbidities are possible along the way:

• sexually transmitted infections, hepatitis B, hepatitis C, tuberculosis and other infections (including the opportunistic infections associated with immune deficiency)
• substance abuse problems, including alcohol and/or illicit drug use
• mental health issues, especially depression, but also including cognitive changes later in the evolution of the illness.6

Optimising immune health is therefore an important primary care task, especially among HIV-infected patients. This is important not just from the perspective of improving outcomes and slowing the rate of progression of HIV, but also because of its potential to improve quality of life at the same time. Measures include:

• improving lifestyle in terms of nutrition and exercise
• minimising the use of alcohol, drugs and smoking
• maintaining family and community involvement and the supports they can provide
• promoting a positive outlook, self-esteem and maintenance of hope
• controlling side effects of medications and optimising adherence
• treating depression
• early detection and treatment of STIs
• controlling herpes simplex virus outbreaks
• regular Pap smears
• use of complementary therapies (see below).7

PRIMARY PREVENTION IN GENERAL PRACTICE

HIV transmission is mainly the result of certain behaviours. General practice is well placed therefore to tackle the following:

• reducing at-risk behaviours—this includes promoting safer sex and safer IV use, and antenatal care such as anti-HIV medication prior to delivery
• case-finding and treating other STIs, because the presence of these will enhance transmission of HIV
• education at an individual and population level—not only about how HIV is or is not transmitted (Box 60.1), but also about how health can be optimised
• in resource-rich settings there may be the option of using post-exposure prophylaxis (PEP for occupational or n-PEP for non-occupational exposure)—this is a two or three anti-retroviral drug treatment for 4 weeks following an episode of moderate to severe risk. In the occupational setting this is usually a sharps injury; in the non-occupational setting it usually involves a sexual contact or intravenous drug use
• advocating for change—for example, policy responses to intravenous drug use (needle exchange programs), provision of clean syringes in prisons, and education, regulation and empowerment of sex industry workers.

BOX 60.1 Transmission of HIV

Transmission possible:

• Sexual intercourse without condoms
• Needlestick injury
• Sharing injecting equipment
• Mother to infant (vertical transmission)
• Transfusion

Transmission risk very low:

• Kissing
• Oral sex
• Sexual intercourse with condoms

Transmission not possible:

• Social contact, embracing
• Sneezing/coughing
• Touch (skin surfaces intact), toilet seats
• Exposure to tears, sweat, faeces or urine
• Sharing of eating utensils

Sources: ASHM 20098 and Australasian Contact Tracing Manual 20069

SECONDARY PREVENTION

HIV infection must now be considered whenever there is uncertainty about the clinical presentation. It is another of those diseases with protean symptoms and signs. Yet early diagnosis is important in order to intervene while immune function is well preserved. Early intervention is also important because patients are most infective in the early stages of the disease, when their viral load is high. The GP’s role may therefore include:

• case-finding of new HIV infections—this may be in the setting of the vague illness of primary infection, or of opportunistic screening of an asymptomatic person. In some cases of established HIV infection there will be presentations with symptoms of severe immune depletion
• working with risk-groups—after all, they will not agree to testing if testing leads to discrimination, and confidentiality needs to be assured
• opportunistic screening of asymptomatic people in novel settings such as in brothels, on the streets, at injection venues and at male saunas
• screening in the more traditional settings of antenatal and sexual health clinics.

TERTIARY PREVENTION

Once the patient is known to have HIV infection, the role of the GP may include:

• timely introduction of treatment (highly active anti-retroviral therapy) to reduce decline of immunity
• contact tracing (Box 60.2) and the optimisation of safe sexual practices
• optimising immune health (as above)
• vaccinations against influenza and pneumococcal disease
• use of prophylactic antibiotics when immune function is very low
• reducing risk of treatment-related morbidities—diabetes, osteoporosis, renal disease, cardiovascular disease, lipodystrophy, peripheral neuropathy and diarrhoea
• addressing issues of adherence—non-adherence leads to early resistance and treatment failure; repeated treatment failures eventually exhaust even the extensive pharmacology now available (Box 60.3)
• managing other comorbidities:

• hepatitis B and hepatitis C
• tuberculosis
• cognitive decline

• managing treatment failure (often in conjunction with specialist centres)
• providing information about treatment and other trials that are available
• advocating for patients’ rights, including access to adequate care
• assisting in the provision of palliative care.

BOX 60.2 Contact tracing

Recent court decisions have re-emphasised the responsibility that all healthcare professionals have for the health and welfare of their patients’ sexual or drug-using partner(s), when the patient has been diagnosed with an infectious disease. This extends to partners or contacts who are not themselves patients or clients of the healthcare worker. However, these responsibilities are exercised with respect for the human rights, dignity and autonomy of the patient; and seek to balance sometimes competing interests.

In the setting of a new HIV diagnosis, often in a male who has sex with other men, the recent sexual contacts may have been anonymous and contact tracing is inappropriate or impossible. The GP can encourage and advise the patient to notify their own contacts (if known) and/or may liaise with contact tracers at the relevant sexual health clinic. These highly trained and experienced professionals can work with the patient (the index case) to trace contacts that may have been at risk.

Very rarely would more onerous sanctions be applied to a patient who continued to expose others to risk. These cases are deeply troubling for doctors, who would be well advised to seek the assistance of their medical defence organisation in deciding their actions.

Source: Australasian Contact Tracing Manual 20069

BOX 60.3 Broad principles of HIV treatment

• Eradication of HIV from the infected patient is not achievable with currently available antiretroviral agents, and management must focus on attempting to control HIV replication with chronic suppressive therapy.
• The first antiretroviral agent (zidovudine) was introduced in 1987. Since then many more drugs have been developed, now grouped in six classes. The agents in each class are designed to interrupt the viral replication at a particular step of that process.
• The standard treatment now is to use at least three agents, from at least two of the classes. Such combination therapy (cART) has been made simpler by the development of tablets and capsules that include two or even three agents. Once-a-day dosing regimens have also helped.
• The broad aim of treatment is to achieve an undetectable viral load—in which setting it can be expected that the CD4 lymphocyte count will gradually rise. With such suppression, the ability of the virus to develop resistance is much reduced.
• The most common reason for viral replication to increase again is the development of resistance, and this is often due to difficulties in maintaining the strict adherence required. A key role for the treating doctor or general practitioner then is to enquire about difficulties with adherence and to help resolve those difficulties. This may include control of side effects, or reminder systems, or using some other drug administration aid.

Source: ASHM 20098

COMPLEMENTARY THERAPIES

The use of complementary and alternative medicine (CAM) among HIV-positive people is widespread. On average, some 60% use CAM to treat HIV-related concerns.10 However, this proportion differs markedly from study to study.11 This is despite the effectiveness of current antiretroviral therapies, and despite the potential for certain types of CAM to compromise those therapies.10,12,13 Some studies suggest that those people who are more likely to use CAM are also more likely to refuse anti-retroviral therapies.11

Published research suggests that those who are more likely to use CAM are Caucasian, men who have sex with men, more educated and of higher income.10 They are also more likely to have AIDS (than just HIV infection), to have symptoms related to HIV (and those symptoms to be more severe) and to have longer disease duration and a higher degree of disability.10

It is not surprising therefore that the reason for CAM use is more often to relieve symptoms and alleviate side effects of treatment, thereby improving quality of life.10

The types of CAM used are varied—Table 60.1 lists rates of use for various types of CAM.

TABLE 60.1 Rates of CAM

Type of CAM % using
Drug or diet therapies 71
Psycho-spiritual therapies 66
Meditation 54
Massage 39
Herbs 34
Faith healing 33
Megavitamins* 28
Chiropractor 25
Visualisation 24

* The most frequently reported of these have been vitamin C, vitamin E, garlic and multiple vitamin and mineral supplements.12

Source: Bormann et al 200911

Reviews of the evidence supporting CAM have pointed to methodological flaws and limited trial numbers and therefore lack of evidence for efficacy. However, stress management did appear to increase quality of life.14

There are other particular recommendations regarding optimising immune health, which include aspects of stress management, diet and supplements. However, data on the efficacy of herbal medicines has been assessed as insufficient to make firm recommendations.15

MIND–BODY

HIV progression to AIDS and speed of AIDS progression has been consistently linked with a range of psychosocial factors. For example, a study controlling for a range of relevant variables, including treatment, showed that increased stressful life events, coping by means of denial, low social support and high serum cortisol (a marker of chronic stress) significantly predicted disease progression.16 The increased risk for progression from HIV to AIDS was two to three times at 5 years follow-up.17 The high cortisol levels associated with chronic stress are also found to be associated with low white cell count and higher dehydroepiandrosterone sulfate (DHEAS) concentrations, both markers of poor prognosis.18 Other studies have also confirmed the findings of social isolation and pessimism being poor prognostic factors19 and ‘active confrontational coping style’ being associated with better prognosis, probably because of both improved compliance and immunological mechanisms described by psychoneuroimmunology.20 Promising findings from a randomised controlled trial also suggest that reducing stress through cognitive-behavioural stress management, relaxation training and increasing social support is associated with reduced anxiety. This finding corresponded with changes in important physiological markers such as reduced catechol output, increased white cell counts,21 reduced cortisol, DHEA-S and herpes simplex virus type 2 antibody titres (a common infection in gay men).22 In another arm of the same study it was also found that the relaxation training on its own was associated with reductions in cortisol levels, depending on the level of compliance.23 This research has now gone further to demonstrate that mind–body interventions like mindfulness meditation can buffer CD4+ T-lymphocyte decline in HIV-1 infected adults.24 Religious coping and religious behaviour (church attendance, prayer, spiritual discussion, reading religious literature) have also been found to be associated with reduced scores for depression and better immune parameters such as higher white cell count, independent of symptom status.25,26

It is therefore important to consider the role of psychosocial factors and mind–body therapies in any complete approach to HIV therapy.

SUMMARY

The role of general practice in caring for HIV-positive patients is well established. The increased complexity of care in resource-rich countries may argue for a more specialist-centric approach, but it is in general practice that the broadest approach can be taken, looking after patients where they are—in their communities. It is also the GP who can draw together a multiplicity of understandings about health and health optimisation.

RESOURCES

Australian Government, Health Insite, Complementary medicines. http://www.healthinsite.gov.au/topics/Complementary_Medicines.

National Association of People Living with HIV/AIDS. http://www.napwa.org.au.

National Institutes of Health, National Center for Complementary and Alternative Medicine (US). http://www.nccam.nih.gov.

REFERENCES

1 UNAIDS. Report on the global AIDS epidemic. Executive summary. Online. Available at: unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008, 2008.

2 UNAIDS. Report on the global AIDS epidemic. Ch 4: Preventing new HIV infections: the key to reversing the epidemic. Online. Available at unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008, 2008.

3 Fahridin S, Miller G. Management of HIV/AIDS. Aust Family Physician. 2009;38(8):573.

4 UNAIDS. Report on the global AIDS epidemic. Ch 5: Treatment and care; 2008. Online. Available: http://unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008.

5 Grierson J, Thorpe R, Pitts M. HIV futures five. The Living with HIV Program at the Australian Research Centre in Sex, Health and Society. Melbourne: La Trobe University; 2006. Online. Available: http://www.latrobe.edu.au/hiv-futures/.

6 Australasian Society for HIV Medicine. HIV, viral hepatitis and STIs: a guide for primary care. Darlinghurst, New South Wales: ASHM, 2008.

7 Hassed C. The essence of health. The seven pillars of wellbeing. Sydney: Ebury Press / Random House, 2008.

8 Australasian Society for HIV Medicine. HIV Management in Australasia. A guide for clinical care. Darlinghurst, New South Wales: ASHM, 2009;37-39.

9 Australasian Contact Tracing Manual. 3rd edn. Australian Government Department of Health and Ageing; 2006.

10 Littlewood RA, Vanable PA. Complementary and alternative medicine use among HIV-positive people: research synthesis and implications for HIV care. AIDS Care. 2008;20(8):1002-1018.

11 Bormann JE, Uphold CR, Maynard C. Predictors of complementary/alternative medicine use and intensity of use among men with HIV infection from two geographic areas in the United States. J Assoc Nurses AIDS Care. 2009;20(6):468-480.

12 Ernst E. The dark side of complementary and alternative medicine. Int J STD AIDS. 2002;13:797-800.

13 Hennessy M, Kelleher D, Spiers JP, et al. St John’s wort increases expression of P-glycoprotein: implications for drug interactions. Br J Clin Pharmacol. 2002;53:75-82.

14 Mills E, Wu P, Ernst E. Complementary therapies for the treatment of HIV: in search of the evidence. Int J STD AIDS. 2005;16(6):395-403.

15 Liu JP, Manheimer E, Yang M. Herbal medicines for treating HIV infection and AIDS. Cochrane Database Syst Rev. 2005;3:CD003937.

16 Leserman J, Petitto JM, Golden RN, et al. Impact of stressful life events, depression, social support, coping, and cortisol on progression to AIDS. Am J Psychiatry. 2000;157(8):1221-1228.

17 Leserman J, Jackson ED, Petitto JM, et al. Progression to AIDS: the effects of stress, depressive symptoms, and social support. Psychosom Med. 1999;61(3):397-406.

18 Petitto JM, Leserman J, Perkins DO, et al. High versus low basal cortisol secretion in asymptomatic, medication-free HIV-infected men: differential effects of severe life stress on parameters of immune status. Behav Med. 2000;25(4):143-151.

19 Byrnes DM, Antoni MH, Goodkin K, et al. Stressful events, pessimism, natural killer cell cytotoxicity, and cytotoxic/suppressor T cells in HIV+ black women at risk for cervical cancer. Psychosom Med. 1998;60(6):714-722.

20 Mulder CL, Antoni MH, Duivenvoorden HJ, et al. Active confrontational coping predicts decreased clinical progression over a one-year period in HIV-infected homosexual men. J Psychosom Res. 1995;39(8):957-965.

21 Antoni MH, Cruess DG, Cruess S, et al. Cognitive-behavioral stress management intervention effects on anxiety, 24-hr urinary norepinephrine output, and T-cytotoxic/suppressor cells over time among symptomatic HIV-infected gay men. J Consult Clin Psychology. 2000;68(1):31-45.

22 Cruess S, Antoni M, Cruess D, et al. Reductions in herpes simplex virus type 2 antibody titers after cognitive behavioral stress management and relationships with neuroendocrine function, relaxation skills, and social support in HIV-positive men. Psychosom Med. 2000;62(6):828-837.

23 Cruess DG, Antoni MH, Kumar M, et al. Reductions in salivary cortisol are associated with mood improvement during relaxation training among HIV-seropositive men. J Behav Med. 2000;23(2):107-122.

24 Creswell JD, Myers HF, Cole SW, et al. Mindfulness meditation training effects on CD4+ T-lymphocytes in HIV-1 infected adults: a small randomized controlled trial. Brain Behav Immun. 2009;23(2):184-188.

25 Woods TE, Antoni MH, Ironson GH, et al. Religiosity is associated with affective and immune status in symptomatic HIV-infected gay men. J Psychosom Res. 1999;46(2):165-176.

26 Dalmida SG, Holstad MM, Diiorio C, et al. Spiritual well-being, depressive symptoms, and immune status among women living with HIV/AIDS. Women Health. 2009;49(2/3):119-143.

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