As HIV care has transitioned more into chronic disease management, primary care physicians are well situated to address the medical needs of this aging population, along with providing the first bulwark against preventing new infections.
While HIV continues to figure as a prevention success story, with a 12% decline in new infections between 2017 and 2021, gaps persist that delay diagnosis and prevention, placing others at risk, according to data published by the CDC in May. An estimated 1.2 million Americans ages 13 years and older carry the virus, but 13% don't realize that they have been infected, according to federal data.
Moreover, clinicians are less likely to prescribe pre-exposure prophylaxis (PrEP) to racial/ethnic groups who comprise the bulk of new cases. In 2021, 40% of new infections were diagnosed in Black teens and adults and an additional 29% in Hispanic people. Yet, 78% of White teens and adults eligible for PrEP got the preventive medication that year compared with 11% of eligible Black individuals and 21% of eligible Hispanic individuals.
“It's shocking. It's completely the flip side of who is getting infected,” said Joseph McGowan, MD, FACP, medical director of HIV services at Northwell Health in New Hyde Park, N.Y., pointing to the CDC data. “Only the most motivated patients are the ones who are getting PrEP, but the people who really need it, who maybe will come to their primary care doctor, that's where we're missing the opportunity.”
The U.S. Preventive Services Task Force first recommended PrEP in 2019 and published updated recommendations in the August 22/29 JAMA, with more medication options. Several guidelines, including the 2022 recommendations from the International Antiviral Society-USA (IAS-USA) Panel, provide primary care physicians with information to manage HIV and other medical issues in this population, in addition to consulting subspecialists if drug resistance or other treatment complications arise.
Referring patients out to an HIV specialist, though, can hinder their care, given that internal medicine physicians are already trained to care for complex medical conditions, and HIV is no different, said Carrie A. Horwitch, MD, MPH, MACP, an internal medicine physician and HIV care specialist in Seattle. That total care management is particularly important as adults with HIV age into their 50s and beyond, acquiring diabetes, heart disease, and other conditions, she said.
“We need to treat all of that and treat their HIV,” she said. “Because knowing about the [HIV] medications and what they are on helps to coordinate their care. So I think most HIV care should actually be in internal medicine primary care.”
More screening and testing
Primary care physicians who routinely ask patients about their sexual and drug history will identify those who need more frequent testing for HIV and other sexually transmitted infections (STIs), and that discussion may organically lead to a conversation about the benefits of PrEP, Dr. McGowan said. Focus on open-ended questions, asking for only enough details to determine if the patient is a candidate for HIV testing or PrEP, he said, pointing to a framework published by the New York State Department of Health as a resource for taking a sexual history in primary care.
Physicians can reduce any stigma by stressing that such risk-related questions are routine, Dr. McGowan said. They also can educate patients about the effectiveness of HIV medication, including that the virus can't be transmitted once treatment reduces it to undetectable levels, he said.
“Now a person with HIV can have normal sexual relations—they are not going to transmit the virus,” he said. “It's empowering. It's a reason to be tested if somebody is reticent, afraid that they might be positive. Now we have a very hopeful message for them.”
Roughly half of people with HIV were infected at least three years prior to their diagnosis, according to CDC officials. They recommend that everyone between the ages of 13 and 64 years get tested at least once, and those at higher risk at least once annually. The IAS-USA Panel, in its recent recommendations published on Jan. 3 in JAMA, cited data showing that too many HIV diagnoses are still being missed in older individuals. More than half of people ages 50 years and older weren't diagnosed until they had progressed to a late stage of the disease, with a CD4 cell count under 350 cells/mm3.
When Dr. Horwitch gives talks about HIV to medical students or other physicians, she often uses cases involving older adults to highlight their vulnerability. She described one patient, a 75-year-old man who came in for routine health care. Only by taking a medical history, including a sexual history, did she identify a risk factor for STIs. He was diagnosed with HIV and started antiretroviral therapy. “And he's been undetectable ever since,” she said.
Too often primary care physicians may punt on this conversation, for reasons ranging from lack of time to a broader discomfort, said ACP Member Joanne Stekler, MD, an infectious disease physician and a professor of medicine at the University of Washington School of Medicine in Seattle. She suggested incorporating questions about sex and drug use into every new patient's visit; one option is to include them in the questionnaire they complete prior to the visit.
But there are situations in which the physician must ask about risk factors during an office visit, such as when a patient has developed an STI or a rash that may be related to HIV, Dr. Stekler said. “Be comfortable asking the questions,” she said. “If you are uncomfortable, you are going to make your patients uncomfortable.”
She also stressed the importance of being open-minded and nonjudgmental. “The moment that you become judgmental or questioning or shocked at what somebody tells you, then they are going to shut down and not be willing to talk about things that are a concern,” she said.
Some patients may prefer home self-testing, such as those who don't like getting their blood drawn, said Dr. Stekler, who coauthored an editorial on the topic that was published on May 1 in Clinical Infectious Diseases. But if a patient is already at the physician's office, it's preferable to order a lab test in case the result is positive, she said. “Otherwise, we're just relying on that the person is then going to call and seek care.”
However, some patients may struggle to get a timely appointment for HIV testing or have other reasons for preferring to test more frequently at home, said Erica Johnson, MD, FACP, an infectious disease physician and an assistant professor of medicine at Johns Hopkins University School of Medicine in Baltimore. “They may want to test after specific exposures or they may want to test on some sort of regular schedule that fits for them and their lifestyle, every couple of months,” she said.
In their updated 2021 PrEP guidance, CDC officials included a flow chart to help physicians assess which patients might benefit. Physicians also should write a prescription for patients who don't appear to be at risk but request the medication, as they might not be comfortable with discussing their behaviors, Dr. McGowan said.
“Prescribing PrEP is basically a cookbook,” Dr. McGowan said. “You follow the outline, the guidelines, and it's easy to do if they [physicians] can do just the first case.” And the need is too great, particularly among vulnerable populations, to be fulfilled only by HIV and infectious disease physicians, he said.
The Task Force, in its recent guidance, has recommended newer formulations of PrEP, including injectable cabotegravir, along with the oral tenofovir disoproxil fumarate/emtricitabine recommended in the prior 2019 statement. Cabotegravir, since it doesn't contain tenofovir, is a good option for patients with kidney disease or bone demineralization, Dr. Johnson said. Other potential candidates are patients who are unable or unwilling to take a pill, she said.
Physicians who prescribe PrEP should check the patient's kidney function every three to six months and screen for STIs if they are sexually active, said Michael Horberg, MD, MAS, FACP, an associate medical director for the Kaiser Permanente Mid-Atlantic Permanente Medical Group and co-chair of the Infectious Diseases Society of America's HIV Primary Care Guideline Committee.
A patient's kidney function will play a key role in PrEP drug selection, Dr. Horberg said. Cabotegravir is approved for patients with a creatinine clearance under 30 mL/min. The cheaper generic option, emtricitabine/tenofovir disoproxil fumarate (F/TDF), can be prescribed to those patients with a creatinine clearance of 60 mL/min or above.
For patients with a creatinine clearance that falls in between, emtricitabine/tenofovir alafenamide (F/TAF) should be prescribed, Dr. Horberg said. It also should be considered if a patient's kidney function is quickly worsening, he said. “Say if the creatinine clearance was 120 mL/min and suddenly now it's down to 90 mL/min, and next time it's down to 85 mL/min. I don't think I would wait. I would switch [the patient to F/TAF].”
There's a notable price difference among the options, Dr. Horberg added. “In our health care system, for one patient on long-acting injectable PrEP, I can put 262 patients on generic F/TDF.”
But there are still situations in which starting cabotegravir injections makes more sense, including patient circumstances, Dr. Horberg said. “Let's say you're in an abusive relationship and you don't trust your partner to be faithful,” he said, and that patient fears their partner may discover their pills. “These are real stories.”
With a few exceptions, such as if the patient has tuberculosis, most patients newly diagnosed with HIV should be started on antiretroviral therapy “on the day of diagnosis or as soon thereafter as feasible,” according to primary care guidance for treating people with HIV published in 2021 in Clinical Infectious Diseases. The IAS-USA Panel offers similar guidance, recommending initiation within seven days, including on the day of diagnosis or the first clinic visit, if the patient is ready “and there is no evidence of a co-occurring opportunistic infection that might affect the timing of initiation of treatment.”
Starting as soon as feasible preserves the immune system, said Dr. Horberg, a coauthor on the primary care guidance, and doesn't allow HIV to “settle and develop reservoirs.” Once that happens, long-term care for patients may be harder, he said, and “long-term effects of HIV may in fact have more of a chance to settle into the body.”
A primary care physician who prefers to refer the patient to an HIV specialist but can't get them in right away can still start antiretroviral therapy in the interim, Dr. Horberg said. One possible initial option is bictegravir combined with emtricitabine and tenofovir alafenamide (Biktarvy), if the patient doesn't have evidence of liver disease and has a creatinine clearance above 30 mL/min, he said. Other tests include screening for hepatitis B and getting a baseline on the patient's CD4 count, he said, noting that the primary care guidance in Clinical Infectious Diseases provides other details about initial and follow-up lab testing.
Ideally, primary care physicians should oversee all of the patient's treatment, including their HIV drug regimens, Dr. Horwitch said. “We need to get the internists more comfortable with these medications,” she said. For information about potential drug-drug interactions, particularly in older patients who may have other medical conditions, Dr. Horwitch recommends an HIV drug interactions resource developed by the University of Liverpool.
By the end of this decade, nearly 25% of people with HIV will be ages 65 years and older and thus more vulnerable to related conditions, including frailty and neurocognitive dysfunction, according to data cited by the IAS-USA Panel. It could be HIV comorbidities that are causing these cognitive changes, Dr. Horberg said. “But in fact, it also could be just the effect of HIV on aging, irrespective of their HIV viral load,” he said. “Their HIV could be well controlled, but still in fact it's this low-level viremia in the body that is crossing the blood-brain barrier.”
For most patients, primary care physicians can be the lead clinician, reaching out to subspecialists when they encounter challenges, such as if a physician is considering switching drug therapy in a patient with a history of treatment resistance, Dr. McGowan said.
“A lot of times as an ID doc, I become the de facto [primary care physician], because patients don't want to go to multiple doctors,” Dr. McGowan said. “They don't want to have to share everything over and over again. If they could get that with a very supportive and knowledgeable primary care doc, I think that would be what they would want.”