“All of the above”

The emphasis of holistic care, especially in persons living with HIV (PLWH) has moved to the forefront of healthcare. HIV was previously considered a death sentence, but with innovative antiretroviral therapy (ART), it is now considered a chronic condition. With patients consistently living longer, there is also an increasing burden of neuropsychiatric disorders that necessitate vigilance on the part of providers. HIV as a chronic health condition often co-occurs with the diseases of addiction and mental illnesses. The patients often present with some of the most common psychiatric mental health conditions: mood disorders, schizophrenia, and substance use disorder, with psychosis sometimes a component of all of them. This burden of comorbid conditions in combination with risk factors and other vulnerabilities can further impair ART adherence and increases the risk of risk-taking behaviors in PLWH, all of which worsen mortality. Treating these patients in a multidisciplinary environment has been shown to be the most effective way to deliver quality care.

“I feel fine. Do I really need to take a cholesterol pill?”

With widespread antiretroviral therapy (ART) accessibility and uptake, HIV has transitioned in many ways to a chronic condition marked by heightened risks of non-communicable diseases. Several clinical and epidemiological studies over the past two decades have demonstrated elevated risks for cardiovascular diseases (CVDs) among people with HIV. These risks appear to be particularly elevated among people with histories of long periods of uncontrolled viremia and CD4 lymphopenia, and dovetail with traditional risk factors (such as smoking) that are common among people with HIV. This chapter presents a discussion of the evolving epidemiology, clinical manifestations, and putative mechanisms of CVDs among people with HIV.

“I did have some cough when I was still living in Africa six months ago”

In patients with HIV infection, tuberculosis (TB) can present at any CD4 T-cell count, with a diversity of pulmonary and extrapulmonary manifestations. Because TB is spread via a respiratory route and may rapidly progress if untreated, providers should maintain a high level of suspicion for TB disease. Diagnostic evaluation includes testing of sputum or other clinical samples using acid-fast bacilli smear, mycobacterial culture, and molecular testing to detect Mycobacterium tuberculosis DNA and mutations that confer TB drug resistance. Treatment of drug-susceptible TB consists of isoniazid, rifampin, pyrazinamide, and ethambutol for 2 months, followed by isoniazid and rifampin for 4 months. Monitoring for drug interactions, toxicity, immune reconstitution inflammatory syndrome, and nonadherence can improve patient outcomes. Patients living with HIV should be screened and treated for latent TB infection and given antiretroviral therapy to prevent TB disease.

“This lump under my jaw doesn’t hurt but keeps getting bigger”

Lymphoma in patients living with HIV/AIDS (PLWHA) is one of the leading causes of cancer and morbidity and mortality. The principles on how to manage cancer in the HIV population, will become important, as patients will be increasingly treated in both the university and private practice setting. Below is a chapter that describes, how the field of lymphoma has evolved and what principles are now utilized that have improved outcomes that are similar to the non-HIV population.

“I’ve been rashed and confused”: Part 3

Stroke syndromes are not markedly increased in persons living with HIV. Watershed strokes involving the distribution of one or more cerebral arteries suggest embolization from within the vascular tree (rather than a cardioembolic source). Increasingly some strokes (and arteritis) are being recognized as being related to infection rather than atherosclerosis or thrombosis. Past medical history can be an important source of clues to arrive the correct diagnosis, and treatment.

“I’ve been rashed and confused”: Part 2

Herpes Zoster is a distressingly common occurrence in people living with HIV and AIDS. But what happens when a patient has multiple recurrences and stops responding to therapeutic and suppressive acyclovir analogs. What clues should lead to a reconsideration of the diagnosis and treatment.

“My hair is falling out, and they told me I have syphilis!”

Sexually transmitted infections (STIs) significantly impact persons living with HIV and occur at relatively high incidence among persons living with HIV. Bacterial STIs, namely, chlamydia, gonorrhea, and syphilis, have increased tremendously since the advent of safe and effective antiretroviral therapy. Thus, while persons living with HIV are living much longer and healthier lives, many are experiencing a higher burden of STIs. The majority of STIs are asymptomatic, which raises challenges in screening and diagnosis and consequently the potential for delayed treatment. Taking a sexual history including sexual practices, partners, and symptoms should be a part of routine care of persons living with HIV. Annual screening for STIs is essential and should be more frequent as determined by sexual history. Prompt treatment can prevent further morbidity and adverse outcomes.

“Do I need to use condoms if I’m taking my meds?”

It has been conclusively proven that sexual transmission of HIV does not occur if the individual living with HIV is adherent to antiretroviral therapy and HIV replication is consistently maintained below a plasma level of 200 copies/mL. What remains to be defined is the frequency of viral load testing to provide assurance that HIV is suppressed and how long must it remain so until suppression can be considered durable. This is required in order to provide guidance for HIV pre-exposure prophylaxis (PrEP) use by a sexual partner who is not living with HIV. Based on currently published studies and until more data are presented, it seems prudent to recommend that sexual partners of individuals living with HIV who are highly adherent to treatment use PrEP for 6 months to 1 year following initiation of HIV treatment and that viral load testing be performed quarterly for at least the first 2 years in the partner living with HIV.

“I’m not that good with taking pills every day”

The treatment goal of antiretroviral therapy is to achieve and maintain an undetectable viral load. Patients on antiretroviral therapy who do not achieve this goal can develop drug resistance to one or more drugs in the regimen. Poor medication adherence is the most likely reason for virologic failure and the development of drug resistance. Development of new drugs and clinical availability of HIV resistance tests has given providers more options for treatment-experienced patients with extensive drug resistance. Evaluating patients with extensive drug resistance requires knowledge of previous antiretroviral drug regimens, previous drug resistance tests, and interpretation of those tests. Managing treatment-experienced patients can be complex and may require consultation with an HIV expert.

“What shots do I need?”

This chapter reviews the current recommendations for adult persons living with HIV (PLWH) in the United States regarding vaccine-preventable diseases. In clinical practice, PLWH should be offered annual influenza vaccine; a combination of tetanus, diphtheria, and pertussis vaccine; depending on previous vaccination, pneumococcal vaccine, meningococcal conjugate vaccine, and hepatitis A and hepatitis B vaccines. Human papilloma virus vaccine can be given in PLWH up until the age of 26. Live vaccines, including the measles-mumps-rubella vaccine and varicella vaccine, can be given in those individuals who have CD4 cell counts of greater than 200 cells/mm3 and did not receive these vaccines during childhood. Some expert panels endorse recombinant zoster vaccination in PLWH at least 50 years old, although there is no current official recommendation from the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices. The chapter covers routine vaccinations for PLWH.