“#121 HIV Care for the Internist” – Help From The Curbsiders

In addition to this post please see the these other posts about the screening and treatment of sexually transmitted diseases (STDs):

Knowing how and when to take a sexual history is a critical skill in the diagnosis of STDs and that is why I’ve included the above link on How To Take A Sexual History.

Today I’ve embedded the podcast of the CurbsidersEpisode #121 below [for my convenience].

And here is the link to the outstanding show notes.

And here are some excerpts from the show notes:

HIV Pearls from Dr. Saag

  1. Dr Saag recommends that clinicians screen every patient for HIV at initiation of care with an HIV 1/2 Antibody/Antigen (Ab/Ag) test and then every 3-4 months if risk factors are identified.
  2. Screen for HIV anytime you treat someone for a new sexually transmitted infection (STI). -Dr Saag
  3. The HIV Ab/Ag test will only miss individuals infected within the last 10-12 days. HIV viral load (RNA) is positive about 10 days after infection.
  4. Follow up a positive HIV Ab/Ag test with an HIV viral load.
  5. Screen for HLA-B*57:01 allele in each patient at diagnosis, and do not start treatment with abacavir if this is pending or positive due to abacavir hypersensitivity.
  6. Start treatment for HIV within 2 weeks of diagnosis. -Dr Saag
  7. Integrase inhibitor regimens are preferred due to potency and low side effect profile.
  8. Regimens that include the integrase inhibitors, dolutegravir or bictegravir, are first-line because they provide a one pill per day regimen. Raltegravir probably has the least likelihood of drug-drug interactions, but has a higher pill burden.
  9. The CD4 count is not a measure of immune system function!!! A high viral load CAUSES immune system dysfunction! Immune function returns rapidly once the viral load is suppressed. –Dr Saag
  10. Dr Saag recommends not following the CD4 count once viral load has been persistently suppressed (Saag JAMA 2018 PMID: 30043070) because it becomes irrelevant to management.

HIV Test Details

There are two major categories of testing for HIV: 1) the rapid HIV Antibody test and 2) the fourth generation HIV 1&2 Antibody/Antigen test. The rapid HIV antibody test is slightly less sensitive (98% vs. 99.5-99.7%). Dr Saag notes the rapid HIV test is more useful in public health settings or when follow up is uncertain. The fourth-generation antibody/antigen test is used to test for established infection (HIV 1 and 2 Antibodies) and acute phase infection (p24 Antigen: p for protein, 24 for kD -which is where the protein travels on a Western blot). The fourth-generation antibody/antigen test misses infection acquired within the last 10-12 days. Tests become positive at different times following viral infection. On average, the HIV RNA (viral load) is positive at 10 days, HIV Ag at 15-20 days, and HIV Antibody at 30 days. HIV 1 and HIV 2 represent different strains of the virus. In the United States, HIV 1 is far more prevalent than HIV 2. HIV 2 infections primarily occur in West Africa.

Additional Resources

(1) Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2018 Recommendations of the International Antiviral Society-USA Panel [PubMed Abstract] [Full Text HTML].  JAMA. 2018 Jul 24;320(4):379-396. doi: 10.1001/jama.2018.8431.

(2) National HIV Curriculum – A free educational web site from the University of Washington and the AETC National Coordinating Resource Center.

It is the goal of the National HIV Curriculum to provide ongoing, up-to-date information needed to meet the core competency knowledge for HIV prevention, screening, diagnosis, and ongoing treatment and care to healthcare providers in the United States.


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