Managing HIV in Primary Care: What Every Physician Needs to Know in 2025

Introduction

HIV primary care has evolved dramatically, with more than 36 million people estimated to be living with HIV in 2019. The disease has claimed 39 million lives worldwide to date, yet its management paradigm has fundamentally changed. Once considered a fatal diagnosis, HIV has transformed into a chronic illness that most patients can manage more effectively than diabetes or heart disease.

Despite these advances, a concerning gap exists in medical preparedness. Approximately 90% of primary care physicians self-rate their HIV knowledge as “none” or “low”, while merely 9% consider themselves competent to diagnose and treat HIV patients. This disconnect is particularly troubling considering the substantial progress in treatment outcomes. Antiretroviral therapy (ART) has reduced HIV-attributed deaths by 48% between 2005 and 2016, and new adult infections declined by 17% between 2007 and 2017 globally. Furthermore, a Danish study estimated that a 25-year-old HIV-positive man without hepatitis C co-infection now has a remaining lifetime of more than 35 years.

The management of chronic HIV in primary care settings requires specific knowledge of treatment guidelines, comorbidity management, and preventive care protocols. As HIV patients age, they frequently develop additional health concerns, including hypertension, hyperlipidemia, endocrine diseases (including diabetes), and renal impairment. Additionally, claims related to cardiovascular events and renal impairment more than doubled between 2003 and 2013. Therefore, primary care physicians must understand both HIV management principles and the complex interplay between HIV, its treatments, and common comorbidities.

This article provides essential, evidence-based guidance for primary care physicians managing HIV patients in 2025, addressing everything from initial diagnosis to long-term care strategies.

Understanding HIV as a Chronic Disease in 2025

With advances in treatment protocols and medication effectiveness, the medical community now clearly recognizes HIV as a manageable long-term health condition rather than the terminal diagnosis it once represented. Modern antiretroviral therapy (ART) has transformed the clinical landscape, creating new challenges and opportunities for primary care physicians managing patients with HIV.

HIV life expectancy with ART

The impact of effective HIV treatment on lifespan has been profound. Life expectancy for individuals living with HIV has increased substantially over the past 25 years. Notably, a recent study examining more than 206,000 adults in North America and Europe found that people with HIV on ART and high CD4 cell counts who started treatment after 2015 had life expectancies only a few years lower than the general population. For 40-year-old women who started ART after 2015, the estimated remaining years of life were 39.0 years, whereas for men, it was 37.0 years.

CD4 count remains a critical determinant of longevity. The same research revealed that for patients with CD4 counts above 500 cells/μL at follow-up who began treatment after 2015, life expectancy at age 40 increased to 42.0 years for women and 39.2 years for men. In contrast, individuals with CD4 counts below 50 cells/μL had significantly shorter life expectancies – 24.9 years for women and 23.7 years for men at age 40.

Several factors influence life expectancy beyond CD4 counts:

Viral load suppression: Sustained viral suppression through adherence to ART is the strongest predictor of long-term survival, as it minimizes immune activation, prevents opportunistic infections, and reduces systemic inflammation.
Absence of AIDS-defining illnesses: People who have never had opportunistic infections or AIDS-defining conditions have better immune recovery and overall health, even if their CD4 counts are the same.
Route of HIV acquisition: Individuals who contract HIV through sexual transmission or other non-injection routes typically encounter fewer complications compared to those with injection-related transmission, partly attributable to reduced rates of hepatitis co-infection and substance-related comorbidities.
Access to consistent healthcare: Regular contact with care leads to early ART initiation, regular monitoring, and prompt management of comorbidities, all of which significantly increase life expectancy.
Lifestyle factors: Avoiding smoking, maintaining a healthy weight, exercising regularly, and moderating alcohol use contribute to cardiovascular and metabolic health, helping narrow the life expectancy gap between people with HIV and the general population.

The data demonstrates how dramatically the outlook has improved – in 1996, a 20-year-old diagnosed with HIV had an average life expectancy of just 39 years, which improved to 73 years by 2011. As a result, many primary care physicians now manage HIV patients through their entire adult lives into advanced age.

Is HIV a chronic disease? Clinical consensus and implications

The current clinical consensus emphatically confirms HIV as a chronic, manageable condition. The World Health Organization explicitly states that “with access to effective HIV prevention, diagnosis, treatment and care, including for opportunistic infections, HIV infection has become a manageable chronic health condition, enabling people living with HIV to lead long and healthy lives”.

This reclassification carries significant implications for primary care delivery models. First, it shifts the focus from acute management to continuous care throughout the lifespan. Second, it necessitates attention to the “95-95-95” goals: ensuring 95% of patients with HIV are diagnosed, 95% of diagnosed patients receive ART, and 95% of those prescribed ART achieve viral load suppression.

The chronic disease model also emphasizes that ART must typically be taken daily for the remainder of one’s life. Although ART lowers virus levels and helps strengthen the immune system, it does not cure the infection. Moreover, HIV creates specific considerations different from other chronic diseases:

HIV-infected patients often experience chronic immune activation, which may accelerate aging-related comorbidities even with viral suppression
People with HIV have higher rates of multimorbidity than uninfected individuals, with conditions appearing at earlier ages.
The nadir CD4 count (lowest lifetime CD4 count) significantly impacts long-term health outcomes.

Primary care physicians now face the challenge of managing HIV alongside these associated conditions. In fact, studies indicate patients with HIV may develop major illnesses approximately 16 years earlier than their HIV-negative counterparts. Consequently, primary care protocols must integrate comprehensive screening for cardiovascular disease, diabetes, osteoporosis, and kidney disease alongside traditional HIV monitoring.

The evolution toward HIV as a chronic disease also underscores the need for multidisciplinary approaches. Integrated healthcare models tailored to reflect the multimorbidity-related needs of people living with HIV can deliver better health outcomes cost-effectively. It proves especially important as the demographic of HIV patients ages—by the end of 2021, more than half of people living with the virus were over 50 years old.

Establishing a Trust-Based Patient-Provider Relationship

Effective HIV care begins with establishing authentic connections between providers and patients. Trust directly influences engagement in prevention and care, medication adherence, and long-term health outcomes. Primary care physicians managing HIV must develop specific skills to navigate sensitive conversations while creating inclusive clinical environments.

Using gender-affirming and non-stigmatizing language

The language healthcare providers use profoundly affects how people living with HIV (PLWH) perceive themselves and their care. Research consistently shows that positive interactions with providers promote engagement in prevention and care. Initially, physicians should gather basic information, including preferred name, pronouns, sexual orientation, and gender identity, during intake assessments.

For transgender and gender-diverse patients, providers should implement the two-step method: first asking about sex assigned at birth, then current gender identity. This approach acknowledges that gender identity may differ from anatomical characteristics, creating space for authentic self-representation. Currently, healthcare facilities collecting such data report acceptance from both transgender and cisgender populations.

Person-first language represents another essential component of stigma reduction. Instead of defining individuals by their condition (e.g., “HIV-infected person”), providers should use terms like “person living with HIV”. This subtle shift emphasizes humanity before diagnosis and helps reduce stigma. Similarly, terms such as “infected” carry negative connotations and should be replaced with more neutral language. Even seemingly minor language choices impact patient comfort—for example, using “partner” instead of gendered terms avoids assumptions about sexual orientation.

The collaborative process of shared decision-making benefits from clinicians demonstrating empathic interest, avoiding stigmatizing language, employing cultural humility, and recognizing systemic barriers to equitable outcomes. Comparatively, clinicians who conflate HIV risk with gender identity or make assumptions about sexual behaviors based on appearance often alienate transgender patients.

Discussing sexual and drug use history respectfully

Obtaining accurate sexual and substance use histories requires creating environments where patients feel safe disclosing sensitive information. One survey found that 38% of LGBTQ+ people in Michigan reported negative healthcare interactions related to their transgender identity. Hence, establishing rapport before asking sensitive questions becomes crucial.

Primary care physicians should:

Begin by asking permission to discuss sexual health
Normalize questions by stating they are asked of all patients
Use open-ended, non-judgmental phrasing
Maintain neutral body language and tone
Ensure shared understanding of terminology
Respect patients’ right to decline answering

Regarding discussions about substance use, physicians must refrain from making moral judgments. Studies indicate that marginalized populations—including those with intersecting identities of Black or Hispanic race/ethnicity, poverty, and drug use—report high levels of perceived stigma in healthcare settings. Undeniably, stigmatizing language like “addict” or “dirty urine” conveys negative judgment and undermines trust.

Trauma-informed approaches benefit all patient interactions but prove particularly valuable when discussing sensitive topics. Many patients have experienced abuse or trauma, making them hesitant to disclose their sexual or substance use history. Furthermore, providers should recognize the power dynamics inherent in clinical relationships, acknowledging how their own identity may influence the therapeutic alliance.

When patients feel pressured to take antiretroviral therapy (ART) without consideration of their “whole person” and life context, they report strained provider relationships. Conversely, when providers adopt judgment-free attitudes and person-centered approaches, patients are more likely to engage in care and disclose necessary health information that impacts treatment decisions.

Initial HIV Diagnosis and Evaluation in Primary Care

Accurate detection and comprehensive evaluation stand as cornerstones for effective HIV management in primary care settings. The diagnostic landscape has evolved considerably, with newer testing methodologies enabling earlier detection and more precise classification of infection status.

Fourth-generation HIV testing and p24 antigen

Fourth-generation HIV tests represent the current standard of care for diagnosing HIV in clinical settings since the 2014 recommendation by the U.S. Centers for Disease Control and Prevention (CDC). Unlike earlier generations that detected only antibodies, these assays simultaneously identify both HIV-1/HIV-2 antibodies and the p24 antigen—a structural protein comprising most of the HIV viral core. This dual detection capability offers substantial clinical advantages.

The p24 antigen typically becomes detectable approximately 14 days after exposure, which is considerably earlier than the development of antibodies. At this point, viral RNA levels generally exceed 10,000-20,000 copies/mL. This earlier detection window proves crucial for identifying acute infections that might otherwise escape detection with antibody-only testing.

Fourth-generation tests demonstrate impressive accuracy, with sensitivity above 99.7% for established infections. In the Vaginal and Oral Interventions to Control the Epidemic (VOICE) study, these assays identified 28% of HIV infections that third-generation tests missed. Most fourth-generation tests can reliably detect HIV infection approximately one month after acquisition, though recent studies suggest the window period may be as short as 18 days.

Primary care physicians should note that, despite excellent sensitivity, a negative result should prompt assessment of whether the patient falls within the window period. Although most individuals test positive within three weeks using these assays, some may not seroconvert for up to three months. Accordingly, every negative result necessitates an explanation of this window period and planning for follow-up testing if warranted.

HIV RNA testing for acute infection

In cases where acute HIV infection is suspected—particularly within the first two weeks following exposure—HIV RNA testing becomes the preferred initial diagnostic approach. RNA tests detect viral genetic material in blood, providing the earliest possible confirmation of infection. Depending on the assay’s sensitivity, viral RNA may become detectable as early as 5-10 days post-infection.

The laboratory diagnosis of acute HIV requires a negative HIV antibody assay coupled with either positive HIV RNA or positive p24 antigen. RNA testing is likewise indicated when fourth-generation test results are indeterminate. Currently, viral levels increase rapidly, typically peaking at approximately 250,000 copies/mL during the subsequent 1-2 weeks.

For individuals with a strong clinical suspicion of acute infection but negative initial testing with HIV-1/2 antigen-antibody immunoassay, additional HIV-1 RNA testing should be performed. Persons with positive HIV RNA (especially at high levels) and negative or indeterminate HIV antibody assay receive a presumptive diagnosis of acute HIV infection; in such scenarios, follow-up antibody testing in 3-6 months documents seroconversion.

Documenting HIV-specific history and social determinants

Upon confirming an HIV diagnosis, primary care physicians must deliver results in a non-judgmental, calm, and confidential environment, allowing sufficient time for counseling and emotional support. The initial evaluation provides a critical opportunity to establish rapport and initiate comprehensive care planning.

Essential documentation elements include:

Laboratory confirmation of HIV diagnosis (if not already available)
Baseline CD4 count and percentage
Quantitative plasma HIV RNA level
HIV genotypic drug-resistance testing

Beyond laboratory parameters, addressing social determinants of health proves vital, as these nonmedical factors profoundly influence outcomes. Key social determinants to document include income level, educational attainment, health insurance coverage, housing stability, and employment status. These factors help identify populations or geographic areas that may benefit from targeted HIV prevention and treatment initiatives.

Documenting these parameters at diagnosis creates a foundation for patient-centered care that addresses both clinical and contextual factors affecting disease management. Stratifying public health data by social determinants enables the monitoring of health inequities and the allocation of resources appropriately to populations that are disproportionately affected.

Rapid ART Initiation and Treatment Readiness

The era of “test and treat” has fundamentally reshaped HIV care protocols, with research demonstrating that prompt antiretroviral therapy (ART) initiation improves clinical outcomes and decreases transmission rates. Current strategies prioritize the rapid initiation of treatment, often within days or even hours of diagnosis, marking a dramatic shift in HIV primary care approaches.

When to start ART: CD4 count and viral load considerations

Current guidelines unequivocally recommend ART for all individuals diagnosed with HIV, regardless of CD4 cell count or clinical stage. It represents a substantial evolution in hiv management in primary care, as previous recommendations often delayed treatment until CD4 counts fell below specific thresholds. The Strategic Timing of Antiretroviral Treatment (START) study demonstrated that patients initiating ART immediately after diagnosis experienced greater than 50% reduction in morbidity and mortality compared to those who deferred treatment until CD4 counts dropped to 350 cells/mm³ or below.

Primary care physicians should initiate ART as soon as possible after diagnosis, ideally within 7 days and even on the same day when feasible. This approach improves linkage to care, reduces pre-treatment loss to follow-up, and accelerates viral suppression. Indeed, one study revealed that patients starting ART within 1-2 days achieved viral suppression in a median of 1.8 months, compared to 4.3 months with standard care.

Nevertheless, baseline CD4 measurement remains essential even as treatment begins promptly. Data show that across various global regions, 30-47% of patients still present with advanced HIV disease (CD4 <200 cells/μL) at ART initiation, highlighting the continued importance of immune status assessment.

Contraindications to same-day ART

Before initiating ART, physicians should evaluate for conditions where immediate therapy may be harmful. Central nervous system opportunistic infections—specifically cryptococcal and tuberculous meningitis—represent the primary contraindications to same-day ART. For patients with tuberculosis meningitis, ART should be initiated 2-4 weeks after starting TB treatment, once clinical improvement is evident.

Subsequently, physicians should order baseline laboratory testing before starting ART, including HIV viral load, CD4 count, resistance testing, hepatitis B/C serologies, and assessments of liver and kidney function. However, treatment need not be delayed while awaiting most results. The exception involves suspected drug resistance, as suboptimal regimen selection may compromise treatment efficacy.

Assessment of patient readiness constitutes another critical consideration. Physicians must remain objective and non-judgmental when evaluating readiness, respecting patients’ views even when they differ from clinical recommendations. This approach strengthens the therapeutic relationship and supports long-term adherence.

Recommended ART regimens for treatment-naïve patients

Integrase strand transfer inhibitor (INSTI)-based regimens currently represent the preferred first-line therapy for most treatment-naïve patients. These regimens demonstrate greater viral suppression rates and lower probability of viral rebound compared to non-nucleoside reverse transcriptase inhibitor (NNRTI)-based alternatives.

Single-tablet regimens (STRs) offer advantages over multi-tablet regimens (MTRs), including simplicity, convenience, and reduced risk of selective non-adherence. A meta-analysis confirmed that STRs had better adherence rates and higher 48-week viral suppression compared to MTRs.

For rapid ART initiation before resistance testing results become available, physicians should avoid regimens with specific viral load or CD4 count requirements (e.g., rilpivirine-based treatments), those potentially affected by transmitted drug resistance (particularly NNRTI-based regimens), and abacavir-containing regimens pending HLA-B*5701 results. Standard regimens suitable for rapid initiation include bictegravir/tenofovir alafenamide/emtricitabine or tenofovir alafenamide/emtricitabine with dolutegravir.

Once ART begins, viral load monitoring should occur within 2-4 weeks after initiation, then at 4-8 week intervals until viral suppression is achieved. Most patients taking ART achieve viral suppression within 6 months, marking a successful transition from diagnosis to effective hiv primary care management.

Monitoring HIV Progression and Lab Follow-up

Laboratory monitoring forms the foundation for tracking HIV disease progression and treatment effectiveness in patients. Primary care physicians must understand appropriate testing frequencies and interpretation of results to optimize patient outcomes.

CD4 count and viral load testing schedule

Quantitative plasma HIV RNA (viral load) monitoring serves as the most accurate measure of antiretroviral therapy (ART) effectiveness in hiv primary care. After ART initiation, viral load should be measured within 2-4 weeks, then at 4-8 week intervals until undetectable. Following ART modification due to suboptimal response, testing should occur within 2-4 weeks, then at 4-8 week intervals until suppression is achieved. For changes related to toxicity or regimen simplification, viral load testing is recommended within 4 to 8 weeks.

Once patients achieve stable suppression, the monitoring schedule can be adjusted. For those on stable, suppressive regimens, viral load testing should be performed every 3-4 months, or every 6 months for patients virally suppressed for more than 2 years. Most patients taking ART achieve viral suppression within 6 months.

Concerning viral load results, prompt attention is required. For patients with previously suppressed virus who develop HIV RNA ≥500 copies/mL, testing should be repeated within 2 weeks. If viral load is detectable but <500 copies/mL, retesting within 4 weeks helps distinguish transient “blips” from actual virologic failure. These blips—temporary increases in viral load—typically return to undetectable levels by the next test.

Annual labs: CBC, LFTs, lipids, renal function

Chronic HIV management requires comprehensive monitoring beyond HIV-specific markers. A complete blood count (CBC) with differential should accompany CD4 testing. Once CD4 monitoring is discontinued, annual CBC assessment remains necessary, with more frequent monitoring for patients on medications potentially causing cytopenia.

Liver function tests—including ALT, AST, and total bilirubin—should be checked every 6 to 12 months. This becomes especially important for patients with hepatitis B co-infection or preexisting liver conditions. In hiv management in primary care, these tests help detect medication-related hepatotoxicity and guide ART selection.

Lipid panels are crucial given the association between specific ART regimens and dyslipidemia. After achieving viral suppression, lipid testing should occur at 3-6 months. Furthermore, patients under 40 years require assessment every 1-3 years, while those with cardiovascular risk factors need more frequent monitoring. Additionally, random or fasting glucose testing should be performed annually to screen for diabetes, which is more prevalent in people with HIV.

Renal function monitoring through basic chemistry panels and urinalysis is essential, particularly for individuals with chronic kidney disease or diabetes. These tests help detect medication-related nephrotoxicity and guide appropriate dosing adjustments.

When to stop CD4 monitoring

As HIV care has evolved, guidelines for CD4 monitoring have been refined. Although baseline CD4 testing remains essential, ongoing monitoring offers limited clinical utility for patients who are stable. Regular immunologic tracking in patients with consistently undetectable viral loads and CD4 counts greater than 200 cells/mm³ rarely influences clinical decision-making.

After ART initiation, CD4 counts should be monitored every 3-6 months during the first 1-2 years. Afterward, for patients with viral suppression and a CD4 count of≥300 cells/mm³, monitoring can occur every 12 months. Even more significantly, if CD4 counts remain consistently above 500 cells/mm³, further monitoring becomes optional.

This reduced frequency is supported by substantial evidence. A study of over 62,000 individuals demonstrated that patients entering care with CD4 counts of≥350 cells/mm³ had a greater than 90% likelihood of maintaining counts of>200 cells/mm³ over nearly two years of observation. Moreover, in patients with sustained viral suppression and CD4 counts between 100 and 200 cells/mm³, the risk of pneumocystis pneumonia remains very low, even without prophylaxis.

By limiting unnecessary CD4 testing, hiv primary care physicians can reduce healthcare costs while maintaining quality care. Approximately USD 10.2 million in annual savings could be realized by lowering biannual CD4 testing to yearly testing for virologically suppressed patients in the US.

Managing Common Comorbidities in HIV Primary Care

As people with HIV (PWH) live longer, comorbidity management becomes increasingly crucial in their care. Physicians must expertly navigate the complex interplay between HIV, antiretroviral therapy (ART), and common health conditions that often develop earlier in this population.

Hypertension and ART interactions

Hypertension affects approximately 25-35% of persons with HIV, representing a major cardiovascular risk factor. Among those over 50 years on ART, more than 50% develop hypertension. PWH with hypertension face twice the risk of acute myocardial infarction compared to HIV-negative individuals with hypertension.

Several ART medications influence blood pressure. Integrase inhibitors, especially when combined with tenofovir alafenamide, increase the risk of hypertension irrespective of weight gain. Dolutegravir-based regimens have also been associated with higher blood pressure in clinical trials.

For treatment, first-line options include:

ACE inhibitors or ARBs – These are preferred first-line options as they have minimal interactions with ART and provide added renal and cardiovascular protection. They are beneficial for people living with HIV (PWH) with diabetes or proteinuria. Monitoring of renal function and potassium levels is advised, especially when used in combination with tenofovir-containing regimens, due to the potential for nephrotoxic overlap.
Thiazide diuretics – These agents have minimal CYP450 interactions, making them safe with most ART combinations. They are effective in salt-sensitive hypertension, which is common in older or Black patients.
Calcium channel blockers – Useful for isolated systolic hypertension but require caution when combined with protease inhibitors (PIs) or pharmacologic boosters such as ritonavir or cobicistat, which inhibit CYP3A4 metabolism and can increase CCB plasma levels.

Given that calcium channel blockers undergo CYP3A4 metabolism, their levels may increase substantially when co-administered with protease inhibitors or cobicistat. In such cases, physicians should initiate treatment with lower doses and carefully monitor the patient’s response. For patients on atazanavir (with or without boosters), diltiazem dosage should be reduced by 50%.

Diabetes screening and HbA1c limitations

Type 2 diabetes occurs more frequently in PWH, yet optimal screening methods remain debated. First and foremost, there is controversy regarding HbA1c reliability in HIV patients. Studies have shown that HbA1c may underestimate glycemia in PWH, particularly those taking zidovudine.

This underestimation results from zidovudine-induced anemia and an increase in mean corpuscular volume (MCV), which affects red blood cell turnover. In one study, HbA1c in patients on zidovudine was underestimated by 0.58% compared to those on non-zidovudine regimens.

According to the American Diabetes Association, HbA1c should not be used alone to diagnose diabetes in PWH. Instead, fasting plasma glucose or the combination of HbA1c with fasting glucose provides a more accurate assessment of diabetes. Fructosamine testing represents another viable alternative that is not affected by ART medications.

Hyperlipidemia and statin selection with ART

High cholesterol affects up to 80% of HIV-infected patients. Risk factors include both traditional factors and HIV-specific considerations—certain HIV medicines, particularly abacavir and ritonavir, can increase LDL cholesterol and triglycerides.

Selecting appropriate statins requires careful consideration of drug interactions. For patients receiving ART, recommended options include:

Pitavastatin (4 mg daily) – minimal interactions with ART. Atorvastatin (20 mg daily) – may require dose reduction with Protease Inhibitors (PIs). Rosuvastatin (10 mg daily) – starting dose of 5 mg with PIs

Importantly, lovastatin and simvastatin should be avoided in patients on protease inhibitors or cobicistat due to the risk of severe myopathy and rhabdomyolysis. For patients with low-to-intermediate ASCVD risk, the current recommendation favors initiating at least moderate-intensity statin therapy.

Preventive Care and Vaccination Guidelines for PLWH

Immunization protocols represent an essential component of comprehensive HIV management, as individuals with HIV face increased susceptibility to vaccine-preventable infections. Proper vaccination timing and selection can substantially reduce morbidity in this population.

Pneumococcal, meningococcal, and influenza vaccines

Pneumococcal disease rates remain five to forty times higher in HIV-infected individuals despite antiretroviral therapy. Currently, two pneumococcal vaccines are recommended: a 13-valent pneumococcal conjugate vaccine (PCV13) and a 23-valent pneumococcal polysaccharide vaccine (PPV23). For optimal protection, PCV13 should be administered first, followed by PPV23 at least 12 months later, with a repeat dose of PPV23 after 5 years.

Meningococcal disease poses a serious risk, with HIV-infected adults experiencing rates of 3.4-6.6 per 100,000 compared to HIV-uninfected persons. All HIV-infected persons aged ≥2 months should receive the meningococcal conjugate vaccine, with those aged ≥2 years requiring a 2-dose primary series. After initial vaccination, boosters should be administered at appropriate intervals—every 3 years if the most recent dose was received before age 7, or every 5 years thereafter.

Annual influenza vaccination remains crucial, as people with HIV face a higher risk of serious flu-related complications. Inactivated or recombinant influenza vaccines are recommended, not the live attenuated nasal spray.

HPV and hepatitis A/B vaccination schedules

HPV vaccination is recommended for individuals up to age 26 who have not previously received the vaccine. People with HIV require the three-dose series regardless of age, administered at 0, 1-2, and 6 months. This three-dose schedule differs from the two-dose series sufficient for immunocompetent individuals under 15 years of age.

Hepatitis A vaccination is recommended for all HIV-infected persons aged 1 year or older, administered at 0 and 6-12 months. Post-vaccination serologic testing should be performed 1-2 months after completing the series.

For hepatitis B, options include Heplisav-B (0 and 1 month), a double-dose recombinant HBV vaccine (0, 1, and 6 months), or a combined hepatitis A/B vaccine.

COVID-19 vaccine recommendations for CD4 <200

Adults with HIV should receive the COVID-19 vaccination regardless of CD4 count. Those with advanced HIV (CD4 count <200 cells/mm3, AIDS-defining illness, or symptomatic HIV) should follow recommendations for moderately or severely immunocompromised patients. It includes the potential for receiving additional doses beyond the standard vaccination schedule. Evidence indicates that individuals with CD4 counts <350 cells/mm3 face a higher breakthrough infection risk, justifying enhanced vaccination protocols.

Mental Health and Substance Use in HIV Management

Depression, anxiety, and substance use disorders occur more frequently in people living with HIV (PLWH) than in the general population and correlate with poorer viral control and increased mortality. Implementing structured mental health screening represents a cornerstone of comprehensive hiv management in primary care.

Routine screening with PHQ-9 and GAD-2

The Patient Health Questionnaire-9 (PHQ-9) for depression and the Generalized Anxiety Disorder-2 (GAD-2) scale offer validated screening tools that can be self-administered electronically. A PHQ-9 score ≥10 indicates clinically relevant depression, while scores >0 on question 9 signal suicidal ideation. For anxiety screening, a GAD-2 score ≥ three or more warrants further evaluation, offering 86% sensitivity and 83% specificity for generalized anxiety disorder. Ultimately, integrating these assessments during regular HIV appointments every 6 months improves detection rates.

Addressing stigma, trauma, and substance use

Non-stigmatizing language fundamentally shapes patient experiences. Terms like “person who injects drugs” should replace “injection drug user”. Trauma histories disproportionately affect PLWH, with up to 95% reporting traumatic experiences. Trauma-informed care approaches enhance treatment effectiveness by acknowledging past experiences without re-traumatization. The Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) tool effectively identifies substance use concerns when integrated with mental health screening.

Referral pathways for behavioral health support

Establishing clear behavioral health referral protocols connects patients with specialized services. Effectively, creating workflows that delineate responsibility throughout the behavioral health continuum—screening, referral, and treatment—ensures comprehensive care. Amid referrals, physicians should recognize that mental health symptoms often intensify during major life stressors.

Conclusion

Primary care physicians now stand at the intersection of HIV management and comprehensive healthcare delivery. The transformation of HIV from a terminal illness to a manageable chronic condition requires practitioners to develop specialized knowledge and skills. Patients with well-controlled HIV can expect near-normal lifespans, yet they face unique challenges, including accelerated aging, increased comorbidities, and psychological burdens that demand holistic approaches.

Trust remains the cornerstone of effective HIV care. Practitioners who employ non-stigmatizing language, respect individuals’ gender identities, and approach sensitive topics with cultural humility tend to achieve better clinical outcomes. This relationship-centered approach also enhances medication adherence and retention in care, both of which are critical factors for achieving viral suppression.

The contemporary HIV management paradigm emphasizes the need for rapid intervention. Early initiation of antiretroviral therapy, regardless of CD4 count, substantially reduces morbidity and mortality while preventing transmission. Additionally, streamlined laboratory monitoring protocols allow physicians to focus resources where they matter most, particularly for stable patients with sustained viral suppression.

Comorbidity management deserves particular attention as HIV patients age. Hypertension, diabetes, and hyperlipidemia appear earlier and progress differently in this population. Healthcare providers must understand the complex interplay between these conditions, HIV infection, and antiretroviral medications. Careful consideration of drug interactions when selecting antihypertensives, awareness of HbA1c limitations for diabetes screening, and appropriate statin selection represent essential clinical skills.

Comprehensive preventive care, including tailored vaccination schedules, helps mitigate infection risks for patients who are immunocompromised. Meanwhile, routine screening for depression, anxiety, and substance use addresses the psychological dimensions of living with HIV.

The gap between medical advances and physician preparedness needs to be closed. Primary care providers equipped with current evidence-based knowledge can deliver care that extends beyond viral suppression to address whole-person wellness. Though challenges remain, physicians who embrace this evolving field can profoundly improve outcomes for the millions living with HIV worldwide. Their commitment to ongoing education, stigma reduction, and patient-centered care transforms HIV management from specialty care to an achievable standard within primary care settings.

Key Takeaways

Modern HIV management has evolved into comprehensive chronic disease care that primary care physicians can effectively deliver with proper knowledge and protocols.

HIV is now a manageable chronic condition – With proper ART, patients can expect near-normal lifespans, making long-term primary care relationships essential.
Start ART immediately after diagnosis – Current guidelines recommend rapid treatment initiation within 7 days, regardless of CD4 count or viral load levels.
Trust-based relationships drive better outcomes – Using non-stigmatizing language, respecting gender identity, and approaching sensitive topics with cultural humility improves adherence and retention.
Monitor comorbidities proactively – HIV patients develop hypertension, diabetes, and cardiovascular disease earlier, requiring careful drug interaction management and modified screening approaches.
Integrate mental health screening routinely – Depression and anxiety occur more frequently in PLWH; use PHQ-9 and GAD-2 tools every 6 months to identify issues early.

The shift from specialty to primary care HIV management represents a critical evolution in healthcare delivery. Primary care physicians who master these evidence-based approaches can provide comprehensive, life-extending care that addresses the whole person, beyond just viral suppression.

Frequently Asked Questions:

FAQs

Q1. How has HIV treatment changed in recent years? HIV is now considered a manageable chronic condition. With modern antiretroviral therapy, people living with HIV can expect near-normal lifespans. Treatment is started immediately after diagnosis, regardless of CD4 count, which has significantly improved outcomes and reduced transmission rates.

Q2. What are the key considerations for managing HIV in primary care? Primary care physicians need to focus on establishing trust-based relationships, using non-stigmatizing language, and addressing both HIV-specific care and common comorbidities. Regular monitoring of viral load, CD4 count, and screening for conditions like hypertension, diabetes, and mental health issues are essential components of comprehensive HIV care.

Q3. How often should HIV patients have their viral load and CD4 count checked? After starting treatment, viral load should be checked every 4-8 weeks until suppression is achieved. For stable patients with suppressed virus, testing can be done every 3-6 months. CD4 count monitoring can be reduced or stopped for patients with consistently high counts (>500 cells/mm³) and suppressed viral loads.

Q4. What vaccinations are important for people living with HIV? People with HIV should receive pneumococcal, meningococcal, and annual influenza vaccines. HPV vaccination is recommended through age 26, and hepatitis A and B vaccines are also important. COVID-19 vaccination is crucial, with potential additional doses for those with low CD4 counts.

Q5. How should primary care physicians address mental health in HIV patients? Regular screening for depression and anxiety using tools like PHQ-9 and GAD-2 is recommended every 6 months. It’s important to use non-stigmatizing language, address trauma histories, and have clear referral pathways for specialized mental health support when needed.