Primary Care in HIV

Sabena Ramsetty

With earlier initiation of highly active antiretroviral therapy (HAART) and increased longevity of HIV patients, practitioners are providing more comprehensive primary care. HIV increases the risk of heart disease, particularly at CD4 cell counts <500 cells/mm¹⁴ as well as certain malignancies including cervical cancer, non-Hodgkin lymphoma, and anal cancer; however, since the advent of HAART, the majority of cancers affecting HIV patients are non-AIDS defining (i.e., lung and liver cancer, Hodgkin lymphoma).⁹ Thus, it is imperative to address cardiovascular risk factors such as hyperlipidemia, diabetes, and tobacco abuse, and perform appropriate cancer screening.

HYPERLIPIDEMIA

HIV patients should have cholesterol goals guided by the National Cholesterol Education Program (see Table 4-1).¹⁰ Diet alone at 24 weeks can lower low density lipoprotein (LDL) by 5.5%. Advise patients to increase intake of whole grains, fruits, and vegetables and decrease saturated fats and refined sugars.¹⁶ Baseline fasting lipids should be checked prior to initiating HAART and at 3 to 6 months after starting any new antiretroviral regimen.⁷ One multicenter prospective study found increased rates of hyperlipidemia in HIV patients on protease inhibitor based regimens compared to patients not receiving protease inhibitors(11). Also, certain antiretrovirals are associated with hyperlipidemia including efavirenz, stavudine, ritonavir, and lopinavir/ritonavir (see Table 4-2).

Check a fasting lipid profile and liver function tests (LFTs) prior to starting lipid therapy, and consider discontinuing therapy if patients have persistent transaminitis greater than three times the upper limit of normal, or creatine phosphokinase greater than five to ten times the upper limit of normal. Drug interactions with ritonavir and other protease inhibitors (PIs) are common as they are potent inhibitors of the cytochrome P450. Pravastatin and atorvastatin are first-line agents for patients with hyperlipidemia on PI-based regimens. Lovastatin and simvastatin are contraindicated for patients on PI regimens. Choose cholesterol drugs with respect to type of dyslipidemia. For example, in patients with isolated hypertriglyceridemia (>500), consider fibrates; for patients with isolated low high density lipoprotein (HDL), consider niacin; if LDL is above goal, triglycerides are 200 to 500 mg/dL, and non-HDL cholesterol is elevated, consider an HMG-CoA reductase inhibitor (statin).⁷ Monitor LDL cholesterol levels 4 to 6 weeks after starting lipid therapy and monitor LFTs closely when initiating statins in patients who are concurrently receiving potentially hepatotoxic medications (i.e., ritonavir, saquinavir, amprenavir, efavirenz, and nevirapine).

If patients are at high cardiovascular risk (>20% risk of heart disease within 10 years using the Framingham score) and their lipids are not sufficiently controlled by medications, consider adjusting HAART to include more lipid friendly drugs.⁷^,¹⁰ Amprenavir and nelfinavir have intermediate effects, indinavir and saquinavir have little effect on lipids, and atazanavir has minimal effect.

Table 4-1 Cholesterol Goals and Indications for Therapy

Risk Factors	LDL Goal	Indications for Therapy
Established CHD or risk equivalent (i.e., diabetes) >2 risk factors^a +10 year risk of CHD >20%	<100 mg/dL	If LDL 100-129, can give trial of dietary therapy alone. If LDL >130mg/dL, begin lipid-lowering medication + diet.
2+ risk factors^a and 10 year risk for CHD ≤20%	<130 mg/dL	If LDL 130-160, and 10-year risk of CHD <10%, can give trial of dietary therapy alone. If LDL 130-160, and 10-year risk of CHD >10%, give lipid-lowering medication +diet. If LDL >160, give lipid-lowering medication +diet.
0-1 risk factor^a	<160 mg/dL	If LDL >160, can give trial of dietary therapy alone. If LDL >190, consider lipid-lowering medication.
^aRisk factors include cigarette smoking, hypertension (sbp >140, family history of premature CHD, age (men >45 and women >55), and low HDL (HDL < 40).

HYPERTENSION

There is no significant difference between the incidence of hypertension in HIV-positive individuals compared to seronegative patients, and treatment of hypertension in HIV patients should be guided by the American Heart Association recommendations: target BP is <140/90 for patients with no cardiovascular risk factors, <130/80 for patients at high cardiovascular risk, and <120/80 for patients with left ventricular dysfunction (decreased ejection fraction, diastolic dysfunction, or history of congestive heart failure).¹²^,¹⁷

Table 4-2 Percentage Increase in Total Cholesterol/Triglycerides in Common Regimen

Regimens	TDF/FTC/Efavirenz	TDF/FTC r/Atazanavir	TDF/FTC r/Darunavir	TDF/FTC/Raltegravir	AZT/3TC/Efavirenz
Total Cholesterol >240 mg/dL	22%	11%	23%	Rare reports	24%
Triglycerides >750 mg/dL	4%	—	2%	Rare reports	2%
TDF (tenofovir), FTC (emtricitabine), AZT (Zidovudine), 3TC (lamivudine).