for Health Care Providers
About This Manual
In many ways, veterans with HIV infection represent the future wave of the HIV epidemic. Compared with the overall HIV-infected population in the United States, veterans with HIV are older, more likely to be members of minority groups, and more likely to have a history of substance use.1 Thus, it is not surprising that they are experiencing an increasing burden of medical and psychiatric comorbid disease.2 Indeed, some data suggest that residual racial disparities in survival of individuals living with HIV may be explained in part by a greater burden of comorbid illness.3
Depending upon the study cited, approximately 60% of the deaths occurring among individuals with HIV infection are now attributed to "non-AIDS" causes.4,5,6 That does not mean those conditions are unassociated with HIV disease or its treatment. Many of the most common and serious comorbid conditions, including liver fibrosis/cirrhosis, anemia, renal insufficiency or failure, selected cancers, thrombosis, intracranial hemorrhage, and obstructive lung disease, are more likely to occur among HIV-infected individuals than among uninfected, demographically similar controls.7,8,9,10 Among persons with HIV infection, these conditions are more likely to be found in those with advanced disease. Further, the liver, renal, and bone marrow toxicities associated with antiretroviral treatment are well known and more likely to occur among persons with preexisting organ injury.11 It must be recognized that HIV infection has become a complex, chronic disease, one for which there are likely multiple etiologies of any problem. Although this disease is substantially improved by antiretroviral treatment, some individuals experience substantial toxicities from treatment.11,12 As individuals age with HIV infection, organ injury associated with HIV infection, aging-related comorbid illnesses, and substance use and abuse likely will lead to even more "non-AIDS" mortality.
We must learn to prioritize and coordinate screening and treatment for important comorbid conditions while maintaining excellence in the care of HIV infection. Although most VA HIV providers consider themselves primary care providers for their patients with HIV infection, their degree of comfort with many of the staples of primary care screening and treatment is not as high as it is among general health care providers.13 This manual offers a practical approach to addressing many of these issues. Further, it attempts to appropriately tailor recommendations to the special issues facing patients who are receiving treatment for HIV infection.
Combination antiretroviral therapy has revolutionized the care of HIV infection. Randomized trial data now support continuous antiretroviral management of HIV infection, even among patients with comorbid disease.12 Earlier data have demonstrated that many "non-AIDS" conditions improve with effective antiretroviral therapy.14,15 Clearly, it remains paramount to get patients started on an effective regimen and ensure that they are acceptably adherent. Yet, there are patients who will require careful attention to alcohol and drug use and depressive symptoms before they can achieve acceptable adherence.
Once adherent to an effective regimen, patients may have substantial comorbidities that require targeted screening and treatment. The approach to these conditions must be guided by the costs and benefits in our population of patients. Screening and treatment that require a life expectancy beyond 10 years, such as colon cancer screening, should be undertaken only for patients who are deemed likely to live that long. Otherwise, we will be exposing our patients to immediate potential harms (eg, risk of perforation from colonoscopy and the pain and discomfort of the preparation and the procedure) without the likelihood of future benefit.16 We also will need to think carefully about conditions for which our patients are at particularly high risk, including hepatitis C infection and alcohol and tobacco use, and target these accordingly. Finally, as more data become available, we need to consider how mechanisms of common comorbid diseases may differ among persons with HIV infection and determine the implications for management.
Thus, it is with great pleasure that I have written the introduction to what I hope will be the first of many editions of this manual, which is the brainchild of Dr. David Ross, the HIV Technical Advisory Group, and the Public Health Strategic Health Care Group. The manual, and this introduction, are dedicated to the hard work, commitment, and good will of the excellent providers who are taking care of our veterans with HIV infection.
Amy C. Justice, MD, PhD
Principal Investigator, Veterans Aging Cohort Study
Section Chief, General Internal Medicine, VA Connecticut
Associate Professor of Medicine and Public Health, Yale University
1. Justice AC, Dombrowski E, Conigliaro J, et al. Veterans Aging Cohort Study (VACS): Overview and description. Med Care. 2006 Aug;44(8 Suppl 2):S13-24.
2. Justice AC. Prioritizing primary care in HIV: comorbidity, toxicity, and demography. Top HIV Med. 2006 Dec-2007 Jan;14(5):159-63.
3. McGinnis KA, Fine MJ, Sharma RK, et al. Understanding racial disparities in HIV using data from the veterans aging cohort 3-site study and VA administrative data. Am J Public Health. 2003 Oct;93(10):1728-33.
4. Lohse N, Hansen AB, Pedersen G, et al. Survival of persons with and without HIV infection in Denmark, 1995-2005. Ann Intern Med. 2007 Jan 16;146(2):87-95.
5. Kohli R, Lo Y, Howard AA, et al. Mortality in an urban cohort of HIV-infected and at-risk drug users in the era of highly active antiretroviral therapy. Clin Infect Dis. 2005 Sep 15;41(6):864-72.
6. Palella FJ Jr, Baker RK, Moorman AC, et al. Mortality in the highly active antiretroviral therapy era: changing causes of death and disease in the HIV outpatient study. J Acquir Immune Defic Syndr. 2006 Sep;43(1):27-34.
7. Justice AC, Lasky E, McGinnis KA, et al. Medical disease and alcohol use among veterans with human immunodeficiency infection: A comparison of disease measurement strategies. Med Care. 2006 Aug;44(8 Suppl 2):S52-60.
8. McGinnis KA, Fultz SL, Skanderson M, et al. Hepatocellular carcinoma and non-Hodgkin's lymphoma: the roles of HIV, hepatitis C infection, and alcohol abuse. J Clin Oncol. 2006 Nov 1;24(31):5005-9.
9. Fultz SL, McGinnis KA, Skanderson M, et al. Association of venous thromboembolism with human immunodeficiency virus and mortality in veterans. Am J Med. 2004 Mar 15;116(6):420-3.
10. Crothers K, Butt AA, Gibert CL, et al. Increased COPD among HIV-positive compared to HIV-negative veterans. Chest. 2006 Nov;130(5):1326-33.
11. DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Washington: Department of Health and Human Services; January 28, 2008.
12. El-Sadr WM, Lundgren JD, Neaton JD, et al. Strategies for Management of Antiretroviral Therapy (SMART) Study Group. CD4+ count-guided interruption of antiretroviral treatment. N Engl J Med. 2006 Nov 30;355(22):2283-96.
13. Fultz SL, Goulet JL, Weissman S, et al. Differences between infectious diseases-certified physicians and general medicine-certified physicians in the level of comfort with providing primary care to patients. Clin Infect Dis. 2005 Sep 1;41(5):738-43.
14. Moore RD, Forney D. Anemia in HIV-infected patients receiving highly active antiretroviral therapy. J Acquir Immune Defic Syndr. 2002 Jan 1;29(1):54-7.
15. Sulkowski MS, Thomas DL, Chaisson RE, et al. Hepatotoxicity associated with antiretroviral therapy in adults infected with human immunodeficiency virus and the role of hepatitis C or B virus infection. JAMA. 2000 Jan 5;283(1):74-80.
16. Braithwaite RS, Concato J, Chang CC, et al. A framework for tailoring clinical guidelines to comorbidity at the point of care. Arch Intern Med. 2007 Nov 26;167(21):2361-5.