Clinical Affiliate Assistant Professor
Department of Integrated Medical Science
Charles E. Schmidt College of Medicine
Florida Atlantic University
Boca Raton, Florida
Medical Director, West Palm Beach, Wilton Manors, and Key West
Midway Specialty Care
Wilton Manors, Florida
Howard Grossman, MD, has disclosed that he has received consulting fees from Gilead Sciences; has received fees for non-CME/CE services from Gilead Sciences and ViiV; and has ownership interest in Esperion, Gilead Sciences, Pfizer, and ViiV.
I recently saw an older patient who had been diagnosed with HIV in 1998, started efavirenz/emtricitabine/tenofovir disoproxil fumarate in 2004, and was switched to bictegravir/emtricitabine/tenofovir alafenamide in 2017. He had an undetectable viral load, and his CD4+ count was up to 798 cells/mm3 from a nadir CD4+ cell count of 225 cells/mm3. Most would consider this a successfully treated patient. However, as soon as he walked in, I noted that his face was covered with severe seborrheic dermatitis. When I asked how long he had been experiencing the skin symptoms, he said it had been 6 years. He also had a large, fluctuant, and erythematous furuncle on his temple that had also been present for a while. In addition, his ears were full of cerumen, and he had a tinea infection on his chest and back. His labs revealed that he had syphilis with an rapid plasma reagin titer of 1:256 and that he had HBV immunity but no HAV immunity. What had gone wrong with his care?
Overlooking the Basics in Care of Aging Patients With HIV
Aging patients with HIV need coordinated care from a clinician or multiple clinicians with expertise in HIV medicine, primary care, and gerontology. In the early days of the epidemic, primary care providers were at the forefront of HIV care. At that time, most patients with HIV were younger, so the HIV infection was the primary concern. Patients were suffering from a myriad of secondary infections and debilitating adverse events from both HIV and the available medications—those were the issues that required immediate attention.
Now many of our patients are older and suffer the complications of aging, which is intensified by the acceleration of aging associated with HIV. This acceleration is evidenced by early onset of cardiovascular disease, cognitive impairment, cancer, and diabetes in patients with HIV compared with aging individuals who do not have HIV.
For too many patients, the focus of the medical establishment remains entirely on their HIV infection. Today, many patients see infectious disease (ID) specialists for their HIV care. Many patients report that the entire visit with their HIV specialist consists only of a discussion of their CD4+ cell count and HIV-1 RNA. Some of these specialists are willing to provide primary care to their patients but may be uncertain what to focus on beyond the HIV infection. In addition, many ID specialists are overwhelmed with treating transplant patients, immunosuppressed patients, and life threatening infections in the hospital, including serious cases of COVID-19.
What Primary Care Issues Are Most Important for Our Aging Patients?
This list is not exhaustive—other primary care issues will also need attention in patients with HIV. Treating the patient mentioned above for his severe seborrhea and treating his furuncle with doxycycline has cleared his face and given him new confidence. However, it is concerning that these problems were ignored for years. A primary care approach to our patients that focuses on all of their healthcare needs, not just their CD4+ cell count and HIV-1 RNA, is vital for maintaining good health and quality of life as our patients age.
What are your experiences with basic preventive or primary care needs in patients with HIV? Please answer the polling question and share your thoughts in the discussion section.
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