Primary care for individuals at risk for human immunodeficiency virus (HIV) and people living with HIV (PLWH) requires an understanding of the epidemiology of HIV, risk factors for HIV, prevention and screening guidelines, as well as ongoing care that tends to the psychosocial needs of PLWH. This chapter reviews how to provide preventative care for those at risk for HIV as well as guidance on disclosure, adherence and retention, and neuropsychiatric manifestations of PLWH, including chronic pain, mental illness, substance use, and HIV-associated neurocognitive disorders.
Approximately 36.9 million people are living with HIV worldwide. Most (75%) people living with HIV know their HIV status, and of these, the majority are accessing treatment and are virally suppressed. More than 1.1 million in the United States are living with HIV. Of those, about 15% are unaware of their HIV status. Young people are the most likely to be unaware of their HIV status with an estimated half of those aged 13–24 years not aware of their HIV status. Among all people living with HIV (including diagnosed and undiagnosed HIV infections), about one-half are in care and about one-half are virally suppressed. In the United States, there are approximately 40,000 new infections annually with about two-thirds occurring in gay and bisexual men; heterosexual contact accounts for about one-quarter. African Americans and Latinos are disproportionately affected by HIV. For example, while African Americans represent about 13% of the US population, they account for almost one-half of the new HIV diagnoses, and while Latinos represent 18% of the population, they account for 26% of new HIV diagnoses. Close to 300,000 women are living with HIV in the United States today. Women of color are particularly affected, and black women account for the majority of new HIV diagnoses among women.
In the United States, HIV is most commonly transmitted through anal or vaginal sex or sharing syringes and other injection equipment with someone who has HIV. Receptive anal sex is the highest-risk sexual behavior. Being the insertive partner in anal sex or having vaginal sex (insertive or receptive) is less risky, though either partner can get HIV. HIV is also acquired through sharing needles or syringes, rinse water, or other equipment used to prepare drugs for injection. Less commonly, HIV may be spread from mother to child during pregnancy, birth or breast-feeding, or via a contaminated needle or sharp object.
There are several prevention strategies for HIV. Treatment as prevention refers to the concept that taking antiretroviral therapy (ART) and getting and keeping an undetectable viral load helps prevent transmission to others through sex or syringe sharing and from mother to child during pregnancy, birth, and breast-feeding. People with HIV who take ART as prescribed and are virologically suppressed have effectively no risk of transmitting HIV to their HIV-negative sexual partners and is the ...