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INTRODUCTION

ESSENTIALS OF DIAGNOSIS

  • Diagnosis of HIV infection is made by HIV antibody testing by ELISA, confirmed by Western blot or multispot ELISA.

  • Absolute CD4 lymphocyte count is widely used for staging HIV disease. Acquired immune deficiency syndrome (AIDS) is defined as a CD4 <200 cells/μL. AIDS represents advanced HIV disease that is associated with opportunistic infections or malignancy in the absence of treatment.

  • HIV RNA level (viral load) is used to monitor response to antiretroviral therapy.

GENERAL CONSIDERATIONS

As the fourth decade of the HIV/AIDS epidemic unfolds, major shifts in the epidemiology and prognosis of HIV disease have occurred. Significant advances in treatment of HIV infection have transformed this fatal disease into a chronic multisystem disease characterized by multiple comorbidities, with noninfectious complications. The Centers for Disease Control and Prevention (CDC) estimated that there are 1.2 million adults and adolescents currently living with HIV infection in the United States.

Another important shift has been the aging of the HIV-infected population in several countries.

It is estimated that in the USA, by 2017, more than half of all HIV-infected individuals will be over 50 years old. As patients are living longer with HIV, the number of patients with chronic infection has increased steadily.

While older studies indicate an association between optimal clinical outcomes and greater provider expertise in managing HIV infection, in several countries, including the United States, it is projected that there is a strong need to develop the HIV care provider workforce. In the United States, many of the clinicians involved in HIV care entered this field at the beginning of the epidemic and are nearing retirement; additionally, fewer infectious diseases physicians are choosing to become HIV primary care providers. New CDC recommendations for universal screening will further increase the demand for care, as patients previously unaware of their HIV status are diagnosed. On account of expanded screening, increasing prevalence of HIV infection, the syndemic of HIV and aging related comorbidities, and a looming shortage of HIV primary care providers, primary care providers (PCPs) have a critical role to play in providing care to HIV-infected individuals and populations.

By virtue of their training, family physicians and other primary care providers, including physician assistants and nurse practitioners, are particularly well suited to provide this type of comprehensive, longitudinal care with an emphasis on addressing multiple medical co-morbidities, and preventive care (UN AIDS 2012 Global Report). It is well documented that the quality of HIV care provided by generalists with HIV experience is comparable to that of infectious disease (ID) specialists. Studies have also shown that general practitioners, when compared with ID physicians, are significantly more comfortable with the management of several comorbidities such as depression, diabetes, hypertension, and hyperlipidemia. These conditions are commonly encountered in HIV-infected individuals.

It is well established that effective HIV care leads to effective suppression of viral replication, improved immune status, near-normal life expectancy, enhanced quality of life, and prevention of HIV transmission (Currier and Havlir ...

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