HIV Primary Care — fellow's quick read

Personal study digest for a new ID fellow. Recommendations are from the HIVMA/IDSA Primary Care Guidance 2024 update (Horberg & Thompson et al, Clin Infect Dis, doi:10.1093/cid/ciae479). The "What's changed since 2024" section is reviewer synthesis of newer evidence, each claim cited. Not a substitute for the full guidance. Queue note: item #20 was labeled "Pneumocystis and HIV opportunistic infections," but the archived file PCM for HIV IDSA 2024.pdf is actually this Primary Care guidance ("PCM" = primary care management, not Pneumocystis) — so this digest covers HIV primary care. A dedicated OI/PJP guideline can be queued separately.

In one line

Modern HIV care is chronic-disease primary care: start ART fast (day 0–7), keep the viral load undetectable (U=U), and prevent what now kills people with HIV — cardiovascular disease, cancer, and STIs — not the OIs. The fellow owns rapid ART, the CD4-gated OI/vaccine decisions, a statin for nearly everyone ≥40, and the newer prevention tools.

◆First visit — rapid ART & a status-neutral start

Rapid ART = start on the day of diagnosis or within 7 days. Offer to everyone unless a specific reason to delay — chiefly cryptococcal or tuberculous meningitis (IRIS risk) — or the patient prefers to wait. Truncate the H&P if needed and complete it at close follow-up.
U=U (undetectable = untransmittable) is core counseling from visit one.
Surgical and dental decisions must NOT hinge on CD4 or HIV RNA alone — shared decision-making among specialist, surgeon, and patient.
People with HIV can be solid-organ recipients AND donors (donor to another person with HIV, regardless of donor HIV status).

◆Baseline labs the fellow orders (Table 4)

Everyone: HIV Ag/Ab (confirm if status undocumented), CD4 count + %, HIV RNA, and a resistance genotype (protease + reverse transcriptase).
INSTI genotype only if transmitted-INSTI resistance is suspected or HIV was acquired on long-acting cabotegravir PrEP — order it regardless of time since the last injection (long PK tail).
HLA-B*5701 only if abacavir is considered; tropism assay only if a CCR5 antagonist is considered. CD8 count and CD4:CD8 ratio are NOT needed (don't drive decisions).
OI serologies are CD4-gated: serum cryptococcal antigen if CD4 <100; Toxoplasma IgG if CD4 <200. Check G6PD before dapsone/primaquine; use sulfonamides with caution unscreened.
Also at entry: CBC, chem/LFTs, lipids + glucose/A1c, UA, and the coinfection panel (below).

◆Monitoring cadence after ART start

HIV RNA at 2–4 wk (no later than 8 wk), then q4–8 wk until suppressed, then q3–4 mo; may extend to q6 mo once suppressed >1 yr and clinically stable.
CD4 q3–6 mo for the first 2 yr; after 2 yr if suppressed with CD4 300–500 → q12 mo; if CD4 >500 → optional.
CBC q12 mo; chem panel 1–2 mo after ART start/change, then q6 mo.
Blip = single HIV RNA <200 that re-suppresses (assess adherence, don't panic). Virologic failure = two consecutive ≥200 → repeat genotype (incl. integrase if on an INSTI).

◆Screening the fellow drives

Target	Who / when	Fellow's note
Latent TB	TST or IGRA at entry (IGRA preferred if BCG history); annually if ongoing risk/exposure	≥5 mm TST is positive in HIV. If CD4 ≤200, repeat once CD4 >200 on ART. Treat close contacts regardless of test result.
HCV	Ab at entry; repeat ≥annually with ongoing risk	If Ab+ → HCV RNA. Use HCV RNA (not Ab) if CD4 <200 — 2–4% false-negative antibody.
GC / CT / syphilis	3-site NAAT at entry + ≥annually; q3–6 mo if multiple/anonymous partners	Trichomonas if receptive vaginal sex. Re-screen 3 mo after any positive (reinfection).
Cervical	Start at 21, annually; may space to 3 yr after 3 normal Paps or a negative co-test	No upper age limit in HIV (unlike the general population).
Anal	Annual digital anal-rectal exam for all; anal Pap (with HRA access) for transgender women, MSM >35, all PWH >45	Treat all HSIL (hyfrecation). HPV-driven; greatly elevated in PWH.
HCC	US ± AFP q6 mo	For cirrhosis (any cause), chronic HBV, or HCV with F3/F4 fibrosis — even after cure.

◆Immunizations — mind the CD4 gate

Live vaccines are CD4-gated: MMR only if CD4 ≥200 (contraindicated <200); varicella primary vaccine contraindicated if CD4 <200 (give if seronegative, >8 yr, CD4 >200).
Hepatitis B: adjuvanted HepB-CpG (Heplisav-B) preferred, 2 doses at 0 and 1 mo; check HBsAb 1–2 mo after and revaccinate if <10 mIU/mL (consider a 3-dose HepB-CpG series at low CD4). Avoid HepB-CpG in pregnancy (no safety data).
Pneumococcal: PCV20 alone, or PCV15 → PPSV23 ≥8 wk later, for all PWH 19–64.
HPV through age 45 (routine 9–26; 27–45 by shared decision). RZV (Shingrix) 2 doses for anyone ≥18. Mpox JYNNEOS (MVA-BN) 2-dose for those at risk.

◆Prevention the fellow initiates

Statin for nearly every patient ≥40: primary-prevention statin for all PWH aged 40–75 regardless of lipids or ASCVD risk (strongest if 10-yr risk ≥5%). Moderate-intensity = pitavastatin 4 mg / atorvastatin 20 mg / rosuvastatin 10 mg; high-intensity if 10-yr risk >20%. Basis: REPRIEVE.
doxyPEP: doxycycline 200 mg once, within 72 h of sex — offer to MSM and transgender women with a syphilis/CT/GC diagnosis in the last 12 mo; not established in cisgender women (shared decision). Screen STIs q3–6 mo; watch gonococcal tetracycline resistance.
Breastfeeding: with ART + suppression, transmission is low but not zero — support an informed choice; formula or banked donor milk eliminates risk. Do not involve Child Protective Services over an infant-feeding choice.

◆Key decisions a fellow owns

Do NOT switch ART solely for weight gain (weigh at every visit, waist circumference annually; counsel diet/exercise).
Let the CD4 gate drive OI prophylaxis and live-vaccine timing (<100 CrAg; <200 Toxo/PJP/MMR/varicella).
After a CAB-LA PrEP breakthrough infection, send an integrase genotype regardless of interval; verify an isolated positive HIV RNA with negative Ab by repeat testing.
Start the statin in the ≥40s and offer doxyPEP to the right populations — these are the two prevention moves most often missed.

What's changed since 2024

Reviewer synthesis of newer evidence — not the guidance. Each claim cited; the guidance was finalized before these developments.

Twice-yearly lenacapavir PrEP (Yeztugo) — the big one the guidance predates. FDA-approved 18 Jun 2025 as the first 6-monthly injectable PrEP. PURPOSE 1 in cisgender women: 0 infections / 2134 on lenacapavir vs 2.02/100 PY on F/TAF (Bekker, NEJM 2024). PURPOSE 2 in men/gender-diverse persons: 2 infections / 2179, ≥99% risk reduction. PURPOSE 1 PMID 39046157, doi:10.1056/NEJMoa2407001 · PURPOSE 2 PMID 39602624, doi:10.1056/NEJMoa2411858 · CDC MMWR 2025 mm7435a1
PCV21 (Capvaxive/V116) is now a simpler pneumococcal option. FDA 17 Jun 2024; ACIP recommends it (27 Jun 2024) as a single-dose option for adults ≥19 with a PCV indication, including HIV — an alternative to the PCV20 or PCV15+PPSV23 regimens the guidance lists. ACIP, MMWR 2024;73:793–798
Still current — statin for all ≥40 rests on REPRIEVE: pitavastatin 4 mg cut major cardiovascular events 36% in 7769 PWH at low–intermediate risk, even below usual LDL thresholds. Grinspoon, NEJM 2023;389:687–699; PMID 37486775, doi:10.1056/NEJMoa2304146
Still current — doxyPEP rests on the DoxyPEP RCT: first-episode chlamydia aHR 0.14, syphilis 0.21, gonorrhea 0.67 in MSM/transgender women; the cisgender-women trial (dPEP Kenya) was negative. Luetkemeyer, NEJM 2023;388:1296–1306; PMID 37018493, doi:10.1056/NEJMoa2211934
No newer HIVMA/IDSA primary care guidance since this 2024 update (it revises the 2020 guidance) — it remains the operative US reference.

◆Anki cards minted this run

doxyPEP — doxycycline 200 mg ≤72 h post-sex, populations offered (DoxyPEP RCT).
INSTI genotype after a CAB-LA PrEP breakthrough — regardless of interval.
Anal cancer screening thresholds in PWH (transgender women / MSM >35 / all >45).
Cervical cancer screening in PWH — starts at 21, no upper age limit.
Held as duplicates: statin-for-all-≥40 / REPRIEVE (in deck), lenacapavir twice-yearly PrEP incl. PURPOSE 1 (in deck), MMR-only-if-CD4≥200 (in deck).

Sources: HIVMA/IDSA Primary Care Guidance 2024 update (Horberg MA, Thompson MA, et al; Clin Infect Dis 2024, doi:10.1093/cid/ciae479); REPRIEVE (PMID 37486775); DoxyPEP trial (PMID 37018493); PURPOSE 1 (PMID 39046157); PURPOSE 2 (PMID 39602624); lenacapavir FDA approval 18 Jun 2025 & CDC MMWR 2025 (mm7435a1); PCV21 ACIP (MMWR 2024;73:793–798).