We need to raise awareness about screening guidelines that identify persons at increased risk of acquiring HIV infection (A-II).

Patient medical histories should include the number of sexual partners, types of practices, condom use, drug use during sexual intercourse, sharing of drug-related material during consumption, history of other sexually transmitted infections (STIs), psychosocial situation, and country of origin. Staff should be given sufficient time to attend to each patient according to their needs (B-III).

Gynecological prevention and family planning (B-III). Prevention of mother-to-child transmission (A-I).

Male circumcision only in settings with generalized/widespread HIV epidemic (C-II).

Condom use (A-II).

Regular HIV testing in populations at high risk (A-III).

Behavioral modification interventions (informational campaigns, sex education, outreach to vulnerable people, risk reduction...) (B-II).

Social assessment, including socio-familial environment and livelihoods, to provide support measures if necessary (B-II).

Syphilis screening annually if there is unprotected sex (B-II), and in gay, bisexual, and other men who have sex with men (GBMSM) with risk factors, monitoring at least N. gonorrhoeae, C. trachomatis and hepatitis C virus (C-II). Screening should be performed every 3-6 months, depending on risk factors.

Offer antiretroviral treatment (ART) to all PLWH (A-I), according to current recommendations in clinical guidelines².

Offer pre-exposure prophylaxis (PrEP) (A-I) and post-exposure prophylaxis (PEP) (A-II) in situations in which they are indicated, following current recommendations³ (table 1 and 2).

Regular screening and early treatment of STIs, since ulcerative and rectal STIs increase the risk of acquiring HIV (B-II).

The guidelines propose different screening recommendations, from the routine offer to the general population⁴ to the targeted offer for people at higher risk^5,6.

In Spain, there is a Guide of Recommendations for the Early Diagnosis of HIV in healthcare settings⁷ (figure 1), which should be updated according to the latest available evidence (A-II).

The training of healthcare professionals on the implications of diagnostic delay should be reinforced so that they request HIV testing more frequently (A-III) (table 3).

Strategies should be implemented to carry out screening in different healthcare settings, providing professionals with the appropriate working conditions in order to perform them (A-II).

In Spain, we have extensive practical experience in strategies to optimize HIV screening, both in healthcare and community settings, including mobile units, pharmacies, premises managed by NGOs, and outreach strategies in high-risk environments with offers in leisure or street venues^8-15.

We especially recommend optimizing screening by implementing strategies in PC and community settings (B-I).

Using all care settings to support early diagnosis, counseling, and shared follow-up of PLWH is recommended (B-III).

Generating evidence on shared care in high-income countries is considered a priority (C-III).

With the increase in age and comorbidities in PLWH, it is necessary to implement effective organizational models in other chronic diseases, which implies improving coordination between HC and PC (A-III).

A chronic and shared care model between PC and HC for PLWH should be implemented as soon as possible, which would greatly benefit both the patient and the healthcare system (B-II) (table 5).

The national medical societies in Spain have guidelines regarding telemedicine in the management of PLWH^16,17.

Models of non-face-to-face care with patients and between HC and PC should be established to achieve greater proximity and accessibility of care (C-III).

Telemedicine should be seen as a complementary support tool to optimize resources and facilitate patient care (C-III).

Progress should be made towards safer and more standardized telemedicine care, and its results on the health of PLWH should be evaluated (C-III).

Vaccinate with the same guidelines as the general population. Live attenuated vaccines with CD4+ cell counts < 200 cells/μL (A-I) are contraindicated.

Pneumococcal (A-II), annual influenza (A-II), SARS-CoV-2 (A-II), high-dose HBV (A-I), and postvaccination serological response (B-I), hepatitis A (A-I), human papillomavirus (A-III), and herpes zoster (B-I) vaccines are indicated (table 6).

Serology against the hepatitis A and B viruses should be performed on all patients at the beginning of the study to assess their vaccination status (A-I). In women of childbearing age, rubella serology is recommended for vaccination if IgG is negative (C-III).

The vaccination status and the vaccination record should be reviewed both in PC and in HC (C-III).

ART consists of a combination of two or three antiretroviral drugs. Laboratory evaluation and aspects related to the choice and monitoring of ART are specified in the corresponding GeSIDA guidelines (table 7)¹⁸.

It is essential to know the main side effects of antiretroviral drugs and to avoid polypharmacy, interactions, and new side effects (A-I).

Special situations, such as pregnancy, tuberculosis, and/or comorbidities, require extreme precautions in monitoring and treatment (A-I).

Collaboration between PC and HC professionals is critical in order to avoid severe interactions and to reduce the risk of polypharmacy (B-III).

ART and concomitant medication should be accessible to all prescribing physicians in real-time (B-II).

All medication for PLWH should be reviewed at every clinical visit, especially if the medication is to be modified. Online tools like the one developed by the University of Liverpool (available at: https://www.hiv-druginteractions.org/) can be used to assess interactions. Contraindications should be considered, and dose adjustments made when necessary (A-II).

Adherence to ART should be monitored at each clinical visit. This should be done through multidisciplinary collaboration between healthcare professionals (A-II).

Adherence to ART should be recorded in the clinical history. This information should be shared between PC and HC (C-III).

The use of two independent methods for measuring adherence is recommended. Pharmacy records and simple validated questionnaires are easily accessible in the clinic (C-III).

Healthcare for PLWH should include implementing adherence improvement programs, such as sending reminders via mobile devices or patient education programs (B-I).

Cardiovascular risk (CVR) should be assessed in the initial evaluation and repeated annually with any of the available tools (Framingham, REGICOR, D:A:D, ACC/AHC...) (A-I).

Patients should be encouraged to change their lifestyle, including avoiding smoking (the main modifiable CVR factor), adopting a diet more suited to their needs, and providing the necessary physical exercise (A-II).

In managing dyslipidemia, diabetes mellitus, and high blood pressure, using the same therapeutic algorithm as in the general population is recommended, while taking interactions with ART into account (A-II) (figure 2).

HbA1c should be requested before starting ART. Subsequently, in patients with diabetes, it should be monitored every six months to maintain a level < 7% (A-I).

Interactions between the drugs used (mainly statins) and some antiretroviral drugs should be considered (A-II).

In patients with HIV infection, all hepatic, renal, bone, pulmonary, and/or CNS comorbidities should be evaluated at each clinical visit (HC and PC). Preventive screening and, if necessary, modification of lifestyle habits, antiretroviral therapy, and specific treatment of the healthcare issue should be performed. (A-I). (table 8).

Knowing the vaccination status, the patient's immunological status, and the use of prophylaxis for opportunistic diseases will help to establish an appropriate differential diagnosis for an infectious condition (A-II). The GeSIDA document on the prevention and treatment of opportunistic infections and other coinfections in PLWH¹⁹ has recently been updated.

Perform STI screening in sexually active patients at least once a year (or more frequently, depending on individual risk assessment) (A-II) (table 9).

Active search for parasitosis in patients from specific countries (migrants, travelers...) (A-II).

In the first year after the diagnosis of HIV infection, it is recommended to perform two cervical cytology tests (every six months). If both are normal, they should be repeated annually, including the inspection of the anus, vulva, and vagina (B-III).

Breast and colon cancer screening should be performed according to the recommendations for the general population (B-III).

In immunosuppressed patients (B-III):

Currently, anal cytology, followed by high-resolution anoscopy if the cytology is abnormal, represents the method of choice for screening for squamous intraepithelial lesions (B-II). Annual anal cytology is recommended for PLWH of the GBMSM group (especially >35 years or advanced immunosuppression) and women with lower genital tract dysplasia (B-III).

PLWH with liver cirrhosis and those with HBV infection and estimated risk of hepatocellular carcinoma greater than 0.2% per year should be screened by biannual liver ultrasound (A-I).

In PLWH, it is advisable to assess their emotional health, paying attention to coping strategies and stigma (A-III). In places where there is no free choice of a mental health specialist, it is recommended to study the case and authorize the requested changes of specialists.

Validated scales such as the HADS can be used to screen for anxiety and depression at the time of diagnosis and on an annual or biennial basis (A-III).

If depressive symptomatology is identified, suicide risk should be assessed using the MINI structured interview (B-II).

Pregnancy is a criterion for an immediate referral from PC to HC. To avoid vertical transmission, all women with HIV should receive ART as early as possible, preferably before conception (A-II).

The ART of choice should be triple therapy. Abacavir-lamivudine or TDF-emtricitabine combinations plus a third drug, which may be raltegravir, dolutegravir, or darunavir/ritonavir, are of choice. The choice will depend on the time of initiation (whether prior to conception or not), the history of resistance or intolerance, and the patient's preference (A-II).

Intrapartum treatment with IV zidovudine is indicated if the plasma viral load is > 1000 copies/ml or unknown at delivery time (A-I).

During delivery, cesarean section is indicated in women with confirmed or suspected viral load of more than 1000 copies/ml (A-II). It is recommended in women with a viral load between 50-1000 copies/ml, although each case should be personalized (B-III).

In these circumstances, breastfeeding is not recommended (A-II).

In PLWH, family planning must be done in the best possible clinical situation, minimizing the risks for the woman, the couple, and the fetus, explaining the different reproductive options (A-II) (table 10).

It is recommended to evaluate the age of onset of menopause, considering the symptoms associated with menopause, premature aging, and comorbidities. Hormone replacement therapy can be assessed with the same indications as in the general population (A-III).

DEXA is advised in postmenopausal women with HIV infection (A-I).