GENERAL MEASURES
. The initial visit:
. Past medical history including STDs and TB with dates and treatment
. Review of systems to include fever, chills, diarrhea, weight loss, fatigue, adenopathy, oral sores, cough,
shortness of breath, dyspnea on exertion, visual changes, headaches, skin rash, neurologic changes,
sinusitis, odynophagia
. Social history
. Physical examination, with Pap smear
. Immunization review (pneumococcal, influenza, and Td recommended in adults. OPV contraindicated in
children [use IPV]). Hepatitis A and B if not immune.
. Studies: CBC with differential and platelets; SMAC; RPR; CD4 absolute count and %lymphocytes CD4;
Hep A IgG, Hep B sAg and sAb; Hep C antibody; chest x-ray; PPD with control; HIV-1 RNA viral quantitation
(viral load); toxoplasmosis IgG, CMV IgG, Pap smears in females
. Patients with CD4<350 or CD4 >350 and viral burden >100,000 copies/mL may benefit from antiretroviral
treatment
. Patients with CD4<200 or with oral candidiasis or other signs of significant immune suppression should receive Pneumocystis carinii prophylaxis
β’ Patients with CD4<100 and toxoplasmosis IgG should receive toxoplasmosis prophylaxis and regular screening for CMV retinitis
β’ Patients with CD4<50 should receive prophylaxis against Mycobacterium avium complex (MAC)
β’ When antiretroviral treatment results in significant increase in CD4#, then certain O.I. prophylaxis may be
discontinued
DIET
β’ Encourage good nutrition
β’ Avoid raw eggs, unpasteurized milk and other potentially contaminated foods
β’ May require vitamin supplementation
DRUG(S) OF CHOICE
. Nucleoside reverse transcriptase inhibitors:
. Abacavir (ABC, Ziagen)
. Didanosine (ddI, Videx)
. Emtricitabine (FTC, Emtriva)
. Lamivudine (3TC, Epivir)
. Stavudine (d4T, Zerit)
. Zalcitabine (ddC, Hivid)
. Zidovudine (AZT, Retrovir)
. Protease inhibitors:
. Amprenavir (Agenerase)
. Atazanavir (Reyataz)
. Indinavir (Crixivan)
. Lopinavir-ritonavir (Kaletra)
. Nelfi navir (Viracept)
. Ritonavir (Norvir)
. Saquinavir (Fortovase)
. Non-nucleoside reverse transcriptase inhibitors:
. Delavirdine (Rescriptor)
. Efavirenz (Sustiva)
. Nevirapine (Viramune)
. Nucleotide reverse transcriptase inhibitors:
. Tenofovir (Viread)
. Fusion inhibitors
. Enfuviritide (Fuzeon)
. Current standard of care requires the use of 3 drugs to attempt to prevent the emergence of resistance. Goal
of therapy is to reduce viral load as much as possible and delay or reverse immunodeterioration.
PATIENT MONITORING
. Frequency determined largely by the patients clinical and psychological status and by the need to monitor
drug toxicity and immune function
. Recheck CD4 counts and viral load at least every 3-6 months depending on stage of illness and medical regimen
. Check at subsequent visits:
. Complete, careful physical exam
. Complete review of systems especially focused on neurologic symptoms (CNS infection, malignancy, or
dementia), visual changes (CMV retinitis), diarrhea, fever, night sweats, shortness of breath, dyspnea on
exertion (early P. carinii pneumonia), and odynophagia (esophageal candidiasis)
. Genotypic and phenotypic tests for resistance to antiretrovirals are available and appear to improve clinical
outcome
PREVENTION/AVOIDANCE When possible: avoid unscreened blood products; avoid unprotected sexual intercourse; use condoms; avoid injection drug abuse; needle exchange for active IDUs
POSSIBLE COMPLICATIONS
. Immunodeficiency
. Opportunistic infections
. Neuropsychiatric symptoms
. HIV-associated malignancies
EXPECTED COURSE/PROGNOSIS
When untreated HIV infection leads to AIDS, life expectancy is two to three years. AIDS defining opportunistic infections usually do not develop until CD4<200. In HIV untreated infection, CD4 counts decline
at a rate of 50-80/year with more rapid decline as counts drop below 200. Potent antiretroviral regimens
may delay or reverse immune dysfunction.