A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

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A Guide to Primary Care of People with HIV/AIDS Chapter 7: Adherence to HIV Therapies CASES 1. AR is a 37-year-old woman who uses heroin and cocaine daily and has a CD4 count of 300 cells/mm 3 and an HIV viral load of 150,000 copies/mL. Since she was diagnosed with HIV infection 10 years ago she has primarily sought care when acutely ill. She comes to clinic for the first time in 6 months because she has decided to start “the cocktail.” Question: How do you manage this patient? Answer: This patient is not engaged in primary care and is using heroin daily. Although she might be able to adhere to therapy, she probably won’t. Beginning ART is reasonable given her CD4 cell count and viral load; however nothing makes it critical to start therapy immediately. 7 The patient did not agree with her physician’s assessment that her substance abuse was a barrier to medical care or medication adherence. She agreed to contract with her physician to start ART after she made 5 consecutive clinic visits. After several attempts at consecutive visits, the patient enrolled in a methadone-based substance abuse treatment program. She began to come regularly to clinic, engaged in in-depth medication education, and eventually started ART. She had good adherence, maintaining an undetectable viral load for 18 months before a drug abuse relapse. When she began to miss doses, she stopped all her medications as instructed and did not develop significant resistance. 2. DP is a 4-year-old with perinatally-acquired HIV infection. He is taken care of by his maternal greatgrandmother, who is also caring for 3 other great-grandchildren. He resists taking ART because of the taste, so that it takes his great-grandmother 30-60 minutes to administer each dose when she can get him to take it. Although she has worked closely with the behavior modification team at the pediatric clinic, the situation has not improved. His viral load and CD4 cell count have not changed significantly on therapy. Question: What do you do to treat this patient? Answer: Given the patient’s refusal to take medication, the decision was made to place a g-tube for ease of administration. Within 1 month the viral load was undetectable, and the time to administer medications had decreased to less than 10 minutes per dose. The great-grandmother reported a significant improvement in their relationship and in DP’s behavior in a number of domains. Although this may seem extreme, this is an example of individualizing the intervention to the barriers that exist for the patient (Shingadia, et al 2000). 54 U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau
A Guide to Primary Care of People with HIV/AIDS Chapter 8: Symptom Management Chapter 8: Symptom Management Tara Evans Nysoe, MD Douglas S. Paauw, MD, FACP WORKUP OF SYMPTOMS MEDICATION-RELATED ISSUES NAUSEA PULMONARY SYMPTOMS FATIGUE NEUROPATHIC PAIN DERMATOLOGIC SYMPTOMS MOUTH LESIONS WASTING MYALGIAS DIARRHEA HEADACHE KEY POINTS SUGGESTED RESOURCES CASES WORKUP OF SYMPTOMS How should you approach the workup of symptoms in patients infected with HIV? Symptom evaluation in HIV-infected patients must include knowledge of the CD4 count and viral load as well as close attention to the medication list. An opportunistic disease (OD) is an unlikely cause of symptoms in patients with CD4 cell counts >200/mm 3 . Antiretroviral medications are a common cause of HIVrelated symptoms. MEDICATION-RELATED ISSUES What are the most common symptoms related to antiretroviral medications? Nausea and diarrhea are the two most common symptoms associated with antiretroviral therapy (ART). Pruritus and skin rashes are also common, especially with nonnucleoside drugs. Lower extremity pain due to neuropathy is seen with didanosine (ddI), stavudine (d4T), and zalcitabine (ddC). What are the common side effects of each of the antiretroviral drugs? The different classes of drugs have many similar as well as distinct side effects (see Table 8-1). What symptoms could be due to lifethreatening acute drug reactions? Symptoms of life-threatening acute drug reactions are not to be missed. A patient with myalgias, nausea, vomiting, diarrhea, abdominal pain, fever, rash, malaise, and extreme fatigue who has started taking abacavir (ABC) within the previous 6 weeks is probably suffering from an abacavir hypersensitivity reaction. In this case, abacavir should be permanently discontinued. The hypersensitivity reaction occurs in up to 5% of patients starting on abacavir and can lead to hypotension and death if the patient is rechallenged with abacavir. If a patient taking one of the “d-drugs” (didanosine [ddI], zalcitabine [ddC], stavudine [d4T], dapsone [for Pneumocystis pneumonia prophylaxis]) has rapid onset of nausea/vomiting and constant, severe abdominal pain in the epigastrium or upper quadrants that radiates to the back, drug-induced pancreatitis is possible. Patients taking a nucleoside (NRTI) who have vague symptoms including nausea, vomiting, abdominal pain, weight loss, malaise, fatigue, dyspnea, or fever must have lactic acidosis with hepatic steatosis ruled out. This occurs 5-13 months after initiating therapy and has a 60% fatality rate. Patients taking nevirapine (NVP) who have fatigue, malaise, nausea, vomiting, jaundice, and right-upper-quadrant abdominal pain could have nevirapine-induced hepatitis. Also, up to half the patients taking nevirapine may have a rash; however, if the rash is moist, involves the mucous membranes, or is extensive with an associated fever, Stevens-Johnson syndrome, which also occurs in patients taking trimethoprim-sulfamethoxazole (TMP/ sulfa), must be considered. Severe cases of Stevens- Johnson syndrome, including toxic epidermal necrolysis (TEN), are medical emergencies and must be managed as burn cases. For all drug-induced, life-threatening illnesses, immediate discontinuation of the offending drug is the crucial first step in care. What are the most important drug interactions that occur with antiretroviral medications? Drug interactions are frequently the cause of symptoms and must be closely watched for. Not only do antiretroviral drugs react with each other, they react with numerous prescribed drugs and recreational drugs (see Tables 4-8 in the Pocket Guide). 8 U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau 55
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