The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 23: Medical Care in Advanced AIDSTable 23-1: Sentinel Clinical Events• Immunologic failure, as indicated by low and falling CD4 count, rising viral load in26 picasthe face of good adherence to primary HAART, or other indicators of failed immunesystem reconstitution despite therapy• Relative and absolute antiviral drug resistance to HAART, salvage therapy, orinvestigational trials• Poor adherence to HAART• Progressive cachexia not secondary to HAART lipodystrophy• AIDS-related malignancy including CNS malignancy and visceral KS• Progressive multifocal leukoencephalopathy• Advanced liver disease• Intensive care hospitalization / mechanical ventilation / Pneumocystis cariniipneumonia• Drug-resistant TBRelative and Absolute Antiviral Drug ResistanceAntiviral drug resistance is more likely in patients with CD4 less than 200, in patients who are lessadherent to the initial drug regimen, and in patients on second and third line drug regimens. 5In a group of 70 protease naïve patients with advanced AIDS started on HAART, the treatment failurerate was 40% and mortality rate was 16% in three months. Brechtl’s study shows mortality was notassociated with nonadherence and, while depression and weight improved, other aspects of qualityof life did not. 1Freedberg developed a statistical model of AIDS survival which showed significant improvement inoverall survival and quality-adjusted years of life with adherent HAART therapy but also revealed arelatively short survival for patients with advanced AIDS. A graphic representation of two hypotheticalpatients is shown in Figure 23-1. Estimated survivals are shown in Table 23-2. 6Table 23-2: Survival with and without HAARTSurvival without Survival withCD4 cells/mm 3 Therapy (yr) Therapy (yr)50 1.39 2.84200 3.33 5.32500 7.05 9.13Source: Freedberg KA, et al. The cost effectiveness of combination antiretroviral therapy for HIV disease.N Engl J Med, 344:824-31, 2001. Copyrighted © 2001 Massachusetts Medical Society. All rights reserved. Reproducedwith permission.480U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau