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3–50 | Clinical Manual for Management of the HIV-Infected Adult/2006 References ♦ ♦ ♦ ♦ ♦ ♦ ♦ Aaron E, M. Thinking about Having a Baby? Preconception Counseling for HIV Discordant Couples [PowerPoint]. Philadelphia: Drexel University College of Medicine; 2005. Accessed March 14, 2006. American College of Obstetricians and Gynecologists. 1999 Management of herpes in pregnancy. ACOG Practice Bulletin #9; October 1999. [Registration required.] American College of Obstetricians and Gynecologists. Immunization during pregnancy. ACOG Committee Opinion No. 282; 2003. [Registration required.] Anderson JR. HIV and Reproduction. In: Anderson JR, ed. A Guide to the Clinical Care of Women with HIV. Rockville, MD: Health Services and Resources Administration; 2005. Accessed March 14, 2006. Antiretroviral Pregnancy Registry Steering Committee. The Antiretroviral Pregnancy Registry International Interim Report for 1 January 1989 through 31 January 2005. Wilmington, NC: Registry Coordinating Center; July 31, 2005. Accessed March 14, 2006. Centers for Disease Control and Prevention. Enhanced Perinatal Surveillance—United States, 1999-2001. Special Surveillance Report 4. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2004. Accessed March 14, 2006. Centers for Disease Control and Prevention. General recommendations on immunization. Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Family Physicians (AAFP). MMWR Recomm Rep. 2002 Feb 8;51(RR-2):1-35. ♦ ♦ ♦ ♦ ♦ ♦ Centers for Disease Control and Prevention. Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States. October 12, 2006. Available online at aidsinfo.nih.gov/Guidelines/GuidelineDetail. aspx?GuidelineID=9. Accessed July 8, 2007. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2006. MMWR 2006;55(No. RR-11):1-100. Ethics Committee of the American Society for Reproductive Medicine. Human immunodeficiency virus and infertility treatment. Fertil Steril. 2004 Sep;82 Suppl 1:S228-31. Minkoff H. Human immunodeficiency virus infection in pregnancy. Obstet Gynecol. 2003 Apr;101(4):797- 810. U.S. Department of Health and Human Services. Guidelines for the Use of Antiretroviral Agents in HIV- 1-Infected Adults and Adolescents. October 10, 2006. Available online at aidsinfo.nih.gov/Guidelines/ GuidelineDetail.aspx?GuidelineID=7. Accessed July 7, 2007. U.S. Public Health Service, Infectious Diseases Society of America. Guidelines for preventing opportunistic infections among HIV-infected persons —2002. MMWR Recomm Rep. 2002 Jun 14;51(RR08);1-46. Available online at aidsinfo.nih. gov/Guidelines/. Accessed May 19, 2006.
Section 3—Antiretroviral Therapy | 3–51 Antiretroviral Medications and Oral Contraceptive Agents Background This chapter highlights the interactions between currently available antiretroviral agents and oral contraceptives. The oral contraceptives ethinyl estradiol and norethindrone may interact in complex ways with protease inhibitors (PIs) and nonnucleoside reverse transcriptase inhibitors (NNRTIs). The mechanism of these interactions may be multifactorial and includes the activity of these agents on cytochrome P450 enzymes. Pharmacokinetic studies have shown changes (either increases or decreases) in levels of ethinyl estradiol Table 1. Interactions between Antiretroviral Agents and Oral Contraceptives Antiretroviral Agent Pharmacokinetic Changes with Oral Contraceptives Protease Inhibitors Atazanavir (ATV, TAZ, Reyataz) • EE AUC increased 48% • NE AUC increased 110% Fosamprenavir (FPV, Lexiva), Amprenavir (AMP, Agenerase) • • C min of EE/NE increased 32-45%; no significant change in AUC Amprenavir AUC decreased 22% and C min decreased 20% Indinavir (IDV, Crixivan) • EE AUC increased 24% • NE AUC increased 26% Lopinavir/ritonavir (LPV/r, Kaletra) • EE AUC decreased 42% • NE AUC decreased 17% Nelfinavir (NFV, Viracept) • EE AUC decreased 47% • NE AUC decreased 18% and norethindrone in women who are taking certain PIs or NNRTIs. Other studies have shown decreases in levels of amprenavir (a PI) in women taking oral contraceptives. The clinical significance of these drug interactions has not been evaluated thoroughly, but may cause oral contraceptive failure or antiretroviral failure, or medication toxicity, depending on whether drug levels are lowered or raised by the interacting drug. Table 1 summarizes the available pharmacokinetic data. A more comprehensive review of oral and nonoral contraceptives for HIV-infected women can be found in the chapter Care of HIV-Infected Pregnant Women. Comments • • • • • • • Use lowest effective dose of each OC component and monitor for adverse effects. Consider alternative methods of contraception to avoid OC adverse effects. To avoid risk of ARV failure, do not coadminister amprenavir or fosamprenavir with OCs. Consider alternative methods of contraception. No dose adjustment is recommended. Use of alternative or additional method of contraception is recommended. Use of alternative or additional method of contraception is recommended to avoid contraceptive failure. Ritonavir (RTV, Norvir) • EE AUC decreased 40% • Use of alternative or additional method of contraception is recommended to avoid contraceptive failure. Saquinavir (SQV, Invirase, Fortovase) • • No data available regarding effect of SQV on EE or NE levels SQV kinetics not affected by OC • Until more data are available alternative methods of contraception is recommended. Tipranavir/ritonavir (TPV/r, Aptivus) • EE C and AUC decreased approximately • Use of alternative or additional method of contraception is recommended to avoid max 50% contraceptive failure. Nonnucleoside Reverse Transcriptase Inhibitors Efavirenz (EFV, Sustiva) • EE levels increased 37% • No data available on NE component Nevirapine (NVP, Viramune) • EE AUC decreased 20% • NE AUC decreased 20% • • Use of alternative method of contraception is recommended to avoid OC side effects. Use of alternative or additional method of contraception is recommended to avoid contraceptive failure. Key to abbreviations: EE = ethinyl estradiol; NE = norethindrone; AUC = area under the curve (drug concentration); C min = minimum concentration; C max = maximum concentration. Adapted from U.S. Department of Health and Human Services. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. October 10, 2006.
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Clinical Manual for Management of t
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Table of Contents Clinical Manual f
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Clinical Manual for Management of t
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Preface—About this Manual | Clini
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Previous Editions Atlanta Contribut
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♦ ♦ ♦ ♦ ♦ | Clinical Manu
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Initial Physical Examination Backgr
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Genitals/Rectum • Inspect the gen
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Initial and Interim Laboratory and
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Section 1—Testing and Assessment
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Patient Education ♦ ♦ ♦ ♦ D
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Section 2—Health Maintenance and
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References ♦ ♦ ♦ ♦ ♦ ♦
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Occupational Postexposure Prophylax
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P: Plan Laboratory Testing Provide
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For hepatitis C, no recommended pro
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as hepatitis C or another sexually
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for treatment is appropriate, and b
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contact with the patient. Patients
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tablet daily of trimethoprim-sulfam
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Opportunistic Infection Prophylaxis
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Discontinuing Primary Prophylaxis P
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Latent Tuberculosis Background Late
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INH may cause liver toxicity and it
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Patient Education ♦ ♦ ♦ ♦
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Eye Problems Background The immunos
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of
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Fever Background Although fever may
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Headache Background Headache may ha
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Lymphadenopathy Background Lymphade
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Treatment Treatment will depend on
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Neurologic Symptoms Background The
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Pulmonary Symptoms Background Short
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Treatment Once the diagnosis is mad
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Candidiasis, Oral and Esophageal Ba
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Maintenance therapy Use caution whe
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Cervical Dysplasia Background Cervi
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Patient Education ♦ ♦ ♦ ♦ P
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Cryptosporidiosis Background Crypto
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Gonorrhea and Chlamydia Background
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Treatment of Gonorrhea Treatment op
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Hepatitis B Infection Background He
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♦ ♦ ♦ ♦ ♦ Some patients t
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Hepatitis C Infection Background He
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pregnancy. Ribavirin is teratogenic
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Herpes Simplex, Mucocutaneous Backg
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References ♦ ♦ ♦ ♦ ♦ Cent
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Kaposi Sarcoma Background Kaposi sa
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Treatment Treatment of KS is not co
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Molluscum Contagiosum Background Mo
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Mycobacterium avium Complex Backgro
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Table 1. Interactions between Rifab
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Mycobacterium tuberculosis: Treatme
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P: Plan Diagnostic Evaluation Durin
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Table 1. Regimens for Treatment of
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Rifabutin may be substituted for ri
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Non-Hodgkin Lymphoma Background Non
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Patient Education ♦ ♦ ♦ ♦ S
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Toxoplasmosis Background Toxoplasma
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♦ Atovaquone 1,500 mg orally twic
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Linear Gingival Erythema Background
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Background Necrotizing ulcerating p
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Oral Health Background Examination
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Maxillary Tori; Mandibular Tori S:
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Periodontal Disease Background The
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Oral Hairy Leukoplakia Background O
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Oral Ulceration Background Oral ulc
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Oral Warts Background Oral warts ar
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Anxiety Disorders Background Anxiet
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Patient Education ♦ ♦ Behaviora
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Insomnia Background Insomnia is a c
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Suicidal Ideation Background Transi
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Section 8—Neuropsychiatric Disord
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P: Plan ♦ ♦ ♦ ♦ ♦ Check t
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Correctional Settings Background Ca
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Adherence Adherence is one of the m
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Karnofsky Performance Scale Backgro
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