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4–4 | Clinical Manual for Management of the HIV-Infected Adult/2006 References ♦ ♦ ♦ ♦ ♦ ♦ Carr A, Workman C, Carey D, et al. No effect of rosiglitazone for treatment of HIV-1 lipoatrophy: randomised, double-blind, placebo-controlled trial. Lancet. 2004 Feb 7;363(9407):429-38. Gallant JE, Staszewski S, Pozniak AL, et al. Efficacy and safety of tenofovir DF vs stavudine in combination therapy in antiretroviral-naive patients: a 3-year randomized trial. JAMA. 2004 Jul 14;292(2):191-201. Martin A, Smith DE, Carr A, et al. Reversibility of lipoatrophy in HIV-infected patients 2 years after switching from a thymidine analogue to abacavir: the MITOX Extension Study. AIDS. 2004 Apr 30;18(7):1029-36. Norris A, Dreher HM. Lipodystrophy syndrome: the morphologic and metabolic effects of antiretroviral therapy in HIV infection. J Assoc Nurses AIDS Care. 2004 Nov-Dec;15(6):46-64. Schambelan M, Benson CA, Carr A, et al. Management of metabolic complications associated with antiretroviral therapy for HIV-1 infection: recommendations of an International AIDS Society- USA panel. J Acquir Immune Defic Syndr. 2002 Nov 1;31(3):257-75. 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.
Dyslipidemia Background In HIV-infected people treated with antiretroviral therapy (ART), improved life expectancy and the aging process are likely to increase morbidity and mortality from coronary heart disease (CHD). Thus, identification and reduction of modifiable risk factors for CHD are important aspects of primary care for HIV-infected patients. Several risk factors for CHD are common among HIV-infected populations in the United States and Europe. Dyslipidemia is a well-described independent risk factor for CHD that occurs in a high proportion of patients treated with antiretroviral (ARV) medications. Other metabolic abnormalities such as insulin resistance and diabetes may be caused or compounded by ARVs. In addition, some traditional CHD risk factors, including smoking, hypertension, and inactivity, are prevalent in many HIV-infected populations. Before the widespread use of ARV medications, increases in triglyceride (TG) levels and decreases in total cholesterol (TC), high-density lipoprotein (HDL) cholesterol, and low-density lipoprotein (LDL) cholesterol were reported in individuals with HIV disease. The introduction of combination ART, particularly the use of protease inhibitors (PIs), increased the prevalence of dyslipidemia in HIVinfected patients. In fact, dyslipidemia is associated with certain agents in each of the 3 major classes of ARVs. In the PI class, ritonavir and ritonavir-boosted PIs (with the exception of atazanavir) are particularly likely to cause marked elevations of TG and LDL levels. Nonnucleoside reverse transcriptase inhibitors (NNRTIs) also may contribute to increases in TC, LDL, and TG levels although the effects, particularly with efavirenz, are more variable. Nucleoside analogue reverse transcriptase inhibitors (NRTIs), specifically stavudine, may increase TC and TG levels. The pathogenesis of ARV-induced dyslipidemia is not well understood. Current research suggests that the dyslipidemia observed in patients taking ART is caused by a combination of factors related to HIV disease, ARV regimens, and individual patient characteristics. Lipid abnormalities may appear or worsen within Section 4—Complications of Antiretroviral Therapy | 4–5 a few weeks to months after starting ART. Not all ARV-treated patients experience lipid abnormalities to the same degree. Patients with a personal or family history of dyslipidemia, glucose intolerance, diabetes, obesity, or a combination of these health problems may be genetically predisposed to lipid abnormalities that become evident once ART is initiated. Published research regarding the relationship between ARVs and the risk of cardiovascular disease has not been conclusive. The largest prospective study of CHD events related to ARVs (the DAD study), showed a small but significant increase in the risk of myocardial infarction among HIV-infected patients treated with ART; moreover, the effect increased with cumulative years of ARV exposure. While awaiting definitive results from this and other studies, it is important to screen and treat patients for lipid abnormalities and for other known CHD risk factors. For patients with CHD or CHD risk equivalents (see below), ARV regimens should, if possible, be selected to minimize the risk of hyperlipidemia. Guidelines for the evaluation and management of dyslipidemia have been developed by the National Cholesterol Education Program (NCEP). These recommendations and follow-up reports are based on studies of HIV-uninfected patients and may not be entirely applicable to HIV-infected patients. Despite this limitation, expert panels generally recommend similar treatment goals when evaluating and managing dyslipidemia in patients with HIV infection. (For recommendations on screening, see chapter Initial and Interim Laboratory and Other Tests.) S: Subjective The history should focus on factors indicating coronary artery disease or cardiovascular risk. CHD risk factors are conditions associated with a greater risk of serious cardiac events. A CHD risk equivalent, such as diabetes, is considered to be equal in risk to known CHD. Both CHD risks and CHD equivalents should be the focus of lifestyle modification strategies and lipid-normalizing treatment.
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Table of Contents Clinical Manual f
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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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Page 175 and 176: Recreational Drugs and Antiretrovir
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Page 181 and 182: Immune Reconstitution Syndrome Back
Page 183 and 184: A: Assessment In the appropriate cl
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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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