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4–36 | Clinical Manual for Management of the HIV-Infected Adult/2006 Immune Reconstitution in Resource-Constrained Settings As access to ART improves in resource-constrained countries, IRS is increasingly being recognized in patients receiving ART. Clinicians should include IRS in the differential diagnosis when evaluating patients who recently have begun ART and present with new or worsening symptoms of an OI. However, limited diagnostic testing resources may make it difficult to establish IRS or other diagnoses. Given that coinfection with HIV and TB, is epidemic in many countries, and because IRS is not uncommon in patients with TB, clinicians should be particularly vigilant about symptoms that may signal IRS. As in resource-abundant countries, a consultation is recommended with a clinician trained in caring for patients with HIV if diagnosis or treatment is in question. References ♦ ♦ ♦ ♦ Bower M, Nelson M, Young AM, et al. Immune reconstitution inflammatory syndrome associated with Kaposi’s sarcoma. J Clin Oncol. 2005 Aug 1;23(22):5224-8. Centers for Disease Control and Prevention, National Institutes of Health, HIV Medicine Association/Infectious Diseases Society of America. Treating Opportunistic Infections Among HIV-Infected Adults and Adolescents. MMWR Recomm Rep. 2004 Dec 17; 53(RR15):1-112. Available online at aidsinfo.nih.gov/Guidelines/GuidelineDetail. aspx?GuidelineID=14. Accessed May 19, 2006. Centers for Disease Control and Prevention. Recommendations on prophylaxis and therapy for disseminated Mycobacterium avium complex for adults and adolescents infected with human immunodeficiency virus. U.S. Public Health Service Task Force on Prophylaxis and Therapy for Mycobacterium avium Complex. MMWR Recomm Rep. 1993 Jun 25;42(RR-9):14-20. Available online at www.cdc. gov/mmwr/preview/mmwrhtml/00021272.htm. Accessed May 19, 2006. DeSimone JA, Pomerantz RJ, Babinchak TJ. Inflammatory reactions in HIV-1-infected persons after initiation of highly active antiretroviral therapy. Ann Intern Med. 2000 Sep 19;133(6):447-54. Patient Education ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ When patients are initiating ART, advise them to contact the clinic promptly if they experience new or worsening symptoms. Advise patients to take their antiretroviral medications exactly as prescribed. Advise patients to take their medications for the treatment or prevention of OIs exactly as prescribed. Domingo P, Torres OH, Ris J, et al. Herpes zoster as an immune reconstitution disease after initiation of combination antiretroviral therapy in patients with human immunodeficiency virus type-1 infection. Am J Med. 2001 Jun 1;110(8):605-9. Drake A, Mijch A, Sasadeusz J. Immune reconstitution hepatitis in HIV and hepatitis B coinfection, despite lamivudine therapy as part of HAART. Clin Infect Dis. 2004 Jul 1;39(1):129-32. Egger M, May M, Chene G, et al. Prognosis of HIV- 1-infected patients starting highly active antiretroviral therapy: a collaborative analysis of prospective studies. Lancet. 2002 Jul 13;360(9327):119-29. Jacobson MA. Clinical Implications of Immune Reconstitution in AIDS. In: Peiperl L, Coffey S, Volberding PA, eds. HIV InSite Knowledge Base [textbook online]. San Francisco: UCSF Center for HIV Information; January 2006. Accessed April 14, 2006. Karavellas MP, Song M, Macdonald JC, et al. Long-term posterior and anterior segment complications of immune recovery uveitis associated with cytomegalovirus retinitis. Am J Ophthalmol. 2000 Jul;130(1):57-64. Leidner RS, Aboulafia DM. Recrudescent Kaposi’s sarcoma after initiation of HAART: a manifestation of immune reconstitution syndrome. AIDS Patient Care STDS. 2005 Oct;19(10):635-44.
♦ ♦ ♦ ♦ ♦ Navas E, Martin-Davila P, Moreno L. Paradoxical reactions of tuberculosis in patients with the acquired immunodeficiency syndrome who are treated with highly active antiretroviral therapy. Arch Intern Med. 2002 Jan 14;162(1):97-9. Olalla J, Pombo M, Aguado JM, et al. Mycobacterium fortuitum complex endocarditis-case report and literature review. Clin Microbiol Infect. 2002 Feb;8(2):125-9. Phillips P, Kwiatkowski MB, Copland M, et al. Mycobacterial lymphadenitis associated with the initiation of combination antiretroviral therapy. J Acquir Immune Defic Syndr Hum Retrovirol. 1999 Feb 1;20(2):122-8. Ratnam I, Chiu C, Kandala NB, et al. Incidence and risk factors for immune reconstitution inflammatory syndrome in an ethnically diverse HIV type 1-infected cohort. Clin Infect Dis. 2006 Feb 1;42(3):418-27. Robinson MR, Reed G, Csaky KG, et al. Immunerecovery uveitis in patients with cytomegalovirus retinitis taking highly active antiretroviral therapy. Am J Ophthalmol. 2000 Jul;130(1):49-56. Section 4—Complications of Antiretroviral Therapy | 4–37 ♦ ♦ ♦ ♦ ♦ Shelburne SA, Montes M, Hamill RJ. Immune reconstitution inflammatory syndrome: more answers, more questions. J Antimicrob Chemother. 2006 Feb;57(2):167-70. Shelburne SA, Visnegarwala F, Darcourt J, et al. Incidence and risk factors for immune reconstitution inflammatory syndrome during highly active antiretroviral therapy. AIDS. 2005 Mar 4;19(4):399- 406. Shelburne SA 3rd, Darcourt J, White AC, et al. The role of immune reconstitution inflammatory syndrome in AIDS-related Cryptococcus neoformans disease in the era of highly active antiretroviral therapy. Clin Infect Dis. 2005 Apr 1;40(7):1049-52. Whitcup SM, Fortin E, Nussenblatt RB, et al. Therapeutic effect of combination antiretroviral therapy on cytomegalovirus retinitis. JAMA. 1997 May 21;277(19):1519-20. Wislez M, Bergot E, Antoine M, et al. Acute respiratory failure following HAART introduction in patients treated for Pneumocystis carinii pneumonia. Am J Respir Crit Care Med. 2001 Sep 1;164(5):847-51.
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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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1-2 | Clinical Manual for Managemen
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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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Reducing Maternal-Infant HIV Transm
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Some states require written informe
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contraindicated during pregnancy be
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Section 3—Antiretroviral Therapy
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Nelfinavir (Viracept) Adequate drug
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Page 175 and 176: Recreational Drugs and Antiretrovir
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Page 183: A: Assessment In the appropriate cl
Page 202 and 203: Eye Problems Background The immunos
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Page 210 and 211: Fever Background Although fever may
Page 212 and 213: Headache Background Headache may ha
Page 214 and 215: Lymphadenopathy Background Lymphade
Page 216: Treatment Treatment will depend on
Page 222 and 223: Neurologic Symptoms Background The
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Page 226 and 227: Pulmonary Symptoms Background Short
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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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