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7–10 | Clinical Manual for Management of the HIV-Infected Adult/2006 DERMATOLOGIC Dry skin • Dehydration • End-stage renal disease • End-stage liver disease • Malnutrition medications (eg, indinavir) Pruritus • Fungal infection • End-stage renal disease • End-stage liver disease • Dehydration • Eosinophilic folliculitis Decubitus ulcers, Pressure sores NEUROPSYCHIATRIC • Poor nutrition • Decreased mobility, prolonged bed rest Delirium/agitation • Electrolyte • • • • • • imbalances, glucose abnormalities Dehydration Toxoplasmosis Cryptococcal meningitis Sepsis Medication adverse effects (eg, benzodiazepines, opioids, efavirenz) Intoxication Dementia • AIDS-related dementia • Other dementia Depression • Chronic illness • Reactive depression, major depression • • • • • • • • Hydration Dialysis Nutritional support Discontinue offending medication Antifungal agents (itraconazole for eosinophilic folliculitis) Dialysis Hydration Topical corticosteroids • Increase mobility • Enhance nutrition • • • • Correct imbalances Hydration Specific treatment of disease entities Discontinue offending medications • Emollients with or without salicylates • Lubricating ointments or creams (eg, petrolatum, Eucerin) • • • • • • • • • • • • Topical agents (menthol, phenol, calamine, doxepin, capsaicin) Antihistamines (doxepin - oral, diphenhydramine) Corticosteroids (topical or systemic) Serotonin antagonists (ondansetron) Opioid antagonists (naloxone, naltrexone) Antidepressants Anxiolytics Neuroleptics Thalidomide Prevention (nutrition, mobility, skin integrity) Wound protection (semipermeable film, hydrocolloid dressing) Debridement (normal saline, enzymatic agents, alginates) • Neuroleptics (haloperidol, risperidone, chlorpromazine) • Benzodiazepines (eg, lorazepam, midazolam) (Note: in some patients, these may have adverse effects.) • ART • Psychostimulants (methylphenidate) • Low-dose neuroleptics (haloperidol) • Antidepressants • Psychostimulants (methylphenidate, pemoline, dextroamphetamine, (SSRIs, tricyclics, modafinil) other) • Corticosteroids (prednisone, dexamethasone) Key to abbreviations: ART = antiretroviral therapy; MAC = Mycobacterium avium complex; NSAIDs = nonsteroidal antiinflammatory drugs; CMV = cytomegalovirus; PCP = Pneumocystis jiroveci pneumonia; TB = tuberculosis; SSRI = selective serotonin reuptake inhibitor. * Some of the palliative treatments may have substantial long-term adverse effects and should be used to alleviate symptoms only in late-stage or dying patients. Adapted with permission from Selwyn PA, Rivard M. Palliative care for AIDS: Challenges and opportunities in the era of highly active anti-retroviral therapy. Innovations in End-of-Life Care. 2002;4(3), Available at http://www.edc.org/lastacts.
Advance Care Planning Advance care planning involves planning for future medical care. Two main documents are produced: ♦ ♦ Advance directive (living will) Health care proxy (a person to speak for the patient or make decisions if the patient is too sick to do so) The clinician should initiate these conversations and make referrals to helpful resources. Patient Education ♦ ♦ ♦ ♦ ♦ Discuss advance care planning with patients, and the option of hospice care, if appropriate. Provide the patient and his or her family with detailed information so that they understand the illness and associated treatments. Instruct patients to discuss their pain or other bothersome symptoms with their health care providers. Encourage patients to talk with their health care providers if they are feeling anxious, depressed, or fearful. Discuss with patients what their death might be like. Some patients may feel relieved to be able to talk openly about their last days. Assure them that their pain will be controlled and that their health care providers will be there to help them. References ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ Section 7—Pain and Palliative Care | 7–11 American Academy of HIV Medicine. Palliative Care. The HIV Medicine Self-Directed Study Guide (2003 ed.). Los Angeles: AAHIVM; 2003. National Hospice Organization. Guidelines for Determining Prognosis for Selected Non-Cancer Diagnoses. Alexandria, VA: National Hospice Organization; 1996. O’Neill JF, McKinney M. Caring for the Caregiver. In: O’Neill JF, Selwyn PA, Schietinger H, eds. The Clinical Guide to Supportive and Palliative Care for HIV/AIDS. Rockville, MD: Health Resources and Services Administration; 2003. Available online at hab.hrsa.gov/tools/palliative/. Accessed May 20, 2006. Selwyn PA, Rivard M. Palliative care for AIDS: Challenges and opportunities in the era of highly active anti-retroviral therapy. Innovations in End-of-Life Care. 2002;4(3). Available online at www.edc.org/ lastacts. Selwyn PA, Rivard M. Palliative care for AIDS: challenges and opportunities in the era of highly active anti-retroviral therapy. J Palliat Med. 2003 Jun;6(3):475-87. University of Washington Center for Palliative Care Education. Module 1: Overview of HIV/AIDS Palliative Care. Accessed February 7, 2006. U.S. Health Resources and Services Administration. A Guide to Primary Care of People with HIV/AIDS, 2004 ed. Rockville, MD: Health Resources and Services Administration; 2004:123-131. Available online at hab.hrsa.gov/tools/primarycareguide/. Accessed May 20, 2006. Weinreb NJ, Kinzbrunner BM, Clark M. Pain Management. In: Kinzbrunner BM, Weinreb NJ, Policzer JS, eds. 20 Common Problems: End-of-life Care. New York: McGraw Hill Medical Publishing Division; 2002:91-145. World Health Organization. Cancer Pain Relief and Palliative Care, Report of a WHO Expert Committee. Geneva: World Health Organization; 1990.
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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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Section 4—Complications of Antire
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♦ ♦ ♦ Toronto General Hospita
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Adverse Reactions to HIV Medication
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♦ ♦ ♦ ♦ ♦ Vital signs: No
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egimen, symptoms of fatigue could i
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Recreational Drugs and Antiretrovir
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Section 4—Complications of Antire
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LSD, Mescaline, Psilocin, and Methy
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Immune Reconstitution Syndrome Back
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A: Assessment In the appropriate cl
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♦ ♦ ♦ ♦ ♦ Navas E, Martin
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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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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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Page 338 and 339: Toxoplasmosis Background Toxoplasma
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Page 342 and 343: Linear Gingival Erythema Background
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Page 346 and 347: Oral Health Background Examination
Page 348 and 349: Maxillary Tori; Mandibular Tori S:
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Page 352 and 353: Oral Hairy Leukoplakia Background O
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Page 356 and 357: Oral Warts Background Oral warts ar
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Page 387 and 388: P: Plan ♦ ♦ ♦ ♦ ♦ Check t
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