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1–32 | Clinical Manual for Management of the HIV-Infected Adult/2006 Table 3. Indications for CD4 Count and Plasma HIV RNA (Viral Load) Testing Patient Education ♦ ♦ ♦ ♦ ♦ ♦ ♦ Clinical Indication Test and Information Provided Use Syndrome consistent with acute or primary HIV infection Initial evaluation of newly diagnosed HIV infection Every 3-4 months in patients not on therapy 2-8 weeks after initiation of or change in ART CD4 counts are the best indicator of how healthy the immune system is and whether a person is at risk of getting certain infections. CD4 counts are variable. Caution patients not to pin emotions and hopes to a single lab result. The HIV viral load is the best indicator of how active HIV is in the patient’s body. Several ARVs may be used in combination to reduce the amount of virus in the body of someone with HIV. For each of these regimens, it is important to take each dose on time, every time. (See chapters on Antiretroviral Therapy and Adherence if the patient is getting ready to start ART.) ART directly affects the activity of HIV in the body and will lower the viral load. With less HIV present, the body is able to produce more CD4 cells and improve the immune system. An undetectable viral load does not mean HIV is cured or that the patient is not infectious to others. It means that virus cannot be detected in the blood, although it exists in other parts of the body. If the patient’s CD4 count increases with successful ART, he or she may be protected from infections and other illnesses related to HIV. HIV viral load: establishes diagnosis when HIV antibody test is negative or indeterminate References ♦ ♦ ♦ ♦ ♦ Diagnosis (should be confirmed by standard HIV antibody test 2-4 months after initial test) Baseline CD4 and viral load values; disease staging Decision to start or defer ART* CD4 cell count and viral load; disease monitoring Decision to start or defer ART* CD4 count and viral load: Initial assessment of drug regimen efficacy Decision to start or defer ART* 3-4 months after starting ART CD4 count and viral load: Assess treatment efficacy; viral load should be undetectable by 16-24 weeks; CD4 cell count likely to continue to increase Every 3-4 months in patients on ART Clinical event, or significant decline in CD4 cells or increase in viral load CD4 count and viral load: Assess durability of immunologic response (CD4 increase) and virologic suppression (undetectable viral load) CD4 count and viral load: Check for association of clinical events with changing or stable CD4 cell count and/or plasma HIV viral load; confirm changes in CD4 and viral load * Decisions to initiate or change antiretroviral therapy (ART) should be based on 2 or more similar CD4 and viral load values. 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. Decision to start or defer ART* Decision to start or defer ART* Decision to initiate, continue, or change therapy* Bartlett JG, Gallant JE. 2005-2006 Medical Management of HIV Infection. Baltimore: Johns Hopkins University Division of Infectious Diseases; 2005. Available online at hopkins-aids.edu/mmhiv/ order.html. 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. 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. Hogg RS, Yip B, Chan KJ, et al. Rates of disease progression by baseline CD4 cell count and viral load after initiating triple-drug therapy. JAMA. 2001 Nov 28;286(20):2568-77. Palella FJ, Deloria-Knoll M, Chmiel JS, et al. Survival benefit of initiating antiretroviral therapy in HIV-infected persons in different CD4+ cell strata. Ann Intern Med. 2003 Apr 15;138(8):620-6.
Primary HIV Infection Background Primary HIV infection refers to the very early stages of HIV infection, or the interval from initial infection to the time that antibody to HIV is detectable. During this stage of HIV infection, patients typically have symptoms of acute HIV seroconversion illness, very high HIV RNA levels of >100,000 copies/mL, and negative or indeterminate HIV antibody tests. The diagnosis of patients with primary HIV infection is a clinical challenge. The symptoms of primary HIV are nonspecific, and although many patients seek medical care for symptoms of HIV seroconversion illness, the diagnosis commonly is missed at initial presentation. The difficulties involve recognizing the clinical presentation of acute HIV infection and testing patients appropriately. In HIV treatment clinics, clinicians generally do not see patients with primary HIV infection, unless they are referred with this diagnosis already established. In other health care settings, clinicians may not be familiar with the signs and symptoms of acute HIV infection and often do not consider this diagnosis. After infection with HIV, it takes a median of 25 days before the HIV antibody test becomes positive; in some individuals, it may be several months before seroconversion. Individuals with known exposures to HIV, whether occupational or not, should be monitored closely beginning at about 3 weeks after exposure (routine monitoring at 6 weeks, 3 months, and 6 months after exposure to HIV is likely to result in delayed diagnosis of HIV infection). For information on postexposure prophylaxis, see chapters Nonoccupational Postexposure Prophylaxis and Occupational Postexposure Prophylaxis. S: Subjective More than three quarters of patients who become infected with HIV develop symptoms consistent with primary HIV infection. Symptoms typically appear a few days to a few weeks after exposure to HIV, and generally include several of the following: ♦ ♦ ♦ Fever Rash, often erythematous maculopapular Fatigue Section 1—Testing and Assessment | 1–33 ♦ Pharyngitis ♦ Generalized lymphadenopathy ♦ Urticaria ♦ Myalgia/arthralgia ♦ Anorexia ♦ Mucocutaneous ulceration ♦ Headache, retroorbital pain ♦ Neurologic symptoms (eg, aseptic meningitis, radiculitis, myelitis) This symptomatic phase usually persists for 2-4 weeks or less, although lymphadenopathy may last longer. These symptoms and signs are similar to those of many other illnesses, including other viral syndromes. To diagnose early HIV infection, clinicians must consider HIV in the differential diagnosis for at-risk patients with symptoms resembling flu or mononucleosis. A history of recent risk behaviors should be obtained from all patients who present with symptoms consistent with acute HIV infection. O: Objective During the symptomatic phase of HIV seroconversion, the HIV antibody test is likely to be negative or indeterminate. For patients who have symptoms consistent with seroconversion illness and a recent high-risk history for HIV exposure, an HIV RNA (viral load) test should be performed, in addition to the HIV antibody test, as part of the evaluation. Patients with negative antibody tests but high HIV viral loads (>100,000 copies/mL) can be considered to be infected with HIV, although the antibody test should be repeated later to confirm seroconversion. False-positive HIV viral loads have been reported in approximately 5% of patients who were tested after HIV exposures. A low viral load (100,000 copies/mL and often millions of copies/mL) in acute infection. Patients who have indeterminate HIV antibody test results, low HIV viral loads, and no clear HIV risk factors or symptoms of primary HIV infection should have repeat antibody testing in 4-6 weeks, without other interventions. For patients without significant risk factors, indeterminate results rarely indicate evolving seroconversion.
Page 1 and 2: Clinical Manual for Management of t
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Page 7 and 8: Preface—About this Manual | Clini
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Page 29 and 30: Section 1—Testing and Assessment
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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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Patient Education ♦ ♦ ♦ ♦
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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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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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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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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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Anxiety Disorders Background Anxiet
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Insomnia Background Insomnia is a c
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Suicidal Ideation Background Transi
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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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