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2–2 | Clinical Manual for Management of the HIV-Infected Adult/2006 Immunizations for HIV-Infected Patients Traveling to Developing Countries Routine vaccinations should be reviewed and updated before travel. All patients traveling to other countries should be evaluated for both routine and destinationspecific immunizations and prophylaxes. Killed and recombinant vaccines (eg, diphtheria-tetanus, rabies, hepatitis A, hepatitis B, Japanese encephalitis) should be used for HIV-infected persons just as they would be used for HIV-uninfected persons anticipating travel. For further information, see the Centers for Disease Control and Prevention (CDC) Web page at http://www.cdc. gov/travel/. Recommendations specific to HIV-infected travelers are located in “The Immunocompromised Traveler” under the section called “Special Needs Travelers.” Select the “Traveler’s Health” option for regional travel documents and information on outbreaks. Decisions about immunization for the HIV-infected traveler should take into consideration the traveler’s current CD4 count, history of an AIDS-defining illness, and clinical manifestations of symptomatic HIV. In the CDC recommendations, asymptomatic HIV-infected persons with CD4 counts of 200-500 cells/µL are considered to have limited immune deficits, whereas patients with CD4 counts >500 cells/µL are considered to have no immunologic compromise. For patients taking antiretroviral therapy, current CD4 counts rather than nadir counts should be used in deciding about immunizations. The following should be noted about specific vaccinations: ♦ ♦ Inactivated (killed) enhanced potency-polio and typhoid vaccines should be given instead of the live, attenuated forms. In adults aged >18 years, vaccinate 8 weeks before travel to allow time for the initial 2 doses of polio vaccine. Measles or measles-mumps-rubella (MMR; omit if patient has evidence of immunity) should not be given to severely immunocompromised patients. Instead, immune globulin should be given to measles-susceptible, severely immunocompromised persons traveling to measles-endemic countries. ♦ ♦ Yellow fever vaccine is a live-virus vaccine with uncertain safety and efficacy for HIV-infected persons and should be avoided if possible. Travelers with asymptomatic HIV infection and relatively high CD4 counts who cannot avoid potential exposure to yellow fever should be offered the choice of vaccination. If travel to a zone with yellow fever is necessary and vaccination is not administered, patients should be advised about the risk of yellow fever, instructed about avoiding the bites of vector mosquitoes, and provided with a vaccination waiver letter. The influenza season in the southern hemisphere is April through September, but in the tropics influenza is a year-round infection. Immunocompromised patients should be protected according to influenza risk at the destination. HIVinfected patients should not be given live intranasal influenza vaccine.
References ♦ ♦ ♦ ♦ ♦ ♦ Centers for Disease Control and Prevention. The Immunocompromised Traveler. In: Health Information for International Travel 2005-2006. Atlanta: US Department of Health and Human Services, Public Health Service, 2005. Accessed February 7, 2006. Available online at www.cdc.gov/travel/spec_needs. htm. Centers for Disease Control and Prevention. Prevention and control of influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2005 Jul 29;54(RR-8):1-40. Centers for Disease Control and Prevention. Prevention and control of meningococcal disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2005 May 27;54(RR-7):1-21. Centers for Disease Control and Prevention. Prevention of hepatitis A through active or passive immunization. MMWR Recomm Rep. 1999 Oct 1;48(RR-12):1-37. Centers for Disease Control and Prevention. Recommended adult immunization schedule, United States, October 2005-September 2006. Accessed February 7, 2006. Available online at www.cdc.gov/ nip/recs/adult-schedule.htm. 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. Section 2—Health Maintenance and Disease Prevention | 2–3 ♦ ♦ ♦ ♦ ♦ Fine AD, Bridges CB, De Guzman AM, et al. Influenza A among patients with human immunodeficiency virus: an outbreak of infection at a residential facility in New York City. Clin Infect Dis. 2001 Jun 15;32(12):1784-91. Kirton C. Immunizations. In: Kirton C, ed. ANAC’s Core Curriculum for HIV/AIDS Nursing, 2nd ed. Thousand Oaks, CA: Sage Publications; 2003:40-43. Kroon FP, van Dissel JT, de Jong JC, et al. Antibody response after influenza vaccination in HIV-infected individuals: a consecutive 3-year study. Vaccine. 2000 Jul 1;18(26):3040-9. Sande MA, Eliopoulos GM, Moellering RC, et al. The Sanford Guide to HIV/AIDS Therapy, 14th ed. Hyde Park, VT: Antimicrobial Therapy, Inc.; 2005. 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.
Page 1 and 2: Clinical Manual for Management of t
Page 3 and 4: Table of Contents Clinical Manual f
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Page 7 and 8: Preface—About this Manual | Clini
Page 9: Previous Editions Atlanta Contribut
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Page 23 and 24: Initial Physical Examination Backgr
Page 25 and 26: Genitals/Rectum • Inspect the gen
Page 27 and 28: Initial and Interim Laboratory and
Page 29 and 30: Section 1—Testing and Assessment
Page 31: Patient Education ♦ ♦ ♦ ♦ D
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Page 51: Section 2—Health Maintenance and
Page 67 and 68: Occupational Postexposure Prophylax
Page 69 and 70: P: Plan Laboratory Testing Provide
Page 71 and 72: For hepatitis C, no recommended pro
Page 73 and 74: Section 2—Health Maintenance and
Page 75 and 76: as hepatitis C or another sexually
Page 77 and 78: for treatment is appropriate, and b
Page 79 and 80: Section 2—Health Maintenance and
Page 81 and 82: contact with the patient. Patients
Page 83 and 84: tablet daily of trimethoprim-sulfam
Page 85 and 86: Opportunistic Infection Prophylaxis
Page 87 and 88: Discontinuing Primary Prophylaxis P
Page 89 and 90: Latent Tuberculosis Background Late
Page 91 and 92: INH may cause liver toxicity and it
Page 93: 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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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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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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♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦
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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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