Clinical Manual for Management of the HIV-Infected ... - myCME.com

More documents

Recommendations

Info

3–2 | Clinical Manual for Management of the HIV-Infected Adult/2006 O: Objective Perform the following objective tests: ♦ ♦ ♦ ♦ Complete physical examination (see chapter Initial Physical Examination) Current CD4 count and HIV viral load: preferably 2 or more separate results approximately 1 month apart Drug resistance test. To try to detect the presence of transmitted ARV resistance mutations, a genotype should be performed in all patients before initiating ART. This should be done as early in the course of infection as possible, because mutations may revert to wild type. Review the results of previous resistance testing or obtain a baseline resistance test, if this was not done earlier. (See chapter Resistance Testing.) Complete blood count (CBC) and platelet count, liver function tests (LFTs), renal function tests, fasting lipid panel (see chapter Initial and Interim Laboratory and Other Tests) fasting glucose, rapid plasma reagin (RPR), tuberculin skin test, hepatitis serologies A: Assessment Make the following basic decisions: ♦ ♦ ♦ The patient is or is not likely to benefit from ART at this time (ie, do potential benefits outweigh the risks)? See the Adult and Adolescent ARV Guidelines noted above, which thoroughly address the issue. A brief summary is included in the tables in the chapter Determining Risk of HIV Progression and in the chapter CD4 Monitoring and Viral Load Testing. The patient is or is not willing to start ARVs at this time (the choice to accept or decline therapy ultimately lies with the patient). The patient is or is not likely to adhere to an ARV regimen (an adherence counselor, with or without a mental health clinician, may be able to assist with this assessment and should be called upon if available). No patient should be automatically excluded from consideration of ART; the likelihood of adherence must be discussed and determined individually. P: Plan After educating the patient about the purpose and logistics of the proposed regimen and assessing the patient’s potential for adherence, the ART regimen can be initiated, changed, or postponed accordingly. The goals of therapy are to achieve maximal and durable viral suppression, restore or preserve immune function, improve quality of life, and reduce HIV-related morbidity and mortality. Considerations before Initiating ART No “average patient” exists. Some patients will do better during treatment and some will do worse than clinical studies would predict. Health care providers must work with each patient to develop a treatment strategy that is both clinically sound and appropriate for that individual’s needs, priorities, and circumstances of daily life. Not all patients will be able to tolerate all drugs, and the patients understanding, readiness to commit to the regimen, and history of adherence to previous regimens must be considered when choosing ARV combinations. Major considerations are as follows: ♦ ♦ ♦ ♦ ♦ Willingness of the individual to begin therapy, coupled with understanding of the purpose and the mechanics of the planned regimen, and how it will fit into his or her life Degree of immunodeficiency and risk of disease progression as reflected by the CD4 count and HIV RNA level (see tables in the chapter Determining Risk of HIV Progression and the chapter CD4 Monitoring and Viral Load Testing) Potential benefits and risks of ARV drugs Likelihood of adherence to the prescribed regimen Resistance, if any, to ARV medications (obtain resistance testing prior to ARV initiation in ARVnaive patients) The patient has the right to decline or postpone ART. This decision should not affect any other aspect of care, and ART should be offered again at each visit to patients who meet the criteria for treatment. If mental health issues, addiction, or the patient's social situation are barriers to adherence, initiate appropriate referrals and reassess adherence barriers at regular intervals.
Initiating Therapy: DHHS ARV Guidelines The following recommendations have been adapted from the DHHS Adult and Adolescent ARV Guidelines. ♦ ♦ ♦ ♦ ART is recommended for all patients with a history of AIDS-defining illness or severe symptoms of HIV infection regardless of the CD4 cell count. ART is also recommended for asymptomatic patients with a CD4 count of 100,000 copies/mL Patient’s interest Risk of toxicity Therapy should probably be deferred for asymptomatic patients with CD4 counts of >350 cells/µL and plasma HIV RNA
Page 1 and 2:
Clinical Manual for Management of t
Page 3 and 4:
Table of Contents Clinical Manual f
Page 5 and 6:
Clinical Manual for Management of t
Page 7 and 8:
Preface—About this Manual | Clini
Page 9:
Previous Editions Atlanta Contribut
Page 12 and 13:
♦ ♦ ♦ ♦ ♦ | Clinical Manu
Page 14 and 15:
1-2 | Clinical Manual for Managemen
Page 16 and 17:
Page 18 and 19:
Page 20 and 21:
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
Page 34 and 35:
1-22 | Clinical Manual for Manageme
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
Page 42 and 43:
Page 44 and 45:
Page 46 and 47:
Page 48 and 49: 1-36 | Clinical Manual for Manageme
Page 51 and 52: Section 2—Health Maintenance and
Page 53: References ♦ ♦ ♦ ♦ ♦ ♦
Page 56 and 57: 2-6 | Clinical Manual for Managemen
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 75 and 76: as hepatitis C or another sexually
Page 77 and 78: for treatment is appropriate, and b
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 ♦ ♦ ♦ ♦
Page 117 and 118: Reducing Maternal-Infant HIV Transm
Page 119 and 120: Some states require written informe
Page 121 and 122: contraindicated during pregnancy be
Page 123 and 124: Section 3—Antiretroviral Therapy
Page 125 and 126: Nelfinavir (Viracept) Adequate drug
Page 131 and 132: Patient Education ♦ ♦ ♦ ♦
Page 133: ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦
Page 148 and 149:
Page 150 and 151:
Page 152 and 153:
Page 154 and 155:
Page 156 and 157:
Page 158 and 159:
Page 160 and 161:
Page 162 and 163:
Page 165 and 166:
Section 4—Complications of Antire
Page 167 and 168:
♦ ♦ ♦ Toronto General Hospita
Page 169 and 170:
Adverse Reactions to HIV Medication
Page 171 and 172:
♦ ♦ ♦ ♦ ♦ Vital signs: No
Page 173 and 174:
egimen, symptoms of fatigue could i
Page 175 and 176:
Recreational Drugs and Antiretrovir
Page 177 and 178:
Section 4—Complications of Antire
Page 179 and 180:
LSD, Mescaline, Psilocin, and Methy
Page 181 and 182:
Immune Reconstitution Syndrome Back
Page 183 and 184:
A: Assessment In the appropriate cl
Page 185 and 186:
♦ ♦ ♦ ♦ ♦ Navas E, Martin
Page 187 and 188:
Page 189 and 190:
Page 191 and 192:
Page 193 and 194:
Page 195 and 196:
Page 197 and 198:
Page 199 and 200:
Page 202 and 203:
Eye Problems Background The immunos
Page 204:
of
Page 207 and 208:
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 219 and 220:
Page 222 and 223:
Neurologic Symptoms Background The
Page 224 and 225:
♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦
Page 226 and 227:
Pulmonary Symptoms Background Short
Page 228:
Treatment Once the diagnosis is mad
Page 231 and 232:
Page 233 and 234:
Page 235 and 236:
Page 238 and 239:
Candidiasis, Oral and Esophageal Ba
Page 240:
Maintenance therapy Use caution whe
Page 243 and 244:
Page 246 and 247:
Cervical Dysplasia Background Cervi
Page 248:
Patient Education ♦ ♦ ♦ ♦ P
Page 251 and 252:
Page 254 and 255:
Cryptosporidiosis Background Crypto
Page 256:
Patient Education ♦ ♦ ♦ ♦
Page 259 and 260:
Page 261 and 262:
Page 263 and 264:
Page 266 and 267:
Gonorrhea and Chlamydia Background
Page 268 and 269:
Treatment of Gonorrhea Treatment op
Page 270 and 271:
Hepatitis B Infection Background He
Page 272 and 273:
♦ ♦ ♦ ♦ ♦ Some patients t
Page 274 and 275:
Hepatitis C Infection Background He
Page 276 and 277:
pregnancy. Ribavirin is teratogenic
Page 278 and 279:
Herpes Simplex, Mucocutaneous Backg
Page 280:
References ♦ ♦ ♦ ♦ ♦ Cent
Page 283 and 284:
Page 285 and 286:
Page 288 and 289:
Kaposi Sarcoma Background Kaposi sa
Page 290 and 291:
Treatment Treatment of KS is not co
Page 292 and 293:
Molluscum Contagiosum Background Mo
Page 294 and 295:
Mycobacterium avium Complex Backgro
Page 296 and 297:
Table 1. Interactions between Rifab
Page 298 and 299:
Mycobacterium tuberculosis: Treatme
Page 300 and 301:
P: Plan Diagnostic Evaluation Durin
Page 302 and 303:
Table 1. Regimens for Treatment of
Page 304 and 305:
Rifabutin may be substituted for ri
Page 306:
Patient Education ♦ ♦ ♦ ♦
Page 309 and 310:
Page 311 and 312:
Page 314 and 315:
Non-Hodgkin Lymphoma Background Non
Page 316:
Patient Education ♦ ♦ ♦ ♦ S
Page 319 and 320:
Page 321 and 322:
Page 323 and 324:
Page 325 and 326:
Page 327 and 328:
Page 329 and 330:
Page 331 and 332:
Page 333 and 334:
6-100| Clinical Manual for Manageme
Page 335 and 336:
6-102| Clinical Manual for Manageme
Page 338 and 339:
Toxoplasmosis Background Toxoplasma
Page 340 and 341:
♦ Atovaquone 1,500 mg orally twic
Page 342 and 343:
Linear Gingival Erythema Background
Page 344 and 345:
Background Necrotizing ulcerating p
Page 346 and 347:
Oral Health Background Examination
Page 348 and 349:
Maxillary Tori; Mandibular Tori S:
Page 350 and 351:
Periodontal Disease Background The
Page 352 and 353:
Oral Hairy Leukoplakia Background O
Page 354 and 355:
Oral Ulceration Background Oral ulc
Page 356 and 357:
Oral Warts Background Oral warts ar
Page 358 and 359:
Page 360 and 361:
Page 362 and 363:
Page 364 and 365:
Page 366 and 367:
Page 369 and 370:
Anxiety Disorders Background Anxiet
Page 371:
Patient Education ♦ ♦ Behaviora
Page 374 and 375:
Page 376 and 377:
Page 378 and 379:
Page 381 and 382:
Insomnia Background Insomnia is a c
Page 383 and 384:
Suicidal Ideation Background Transi
Page 385 and 386:
Section 8—Neuropsychiatric Disord
Page 387 and 388:
P: Plan ♦ ♦ ♦ ♦ ♦ Check t
Page 389 and 390:
Correctional Settings Background Ca
Page 391 and 392:
Adherence Adherence is one of the m
Page 393:
Karnofsky Performance Scale Backgro
Page 396 and 397:
Page 398 and 399:
Page 400:
show all

Clinical Manual for Management of the HIV-Infected ... - myCME.com

Create successful ePaper yourself

Delete template?

Save as template?