CLINICAL MANAGEMENT
Symptoms/diagnosis Acute or primary HIV infection is the period
illness, comorbidities, economic factors, medical insurance status, and other factors that may impair adherence to therapy and increase the risk of transmission. Once evaluated, these factors should be managed accordingly. The baseline encounter should also include a discussion of the importance of risk or transmission reduction and disclosure of HIV status to sexual and/or needle- sharing partners, especially with untreated patients who are still at high risk of HIV transmission. Education about HIV risk behaviors and effective strategies to prevent HIV transmission should be provided at each patient visit. 27 During the initial history and physical examination, the clinicians should: 28 ● Identify possible clinical manifestations of HIV and related conditions. ● Elicit details about sexually transmitted infections, hepatitis, substance use, and sexual practices. ● Obtain a history of any previous HIV treatment. ● Review patient’s social and support networks. The presence of thrush, oral or anogenital ulcers or warts, generalized lymphadenopathy, rashes, or skin lesions identified during the physical exam should prompt further evaluation, especially when substantial immunosuppression is present. 28 HIV RNA (viral load) and CD4 cell count are the two surrogate markers used to monitor response to antiretroviral treatment (ART) and evaluate for HIV disease progression. These two tests provide the foundation for medical management and monitoring for persons with HIV infection. 27 Viral load is a surrogate marker of response to ART. The magnitude of a patient’s pre-ART viral load provides information about the probability and rapidity of subsequent disease progression. The key goal of ART is to achieve and maintain durable viral load suppression to a level of HIV RNA below the level of quantitation for currently available commercial laboratory assays. Therefore, the most important use of viral load is to monitor the effectiveness of therapy after initiation of ART. 27 Several systematic reviews established that decreases in viral load following initiation of ART are associated with reduced risk of progression to AIDS or death. 27 Measurement of CD4 cell count is particularly useful before and after initiation of ART. The CD4 cell count provides information on the overall cellular immune function of a person with HIV and is the strongest predictor of subsequent disease progression and survival. 27 Untreated HIV infection generally has a 10-year progression until opportunistic infections and malignancies appear, usually when the CD4 cell count decreases to <200 cells/mm 3 . 29 Normal ranges for CD4+ T cell counts vary from laboratory to laboratory, but in general are approximately 500
immediately after initial HIV exposure, generally before and during seroconversion. 27 Although some patients remain asymptomatic, acute HIV infection often presents with transient symptoms related to high levels of viral replication and subsequent immune response. Symptoms of acute HIV infection are nonspecific and can include fever, malaise, myalgias, and rash, making misdiagnosis common. A wide range of conditions may produce similar symptoms, so an accurate diagnosis of acute HIV infection involves a high index of suspicion, a thorough assessment of HIV exposure risk, and appropriate HIV-related laboratory tests. Between 50% and 90% of patients with acute infections develop symptoms although the timing and duration varies. 27 For most symptomatic patients, acute illness develops within one to four weeks after transmission, with symptoms persisting for two to four weeks. 27 Patients living with HIV infection often must cope with many social, psychiatric, and medical issues that are best addressed through a patient-centered, multidisciplinary approach. 27 The initial encounter should include an evaluation of the patient’s readiness to start ART, including an assessment of high-risk behaviors, substance use, social support, mental The following laboratory tests performed during the initial visit with the patient can be used to “stage” HIV infection and associated disease manifestations: 27 [A complete schedule of laboratory testing and monitoring of people with HIV before and after initiation of antiretroviral therapy can be found in reference 27 .] ● HIV antibody testing (if prior documentation is not available or if current HIV RNA is below the assay’s limit of detection. This is routinely done to confirm a history of HIV infection at the time of clinic transfer). ● CD4+ T lymphocyte cell count (CD4 cell count). ● Plasma HIV RNA by PCR (viral load). ● Complete blood count, chemistry profile, transaminase levels, blood urea nitrogen (BUN), and creatinine, urinalysis, and serologies for hepatitis A, B, and C viruses, sexually transmitted disease screening as appropriate. ● Fasting blood glucose and serum lipids. ● Genotypic resistance testing. This is recommended Treatment/monitoring Laboratory tests for all newly diagnosed persons with HIV or previously diagnosed and not receiving ART. A successful genotypic test requires a minimum of 500 copies/ mL of plasma HIV RNA. For patients who have HIV RNA levels <500 copies/mL, viral amplification for resistance testing may not always be successful. Genotypic tests drawn greater than 4 weeks after discontinuation of ART may not detect all resistance-associated mutations.
Book Code: CT24CME
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