ITEMS IN AFP WITH MESH TERM:
Conference Highlights - Conference Highlights
ABSTRACT: Appropriate management of pregnant patients who have human immunodeficiency virus (HIV) disease can have a major impact on maternal and infant health. The goals of therapy are to properly manage the pregnancy, treat the maternal HIV infection and minimize the risk of vertical transmission of HIV. Early detection of HIV through aggressive screening programs is necessary to initiate timely therapy. Zidovudine therapy given antepartum and intrapartum to the mother and after birth to the newborn has been shown to decrease the risk of vertical transmission. Evidence suggests that more aggressive antiretroviral therapy for the mother, which allows suppression of viral loads to undetectable levels, may be safe and may provide significant additional benefits. However, treatment needs to be individualized, weighing the possible teratogenic risks against the benefits of decreased transmission. Multiple prospective cohort studies support elective cesarean section as an additional means to decrease vertical transmission, but its role in relation to other therapies has not been determined. As in nonpregnant patients infected with HIV, prevention of opportunistic infections and adequate psychosocial support are essential.
ABSTRACT: The polymerase chain reaction assay, branched DNA assay and nucleic acid sequence-based amplification assay quantitate human immunodeficiency virus (HIV) RNA levels. Plasma viral load (PVL) testing has become a cornerstone of HIV disease management. Initiation of antiretroviral drug therapy is usually recommended when the PVL is 10,000 to 30,000 copies per mL or when CD4+ T-lymphocyte counts are less than 350 to 500 per mm3 (0.35 to 0.50 x 10(9) per L). PVL levels usually show a 1- to 2-log reduction within four to six weeks after therapy is started. The goal is no detectable virus in 16 to 24 weeks. Periodic monitoring of PVL is important to promptly identify treatment failure. When feasible, the same assay should be used for serial PVL testing in the individual patient. At least two PVL measurements usually should be performed before antiretroviral drug therapy is initiated or changed. PVL testing may be helpful in the rare instance of indeterminate HIV antibody testing, especially in a patient with recent infection.
ABSTRACT: The management of infants whose mothers are infected with the human immunodeficiency virus (HIV) involves minimizing the risk of vertical transmission of HIV, recognizing neonatal HIV infection early, preventing opportunistic infections, and addressing psychosocial issues. Maternal antiretroviral drug therapy during pregnancy and labor, followed by six weeks of neonatal zidovudine therapy, can significantly decrease the risk of vertical transmission. Additional antiretroviral drugs may be needed in some high-risk newborns. Elective cesarean section also may prevent vertical transmission of HIV. Virologic tests allow early diagnosis of HIV infection, facilitating the timely initiation of aggressive treatment and the prevention of opportunistic infections. Even when tests are negative, infants must be closely monitored until age 18 months to completely rule out HIV infection. Prophylaxis for Pneumocystis carinii pneumonia should be initiated when HIV-exposed infants are six weeks old and should be continued for at least four months, regardless of negative virologic tests, because P. carinii pneumonia is often the initial presentation of HIV infection in infants. Laboratory monitoring, screening for perinatal infections, appropriate social support, and other modifications of standard infant care are also necessary.
ABSTRACT: Antiretroviral regimens are complicated and difficult for patients to follow, and they can have serious side effects, such as osteonecrosis and bone demineralization. Protease inhibitor therapy has been associated with hyperlipidemia, hyperglycemia, gastrointestinal symptoms, and body-fat distribution abnormalities. Nonnucleoside reverse transcriptase inhibitors can cause rashes and hepatotoxicity, and nucleoside reverse transcriptase inhibitors can cause lactic acidosis, hypersensitivity reactions, neuropathies, pancreatitis, anemia, and neutropenia. Malabsorption can occur if antiretroviral agents are taken improperly with regard to meals or if they are taken with certain other drugs or herbal remedies. Some commonly prescribed drugs can cause dangerous drug toxicities if they are taken by patients who are also taking certain antiretroviral medications. Suboptimal exposure to antiretrovirals because of noncompliance or malabsorption can result in viral resistance and loss of future treatment options.
HIV Counseling, Testing, and Referral - Article
ABSTRACT: Over the past decade, the annual number of new cases of human immunodeficiency virus (HIV) infection has been relatively stable but remains unacceptably high (an estimated 40,000 new cases per year). Furthermore, the demographics for HIV infection are changing. Rates of new infections are declining in newborns, older men who have sex with men, and whites. However, rates of new infections are rising in young persons, women, Hispanics, and blacks. In 2001, the Centers for Disease Control and Prevention issued revised guidelines for HIV counseling, testing, and referral. The guidelines focus on the reduction of barriers to testing, voluntary routine testing of high-risk populations and persons with risk factors, case management and partner tracing for infected persons, and universal testing of pregnant women. Effective strategies for reducing HIV infection include behavioral interventions, comprehensive school-based HIV and sex education, access to sterile drug equipment, screening of the blood supply, and postexposure prophylaxis for health care workers.
Update on the Treatment of Tuberculosis - Article
ABSTRACT: Approximately one third of the world's population, including more than 11 million persons in the United States, is latently infected with Mycobacterium tuberculosis. Although most cases of tuberculosis in the United States occur in foreign-born persons from endemic countries, the prevalence is generally greater in economically disadvantaged populations and in persons with immunosuppressive conditions. Delays in detection and treatment allow for greater transmission of the infection. Compared with the traditional tuberculin skin test and acid-fast bacilli smear, newer interferon-gamma release assays and nucleic acid amplification assays lead to more rapid and specific detection of M. tuberculosis infection and active disease, respectively. Nine months of isoniazid therapy is the treatment of choice for most patients with latent tuberculosis infection. When active tuberculosis is identified, combination therapy with isoniazid, rifampin, pyrazinamide, and ethambutol should be promptly initiated for a two-month "intensive phase," and in most cases, followed by isoniazid and a rifamycin product for a four- to seven-month "continuation phase." Directly observed therapy should be used. Although currently limited in the United States, multidrug-resistant and extensively drug-resistant strains of tuberculosis are increasingly recognized in many countries, reaffirming the need for prompt diagnosis and adequate treatment strategies. Similarly, care of persons coinfected with human immunodeficiency virus and tuberculosis poses additional challenges, including drug interactions and immune reconstitution inflammatory syndrome.
ABSTRACT: The epidemic of human immunodeficiency virus (HIV) continues, and the infection is converting into a treatable chronic disease; therefore, it is increasingly important for family physicians to be current with and comfortable in providing basic care to patients infected with HIV. Important aspects of counseling and patient education include stabilization of psychosocial issues and prevention of HIV transmission through behavior change counseling. Reporting HIV and acquired immunodeficiency syndrome (AIDS) is mandatory in most states, whereas partner notification laws vary from state to state. Baseline evaluation includes screening for comorbid conditions such as viral hepatitis, syphilis, and tuberculosis, as well as common HIV-related manifestations such as recurrent candidal infections and thrombocytopenia. Baseline testing includes CD4+ T-lymphocyte cell counts and HIV viral RNA levels to assess HIV disease stage, and numerous studies to screen for opportunistic infections. Initial preventive interventions include patient education to reduce exposure to infections, treatment of comorbid conditions such as human papillomavirus-related dysplasia, and vaccinations such as for pneumococcus and hepatitis B. Prophylaxis against opportunistic pathogens is recommended when CD4+ cell counts fall below 200 cells per mm3. Lastly, the indications for antiretroviral therapy include symptomatic patients or those with AIDS, and pre-AIDS patients with CD4+ cell counts of 200 to 350 cells per mm3 or HIV RNA above 55,000 to 100,000 copies per mL.