FP Report -- 1999 Post-Assembly Edition
New drugs make HIV management more complex
Managing patients infected with the human immunodeficiency virus and AIDS is a challenge to any physician, especially in light of new combination therapies that are offering renewed hope to these patients.
In an Assembly clinical seminar held Sept. 17, Scott Warner, D.O., J.D., assistant director of the family practice residency at Florida Hospital in Orlando, reviewed the latest testing and treatment techniques for opportunistic infections and other complications of HIV infection and AIDS.
"There are now 17 antiretroviral medications available to treat these patients," Warner said, "and sorting out the right ones to use can be a formidable task." To help family physicians make informed decisions about management, he offered these suggestions:
- Use a standardized approach to treating HIV patients.
- Offer highly active antiretroviral therapy (HAART) early in the disease process and be sure to emphasize to the patient the importance of compliance with the therapy.
- Always consider tuberculosis when an AIDS patient coughs because the lifetime risk of TB in HIV-infected patients is 20 percent.
Some common methods used to evaluate HIV-infected patients include: hemoglobin testing, because about 85 percent of patients have some form of anemia; white blood cell counts; platelet counts, because thrombocytopenia occurs in 11 percent; creatinine levels; testing for toxoplasmosis; TB testing; a baseline chest x-ray; Pap smears; genotype testing; phenotype testing; absolute CD-4 counts; and HIV-RNA measurements of viral load.
Warner pointed to the latest (eighth) edition of the Sanford Guide to HIV/AIDS Therapy as a seminal source of treatment information. The guide recommends that physicians initiate antiretroviral therapy "early in the course of the disease when viral load is still low (and near-complete suppression can still be achieved) and before clonal depletion of CD-4 has occurred," but only if the patient is committed to following the regimen.
"Begin HAART therapy if CD-4 counts are greater than 500 and HIV-RNA measures are less than 10,000 within six months of seroconversion when the patient has such symptoms as thrush and unexplained fever," Warner said. "Response to therapy should be monitored by RNA copies until they are undetectable."
The recommended initial HAART treatment consists of a combination of two nucleoside reverse-transcriptase inhibitors plus one protease inhibitor or one non-nucleoside reverse-transcriptase inhibitor. If a patient shows resistance to HAART, genotype testing may be indicated to determine which drugs he or she may tolerate, Warner said. Unfortunately, if a patient is resistant to one PI, he or she is usually resistant to all PIs.
In HIV-infected patients, opportunistic infections first begin to occur when CD-4 counts slip below 71. Among the opportunistic infections common to HIV-infected patients are Pneumocystis carinii pneumonia, depression and dementia from wasting, chronic non-healing ulcers, disseminated Mycobacterium avium-intracellular complex, candidal esophagitis, Kaposi's sarcoma (but rarely in women), cytomegalovirus-related retinitis, cerebral toxoplasmosis, TB, lymphoma, chronic herpes and cryptococcal meningitis.
PCP can be treated with trimethoprim and sulfamethoxazole, Warner said. Dapsone is useful as prophylaxis against PCP when the patient's CD-4 count is less than 200. Patients who have DMAC and a CD-4 count below 50 may be treated with clarithromycin.
For patients who suffer wasting, Warner recommended treating the depression and dementia first. If the patient is not depressed or demented, try treating with megestrol (Megace) or dronabinol (Marinol). If the wasting continues and the patient is male, check the patient's testosterone levels and consider anabolic steroids. If the patient is resistant to steroids, consider human chorionic gonadotropin therapy.
FP Report is published by the AAFP News Department. Copyright © 1999 by American Academy of Family Physicians.
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