Lecture HIV Infection: What Does the General Doctor Need to Know? - Howard Libman, M.D

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Lecture HIV Infection - What Does the General Doctor Need to Know? help you: overview and epidemiology; HIV diagnostic testing; initial evaluation of new patient; general principles of antiretroviral therapy; long term treatment complications; prophylaxis of opportunistic infections; health care maintenance issues.

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Nội dung Text: Lecture HIV Infection: What Does the General Doctor Need to Know? - Howard Libman, M.D

HIV Infection: What Does the General Doctor Need to Know? Howard Libman, M.D. Beth Israel Deaconess Medical Center Harvard Medical School
Outline • Overview and epidemiology • HIV diagnostic testing • Initial evaluation of new patient • General principles of antiretroviral therapy • Long term treatment complications • Prophylaxis of opportunistic infections • Health care maintenance issues
Acute HIV Syndrome 800 10,000,000 1,000,000 100,000 500 10,000 1,000 200 HIV Disease/AIDS 100 100 (copies/ 50 mL) 10 Months | Years 0 HIV-infected/Infectious (cells/ mm3) Acute HIV Seropositive Syndrome Clinical Latency HIV Disease/AIDS
Spectrum of HIV Infection • CD4 cell count > 500/mm3 Most patients asymptomatic Bacterial infections, TB, shingles • CD4 cell count 500-200/mm3 Many patients asymptomatic Generalized lymphadenopathy, KS, thrush • CD4 cell count < 200/mm3 PCP, cryptococcosis, toxoplasmosis • CD4 cell count < 50/mm3 CMV and MAC infections Increased risk of lymphoma Mortality highest
Reported Cumulative Cases of HIV, AIDS, and Deaths in Vietnam by Year 200,000 180,000 160,000 140,000 120,000 100,000 80,000 60,000 40,000 20,000 0 ct 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 -O 19 19 19 19 19 19 19 20 20 20 20 20 20 20 20 20 20 10 AIDS Patients Death HIV infection Vietnam MoH, 2010.
Distribution of HIV Infection in Vietnam by Age 50% 45.4% 45% 39.7% 40% 35% 30% 25% 20% 15% 8.3% 10% 1.8% 2.3% 2.3% 5% 0.3% 0% n 3 0 9 9 9 9 w 5 -1 -2 -3 -4 no 13 20 30 40 nk U VAAC/Vietnam MoH, 2010.
Distribution of HIV Infection in Vietnam by Gender Men 73.5% Women 26.5% VAAC, 2010.
Distribution of HIV Cases in Vietnam by Risk Behaviors • Over 50% from injection-drug use • 40% likely from sexual transmission (heterosexual and homosexual) • 5% of cases unknown risk behavior VAAC/Vietnam MoH, 2010.
Outline • Overview and epidemiology • HIV diagnostic testing • Initial evaluation of new patient • General principles of antiretroviral therapy • Long term treatment complications • Prophylaxis of opportunistic infections • Health care maintenance issues
Traditional Historical Indications for HIV Antibody Testing • Men who have sex with men • Persons with multiple sexual partners • Current or past injection drug users • Recipients of blood products between 1978 and 1985 • Persons with current or past STD's • Commercial sex workers and their contacts • Pregnant women and women of child-bearing age • Children born to HIV-infected mothers • Sexual partners of those at risk for HIV infection • Donors of blood products, semen, or organs • Persons who consider themselves at risk or request testing
Traditional Clinical Indications for HIV Antibody Testing • Tuberculosis • Syphilis • Recurrent shingles • Chronic constitutional symptoms • Chronic generalized adenopathy • Chronic diarrhea or wasting • Encephalopathy • Thrombocytopenia • Unexplained thrush or chronic/recurrent vaginal candidiasis • HIV-associated opportunistic diseases
CDC Recommendations for “Routine” HIV Antibody Testing • Screen all healthy patients after notification that an HIV test will be performed unless they decline (“opt-out” testing) • Specific informed consent is unnecessary • Persons at high risk for HIV infection should be screened at least annually • Prevention counseling should be not required as part of routine HIV testing, but it is strongly encouraged for persons at high risk
WHO Recommendations for HIV Antibody Testing • HIV screening should be voluntary, confidential, and undertaken with consent • Recommended in all patients presenting for care in countries with a generalized HIV epidemic • In countries with concentrated or low-level epidemics, recommended in patients presenting for care in antenatal, tuberculosis, and sexual health clinics • Specific HIV screening policies vary by country
Diagnostic Tests for HIV Infection • In the US, HIV antibody testing is performed by using enzyme-linked immunosorbent assay (ELISA), which is highly sensitive • If result is negative, the test is reported as negative • If result is positive, a Western blot (WB) assay is performed for confirmation • If WB assay result is positive, the test is reported as positive • WB results are occasionally described as indeterminate; supplemental testing may be recommended
MOH Testing Strategies Testing Strategy I: At the blood banks • Positive test with one of these test: ELISA, SERODIA, rapid test • One positive screening test is sufficient to reject blood for safe transfusion Testing Strategy II: Routine screening in high prevalence areas • Two different ELISA tests • Positive result if both ELISAs are positive Testing Strategy III: HIV diagnosis • Three different ELISA tests • Positive result if all three tests are positive Guidelines for Diagnosis and Treatment of HIV/AIDS, Ministry of Health, Vietnam. August, 2009.
Outline • Overview and epidemiology • HIV diagnostic testing • Initial evaluation of new patient • General principles of antiretroviral therapy • Long term treatment complications • Prophylaxis of opportunistic infections • Health care maintenance issues
History • Risk behaviors • Knowledge of HIV infection • Emotional response • Family/social situation • Employment/insurance status • General health issues • Syphilis, other STDs, TB, hepatitis
Physical Examination • Integument: seborrhea, psoriasis, EF, onychomycosis, HSV, VZV, KS, generalized adenopathy • HEENT: CMV retinitis, CWS, thrush, OHL, ANUG • Pulmonary: PCP • Gastrointestinal: organomegaly • Genitourinary: vaginitis, PID, HPV, cervical and anal dysplasia/carcinoma • Neurological: mental status, focal central/peripheral findings
Pulmonary Tuberculosis
Extrapulmonary Tuberculosis