April / May #1 : HIV Standard of Care

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Ty Ross Comes Clean

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AIDS Zen

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HIV Testing Requirements for Entry Into Foreign Countries

HIV Standard of Care



Most Popular Lessons

The HIV Life Cycle

Shingles

Herpes Simplex Virus

Syphilis & Neurosyphilis

Treatments for Opportunistic Infections (OIs)

What is AIDS & HIV?

Hepatitis & HIV


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April / May 1994

HIV Standard of Care

This HIV Standard of Care chart is reproduced from ACT UP/Philadelphia's HIV Standard of Care published in May, 1993. This is the fourth version with a fifth version expected soon. This chart is meant as a minimum standard of care for adults (children require a different standard) who are HIV positive -- a minimum level by which patients can determine and measure the quality of their care. HIV Standards of Care differ by region, treatment philosophy and patient population. POZ will present different Standards of Care in future issues.



WHEN PATIENTS TEST HIV POSITIVE
ANY LEVEL OF T4 CELLS
TESTS TO BE PERFORMEDTREATMENT OR INOCULATION
T4 count and T8 ratio as baselineRepeat every six months if over 500
Anergy Skin TestingPneumovax inoculation, if not previously
Syphilis Test (use MHATP)Over treat with Benzathine Penicillin
All patientsFlu shot once a year (October)
All patientsH. Influenza inoculation, if not previously
Hepatitis B negative?If not, consider Hepatitis B vaccination
Baseline Chemscreen / Baseline Toxoplasmosis TiterIf positive, follow carefully, monitor for symptoms
Tuberculosis PPD testIf positive at 5mm., treat one year with INH+ Rifampin
Baseline Ophthalmic eye testsTreat if symptomatic for CMV or other problems
Herpes Zoster outbreakTreat aggressively with Zovirax*
Vaginal examEvery 6 months, treat for candidiasis, if present, with topical cream; oral drugs if refractory
Pap SmearIf positive, immediate colposcopy, otherwise repeat smears every 3-6 months; if colposcopy is positive, therapy as appropriate
Baseline dental examRepair obvious gum and tooth problems
Baseline Psychatric examSome new "positives" need treatment for depression
Do your own reading and researchEducate yourself for the many decisions to be made

T4 ABSOLUTE COUNT* >500
TESTS TO BE PERFORMEDTREATMENT, INOCULATION OR FOLLOW-UP
T4/T8Repeat every 6 months; take test same time of day; send to same lab
HPV (women)Continue pap spear every 3-6 months. If positive, immediate colposcopy; if this is positive, therapy as appropriate
Office visit to primary physician every 4-6 monthsVisual exam to include inspection of mouth skin
Dental examExam and cleansing every 4-6 months
PsychiatricContinue counseling or join a support group

T4 ABSOLUTE COUNT* 500-200
TESTS TO BE PERFORMEDTREATMENT OR FOLLOW-UP
HIV InfectionStart anti-retroviral duo therapy with DDI & AZT. Move on to AZT & DDC as next step, use d4T or Alpha Interferon as backups
T4/T8 testsEvery 3 months -- constant time and lab
PCPIf <300 T4 cells, and symptomatic, test for active infection by induced sputum test or broncoscopy. If asymptomatic do not begin prophylaxis until T4 cells <200 or percentage is below 15%.
CMVEye exam immediately if symptoms occur
HPV (women)Pap smear every 3-6 months; colposcopy if positive; therapy if appropriate
Candidiasis (oral, esophageal)Local clotrimazole therapy (Mycelex®); fluconazole (Diflucan®) or ketoconazole (Nizoral®) if refractory
Dental2 or 4 times per year visits; repair longstanding problems. Expect some mouth ulcers or dry mouth conditions
Skin problems, including foot fungusSee dermatologist; treat topically, aggressively
Expect Sinusitis problemsTreat aggressively with decongestants, antihistamines. Take care to have any pneumonia symptoms checked
Nutrition inventory & ChemscreenTreat nutritional deficiencies through counseling and vitamins
Office visit every three monthsTreat other problems immediately
PsychiatricContinue therapy or support group

T4 ABSOLUTE COUNT* 200-100
TESTS TO BE PERFORMEDTREATMENT OR FOLLOW-UP
HIV InfectionContinue therapy if working; switch to other combinations (AZT/DDC or AZT/DDI); frequent amylase levels if on DDI; watch for anemia if on AZT. Treat anemia with dose reduction or transfusions or EPO injections; folic acid tabs and B-12 injections can be helpful. Do not use Alpha Interferon as backup as it can lower T4 count at these levels. PCP prophylaxis Bactrim (double strength 3x per week) or aerosol pentamidine (with posturing). Add Dapsone to pentamidine twice per week as adjunct if previous PCP patient. Bactrim is now viewed as a preferred therapy. Use Atovaquone (566c80) as a backup.
HPV (women)Pap smear every 3 months; colposcopy every 6 months
CandidiasisTreat locally with topicals; fluconazole (safer) or ketoconazole (cheaper) if refractory
Vaginal CandidiasisVaginal exam every 3 to 6 months; treat aggressively with local clotrimazole cream; fluconazole if refractory
CMVContinue eye exams; treat with Gancyclovir if proven CMV infection
Toxoplasmosis TiterOnce a year; if positive, consider pyrimethamine prophylaxis; or with Bactrim combination (prophylaxis is as yet unproven)
TBAny suspicion of TB should be x-rayed and cultured; treat very aggressively with ING and Rifampin, usually along with other drugs (PZA, etc.)
Office VisitVisual exam to include inspection of mouth and skin every 3 months
FeversIdentify cause and treat. (Most people use too little Tylenol®)
DiarrheaTreat with Immodium; if continues more than 2 weeks identify cause and treat aggressively; eliminate milk products. If continues may treat with Humatin if cryptosporidiosis is suspected
Peripheral NeuropathyBest available treatment is acupuncture (really!), but some success with Tegretol or Elavil. Experimentation with gel insoles can be helpful for feet. Try using Mexiletine
Dental ExamExam and cleaning 4-6 months. Fix problems
Nutrition and VitaminsCorrect deficiencies; add vitamin supplements
PsychiatricContinue therapy and/or support group

T4 ABSOLUTE COUNT* <100
TESTS TO BE PERFORMEDTREATMENT OR FOLLOW-UP
HIV InfectionContinue combination therapy; high dose Acyclovir (800 TID) also has survival benefit at these levels
PCPContinue prophylaxis (Bactrim or Pentam with Dapsone). Use Atoquavone (566c80) as a backup; Trimetrexate with Leucovorin rescue is being used as a salvage (last ditch) therapy
CMVUse Gancyclovir or foscarnet if actual CMV is proven. Eye exam every 3 months. WAtch for CMV gut problems
Toxoplasmosis TiterIf positive, use Prophylax with pyrimethamine, Bactrim or combination
MAI/MACMAI blood culture every 3 months. If positive, tret with clarithromycin or azithromycin usually with Rifabutin, or traditional multiple drug combination therapies. If wasting occurs, treat for MAI aggressively; consider prophylaxis with Rifabutin, adding clarithromycin or azithromycin later on
CryptosporidiosisAggressive testing and treatment; consider Humatin prophylaxis
CandidiasisTreat aggressively with fluconazole; Sporanox® backup
Cryptococcal meningitisTreat aggressively wityh Amp B+5FU; prophylaxis with fluconazole. Prophylax all patients with fluconazole to prevent cryptococcal meningitis
HPV (women)Pap smear every 3 months; colposcopy every 6 months or if positive, consider aggressive therapy
WastingConsider treatment for MAI presumptively; also use Megace or Marinol; consider Trental (TID) prophylaxis
Office VisitMonthly to bimonthly. Treat all other problems aggressively

*T4 count is CD4 cell count. Practitioners should also count percentage of Lymphocytes and treat accordingly. The 20% level is frequently considered a "trigger" for aggressive therapy even if T4 count is more than 200. Many physicians consider percentage as important as absolute T4 count. Delayed Hypersensitivity Skin Tests, which are under-administered in the U.S., are useful as an adjunctive test of immune function.

Source: HIV Standard of Care, ACT UP/Philadelphia, Version 4; published May, 1993

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