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 PERFORMED TREATMENT OR INOCULATION
T4 count and T8 ratio as baseline Repeat every six months if over 500
Anergy Skin Testing Pneumovax inoculation, if not previously
Syphilis Test (use MHATP) Over treat with Benzathine Penicillin
All patients Flu shot once a year (October)
All patients H. Influenza inoculation, if not previously
Hepatitis B negative? If not, consider Hepatitis B vaccination
Baseline Chemscreen / Baseline Toxoplasmosis Titer If positive, follow carefully, monitor for symptoms
Tuberculosis PPD test If positive at 5mm., treat one year with INH+ Rifampin
Baseline Ophthalmic eye tests Treat if symptomatic for CMV or other problems
Herpes Zoster outbreak Treat aggressively with Zovirax*
Vaginal exam Every 6 months, treat for candidiasis, if present, with topical cream; oral drugs if refractory
Pap Smear If positive, immediate colposcopy, otherwise repeat smears every 3-6 months; if colposcopy is positive, therapy as appropriate
Baseline dental exam Repair obvious gum and tooth problems
Baseline Psychatric exam Some new "positives" need treatment for depression
Do your own reading and research Educate yourself for the many decisions to be made

T4 ABSOLUTE COUNT* >500
TESTS TO BE PERFORMED TREATMENT, INOCULATION OR FOLLOW-UP
T4/T8 Repeat 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 months Visual exam to include inspection of mouth skin
Dental exam Exam and cleansing every 4-6 months
Psychiatric Continue counseling or join a support group

T4 ABSOLUTE COUNT* 500-200
TESTS TO BE PERFORMED TREATMENT OR FOLLOW-UP
HIV Infection Start anti-retroviral duo therapy with DDI & AZT. Move on to AZT & DDC as next step, use d4T or Alpha Interferon as backups
T4/T8 tests Every 3 months -- constant time and lab
PCP If <300 t4="" cells="" and="" symptomatic="" test="" for="" active="" infection="" by="" induced="" sputum="" or="" broncoscopy="" if="" asymptomatic="" do="" not="" begin="" prophylaxis="" until="" 200="" percentage="" is="" below="" 15="" td="">
CMV Eye 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
Dental 2 or 4 times per year visits; repair longstanding problems. Expect some mouth ulcers or dry mouth conditions
Skin problems, including foot fungus See dermatologist; treat topically, aggressively
Expect Sinusitis problems Treat aggressively with decongestants, antihistamines. Take care to have any pneumonia symptoms checked
Nutrition inventory & Chemscreen Treat nutritional deficiencies through counseling and vitamins
Office visit every three months Treat other problems immediately
Psychiatric Continue therapy or support group

T4 ABSOLUTE COUNT* 200-100
TESTS TO BE PERFORMED TREATMENT OR FOLLOW-UP
HIV Infection Continue 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
Candidiasis Treat locally with topicals; fluconazole (safer) or ketoconazole (cheaper) if refractory
Vaginal Candidiasis Vaginal exam every 3 to 6 months; treat aggressively with local clotrimazole cream; fluconazole if refractory
CMV Continue eye exams; treat with Gancyclovir if proven CMV infection
Toxoplasmosis Titer Once a year; if positive, consider pyrimethamine prophylaxis; or with Bactrim combination (prophylaxis is as yet unproven)
TB Any suspicion of TB should be x-rayed and cultured; treat very aggressively with ING and Rifampin, usually along with other drugs (PZA, etc.)
Office Visit Visual exam to include inspection of mouth and skin every 3 months
Fevers Identify cause and treat. (Most people use too little Tylenol®)
Diarrhea Treat 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 Neuropathy Best 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 Exam Exam and cleaning 4-6 months. Fix problems
Nutrition and Vitamins Correct deficiencies; add vitamin supplements
Psychiatric Continue therapy and/or support group

T4 ABSOLUTE COUNT* <100
TESTS TO BE PERFORMED TREATMENT OR FOLLOW-UP
HIV Infection Continue combination therapy; high dose Acyclovir (800 TID) also has survival benefit at these levels
PCP Continue 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
CMV Use Gancyclovir or foscarnet if actual CMV is proven. Eye exam every 3 months. WAtch for CMV gut problems
Toxoplasmosis Titer If positive, use Prophylax with pyrimethamine, Bactrim or combination
MAI/MAC MAI 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
Cryptosporidiosis Aggressive testing and treatment; consider Humatin prophylaxis
Candidiasis Treat aggressively with fluconazole; Sporanox® backup
Cryptococcal meningitis Treat 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
Wasting Consider treatment for MAI presumptively; also use Megace or Marinol; consider Trental (TID) prophylaxis
Office Visit Monthly 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