The second decade of the acquired immunodeficiency syndrome (AIDS) epidemic began in 1991. In May 1981, five cases of Pneumocystis carinii pneumonia were reported to the Centers for Disease Control (CDC). During that same period, the CDC was receiving reports of Kaposi's sarcoma in homosexual men; by late 1981, more than 100 cases had been reported. In September 1982, the CDC defined this new syndrome as the acquired immunodeficiency syndrome. In 1983, the human immunodeficiency virus type 1 (HIV-1) was isolated from persons with AIDS.
Since that time, the AIDS epidemic has become worldwide despite significant advances by the medical and scientific community in understanding the pathogenesis of HIV, recognizing and treating the related opportunistic infections, and developing drugs to slow the progression of HIV disease. Despite the best available medical care, there is disease progression in most infected persons. Ultimately, most infected persons will develop an AIDS-defining opportunistic infection or malignancy. HIV infection and AIDS will lead to premature death for the great majority of infected persons.
Daunting projections are being made by the World Health Organization and others concerning the worldwide impact of the AIDS pandemic in the 1990s. It is estimated that between 30 and 110 million persons will be infected with HIV by the year 2000. In Africa and Asia, the future toll of this epidemic is difficult to comprehend. It is estimated that there will be more than 10 million orphans in sub-Saharan Africa alone.
Over time, HIV-infected persons will experience progression of their HIV infection with all of the concomitant medical, social, and economic problems. It is essential that the late stage HIV/AIDS patient have medical, social, and psychological support. Persons with more advanced HIV disease face the need for hospitalization; the loss of employment; the decreased capacity to care for the daily needs of themselves and their dependents; the issues of loss of autonomy, dying, and death; and the needs of dependents, especially infants and children. For the foreseeable future, the delivery of this support to the ever increasing number of HIV-infected persons - men, women, and children - will challenge and strain the health care and social service systems of this country, especially in large inner cities.
Infection with the human immunodeficiency virus (HIV) is usually associated with a progressive disease process. The clinical spectrum ranges from asymptomatic infection to the acquired immunodeficiency syndrome (AIDS). Many persons with HIV infection are unaware that they are infected. Although some HIV-infected persons will remain asymptomatic for 10 or more years, most will ultimately develop some symptoms related to this infection.
HIV is spread from person to person by three well-recognized routes. The overwhelming majority of cases are transmitted sexually through either heterosexual or male-to-male intimate sexual contact where there is exposure to body fluids such as semen, blood, and vaginal or cervical secretions. Other cases are spread by parenteral transmission (either through transfusion of contaminated blood or blood products or through injection with a blood-contaminated needle or syringe) or by perinatal transmission, which may occur in utero, intrapartum, or through breastfeeding. Although these transmission routes are well understood, successful intervention to prevent the spread of HIV infection remains a major worldwide public health issue.
As of June 1992, there were more than 480,000 reported cases of AIDS worldwide and an estimated 10 million persons infected with HIV. In the United States, it is estimated that between 1 million and 1.2 million persons are infected with HIV; 230,000 of these persons have AIDS and more than 171,890 have died. Table 1 shows the characteristics of persons diagnosed with AIDS in the United States in 1992. It is apparent from this table that nearly one third (31.9 percent) of cases are attributable to injection drug use, either alone or combined with male single-sex/bisexual sexual contacts. Among women with AIDS, 71 percent of all cases are linked directly or indirectly to injection drug use. Also, 70 percent of the pediatric cases resulting from maternal-infant transmission are related to the mother's exposure to HIV through injection drug use or through sex with an injection drug user.
During 1991, the proportion of new AIDS cases increased most among women, among persons infected via heterosexual contact, among persons living in the South, and among African Americans and Hispanics. In 1991, 49 percent of all AIDS cases occurred in non-Hispanic whites, 32 percent in African Americans, and 18 percent in Hispanics. African Americans accounted for 45 percent of HIV cases attributed to injection drug use, and Hispanics for 26 percent. Both male and female adolescents - particularly young African-American women - are at increasing risk of HIV infection, especially through unprotected heterosexual intercourse.
Once infected with HIV, a person may have a relatively asymptomatic period when there are few if any clinical manifestations of the infection. HIV itself infects primarily the CD4 lymphocytes, monocytes, and macrophages, all of which are vital to the body's ability to prevent serious infections or malignancies. HIV has the ability not only to kill these cells or decrease their function but also to remain latent in these and other cells. Over time, most persons infected with HIV will have disease progression marked by clinical manifestations as well as a progressive decline in the number of CD4 cells.
Any HIV-infected person benefits from ongoing and regular medical care with the institution of antiretroviral therapy and preventive prophylaxis when appropriate.
The prevention and treatment of HIV/AIDS is a matter of serious concern to drug treatment programs in terms of the health of their patients and staff and of helping to protect the public health of the community at large. Injection drug users are a group at special risk of HIV infection. Approximately 32 percent of all adult and adolescent AIDS cases are related to injection drug use.
Because of this high risk of HIV infection among injection drug users, control of AIDS is inevitably tied to the availability of drug treatment and to other prevention services targeted to injection drug users. The city of New York alone has an estimated 200,000 injection drug users, 50 percent of whom are HIV-infected. Yet New York City has only 38,000 publicly funded drug treatment slots. On a national basis, the National Institute on Drug Abuse recently estimated that more than 100,000 persons are currently on waiting lists for drug treatment programs.
It is recommended that drug treatment clinics undertake the following steps to provide for the prevention and diagnosis of HIV among their patients, and to enable patients to receive medical treatment as early in the disease process as possible.
Encourage all patients entering drug treatment to be screened for HIV infection at the time of entry to the program or as soon as feasible if the patient initially refuses testing. The Consensus Panel recommends that consent should be obtained before any testing begins. Informed consent is required for HIV testing in some jurisdictions. See Issues Concerning HIV Testing in "Legal and Ethical Issues," this volume, for more information on this topic.
Provide periodic followup screening and risk-reduction counseling for patients who are HIV-negative.
Provide counseling to patients both before and after the HIV screening test, with counseling done in a private and confidential setting.
Ensure that patients with HIV infection receive appropriate medical care, including immunizations and scheduled medical followup examinations and treatment.
Ensure that patients with HIV infection receive psychosocial evaluation and referral for services, including employment, social services, legal assistance, and transportation, if needed.
Provide training for program staff if the drug treatment program plans to conduct HIV counseling and testing on site instead of referring patients out for testing. For information on training, see "Issues for Counselors."
Ongoing education should be provided for staff and for all persons enrolled in the drug treatment program. This education needs to take into consideration the different cultural backgrounds as well as the age and level of education of the persons involved. The educational program should include comprehensive coverage of the following subjects:
Modes of transmission and manifestations of HIV infection
Reduction of risk behavior - both sexual and related to drug use
Explicit and clear instructions concerning safer sex, including help to both men and women on use of condoms and safer sex practices, as well as the role of abstinence
Discussion of pregnancy and HIV, including the risk of transmission to the fetus or newborn
Sharing needles, syringes, drug vials, and cookers can transmit infection, since any part of this equipment may be contaminated. The patient should be given instructions about safer usage of needles, syringes, and other drug paraphernalia, including refraining from sharing needles and the dangers of purchasing presumably "clean" needles on the street. The limitations of bleach should be stressed. Users should be told that cleaning syringes, needles, or other drug paraphernalia with bleach may not kill the HIV virus. Treatment centers should contact the Centers for Disease Control and Prevention frequently to obtain updated guidelines on the disinfection of drug injection equipment and should keep drug users up to date on the guidelines. See appendix G for a further discussion on bleach.
The impact of continued drug, alcohol, and tobacco use on the immune system and HIV infection
Instituting universal precautions in the workplace is mandatory, especially in areas where blood is drawn and handled. Immediate medical followup must be made available to anyone who sustains a needlestick injury or has cutaneous or mucous membrane exposure to blood or other potentially infectious body fluids. Issues concerning potential exposure to HIV-1 and viral hepatitis B and C must be addressed.
State laws vary. All States require the reporting of AIDS cases, as defined by the Centers for Disease Control and Prevention, to health departments. A growing number of States also specifically or implicitly require reporting on HIV-positive test results. For further information on issues of confidentiality, anonymous and confidential testing, and partner notification, refer to the chapter "Legal and Ethical Issues."
All persons entering drug treatment programs should have a blood test for HIV infection at the time of entry into the program or as soon as feasible if the person initially refuses testing. If HIV negative after the initial screening, the person should be tested periodically thereafter. Behavioral and other factors placing people at particular risk for HIV infection are listed in table 2.
General clinical manifestations often associated with HIV infection are shown in table 3. Persons with a history of tuberculosis, viral hepatitis B or C, or any sexually transmitted disease should be counseled and tested for HIV. An HIV-infected person is more likely than a non-HIV-infected person to develop serious bacterial infections, especially pneumonia and tuberculosis. Any patient with such a history should receive HIV counseling and testing.
It is important to choose a reliable laboratory that is experienced with HIV testing. If there are any concerns about the reliability of a test, repeat it at a different laboratory.
Serologic testing for HIV consists of the following tests:
The initial screening test is the enzyme immunoassay (EIA). If this test is reactive, the test is repeated.
If the repeat EIA is reactive (that is, positive), a supplemental test, the Western blot, is performed. The Western blot detects antibodies to specific HIV proteins. Certain bands must be present to be considered positive, as follows:
Reactive Western blot: any two of three major diagnostic bands (p-24, gp-41, gp-120/160).
Indeterminate Western blot: presence of one or more viral-specific bands that fail to meet the criteria for reactive Western blot.
Nonreactive Western blot: no bands.
A positive HIV-1 test: a positive EIA and reactive Western blot mean that the person is infected and infectious.
Detectable antibody usually develops within 3 months after infection but takes longer in some people . Although a nonreactive antibody test usually means that a person is not infected, nonreactive antibody tests cannot rule out infection from a recent exposure (i.e., within 3 to 6 months of testing in most cases).
For a person at risk for HIV-1 infection, the tests should be repeated in 3 months if the EIA is negative or if the Western blot is indeterminate or nonreactive. If the tests are still indeterminate at 3 months, the tests should be repeated at 6 months. Very rarely, infected persons may not become antibody positive for 12 months or longer. If the person continues to engage in high-risk behavior or to have any clinical evidence of possible HIV infection, the tests should be repeated every 6 to 12 months thereafter.
In rare instances, additional serologic testing, such as the immunofluorescent antibody assay, HIV viral culture, or polymerase chain reaction (PCR) may be appropriate.
At the time of HIV serologic testing, pre-test counseling by a qualified counselor should be available. Testing and counseling should be conducted in a private setting and in a professional and confidential manner. The counseling should include
A client-centered risk assessment that will assist the person to arrive at a self-perception of risk and development of a risk-reduction plan. (See the 1993 CDC publication, Recommendations for HIV Testing Services, listed in the Sources.)
A discussion of the implications of a positive, indeterminate, or negative test
The psychosocial and medical significance of a positive test
An assessment of the appropriateness of the response of the person being tested
A discussion of the need for the person to notify his or her sexual or injection drug-using partners of a positive test result, so that they may be tested and avail themselves of medical care as needed
The need to practice safer sex and not share syringes, needles, or other drug paraphernalia
The post-test counseling should be done at the time that the HIV test results are discussed. The HIV test results should not be given over the phone or by letter, but should be discussed in person in a private setting. The confidentiality of the person should be respected.
HIV-positive patients should be told their test results by a person who is able to discuss the medical, psychological, and social implications of HIV infection. Test results for an HIV-negative patient should be transmitted by a person who can explain the need to reduce or modify high-risk practices to eliminate potential exposure. Appropriate psychosocial and medical followup should be arranged at that time for an HIV-infected person or at-risk person with negative or equivocal test results. (For further information, see the section Counseling the HIV-Positive Patient in the chapter "Issues for Counselors.")
Certain factors are thought to increase the infectiousness of the HIV-infected person. Patients with HIV need to be aware of these factors, which include
Advanced HIV disease
Genital/rectal/oral ulcer disease
Low CD4 lymphocyte count
Increasing the likelihood of sustained behavior change may require that post-test counseling include multiple sessions. Counseling guides or formats are available through State health department HIV-prevention programs and are usually made available as part of training in this process. Help with counseling is also available from the National Clearinghouse on AIDS.
For the HIV-infected person, access to both appropriate medical care and to appropriate psychosocial support is imperative. Recent studies have demonstrated the benefit of the early use of antiviral therapy for HIV and of prophylaxis for certain opportunistic infections, even in asymptomatic patients. The availability of such therapy underscores the importance of identifying persons who are infected and of providing early intervention services.
One to six weeks after the initial infection, many infected persons experience a nonspecific flu-like febrile illness that lasts several days to weeks. The clinical features may include fever, rash, fatigue, generalized lymphadenopathy, malaise, muscle aches, joint pain, headache, pharyngitis, photosensitivity, and encephalitis. Symptoms may be masked by drug use. Many patients may have only one or several of these symptoms; most patients will recall none of these symptoms. Many patients will not attribute these symptoms to acute HIV infection.
After acute infection, most persons have no signs or symptoms of HIV infection for a number of years (median about 10 years). Fauci and his colleagues and Haase and his colleagues have recently confirmed that the HIV virus is sequestered in lymphoid tissue during the acute phase and then in the clinically latent phase of infection. While most patients remain asymptomatic, it now appears that there is significant impairment of the immune system during this stage of illness. (These new studies suggest that it may be possible and preferable to some day treat HIV early on, rather than after the immune system shows signs of deterioration.) During this asymptomatic phase, there is, however, a progressive decline in the CD4 lymphocyte count, which is detectable only through lab testing.
During this stage, most patients will have no significant findings on physical examination other than enlarged lymph nodes. Some patients will have several groups of enlarged lymph nodes. The lymph nodes most frequently involved are the axillary, inguinal, posterior cervical, preauricular, epitrochlear, postauricular, and femoral nodes.
As HIV infection progresses and the CD4 lymphocyte cell count decreases, patients will experience more complications. Any organ system may be involved.
A person who has a positive screening test for HIV is both infected and infectious. In August 1987, the Centers for Disease Control and Prevention (CDC) established criteria for defining AIDS in adult, adolescent, and pediatric (less than 13 years of age) cases. In 1993, CDC revised and expanded the case definition for AIDS. The following changes were made in the AIDS surveillance case definition for adults and children 13 years of age and older:
The case definition was expanded to include all HIV-infected persons with a CD4 count of less than 200 cells/mm3 or a CD4 lymphocyte percentage of total lymphocytes of less than 14.
Three new clinical conditions were added as AIDS-defining illnesses: pulmonary tuberculosis, recurrent pneumonia (two or more episodes in a 1-year period), and invasive cervical cancer.
The 23 clinical conditions in the AIDS surveillance case definition published in 1987 are retained. Table 4 shows the CDC case definition for adults and adolescents with AIDS. The Centers for Disease Control and Prevention considers that a person has AIDS if that person has certain specific secondary opportunistic infections or malignancies or fulfills the criteria for HIV encephalopathy or HIV wasting syndrome.
HIV encephalopathy is defined as being a progressive decline in cognitive function, memory, and behavior, as well as other changes on neurologic examination and neuropsychiatric assessment. The HIV wasting syndrome is defined as involuntary weight loss of more than 10 percent below baseline weight coupled with the presence of fever for more than 1 month or diarrhea persisting for more than 1 month. Diagnosis of these diseases is made presumptively, after laboratory confirmation of HIV infection.
A health care provider knowledgeable about HIV infection should conduct a complete history and physical examination. The history should include previous medical illnesses; family history; allergies and adverse drug reactions; current drugs and medications; use of drugs including alcohol, tobacco, and habitual or illicit drugs; psychosocial history; sexual history; and review of symptoms.
Patients should receive a complete physical examination and a mental status examination. For women, the physical examination should include a pelvic examination, Pap smear, breast examination, and evaluation for STDs.
Since diseases may be more severe in persons with HIV infection, the CDC recommends that all persons at risk for HIV have their history of vaccination and immune status evaluated for diseases for which vaccines are available (pneumococcal pneumonia, influenza, diphtheria, tetanus, measles, mumps, rubella, Haemophilus influenza type B, and hepatitis B).
For maximum benefit to those with HIV, vaccines should be administered as soon as possible after HIV is diagnosed. Many patients with suppressed CD4+ cell counts have a diminished antibody response. Live-virus vaccines such as the oral polio vaccine and bacillus Calmette-Gurin (BCG) for tuberculosis prevention are contraindicated. Adults with HIV should receive the following vaccines:
Pneumococcal vaccine if not previously administered; revaccination after 6 years
Influenza vaccine during the flu season each fall
Hepatitis B vaccine if there is no serologic evidence of prior infection or if the person was not previously vaccinated. One to 6 months after the vaccine series is completed, antibody to HBsAg (anti-HBs) should be measured. If anti-HBs is less than 10 mIU/mL, revaccination with one or more doses should be offered.
Tetanus booster every 10 years with Td (tetanus/diphtheria toxoids, absorbed).
For patients with HIV, Haemophilus influenza type B conjugate vaccine should also be considered. All adults born in or after 1957 should have evidence of immunity to measles: documentation of measles vaccine after the first birthday; serologic evidence of a protective titer; or history of measles with physician's documentation. Although measles, mumps, and rubella vaccines are live attenuated vaccines, they may be given to HIV-infected persons. For an HIV-infected person born in or after 1957 or for an HIV-infected person born before 1957 without evidence of immunity to measles, the measles, mumps, rubella (MMR) vaccine should be considered.
For nonpregnant HIV-infected women of childbearing potential, measles, mumps, and rubella vaccine should be administered, especially to women born in or after 1957. Such vaccination is not needed for women who have a dated record of at least one dose of live measles vaccine on or after their first birthday, of physician-diagnosed disease, or of laboratory evidence of immunity.
Any significant abnormal findings from the review of symptoms or physical examination should be appropriately followed up.
Laboratory abnormalities should be addressed. The results of the CD4-lymphocyte count will frequently serve as the basis for followup. Patients with HIV infection, especially drug users, are at risk for bacterial infections such as pneumonia, bacteremia, and tuberculosis even before the CD4 count falls below 200 cells/mm3. When the CD4 count is less than 200, HIV-infected persons are at increased risk of developing opportunistic infections, especially pneumocystis pneumonia. More serious complications usually occur with a CD4 count of less than 100. The greatest risk for death occurs when the CD4 count is less than 50.
CD4 greater than 800 - schedule followup in 6 months.
CD4 500 to 800 - schedule a 3-month followup.
CD4 less than 500 but greater than 200 with a patient who is (a) symptomatic, institute antiretroviral therapy; (b) asymptomatic, consider instituting antiretroviral therapy or consider continued observation and monitoring for clinical or laboratory evidence of disease progression. When disease progression occurs, antiretroviral therapy should be instituted. For persons with persistent and unexplained fever (greater than 100 F) for 2 weeks or oropharyngeal candidiasis, primary prophylaxis to prevent Pneumocystis carinii pneumonia (PCP) should be started. Similarly, for persons with a prior episode of PCP, secondary prophylaxis is indicated.
CD4 less than 200 - institute antiretroviral therapy as well as primary prophylaxis to prevent PCP. Schedule monthly to bimonthly clinic visits. At any time, should a patient's condition change, that patient may require a more thorough evaluation. Close followup and evaluation need to be provided, especially if there is physical or mental deterioration.
Preliminary recommendations to guide health care providers concerning the use of the antiretroviral drugs zidovudine (AZT), didanosine (ddI), and zalcitabine (ddC) in adults in the early, intermediate, and late stages of HIV disease have been issued by an expert panel (National Institute of Allergy and Infectious Diseases 1993). A decision to intervene with antiretroviral drugs should be made by the health care provider and the patient; the choice to accept or decline antiretroviral therapy ultimately rests with the patient, according to the panel. The intervention should include primary medical care - with management of the patient's overall health status - and should provide emotional and psychological support. Current information on clinical trials is available from the AIDS Clinical Trials Information Service, 1-800-TRIALS-A.
The following is excerpted from the panel's preliminary recommendations:
The recommendations for patients who have never before received antiretroviral therapy are:
For patients without symptoms whose CD4+ T cell counts are above or equal to 500 cells/mm3, the panel recommends continued observation, and clinical and immunological monitoring, (measurement of CD4+ T cell counts) every 6 months.
For patients without symptoms whose CD4+ T cell counts are between 200 to 500 cells/mm3 and who are stable over time, the panel recommends consideration of the following two options:
initiation of antiretroviral therapy;
continued observation and monitoring for clinical or laboratory evidence of deterioration, at which point antiretroviral therapy should be initiated.
For patients with CD4+ T cell counts between 200 to 500 cells/mm3 who present with symptoms related to HIV disease, the panel recommends starting antiretroviral therapy.
When choosing an initial antiretroviral therapy:
Use AZT as first-line therapy in patients who have received no prior antiretroviral therapy. The recommended dose is 600 mg/day in divided doses.
The recommendation to initiate therapy with AZT applies to patients with or without symptoms, with CD4+ T cell counts between 200 to 500 cells/mm3 or below 200 cells/mm3, or to patients with severe AIDS-Related Complex or AIDS regardless of their CD4+ T cell counts.
Combination therapy with AZT and ddI or AZT an d ddC also may be considered, although clinical trials have not conclusively demonstrated clinical benefit to date.
On changing initial therapy in patients who are tolerating an initial antiretroviral therapy:
In patients tolerating initial therapy, the panel recommends continuing AZT for patients who appear to be stable with CD4+ T cell counts above 300 cells/mm3.
For patients who have CD4+ T cell counts below 300 cells/mm3, the panel recommends consideration of two options:
continuing AZT; or
changing to ddI.
The panel notes that the strongest data supporting a change in therapy to ddI were seen in patients who had been on AZT for 4 months or longer (median duration of 13 months prior to AZT).
For patients who are intolerant to AZT or who experience progression of disease despite AZT therapy:
In patients with CD4+ T cell counts between 200 to 500 cells/mm 3 and 50 to 200 cells/mm3 who are intolerant of AZT, the panel recommends switching to ddI monotherapy. For AZT intolerant patients with CD4+ T cell counts of less than 50 cells/mm3, the panel recommends switching to ddI or ddC monotherapy. Another option includes discontinuing antiretroviral therapy [for persons with CD4+ T cell counts of less than 50 cells/mm3].
For patients with CD4+ T cell counts between 200 to 500 cells/mm3 and 50 to 200 cells/mm3 who show signs of clinical progression, the panel recommends initiating an alternative antiretroviral regimen. Options include monotherapy, for example with ddI, or initiation of combination therapy by adding a second agent, either ddI or ddC.
For patients with CD4+ T cell counts below 50 cells/mm3 and who have evidence of disease progression, the panel recommends switching to an alternative monotherapy, either ddI or d ddC.
Other options include combination therapy.
For patients with CD4+ T cell counts above 500 cells/mm3 who are taking AZT but experience intolerance, the panel recommends discontinuation of therapy.
Table 5 gives dosages and side effects of treatment of the antiretroviral drugs AZT, ddI, and ddC.
In addition to antiretroviral therapy, prophylaxis is currently recommended by the U.S. Public Health Service for the prevention of two AIDS-related opportunistic infections, Pneumocystis carinii pneumonia (PCP) and disseminated infection caused by Mycobacterium avium complex (MAC).
It is estimated that up to 85 percent of HIV-infected persons will develop PCP with over 65,000 cases occurring each year in this country. Without prophylaxis, persons with a CD4 count below 200 cells/mm3 have an 8.4 percent risk of developing PCP within 6 months. Even with prompt diagnosis and appropriate treatment, with the first episode of a mild case of PCP, up to 10 percent of patients will die. For persons with moderate to severe PCP, reported mortality rates are even higher. Appropriate lifelong prophylaxis to prevent PCP should be instituted for any HIV-infected persons with a CD4 count less than 200 cells/mm3; for patients with persistent and unexplained fever (greater than 100 F) for 2 weeks or oropharyngeal candidiasis regardless of CD4 count; or for persons who have had a prior episode of PCP. Table 6 gives the doses and more common side effects of the drugs available for PCP prophylaxis.
Persons with acute PCP have primarily respiratory symptoms, with the majority having cough, fever, dyspnea on exertion, and fatigue. The typical chest x-ray in PCP shows diffuse interstitial infiltrates in both lung fields. Any HIV-infected person with respiratory symptoms should be evaluated for PCP as well as tuberculosis and other pulmonary infections; appropriate treatment should be started if the clinical and laboratory findings are consistent with acute PCP.
Mycobacterium avium complex (MAC) causes disseminated disease in up to 40 percent of patients with HIV infection. The majority of cases of disseminated MAC occur in persons with a CD4 count of less than 75 cells/mm3. Patients with advanced HIV infection who develop disseminated MAC experience fever, night sweats, weight loss, abdominal pain, and diarrhea. The main laboratory abnormalities are anemia and an elevated alkaline phosphatase. Patients with disseminated MAC die sooner than similar patients without disseminated MAC. The diagnosis of disseminated MAC is dependent on the isolation of MAC in a blood culture or from a sterile body tissue or fluid.
Given the severity of symptoms associated with disseminated MAC and the increased mortality, the U.S. Public Health Service has issued recommendations for the prophylaxis and treatment of disseminated MAC. The current recommendation is that all HIV-infected persons with a CD4 count less than 100 cells/mm3 receive 300 mg rifabutin orally daily for life unless disseminated MAC develops. Prior to beginning rifabutin prophylaxis, all patients must be evaluated to ensure that they do not have active MAC or M. tuberculosis (Mtb). The medical evaluation should include a chest x-ray and tuberculin skin test. If there is any concern that the patient has active MAC disease or active Mtb, rifabutin prophylaxis should not be given. If, after placing a patient on rifabutin, there is concern that the patient may have active MAC or Mtb, the rifabutin should be discontinued and appropriate clinical and laboratory followup obtained. Table 7 summarizes the recommended prophylaxis to prevent disseminated MAC.
Any patient who shows signs and symptoms of a serious opportunistic infection, such as those shown in table 8, or possible tuberculosis, should be referred for prompt medical evaluation. Opportunistic infections or malignancy suggest advanced HIV disease and the need for immediate referral, prompt evaluation, and treatment.
Because complications may develop at any time, provisions for appropriate care, including emergency care, after-hours care, and specialty consultation, must be made available for all patients. Drug treatment programs should have established relationships with infectious disease specialists, early intervention clinics, comprehensive care centers, and hospitals.
At the time of diagnosis of HIV infection, all HIV-infected persons should be evaluated by a social worker or other person qualified to do a psychosocial evaluation. The evaluation should address the following issues:
Understanding of the implications of HIV infection
Family, community, and other support systems
Employment and economic circumstances
Adequacy of housing, food, medical care
Ability of patient to obtain prescribed medications
Access to a support group, buddy system, or other social support system
Eligibility for food stamps, housing subsidy, Medicare, Medicaid, Social Security benefits, etc., as appropriate
Arrangement of child care for children of HIV-infected parents, especially mothers, so that they can obtain medical care and meet other needs
Assessment of transportation needs
For further information, see Counseling the HIV-Positive Patient in the chapter "Issues for Counselors."
Instruction should be provided in the reduction of at-risk behavior. Culturally appropriate HIV/AIDS education and counseling need to reinforce changed behavior and safer sex. For example, both male and female patients may need instruction in how to use a condom and how to negotiate safer sex practices with partner(s). Patients with HIV need to understand the impact of continued drug use on the immune system and on HIV infection. Patients should be told that harm-reduction initiatives and reduction of drug use have the potential to improve the quality and duration of life. For further information, see Risk Reduction in the chapter "Issues for Counselors."
Transmission of HIV from an infected mother to her unborn fetus or to her infant before or during delivery can occur. If an HIV-infected woman becomes pregnant, she needs to be informed of these risks. She should also be told that if she has more advanced HIV infection, the risk of HIV transmission may be greater than one third. For an HIV-infected pregnant woman, nondirective counseling on pregnancy options should be offered.
In addition, should an HIV-infected mother have a baby, she should be advised that even if the infant was not infected at birth, there is a risk of transmission from breastmilk of the HIV virus to the infant. The current recommendation in the United States is that an HIV-infected woman not breastfeed her infant. In addition, there is a risk of transmitting HIV infection to an infant if the mother was infected after delivery of the baby during the time she was breastfeeding that child.
The HIV status of any children should be determined and testing, if needed, should be arranged. Infected or at-risk children should be referred for care. The parent needs to be informed that the results of HIV testing in infants and babies may not be reliable up to 15 months of age and additional HIV testing of the child may be necessary.
Some drug treatment patients who are HIV negative may be the sexual or injection drug-sharing partners of persons who are HIV positive. In addition to education and counseling about risk-reduction measures, these patients also need to be aware of personal factors that may increase their risk of contracting HIV infection. Factors associated with increased risk of infection for the uninfected sexual partner include
Revision of the CDC surveillance case definition of acquired immunodeficiency syndrome. Morbidity and Mortality Weekly Report 36 (Supplement No.1):1S-15S; Dec. 25, 1987.
STD medical protocols. In: Sexually Transmitted Diseases: Clinical Practice Guidelines May 1991. Atlanta, GA: U.S. Department of Health and Human Services, 1991.
1993 Revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. Morbidity and Mortality Weekly Report 41(RR-17):1-19, 1992.
Recommendations for HIV testing services for inpatients and outpatients in acute-care hospital settings and technical guidance on HIV counseling. Atlanta, GA: Morbidity and Mortality Weekly Report 42(RR-2), 1993.
Recommendations on Prophylaxis and Therapy for Disseminated Mycobacterium Avium Complex for Adults and Adolescents Infected With Human Immunodeficiency Virus. June 14, 1993.
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