Managing a patient with HIV

This summary is an adaptation of the e-Therapeutics Evaluation published by the Canadian Pharmacists Association (CPhA): Infectious Diseases: HIV Infection

Investigations

Clinical History

• Risk behaviours, social support and need for counselling
• Establish date of infection, if possible, based on a review of past sexual contacts, period of needle sharing, receipt of blood or blood products, availability of a previous negative test or a history of possible seroconversion illness (e.g., mononucleosis-like or severe flu-like illness) shortly after a high-risk exposure
• General indicators: anorexia, weight loss, fatigue or malaise, lymphadenopathy
• Symptoms of opportunistic infections, e.g., fever, night sweats, cough, dyspnea, diarrhea, headache or skin rashes
• Travel history

Past medical history

• Sexually transmitted infections (including syphilis, gonorrhea, chlamydia, granuloma inguinale, lymphogranuloma venereum, herpes simplex, genital warts, pubic lice)
• Past history or exposure to tuberculosis (TB), hepatitis B or C, varicella
• Conditions that may compromise future drug therapy, e.g., kidney dysfunction, peripheral neuropathy, liver disease, pancreatitis, cardiovascular disease, psychiatric disorders, substance abuse
• Allergies
• Immunization history

Physical examination

• Focus on signs of immune dysfunction and indications of opportunistic disease
• Direct specific attention to examination of the mental status, skin, visual fields, ocular fundi, oral cavity, and lymph nodes.

Therapeutic Choices

Non-Pharmacologic Choices (PDF)

Pharmacologic Choices (PDF)

Planned treatment interruptions (“drug holidays”) had been proposed as a strategy to reduce long-term toxicity and treatment cost for patients. However, the risk of opportunistic infections and death was higher in patients randomized to episodic treatment interruptions based on CD4 count as compared with continuous cART in the SMART study. For this reason, treatment interruptions are not recommended.

More on Antiretroviral Medications for HIV Therapy (PDF Table)

Therapeutic Tips

• Develop a long-term treatment strategy in advance to deal with drug intolerance and treatment failure due to resistance.
• Poor adherence is the single most critical determinant of therapeutic failure. Promote adherence by prescribing the simplest possible regimen that is likely to be effective.
• Nonquantifiable plasma viral levels (below the detectable threshold) do not imply cure, eradication or a reason for complacency with safer sex practices or similar safety measures.
• The variability of the plasma viral load assays is approximately 0.3 to 0.5 log₁₀. Hence, in untreated patients changes in plasma viral load of <0.3 to 0.5 log₁₀ are usually not regarded as clinically significant.
  
• Intercurrent illnesses or vaccinations can transiently but substantially increase plasma viral load in patients not receiving cART.
  
• CD4 counts show diurnal variation, being lowest in the morning and highest in the evening. Fluctuations of up to 30% may occur, which are not attributable to a change in disease status. Overall, it is important to monitor the trends in CD4 counts over time rather than placing too much emphasis on one specific reading.
• From a practical standpoint it is useful to consider the CD4 count as indicative of “the immunologic damage that has already occurred” and the plasma viral load as “the damage that is about to occur.”
• If the plasma viral load rebounds despite ongoing therapy, consider nonadherence and resistance as the most likely causes.
  
• Some antiretroviral agents have variable pharmacokinetic profiles which may lead to suboptimal therapeutic responses even in an adherent patient.
  
• As the immune system recovers with cART, patients may experience new or worsening symptoms of opportunistic infections. 

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