Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Asymptomatic patients with HIV infection Geralyn M. Sarti MD To cite this article: Geralyn M. Sarti MD (1990) Asymptomatic patients with HIV infection, Postgraduate Medicine, 87:8, 143-154, DOI: 10.1080/00325481.1990.11704679 To link to this article: http://dx.doi.org/10.1080/00325481.1990.11704679
Published online: 17 May 2016.
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Date: 03 July 2016, At: 10:52
AsJinptomatic patients with HIV infection Keeping them well
Geralyn M. Sarti, MD
Downloaded by [Monash University Library] at 10:52 03 July 2016
Preview More than 1 million Americans may now be infected with the human immunodeficiency virus (HIV), which may not progress to acquired immunodeficiency syndrome (AIDS) for 10 years. Therefore, primary care physicians should be prepared to care for HIV-infectec:l patients in the early stages of their illness. In this article, Dr Sarti provides specific advice on counseling and managing these patients.
As the epidemic of acquired improlong life and prevent some munodeficiency syndrome (AIDS) complications from developing. continues, prima.ty care physicians will see more and more patients Testing for HN who are infected with human imThere are two commonly used munodeficiency virus (HIV). This serologic tests to measure antibody AIDS-causing virus infects and de- to HIY. An enzyme-linked imstroys T4 (helper) lymphocytes, munosorbent assay (ELISA) is first which play a central role in the im- used to test serum. Reactive sammune system. The spectrum of ples are retested (preferably on a HN infection ranges from an newly drawn blood sample), and if asymptomatic state in which the they are again reactive, results are immune system is relatively intact confirmed by Western blot assay to a state in which the immune (or an alternative confirmatory system is severely compromised, re- test). The specificity of the ELISA sulting in life-threatening opporand Western blot assay are 99.8% tunistic infections or malignancies. and 99.4%, respectively, in referThe term "AIDS" is used to deence laboratories with high perforscribe the more severe manifestamance standards.4 The accuracy of tions of this disease. Reported cases tests perfOrmed in nonreference (now more than 100,000) reprelaboratories may be much lower. sent only about 10% of the HNThis problem is compounded by infected patient population.' the fact that false-positive results The incubation period from on- are more common in persons who do not have high-risk behaviors. set of infection to development of Therefore, when nonreference labfull-blown AIDS is now believed to be 8 to 10 years. z.3 Many pa.oratories report positive results in patients with no high-risk behavtients present in the early stages of disease. Appropriate counseling and iors, physicians should recommend confirmation of those results by a medical management of asymptomatic patients may significantly reference laboratory.' VOL87/NO 8/JUNE 1990IPOSTGRADUATE MEDICINE • AIDS
Newer tests, such as HN p24 antigen assays and immunoassays using recombinant polypeptides, are being evaluated for use in clinical practice. Polymerase chain reaction techniques, radioimmunoprecipitation and radioimmunoabsorbent assays, and cultures for HN are also being performed at research centers. 5 These new tests have allowed isolation ofHN from asymptomatic patients before antibodies to the virus develop. A recent studf of HN-seronegative homosexual men involved in high-risk sexual activity showed that HN infection can occur as much as 35 months before antibodies to the virus can be detected. The degree of infectiousness during this period is unknown.
Counseling the HN-positive patient
Education and counseling of patients should begin before testing for HIY. Informed (preferably written) consent for testing should be obtained. The American Medical .Association has published physician guidelines for HN blood test counseling? Physicians who do not have enough time to properly counsel patients should refer them to a public health test site. WHEN RFSUITS ARE POSITIVE-
Patients should be notified of a positive HN test result in person rather than by phone or mail. They may react with disbelief, continued 143
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Patients should understand that a positive result on a test for HIV does not mean that they have AIDS.
anger, fear, anxiety, or guilt and may be distraught for weeks or months. Depression often occurs and suicidal ideation is frequent. Records of a group ofHIVseropositive patients revealed that one in five admitted to considering suicide as an option in the year following notification of test results. 8 The patient's support system should be assessed, and referral to community support groups and professional counselors should be offered. Patients should understand that a positive result on a test for HIV does not mean that they have AIDS. A person infected with HIV may remain free of clinical symptoms for many years. A cohort study of homosexual and bisexual HIV-seropositive men suggests that cumulative progression to AIDS increases from 15% to 39% to 54% among those infected for 5, 8, and 10 years, respectively. 9 Early intervention may alter the course of the disease. Asymptomatic patients should realize that close monitoring and medical intervention before the onset of symptoms may now make HN infection a relatively long-term disease--one that can be controlled despite lack of a cure. PREVENTION OF TRANSMISSION
-Infection with HIV is probably lifelong, and patients must avoid infecting others. HIV-seropositive persons must understand that the virus can be transmitted by intimate sexual contact, transfusion of 144
infected blood, and sharing of needles among intravenous drug users. They should refrain from donating blood, plasma, sperm, body organs, or other tissues. Safe-sex guidelines should be discussed in simple language. Safe sex is body massage, hugging, mutual masturbation, and closedmouth kissing. HIV-seropositive patients must protect their sexual partners from corning into contact with infected blood or bodily secretions. Although consistent use of latex condoms with spermicide containing nonoxynol-9 can decrease the chance ofHIV transmission, the rate of condom failure may be as high as 17%. 10 Patients should also be cautioned against having unsafe sex with other HIV-infected persons. New exposure to HIV may theoretically accelerate disease progression by an increase in viral load, infection with another HIV strain, or infection with other sexually transmitted diseases. Intravenous drug users should not share needles or syringes. Referral to a drug treatment center should be offered. Patients who refuse referral should be instructed to clean their needles or "works" by rinsing them twice with bleach and twice more with water after each use. Patients should not share rawrs, toothbrushes, tweezers, or other items that could be contaminated with blood. Sanitary napkins should be disposed of in a sealed
plastic bag. Accidental spills of blood or body fluids should be wiped up with gloved hands using a solution of 1 part household bleach to 10 parts water. HIV-ser?yositive patients should notify present and past sexual partners and needle sharers and encourage them to seek counseling and testing. Public health officials may be able to assist in alerting these people. Children under 10 years of age born to HIV-seropositive mothers should be referred for testing. Infected women of childbearing age should be advised that the virus can be passed to the child during pregnancy, birth, or lactation. About 20% to 50% of infants born to infected women are also infected. 11 The Centers for Disease Control has recommended that HIV-infected mothers not breastfeed their children. This recommendation does not apply to Third World countries, where breast milk is the principal source of nutrition for infants. Patients should be reassured that casual contact at school, work, or home does not transmit the virus. There is no evidence that the HIV virus is transmitted by food, fomites, swimming pools, insects, pets, tears, or saliva. Laundry not soiled with body fluids, eating utensils, and dishware can be cleaned as usual. HIV-seropositive patients should report their positive antibody status to all of their medical continued
AIDS • VOL 87/NO 8/JUNE 1990/POSTGRADUATE MEDICINE
There is no evidence that the HIV virus is transmitted by food, fomites, swimming pools, insects, pets, tears, or saliva.
Downloaded by [Monash University Library] at 10:52 03 July 2016
Basic health maintenance recommendations for HN-seropositive patients Asymptomatic patients infected with human immunodeficiency virus (HIV) should know how to maintain a healthy life-style and reduce the risk of acquiring an opponunistic infection. The following advice, along with information on safe sex and preventing transmission of infection, should be used in counseling. • Eat a balanced diet containing an adequate amount of protein and calories. The Task Force on Nutrition Suppon in AIDS 1 recommends that nontraditional dietary practices such as macrobiotic and fad diets, herbal powders, and vitamin megadosing be avoided. These praaices may prevent a balanced intake of nutrients, which may further compromise immune status. • Wash all fresh fruits and vegetables well. Cook meat well and avoid raw fish. Wash hands after contaa with raw meat. Consume only pasteurized dairy products. Concern about raw eggs contaminated with SalmoneUa enteriditis has prompted the Food and Drug Administration to recommend that raw or undercooked eggs be eliminated from the diets ofimmunocompromised persons. 2 Pasteurized eggs may be substituted for fresh eggs in recipes calling for raw or undercooked eggs, such as Caesar salad, eggnog, or ice cream. • Exercise regularly but avoid undue fatigue. A regular exercise program may help relieve depression and anxiety. • Try to get 8 hours of sleep each night. Shorr naps may be needed if fatigue is excessive. • Change life-style and modifY work schedules to reduce stress. Relaxation exercises, counseling, or panicipation in an HIV suppon group may be beneficial. • Do not smoke, consume alcohol, or use recreational drugs. These substances may have adverse effects on the immune system and may
VOL 87/NO 8/JUNE 1990IPOSTGRADUATE MEDICINE • AIDS
also impair judgment regarding sexual behavior. • Maintain good oral hygiene. Brush teeth regularly and floss at least once a day. Schedule regular dental checkups. • Exercise caution in pet care to avoid conuaaing infectious diseases from pets. Indoor cats pose little risk when fed only commercial cat food and not allowed raw meat or unpasteurized milk. Avoid cleaning cat liner boxes as well as fish tanks and bird cages. If no one else can do these tasks, wear gloves and wash hands thoroughly. Cat liner should be cleaned daily. Pets' nails should be kept trimmed to avoid scratches. Pet bites should be washed thoroughly and checked by a physician. Potential zoonoses that have been diagnosed in AIDS patients include toxoplasmosis, campylobaaeriosis, salmonellosis, ringworm, cryptosporidiosis, cat-scratch disease, mites, psittacosis, pasturellosis, and brucellosis.-1 It is unknown how frequently these diseases are transmitted from animals to humans. The possibility of contraaing toxoplasmosis is a concern of Toxoplasnurnegative patients. • Avoid recreational aaivities that increase risk of opportunistic infection.4 Desen camping may pose a risk of coccidioidomycosis and spelunking a risk of histoplasmosis. To decrease the risk of infections such as amebiasis, cryptosporidiosis, and giardiasis when camping, do not drink water that could be contaminated with sewage. Avoid walking barefoot, because soil in some areas may contain harmful organisms. Wear gloves when gardening. Rdaalces I. Task Fora: on Nuailion Support in AIDS. Guidelines for nurrition support in AIDS. Nurririon 1989;5( I ):39-46 2. Updare on S mtnitidis in shelled 400/ mm3) •3 Physicians may want to discuss early therapeutic intervention with these patients. BETA2 MICROGLOBUUN CON-
CENTRATION-The test for serum concentration ofbeta2 microglobulin, available for about $45, may be the best predictor of progression to AIDS. HN-seropositive patients with an elevated concentration (>3 mg/L) are at risk for progres*The Food and Drug Administration has approved a new enzyme immunoassay test for HN antigens to be marketed by Abbott Laboratories under the name HNAG-1 (cost $6.50). 32
150
sion to AIDS despite relatively high T4lymphocyte counts. About 25% ofHN-seropositive men with beta2 rnicroglobulin concentrations of more than 3 mg!L progress to AIDS in 3 years despite T 4lymphocyte counts of 400/mm3 or more. 3 Physicians may want to discuss early intervention with these patients as well.
Therapeutic intervention The incidence of drug reactions in HN-infected patients is high. 33-35 Physicians should avoid the unnecessary use of medications, particularly antibiotics. However, the judicious use of vaccines to prevent infections is recommended. Zidovudine may delay the onset of full-blown AIDS. Regimens to prevent P carinii pneumonia may also be effective. VAOCINFS--Patients with HN infection have a component of humoral (B cell) immunodeficiency. An increased incidence of infections with encapsulated organisms such as Streptococcus pneumonia£ and Haemophilus influenzae have been reported in these patients.36 The pneumococcal polysaccharide vaccine (Pneumovax 23, Pnu-Imune 23) and the H influenzaetype b vaccine (Hib-Imune, b-Capsa I) should be given early in the course ofHN disease to maximize antibody response. Influenza virus vaccine (Fluogen, Fluwne) should be given each year, and pa-
tients who are not vaccinated should be offered amantadine hydrochloride (Symadine, Symrnetrel) when appropriate. Hepatitis B vaccine (Heptavax-B, Recombivax HB, Engerix-B) should be given if indicated. Children living in the household of an HN-infected person should not receive the oral (live) polio vaccine (Orimune). Inactivated polio vaccine should be given instead. ZIOOVUDINE-This agent is the only anti-HN drug approved by the Food and Drug Administra-. cion (FDA). Zidovudine does not cure HN infection, but it does block replication of the virus. Until recently, it had been officially approved for adults with symptomatic HN infection (ie, AIDS and advanced AIDS-related complex) who had a history of cytologically verified P carinii pneumonia or an absolute T 4lymphocyte count of fewer than 200/mm3• The recommended dosage was 200 mg every 4 hours around the dock. Early this year, the FDA cut the recommended dosage of zidovudine to 600 mglday after 1 month of treatment at the previously recommended dosage of 1,200 mglday. In early August 1989, researchers at the National Institute of Allergy and Infectious Disease announced that zidovudine delayed the onset ofAIDS in patients with early symptoms of the disease.37 A placebo-controlled multicenter
AIDS • VOL 87/NO 8/JUNE 1990/POSTGRADUATE MEDICINE
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Active pulmonary disease must be excluded in HIV-positive patients before prophylaxis for P carinii pneumonia is begun.
study included 713 HN-infected patients with T 4 lymphocyte counts over 200/mm3 and one or two HN-related symptoms. Significantly fewer patients receiving zidovudine progressed to AIDS or advanced AIDS-related complex compared with those receiving placebo. Two weeks after their first announcement, researchers at the same institution announced that zidovudine could delay the onset of disease in asymptomatic HNinfected patients.28 Their multicenter drug trial tested two regimens of zidovudine in 3,200 HN-infected patients. The study compared dosages of1,500 and 500 m'{/day with placebo in asymptomatic patients with T 4 lymphocyte counts of 200 to 800/mm3• Researchers found that those patients with T 4 lymphocyte counts of 200 to 500/mm3 who were taking 500 m'{/day of zidovudine were half as likely to manifest AIDS symptoms as patients taking placebo. With the exception of nausea (which occurred in about 3% of participants taking zidovudine), no difference in side effects was observed between the 500-m'{/day zidovudine dosage and placebo. Whether zidovudine should be used in asymptomatic patients with T 4 counts of more than 500/mm3 remains to be seen. The trial is continuing with 1,900 asymptomatic
patients who have T 4lymphocyte counts of more than 500/mm3 receiving the drug. Physicians should consider starting zidovudine therapy at a dosage of500 m'{/day (in 100-rng doses every 4 waking hours) in asymptomatic HN-infected patients with T4lymphocyte counts ofless than 500/mm3• The annual cost of this treatment at current prices will be about $2,700. The FDA recently approved new labeling for zidovudine to include patients with T 4 lymphocyte counts ofless than 500/mm3• A recent studf' has shown that some strains ofHN may be developing a resistance to zidovudine. The appearance of these resistant strains in serum has not coincided with any deterioration in clinical status of the patient. The implications of these resistant strains of HN remain unclear. PROPHYlAXIS FOR P CARINli
PNEUMONIA:-P carinii pneumo-
has recommended that this group of patients receive primary prophylaxis fOr P carinii pneumonia.31 Prophylaxis should be given even if the patient is receiving zidovudine. Tests that show low T4lymphocyte counts or low percentages of total lymphocytes should be repeated befOre beginning prophylaxis, unless the test result is consistent with an established trend. Active pulmonary disease must be excluded before prophylaxis is be-
gun. Two regimens have been recommended for primary prophylaxis of P carinii pneumonia: • Oral trimethoprim-sulfamethoxazole (160 rng trimethoprim and 800 rng sulfamethoxazole) may be given twice daily; along with leucovorin calcium (Wellcovorin), 5 mg once daily. This form of prophylaxis should not be given to patients allergic to sulfonarnides or trimethoprim. • Aerosolized pentamidine isethionate (Pentarn 300, NebuPent) delivered via a Respirgard II nebulizer* may be given in a dose of 300 rng every 4 weeks. The dose of pentamidine is diluted with 6 mL of sterile water and administered at 6 Ll minute from a 50-psi compressed air source. Patients in
nia is the initial opportunistic infection in about 62% ofHNinfected patients.39 It develops in another 20% ofAIDS patients at some point in the course of their illness.40 Patients who have baseline T 4 lymphocyte counts of fewer than continued 200/mm3 or less than 20% of total lymphocytes have been found to have a high frequency of subse*Available from Marquest Medical Prodquent Pneumocystis infections. 19'2930 ucts, Inc, 11039 E lansing Circle, Englewood, CO 80112. The Centers for Disease Control
VOL 87/NO 8/JUNE 1990IPOSTGRADUATE MEDICINE • AIDS
151
Specey Adjunctive
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UIIUX®
whom cough or wheezing develops while they are receiving aerosolized pentamidine should be treated with a bronchodilator before subsequent doses. Patients with severe asthma may not tolerate this form of therapy. Aerosolized pentamidine should not be given to patients who have a history of lifethreatening reactions to parenteral pentamidine.
Each capsule contains 5 mg chlordiazepoxide HCI and 2.5 mg clidinium bromide.
Please consult complete prescn"blng lnfonnation, a summary of which follows:
*
Summary
Primary care physicians need to be prepared to counsel and manage patients with human immunodeficiency virus (HIV) infection. Asymptomatic seropositive patients should be seen quarterly, and T4lymphocyte counts should be followed. Other serologic markers that may detect disease progression are p24 antigen and~ microglobulin. Abnormalities in the levels of these markers may influence the decision to initiate early antirettoviral therapy. Therapeutic regimens are now available for delaying progression ofHN disease and for preventing Pneumocystis carinii pneumonia, the most common opportunistic infection to develop in patients with HN infection. Whether antiretroviral therapy should be initiated in all asymptomatic HN-positive pacontinued
Indications: Based on a review of this drug by the National Academy of Sciences-National Research Council and/or other infonnation, FDA has classified the indications as follows: "Possibly'' effective: as adjunctive therapy in the treatment of peptic ulcer and in the treatment of the irritable bowel syndrome {irritable colon, spastic colon, mucous colitis) and acute enterocolitis. Final classification of the less-than-effective indications requires further investigation.
Contraindication&: Glaucoma; prostatic hypertrophy, benign bladder neck obstruction; hypersensitivity to chlordiazepoxide HCI and/or clidinium Br. Warnings: Caution patients about possible combined effects with alcohol and other CNS depressants, and against hazardous occupations requiring complete mental alertness (e.g., operating machinery. driving). USDII" in Pregnancy: Use of minor tranquilizers during first trimester should almost always be avoided because of increased risk of congenital malfonnations as suggested in several studies. Consider possibility of pregnancy when instituting therapy. Advise patients to discuss therapy if they intend to or do become pregnant. As with all anticholinergics, inhibition of lactation may occur. Withdrawal sYffiptoms of the barbiturate type have occurred after discontinuation ofbenzodiazepines (see Drug Abuse and Dependence). Precautions: In elderly and debilitated, limit dosage to smallest effective amount to preclude ataxia, oversedation, confusion (no more than 2 capsules/day initially; increase gradually as needed and tolerated). Though generally not recommended, if combination therapy with other psychotropics seems indicated, carefully con· sider pharmacology of agents, particularly potentiating drugs such as MAO inhibitors, phenothiazines. Observe usual precautions in presence of impaired renal or hepatic function. Paradoxical reactions reported in psychiatric patients. Employ usual precautions in treating anxiety states with evidence of impending depres· sian; suicidal tendencies may be present and protective measures necessary. Variable effects on blood coagulation reported very rarely in patients receiving the drug and oral anticoagulants; causal relationship not established. Inform patients to consult physician before increasing dose or abruptly discontinuing this drug. Adverse Reactions: No side effects or manifestations not seen with either compound alone reported with Librax. When chlordiazepoxide HCI is used alone, drowsiness, ataxia, confusion may occur, especially in elderly and debilitated; avoidable in most cases by proper dosage adjustment, but also occasionally observed at lower dosage ranges. Syncope reported in a few instances. Also encountered: isolated instances of skin eruptions, edema, minor menstrual irregularities, nausea and constipation, extrapyramidal symptoms, increased and decreased libido-all infrequent, generally controlled with dosage reduction; changes in EEG patterns may appear during and after treatment; blood dyscrasias (including agranulocytosis),jaundice, hepatic dysfunction reported occasionally with chlordiazepoxide HCI, making periodic blood counts and liver function tests advisable during protracted therapy. Adverse effects reported with Librax typical of anticholinergic agents, i.e., dryness of mouth, blurring of vision, urinary hesitancy, constipation. Constipation has occurred most often when Librax therapy is combined with other spasmolytic& and/or low residue diets. Drug Abuse and Dependence: Withdrawal symptoms similar to those noted with barbiturates and alcohol have occurred following abrupt discontinuance of chlordiazepoxide; more severe seen after excessive doses over extended periods; milder after taking continuously at therapeutic levels for several months. After extended therapy, avoid abrupt discontinuation and taper dosage. Carefully supervise addiction-prone individuals because of predisposition to habituation and dependence. P.l. 0288
152
AIDS
-
Roche Products
Roche Products Inc. Manati, Puerto Rico 00701
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tients remains to be seen. Physicians can do their part by educating themselves about lDV infection so they can provide competent, nonjudgmental care to patients and by supporting
Refaatas 1. Estimares ofHIV prevalence and projecred AIDS cases: swnmai}' of a workshop, October 31-November I, 1989. MMWR 1990;39:110..9 2. Lui KJ, Darrow WW, Rutherford GW 3d. A
model-based esrimare of rhe mean inrubation period fOr AIDS in homosexual men. Science 1988;240 (4857):1333-5 3. Moss AR. Predicting who will progress ro AIDS. BMJ 1988;297(6656):1067-8 4. Updare: serologic resting fOr antibody ro human immunodeficiency virus. MMWR 1988;36(52): 833-40,845 5. LoB, Suinbrook RL, Cooke M, ct al. Volunrary screening fOr human immunodeficiency virus (HIV) infection: weighing rhe benefits and harms. Ann lnrem Med 1989;110(9):727-33 6. Imagawa DT, I..ce MH, ~ SM, ct al. Human immunodeficiency virus rype I infecrion in homosexual men who remain seronegative fOr prolonged periods. N Engl J Med 1989;320(22): 1458-62 7. Rinaldi RC. HIV blood resr cmrnseling: AMA physician guidelines. Chicago: American Medical Assn, 1988 8. Runddl JR, Hebert FE, Brown GR. Use of home tesr kits for HIV is bad medicine. (l.ener) JAMA 1989;262(17):2385-6 9. Amo PS, Sbemon D, Si
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Asymptomatic patients with HIV infection Geralyn M. Sarti MD To cite this article: Geralyn M. Sarti MD (1990) Asymptomatic patients with HIV infection, Postgraduate Medicine, 87:8, 143-154, DOI: 10.1080/00325481.1990.11704679 To link to this article: http://dx.doi.org/10.1080/00325481.1990.11704679
Published online: 17 May 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Monash University Library]
Date: 03 July 2016, At: 10:52
AsJinptomatic patients with HIV infection Keeping them well
Geralyn M. Sarti, MD
Downloaded by [Monash University Library] at 10:52 03 July 2016
Preview More than 1 million Americans may now be infected with the human immunodeficiency virus (HIV), which may not progress to acquired immunodeficiency syndrome (AIDS) for 10 years. Therefore, primary care physicians should be prepared to care for HIV-infectec:l patients in the early stages of their illness. In this article, Dr Sarti provides specific advice on counseling and managing these patients.
As the epidemic of acquired improlong life and prevent some munodeficiency syndrome (AIDS) complications from developing. continues, prima.ty care physicians will see more and more patients Testing for HN who are infected with human imThere are two commonly used munodeficiency virus (HIV). This serologic tests to measure antibody AIDS-causing virus infects and de- to HIY. An enzyme-linked imstroys T4 (helper) lymphocytes, munosorbent assay (ELISA) is first which play a central role in the im- used to test serum. Reactive sammune system. The spectrum of ples are retested (preferably on a HN infection ranges from an newly drawn blood sample), and if asymptomatic state in which the they are again reactive, results are immune system is relatively intact confirmed by Western blot assay to a state in which the immune (or an alternative confirmatory system is severely compromised, re- test). The specificity of the ELISA sulting in life-threatening opporand Western blot assay are 99.8% tunistic infections or malignancies. and 99.4%, respectively, in referThe term "AIDS" is used to deence laboratories with high perforscribe the more severe manifestamance standards.4 The accuracy of tions of this disease. Reported cases tests perfOrmed in nonreference (now more than 100,000) reprelaboratories may be much lower. sent only about 10% of the HNThis problem is compounded by infected patient population.' the fact that false-positive results The incubation period from on- are more common in persons who do not have high-risk behaviors. set of infection to development of Therefore, when nonreference labfull-blown AIDS is now believed to be 8 to 10 years. z.3 Many pa.oratories report positive results in patients with no high-risk behavtients present in the early stages of disease. Appropriate counseling and iors, physicians should recommend confirmation of those results by a medical management of asymptomatic patients may significantly reference laboratory.' VOL87/NO 8/JUNE 1990IPOSTGRADUATE MEDICINE • AIDS
Newer tests, such as HN p24 antigen assays and immunoassays using recombinant polypeptides, are being evaluated for use in clinical practice. Polymerase chain reaction techniques, radioimmunoprecipitation and radioimmunoabsorbent assays, and cultures for HN are also being performed at research centers. 5 These new tests have allowed isolation ofHN from asymptomatic patients before antibodies to the virus develop. A recent studf of HN-seronegative homosexual men involved in high-risk sexual activity showed that HN infection can occur as much as 35 months before antibodies to the virus can be detected. The degree of infectiousness during this period is unknown.
Counseling the HN-positive patient
Education and counseling of patients should begin before testing for HIY. Informed (preferably written) consent for testing should be obtained. The American Medical .Association has published physician guidelines for HN blood test counseling? Physicians who do not have enough time to properly counsel patients should refer them to a public health test site. WHEN RFSUITS ARE POSITIVE-
Patients should be notified of a positive HN test result in person rather than by phone or mail. They may react with disbelief, continued 143
Downloaded by [Monash University Library] at 10:52 03 July 2016
Patients should understand that a positive result on a test for HIV does not mean that they have AIDS.
anger, fear, anxiety, or guilt and may be distraught for weeks or months. Depression often occurs and suicidal ideation is frequent. Records of a group ofHIVseropositive patients revealed that one in five admitted to considering suicide as an option in the year following notification of test results. 8 The patient's support system should be assessed, and referral to community support groups and professional counselors should be offered. Patients should understand that a positive result on a test for HIV does not mean that they have AIDS. A person infected with HIV may remain free of clinical symptoms for many years. A cohort study of homosexual and bisexual HIV-seropositive men suggests that cumulative progression to AIDS increases from 15% to 39% to 54% among those infected for 5, 8, and 10 years, respectively. 9 Early intervention may alter the course of the disease. Asymptomatic patients should realize that close monitoring and medical intervention before the onset of symptoms may now make HN infection a relatively long-term disease--one that can be controlled despite lack of a cure. PREVENTION OF TRANSMISSION
-Infection with HIV is probably lifelong, and patients must avoid infecting others. HIV-seropositive persons must understand that the virus can be transmitted by intimate sexual contact, transfusion of 144
infected blood, and sharing of needles among intravenous drug users. They should refrain from donating blood, plasma, sperm, body organs, or other tissues. Safe-sex guidelines should be discussed in simple language. Safe sex is body massage, hugging, mutual masturbation, and closedmouth kissing. HIV-seropositive patients must protect their sexual partners from corning into contact with infected blood or bodily secretions. Although consistent use of latex condoms with spermicide containing nonoxynol-9 can decrease the chance ofHIV transmission, the rate of condom failure may be as high as 17%. 10 Patients should also be cautioned against having unsafe sex with other HIV-infected persons. New exposure to HIV may theoretically accelerate disease progression by an increase in viral load, infection with another HIV strain, or infection with other sexually transmitted diseases. Intravenous drug users should not share needles or syringes. Referral to a drug treatment center should be offered. Patients who refuse referral should be instructed to clean their needles or "works" by rinsing them twice with bleach and twice more with water after each use. Patients should not share rawrs, toothbrushes, tweezers, or other items that could be contaminated with blood. Sanitary napkins should be disposed of in a sealed
plastic bag. Accidental spills of blood or body fluids should be wiped up with gloved hands using a solution of 1 part household bleach to 10 parts water. HIV-ser?yositive patients should notify present and past sexual partners and needle sharers and encourage them to seek counseling and testing. Public health officials may be able to assist in alerting these people. Children under 10 years of age born to HIV-seropositive mothers should be referred for testing. Infected women of childbearing age should be advised that the virus can be passed to the child during pregnancy, birth, or lactation. About 20% to 50% of infants born to infected women are also infected. 11 The Centers for Disease Control has recommended that HIV-infected mothers not breastfeed their children. This recommendation does not apply to Third World countries, where breast milk is the principal source of nutrition for infants. Patients should be reassured that casual contact at school, work, or home does not transmit the virus. There is no evidence that the HIV virus is transmitted by food, fomites, swimming pools, insects, pets, tears, or saliva. Laundry not soiled with body fluids, eating utensils, and dishware can be cleaned as usual. HIV-seropositive patients should report their positive antibody status to all of their medical continued
AIDS • VOL 87/NO 8/JUNE 1990/POSTGRADUATE MEDICINE
There is no evidence that the HIV virus is transmitted by food, fomites, swimming pools, insects, pets, tears, or saliva.
Downloaded by [Monash University Library] at 10:52 03 July 2016
Basic health maintenance recommendations for HN-seropositive patients Asymptomatic patients infected with human immunodeficiency virus (HIV) should know how to maintain a healthy life-style and reduce the risk of acquiring an opponunistic infection. The following advice, along with information on safe sex and preventing transmission of infection, should be used in counseling. • Eat a balanced diet containing an adequate amount of protein and calories. The Task Force on Nutrition Suppon in AIDS 1 recommends that nontraditional dietary practices such as macrobiotic and fad diets, herbal powders, and vitamin megadosing be avoided. These praaices may prevent a balanced intake of nutrients, which may further compromise immune status. • Wash all fresh fruits and vegetables well. Cook meat well and avoid raw fish. Wash hands after contaa with raw meat. Consume only pasteurized dairy products. Concern about raw eggs contaminated with SalmoneUa enteriditis has prompted the Food and Drug Administration to recommend that raw or undercooked eggs be eliminated from the diets ofimmunocompromised persons. 2 Pasteurized eggs may be substituted for fresh eggs in recipes calling for raw or undercooked eggs, such as Caesar salad, eggnog, or ice cream. • Exercise regularly but avoid undue fatigue. A regular exercise program may help relieve depression and anxiety. • Try to get 8 hours of sleep each night. Shorr naps may be needed if fatigue is excessive. • Change life-style and modifY work schedules to reduce stress. Relaxation exercises, counseling, or panicipation in an HIV suppon group may be beneficial. • Do not smoke, consume alcohol, or use recreational drugs. These substances may have adverse effects on the immune system and may
VOL 87/NO 8/JUNE 1990IPOSTGRADUATE MEDICINE • AIDS
also impair judgment regarding sexual behavior. • Maintain good oral hygiene. Brush teeth regularly and floss at least once a day. Schedule regular dental checkups. • Exercise caution in pet care to avoid conuaaing infectious diseases from pets. Indoor cats pose little risk when fed only commercial cat food and not allowed raw meat or unpasteurized milk. Avoid cleaning cat liner boxes as well as fish tanks and bird cages. If no one else can do these tasks, wear gloves and wash hands thoroughly. Cat liner should be cleaned daily. Pets' nails should be kept trimmed to avoid scratches. Pet bites should be washed thoroughly and checked by a physician. Potential zoonoses that have been diagnosed in AIDS patients include toxoplasmosis, campylobaaeriosis, salmonellosis, ringworm, cryptosporidiosis, cat-scratch disease, mites, psittacosis, pasturellosis, and brucellosis.-1 It is unknown how frequently these diseases are transmitted from animals to humans. The possibility of contraaing toxoplasmosis is a concern of Toxoplasnurnegative patients. • Avoid recreational aaivities that increase risk of opportunistic infection.4 Desen camping may pose a risk of coccidioidomycosis and spelunking a risk of histoplasmosis. To decrease the risk of infections such as amebiasis, cryptosporidiosis, and giardiasis when camping, do not drink water that could be contaminated with sewage. Avoid walking barefoot, because soil in some areas may contain harmful organisms. Wear gloves when gardening. Rdaalces I. Task Fora: on Nuailion Support in AIDS. Guidelines for nurrition support in AIDS. Nurririon 1989;5( I ):39-46 2. Updare on S mtnitidis in shelled 400/ mm3) •3 Physicians may want to discuss early therapeutic intervention with these patients. BETA2 MICROGLOBUUN CON-
CENTRATION-The test for serum concentration ofbeta2 microglobulin, available for about $45, may be the best predictor of progression to AIDS. HN-seropositive patients with an elevated concentration (>3 mg/L) are at risk for progres*The Food and Drug Administration has approved a new enzyme immunoassay test for HN antigens to be marketed by Abbott Laboratories under the name HNAG-1 (cost $6.50). 32
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sion to AIDS despite relatively high T4lymphocyte counts. About 25% ofHN-seropositive men with beta2 rnicroglobulin concentrations of more than 3 mg!L progress to AIDS in 3 years despite T 4lymphocyte counts of 400/mm3 or more. 3 Physicians may want to discuss early intervention with these patients as well.
Therapeutic intervention The incidence of drug reactions in HN-infected patients is high. 33-35 Physicians should avoid the unnecessary use of medications, particularly antibiotics. However, the judicious use of vaccines to prevent infections is recommended. Zidovudine may delay the onset of full-blown AIDS. Regimens to prevent P carinii pneumonia may also be effective. VAOCINFS--Patients with HN infection have a component of humoral (B cell) immunodeficiency. An increased incidence of infections with encapsulated organisms such as Streptococcus pneumonia£ and Haemophilus influenzae have been reported in these patients.36 The pneumococcal polysaccharide vaccine (Pneumovax 23, Pnu-Imune 23) and the H influenzaetype b vaccine (Hib-Imune, b-Capsa I) should be given early in the course ofHN disease to maximize antibody response. Influenza virus vaccine (Fluogen, Fluwne) should be given each year, and pa-
tients who are not vaccinated should be offered amantadine hydrochloride (Symadine, Symrnetrel) when appropriate. Hepatitis B vaccine (Heptavax-B, Recombivax HB, Engerix-B) should be given if indicated. Children living in the household of an HN-infected person should not receive the oral (live) polio vaccine (Orimune). Inactivated polio vaccine should be given instead. ZIOOVUDINE-This agent is the only anti-HN drug approved by the Food and Drug Administra-. cion (FDA). Zidovudine does not cure HN infection, but it does block replication of the virus. Until recently, it had been officially approved for adults with symptomatic HN infection (ie, AIDS and advanced AIDS-related complex) who had a history of cytologically verified P carinii pneumonia or an absolute T 4lymphocyte count of fewer than 200/mm3• The recommended dosage was 200 mg every 4 hours around the dock. Early this year, the FDA cut the recommended dosage of zidovudine to 600 mglday after 1 month of treatment at the previously recommended dosage of 1,200 mglday. In early August 1989, researchers at the National Institute of Allergy and Infectious Disease announced that zidovudine delayed the onset ofAIDS in patients with early symptoms of the disease.37 A placebo-controlled multicenter
AIDS • VOL 87/NO 8/JUNE 1990/POSTGRADUATE MEDICINE
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Active pulmonary disease must be excluded in HIV-positive patients before prophylaxis for P carinii pneumonia is begun.
study included 713 HN-infected patients with T 4 lymphocyte counts over 200/mm3 and one or two HN-related symptoms. Significantly fewer patients receiving zidovudine progressed to AIDS or advanced AIDS-related complex compared with those receiving placebo. Two weeks after their first announcement, researchers at the same institution announced that zidovudine could delay the onset of disease in asymptomatic HNinfected patients.28 Their multicenter drug trial tested two regimens of zidovudine in 3,200 HN-infected patients. The study compared dosages of1,500 and 500 m'{/day with placebo in asymptomatic patients with T 4 lymphocyte counts of 200 to 800/mm3• Researchers found that those patients with T 4 lymphocyte counts of 200 to 500/mm3 who were taking 500 m'{/day of zidovudine were half as likely to manifest AIDS symptoms as patients taking placebo. With the exception of nausea (which occurred in about 3% of participants taking zidovudine), no difference in side effects was observed between the 500-m'{/day zidovudine dosage and placebo. Whether zidovudine should be used in asymptomatic patients with T 4 counts of more than 500/mm3 remains to be seen. The trial is continuing with 1,900 asymptomatic
patients who have T 4lymphocyte counts of more than 500/mm3 receiving the drug. Physicians should consider starting zidovudine therapy at a dosage of500 m'{/day (in 100-rng doses every 4 waking hours) in asymptomatic HN-infected patients with T4lymphocyte counts ofless than 500/mm3• The annual cost of this treatment at current prices will be about $2,700. The FDA recently approved new labeling for zidovudine to include patients with T 4 lymphocyte counts ofless than 500/mm3• A recent studf' has shown that some strains ofHN may be developing a resistance to zidovudine. The appearance of these resistant strains in serum has not coincided with any deterioration in clinical status of the patient. The implications of these resistant strains of HN remain unclear. PROPHYlAXIS FOR P CARINli
PNEUMONIA:-P carinii pneumo-
has recommended that this group of patients receive primary prophylaxis fOr P carinii pneumonia.31 Prophylaxis should be given even if the patient is receiving zidovudine. Tests that show low T4lymphocyte counts or low percentages of total lymphocytes should be repeated befOre beginning prophylaxis, unless the test result is consistent with an established trend. Active pulmonary disease must be excluded before prophylaxis is be-
gun. Two regimens have been recommended for primary prophylaxis of P carinii pneumonia: • Oral trimethoprim-sulfamethoxazole (160 rng trimethoprim and 800 rng sulfamethoxazole) may be given twice daily; along with leucovorin calcium (Wellcovorin), 5 mg once daily. This form of prophylaxis should not be given to patients allergic to sulfonarnides or trimethoprim. • Aerosolized pentamidine isethionate (Pentarn 300, NebuPent) delivered via a Respirgard II nebulizer* may be given in a dose of 300 rng every 4 weeks. The dose of pentamidine is diluted with 6 mL of sterile water and administered at 6 Ll minute from a 50-psi compressed air source. Patients in
nia is the initial opportunistic infection in about 62% ofHNinfected patients.39 It develops in another 20% ofAIDS patients at some point in the course of their illness.40 Patients who have baseline T 4 lymphocyte counts of fewer than continued 200/mm3 or less than 20% of total lymphocytes have been found to have a high frequency of subse*Available from Marquest Medical Prodquent Pneumocystis infections. 19'2930 ucts, Inc, 11039 E lansing Circle, Englewood, CO 80112. The Centers for Disease Control
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Specey Adjunctive
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UIIUX®
whom cough or wheezing develops while they are receiving aerosolized pentamidine should be treated with a bronchodilator before subsequent doses. Patients with severe asthma may not tolerate this form of therapy. Aerosolized pentamidine should not be given to patients who have a history of lifethreatening reactions to parenteral pentamidine.
Each capsule contains 5 mg chlordiazepoxide HCI and 2.5 mg clidinium bromide.
Please consult complete prescn"blng lnfonnation, a summary of which follows:
*
Summary
Primary care physicians need to be prepared to counsel and manage patients with human immunodeficiency virus (HIV) infection. Asymptomatic seropositive patients should be seen quarterly, and T4lymphocyte counts should be followed. Other serologic markers that may detect disease progression are p24 antigen and~ microglobulin. Abnormalities in the levels of these markers may influence the decision to initiate early antirettoviral therapy. Therapeutic regimens are now available for delaying progression ofHN disease and for preventing Pneumocystis carinii pneumonia, the most common opportunistic infection to develop in patients with HN infection. Whether antiretroviral therapy should be initiated in all asymptomatic HN-positive pacontinued
Indications: Based on a review of this drug by the National Academy of Sciences-National Research Council and/or other infonnation, FDA has classified the indications as follows: "Possibly'' effective: as adjunctive therapy in the treatment of peptic ulcer and in the treatment of the irritable bowel syndrome {irritable colon, spastic colon, mucous colitis) and acute enterocolitis. Final classification of the less-than-effective indications requires further investigation.
Contraindication&: Glaucoma; prostatic hypertrophy, benign bladder neck obstruction; hypersensitivity to chlordiazepoxide HCI and/or clidinium Br. Warnings: Caution patients about possible combined effects with alcohol and other CNS depressants, and against hazardous occupations requiring complete mental alertness (e.g., operating machinery. driving). USDII" in Pregnancy: Use of minor tranquilizers during first trimester should almost always be avoided because of increased risk of congenital malfonnations as suggested in several studies. Consider possibility of pregnancy when instituting therapy. Advise patients to discuss therapy if they intend to or do become pregnant. As with all anticholinergics, inhibition of lactation may occur. Withdrawal sYffiptoms of the barbiturate type have occurred after discontinuation ofbenzodiazepines (see Drug Abuse and Dependence). Precautions: In elderly and debilitated, limit dosage to smallest effective amount to preclude ataxia, oversedation, confusion (no more than 2 capsules/day initially; increase gradually as needed and tolerated). Though generally not recommended, if combination therapy with other psychotropics seems indicated, carefully con· sider pharmacology of agents, particularly potentiating drugs such as MAO inhibitors, phenothiazines. Observe usual precautions in presence of impaired renal or hepatic function. Paradoxical reactions reported in psychiatric patients. Employ usual precautions in treating anxiety states with evidence of impending depres· sian; suicidal tendencies may be present and protective measures necessary. Variable effects on blood coagulation reported very rarely in patients receiving the drug and oral anticoagulants; causal relationship not established. Inform patients to consult physician before increasing dose or abruptly discontinuing this drug. Adverse Reactions: No side effects or manifestations not seen with either compound alone reported with Librax. When chlordiazepoxide HCI is used alone, drowsiness, ataxia, confusion may occur, especially in elderly and debilitated; avoidable in most cases by proper dosage adjustment, but also occasionally observed at lower dosage ranges. Syncope reported in a few instances. Also encountered: isolated instances of skin eruptions, edema, minor menstrual irregularities, nausea and constipation, extrapyramidal symptoms, increased and decreased libido-all infrequent, generally controlled with dosage reduction; changes in EEG patterns may appear during and after treatment; blood dyscrasias (including agranulocytosis),jaundice, hepatic dysfunction reported occasionally with chlordiazepoxide HCI, making periodic blood counts and liver function tests advisable during protracted therapy. Adverse effects reported with Librax typical of anticholinergic agents, i.e., dryness of mouth, blurring of vision, urinary hesitancy, constipation. Constipation has occurred most often when Librax therapy is combined with other spasmolytic& and/or low residue diets. Drug Abuse and Dependence: Withdrawal symptoms similar to those noted with barbiturates and alcohol have occurred following abrupt discontinuance of chlordiazepoxide; more severe seen after excessive doses over extended periods; milder after taking continuously at therapeutic levels for several months. After extended therapy, avoid abrupt discontinuation and taper dosage. Carefully supervise addiction-prone individuals because of predisposition to habituation and dependence. P.l. 0288
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AIDS
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Roche Products
Roche Products Inc. Manati, Puerto Rico 00701
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tients remains to be seen. Physicians can do their part by educating themselves about lDV infection so they can provide competent, nonjudgmental care to patients and by supporting
Refaatas 1. Estimares ofHIV prevalence and projecred AIDS cases: swnmai}' of a workshop, October 31-November I, 1989. MMWR 1990;39:110..9 2. Lui KJ, Darrow WW, Rutherford GW 3d. A
model-based esrimare of rhe mean inrubation period fOr AIDS in homosexual men. Science 1988;240 (4857):1333-5 3. Moss AR. Predicting who will progress ro AIDS. BMJ 1988;297(6656):1067-8 4. Updare: serologic resting fOr antibody ro human immunodeficiency virus. MMWR 1988;36(52): 833-40,845 5. LoB, Suinbrook RL, Cooke M, ct al. Volunrary screening fOr human immunodeficiency virus (HIV) infection: weighing rhe benefits and harms. Ann lnrem Med 1989;110(9):727-33 6. Imagawa DT, I..ce MH, ~ SM, ct al. Human immunodeficiency virus rype I infecrion in homosexual men who remain seronegative fOr prolonged periods. N Engl J Med 1989;320(22): 1458-62 7. Rinaldi RC. HIV blood resr cmrnseling: AMA physician guidelines. Chicago: American Medical Assn, 1988 8. Runddl JR, Hebert FE, Brown GR. Use of home tesr kits for HIV is bad medicine. (l.ener) JAMA 1989;262(17):2385-6 9. Amo PS, Sbemon D, Si
