David H. Spach, MD The International AIDS Society–USA Initial Evaluation and Common Clinical...
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David H. Spach, MD
The International AIDS Society–USA
Initial Evaluation and Common Clinical Manifestations
DH Spach, MD.Presented at IAS–USA/RWCA Clinical Conference, August 2004.
Slide #2
DH Spach, MD. Presented at IAS–USA/RWCA Clinical Conference, August 2004.
Recommended Routine Serologic Tests
Toxoplasmosis
Syphilis
Hepatitis A Virus
Hepatitis B Virus
Hepatitis C Virus
Cytomegalovirus
DHS/HIV//PP
Anti-Toxoplasma IgG
VDRL or RPR
HAV total antibody
Anti-HBc, HBsAb
Anti-HCV IgG
*Anti-CMV IgG
Disease Test
*Only in persons with relatively low risk
Slide #3
DH Spach, MD. Presented at IAS–USA/RWCA Clinical Conference, August 2004.
Acquisition of Toxoplasma gondii
DHS/HIV/PP
Cat Feces
Undercooked Red Meat
Slide #4
DH Spach, MD. Presented at IAS–USA/RWCA Clinical Conference, August 2004.
ACIP: Recommended Vaccinations
Influenza Vaccine
Pneumococcal
Hepatitis A Vaccine
Hepatitis B Vaccine
Tetanus-Diphtheria
DHS/HIV/PP
Yearly
*Once & Repeat after 5 Years
0 & 6-12 months
0, 1, 6 months
Every 10 Years
Vaccine Schedule
*Optimal to vaccinate when CD4 counts highest
From: ACIP. MMW 2002;51 (40):904-8.
Slide #5
DH Spach, MD. Presented at IAS–USA/RWCA Clinical Conference, August 2004.
Pneumococcal Disease in HIV-Infected PersonsSummary of Data
Pneumonia: 10-fold increase in HIV-infected persons
Bacteremia: 50-100 fold increase in HIV-infected persons
Mortality: no evidence for increase in HIV-infected persons
CD4 Count: risk greatest with CD4 count less than 200 cells/mm3
Antimicrobial Prophylaxis: risk decreased with TMP-SMX or Azithromycin
DHS/HIV/PPFrom: Feikin DR et al. Lancet ID 2004;187:44-55.
Slide #6
DH Spach, MD. Presented at IAS–USA/RWCA Clinical Conference, August 2004.
Vaccines Related to TravelAdvice for HIV-Infected Persons
Centers for Disease Control and Prevention. General Information Regarding HIV and Travel.
www.cdc.gov/travel/hivtrav.htm
DHS/HIV/PP
Slide #7
DH Spach, MD. Presented at IAS–USA/RWCA Clinical Conference, August 2004.
Vaccinations in HIV-Infected AdultsKey Points
Give as early as possible (high CD4 count)
No significant impact on CD4 count or HIV RNA levels
Avoid most live vaccines
Get expert advice regarding travel-related vaccines
DHS/HIV/PP
Slide #8
DH Spach, MD. Presented at IAS–USA/RWCA Clinical Conference, August 2004.DHS/HIV/PP
Oral CandidiasisClinical Types
Erythematous Pseudomembranous Angular Cheilitis
Slide #9
DH Spach, MD. Presented at IAS–USA/RWCA Clinical Conference, August 2004.
Oropharyngeal CandidiasisTreatment Options
Topical Therapy- Clotrimazole troches: 10 mg 5x/d x 7-10d- Nystatin pastilles: 1-2 pastilles 5x/d x 7-10d
Systemic Therapy (Oral)- Fluconazole: 100 mg qd x 7-10d- Itraconazole solution: 200 mg qd x 7-10d- Ketoconazole: 200 mg qd x 7-10d
DHS/HIV/PP
Slide #10
DH Spach, MD. Presented at IAS–USA/RWCA Clinical Conference, August 2004.
Oropharyngeal CandidiasisSuggested Guidelines for Therapy
Indications for Topical Agents- No esophageal involvement- CD4 count greater than 50 cells/mm3
- Receiving or expect to receive HAART
Indications for Systemic Agents- Esophageal involvement- CD4 count less than 50 cells/mm3
- NOT receiving or expecting to receive HAART
Chronic Suppressive Therapy - NOT recommended
DHS/HIV/PPFrom: Powderly WG et al. AIDS Research & Human Retroviruses. 1999;15:1619-23.
Slide #11
DH Spach, MD. Presented at IAS–USA/RWCA Clinical Conference, August 2004.
Fluconazole-Resistant Oropharyngeal CandidiasisTreatment Options
Topical Therapy- Amphotericin B solution: 5 ml (100 mg/ml) qid x 7-10d
Systemic Therapy- Amphotericin B: 0.3 mg/kg IV qd x 7-10d- Caspofungin: 50 mg/kg* IV qd x 7-10d- Itraconazole solution: 100 mg bid x 7-10d - Fluconazole: 800 mg PO/IV qd x 7-10d- Voriconazole: 200 mg PO/IV bid x 7-10d
DHS/HIV/PP
* Use 70 mg/kg IV qd for the first dose
Slide #12
DH Spach, MD. Presented at IAS–USA/RWCA Clinical Conference, August 2004.DHS/ HIV/PP
Aphthous LesionsClinical Types
Minor (Lip) Minor (Tongue) Major
Slide #13
DH Spach, MD. Presented at IAS–USA/RWCA Clinical Conference, August 2004.
Oral Aphthous LesionsTreatment Options
Topical Therapy- Topical Corticosteroids
Intralesional - Triamcinolone: 40 mg /ml (0.5 ml-1.0 ml injected bid)
Systemic Therapy- Prednisone: 0.5-1.0 mg/kg qd x 7-10d, then taper- Thalidomide: 200 mg PO qd
DHS/HIV/PP
Slide #14
DH Spach, MD. Presented at IAS–USA/RWCA Clinical Conference, August 2004.DHS/HIV/PP
Herpes Simplex Virus InfectionChronic Ulcerative Lesions Types
Ear Face Scrotum
Slide #15
DH Spach, MD. Presented at IAS–USA/RWCA Clinical Conference, August 2004.
Cutaneous HSV InfectionsTreatment Options
Recurrent HSV- Acyclovir: 400 mg PO tid x 5-10d*- Valacyclovir: 500 mg PO bid x 5-10d*- Famciclovir: 500 mg PO bid x 5-10d*
Suppressive Therapy- Acyclovir: 400-800 mg PO bid- Valacyclovir: 500 mg PO bid- Famciclovir: 250-500 mg PO bid
DHS/HIV/PP
*Longer courses typically needed for chronic ulcerative herpes simplex