Updated HRSA Guide for HIV/AIDS Clinical Care/Comorbidities now Available Online - see excerpted highlights on comorbidities below
Link to Guide:|
ROCKVILLE, Md., June 6, 2011 /PRNewswire-USNewswire/ -- The Guide for HIV/AIDS Clinical Care, a comprehensive roadmap for physicians, nurse-practitioners, dentists and other clinicians on how best to manage the long-term care of patients with HIV/AIDS, is now available online.
Produced by the Health Resources and Services Administration (HRSA), the updated volume covers more than 90 topics and provides guidance on a broad range of clinical care issues, including testing and assessment, health care maintenance and disease prevention, oral health, antiretroviral medications, and more.
"Providing care and treatment to people living with HIV/AIDS is a key goal for our agency," said HRSA Administrator Mary Wakefield, Ph.D., R.N. "The Guide for HIV/AIDS Clinical Care is precisely the kind of information that we strive to disseminate as widely as possible, so that we can share our expertise, stimulate ideas and encourage best practices for those working with this community."
Among the major trends identified in the guide:
· Many patients continue to be identified when they are in the "late stages" of the disease and have developed other health problems, making their care and treatment more complex, especially as they live longer;
· Expansion of routine HIV screening in primary care offices and clinics means more patients are being identified by clinicians who have limited experience with the disease;
· Shortages in the health care workforce - particularly in rural areas - and the retirements of senior clinicians equates to fewer "front line providers" who know how to manage the long-term needs of those living with the virus.
"Positive change on such a massive scale over the last 30 years - including significantly extended life expectancy, thanks to advances in anti-retroviral medication - brings with it new demands on clinicians. Given the long-term implications for those living with the virus there is no better time for a comprehensive guide book to provide easy access to crucial facts for a busy clinician," said Dr. Laura Cheever, deputy associate administrator for HRSA's HIV/AIDS Bureau.
The guidelines, originally published in 1993 and last updated in 2006, are meant to be simple and comprehensive, so that clinicians who do not treat people with HIV on a regular basis can become familiar with the management and complications of the disease.
The guidelines are broader and more basic than the Department of Health and Human Services (DHHS) treatment guidelines, although HRSA used the DHHS guides in creating the Guide for HIV/AIDS Clinical Care.
The guide notes that as HIV specialists become scarcer and care transitions to primary care physicians, the need for such guidelines will become greater (see related AIDS Beacon news).
The guidelines are organized into ten sections:
* The HIV Clinic: Providing Quality Care, which discusses topics such as clinic management, HRSA performance measures for HIV and AIDS care, and caring for patients who are incarcerated or are from racial or sexual minorities
* Testing and Assessment, which covers taking patient histories, initial physical exams, indications of when patients should start antiretroviral therapy, and common tests such as resistance testing, viral load (amount of HIV in the blood) testing, and CD4 (white blood cell) counts
* Health Care Maintenance and Disease Progression, which includes preventing opportunistic infections (infections that occur in people with compromised immune systems) and preventing HIV transmission
* HIV Treatment, which covers antiretroviral therapy as well as treating women, including pregnant women
* Common Complaints, includes common problems, infections, and side effects experienced by people with HIV, how they are diagnosed, and how they should be treated
* Comorbidities, Coinfections, and Complications, which includes additional information on lipodystrophy (abnormal fat redistribution that is a common side effect of certain antiretrovirals), heart disease, and several common coinfections like herpes and hepatitis
* Antiretroviral Interactions and Adverse Events, which is on side effects and common drug-drug interactions for antiretrovirals, including interactions with birth control pills and other hormonal contraceptives
* Neuropsychiatric Disorders, which discusses common psychiatric problems and disorders in people with HIV, including dementia, depression, insomnia, and post-traumatic stress disorder
* Oral Health, includes diagnosing and treating common oral complaints and problems in people with HIV
* Resources and References, which covers additional online sources of information about HIV and AIDS for patients and clinicians, information on antiretrovirals available in the United States and Mexico, and further discussion of appropriate antiretroviral regimens.
The guidelines are online, and free paper copies can also be requested.
For more information on the Guide for HIV/AIDS Clinical Care, visit: http://hab.hrsa.gov/deliverhivaidscare/clinicalguide11/
Excerpts of Particular Interest on Comorbidities:
Liver disease owing to hepatitis C virus (HCV) infection has become a leading cause of death among HIV-infected patients. Patients with HCV infection, whether acute or chronic, often have no symptoms, and the infection is discovered via screening tests or on workup of an abnormal liver test result.. More than 20% of HIV/HCV-coinfected patients are thought to develop cirrhosis, and at a faster rate. Once patients have developed cirrhosis, approximately 50% will decompensate within the first 5 years. The median survival time from the onset of HCC is approximately 5 months and, the 1-year survival rate is 29%.
HIV-Associated Dementia and Other Neurocognitive Disorders:
HIV is a neurotropic virus that directly invades the brain shortly after infection. HIV replicates in brain macrophages and microglia, causing inflammatory and neurotoxic host responses. HIV may cause cognitive, behavioral, and motor difficulties. These difficulties may range in severity from very mild to severe and disabling; if moderate or severe, they constitute minor cognitive motor disorder (MCMD) or HIV-associated dementia (HAD), respectively. These conditions are distinguished from the milder cognitive changes seen in some people with HIV infection by the greater impact and duration of the functional deficits. MCMD is thought to involve neuronal cell dysfunction, whereas HAD often involves actual cell death. A note on nomenclature: There have been multiple shifts in the nomenclature used to describe HIV-associated neurocognitive disorders. The most recent proposed system, published in the journal Neurology in 2007, suggests three categories: asymptomatic neurocognitive impairment (ANI), mild neurocognitive disorder (MND), and HAD. However, the diagnoses of ANI and MND require neuropsychological testing that is more likely to be available in research settings as opposed to clinical settings. This chapter will therefore address the clinical diagnoses of MCMD and HAD. The use of effective antiretroviral therapy (ART) that maintains the plasma HIV RNA at undetectable or low values is the best way to prevent and treat HIV-related neurocognitive disorders. Thus, it is essential to choose an ART regimen that takes into consideration resistance testing and adherence issues.
Minor Cognitive Motor Disorder
MCMD is characterized by mild impairment in functioning and may escape diagnosis by the clinician. The course and onset of MCMD can vary dramatically. The more demanding the activities of a particular individual, the more likely that person would be to notice the difficulties. MCMD does not necessarily progress to dementia.
HAD is characterized by symptoms of cognitive, motor, and behavioral disturbances. There is often a progressive slowing of cognitive functions, including concentration and attention, memory, new learning, sequencing and problem solving, and executive control. HAD also can present with behavioral changes, which mainly take the form of apathy, loss of motivation, poor energy, fatigue, and social withdrawal. Motor changes, including slowing, clumsiness, unsteadiness, increased tendon reflexes, and deterioration of handwriting may occur.
Anxiety symptoms are common and can develop or recur for many reasons, including a patient's worries about HIV infection and treatment, or issues unrelated to HIV. Symptoms can range from mild distress to full- blown anxiety disorders. Symptoms of anxiety can mimic symptoms of physical illness, and an appropriate workup should be performed to rule out other illnesses. Use of illicit drugs (e.g., amphetamines, cocaine) or alcohol can cause or substantially worsen anxiety symptoms; all patients should be screened for substance use. Anxiety disorders include generalized anxiety disorder, obsessive-compulsive disorder, specific phobia, social phobia, acute stress disorder, posttraumatic stress disorder (PTSD), and panic disorder. This chapter focuses primarily on anxiety symptoms and generalized anxiety disorder. See chapters Panic Disorder and Posttraumatic Stress Disorder for further information about these conditions.
The criteria for a diagnosis of generalized anxiety disorder include unrealistic or excessive worry about two or more life circumstances for >6 months, and at least three of the following subjective complaints:
· Restlessness or feeling keyed-up or on edge
· Difficulty concentrating or mind going blank
· Muscle tension
· Being easily fatigued
· Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep) Other subjective complaints may include the following:
· Shortness of breath or smothering sensations
· Palpitations or accelerated heart rate
· Dizziness or lightheadedness
· Exaggerated startle response
· Trembling, twitching, or feeling shaky
· Dry mouth · Flushes or chills · Frequent urination · Muscle aches or soreness · Nausea, diarrhea, or other abdominal distress · Skin rashes · Sweating or cold, clammy hands · Trouble swallowing or "lump in the throat" Ask about the symptoms indicated above, and about the following:
· Anxiety patterns (e.g., constant or intermittent; timing, duration, precipitants) · Onset: sudden or gradual
· Caffeine intake
· Recreational drug or alcohol use (current or recent)
· Concomitant illnesses (e.g., cardiac, pulmonary, endocrine)
· Family history of similar problems
· Medications, supplements, and herbal preparations
· History of previous episodes
Panic disorder is an anxiety disorder whose essential feature is the presence of recurrent, unexpected panic attacks. Panic attacks are discrete, sudden-onset episodes of intense fear or apprehension accompanied by specific somatic or psychiatric symptoms (e.g., palpitations, shortness of breath, fear of losing control). A patient is diagnosed as having panic disorder when he or she has experienced such attacks, and at least one of the attacks has been followed by ≥1 month of persistent concern about additional attacks, worry about the implications or consequences of the attack, or a significant change in behavior related to the attack.
Insomnia is a common accompaniment to HIV infection, especially as the disease progresses and complications worsen. Once present, insomnia tends to be chronic, unlike the transient disturbances of sleep that are a normal part of life. Most insomnia related to HIV can be characterized by the amount, quality, or timing of sleep. Insomnia may cause progressive fatigue and diminished functioning.
Treatments for lipohypertrophy and lipoatrophy have not reliably reversed body shape changes once these changes have occurred. In general, treatment interventions have shown poor results in patients with marked or severe fat maldistribution and inconsistent or limited responses in those with milder conditions. The best approaches to managing lipodystrophy are prevention and early intervention.
A number of studies suggest that inflammation and immune activation owing to uncontrolled HIV infection also likely contribute to atherosclerosis
Renal disease in HIV-infected individuals can occur as a primary disease, as a secondary disease in the setting of other systemic illness, or as an adverse effect of medications. In the United States, the most common causes of end-stage renal disease in the general population are diabetes mellitus and hypertension. HIV-infected patients are at a fourfold higher risk of developing diabetes mellitus and a threefold higher risk of developing hypertension compared with seronegative individuals. Chronic hepatitis C, seen in 30-40% of HIV-infected individuals in the United States, is associated with several types of chronic kidney disease, including progressive secondary glomerulonephropathy, membranoproliferative glomerulonephropathy, and mixed cryoglobulinemia.
Proteinuria can be present in patients with primary renal disease, and also in those with hypertension, diabetes mellitus, vascular disease, collagen vascular disease, malignancy, or certain infections. Proteinuria is not always pathologic and may be caused by transient conditions such as pregnancy, strenuous exercise, fever, seizure, or congestive heart failure; in some cases, it may be benign. However, proteinuria should be evaluated if it persists. Patients with proteinuria will benefit from angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs).
In HIV-infected men and women, the incidence of anal cancer and the prevalence of its precursors are significantly higher than in the general population. Rates of anal cancer also are higher among men who have sex with men (MSM), whether HIV infected or uninfected, compared with the general population. Although most studies have examined anal dysplasia and cancer among MSM, the prevalence of anal intraepithelial neoplasia (AIN), a precursor to anal cancer, also is high among HIV-infected women.
Peripheral neuropathy is clinically present in approximately 30% of HIV-infected individuals and typically presents as distal sensory polyneuropathy (DSP). It may be related to HIV itself (especially at CD4 counts of <200 cells/μL), to medication toxicity (e.g., from certain nucleoside analogues such as stavudine or didanosine), or to the effects of chronic illnesses (e.g., diabetes mellitus). Patients with peripheral neuropathy may complain of numbness or burning, a pins-and-needles sensation, shooting or lancinating pain, and a sensation that their shoes are too tight or their feet are swollen. These symptoms typically begin in the feet and progress upward; the hands may be affected. Patients may develop difficulty walking because of discomfort, or because they have difficulty feeling their feet on the ground