Diagnosis & Management:

• Introduction

• Contents

• Disclaimer
  Please read before using the guidelines

• Clinical assessment guidelines

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HIV information contents

HIV: Essential facts

HIV: More details

HIV: Management guidelines

Case definitions of AIDS-defining illnesses

Statistics

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HIV infection

• Risk assessment

• Diagnosis

• Management

• Patient education

• Follow-up

• Post-exposure prophylaxis

Risk assessment 

Patients presenting for HIV serology should  be assessed by a medical officer for STD and HIV risk, which requires taking a detailed sexual and blood exposure history. In addition to routine risk assessment (see Chapter 1), it is useful to determine if the patient has had a previous HIV test, and ask why the patient believes they need a test. Infection with an STD at the time of exposure increases the risk of HIV acquisition.

Therefore, all patients who are at risk of HIV should be advised of the risk of other STDs and be offered testing.

Clinical presentation

 Clinical presentations of HIV vary depending on the stage of infection, which includes the following.

Acute infection (seroconversion)

50-70% of patients experience a mononucleosis-like illness including  fever, lethargy, myalgia, arthralgia, headache, maculopapular rash, lymphadenopathy, splenomegaly  3-6 weeks after infection.

Asymptomatic infection

Following seroconversion patients may remain asymptomatic for many years.

Symptomatic infection

Persistent generalised lymphadenopathy (nodes ³ 1 cm diameter, at 2 extrainguinal sites for 3 months) occurs commonly but is not of prognostic significance.

The degree of immune suppression ( measured as the CD4 cell count) predisposes to the development of certain illnesses.

Diagnosis

Pre test counselling should be performed and informed consent obtained prior to testing.  HIV testing is performed by a screening ELISA which detects both HIV p24 antigen and HIV antibodies.  A positive screening ELISA is confirmed on a Western Blot assay  If the Western Blot is negative, the ELISA result is considered to be a false positive, indicating the patient is not infected with HIV. Repeat testing is only indicated if the patient has been at risk in the three month period prior to the test.

If the Western Blot yields an indeterminate result, the patient may have been recently infected with HIV and may be in the process of seroconverting.  HIV  screening ELISA testing should be repeated at 2 weekly intervals to determine whether the Western Blot assay becomes positive .

If the Western Blot is positive, a report is returned with a “confirmed positive” statement.  These patients require specific post test counselling and appropriate medical assessment. Further  assessment should be conducted at 3-6 monthly intervals.

The  following table outlines the clinical features of the above infections   

The case definition of AIDS-defining illnesses used in Australia and the United States is shown in Appendix 3.

Management

 Medical history 

At the first appointment after diagnosis complete assessment includes a full medical and sexual history, including current state of health and systems review.

Examination

A complete medical examination  including:

• the patient’s weight and vital signs

• lymphadenopathy: cervical, axillary and inguinal

• skin lesions or rashes

• oral lesions

• hepatosplenomegaly

• genital, including anorectal, lesions

• any neurologic abnormalities

• inspection of fundi (in patients with CD4 < 50/mL review by an ophthalmologist should be performed 3 to 6 monthly)

 Investigations

The following investigations are conducted:

 at first visit  after diagnosis

• repeat HIV ELISA  for confirmation

• HIV viral load

• liver function tests (LFTs), electrolytes, renal function tests

• amylase, CK

• full blood examination (FBE)

• CD4, CD8 lymphocyte markers

• serologic tests for syphilis

• Hepatitis A serology

• Hepatitis B serology

• Hepatitis C serology

• HSV type 2, EBV, CMV, toxoplasmosis serology

• G6PD in case future use of sulphonamides is required.

 Subsequent routine 3-6 monthly follow up 

• FBE, CD4/CD8 lymphocyte surface markers, HIV viral load, LFTs, electrolytes, renal function tests. 

• amylase, CK, lipase,to check for medication side effects if on HAART

• when the CD4 count falls below 100, regular screening for MAC should be performed (Mycolytic F)

• Pap smear should be performed 6-12 monthly, more frequently as CD4 count declines 

• STD check should be included if relevant symptoms exist or if exposure has occurred.

Antiretroviral therapy

Combination antiretroviral therapy has been demonstrated to significantly increase life expectancy and delay the progression to AIDS in individuals with a CD4 cell count below 500/mL. As yet, there are no published data on the effect of combination therapy in individuals with early infection and a normal CD4 cell count.  

Patients are usually prescribed a minimum of three drugs to include drugs from at least two of the following categories.

Treatment recommendations are constantly changing and a detailed description of specific treatment of HIV infection is beyond the scope of these guidelines . Antiretroviral therapy should only be initiated by practitioners experienced in their use.

Currently, the main antiretroviral agents for the management of HIV infection in Australia include:

Nucleoside analogue reverse transcriptase inhibitors 

• abacavir (Ziagen)

• didanosine (ddI, dideoxyinosine, Videx)

• didanosine enteric coated (ddI EC, dideoxyinosine EC, Videx EC)

• lamivudine (3TC;)

• stavudine (d4T, Zerit)

• zalcitabine (ddC, dideoxycytidine, Hivid)

• zidovudine (ZDV, AZT, Retrovir;)

• combine formulations

• abacavir, lamivudine, zidovudine (Tizivir) 

• lamivudine, zidovudine (Combivir)

Nucleotide analogue reverse transcriptase inhibitors

• tenofivir (Viread)

 Non-nucleoside analogue reverse transcriptase inhibitors

• delavirdine (Rescriptor)

• efavirenz (Stocrin)

• nevirapine (Viramune)

 Protease inhibitors

• atazanavir (Reyataz)

• indinavir (Crixivan)

• lopinavir (combined formulation with ritonavir, Kaletra)

• Fosamprenavir (Telzir)

• nelfinavir (Viracept)

• ritonavir (Norvir)

• saquinavir (Invirase – hard-gel capsule, Fortovase – soft gel capsule)

 Fusion inhibitors

• enfurvirtide (Fuzeon)

Management of Opportunistic Infections 

(less likely to occur because of the efficacy of antiretroviral and preventive therapy)

 Prophylactic therapy against opportunistic infections

Primary prophylaxis is given in order to prevent opportunistic infection in an immunosuppressed patient.

• Trimethoprim-sulfamethoxazole (TMP-SMX, co-trimoxazole) is usually commenced when the CD4 count falls below 200/mL or 20% as prophylaxis against Pneumocystis  jirovecipneumonia.

• Valaciclovir is given to immunosuppressed patients with a history of anogenital HSV infection.

Secondary prophylaxis is prescribed after an infection has been successfully treated to prevent relapse.

 Patient education 

Patient education is complex and best performed slowly in stages using a range of resources.  Some important considerations include the following:

• interpretation of a positive result

• nature of HIV and treatment options

• method of transmission

• need for ongoing medical and psychological care

• availability of psychological and social support services and groups

• NOT to donate blood, semen or other body tissues or organs

• to use safe sexual practices, ie body fluids should not be exchanged

• notify all  health workers dealing with the patient’s ongoing care 

• the patient should not receive any vaccinations without prior discussion with the medical officer involved in the ongoing HIV management.

The patient should be assured of confidentiality at all times.

As with all STD matters, no information regarding any patient is to be divulged to anyone without the patient’s written consent. 

Contact tracing

Contact tracing is required and the patient may be referred to Clinic 275 for this purpose.

Follow-up

The frequency of follow-up visits depends upon the duration of infection and state of disease.

The asymptomatic patient with normal CD4 cell count can be seen for assessment and investigations 3-6 monthly.

Patients on therapy should be assessed 2-3 monthly.

Patients with AIDS need close medical surveillance by their general practitioner in conjunction with the consultant staff of an infectious diseases department at Royal Adelaide Hospital (RAH), Flinders Medical Centre (FMC) or The Queen Elizabeth Hospital (TQEH).

Reasons for referral include

• Initiation of antiretroviral therapy

• Prophylactic pentamidine aerosol therapy

• Onset of a serious opportunistic infection

• Onset of a secondary malignancy

• Investigation of persistent symptoms such as diarrhoea with weight loss, pyrexia of unknown origin and neurological symptoms.

HIV is a notifiable infection in South Australia.

Occupational 

Provision of PEP is the responsibility of the employer. Staff members should be assessed by the Occupational Health Unit. If prophylaxis is considered appropriate, the Infectious Diseases Unit will manage this. Patients are offered double or triple antiretroviral therapy, depending on the circumstances, for one month.

 Sexual

Non-occupational post-exposure prophylaxis (nPEP) is available at the RAH, TQEH and FMC. STD Services provides nPEP following 

sexual exposures. Patients requesting nPEP require an STD and HIV risk assessment. This requires taking a detailed sexual and blood exposure history. After counselling, and with informed consent, baseline HIV serology, FBE and LFTs are performed. It is advisable that all patients who are at risk of HIV should be advised of the risk of other STDs and be offered testing for these. 

Post exposure prophylaxis can be administered up to 72 hours after the exposure. Patients with significant exposures are offered double antiretroviral therapy, eg Combivir, for one month. Starter packs are available in the Clinic and medication is prescribed for one or two weeks at a time. Patients should be advised about safe sexual practices and clean needle programs for injecting drug users. Some patients may require additional psychological support and should be referred to MOSAIC counselling. 

If the baseline HIV test was positive patients are assessed as per HIV management guidelines (see chapter 2). 

Patients are monitored closely for side effects of medication and sero-conversion illness. FBE and LFTs are repeated weekly. Check whether medication has been taken in accordance with instructions and whether further sexual activity has occurred since exposure. At the completion of treatment, reinforce safer sexual practices and the need for follow up. Serology at 3 and 6 months after exposure is recommended. Hepatitis B vaccination should be offered to all those at risk (see chapter 15). 

There is a requirement by the Department of Health to notify the prescribing of anti-retroviral medication for nPEP and the outcome of treatment.