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Primary Care of HIV-Infected Adults 

Initial evaluation

The initial evaluation of the HIV-infected adult should include an assessment of the patient's past medical history, current symptoms and treatments, a complete physical examination.

Previous conditions

Prior medical conditions related to HIV infection should be assessed. Mucocutaneous candidiasis, oral hairy leukoplakia, hepatitis, pneumonia, sexually transmitted diseases, and tuberculosis should be sought. Past episodes of varicella-zoster, herpes simplex virus lesions, and opportunistic infections.

Dates and results of earlier tuberculin skin tests should be obtained. Women should be are asked about dates and results of Pap smears. Previous immunizations and antiretroviral therapy.

Current conditions and symptoms. Fever, night sweats, unexplained weight loss, lymphadenopathy, oral discomfort, visual changes, unusual headaches, swallowing difficulties, diarrhea, dermatologic conditions, and respiratory and neurologic symptoms are suggestive of opportunistic infections.

Physical examination

Weight, temperature, skin, oropharynx, fundi, lymph nodes, lungs, abdominal organs, genitalia, rectum, and the nervous system should be assessed. A cervical Pap smear should be obtained from women who have not had a normal result in the past year.

Screening for Neisseria gonorrhoeae and chlamydial infection should be considered for sexually active men and women.

Laboratory tests

Complete blood count, chemistry profile, and serologic studies for syphilis (rapid plasma reagin or VDRL), Toxoplasma gondii (IgG antibody), and hepatitis B (surface antigen, core antibody) should be obtained.

Patients should have a tuberculin skin test unless they have been reactive in the past or have been treated for the disease. In HIV-infected persons, a positive test is 5 mm or more of induration.

A baseline chest film is useful because many opportunistic pulmonary infections present with very subtle radiographic findings. A chest radiograph may suggest unrecognized tuberculosis.

CD4+ counts assist in determination of the degree of immunologic damage, assess risk of opportunistic complications, and guide the use of prophylaxis against infections.

HIV RNA levels

Quantitation of plasma HIV RNA (viral load), a marker of the rate of viral replication, is useful in determining prognosis. It is used to estimate the risk of disease progression and to aid in making antiretroviral therapy decisions.

HIV RNA levels generally vary no more than 0.3 log in clinically stable patients. Sustained changes greater than threefold (0.5 log) are significant. A decrease occurs with successful antiretroviral therapy. A upward trend in a

Quantitative HIV RNA assays include branched DNA ( bDNA) ( Multiplex) and reverse transcriptase-initiated polymerase chain reaction ( RT-PCR) ( Amplicor HIV-1 Monitor). While both tests provide similar information, concentrations of HIV RNA obtained with the RT-PCR test are about twofold higher than those obtained by the bDNA method. For this reason, all HIV RNA determinations in a single patient should be obtained using the same assay.

Antiretroviral therapy

Antiretroviral drug regimens may suppress HIV replication almost completely in some patients. These changes are associated with improved survival and a lengthening.

HIV RNA levels are used to identify those patients who are at greatest risk for progression of disease and likely to benefit from antiretroviral therapy. HIV RNA quantitation also documents treatment efficacy and failure.

Antiretroviral Therapy

Initiate therapy for patients with:

Symptomatic HIV disease

Asymptomatic HIV disease but CD4+ count <500 cells/FL

HIV RNA levels >5,000 to 10,000 copies/mL

Consider therapy for patients with:

Detectable HIV RNA levels who request it and are committed to lifelong adherence

Recommended initial regimens:

2 NRTIs and 1 protease inhibitor

Zidovudine ( AZT, Retrovir) + lamivudine ( 3TC, Epivir), didanosine ( ddI, Videx), or zalcitabine ( ddC, Hivid) + potent protease inhibitor or

Stavudine (d4T, Zerit) + lamivudine or didanosine + potent protease inhibitor

2 NRTIs and 1 NNRTI

Zidovudine (AZT, Retrovir) + lamivudine, didanosine, or zalcitabine + nevirapine (Viramune) or delavirdine mesylate (Rescriptor) or

Stavudine + lamivudine or didanosine + nevirapine or delavirdine

Change therapy for:

Treatment failure, as indicated by

Rising HIV RNA level

Failure to achieve target decrease in HIV RNA

Declining CD4+ count

Clinical progression

Toxicity, intolerance, or nonadherance