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Recommendations for the Triage of HIV-Positive Patients

September 8, 2005

These are general recommendations for clinicians who are not HIV specialists. We encourage you to call the NIH Medical Consultation Services at 1-866-887-2842 or the National HIV/AIDS Clinical Consultation Center at 1-800-933-3413 to consult with HIV experts. Visit www.aahivm.org or www.hivma.org for updates to this document.

  1. First priority is to treat active infections. Most HIV patients will respond to treatment with antibiotics just like non-HIV patients.

  2. Find out the patient's last CD4 (T-cell) count if possible. The most frequent infections by CD4 count are:


    CD4 <500TB, Herpes zoster, sinusitis, bronchitis.
    CD4 <200 PulmonaryInclude Pneumocystis jiroveci (former carinii) pneumonia (PCP) in your differential diagnosis. Subacute symptoms include dry cough.

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    Especially important in patients who are not getting prophylaxis with SMX/TMP, Dapsone or Atovaquone.

    CD4 <100 CNSInclude toxoplasmosis and cryptococcal meningitis in differential diagnosis.
    CD4 <50 with unexplained feverConsider Mycobacterium avium complex (MAC) and systemic fungal disease in differential diagnosis, especially if patient is not on clarithromycin or azithromycin prophylaxis.

  3. If it is a choice between getting antiretroviral medications and getting prophylaxis for opportunistic infections (OI) for patients on HAART, get the antiretrovirals first to avoid treatment interruptions. Such interruptions can lead to the development of drug-resistant virus. For patients not on HAART and CD4 <200, SMX/TMP is the preferred prophylaxis. Recommendations for antiretroviral therapy are available at www.aidsinfo.nih.gov/guidelines. After HAART is resumed, individuals being treated for an OI should resume such treatment.

  4. If patients cannot obtain their medications, make sure that they stop all antiretroviral drugs, rather than continuing on only one or two.

  5. Once continued access to antiretroviral therapy is assured -- patients should have their OI prophylaxis continued. Federal guidelines on the prevention and treatment of OI are available at www.aidsinfo.nih.gov/guidelines.

  6. People with HIV should get tetanus shots, just like everyone else.

  7. Live virus vaccines should be used with caution in people with HIV. However, people with CD4 (T-cell) counts over 350 should do fine and have a normal response. Use clinical judgment -- preventing epidemics remains a priority even with people with HIV.


Basic Medication Information

  • An easy-to-read chart of AIDS drugs with photos is available at www.aidsmeds.com/lessons/drugchart.htm.

  • Ritonavir (Norvir) and Lopinavir/Ritonavir (Kaletra) are heat sensitive and are best kept refrigerated. They should maintain potency at room temperature (77°F) for up to 60 days. Exposure to extreme heat and/or sunlight can greatly diminish potency necessitating replacement.


Important Drug Interactions to Consider

efavirenz (Sustiva)AVOID clarithromycin, triazolam, rifampin.
ritonavir (Norvir) or lopinavir + ritonavir (Kaletra)AVOID alprazolam, buspirone, daizepam, flurazepam, triazolam, zolpidem.
Protease inhibitors:
saquinavir (Invirase, Fortovase), indinavir (Crixivan), ritonavir (Norvir), nelfinavir (Viracept), fosamprenavir (Lexiva), lopinavir/ritonavir (Kaletra), atazanavir (Reyataz), tipranavir (Aptivus)
USE CAUTION WITH rifampin and rifabutin, dose modification required.
atazanavir (Reyataz)AVOID Proton pump inhibitors and H2 blockers.


Pregnant Women: For pregnant patients be sure to consult fact sheets about appropriate antiretroviral medications. Recommendations on antiretroviral treatment for pregnant women and interventions to reduce perinatal HIV transmission are available at http://aidsinfo.nih.gov/guidelines. An easy-to-read chart of acceptable medications for pregnant women is available at www.aidsmeds.com/lessons/Pregnancy8a.htm.

Treatment for Possible Exposure to HIV Infection: Prophylactic antiretrovirals should be administered if at all possible in occupational and non-occupational exposures. Recommendations for healthcare workers are available at http://aidsinfo.nih.gov/guidelines/health-care/HC_062901.pdf. Recommendations for non-occupational exposures are available at http://aidsinfo.nih.gov/guidelines/nonexposure/NE_012105.pdf. Consultation on PEP is available from the National PEPline at 1-888-HIV-4911

Rapid HIV Testing: If possible -- do rapid HIV testing. People will need proof of their HIV status to obtain help from HIV service providers.

Locating HIV Providers and Clinics: For a list of HIV clinics, go to www.aahivm.org or www.hivma.org and click on the Hurricane Katrina links. HIVMA and AAHIVM members accepting patients also are available from our websites or by calling 888-844-4372 (HIVMA) or 866-241-9601 (AAHIVM).

Patients Enrolled in Clinical Trials: Patients enrolled in clinical trials should contact the trial sponsor to obtain experimental study drugs. Some contacts are:

  • AIDS Clinical Trials Group: 301-628-3000

  • Bristol Myers Squibb: 800-272-4878

  • Community Programs for Clinical Research on AIDS: 301-628-3000

  • GlaxoSmithKline: 888-825-5249

  • Tibotec: 609-730-7500

For others, call the main number for the pharmaceutical company involved.



  
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This article was provided by American Academy of HIV Medicine.
 
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