david h. spach, md the international aids society–usa initial evaluation and common clinical...

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.

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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

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DH Spach, MD. Presented at IAS–USA/RWCA Clinical Conference, August 2004.

Acquisition of Toxoplasma gondii

DHS/HIV/PP

Cat Feces

Undercooked Red Meat

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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.

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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.

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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

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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

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DH Spach, MD. Presented at IAS–USA/RWCA Clinical Conference, August 2004.DHS/HIV/PP

Oral CandidiasisClinical Types

Erythematous Pseudomembranous Angular Cheilitis

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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

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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.

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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

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DH Spach, MD. Presented at IAS–USA/RWCA Clinical Conference, August 2004.DHS/ HIV/PP

Aphthous LesionsClinical Types

Minor (Lip) Minor (Tongue) Major

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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

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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

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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