HIV Learning Objectives
Author: Michelle Carey
Editor: Lauren Peccoralo, MD
I. General
Learning Objectives
A. Clinical Skills:
1. Take a thorough
and complete history in an HIV patient (CD4 count—most recent and nadir,
VL, history of HAART treatment, history of OIs).
2. Recognize
HIV-related physical exam findings such as lipodystrophy, bitemporal wasting,
importance of fundoscopic exam
3.
Workup a fever in an HIV patient
B. Interpersonal Skills:
1.
Communicate a new diagnosis of HIV to a patient
a.
Break the news
b.
Provide follow-up advice/information during initial discussion.
C. Procedural Skills:
1. Lumbar puncture: View
video demonstration of LP procedure via the NEJM
website: http://content.nejm.org/cgi/content/short/355/13/e12
*Intern
focused topics
II.
Medical
Knowledge:
A. Opportunistic Infections
1. *Describe
diagnosis and management of opportunistic infections at varying levels of
immunosuppression (i.e. what OIs to consider at various CD4 count levels and
how to treat them)
a. Reference:
Benson CA et al. Treating opportunistic
infections among HIV-infected adults and adolescents. Recommendations from CDC,
NIH, and HIV Medicine Association/Infectious Diseases Society of America.
December 2004: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5315a1.htm
2. *Describe the appropriate OI
prophylaxis at varying levels of immunosuppresion
a. PCP prophylaxis
b. MAC prophylaxis
c. Reference:
Masur H, et al. Guidelines for preventing
opportunistic infections among HIV-infected persons--2002. Recommendations of
the U.S. Public Health Service and the Infectious Diseases Society of America.
Ann Intern Med 2002 Sep 3;137(5 Pt 2):435-78.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5108a1.htm
PDF version http://aidsinfo.nih.gov/contentfiles/OIpreventionGL.pdf
B. HIV screening:
1.
*Recognize what population to screen, what prevalence is
cost-effective etc. and describe diagnosis/initial labs including ELIZA,
western blot, and the use of rapid HIV testing.
a. References:
· Branson BM et al. CDC Revised recommendations for HIV
testing of adults, adolescents and pregnant women in healthcare settings.
September 2006
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm?s_cid=
· Sanders et al. Cost-effectiveness of HIV screening in patients older than 55 years of age. Ann
Internal Medicine 2008; 148: 889-903
http://eresources.library.mssm.edu:2299/cgi/content/full/148/12/889
· Delaney KP et al.
Performance of an oral fluid rapid HIV-1/2 test: experience from four CDC
studies. AIDS 2006; 20: 1655-1660
2.
*Describe appropriate counseling and available resources if positive
screen.
a. Reference:
· Branson BM et al. CDC Revised recommendations for HIV
testing of adults, adolescents and pregnant women in healthcare settings.
September 2006
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm?s_cid=
3. Recognize
and define signs and sx of acute HIV (rash, LAD, fever...)
4.
Describe how to use the viral load to screen for acute HIV
a. References (3,4)
· Schacker T et al. Clinical and epidemiologic features
of primary HIV infection. Ann
Internal Medicine 1996;
125 (4): 257-264
http://eresources.library.mssm.edu:2299/cgi/content/full/125/4/257
· Kahn JO and Walker BD. Acute Human Immunodeficiency
Virus Type I infection.
NEJM 1998.; 339: 33-39.
http://eresources.library.mssm.edu:2368/cgi/content/extract/339/1/33
C.
Fever in HIV
1.
Describe how to work-up and
treat fever in an HIV patient: i.e.empiric antibiotic
regimens to start on admission
a. References:
·
Hot A et al. Fever of unknown origin in HIV/AIDS patients. Infect Dis
Clin North Am 2007; 21 (4): 1013-32
· Pizzo P. Fever in immunocompromised patients. NEJM
1999; 341 (12): 893-900
http://eresources.library.mssm.edu:2368/cgi/content/extract/341/12/893
D. Altered Mental Status (AMS) in HIV
1. Describe how to work-up AMS in HIV and the
common causes of AMS in HIV patients
a. References:
·
Newton HB. Common neurologic
complications of HIV-1 infection and AIDS. Am Fam Physician 1995; 51(2): 387-98
http://eresources.library.mssm.edu:2115/sites/entrez
· Boisse L et al. HIV infection of the central nervous
system: clinical features and neuropathogenesis. Neurol Clin 2008; 26(3):
799-819
E.
HIV Treatment
1. *Describe how/when to start a HAART regimen: what
combinations of drug classes to use
and what the usual
regimens are. (JAMA ART guidelines)
2. *Know
literature on HAART holidays (SMART) (DAD)
a. References (1,2):
· Hammer SM et al. Treatment for adult HIV infection:
2008 recommendations of the International AIDS Society-USA panel. JAMA 2008;
300(5): 555-570
http://eresources.library.mssm.edu:2213/cgi/content/full/300/5/555
· Julg B, Goebel FD. Treatment interruption in HIV: a
SMART strategy? Infection June 2006. 34(3): 186-188
http://eresources.library.mssm.edu:2292/content/573032284h528150/fulltext.pdf
·
DAD
Study Group. Combination antiretroviral therapy and the risk of myocardial
infarction. NEJM 2003; 349(21): 1993-2003.
http://eresources.library.mssm.edu:2368/cgi/content/abstract/349/21/1993
3. *Recognize the side
effects/complications of ART, patients get admitted for these, and
long
term complications of ART - lipodystrophy, dyslipidemia, cardiovascular dz,
hepatotoxicity, etc.
a. References:
·
NY
State Department of Health AIDS Institute HIV guidelines: Long-tern
complications of antiretroviral therapy 2007. http://hivguidelines.org/GuideLine.aspx?pageID=257&guideLineID=11
·
Mallal
S et al. HLA B5701 screening for hypersensitivity to abacavir. NEJM 2008; 358
(6): 568-579
http://eresources.library.mssm.edu:2368/cgi/content/full/358/6/568
· Huang L.
Intensive care of patients with HIV infection. NEJM 2006; 355(2): 173-181
http://eresources.library.mssm.edu:2368/cgi/content/full/355/2/173
F.
HIVAN
1. Describe the diagnosis and management
of HIVAN
a. References:
·
Atta MG et al. HIV-associated
nephropathy: epidemiology, pathogenesis, diagnosis and management. Expert Rev Anti Infect Ther 2008; 6(3):365-71
http://eresources.library.mssm.edu:9305/doi/full/10.1586/14787210.6.3.365?cookieSet=1
·
Klotman
PE. HIV-associated nephropathy. Kidney International 1999; 56: 1161-1176
http://eresources.library.mssm.edu:2106/ki/journal/v56/n3/full/4495459a.html
·
Ross
MJ and Klotman PE. Recent progress in HIV-associated nephropathy. J Am Soc
Nephrol 2002; 13(12): 2997-3004.
http://eresources.library.mssm.edu:6533/cgi/content/full/13/12/2997
G.
Malignancy in HIV
1. Describe
inpatient work-up and management of malignancy in HIV
a. Reference:
·
Bower
M et al. British HIV Association guidelines for HIV-associated malignancies
2008. HIV Medicine 2008; 9: 336-388.
http://eresources.library.mssm.edu:2097/cgi-bin/fulltext/120747248/HTMLSTART
H. HIV/HCV Coinfection
1. Describe the risk factors and
management of pts with HIV/HCV co-infection
a. References:
·
Klenerman
P and Kim A. HCV-HIV coinfection: simple messages from a complex disease. PLOS
Medicine 2007; 4(10): 1608-1614.
http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.0040240
·
Sulkowski
MS and Benhamou Y. Therapeutic issues in HIV/HCV-coinfected patients. J Viral
Hepat 2007; 14(6): 371-386.
http://eresources.library.mssm.edu:2097/cgi-bin/fulltext/118000914/HTMLSTART
·
Tien
PC. Management and treatment of hepatitis C virus infection in HIV-infected
adults: recommendations from the Veterans Affairs Hepatitis C Resource Center
Program and National Hepatitis C Program Office. Am J Gatroenterol 2005;
100(11): 2338-54.
http://eresources.library.mssm.edu:2106/ajg/journal/v100/n10/full/ajg2005414a.html
I. Outpatient HIV Care
1. Describe how to
care for outpatient HIV patients, i.e. lab monitoring depending on ART
regimen, checking for STDs, etc.
a. References:
·
Aberg J et al. Primary care guidelines for the management of
persons infected with HIV: recommendations of the HIV Medicine Association of
the Infectious Diseases Society of America; IDSA Guidelines. Clinical
Infectious Diseases 2004; 39:609-629.
http://eresources.library.mssm.edu:2284/doi/full/10.1086/423390
·
Hammer S. Management of newly diagnosed HIV infection. NEJM 2005;
353(16): 1702-1710.
http://eresources.library.mssm.edu:2368/cgi/content/full/353/16/1702