HIV management for family practice residents

1. HIV Infection and AIDS 2007 Family Practice Board Review Miguel G. Madariaga, MD Assistant Professor of Medicine University of Nebraska Medical Center

2. HIV epidemiology in a capsule

3. The natural history of HIV

5. Case definition of HIV infection C3 B3 A3 < 200 mm 3 (<14%) C2 B2 A2 200-499 mm 3 (14 to 28%) C1 B1 A1 > 500 mm 3 (>29%) AIDS indicator condition (Category C) Symptomatic, but not with AIDS indicator condition (Category B) Asymptomatic (Category A) CD4 cell categories

11. Resistance testing I doubt you have to remember funny numbers, but M184V is a “popular” mutation

15. Probability of developing AIDS based on CD4 cell count and viral load

17. HIV life cycle and potential pharmacological targets

22. Interclass adverse effects Symptomatic treatment Treat osteoporosis Surgery? XR followed by MRI if symptoms present Any agent Osteopenia, osteonecrosis Switch antiretrovirals Liver function tests every 3-6 months Nevirapine, efavirenz, stavudine, zidovduine, didanosine, tipranavir Hepatitis Check for associated metabolic complications Cosmetic treatment? Consider switching antiretrovirals Question patient Imaging not recommended routinely Stavudine, zidovudine, protease inhibitors (lipoatrophy) Efavirenz (lipohyperthrophy) Lipodistrophy Use insulin sensitizing agents Consider switching antiretrovirals Fasting glucose every 3-6 months Mainly protease inhibitors Insulin resistance Use National Cholesterol Educational Program guidelines Consider switching antiretrovirals Fasting lipid profile every 3-6 months Stavudine Protease inhibitors (except atazanavir) Hyperlipidemia Treatment Testing Agents Toxicity

24. Class and specific adverse effects Discontinue medication Never rechallenge Abacavir Hipersensitivity Discontinue medication Didanosine, zalcitabine, stavudine Peripheral neuropathy Discontinue medication Didanosine, zalcitabine Pancreatitis Erythropoietin, switch agent Zidovudine Bone marrow supression, especially anemia Discontinue medication NNRTI Rash including Steven Johnson’s syndrome Symptomatic PI, NRTI GI toxicity Treatment Agents Toxicity

25. Class and specific adverse effects Actually not adverse effects, but some physicians and patients get excited about them (they are “markers” of adherence) Reassure patient Atazanvir Indirect hyperbilirrubinemia (Gilbert’s syndrome) Reassure patient Zidovudine Macrocytosis without anemia Good hydration Avoid other nephrotoxic agents Indinavir (stones), tenofovir Nephrotoxic Avoid during pregnancy Efavirenz Teratogenicity Consider switching agent Efavirenz CNS toxicity Treatment Agents Toxicity

48. Pneumocystis jirovecii pneumonia

56. Good luck!