New OI prevention and treatment guidelines
Pediatric guidelines now are entirely separate
HIV clinicians likely will find the latest version of the government's opportunistic infections (OIs) guidelines to be pertinent to their daily practice. This is especially true as the trend continues of patients being diagnosed with very low CD4 cell counts.
At many HIV clinics, patients continue to present with CD4 cell counts of less than 200, which means they often have had diagnoses of opportunistic infections before they had an HIV test.
"The median CD4 count of people showing up at our clinic is around 180 to 200, so for most of these patients the horse is out of the barn," says Michael S. Saag, MD, professor of medicine and director of the University of Alabama Center for AIDS Research in Birmingham, AL.
"They have already had more diagnoses before getting into care," Saag says.
The revised OI guidelines are expected to be published in the Centers for Disease Control and Prevention's (CDC's) Morbidity and Mortality Report (MMWR) sometime later this year, but the final draft under review by the CDC was released this summer online by the National Institutes of Health (NIH) of Bethesda, MD.
"The version on the Web now is essentially the final document unless we receive comments identifying errors from the CDC," says Henry Masur, MD, FIDSA, chief of critical care medicine for NIH and the immediate past president of the Infectious Diseases Society of America (IDSA) of Arlington, VA.
The OI infection rate has continued a downward trend since the mid-1990s, but it remains an important focus for providers because of the many urban areas where late testers are concentrated, Masur notes.
"People still are coming in with opportunistic infections," he adds. "It is not exclusively an urban issue, but there are large urban areas where it's a huge problem."
The revised guidelines emphasize universal HIV testing and antiretroviral treatment as the best OI prevention strategies, Masur and Saag say.
"If we really want to prevent OIs, the most important thing we can do is emphasize more universal HIV testing with better access to care," Masur says. "Antiretroviral therapy is the most effective way to prevent OIs, but we have to identify the people who are HIV-infected first."
The best thing a provider can do to prevent an OI is to keep the immune system intact, Saag says.
"The pathogen takes advantage of a weakened immune system," Saag adds. "So if you prevent it from becoming compromised then the opportunity for an OI doesn't materialize."
The updated guidelines combine prevention and treatment, which were separated previously. Also the new guidelines separate pediatric OI guidelines from the adult guidelines, says Lynne Mofenson, MD, chief of the pediatric, adolescent, and maternal AIDS branch at the National Institute of Child Health and Human Development in Rockville, MD.
Among the new items in the guidelines are information about malaria, a section on hepatitis B, and advice on monitoring for immune reconstitution inflammatory syndrome (IRIS).
IRIS is not common domestically among pediatric HIV patients, but it does occur in adults who are advanced in their disease before diagnosis and among both adults and children in developing countries, Mofenson says.
"IRIS occurs when you have a worsening of existing latent infection where the pathogens weren't previously recognized, and once treatment begins there's a sudden immune response," Mofenson explains.
The classic example is with tuberculosis where clinicians might see a paradoxical inflammatory response, she says.
The reason the guidelines include information in each OI section about IRIS is because it is something that should be considered whenever patients who are initiated to ARTs have symptoms that are suggestive of a separate disease or problem.
"Patient care characteristics and timing are important," Masur says. "IRIS will occur within a few days or weeks after the patient starts ART, and it is more likely in those with very low CD4 counts and high viral loads."
Such patients need to be carefully evaluated, and cultures need to be done, he adds.
Hepatitis B was added to the guidelines because there's a recognition that both hepatitis B and hepatitis C infections are worse in people who are co-infected, Masur says.
The revised guidelines, which took about 14 months to create and edit, are designed to be a document for reference, rather than a document to read like a textbook, he notes.
"It has tables for what the drug of choice is for this condition and what drug interactions you need to be aware of," Masur says. "These guidelines in the past have been heavily used with 5,000 to 20,000 downloads each month."
HIV clinicians likely will find the latest version of the government's opportunistic infections (OIs) guidelines to be pertinent to their daily practice. This is especially true as the trend continues of patients being diagnosed with very low CD4 cell counts.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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