ID

Question 1

Ongoing management of HIV?

Answer 1

Goals

• Virologic suppression & preserve immunological function (CD4)
• Minimize transmission
• Surveillance & management of HIV related morbidity: infection, malignancy, CV risks
• Surveillance & management of complications of medical therapy

Assess current state

• CD4, HIV VL

Virologic suppression & preserve immunological function (CD4)​

• Ix: 3 monthly CD4, HIV VL - to detect virologic failure
• Mx
  
  • If adherence problem
    
    • Peer group counsellers, support groups
    • CBT, reminders
    • Case manager
    • DOT as a last resort
  • Resistance testing
  • Genotype - can direct further ARV choices

Minimise transmission

• If patient knowingly putting others at risk…
• Educate, counsel and support
• Involve HIV case worker
• D/W Department of Health, CDC section

Surveillance & management of HIV related morbidity: infection, malignancy, CV risks

• Ix:
  
  • 3 monthly ECG, lipids, HBA1C, clinical exam for VA/fundoscopy (CMV retinitis), LN/B-symptoms/splenomegaly, skin for KS
  • Perineal & rectal exam for ulcers/rectal Ca
• Mx:
  
  • Vaccinate for Flu, Pneumococcus, Hepatitis A&B
  • Bactrim if CD4 <200 (PJP), Azithro if CD4 <50 (MAC)
  • Age-appropriate malignancy screening is up-to-date
  • HPV (cervical) and Anal Ca surveillance
  • CV: chol <4, LDL <2, exercise, dietician, smoking cessation, pharmacological…etc.

Surveillance & management of complications of medical therapy

• Ix:
  
  • Examine for lipodystrophy, PN (NRTI), mood, psychological disturbances (EFV/NVP)
  • FBC (BM suppression), LFTs/Lipase (pancreatitis/hepatitis), lipids, HBA1C
  • Osteoporosis (DEXA q2y, q6m Vit D, Ca, Phos, PTH)