Management of HIV infection. A 1995-96 overview for the clinician

Although the challenges of HIV/AIDS care may seem overwhelming, we are better able than ever to positively affect the course of HIV for each individual patient. Treatment goals involve three areas: 1) Antiretroviral drugs aimed at retarding the rate of HIV replication, thus reducing the rate of damage to the immune system; 2) drugs used to treat or prevent opportunistic infections seen in the context of HIV-related immune deficiency; and 3) drugs used to treat symptoms or syndromes commonly seen in these patients (including dementia and wasting syndrome). The multitude of clinical problems seen in advanced HIV disease leads to significant polypharmacy and costs resulting in a very complex and confusing situation. I recommend that physicians with little HIV experience link up with an HIV specialist when caring for HIV-infected patients to optimize access to the best therapies or research studies currently available. With no cure in sight, physicians need to focus on educating the public and patients about how to avoid HIV infection and to identify persons who are infected to minimize spread.     

Examining HIV-related knowledge among adults in the U.S

Supplemental AIDS data from the 1987 National Health Interview Survey indicate that adults in the U.S. know the most frequent modes of HIV transmission, but lack a more comprehensive understanding of HIV and AIDS. Elements from a diffusion model were isolated to create a path-analytic framework for examining the effects of population or recipient characteristics and information sources or communication channels on HIV-related knowledge with these data. This multivariate analysis suggests that persons of lower socioeconomic status, older adults, those from racial/ethnic minority groups, those living outside of metropolitan areas, men, and those citing mass media (television or newspapers) as their primary source of information about HIV and AIDS have slightly lower levels of HIV-related knowledge. Decomposition of the effects in the path analysis suggests that use of information sources or channels, as measured by survey data, accounts for little of the observed variation in HIV-related knowledge. The implications of these results for future research and HIV-related education are discussed.     

Gastrointestinal disease in the immunocompromised patient

Gastrointestinal (GI) disease is frequent in all types of immunocompromised patients but occurs with greatest frequency in patients with acquired immunodeficiency syndrome (AIDS). Thus, much of this review deals with human immunodeficiency virus (HIV)-related GI diseases. Gastrointestinal diseases in other immunocompromised patients are compared with those in patients with AIDS. Conditions unique to transplant recipients, such as graft-versus-host disease (GVHD) and posttransplant lymphoproliferative disorders (PTLDs), are discussed separately. We have divided these GI diseases into four main categories: (1) HIV-related inflammatory conditions other than opportunistic infections (HIV-related enteropathy, proctocolitis, and CD8 lymphocytosis); (2) inflammatory conditions unrelated to HIV or opportunistic infections (neutropenic enterocolitis, regional enteritislike enteropathy, and GVHD); (3) opportunistic infections (illnesses caused by herpesvirus, cytomegalovirus, and miscellaneous other viruses; Mycobacterium, Candida, Histoplasma, Cryptococcus, Cryptosporidium, Microsporida, Isospora, Leishmania, Toxoplasma and Strongyloides organisms as well as Pneumocystitis carinii; and (4) neoplasias (Kaposi's sarcoma [KS], AIDS-related non-Hodgkin's lymphoma [NHL], HIV-related Hodgkin's disease [HD], PTLDs, and miscellaneous neoplasms). The prevalence, pathogenesis, clinical manifestations, gross pathological findings, and microscopic features of each disease entity are discussed.     

Do physicians discuss HIV and AIDS with patients? A survey of physician practices

HIV and AIDS continue to be major concerns to the health care community and the world around them. Preventive efforts and education have been the focus of the fight against AIDS thus far. By the year 2000, 75% of physicians are expected to conduct risk-reduction counseling for patients regularly. Previous studies show that a smaller percentage "routinely" follow this recommendation. The purpose of our study was to assess with what percentage of patients physicians discuss several HIV/ AIDS-related topics, what percentage of their patients are considered at risk for infection, and how comfortable the physicians are with their knowledge level and discussing the subject matter. We sent surveys to the last five graduating classes from St. Louis University School of Medicine and to 169 physician preceptors in the community. The survey asked about patients considered at risk, physician comfort level with HIV/ AIDS, the percentage of patients they discuss various HIV/AIDS topics with, and his or her preparedness for these discussions. Total responses were 464 (53.7%) representing all areas of medicine. Most of the physicians (72.9%) consider 0-25% of their patients at risk for HIV/AIDS. Eighty-one percent claim they are moderately or very comfortable discussing the material with patients and more than 90% feel they have at least adequate knowledge. Most of the respondents discuss the HIV/ AIDS topics with 0-25% of patients. Recent medical school graduates and primary care physicians are more comfortable with HIV/AIDS and discuss the surveyed topics with a higher percentage of patients.     

HIV/AIDS related knowledge, attitudes, and preventive behavior of pregnant Korean women

OBJECTIVE: To assess HIV-AIDS-related knowledge, attitudes, and preventive behavior of pregnant Korean women before designing patient and public education programs. DESIGN: Pre-experimental cross-sectional survey. POPULATION, SAMPLE, SETTING, YEARS: Convenience sample of 409 women at six prenatal clinics in Seoul, Korea, in 1993. OUTCOME MEASURES: HIV-AIDS-related knowledge, attitudes, and preventive behavior. METHODS: Self-administered questionnaires. FINDINGS: The women described high levels of knowledge about HIV and AIDS risk factors but less knowledge about transmission of the virus, as well as attitudes of rejection toward unrelated people with HIV/AIDS; 16% provided condoms for their husband's use in extramarital sex, the primary risk behavior. CONCLUSIONS: Korean women are at risk for heterosexual transmission of HIV despite knowledge of risk factors. CLINICAL IMPLICATIONS: Korean education programs for women should focus on modes of heterosexual transmission, care of individuals with HIV or AIDS, self-assessment of HIV-AIDS risk, and self protection.     

Attitudes, beliefs, and practices of nursing students concerning HIV/AIDS: implications for prevention in women

Nursing students are a group of predominantly young women who may be sexually active but who are well educated and presumably health conscious. It might be expected, therefore, that they are not a population at risk for sexually acquired HIV infection. Recent studies indicate that heterosexual women constitute the fastest growing population of persons with AIDS in the United States and Canada (Health and Welfare Canada, 1993b; Wofsky, 1992) and that women and adolescents will constitute the next surge of the AIDS epidemic (Novello, 1993). First-year nursing students in a major Canadian city were surveyed regarding HIV-related knowledge, attitudes, beliefs, and behaviors. The women were highly knowledgeable about HIV transmission but 15% to 25% reported high risk sexual behavior. The results reinforce that knowledge is not enough to prevent HIV infection among young women and that interventions must be based on an understanding of the social context of women's lives.     

Severe mental illness and HIV-related medical and neuropsychiatric sequelae

Medical and neuropsychiatric sequelae of HIV infection present a spectrum of diagnostic and treatment challenges to mental health clinicians. Both HIV and the many opportunistic infections that manifest in patients due to their immunocompromised state also can affect the central nervous system (CNS). Thus, mental health clinicians need to be familiar with the diagnosis and management of HIV-related medical and psychiatric complications. This article provides an overview of the CNS-related manifestations resulting from HIV disease, including HIV-related dementia, psychotic disorders, delirium, CNS opportunistic infections and tumors, systemic abnormalities, psychoactive substances, and the adverse effects of certain medical treatments. Treatment strategies for individuals with HIV disease and comorbid severe mental illness are outlined and recommendations for future research are offered.     

Involutional lower eyelid entropion: results of a combined approach

CONTEXT: There is urgent need to strengthen the area of pediatric HIV/AIDS care in developing countries. Clinical research in this area is also scarce. METHODOLOGY: A literature review and a postal survey were used to obtain updated information on mortality, morbidity and current standards of care of children born to HIV-infected mothers in developing countries. A 2-day workshop was organized to review the available data and to identify the key areas where clinical research should be conducted. MAIN FINDINGS: Rates of mortality and morbidity were very different from one study to another but generally higher than in industrialized countries. Prognostic studies for HIV-1-infected children in developing countries were not available. Based on the report of 14 teams from 11 countries, specific protocols for HIV-infected children with persistent diarrhea or severe malnutrition were documented in fewer than one-half of the cases. Secondary antimicrobial prophylaxis after interstitial pneumonia or recurrent infections was still infrequent, as primary prophylaxis of opportunistic infections. The following list of clinical research priorities was identified by the workshop participants: primary prophylaxis of opportunistic and bacterial infections; case management of persistent diarrhea; reassessment of the performance of p24 antigen for diagnostic and prognosis use; studies on the etiology of pulmonary infections; long term observational pediatric cohorts; current weaning practices and duration of breast-feeding; counseling and HIV testing of children and families; prevention of HIV sexual transmission in children and adolescents.     

Radiolabelled monoclonal antibodies (McAb): an alternate approach to the conventional methods for the assessment of cardiomyocyte damage in an experimental brain-death pig model

BACKGROUND: According to the Ministry of Health and Welfare AIDS Surveillance Committee's report on vertically transmitted human immunodeficiency virus (HIV) infection, there have been eight children with acquired immune deficiency syndrome (AIDS) and 18 children with HIV infection in Japan, totalling 26 in all as of February 1997. A search of the literature fails to reveal any report that deals with many cases of vertically transmitted HIV infection in Japan. METHODS: A primary questionnaire survey was taken of the main medical institutions across the country, followed by a secondary questionnaire survey of physicians and pediatricians who treated the disease. A clinical review was made of 19 children with vertically transmitted HIV infection (including eight AIDS children) according to the 1994 Revised Classification System for HIV Infection in Children. RESULTS: The mean age at diagnosis was 14.5 months and the diagnosis was made at less than 18 months of life in approximately 70% of infected children. In the mean observation period of 16 months, six of eight AIDS children (75%), and one child of group B died. The mean period of observation for the seven dead children was 7 months, and six of seven children died by 36 months of life. The survival period after the diagnosis of AIDS was 15 months. The diagnosis of HIV infection was made based on the clinical symptoms of all children with AIDS. Of 11 children, six (45%) presented with symptoms of HIV infection by 6 months of life, and 10 of 11 children (91%) presented with symptoms by 26 months of life. The noteworthy clinical findings included hepatomegaly, splenomegaly, recurrent respiratory tract infection, lymph node swelling, oral candidiasis, hepatitis, wasting syndrome, HIV encephalopathy and severe pneumonia. The favored age for the start of complications and the magnitude of decrease in the HIV helper cell count varied with each case of complications of HIV infection (wasting syndrome, HIV encephalopathy) or opportunistic infections (cytomegalovirus infection, Mycobacterium avium complex infection). Anti-HIV drugs (mainly zidovudine) had been used in five of eight children with AIDS and were effective in two long survivors alone. CONCLUSIONS: Children who are diagnosed with HIV infection, based on their clinical symptoms, carry a poor prognosis. In this respect, early diagnosis and progress in anti-HIV therapy are necessary.     

Perivascular inflammatory reaction after percutaneous placement of covered stents

AIDS ocular complications have been researched in 70 hospitalised patients in the two main hospitals of Bamako (Mali) during one year (1992-1993). Men were predominant (sex ratio 1.6). HIV1 infections (67%) were most frequent than HIV1 + HIV2 (21.4%) or HIV2 infections (11.4%). Most of the patients were on the WHO's clinical stage III; 34% of them had ocular complications, quite often non infectious: cotonous nodules (10%), vascularitis (5.7%) and retineous haemorrhages (4.3%). Ocular opportunistic infections were rare: only one case of toxoplasmic chorio-retinitis was reported. Ocular complications were observed with all types of HIV. Vascular abnormalities were observed in the stage II or IV of AIDS and seemed, in Bamako, as a serious sign during the AIDS course.     

AIDS-related malignancies

In the US over one million persons are currently infected with the HIV, over half a million have had AIDS, and over 300,000 have died from AIDS. Worldwide, it is estimated that more than 17 million people are currently infected with HIV, and over 1,200,000 cases of AIDS have been reported to the World Health Organization. By some estimates, up to 40% of patients with AIDS will ultimately develop some form of cancer. Non-Hodgkin's lymphoma, Kaposi's sarcoma and invasive cervical cancer have a higher incidence in persons with HIV infection and all three are AIDS-defining illnesses. In addition, several reports suggest that a number of other malignancies may occur at an increased incidence in persons with HIV infection, including squamous-cell carcinoma of the head, neck and anus, plasmacytoma, melanoma, small-cell lung cancer, basal-cell cancer, and germ-cell tumours. Clinicians should become familiar with HIV-related malignancies as their incidence is expected to further increase as more effective therapies for HIV and associated opportunistic infections allow patients to live longer in an advanced state of immunodeficiency. In the current article, we will review the clinical and therapeutic aspects of the most common AIDS-related malignancies including non-Hodgkin's and Hodgkin's lymphomas, Kaposi's sarcoma and anogenital epithelial neoplasias.     

Effects of AIDS-related bereavement and HIV-related illness on psychological distress among gay men: A 7-year longitudinal study, 1985–1991.

Examined the influence of AIDS-related bereavement on psychological distress from 1985 through 1991. It was predicted that this relation would be influenced by personal knowledge of HIV infections and symptoms consistent with HIV-related illness. Interview data collected each year on a cohort of 746 gay men included information on the deaths and illnesses of network members caused by AIDS, as well as on psychological distress, sedative use, HIV-related symptoms, and HIV infection status. Significant main effects of bereavement were found in each year after controlling for both losses occurring from 1 to 2 yrs previously and for AIDS and HIV health status. The intensity and duration of these bereavement effects diminished over time. Groups of men who were both bereaved and classified as having AIDS or were HIV positive reported the highest level of distress in every year compared with the 3 other groups. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contribution to the treatment of acute bovine mastitis with cefquinome

The recombinant human colony-stimulating factors, granulocyte colony-stimulating factor (G-CSF) and granulocyte-macrophage colony-stimulating factor (GM-CSF) are hematopoietic cytokines that increase neutrophil number and enhance their function. In patients with HIV infection, G-CSF and GM-CSF have reversed or prevented neutropenia even during periods of full-dose myelotoxic therapy. Both colony-stimulating factors (CSFs) also have improved defects in neutrophil function in the setting of HIV infection. In non-neutropenic animal models of opportunistic bacterial or fungal infections, use of CSFs has increased survival. Future clinical applications of CSFs may include the adjunctive treatment of specific HIV-related opportunistic infections in addition to an expanding role in the treatment of HIV-associated neutropenia and defects in neutrophil function.     

AIDS 1988: The science and the limits of science.

Reviews the epidemiology, virology, and immunology of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) and discusses the limits of current knowledge in these areas. AIDS came to the attention of public health officials in 1981. At 1st confined to homosexual and bisexual males, heterosexual transmission of AIDS has increased. The concept of high-risk group has been replaced by that of high-risk behaviors (e.g., intravenous drug use, intercourse). HIV damages the immune system by selectively infecting and killing T-4 lymphocytes, thus rendering the body susceptible to opportunistic infections. AIDS research has been limited by inadequate funding. Psychologists are urged to become informed about the science of AIDS as generated by their colleagues in medicine, biology, and public health. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Attitudes of medical students to HIV and AIDS

OBJECTIVE--To assess the knowledge and attitudes of medical students to HIV/AIDS and whether attitudes correlate with knowledge and clinical experience. To determine if students felt adequately prepared to deal with medical and psychological aspects of HIV/AIDS. SUBJECTS AND METHODS--The subjects consisted of 190 London and 99 Cambridge medical students at the end of their genitourinary medicine attachment, plus 230 Cambridge medical students at the end of their second pre-clinical year. Between March 1991 and February 1992 all were asked to complete an anonymous questionnaire, covering factual knowledge and attitudes towards HIV/AIDS. MAIN RESULTS--Cambridge genitourinary medicine students, despite spending less time studying HIV infection than their London counterparts gave more correct answers to the factual questions, although this difference did not reach significance (52.4% vs. 47.5%, p = 0.14). One third of students believed that many health care workers were at high risk of acquiring HIV at work and one fifth thought doctors should have the right to refuse to treat people with HIV. Fourteen percent of Cambridge genitourinary medicine students indicated that most British people with HIV have only themselves to blame, by comparison with 4% of London students (p = 0.003). Thirty-nine per cent of Cambridge genitourinary medicine students expressed reluctance to care for someone with AIDS by comparison with 10% of London students (p = 0.0001). CONCLUSIONS--It is important that medical educators convey accurate information about HIV, including the actual risks posed by occupational exposure and try to ensure that medical students spend sufficient time seeing patients with HIV/AIDS during their training.     

Occult HIV infection: diagnosis and treatment of older patients

The decrease in immune status that accompanies normal aging leaves individuals age 50 and older increasingly susceptible to the two main modes of HIV infection: sexual activity and blood transfusions. Although therapy for older HIV patients is essentially the same as for younger patients, knowledge of appropriate drug dosages and nutritional issues that influence the care of the older HIV patient is essential for physicians treating this population. Physicians need to recognize the clinical features of HIV-related dementia and opportunistic infections that distinguish it from other age-related illnesses such as Alzheimer's and Parkinson's disease. Known risk factors that affect older patients should influence physicians to routinely include HIV in their differential diagnoses.     

Cystic prostatic disease associated with adrenocortical lesions in the ferret (Mustela putorius furo)

CONTEXT: In British Columbia, human immunodeficiency virus (HIV)-infected persons eligible for antiretroviral therapy may receive it free but the extent to which HIV-infected injection drug users access it is unknown. OBJECTIVE: To identify patient and physician characteristics associated with antiretroviral therapy utilization in HIV-infected injection drug users. DESIGN: Prospective cohort study with record linkage between survey data and data from a provincial HIV/AIDS (acquired immunodeficiency syndrome) drug treatment program. SETTING: British Columbia, where antiretroviral therapies are offered free to all persons with HIV infection with CD4 cell counts less than 0.50 x 10(9)/L (500/microL) and/or HIV-1 RNA levels higher than 5000 copies/mL. SUBJECTS: A total of 177 HIV-infected injection drug users eligible for antiretroviral therapy, recruited through the prospective cohort study since May 1996. MAIN OUTCOME MEASURES: Patient use of antiretroviral drugs through the provincial drug treatment program and physician experience treating HIV infection. RESULTS: After a median of 11 months after first eligibility, only 71 (40%) of 177 patients had received any antiretroviral drugs, primarily double combinations (47/71 [66%]). Both patient and physician characteristics were associated with use of antiretroviral drugs. After adjusting for CD4 cell count and HIV-1 RNA level at eligibility, odds of not receiving antiretrovirals were increased more than 2-fold for females (odds ratio [OR], 2.53; 95% confidence interval [CI], 1.08-5.93) and 3-fold for those not currently enrolled in drug or alcohol treatment programs (OR, 3.49; 95% CI, 1.45-8.40). Younger drug users were less likely to receive therapy (OR, 0.47/10-y increase; 95% CI, 0.28-0.80). Those with physicians having the least experience treating persons with HIV infection were more than 5 times less likely to receive therapy (OR, 5.55; 95% CI, 2.49-12.37). CONCLUSIONS: Despite free antiretroviral therapy, many HIV-infected injection drug users are not receiving it. Public health efforts should target younger and female drug users, and physicians with less experience treating HIV infection.     

Diagnosis and management of esophageal disease in the acquired immunodeficiency syndrome

BACKGROUND: Esophageal disorders are common complications of human immunodeficiency virus (HIV)-infected patients. In a significant number of patients, the esophagus may be the site of the first acquired immunodeficiency syndrome (AIDS)-defining opportunistic illness. METHODS: We reviewed pertinent articles, obtained from a MEDLINE search, on the diagnosis and treatment of esophageal diseases in HIV disease. RESULTS: Infections are the most common cause of esophageal disease, and opportunistic disorders such as cytomegalovirus and idiopathic esophageal ulceration rarely present until the CD4 lymphocyte count falls below 100/mm3. Endoscopy is the most valuable tool for evaluating esophageal complaints in AIDS. CONCLUSIONS: Almost all esophageal infections in patients with AIDS are treatable; therefore, a thorough work-up is indicated. With the widespread use of more effective antiretroviral therapy including the protease inhibitors, there is a general consensus that the incidence of many opportunistic diseases appears to be decreasing.     

Role of the nurse: introducing theories and concepts

The aim was to determine the association between frequency of alcohol use in the past 30 days and HIV-related risk behaviours among adults in an African-American community. Data were collected by trained street outreach workers, from 522 persons in 4 areas selected on the basis of 7 health and criminal justice indicators of high risk for HIV, STD and substance abuse, and drug-related arrests. A survey assessed demographics, substance use, sexual behaviour, HIV knowledge, attitudes and depression. Subjects reporting using drugs other than alcohol (n=201) were excluded from analyses to avoid the confounding influence of polysubstance use. Of the remaining 321 subjects (mean age=37.1; 58.5% were male), 43.6% reported no alcohol use in the past 30 days, with 37.4% and 19.0%, respectively, having used alcohol < =15 days and = > 16 days in the past 30 days. Alcohol use frequency (no alcohol, 1-15 days, 16-30 days in past month) was significantly associated with being male, STD history, non-use of condoms, higher perceived risk of HIV, lower condom use self-efficacy, multiple sex partners in the past 30 days, and lower HIV-related knowledge. Frequent alcohol use, in the absence of other drugs, is associated with higher levels of HIV risk behaviours. Though an underserved population with respect to HIV prevention and, given the prevalence of alcohol use, the findings suggest that programmes need to target frequent alcohol users to reduce their HIV-associated risk behaviours and enhance HIV risk-reduction knowledge and attitudes associated with the adoption of HIV prevention practices.     

Evolving trends revealed by autopsies of patients with the acquired immunodeficiency syndrome. 565 autopsies in adults with the acquired immunodeficiency syndrome, Los Angeles, Calif, 1982-1993 [corrected

OBJECTIVE: To determine changes in causes of death, survival, and organ system distribution of major opportunistic infections and neoplasms in adults dying with the acquired immunodeficiency syndrome (AIDS) following the widespread use of antiretroviral therapy and prophylaxis for opportunistic infections since 1988. DESIGN: A retrospective review of autopsy records with gross and microscopic pathologic findings, laboratory data, and clinical histories in cases of AIDS, comparing findings from 1982 through 1988 with those from 1989 through May 1993. SETTING: All autopsies were performed on persons dying in the metropolitan Los Angeles, Calif, area from January 1982 through May 1993. RESULTS: In 565 adult cases of AIDS at autopsy, Pneumocystis carinii pneumonia (PCP) remained the most common cause of death, but both the frequency of and number of deaths of PCP declined over time. Deaths from bacterial sepsis, cytomegalovirus infection, Mycobacterium avium complex infection, and toxoplasmosis also declined during this period, but mortality from fungal infections, tuberculosis, encephalopathy, and causes unrelated to AIDS increased. The death rate from malignant lymphoma remained high. Kaposi's sarcoma (KS) continued to occur more frequently in patients whose risk factor for human immunodeficiency virus infection (HIV) was homosexuality or bisexuality, but the death rate from KS was greatest for patients with a risk factor of blood exposure to HIV. Survival was shorter and deaths from tuberculosis more common in patients with a history of intravenous drug use. Overall survival of patients in other AIDS risk groups increased over time, particularly in those treated with antiretroviral therapy. The organ system distribution of major opportunistic infections and neoplasms was similar throughout the years of the study. The lung was the most frequent organ involved by AIDS-associated diseases leading to death, followed by the gastrointestinal tract and the central nervous system. CONCLUSIONS: The causes of death in AIDS have evolved since 1988 following the widespread use of prophylactic and antiretroviral therapies in patients with HIV infection. This has occurred primarily from changes in overall frequency and death rates from infections. Organ system involvement by AIDS-associated diseases has not changed significantly over time.