For more information, visit the Peer-to-Peer Katrina Survivors Support Home Page
These are general recommendations for clinicians who are not HIV specialists. We encourage you to call the NIH Medical Consultation Services at 1-866-887-2842 or the National HIV/AIDS Clinical Consultation Center at 1-800-933-3413 to consult with HIV experts. Visit www.aahivm.org
or www.hivma.org for updates to this
document.
1) First priority is to treat active infections. Most HIV patients will respond to treatment with antibiotics just like non-HIV patients.
2) Find out the patient's last CD4 (T cell) count, if possible. The most frequent infections by CD4 count are:
CD4 <500 |
TB, Herpes zoster, sinusitis, bronchitis |
CD4 <200 Pulmonary |
Include Pneumocystis jiroveci (formerly carinii) pneumonia (PCP) in your differential diagnosis. Subacute symptoms include dry cough.
Especially important in patients who are not getting prophylaxis with SMX/TMP, Dapsone, or Atovaquone. |
CD4 <100 CNS |
Include toxoplasmosis and cryptococcal meningitis in differential diagnosis. Histoplasmosis is also very common in the Mississippi delta region. It may occur with higher CD4 counts but may show up in unexpected and more virulent forms with lower CD4 counts. Also consider if CD4<200 and taken some time ago. |
CD4 <50 with unexplained fever |
Consider Mycobacterium avium complex (MAC) and systemic fungal disease in differential diagnosis, especially if patient is not on clarithromycin or azithromycin prophylaxis. |
3) If it is a choice between getting antiretroviral medications and
getting prophylaxis for opportunistic infections (OI) for patients on
HAART, get the antiretrovirals first to avoid treatment interruptions.
Such interruptions can lead to the development of drug-resistant virus.
However, if drug supply in the general community is not an issue, make
every attempt to continue all medications for OI prophylaxis and antiretrovirals.
If medications are interrupted, make sure to restart all antiretrovirals
and OI prophylaxis medications. For patients not on HAART and CD4 <200,
SMX/TMP is the preferred prophylaxis. Recommendations for antiretroviral
therapy are available at http://www.aidsinfo.nih.gov/guidelines.
4) If patients cannot obtain their medications, make sure that they stop all antiretroviral drugs, rather than continuing on only one or two.
5) Once continued access to antiretroviral therapy is enssured, patients
should have their OI prophylaxis continued. Federal guidelines on the
prevention and treatment of OI are available at http://www.aidsinfo.nih.gov/guidelines.
6) People with HIV should get tetanus shots, just like everyone else.
7) Live virus vaccines should be used with caution in people with HIV. However, people with CD4 (T cell) counts over 350 should do fine and have a normal response. Use clinical judgment--preventing epidemics remains a priority, even with people with HIV.
Basic Medication Information
- An easy-to-read chart of AIDS drugs with photos is available at
www.aidsmeds.com/lessons/drugchart.htm.
- Certain medications are heat sensitive and are best kept refrigerated.
Ritonavir (Norvir) and Lopinavir/Ritonavir (Kaletra) should maintain
potency at room temperature (77F), Ritonavir for 30 days, and Lopinavir/Ritonavir
for 60 days. Saquinavir (Fortovase) soft gel can be out of refrigeration
for 90 days. Tipranavir can be at room temperature for 60 days. Exposure
to extreme heat and/or sunlight can greatly diminish potency, necessitating
replacement (be aware of this in places that still have no power or
air conditioning).
Important Drug Interactions to Consider
efavirenz (Sustiva) |
AVOID clarithromycin, triazolam |
ritonavir (Norvir) or lopinavir+ritonavir (Kaletra)) |
AVOID alprazolam, buspirone, daizepam, flurazepam, triazolam, zolpidem |
Protease Inhibitors
saquinavir (Invirase, Fortavase), indinavir (Crixivan), ritonavir (Norvir), nelfinavir (Viracept), fosamprenavir (Lexiva), lopinavir/ritonavir (Kaletra), atazanavir (Reyataz), tipranavir (Aptivus)
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USE CAUTION WITH rifampin; dose modification required. It is far preferable
to use other classes of drugs, specifically sustiva (Efavirenz),
if possible. |
atazanavir (Reyataz) |
AVOID Proton pump inhibitors and H2 blockers |
Pregnant Women: For pregnant patients be sure to consult
fact sheets about appropriate antiretroviral medications. Recommendations
on antiretroviral treatment for pregnant women and interventions to
reduce perinatal HIV transmission are available at http://aidsinfo.nih.gov/guidelines.
An easy-to-read chart of acceptable medications for pregnant women is
available at http://www.aidsmeds.com/lessons/Pregnancy8a.htm.
Treatment for Possible Exposure to HIV Infection:
Prophylactic antiretrovirals should be administered if at all possible
in occupational and non-occupational exposures. The current recommendations
for healthcare worker occupational exposure are out of date. Use the
same protocols for occupational as for non-occupational exposures. New
recommendations for occupational exposures are due to be released in
MMWR in late September. Consultation on PEP is available from the National
PEPline at 1-888-HIV-4911.
Rapid HIV Testing: If possible, do rapid HIV testing.
People will need proof of their HIV status to obtain help from HIV service
providers.
Locating HIV Providers and Clinics: For a list of
HIV clinics, go to www.aahivm.org
or www.hivma.org and click on the
Hurricane Katrina links. HIVMA and AAHIVM members accepting patients
also are available from our Websites or by calling 1-888-844-4372 (HIVMA)
or 1-866-241-9601 (AAHIVM).
Patients Enrolled in Clinical Trials: Patients enrolled
in clinical trials should contact the trial sponsor to obtain experimental
study drugs. Some contacts are: AIDS Clinical Trials Group - 301-628-3000;
Bristol Myers Squibb - 800-272-4878; Community Programs for Clinical
Research on AIDS - 1-301-628-3000; GlaxoSmithKline - 1-888-825-5249; TIBOTEC - 1-609-730-7500.
For others, call the NIH consultation number at 1-866-887-2842 or the main number for the pharmaceutical company involved.
The American Academy of HIV Medicine and HIV Medicine Association collectively
represent more than 3,500 HIV medical providers throughout the United States
More resources are available on our Websites at http://www.aahivm.org
and http://www.hivma.org.
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