IMPORTANT NOTE: JAAPA CME activities consist of 2 articles. To obtain credit, you must also read
Breaking bad news: Communication skills for difficult conversations; the post-test will include questions related to both articles. AAPA Fellow members should complete and submit the post-test on the AAPA Web site by going to
www.aapa.org and searching for keyword
JAAPA post-tests. All others may complete and submit the post-test online at no charge at
www.mycme.com. To obtain 1 hour of AAPA Category I CME credit, PAs must receive a score of 70% or better on each test taken.
KEY POINTS
■ Describe current guidelines for treatment of the HIV-1-infected adult and adolescent
■ Discuss the criteria and controversy regarding when to initiate antiretroviral therapy
■ Review laboratory monitoring for patients prior to and after initiation of antiretroviral therapy
■ Explain first-line highly active antiretroviral treatment (HAART) regimens
In most urban clinical settings, clinicians providing HIV care practice in an environment where infectious disease specialists and pharmacists well-versed in the treatment of HIV disease are readily available. Additionally, a standard of care has been established based on the documented proficiency of the clinicians providing HIV care. This standard of care states that only those clinicians seeing 20 or more patients ongoing are considered to be experienced and proficient in providing HIV care.1 Nonetheless, PAs in many non-HIV clinical settings are confronted with patients at risk for exposure or already infected and must provide education about and medical care for HIV disease. Thus PAs are responsible for knowing the most current information on the treatment of HIV disease.
The US Department of Health and Human Services (DHHS) sets the standard of care in many areas of medicine in the United States. The CDC, one of the DHHS agencies, is responsible for maintaining the guidelines for the use of antiretroviral (ARV) agents in HIV-1-infected adults and adolescents. The December 2009 DHHS guidelines provide the most current evidence-based information.2 The literature evaluated and summarized in the guidelines is extensive and addresses multiple issues related to medication resistance, drug interactions, adverse reactions, and adherence to therapy. This review addresses only the following subjects: the timing of antiretroviral therapy, criteria for initiation of therapy, and new data on potential first-line options for antiretroviral therapy.
WHEN TO START THERAPY
One of the most difficult patient questions to answer is,
"When should I start taking medication for HIV?" Clinicians should look to the DHHS guidelines to assist them in answering this question.
The members of the guidelines committee had extensive discussions on the optimal time to initiate antiretroviral therapy, and the final recommendation is to start therapy in anyone with a CD4+ T-cell count (CD4 count) between 350 and 500 cells/mm3. Although this recommendation is established, the committee members were split on how strong the recommendation should be; 55% strongly supported it and 45% moderately supported it. In addition, approximately one-half of the DHHS panel favored starting ARV therapy for patients with CD4 counts ≥500 cells/mm3.2
The baseline evaluation of a patient with newly diagnosed HIV infection is extensive and includes a complete medical history, physical examination, laboratory evaluation, and counseling regarding the implications of HIV infection.2 In addition to confirming the diagnosis with a repeat of HIV antibody screening, an HIV viral load, CD4 count, and T-lymphocyte differentiation must also be obtained. If the patient's viral load is at least 500 to 1,000 copies/mL, genotypic resistance testing is advised as well. Additionally, the patient must be screened for tuberculosis; hepatitis A, B, and C; syphilis; and many of the other sexually transmitted infections. HIV-infected women should have a Pap smear annually, and HIV-infected men who have sex with men (MSM) are advised to have anal Pap smear screening for abnormalities secondary to exposure and infection with the human papillomavirus (HPV). HIV-1-infected patients must also be screened for antibodies to those pathogens, such as Toxoplasma, that may emerge as opportunistic infections if the patient's CD4 count continues to decline to less than 100 cells/mm3.2
Adding to the complexity of care, the HIV-infected patient may present with multiple barriers to care and to the initiation and maintenance of treatment. These cofactors are often identified in the screening history and physical examination and may be related to a wide range of factors, including substance abuse, unstable housing and economic support, homelessness, mental illness, and medical comorbidities. Subsequently, adherence to antiretroviral therapy may be interrupted, creating additional complexities in the form of resistance to the most efficacious and least toxic ARV medication regimens available.3