The staging and monitoring by primary care providers of patients with human immunodeficiency virus infections

As HIV testing expands through the population, primary care physicians will become more involved in the testing process. They will also be caring for increasingly larger numbers of HIV infected people from the asymptomatic through those with AIDS, through hospice care, should that become appropriate. This article summarizes key areas of clinician support for the HIV infected, clinical and laboratory markers associated with rapid progression of the disease, and important problem areas in clinical management. It also presents a series of staging diagrams that have proven useful in assisting clinicians in educating patients about the natural history of the HIV infection, the rationale for staging, the rationale for the timing of AZT therapy and Pneumocystis prophylactic treatment, and the significance of various prognosticators in management as the disease progresses.

[A cursed duo: HIV infection and tuberculosis]

Tuberculosis remains a health problem of extraordinary magnitude, especially in developing countries. Unfortunately, many of the same countries have the additional burden of a remarkably high prevalence of HIV infection. Because of the inherent capacity of tubercle bacilli to take advantage of deficiencies in cell-mediated immunity, tuberculosis has become an extremely important infectious complication of HIV disease in those developing countries in which the two infections coexist; the same is true, although to a lesser extent, in developed countries among those groups of patients with HIV infection, in which there is also a high prevalence of remotely acquired tuberculosis.

Toward rational nutritional support of the human immunodeficiency virus-infected patient

The acquired immunodeficiency syndrome and (human immunodeficiency virus) infection loom as our major public health priorities for at least the next two decades. Despite the recent exciting early development of vaccines and newer drug therapies, we are all faced with a reservoir of almost one-quarter million cases in the United States and several times that worldwide. Since the vast majority of HIV-infected patients develop AIDS, which is a chronic progressive disease that produces gastrointestinal dysfunction and wasting, development of rational strategies for nutritional support of these patients should also be a high priority.

Analysing the workload from HIV inpatients: a 10-month retrospective study

To assess the clinical and laboratory workload arising from human immunodeficiency virus (HIV)-related inpatient admissions in a London teaching hospital, a 10-month retrospective audit was performed of the casenotes of all HIV-infected inpatients admitted under the care of one consultant physician. During this period, 84 inpatients were identified who generated 371 admissions, of whom 71 (84.5%) had acquired immunodeficiency syndrome (AIDS). Over two-thirds of admissions were essentially day cases, attributed to blood transfusions, antimicrobial and tumour, chemotherapy, and minor surgery; with blood transfusions alone accounting for 43% of all admissions. Pulmonary infections (pyogenic and cell-mediated opportunist) accounted for 46 (12%) of admissions, with Pneumocystis carinii pneumonia second only to blood transfusions in caseload prevalence score (see below). Neurological complications of AIDS were associated with the longest admissions. Laboratory-based investigations were heavily utilized by AIDS inpatients, particularly bacteriological services. Choice of radiological investigation correlated with the anatomical site of disease presentation: plain radiology for chest symptoms, ultrasound for abdominal symptoms and computerized tomography (CT scanning) for neurological presentations. Drug-induced anaemia accounted for a substantial number of HIV-related admissions for red cell transfusions, which together with the disproportionate workload from daycase-type admissions, might be better handled in lower dependency day wards.

The cost of caring for patients with HIV infection in hospice

This article explores the organizational barriers that have limited the number of persons with AIDS cared for by hospice programs throughout the United States. The financial implications of caring for persons with AIDS are discussed and data from a survey of 15 hospice providers is presented. Examples of creative and cooperative coalitions among hospice programs and other community organizations that maximize scarce resources and share the financial burden of caring for those infected with HIV are presented as models. The diverse funding sources and individual hospice program decisions about palliative treatments and drugs and admission criteria highlight the difficulty of generalizing from the survey.

[HIV-infection and psychiatric emergency. A clinical example]

The case illustrates the interaction between a hospitalized patient and staff members who are not well enough prepared to meet problems related to HIV-infection. A 41 year-old homosexual man with HIV-infection discovered in 1984 developed an acute psychosis in 1986. He was hospitalized in a psychiatric ward, where he triggered off a crisis reaction among staff members. They were afraid of being contaminated by a painful and mortal disease, and had obviously not worked through their feelings about sexuality and death. Their crisis made them unable to recognize the patient's emotional problems and therapeutic needs. The patient's situation deteriorated until staff members succeeded in clarifying their own reactions. Subsequently they were able to work out a better therapeutic approach in line with what they usually managed when treating psychotic patients.

[Relationship between the use of postgraduate educational material on human immunodeficiency virus and the number of HIV consultations in family practice]

An enquiry using a structured questionnaire was conducted among all 6300 GPs in the Netherlands in order to assess the distribution of HIV-related problems over general practices in the Netherlands and the influence on it of the use of the 'HIV-wijzer voor de huisarts', a loose-leaf handbook on HIV, distributed since 1988 among all Dutch general practitioners. The enquiry was conducted one year after its publication. The 2156 respondents (34%) appeared to be reasonably representative of all GPs. The results show minor imperfections because a small proportion of the questionnaires was filled out incompletely. Almost 90% of respondents mentioned HIV-related consultations, 24% had HIV-seropositive patients and 18% had AIDS patients. These numbers were correlated mainly with municipality size, less with region. The use of the 'HIV-wijzer' was related to occurrence of HIV-related consultations and AIDS patients in a practice. GPs who do not encounter these problems are little motivated to read the 'HIV-wijzer'. For them, other means of education have to be developed or HIV has to be included in existing education programmes on other subjects.

Oral manifestations of HIV infection and their management. I. More common lesions

Oral lesions are common at all stages of HIV infection. This first of two articles reviews the clinical features and pathogenesis of common oral manifestations of HIV disease (candidiasis, hairy leukoplakia, Kaposi's sarcoma, and HIV-related periodontal disease) and considers current treatment measures.

Current status of immunotherapy of patients with HIV-infection

Immunotherapy is receiving increasing attention as an approach to managing HIV-infection and its complications. As the immune response to HIV becomes better understood, new approaches to HIV immunotherapy are possible. Approaches under development include, first and foremost, the use of vaccines, not only for prophylaxis but also for therapy of established disease. Other approaches being studied include passive serotherapy, use of synthetic HIV-binding molecules such as CD4, immunorestoration and immunomodulation with immunomodulatory drugs, thymic hormones, cytokines and anti-infective immunotherapy directed against the opportunistic infecting organisms of HIV. The current role of these modalities as single agents and in combination and their potential role in the future is discussed.

In vitro immunomodulation and in vivo immunotherapy of retrovirus-induced immunosuppression

Early studies with the Gross passage A leukemia virus demonstrated that retroviral infection suppresses cellular and humoral immune responses. In extensive studies of the feline leukemia (FeLV) virus, which can induce profound immunodeficiency disease, are generative anemia and lymphoid, myeloid and erythroid neoplasia, the immunosuppressive effects of this retrovirus could be attributed to the actions of the retroviral envelope protein p15E. We found that a highly conserved, synthetic 17 amino acid peptide synthesized by Cianciolo and co-workers that is homologous to the hydrophilic portion of the otherwise hydrophobic transmembrane envelope protein can suppress polyclonal activation of B-cells, impair production of gamma- and alpha-interferon, inhibit production of interleukin-2, inhibit expression of IL-2 receptors, and suppress responses of cytotoxic lymphocytes. In analyses with inactivated preparations of the human immunodeficiency virus, with Pahwa et al. we demonstrated that purified non-infectious retrovirus and also retroviral proteins, in particular gp120, appeared to produce some of the immunosuppressive properties of HIV, particularly suppression of B-cell activation in response to known B-cell stimulants irrespective of T-cell influence, suppression of T-helper cell functions essential to B-lymphocyte responsiveness, and impaired function of immunoglobulin-secreting cells. Other investigators have also reported strong immunosuppressive or immunostimulatory influences for components of the HIV retrovirus and also gp120 through yet poorly elucidated but certainly complex actions on both T- and B-lymphocyte-mediated immune functions.

Clinical and immunologic effects of combination therapy with intravenous immunoglobulins and AZT in HIV-infected patients

30 patients with HIV infection were enrolled to evaluate the clinical efficacy and toxicity of zidovudine (AZT), 0.5 g/day p.o. (Group A) vs. AZT 0.5 g/day p.o. plus intravenous immunoglobulins (IVIG), 0.4 g/kg of body weight for three consecutive days, followed by one treatment of 0.6 g/kg of body weight every fourth week (Group B), over a period of one year. The study was open and randomized. The treatment groups were compared using the following study variables: 1) type of infections, recurrences and severity; 2) change in CD4+ T and CD8+ T cell count; 3) change in platelet count; 4) change in TNF alpha serum levels; 5) the probability of not developing an opportunistic infection over a period of 12 months. Patients from Group B developed less pathological events in comparison to Group A. No significative differences were evident with regard to values of T cell subsets obtained before and after treatment in each group and between the two groups. On the contrary, in 12 out of 15 patients from Group B there was a significant increase in platelet count. In both groups there was a significant decrease of mean serum levels of TNF alpha when a comparison was made between time 12 vs. time 6. However, when data were expressed as single values, in three subjects from Group B TNF alpha was still detectable by time 12 vs. 9 individuals in Group A. The cumulative probabilities of developing an opportunistic infection over the 12 months of treatment in the Group A subjects were significantly higher than in the Group B subjects (p less than 0.01). Adverse effects--nausea and gastric pain--were reported for 3 individuals (20%) from Group A and 4 patients (26%) from Group B. In conclusion, patients treated with AZT are especially likely to benefit from IVIG prophylaxis.

Use of DHCP to provide essential information for care and management of HIV patients

The Department of Veterans' Affairs (VA) has reported over 10,000 Acquired Immune Deficiency Syndrome (AIDS) cases since the beginning of the epidemic. These cases were distributed throughout 152 of the VA's network of 172 medical centers and outpatient clinics. This network of health care facilities presents a unique opportunity to provide computer based information systems for clinical care and resource monitoring for these patients. The VA further facilitates such a venture through its commitment to the Decentralized Hospital Computer Program (DHCP). This paper describes a new application within DHCP known as the VA's HIV Registry. This project addresses the need to support clinical information as well as the added need to manage the resources necessary to care for HIV patients.

Report of an expert panel on the Public Health Laboratory role in early intervention and treatment of human immunodeficiency virus infections

A coordinated national effort to control the HIV epidemic based on an early intervention model must be initiated. This national strategy will provide for an effective distribution, application, and utilization of limited Federal, State, and local resources.

HIV vaccine therapy

The immunoregulatory mechanisms responsible for effective the in vivo post-infection control of HIV are unknown. In the setting of natural HIV infection, host-directed immune responses directed against gp120 are minimal. This includes poor gp120 epitope specific antibody responses to C1, C2 and C3; lack of T-cell recognition and proliferation to gp120; and minimal envelope cytotoxic T-cell responses. The historical important of anti-envelope responses in the control of other viral pathogens, coupled with the paucity of anti-envelope responses elicited as a consequence of HIV infection, formed the basis for our rationale to pursued a research program which focused on post-infection vaccination utilizing HIV enveloped derived products. Recently we have demonstrated the scientific feasibility of post-infection vaccination with an HIV envelope based vaccine to broaden host-directed HIV-specific immune responses to include seroconversion to gp120 C1, C2 and C3; the induction of T-cell recognition to gp160; and cytotoxic T-cell responses to envelope peptides. The in vivo safety and immunogenicity of the product in adult patients with early HIV infection has been demonstrated. An expanded phase II trial with rgp160 (MGS) is ongoing to examine the potential role of HIV-specific vaccine therapy to alter the natural history of HIV infection. Finally, we are exploring the value of post-infection immunization in defining specific immune responses and their in vivo HIV immunoregulatory relevance.

The use of interferon-alpha in virus infections

The interferons (IFN) act too slowly to arrest acute viral infections, but interferon-alpha (IFN alpha) preparations have proved useful in some chronic infections and will clearly be used increasingly in these in the future. In the preparations derived from human leucocytes or cultured B lymphoblastoid cells, which are in routine clinical use, mixtures of a number of distinct subtypes of human IFN alpha have been identified. There are also 3 slightly different versions of the same single subtype, IFN alpha-2, made by recombinant DNA procedures in bacteria. IFN alpha preparations are injected intramuscularly or subcutaneously. Dose-related side effects are common but usually tolerable, but prolonged treatment may cause increasing fatigue and depression. Some patients form neutralising antibodies which block the effects of the IFN; these appear to be relatively more common after recombinant IFN alpha-2 than after IFN derived from human cells. Given intranasally, IFN alpha can prevent a subsequent experimental rhinovirus infection, or the spread of natural colds within a family. Repeated administration progressively damages the nasal mucosa, so that long term prophylaxis is not possible. IFN alpha has proved useful in patients with papillomavirus warts of the larynx, ano-genital region (condyloma acuminata) and skin (common warts). Treatment regimens remain to be optimised and are likely to include surgery or other treatments. IFN alpha and zidovudine (azidothymidine) synergistically inhibit the growth of HIV in vitro, and combination are on trial in patients with early AIDS. Very large doses of IFN alpha are effective against Kaposi's sarcoma in some AIDS patients. In chronic hepatitis B, continuing virus replication may lead to cirrhosis or primary liver cancer. Earlier clinical trials with IFN alpha gave inconclusive results, but recent large studies have confirmed that 25 to 40% of patients obtain benefit; this probably results from both the antiviral and the immunomodulatory effects of IFN alpha. In patients with chronic hepatitis C, the biochemical markers usually improve rapidly during IFN alpha administration, but relapse if treatment is stopped after only a few months; to increase the chances of sustained cure, the treatment period is now being prolonged.

Primary care and HIV disease

Nearly one million Americans are infected with the human immunodeficiency virus (HIV). With the advent of increasingly effective therapy, including intervention early in the course of infection, there will be a growing need for physicians technically and attitudinally prepared to provide primary care for HIV-infected individuals. For any disease, however, determination of which physicians provide the bulk of care depends on several factors, including the prevalence and chronicity of the disease, the complexity, rate of change, and toxicity of therapy, and the socioeconomic characteristics of patients with the disease. General internists will clearly constitute a large part of the pool of practitioners caring for HIV-infected patients, especially in the earlier stages of infection. It seems reasonable to expect every general internist to be competent in four aspects of HIV care: counseling about transmission and prevention; the proper administration and interpretation of diagnostic tests; monitoring and care of patients in early stages of infection; and recognition of complications of advanced infection for proper management or referral. Academically based generalists will have a major role in research, teaching, and patient care in the AIDS epidemic. The organization and delivery of primary and specialty care for HIV-infected people in future years will continue to evolve with changes in therapy and in the demography of the epidemic.

The combined treatment of human peripheral blood mononuclear cells with thymolymphotropin and interleukin 2 increases PPD-driven T-cell proliferation and IL-2 induced cellular cytotoxicity against HIV-infected cells

Two in vitro systems (the DNA synthetic response to mycobacterial antigens and cytotoxicity against lymphoid cells) were used to analyse the effect of thymolymphotropin (TLT) on peripheral blood mononuclear cells (PBMC). Purified protein derivative of mycobacteria (PPD)-driven T-cell proliferation in low-responder donors was increased by the combined treatment with TLT and suboptimal doses of recombinant interleukin 2 (IL-2). Similarly, the activities of natural killer (NK) cells and lymphokine-activated killer (LAK) cells have been enhanced in PBMC cultures pretreated with TLT. Also, TLT showed an enhancing effect on the development of LAK cells capable of lysing Epstein-Barr virus (EBV)-transformed B-lymphocytes infected or uninfected with the human immunodeficiency virus (HIV).

What's in a name? The policy implications of the CDC definition of AIDS

Disease classification systems and surveillance definitions are ordinarily tools for medical professionals, not matters for political debate and patient advocacy. It is hard to imagine a protest march complaining about the classification system for colon cancer. But when it comes to AIDS, nothing is ordinary.

The Centers for Disease Control's (CDC) case definition of AIDS is used by public health officials, researchers, clinicians, hospital administrators, disability specialists, insurance administrators, health economists, legislators, social workers, policy makers, and the media. It has influenced the way the HIV epidemic is perceived, managed, and funded.

It is not surprising, then, that the CDC definition of AIDS and its proposed revision is currently the subject of intense scrutiny. The case definition has transcended epidemiology to become a symbol for the inadequacies of the U.S. government's response to the HIV epidemic, and a particular symbol for the failure to address the needs of HIV-infected women.

Production of a murine monoclonal antibody with anti-HIV-1 neutralizing properties

A mouse monoclonal hybridoma cell line producing IgG 1k to human immunodeficiency virus (HIV-1) gp120 envelope protein was cultured in several systems. A small-scale flask culture was essential for characterizing the culture variables of the hybridoma. A dialysis tubing culture appeared to be an excellent alternative to in vivo cultures of ascitic fluid, and gave high mouse monoclonal antibody (Mab) concentrations. Two continuous culture systems were both very effective in producing large amounts of Mabs. The hollow fiber system has the advantage of giving a concentrated product in the harvest. The ceramic core system, on the other hand, allows excellent monitoring of the cellular growth and production phases and gave the highest HIV antigen reactivity/micrograms of the produced IgG. Twelve grams of HIV-1 neutralizing Mabs were produced. The Mab was purified with a yield of 61%. The neutralizing capacity of the Mab was studied in vitro and shown to be excellent with 50% neutralizing titers using 5 ng Mab. The biological half-life of the Mab given intravenously to an HIV-infected individual was shown to be around 30 h.

Model of care for the hospital treatment of individuals with HIV infection

This study was undertaken and completed in 1988, in an attempt to determine the reasons for admission to hospital, and the optimum care required for patients with Human Immunodeficiency Virus related illnesses. Approximately half of the total medical admissions stayed for less than a week, and patients admitted for terminal care and social care occupied a relatively small proportion of the beds. The single largest group of admissions were those for inpatient management of AIDS-related pneumonias. The results of this study provide a greater understanding of the resources currently required for such care, and suggest initiatives for meeting future needs.

Report of a WHO informal consultation on preclinical and clinical aspects of the use of immunomodulators in HIV infection. Geneva, 3-5 April 1989. World Health Organization Global Programme on AIDS

A wide spectrum of immunomodulatory strategies offer promise for treating people with HIV infection; however, numerous gaps still exist in our understanding of the normal regulation of the immune system during the progression of HIV infection. Preclinical development of immunomodulators must include a strong rationale for the use of the immunomodulating substance substantiated by appropriate laboratory studies, in vitro as well as in vivo. Preclinical studies must demonstrate the safety of the proposed therapeutic agent, including an assessment of the potential for adverse effects on immune function and virus replication. Combined therapeutic modalities should also be appropriately evaluated at the preclinical level. Clinical evaluations should be instituted only after a strong rationale is substantiated and safety concerns are fully considered. Initial studies should be conducted with patients at an intermediate stage of HIV disease progression. Immunomodulators may exhibit unusual dose-response patterns, and this should be considered when designing the trials. The consultation recommended that WHO continue to provide a forum for the timely exchange and validation of information related to the development and clinical evaluation of immunomodulators for the treatment of individuals infected with HIV.

Preventing and treating human immunodeficiency virus infection in the homeless

The problem of human immunodeficiency virus infection in the homeless has received little attention in the literature but is a cause for serious concern. Nineteen health care agencies were studied to explore the types and outcomes of programs targeting this population, and factors associated with prevention and treatment strategies. The results showed that a variety of services were provided, but that little formal evaluation had been conducted. Factors identified were population variability, altered health status, daily survival, provider role conflicts and attributes, and a so-called nonsystem of care. The numerous gaps in knowledge about human immunodeficiency virus infection in the homeless inform future psychiatric nursing care and research.

[Psychosocial problems in HIV infected families--possibilities for coping]

The psychosocial problems of 49 HIV-exposed children (data given as of September 1989) and 19 HIV-infected hemophiliacs cared for in the pediatric immuno-deficiency clinic of the Munich university hospital are described in detail. Drug addiction, financial needs, housing problems and delinquency play an important role in the first group. Hemophiliacs, however, live in more stable family conditions. Both groups are offered counseling, home and hospital visits, and legal, administrative and financial support. Furthermore we help with coordinating regular meetings, obtaining short-time housekeepers and arranging long-term addiction-treatments for mother and child. When dealing with hemophilic patients our team is frequently confronted with problems of friendship, sexuality and professional training.

AZT demonstrates anti-HIV-1 activity in persistently infected cell lines: implications for combination chemotherapy and immunotherapy

A sensitive and quantitative focal immunoassay has been used to measure the effects of three different therapeutic agents on tissue culture cells infected with human immunodeficiency virus (HIV). The effects of the drugs were studied on both acutely and persistently infected CD4+ cell lines. The three agents, azidothymidine (AZT), interferon-alpha (IFN-alpha), and an anti-HIV envelope antibody coupled to ricin A chain, were tested alone and in combination. AZT was found to have its greatest effect during early stages of the infection, but also had an action on persistently infected T cell lines. The effect of AZT on persistently infected cells was seen within 24 h, increased with extended exposure to the drug, and persisted after its removal. IFN-alpha had variable effects on acutely infected cells but suppressed chronic infection. Combinations of the therapeutic agents were studied. Using a model that allowed for treatment during both acute and persistent stages of infection, the most effective combination in suppressing HIV infection was the continual use of both AZT and IFN-alpha at the highest tolerable doses. Knowledge of the efficacy of AZT on persistently infected cells will allow for the most effective design of clinical protocols.

Stand-alone HIV clinic expected to save money, help patients

Images

Elimination of infectious human immunodeficiency virus from human T-cell cultures by synergistic action of CD4-Pseudomonas exotoxin and reverse transcriptase inhibitors

We have previously described a recombinant protein, designated CD4(178)-PE40, consisting of the human immunodeficiency virus (HIV) envelope glycoprotein-binding region of human CD4 linked to the translocation and ADP-ribosylation domains of Pseudomonas aeruginosa exotoxin A. By virtue of its affinity for gp120 (the external subunit of the HIV envelope glycoprotein), the hybrid toxin selectively binds to and kills HIV-1-infected human T cells expressing surface envelope glycoprotein and also inhibits HIV-1 spread in mixed cultures of infected and uninfected cells. We now report that CD4(178)-PE40 and reverse transcriptase inhibitors exert highly synergistic effects against HIV-1 spread in cultured human primary T cells. Furthermore, combination treatment can completely eliminate infectious HIV-1 from cultures of human T-cell lines. This conclusion is based on protection of a susceptible cell population from HIV-induced killing, complete inhibition of virus protein accumulation, and elimination of HIV DNA (as judged by quantitative polymerase chain reaction analysis). The results highlight the therapeutic potential of treatment regimens involving combination of a virostatic drug that inhibits virus replication plus an agent that selectively kills HIV-infected cells.

Sexually transmitted arthritis syndromes

Sexually transmitted infections may provoke a wide variety of rheumatic lesions. Disseminated N. gonorrhoeae infection leads to septic arthritis, which may be rapidly destructive but which responds promptly to appropriate antibiotic therapy. In contrast, both gonococcal and nongonococcal infections may lead to aseptic "reactive" arthritis or Reiter's syndrome. Inheritance of HLA B27 confers a relative risk of 30 to 50 times for the development of this condition. The demonstration of C. trachomatis antigen in joint material from a minority of patients suggests that direct interaction between microbial components and class I HLA antigens in the joint may be central to the pathogenesis of this disease. Arthralgia and arthritis occur in up to 50% of individuals in the prodrome of hepatitis B infection. Joint symptoms may be accompanied by urticarial or cutaneous vasculitic lesions, especially on the legs; both features resolve with the onset of jaundice. Hepatitis B infection is also a major cause of necrotizing vasculitis, which may or may not be associated with overt hepatitis. Seronegative arthritis, including Reiter's syndrome, psoriatic arthritis, and undifferentiated arthritis, a Sjögren's-like syndrome, vasculitis, and myopathies have been described in association with HIV infection. It is clear that synovitis occurs in those patients despite the fact that HIV is present in immune cells within the joint during inflammatory arthritis and that both antigen presentation and lymphocyte responsiveness within the joint are impaired. Nevertheless, synovitis may occur in the presence of marked CD4-positive lymphocyte depletion. Rheumatic syndromes, including arthralgia, inflammatory arthritis, and neuropathic arthritis, may occur during any stage of congenital or acquired syphilis. Syphilitic synovitis responds well to antibiotic therapy, but neuropathic lesions cannot be treated effectively. Septic arthritis has rarely been described as a complication of disseminated Mycoplasma or Urea-plasma infections, and joint lesions sometimes associated with erythema nodosum have also been reported in lymphogranuloma venereum and granuloma inguinale.

[Methods of hospital management of patients with HIV infection]

Analysis of data on case-management and referral of persons infected by HIV is based upon a cross-sectional study at the national level. The evolution of trends over the last 2 years reveals a rise in the number of AIDS cases undergoing full hospital treatment and a decline in the number of seropositives hospitalised. Irrespective of the clinical presentation, there has been above an increase in hospital care day treatment and consultations. Amongst all AIDS patients there is a growing need for increased treatment and case in the home as well as intermediary length hospital case management--a crucial consideration for the future.

Office management of patients infected with the human immunodeficiency virus (HIV)--1990

Human immunovirus (HIV) infections and related diseases continue to consume a major portion of health care resources nationwide and in the state of Oklahoma. There were 162 new cases of acquired immunodeficiency syndrome (AIDS) diagnosed in Oklahoma in 1989 and an additional 347 cases of other HIV infections were reported. It appears almost certain that few physicians in practice, if any, will escape seeing HIV-related illnesses. It is, therefore, important that all physicians have an adequate understanding of the basic management of these related illnesses. The reader is referred to our original article in the October 1988 issue of the Journal of the Oklahoma State Medical Association, which outlined the office management of HIV-positive patients. The current paper represents an update on this problem. Many of the original tenets and descriptions of management remain the same, and they will not be repeated.