Recent advances in the medical management of early HIV disease

A checklist for evaluation of HIV-infected patients

To aid in making care of HIV-infected patients part of your office routine, Dr Coodley presents here a checklist that combines the various clinical aspects of initial management. Covering the steps from the history to plans for follow-up, this article should allay anxiety and promote confidence in your entire staff by explaining the necessary basics in a simple-to-read format.

Causes of death in persons with human immunodeficiency virus infection

PURPOSE

Pneumocystis carinii pneumonia (PCP) was reported to be the predominant cause of human immunodeficiency virus (HIV)-related deaths prior to 1988, the year that effective prophylaxis against PCP entered routine use. Our study was performed to study the causes of HIV-related death since January 1988 in a region where patient tracking is virtually complete.

PATIENTS AND METHODS

We surveyed physicians associated with the Brown University Acquired Immunodeficiency Syndrome (AIDS) Program who cared for greater than 95% of known HIV-positive patients in Rhode Island. These physicians identified all those HIV-infected persons who had died under their care between January 1988 and July 1990, and determined these patients' causes of death by chart review. For comparison, death certificates of identified persons were also reviewed at the Rhode Island Department of Vital Statistics.

RESULTS

Among 126 deaths since January 1988, bacterial infections were the most common cause of death (30%), whereas PCP was responsible for only 16% of deaths. Persons not receiving any form of PCP prophylaxis were more likely to die from PCP than were those who received prophylaxis (26% versus 11% [p = 0.04]). Cause of death as recorded on actual death certificates was imprecise, although bacterial infections were again the most common cause indicated. Only one death occurred in a patient with a CD4 count greater than 200/mL, and this was not HIV-related.

CONCLUSION

PCP has not been the leading cause of death in our region since January 1988. Bacterial infections contribute substantially to mortality, and this may influence future prophylactic regimens. HIV-related deaths in patients with CD4 counts greater than 200/mL are unusual.

The ambulatory care of HIV-infected persons: a survey of physician practice patterns

OBJECTIVE

To describe the use of various counseling practices, examinations, and laboratory tests used by general internists in the primary care of HIV-infected persons.

DESIGN

Mailed questionnaire survey.

SUBJECTS

Random sampling of members of the Society of General Internal Medicine.

RESULTS

Based on a 64% response rate (131/205), there are many areas of physician agreement in the ambulatory care of HIV-infected persons. Greatest physician consensus was seen in the use of viral serologic testing, vaccinations, and Pap tests. Most (70-80%) primary care physicians do not use surrogate markers such as beta 2-microglobulin and p24 antigen to follow disease progression; instead, they rely mostly on CD4 lymphocyte counts. Sixty percent of physicians continue to order CD4 lymphocyte counts when a baseline count is under 200 cells/mm3. All studies are ordered more frequently for patients with more advanced disease. As a group, those physicians following the largest number of patients do not manage patients significantly differently from the less HIV-experienced physicians.

CONCLUSIONS

Despite some variation, there is substantial consensus on the "routine" management of HIV-infected persons. Clinical guidelines would be one mechanism for defining appropriate care of HIV-infected patients. The majority judgments of the practitioners studied here could be one component among various sources of information used by expert panels to define guidelines except where studies clearly indicate a different and more effective approach. Such incorporation might increase guideline acceptance by practicing clinicians.