Managing Fever and Febrile Symptoms in HIV: Evidence-Based Approaches

Non-pharmacological fever management for persons living with HIV: a best practice implementation project

OBJECTIVES

The aim of this evidence implementation project was to integrate the best available evidence on non-pharmacological fever and febrile symptom management into nursing practice at the Shanghai Public Health Clinical Centre, China.

INTRODUCTION

Fever is challenging for patients with the human immunodeficiency virus (HIV). Guidelines assert that successful non-pharmacological fever management should be the standard of care. To introduce evidence into clinical practice, the Department of Infectious Disease of the Shanghai Public Health Clinical Centre implemented a best practice project.

METHODS

This evidence implementation project utilized the Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI PACES) and Getting Research into Practice (GRiP) audit and feedback tool. Seven audit criteria were established on the best available evidence. The project was divided into three phases and conducted over five months.

RESULTS

Follow-up audits showed significant improvements. The most significant improvements in compliance occurred in the assessment of suitability of external cooling methods (100%), education for nurses (100%) and patients (100%), and monitoring (93%). A moderate increase was noted in the assessment of fluid intake and output volume (73%). A small increase of 30% in compliance was found in hydration support. No changes in compliance were found in assessment of the cause of fever in the HIV-positive population.

CONCLUSIONS

This project led to various changes in the unit including a formal assessment of intake and output volume for PLWHs with chronic fever, a formal assessment of some factors related to the "cause of fever", tailored education programs and materials for both nurses and patients. All these changes are now part of routine nursing practice. Further audits will need to be carried out to sustain practice behavior change and monitor areas for further improvements.

Prevalence of markers of HIV infection among febrile adults and children in Bo, Sierra Leone, 2012-2013

OBJECTIVE

The goal of this study was to examine the prevalence of HIV among febrile patients seeking care in Mercy Hospital, Bo, Sierra Leone, in 2012-2013.

RESULTS

A total of 1207 febrile persons were tested for HIV with Determine™ and SD Bioline rapid diagnostic tests kits that detect the presence of HIV antibodies and HIV p24 antigens. The overall prevalence of HIV among the tested patients was 8.9%, which is considerably higher than the < 2% prevalence of HIV reported previously in the general population. While these results are not sufficient to prove a causal relationship, the obtained data imply that HIV positive individuals may be more likely to suffer from febrile infectious diseases than individuals without HIV infection. Increasing the availability and use of HIV testing services will allow antiretroviral therapy to be accessed in a timely manner and improve health status among people living with HIV.

Consensus Guidelines on Evaluation and Management of the Febrile Child Presenting to the Emergency Department in India

JUSTIFICATION

India, home to almost 1.5 billion people, is in need of a country-specific, evidence-based, consensus approach for the emergency department (ED) evaluation and management of the febrile child.

PROCESS

We held two consensus meetings, performed an exhaustive literature review, and held ongoing web-based discussions to arrive at a formal consensus on the proposed evaluation and management algorithm. The first meeting was held in Delhi in October 2015, under the auspices of Pediatric Emergency Medicine (PEM) Section of Academic College of Emergency Experts in India (ACEE-INDIA); and the second meeting was conducted at Pune during Emergency Medical Pediatrics and Recent Trends (EMPART 2016) in March 2016. The second meeting was followed with futher e-mail-based discussions to arrive at a formal consensus on the proposed algorithm.

OBJECTIVE

To develop an algorithmic approach for the evaluation and management of the febrile child that can be easily applied in the context of emergency care and modified based on local epidemiology and practice standards.

RECOMMENDATIONS

We created an algorithm that can assist the clinician in the evaluation and management of the febrile child presenting to the ED, contextualized to health care in India. This guideline includes the following key components: triage and the timely assessment; evaluation; and patient disposition from the ED. We urge the development and creation of a robust data repository of minimal standard data elements. This would provide a systematic measurement of the care processes and patient outcomes, and a better understanding of various etiologies of febrile illnesses in India; both of which can be used to further modify the proposed approach and algorithm.

Differences in acquired immune deficiency syndrome treatment and evaluation strategies between Chinese and Western Medicine

Complementary and alternative medicine, including Chinese medicine (CM), has been used to treat acquired immune deficiency syndrome (AIDS) foralmost 30 years. We aimed to compare the main differences between AIDS treatment and evaluation strategies between CM and Western Medicine (WM), and analyze advantages and disadvantages. The characteristics of integrative medicine (IM), based on CM and WM, include a patient-centered mode of medicine based on evidence. IM focuses on complex intervention and management with systemic and individual treatment. The evaluation indexes of IM might consist of objective indicators and subjective indexes. IM might be a more valuable method for treating AIDS in the future instead of WM or CM alone.

Connecting the dots: could microbial translocation explain commonly reported symptoms in HIV disease?

Microbial translocation within the context of HIV disease has been described as one of the contributing causes of inflammation and disease progression in HIV infection. HIV-associated symptoms have been related to inflammatory markers and sCD14, a surrogate marker for microbial translocation, suggesting a plausible link between microbial translocation and symptom burden in HIV disease. Similar pathophysiological responses and symptoms have been reported in inflammatory bowel disease. We provide a comprehensive review of microbial translocation, HIV-associated symptoms, and symptoms connected with inflammation. We identify studies showing a relationship among inflammatory markers, sCD14, and symptoms reported in HIV disease. A conceptual framework and rationale to investigate the link between microbial translocation and symptoms is presented. The impact of inflammation on symptoms supports recommendations to reduce inflammation as part of HIV symptom management. Research in reducing microbial translocation-induced inflammation is limited, but needed, to further promote positive health outcomes among HIV-infected patients.

Clinical aspects of headache in HIV

BACKGROUND

Headaches are commonly seen in those patients with human immunodeficiency virus (HIV) and are the most common form of pain reported among HIV patients. There have been relatively few studies attempting to determine the rates and phenotypes of the headaches that occur in patients with HIV.

DISCUSSION

Patients with HIV are susceptible to a much broader array of secondary headache causes, sometimes with atypical manifestations due to a dampened inflammatory response. The investigation of a headache in the HIV patient should be thorough and focused on making sure that secondary and HIV-specific causes are either ruled out or treated if present.

CONCLUSION

An effective treatment plan should incorporate the use of appropriate pharmacological agents along with the integration of non-pharmacological therapies, such as relaxation and lifestyle regulation. When treating for headaches in patients with HIV, it is important to keep in mind comorbidities and other medications, especially combination antiretroviral therapy. For those with complicated headache histories, referral to a specialized headache center may be appropriate.