Southern Alberta HIV Clinic

Information for Patients

Disease Management Plan

Introduction

Both patients and health care workers involved in the delivery of HIV care in Southern Alberta believe that a multidisciplinary cooperative approach is essential for providing the best possible care to patients with a disease that has so many medical manifestations and social implications. A multidisciplinary team of health care workers including physicians (primary care, specialty and sub-specialty), peer counsellors, pharmacists, social workers, clinical researchers, nurses, and a dietitian is available in the clinic. Other expertise is provided outside the clinic by referral.

Initial Assessment

Our philosophy is the initial assessment and the resulting management plan, developed with the patient during their first few visits to the clinic, is critical for a successful long-term HIV management strategy. Each assessment must be customized and appropriate for an individual patient. Our initial assessment consists of four integral parts.

Social Work

The psychosocial component consists of understanding the patient's social, psychological and emotional background so as to develop an appropriate management plan. Issues often best addressed at an early stage may include when, how and if to tell partners, relatives, friends, employers and coworkers of the HIV infection. Such issues are sometimes of immediate and primary importance to the patient.

Interventions to promote harm reduction, for example, referral to appropriate drug treatment or social programs, are often best integrated into the initial assessment.

During the first few visits other issues may be addressed including:

Employment
Further education
Location of residence
Birth control and family planning
Access to disability programs
Future care needs
Drug plan insurance

These are often best dealt with early rather than later in the course of HIV infection. For more information see Social Work.

Public Health

A second component of the initial assessment involves fulfilling public health requirements. This may entail providing to the clinic nurses some information to allow for contact tracing previous sexual exposures, shared needle exposures, or blood receipt or blood donation.

A full explanation regarding practices to prevent further transmission (e.g., safer sex) is offered during the initial assessment and reinforced during subsequent visits. Potential risks of transmission of other infectious diseases during safer sex are also addressed (e.g., enteric viruses, pathogens). For more information see Public Health.

Nutrition

Nutritional counselling is offered during the early stage of disease. This will provide the patient with a solid basis for understanding evidence based nutritional advice and open the channel for further communications to answer questions regarding the use of additional nutritional support. For more information see Nutrition Services.

Medical

A full medical assessment is provided during the initial visit. This assessment entails a full patient history, physical examination and a variety of baseline tests including measurements of the activity of the viral replication (viral load), the level of damage to the immune system (CD4 count), and a variety of serologic tests and skin testing assessments to determine previous exposure to pathogens that may cause future problems. This baseline assessment allows us to provide information customized to the patient with regard to the natural history of untreated HIV infection, the individual's prognosis and the recommended management approaches.

Intervention Strategy

Immediate Interventions

The results of the initial assessment may direct certain immediate medical interventions as described below.

The presence of delayed type hypersensitivity to tuberculosis in an individual who has not received BCG immunization or has not received a documented course of adequate prophylaxis against tuberculosis triggers an immediate referral for assessment of prophylaxis against tuberculosis.
The presence of positive serology to syphilis in the absence of a documented, adequate course of therapy triggers appropriate investigation management of the syphilis.
The presence of pathogenic bacteria, ova or parasites in the stool usually triggers empiric therapy for these pathogens even in the absence of significant symptoms. The presence of these infections in the stools of an individual may lead to a telephone call from public health officials to confirm that the patient is not involved in commercial food handling and that appropriate hygienic measures are in place until the infection has cleared. Public health officials are not aware that the patient has HIV infection.
A very low CD4 count without another explanation is strongly suggestive that prophylaxis against pneumocystis pneumonia should be offered as an immediate intervention. Once stabilized on PCP prophylaxis other interventions such as initiation of antiviral therapy or toxoplasma and MAC prophylaxis may be offered if indicated.

Less Immediate Considerations

Next we consider immunizations against pneumococcus, influenza and hepatitis B infection. As described elsewhere, the merits of these interventions for any individual have to be put in context of their ability to possibly stimulate enhanced viral replication and in the context of the individual's risk in acquiring the infection. For example, a patient with no previous exposure to HBV having unprotected sexual activity with another individual who is HIV positive but is also a hepatitis B carrier should likely receive hepatitis vaccine regardless of the potential enhancement of viral replication. However, an individual with no predictable exposure to hepatitis B might not benefit from such an intervention.

Long-Term Considerations

Patients who are toxoplasma gondii serologically negative should be advised of approaches to avoid acquiring infection, e.g., handling of cat litter and food preparation. Management of patients with positive serology is given later.
For patients who are CMV seronegative it is important to advise them that any blood transfusions received in the future should be, screened to be CMV negative or at reduced risk of transmitting CMV infection, e.g., Leukocyte depleted.

Viral Load and CD4 Counts as Markers of Disease Activity and Progression

CD4 counts and viral load measurements provide different kinds of information. Viral load measures the number of viruses in the blood. The CD4 count provides a crude measurement of the health of the immune system.

CD4 counts are currently used to suggest when to begin prescribing drugs. It is also used with viral load as a guide to initiating or changing antiviral drug therapies. Viral load measurements at the initial assessment is a very accurate predictor of prognosis.

Recently, a set of interim recommendations have been made with regard to the use of viral load measurements to direct clinical care. The Southern Alberta Clinic uses a modified version as below.

At least one viral load measurement will be taken to establish a baseline level. If the viral load measures greater than 30,000-50,000 copies/mL, or if there are signs of clinical illness with HIV or CD4 depletion with a viral load of 5,000-10,000 copies/mL, intervention with antiretroviral drugs is generally recommended. Routinely, we hope to follow patients every three to four months with viral load measurements. Response to antiretroviral drugs will be deemed acceptable if there are fewer than 5,000 copies of virus/mL, and therapy will be reconsidered if there is less than a 0.5-1.0 log decrease in viral load after initiating therapy.

Antiretroviral Therapy

Timing

We aim to provide all patients with current and customized advice regarding the potential benefits and problems for them with antiretroviral treatment. This approach recognizes that when a patient has elected to start antiviral therapy, because he or she feels it is an appropriate intervention, there is clearly superior compliance and a much better outcome than in individuals who are ambivalent regarding initiating therapy and then are subsequently poor in complying with such therapy. Good compliance is critical for some of the newer treatment regimens to be effective.

Patients used to be advised of the potential merits in initiating antiretroviral therapy when the CD4 count dropped below 500 cells/mm�. This approach is being radically reviewed in view of:

Evidence suggesting that viral load measurements may be the optimal test in determining the appropriate time for initiating therapy.
The availability of certain double and triple antiretroviral regimens, when used early in the course of infection, offer significant promise of a major breakthrough in controlling the disease.

Initial Therapy

Historically patients in southern Alberta have usually been initiated on antiretroviral therapy with Zidovudine (200 mg TID) with either DDC (0.75 mg TID) or DDI (200 mg BID). More recently, many patients are being initiated on AZT (200 mg TID) with 3TC (150 mg BID). Clinic physicians now indicate they wish to use triple therapy as initial treatment. Therapy would be initiated based on criteria stated earlier for patients enthusiastic to take three drugs on a regular basis. Earlier therapy even during the seroconversion phase in compliant patients offers the best opportunity for controlling viral replication.

Subsequent Therapies

A switch to at least two different antivirals should be considered for patients with:

A clinical deterioration on a drug regimen.
A deterioration in immunity as shown by a CD4 count drop.
A lack of response in viral load measurements.
Intolerance to drugs.

Many considerations such as previous antiretroviral use, cross resistance patterns, concurrent medical conditions, e.g., malabsorption, neuropathies, hepatitis, pancreatitis, access programs for unlicensed drugs and pill burden all should be considered in making a decision customized to an individual patient.

If you are interested in the work being conducted with new drugs and approached in the clinic visit Research Activity.

Prophylaxis Against Opportunistic Infections

The clinic uses the United States Public Health Service Guidelines for the prevention of opportunistic infections in persons with HIV modified to southern Alberta as a basis for its interventions. Some disease specific recommendations for pathogens commonly encountered in our geographic region are listed below.

Pneumocystis Carinii Pneumonia

For patients with a CD4 count of less than 200 cells/mm³, an unexplained fever for greater than two weeks or a history of oral candidiasis or a previous episode of pneumocystis pneumonia, prophylaxis is recommended.
For patients with no allergy to sulfonamides, a regimen of 1 double-strength TMP/SMX (septra, bactrum, sulfamethoxazole/trimethoprim) tablet three days/week is usually prescribed as it provides a minimum pill burden and is associated with little toxicity to bone marrow. For patients with diarrhea, poor compliance in taking medications on an intermittent schedule, or patients at extreme risk of pneumocystis pneumonia a daily dose of TMP/SMX double strength is prescribed. The daily regimen is also used as prophylaxis for patients with toxoplasma gondii seropositivity.
A small number of patients describe a mild allergic reaction on previous exposure to sulfonamides. Additional patients also describe mild to moderate reactions when receiving a high dose of TMP/SMX for the treatment of pneumocystis pneumonia. For such patients we attempt desensitization using the protocol provided elsewhere. For patients absolutely intolerant of TMP/SMX we routinely use dapsone 100 mg/day. For patients with possible genetic susceptibility to toxicity to dapsone a glucose 6, phosphate dehydrogenase test should be ordered. For patients at extreme risk of developing pneumocystis pneumonia the addition of pyrimethamine 50 mg/day to a daily dose of dapsone 100 mg with 25 mg of leucovorin weekly is considered. For more information, see Desensitization to Septra or Bactrim Protocol.
As third line for prophylaxis against pneumocystis pneumonia we recommend monthly or biweekly aerosolized pentamidine.
For patients who are intolerant or unable to comply with any of the above regimens intermittent administration of parenteral pentamidine or oral clindamycin plus primaquine have been used on an individual patient bases.
Research options may be available.

Mycobacterium Avium Prophylaxis

Prophylaxis against mycobacterium avium infection is offered to patients with a CD4 count of less than 75 cells/mm³. Azithromycin 1250 mg/week or Rifabutin 300 mg/day are two regimens that are commonly used. Selection of the individual regimen is often decided by issues such as drug reimbursement plan, tolerance of medications and potential interactions with other treatments.

Herpes Simplex Infection

For patients with recurrent herpes simplex infections, long-term suppression is usually used with acyclovir 400 mg/BID. Low CD4 counts and a high frequency of recurrence of recurrences usually precipitate intervention with long-term suppression.

Other Infections

Prophylaxis against other opportunistic infections is usually offered as needed on an individual basis.

The SAC Team

Pharmacy Role in Management Strategy

The clinical pharmacist's role in the area of patient care includes the following:

Pharmaco-therapy monitoring (e.g., drug interactions, efficacy, and side effects).
Patient counseling with regard to medications as well as providing written information and schedules.
Providing medications or arranging for their dispensing.
Dispensing clinic study medications.
Phone support regarding drug questions and/or concerns.

Nursing Role in Management Strategy

The nursing staff play an important role in the clinic team. Some of their activities in the patient care area are listed below:

Public Health facilitation of contact tracing. Supported HIV testing of partners. Disease notification as applicable.
Identifying, prior to physician contact, key medical and social problems requiring management.
Liaison between clinic and home care services.
Patient counselling (in person or on the telephone) with regard to interpretation of normal and abnormal laboratory tests or disease specific information.
Telephone support as time allows regarding questions, etc.

Primary Care Physician

The clinic is the focus for the management of HIV infection and its associated problems. It is the aim of the clinic to keep the primary care physician completely informed of all interventions including their rationale and potential problems by the use of letters after every clinic visit and by copying all laboratory tests ordered.

Most referring primary care physicians are active in dealing with all non HIV-related conditions, managing acute medical problems (HIV or non-HIV) between clinic visits, providing continuity of care during hospitalizations, providing a second opinion on treatment issues and often assume complete patient management when he or she enters the palliative stage of care.

Research

A variety of randomized control trials and observational studies both with regard to pathogenesis, prognostic markers and economic analysis are conducted in the Southern Alberta HIV Clinic. The aim of these studies is to enhance our understanding of the disease and discover better treatments. Most of the therapeutic trials are sponsored by the Canadian HIV Trials Network. Participation in research is entirely voluntary. Information with regard to the research studies is available on the clinic notice board and also elsewhere on this web site. For more information see Research.

Clinic Protocols: Immunization

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