HIV Infection

HIV INFECTION

Rationale

HIV (human immunodeficiency virus) infection represents one of the most difficult challenges in clinical medicine today. The majority of cases in the United States occur from sexual contact, although other risk factors include intravenous drug use, receipt of tainted blood products, and infants born of high risk mothers.

Prerequisites

knowledge of the worldwide epidemiology, biology and immunology of HIV infection

understanding of universal precautions

Knowledge

Students should be able to define and describe:

CDC AIDS case definition

symptoms and signs of HIV-related opportunistic infections

P. carinii

Candidiasis (oral, esopagael, vaginal)

Cryptococcal meningitis

Cryptosporidiosis

Cytomegalovirus infection (GI, neurologic, retinal)

Mycobacterium avium complex

Mycobacterium tuberculosis

Toxoplasmosis

symptoms and signs of the following HIV-related malignancies:

Kaposi’s sarcoma

Non-Hodgkin’s lymphoma

Cervical carcinoma

relationship of CD4 count to opportunistic infections as well as relationship between CD4 count and viral load to overall disease progression signs and symptoms of acute seroconversion

the principles of HAART therapy, including the different classes of antiviral medications and their use, as well as common side effects and drug-drug interactions

Skills

Students should demonstrate specific skills, including:

History-Taking Skills: Students should be able to obtain, document, and present an age-appropriate medical history, that addresses:

HIV infection risk factors:

sexual contacts

parenteral exposure to infected blood by needle sharing or transfusion

occupational exposures

other sexually transmitted infections that establish increased risk for HIV infection

HIV serology results, CD4 lymphocyte count, viral load and HIV-related opportunistic infections

HIV medications and side effects

Appropriate review of systems questions, including:

fever, sweats, weight loss, wasting

dyspnea, diarrhea or headache

neuropsychiatric complaints

history of vaginal candidiasis, cervical dysplasia and neoplasia, and/or pelvic inflammatory disease

travel history

diet history to assess:

number of meals eaten per day

use of supplements

Physical Exam Skills: Students should be able to perform a physical exam to determine the diagnosis and severity of disease including assessing for:

lesions of Kaposi’s sarcoma and other skin diseases associated with HIV

lymphadenopathy

retinitis/fundoscopy

oral candidiasis

sinusitis

oral hairy leukoplakia

gingivitis

abnormal pulmonary findings

pelvic inflammatory disease

mental status alterations

cognitive function deficits

focal neurologic deficits

muscle wasting of extremities and temporal muscles, lipodystrophy

Differential Diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings in and HIV-positive patient who presents with:

fever

dypsnea

diarrhea

headache

altered mental status

Laboratory Interpretation: Students should be able to recommend and interpret diagnostic and laboratory tests, both prior to and after initiating treatment.

Laboratory and diagnostic tests should include, when appropriate:

specific tests for HIV (with appropriate application of sensitivity and specificity)

hematologic abnormalities of HIV infection

CD4 lymphocyte count and viral load as predictors of disease progression

induced sputum, pulse oximetry and LDH for the diagnosis of PCP

chest x-ray for Pneumocystis carinii/TB/Community Acquired

Pneumonic

serum and cerebral spinal fluid cryptococcal antigen

stool isolates for O and P, crypto/iso/microsporidium

Communication Skills: Students should be able to:

counsel and educate patients about HIV and exposure prevention

educate about HIV exposure and seroconversion rates

educate patients about complications of HIV drug therapy and drug-drug interactions

educate patients about community health resources available for the care of AIDS patients

Management Skills: Students should be able to outline a treatment plan for patients with HIV infection that includes:

combination anti-retroviral therapy

P. carinii and MAI prophylaxis when indicated

assessing PPD status and treatment for latent versus active TB

scheduling pneumococcal and H. influenza vaccines

ordering nutritional supplements to manage and prevent malnutrition

Attitudes and Professional Behaviors

Students should be able to:

consider the bioethical and social issues concerning patient confidentiality of HIV infection

understand and have tolerance towards alternative life styles

maintain a non-judgmental attitude

Resources

Internal Medicine Clerkship Guide, Paauw et al, Mosby 2003, 344-358

Clerkship Seminar, “HIV/AIDS, Janak Koirala MD

Guidelines for Prevention of Opportunistic Infections in HIV Infections
http://www.cdc.gov/mmwr/PDF/RR/RR5108.pdf

Guidelines for Management of HIV in Adolescents and Adults
http://www.cdc.gov/mmwr/PDF/RR/RR5107.pdf

"Management of Newly Diagnosed HIV Infection", Scott M. Hammer, M.D., N Engl J Med 2005;353:1702-10.

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