SIU School of Medicine

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Department of Internal Medicine

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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