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CDHB

HIV and AIDS

Managing these patients is complicated and requires close cooperation with Infectious Diseases and Microbiology. The indications for treatment with antiviral drugs require expert advice. The infections that have been found in association with HIV constitute a huge and expanding list and are often unusual. All patients with HIV should be discussed with an Infectious Diseases Consultant.

Infectivity and Isolation

• HIV may be carried by any patient within the hospital. Please protect yourself. The hospital policy is that all patients should be treated as if they are infected (i.e., Standard Precautions).
• The virus is present in body fluids and can be transmitted if splashed onto inflamed or broken skin or on to mucous membranes. It is not transmitted by aerosol, casual contact or physical examination.
• Put a barrier between you and body fluids from patients. Gloves, gowns and plastic aprons are generally only needed if patient is incontinent or has cognitive impairment, or for performing procedures.
• Goggles should be worn if splashes likely e.g., putting in a nasogastric tube.
• Venesection - Take container for sharps into patient's room. Do not recap needles. Drop sharps directly into box. If you have a minor skin lesion wear gloves. If skin is intact gloves are optional. They will not protect against needle stick and may make you more clumsy.
• If you get a needle stick or splash of blood make the lesion bleed and wash with soap or detergent. Obtain a blood sample from the patient unless known to be HIV positive. Contact the on-call Infectious Diseases Physician (not the Registrar) immediately for advice. Prophylactic therapy may be indicated and should be administered urgently.
• Follow protocol for needle stick injury. This is available in all wards and departments and the CDHB intranet.

Antibody Testing

• Provide full explanation of test. Consult with Infectious Diseases if you are uncertain.
• Obtain oral consent to test for HIV antibody.
• Tell patient of the limitations of the test.
• Preserve patient confidentiality. Tests should not have the patient's name on the form unless the patient agrees. A commonly used code is:
  • First two letters of surname.
  • First letter of first name.
  • M or F (Sex).
  • Date of birth (DDMMYY).

Other Investigations

If HIV infection suspected or proven a yellow "Infectious" label must be placed on all request forms accompanying blood or body fluids or if patient is to undergo invasive investigation.

Clinical Presentation

• Acute infection:
  • "Mononucleosis-like" fever, lymphadenopathy, sore throat, truncal rash (maculopapular), diarrhoea.
  • Aseptic meningitis.
  • These patients are infectious. Current generation HIV antigen/antibody EIA tests are likely to be positive early in the course of the infection from as early as 10 days onward. If negative and high clinical suspicion this should be repeated and consider viral RNA testing. Seek advice since treatment in the acute phase may be indicated.
  • If diagnosis suspected ensure a sexual, drug and blood transfusion history taken.
• Persistent generalized lymphadenopathy:
  • Lymph node enlargement in axillae, neck and groin present for over 3 months and for which no other explanation is found.
  • HIV serology is positive.
• Complicated disease:
  • Most patients who have progressed to complicated disease have sentinel infections in mouth and skin. These are important clinical clues.
    • Mouth - candidiasis, hairy leukoplakia, herpes simplex, gingivitis
    • Skin - herpes zoster, fungal infections.
• Suggestive laboratory findings:
  • Anaemia.
  • Thrombocytopaenia.
  • Leucopaenia/lymphopaenia.
  • Reduced CD4 T lymphocyte count.

Some Specific Complications of Late Stage HIV Disease

May be presenting feature.

Pneumonia - P. jirovecii (previously known as P. carinii) is most common but bacterial (e.g., pneumococcal, legionella and mycobacterial) and viral pneumonias also occur. If presentation is suggestive of a bacterial pneumonia investigate as usual (e.g., blood and sputum cultures) and treat as community acquired pneumonia. Otherwise treat as pneumocystis jirovecii pneumonia.

• Pneumocystis jirovecii pneumonia: Symptoms are usually of slow onset over several days and up to eight weeks. Shortness of breath (initially on exertion), non-productive cough, fever, and chills.
• Investigations:
  • Arterial blood gases and pulse oximetry - hypoxemia and desaturation (>5%) on exercise are common.
  • CXR - diffuse interstitial infiltration but CXR may be normal in up to 5% of cases.
  • Induced sputum in a side room (as TB may also be present). Use nebulized hypertonic saline - ask Physiotherapy Department for help. Send for bacterial, Legionella, mycobacterial and viral culture and stain for pneumocystis.
  • Throat swab - viral immunofluorescence and culture.
  • Bronchoscopy may be indicated. Consult Infectious Diseases.
• Treatment:
  • Begin treatment for presumed pneumocystis pneumonia with co-trimoxazole when one induced sputum specimen has been taken. If diagnosis clear and patient is unwell (PaO₂ on air <65 mm Hg) add prednisone 40 mg BD PO. If a definite diagnosis has not been made and the patient is not responding within 48 hours bronchoscopy is indicated.
  • Co-trimoxazole - Dose to include trimethoprim 15-20 mg/kg/day (four divided doses). Usually begin with IV infusion therapy. This may be given in a smaller volume than recommended in drug insert e.g., 320 mg in 500 mL. Change to oral after 5 days if patient improving. Nausea is very common but often responds to prochlorperazine. Rash occurs in up to 50% of HIV patients and may necessitate a change to clindamycin-primaquine.
  • Clindamycin - primaquine - clindamycin 450 mg QID PO and primaquine 15 mg once daily PO (check G6PD). Diarrhoea is a frequent side effect.

CNS Disease

• May be due to direct effects of HIV, opportunistic infection or neoplasm.
• Encephalopathy - Main features; forgetfulness, poor concentration, lethargy, loss of balance, poor handwriting, withdrawal, ataxia, hyperreflexia, weakness, with progression to dementia and incontinence over weeks to months. Usually due to HIV, but this is a diagnosis of exclusion. CMV, HSV, lymphoma or atypical mycobacteria should be sought.
• Meningitis - Usually Cryptococcus neoformans. Headache universal, lethargy, fatigue, fever and weight loss are common. Neck stiffness and photophobia often absent. TB meningitis should be considered.
• Space occupying lesions - lethargy and confusion progressing to seizures and focal signs. Causes are lymphoma, toxoplasmosis and other infections.
• Investigations - please consult Infectious Diseases.

Note: In all the above situations it is essential to obtain advice from an Infectious Diseases Consultant.

Retinitis

• Most often due to cytomegalovirus. This infection may progress to blindness very rapidly.
• Consult Infectious Diseases and Ophthalmology urgently.

GI Disease

• Oesophagitis is generally due to candida or herpes simplex. Endoscopy may be needed for diagnosis.
• Consult Infectious Diseases.

Constitutional Disease

• Systemic symptoms - fever, weight loss >10%, sweats, fatigue
• If fever is documented but no localizing symptoms, a systematic search for a cause is needed. Consult Infectious Diseases.

All patients will need thorough work up for other sexually transmitted infections, and decisions made about appropriate use of antiretroviral drugs and prophylactic antibiotic regimens.

Topic Code: 1465