| |
New IDSA HIV Guidelines Push 'Adherence to Care'
|
| |
| |
2009 Update by the HIV Medicine Association of the Infectious Diseases Society of America in CID
link pdf of full Guidelines:
Bone Guidelines Excerpted From New IDSA Guidelines- pdf of full paper attached - (08/12/09)
"regular monitoring and medical attention".....list of HIV diagnostic tests has been expanded.....adhere not only to medications but also to the wider spectrum of care.....Such "adherence to care" is important because patients who don't keep medical appointments and actively engage in their care have been found to have about a 50% higher mortality rate....."data from recent studies suggest those living with HIV are at higher risk for developing common health problems, such as heart disease, diabetes, or cancer,"....."it's imperative that HIV care providers be aware of the primary care needs of their patients, and that includes routine screening for these kinds of conditions.".....team approach to HIV care -- the so-called "medical home" -- that addresses all of a patient's medical needs.....Emphasis should be placed on the importance of adherence to care rather than focusing solely on adherence to medications.....providers should assess the presence of depression and domestic violence....neurological examination......testosterone level In males with fatigue, weight loss, loss of libido, erectile dysfunction, or depression or who have evidence of reduced bone mineral density.....A baseline urinalysis and calculated creatinine clearance assay should be considered, especially in black HIV-infected patients and those with advanced disease or comorbid conditions, because of an increased risk of nephropathy......a screening urinalysis for proteinuria should be considered at initiation of care and annually thereafter, especially in patients who are at increased risk for developing proteinuric renal disease"
"Baseline bone densitometry measurement should be obtained in postmenopausal women aged 65 years and in younger postmenopausal women who have >1 risk factor for premature bone loss (B-III).'
"Routine screening for osteoporosis in HIV-infected patients without other risk factors for premature bone loss is not recommended at this time, on the basis of available data, but it should be considered in persons aged >50 years, especially if they have >1 risk factor for premature bone loss (B-III)."
If the test demonstrates osteopenia or if the patient has a history of fragility or fracture, intervention with a bisphosphonate or other medical therapy should be considered. Bisphosponates appear to be effective in improving bone density in small studies of HIV-infected patients, but the data are limited [77, 78]. A follow-up study 1 year later to monitor the response to therapy is advised. Patients should be reminded of the health benefits of regular exercise and adequate calcium and vitamin D intake. They should also be counseled about the risks of cigarette smoking and excessive alcohol consumption. Secondary causes of decreased bone density, such as hypogonadism and vitamin D deficiency, should be investigated and treated accordingly
"Fasting glucose and lipid levels should be monitored prior to and within 4-6 weeks after starting antiretroviral therapy (A-III)"....."HCV-infected patients are known to have an increased risk of insulin resistance and type 2 diabetes mellitus, and HIV- and HCV-coinfected patients have a 5-fold greater risk of developing hyperglycemia, compared with those with HIV infection alone."
"Computed tomography scanning at L4/5 can be used to assess visceral fat and quantitate subcutaneous fat. The body mass index assesses lean body mass but cannot determine fat distribution. None of these tools is currently recommended for clinical practice."
MedPage Today
August 14, 2009
Action Points
* Explain to interested patients that advances in HIV treatment have improved the prognosis for many patients but also present new challenges to the physician.
* Note that these guidelines reflect the primary care needs of HIV patients in an era of better treatment and longer life.
Doctors caring for people with HIV need to ensure that their patients adhere not only to medications but also to the wider spectrum of care.
That's the bottom line of the 2009 primary care guidelines for management of HIV patients issued by the HIV Medicine Association and the Infectious Diseases Society of America.
Such "adherence to care" is important because patients who don't keep medical appointments and actively engage in their care have been found to have about a 50% higher mortality rate, according to Judith Aberg, MD, of New York University School of Medicine, and colleagues.
The guidelines -- last updated in 2004 -- appear in the Sept. 1 issue of Clinical Infectious Diseases.
Although advances in therapy have improved the prognosis for many HIV patients, Aberg said in a statement, "data from recent studies suggest those living with HIV are at higher risk for developing common health problems, such as heart disease, diabetes, or cancer,"
"Now more than ever," she said, "it's imperative that HIV care providers be aware of the primary care needs of their patients, and that includes routine screening for these kinds of conditions."
"It's not just about adherence to medication, it's also about adherence to care," Aberg said. "These patients must have access to a range of services to help them stay engaged in their medical care and should receive the regular monitoring and medical attention this chronic infection demands."
The guidelines include a suite of changes that reflect improvements in HIV diagnosis and care. Among the changes:
* The list of HIV diagnostic tests has been expanded.
* The guidelines now suggest genotypic resistance tests when a patient enters care, even if antiretroviral therapy will not be started immediately.
* Testing for the HLA-B*5701 haplotype -- which increases the risk of an abacavir (Ziagen) hypersensitivity reaction -- should be done before starting therapy with the drug. Patients positive for the haplotype should not be treated with abacavir.
* Baseline urinalysis and calculated creatinine clearance should be considered, especially in black patients, because of an increased risk of HIV-associated nephropathy, and the tests should also be done before starting treatment with drugs with a potential for nephrotoxicity.
* Before starting treatment with a CCR5-antagonist -- one of the new classes of antiretroviral drugs -- patients should be tested to see if their virus is likely to be susceptible. (Tropism test)
· For women aged 40-49 years, providers should periodically perform individualized assessment of risk for breast cancer and inform the patient of the potential benefits and risks of screening mammography (B-II).
· As part of the initial evaluation and at periodic intervals thereafter, providers should assess the presence of depression and domestic violence by means of direct questions or validated screening tools
· perform a careful anogenital examination for evidence of rectal cancer, prostate cancer in men, and STDs, including condylomata and herpes simplex infection. Examination of HIV-infected women should include careful palpation of the breasts and a pelvic examination
· The neurological examination should include a general assessment of cognitive function, as well as motor and sensory testing. Patients in whom cognitive dysfunction is suspected may benefit from formal neuropsychological testing.
· Serum testosterone level In males with fatigue, weight loss, loss of libido, erectile dysfunction, or depression or who have evidence of reduced bone mineral density
· a screening urinalysis for proteinuria should be considered at initiation of care and annually thereafter, especially in patients who are at increased risk for developing proteinuric renal disease
· Anal cytologic screening (ie, anal Pap smears) in HIV-infected women and MSM is not considered to be the standard of care at this time but is being performed in some health care centers. Additional studies of screening and treatment protocols for anal dysplasia are in progress to clarify this issue
· All HIV-infected women of childbearing age should be asked about their plans and desires regarding pregnancy upon initiation of care and routinely thereafter (A-III).
· HIV-infected women should have a cervical Pap smear performed upon initiation of care, and this test should be repeated at 6 months and, if results are normal, annually thereafter (A-I).
The guidelines urge a team approach to HIV care -- the so-called "medical home" -- that addresses all of a patient's medical needs, according to Michael Saag, MD, of the University of Alabama at Birmingham, who is also chair-elect of the HIV Medicine Association.
"Many HIV programs are effectively using the medical home model today to manage the complex needs of HIV patients," Saag said in a statement. "This successful track record offers a valuable lesson, not only for HIV care but for all patients, as lawmakers finalize healthcare reforms."
The guidelines were supported by the Infectious Diseases Society of America.
Aberg reported financial links with Abbott Laboratories, Boehringer Ingelheim, Bristol Myers Squib, Gilead Sciences, GlaxoSmithKline, Merck, Pfizer, Schering-Plough, and Tibotec Therapeutics.
|
|
| |
| |
|
|
|
