Initial Evaluation and Common Clinical Manifestations David H. Spach, MD DH Spach, MD. Presented at IAS–USA/RWCA Clinical Conference, August 2004. The International AIDS Society–USA

Recommended Routine Serologic Tests Disease Test Toxoplasmosis Syphilis Hepatitis A Virus Hepatitis B Virus Hepatitis C Virus Cytomegalovirus Anti-Toxoplasma IgG VDRL or RPR HAV total antibody Anti-HBc, HBsAb Anti-HCV IgG *Anti-CMV IgG *Only in persons with relatively low risk DHS/HIV//PP 1

Acquisition of Toxoplasma gondii Cat Feces Undercooked Red Meat DHS/HIV/PP 1

ACIP: Recommended Vaccinations Vaccine Schedule Influenza Vaccine Pneumococcal Hepatitis A Vaccine Hepatitis B Vaccine Tetanus-Diphtheria Yearly *Once & Repeat after 5 Years 0 & 6-12 months 0, 1, 6 months Every 10 Years *Optimal to vaccinate when CD4 counts highest From: ACIP. MMW 2002;51 (40):904-8. DHS/HIV/PP 1

Pneumococcal Disease in HIV-Infected Persons Summary of Data Pneumonia: 10-fold increase in HIV-infected persons Bacteremia: 50-100 fold increase in HIV-infected persons Mortality: no evidence for increase in HIV-infected persons CD4 Count: risk greatest with CD4 count less than 200 cells/mm3 Antimicrobial Prophylaxis: risk decreased with TMP-SMX or Azithromycin From: Feikin DR et al. Lancet ID 2004;187:44-55. DHS/HIV/PP 1

Vaccines Related to Travel Advice for HIV-Infected Persons Centers for Disease Control and Prevention. General Information Regarding HIV and Travel. www.cdc.gov/travel/hivtrav.htm DHS/HIV/PP 1

Vaccinations in HIV-Infected Adults Key Points Give as early as possible (high CD4 count) No significant impact on CD4 count or HIV RNA levels Avoid most live vaccines Get expert advice regarding travel-related vaccines DHS/HIV/PP 1

Oral Candidiasis Clinical Types Erythematous Pseudomembranous Angular Cheilitis DHS/HIV/PP 1

Oropharyngeal Candidiasis Treatment Options Topical Therapy - Clotrimazole troches: 10 mg 5x/d x 7-10d - Nystatin pastilles: 1-2 pastilles 5x/d x 7-10d Systemic Therapy (Oral) - Fluconazole: 100 mg qd x 7-10d - Itraconazole solution: 200 mg qd x 7-10d - Ketoconazole: 200 mg qd x 7-10d DHS/HIV/PP 1

Oropharyngeal Candidiasis Suggested Guidelines for Therapy Indications for Topical Agents - No esophageal involvement - CD4 count greater than 50 cells/mm3 - Receiving or expect to receive HAART Indications for Systemic Agents - Esophageal involvement - CD4 count less than 50 cells/mm3 - NOT receiving or expecting to receive HAART Chronic Suppressive Therapy - NOT recommended From: Powderly WG et al. AIDS Research & Human Retroviruses. 1999;15:1619-23. DHS/HIV/PP 1

Fluconazole-Resistant Oropharyngeal Candidiasis Treatment Options Topical Therapy - Amphotericin B solution: 5 ml (100 mg/ml) qid x 7-10d Systemic Therapy - Amphotericin B: 0.3 mg/kg IV qd x 7-10d - Caspofungin: 50 mg/kg* IV qd x 7-10d - Itraconazole solution: 100 mg bid x 7-10d - Fluconazole: 800 mg PO/IV qd x 7-10d - Voriconazole: 200 mg PO/IV bid x 7-10d * Use 70 mg/kg IV qd for the first dose DHS/HIV/PP 1

Aphthous Lesions Clinical Types Minor (Lip) Minor (Tongue) Major DHS/ HIV/PP 1

Oral Aphthous Lesions Treatment Options Topical Therapy - Topical Corticosteroids Intralesional - Triamcinolone: 40 mg /ml (0.5 ml-1.0 ml injected bid) Systemic Therapy - Prednisone: 0.5-1.0 mg/kg qd x 7-10d, then taper - Thalidomide: 200 mg PO qd DHS/HIV/PP 1

Herpes Simplex Virus Infection Chronic Ulcerative Lesions Types Ear Face Scrotum DHS/HIV/PP 1

Cutaneous HSV Infections Treatment Options Recurrent HSV - Acyclovir: 400 mg PO tid x 5-10d* - Valacyclovir: 500 mg PO bid x 5-10d* - Famciclovir: 500 mg PO bid x 5-10d* Suppressive Therapy - Acyclovir: 400-800 mg PO bid - Valacyclovir: 500 mg PO bid - Famciclovir: 250-500 mg PO bid *Longer courses typically needed for chronic ulcerative herpes simplex DHS/HIV/PP 1