Opportunistic infections

Human immunodeficiency virus (HIV) infection is a chronic disease. Family physicians can contribute to the health and well-being of patients infected with HIV through the prevention of psychologic illnesses and opportunistic infections. It has. been shown that prophylaxis against specific opportunistic infections is cost-effective and leads to an increased quality of life and a lower mortality rate.[1,2]

Initial Evaluation

HISTORY

The cornerstone of morbidity prevention remains a thorough history and physical examination. The history must encompass medical conditions unrelated to HIV (e.g., diabetes mellitus, asthma), as well as those related to HIV (e.g., thrush, Pneumocystis carinii pneumonia). This information allows the physician to give routine care as well as to stage the patient's HIV condition and anticipate future concerns. Lifestyle choices such as cigarette,[3] alcohol and/or drug use should be assessed, and the social history should include information about sexual practices, occupation, pets, travel and support systems.[4,5] Taking the history provides "teachable moments" for patient education, which are often the most important interventions we can offer our "well" patients with HIV. Figures 1 and 2 contain mnemonics that may help physicians obtain a thorough history and provide useful patient education.

FIGURE 1. Psychosocial mnemonic (" Discretion") that can be used to evaluate and counsel patients with HIV infection. (HIV = human immunodeficiency virus; AIDS = acquired immunodeficiency syndrome)

Deaths related to HIV in friends?

Most persons with HIV live in communities where HIV is prevalent and have, therefore, experienced HIV-related diseases and deaths in neighbors, friends and/or family members. Those experiences may play an important role in shaping their thoughts about what it means to be HIV-seropositive.

Insurance

Both current medical/disability/death coverage and future-anticipated coverage are topics that should be explored.

Spiritual/religious

Knowing a patient's religious affiliation (or lack of affiliation) can be important when discussing many issues related to HIV infection. However, sometimes more general questions such as "What is it you assume happens after death?" "Where do you find spiritual support?" or "What do you do to help yourself relax and/or find peace?" can lead to a more helpful dialog as issues of support and dealing with death and dying arise.

Counseling history

Since many persons with HIV will benefit from counseling during their illness, a look at their past experiences with counseling may be helpful.

Reporting: tell the patient about the following

States have different reporting laws regarding (1 ) an HIV-positive test, (2) an AIDS diagnosis, and (3) death certificates. Discuss these issues with your patients. This is also a good time (during discussions of legal issues) to bring up the matter of durable power of attorney for health care and living wills.

Explain HIV variability

Many persons with HIV, because of a lack of appropriate education or experience, or because of denial, do not understand the variability possible with this disease.

Test results known to?

Physicians should find out if the patient's HIV status is known to family, friends, sexual contacts, needle contacts or medical and dental consultants early in the management process.

Important people in patient's life

Significant others should be identified early in the patient-doctor relationship.

Other

What is important to you as a practitioner and/or to this specific patient, that has not been assessed?

Needles

A solution of 10 percent household bleach and 90 percent water can disinfect syringes that are shared. If your city has a needle-exchange program, urge injecting drug users to make use of it.

Deaths related to HIV in friends Insurance Spiritual/religious Counseling history Reporting: tell patient about Explain HIV variability Test results known to Important people in patient's life Other Needles

FIGURE 2. Psychosocial mnemonic ("A Wise Chant") that can be used to evaluate and counsel patients with HIV infection. (HIV = human immunodeficiency virus; AIDS = acquired immunodeficiency syndrome; ENT = ears, nose and throat)

Assess handwashing techniques and habits

Infections can be transmitted from soil, raw eggs, poultry, meat, unwashed fruits and vegetables, and cat and human feces.

Work

Jobs may pose risks such as exposure to Mycobacterium tuberculosis (prison workers) or cytomegalovirus (child care workers). Evaluate the patient's financial stability and type of daily activity. Health care professionals require special consideration.

Illicit and other drugs

Psychoactive drugs can lead to poor decision-making capacity, interact with prescribed medication, and put patients at risk for endocarditis or respiratory compromise. Careful attention should be paid to use of over-the-counter drugs and "alternative" medications.

Sexual behaviors

Birth control is an important consideration. Safe-sex advice includes using condoms and knowing one's sexual partner well.

ENT

Periodontal disease is common in persons with AIDS. Careful oral examinations and a dentist familiar with the patient's HIV status can help identify early thrush and other abnormal lesions. Chronic sinusitis, often occult, is common in persons with AIDS.

Cigarettes

Along with the many well-documented reasons to avoid tobacco abuse, studies have indicated that smoking can increase pulmonary-based pathology in persons with HIV.

Hobbies

Gardening and other hobbies that result in frequent soil contact may warrant extra education efforts because of the potential for exposure to organisms that can cause opportunistic infections.

Animals

The psychologic benefits of living with pets must be kept in mind. Toxoplasmosis can be transmitted from cat feces via air: Cats kept indoors are less likely to acquire the disease. Cat fleas can spread bartonella. Birds can harbor disease although, if they have gone through U.S. Customs, they are generally disease-free. Patients with HIV should avoid bird droppings. Pigeon droppings may carry cryptococcus. Reptiles (e.g., turtles, snakes, lizards) may carry salmonella. Patients should wear rubber gloves when cleaning fish bowls to avoid exposure to Mycobacterium marinium. Patients should avoid contact with pets that have diarrhea or that are less than six months old. If a pet has diarrhea, patients should consider having a veterinarian check the pet's stool for cryptosporidium, salmonella and campylobacter. Pets should be fed only store-bought canned or dried pet food, and exotic pets should be avoided.

Nutrition

An otherwise unexplained weight loss of greater than 10 lb. in four months in a person who is having anorexia may be an indication to consider megastrol. Anorexia secondary to nausea may be an indication to treat the patient with dronabinol.

Food-borne illness

Salmonella, transmitted through raw eggs and chicken, is killed in cooking. Cutting boards (particularly wooden boards) can harbor organisms, but a disinfectant solution of one part chlorine bleach to 10 parts water will suffice for cleaning. Raw fish can contain gastrointestinal pathogens. Water-borne illness is also a consideration; cryptosporidium is found in some water supplies. The Centers for Disease Control and Prevention recommends that persons with AIDS consider boiling their water for one minute before consuming it. Swimming in lakes or rivers may lead to accidental swallowing of contaminated water. A check with your local health department can help you make these decisions. Alcohol is another consideration; the effect of small or moderate alcohol intake in persons with HIV is unknown. As with all patients, those misusing or abusing alcohol should be considered for dependency referral.

Travel plans

Travel histories may point the physician to endemic diseases. Patients with AIDS should have information on where to go if an emergency arises while they are away from home. Antimicrobial prophylaxis for traveler's diarrhea in persons with HIV may reduce the incidence of diarrhea but may also promote drug-resistant organisms. All HIV-infected travelers should carry antibiotics, with directions on how to use them if diarrhea develops.

Assess handwashing Work Illicit and other drugs Sexual behaviors Ent Cigarettes Hobbies Animals Nutrition Travel plans

REVIEW OF SYSTEMS

The review of systems can be focused on early detection of manageable symptoms and/or opportunistic infections. Early stages of cryptococcal meningitis can be heralded by chronic headache without meningeal signs. Chronic headache can also signal toxoplasmosis or lymphoma, which often occur with at least some other neurologic localizing signs. Dyspnea with mild exertion or a dry cough suggests early stages of P. carinii pneumonia. Fever of unknown origin may be caused by mycobacterial infections. Integral components of HIV-related care include early education regarding the warning signs and symptoms of opportunistic diseases, as well as education about when to confer by telephone with the physician and when to obtain an office appointment. Some symptoms that may indicate opportunistic infections are summarized in Table 1.

TABLE 1 Signs and Symptoms that May Signal Opportunistic Infection in Persons with HIV and Severe Immunodeficiency

Prevention of Opportunistic Infections

ANTIRETROVIRAL THERAPY

Antiretroviral agents are briefly mentioned here to highlight several points. First, the addition of protease inhibitors to combinations of older antiretrovirals has radically changed the care of persons with HIV infection. Patients taking these medications often have more "well" time before acquiring an opportunistic infection, as well as a prolongation of life.[10,11] We do not yet know enough about the relationship between decreased viral load, therapeutically induced increases in CD4 levels and opportunistic infections to make definitive recommendations about prophylaxis regimens in patients whose CD4 count rises above 200 per [mm.sup.3] (200 x [10.sup.6] per L) after initiation of therapy.

Consultation with an AIDS specialist can help a physician sort out these issues while the effectiveness of these drugs in decreasing viral load and improving patient health remains under study. Since the CD4 count is correlated with opportunistic infections and antiretrovirals can help both by increasing CD4 counts and treating some AIDS-related complications (e.g., thrombocytopenia,[12] dementia[13]), antiretroviral agents are an important component of secondary prevention in persons with HIV infection. The best time to initiate antiretroviral therapy is being studied, but most experts agree that treatment should be initiated in all patients with CD4 counts below 500 per [mm.sup.3] (500 x [10.sup.6] per L), and many experts begin therapy with three antiretroviral agents as soon as an HIV diagnosis is made.[14]

Other Therapy and Recommendations

In 1995, the U.S. Public Health Service and the Infectious Diseases Society of America (USPHS/IDSA) published up-to-date information regarding the prevention of 17 opportunistic infections in persons with HIV.[4(pp1-43] Their pharmacotherapeutic recommendations, rated according to strength and quality of evidence supporting them, included information on initial exposure, first episode and recurrence. The USPHS/IDSA articles also gave very specific recommendations regarding potential environmental hazards posed by pets and occupation. Those recommendations are summarized in Table 3. Revised USPHS/ IDSA recommendations are expected to be published in 1997. Before that publication, family physicians may wish to make use of the National HIV Telephone Consultation Service, an excellent source of free expert consultation on all aspects of HIV-related care (Table 4).

[TABULAR DATA 4 NOT REPRODUCIBLE IN ASCII]

Family physicians caring for patients with HIV or AIDS are ideally situated to help their patients through prevention, early detection and/or early treatment of both psychologic illnesses and opportunistic infections. Commitment and a good working relationship with an AIDS specialist can help us achieve these goals.

REFERENCES

[1.] Flanigan TP, Uvin SC, Rich JD, Mileno MD, Vigilante K, Tashima K. Update of HIV and AIDS in North America. Med Health R I 1996;79(5):180-7.

[2.] Bartlett JG, ed. The Johns Hopkins Hospital 1996 guide to medical care of patients with HIV infection. 6th ed. Baltimore: Williams & Wilkins, 1996: 46-8.

[3.] Nieman RB, Fleming J, Coker RJ, Harris JR, Mitchell DM. The effect of cigarette smoking on the development of AIDS in HIV-1-seropositive individuals. AIDS 1993;7:705-10.

[4.] Kaplan JE, Masur H, Holmes KK, McNeil MM, Schonberger LB, Navin TR, et al. USPHS/IDSA guidelines for the prevention of opportunistic infections in persons infected with human immunodeficiency virus: introduction. USPHS/IDSA Prevention of Opportunistic Infections Working Group. Clin Infect Dis 1995; 21(Suppl 1):S1-43.

[5.] Conley LJ, Bush TJ, Buchbinder SP, Penley KA, Judson FN, Holmbery SD. The association between cigarette smoking and selected HIV-related medical conditions. AIDS 1996;10:1121-6.

[6.] Perry SW, Jacobsberg LB, Fishman B, Weiler PH, Gold JW, Frances AJ. Psychological responses to serological testing for HIV. AIDS 1990;4:145-52.

[7.] Kelly JA, Murphy DA. Psychological interventions with AIDS and HIV: prevention and treatment. J Consult Clin Psychol 1992;60:576-85.

[8.] Lackner JB, Joseph JG, Ostrow DG, Kessler RC, Eshleman S, Wortman CB, et al. A longitudinal study of psychological distress in a cohort of gay men. Effects of social support and coping strategies. J Nerv Ment Dis 1993;181:4-12.

[9.] Semple SJ, Patterson TL, Temoshok LR, McCutchan JA, Straits-Troster KA, Chandler JL, et al. Identification of psychobiological stressors among HIV-positive women. HIV Neurobehavioral Research Center (HNRC) Group. Women Health 1993;20:15-36.

[10.] Enger C, Graham N, Peng Y, Chmiel JS, Kingsley LA, Detels R, et al. Survival from early, intermediate, and late stages of HIV infection. JAMA 1996; 275:1329-34.

[11.] Deeks SG, Smith M, Holodniy M, Kahn JO. HIV-1 protease inhibitors. A review for clinicians. JAMA 1997;277:145-53.

[12.] Montaner JS, Le T, Fanning M, Gelmon K, Tsoukas C, Falutz J, et al. The effect of zidovudine on platelet count in HlV-infected individuals. J Acquir Immune Defic Syndr 1990;3:565-70.

[13.] Portegies P. Review of antiretroviral therapy in the prevention of HIV-related AIDS dementia complex (ADC). Drugs 1995;49(Suppl 1):25-31.

[14.] Hecht F. A new focus on primary HIV infection. AIDS Clin Care 1996;8(9):72,75.

[15.] Simonds RJ, Hughes WT, Feinberg J, Navin TR. Preventing Pneumocystis carinii pneumonia in persons infected with human immunodeficiency virus. Clin Infect Dis 1995;21(Suppl 1):S44-8.

[16.] Huang L, Stansell JD. AIDS and the lung. Med Clin North Am 1996;80:775-801.

[17.] Belchi-Hernandez J, Espinosa-Parra FJ. Management of adverse reactions to prophylactic trimethoprimsulfamethoxazole in patients with human immunodeficiency virus infection. Ann Allergy Asthma Immunol 1996;76:355-8.

[18.] Downing D. HIV and pet ownership. STEP Perspect 1995;7(1):18-20.

[19.] Horsburgh CR Jr. Advances in the prevention and treatment of Mycobacterium avium disease [Editorial]. N Engl J Med 1996;335:428-30.

[20.] Pierce M, Crampton S, Henry D, Heifets L, LaMarca A, Montecalvo M, et al. A randomized trial of clarithromycin as prophylaxis against disseminated Mycobacterium avium complex infection in patients with advanced acquired immunodeficiency syndrome. N Engl J Med 1996;335: 384-91.

[21.] Havlir DV, Dube MP, Sattler FR, Forthal DN, Kemper CA, Dunne MW, et al. Prophylaxis against disseminated Mycobacterium avium complex with weekly azithromycin, daily rifabutin, or both. California Collaborative Treatment Group. N Engl J Med 1996;335:392-8.

[22.] Ward DJ, Fisher DJ, Holmberg SD, Delaney K, Moorman A. Experience with MAC prophylaxis in the HIV Outpatient Study (HOPS). 3d Conf Retro and Opportun Infect; 1996 Jan 28-Feb 1; Washington, D.C.: HIV Outpahent Study (HOPS) Group, 1996:85.

[23.] Benson CA, Ellner JJ. Mycobacterium avium complex infection and AIDS: advances in theory and practice. Clin Infect Dis 1993;17:7-20.

[24.] USPHS/IDSA guidelines for the prevention of opportunistic infections in persons infected with human immunodeficiency virus: a summary. MMWR Morb Mortal Wkly Rep 1995;44(No. RR8):1-34.

SUSAN LOUISA MONTAUK, M.D. is a family physician and associate professor of clinical family medicine at the University of Cincinnati (Ohio) College of Medicine. Dr. Montauk graduated from Ohio State University College of Medicine and completed a family medicine residency at Grant Medical Center Columbus, Ohio, as well as a fellowship in family and adolescent medicine. She is National Chairperson for the Society of Teachers of Family Medicine Group on HIV Education.

BRUCE GEBHARDT, M.D. is assistant professor of clinical family medicine at the University of Cincinnati College of Medicine. Dr. Gebhardt graduated from the University of Cincinnati College of Medicine and completed a residency in family medicine at St. Vincent Medical Center, Erie, Pa.

Address correspondence to Susan Louisa Montauk, M.D., Department of Family Medicine, University of Cincinnati, PO. Box 670582, Cincinnati, OH 45267.

COPYRIGHT 1997 American Academy of Family Physicians
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