New Guidelines for Primary Care Practitioners
New guidelines released today by the Public Health Service's Agency for Health Care Policy and Research improve the ability of family doctors, pediatricians and other "front line" primary care practitioners to provide critically important early care for persons recently infected with the human immunodeficiency virus.
A key recommendation is that some patients who have not yet developed symptoms be given daily preventive doses of a sulfa drug shown to prevent the onset of Pneumocystis carinii pneumonia, a principal killer of HIV-infected persons," said HHS Assistant Secretary for Health Philip R. Lee, M.D. who heads the Public Health Service.
Dr. Lee said that using the drug for asymptomatic persons whose CD4 count falls below 200 cells per microliter, could help "perhaps thousands of people, extending their lives and preventing debilitating bouts of illness."
According to Dr. Lee, more than half the people infected with HIV may not know they have the infection, partly because few examining doctors take sexual or drug-use histories that could lead to testing.
Many Americans with HIV are not receiving the early counseling and care they need to optimally manage their illness. But this situation should change. And it can change -- if more physicians and people who may have HIV infection are provided the information they need for early appropriate care.
National AIDS Policy Coordinator Kristine M. Gebbie, R.N., M.N., said "This recommendation is just one of many targeted at primary care physicians who are not as current as they should be about HIV." Ms. Gebbie said that too often individuals discover they are HIV positive only after AIDS is detected, or when the opportunistic illnesses that accompany AIDS appear.
Evaluating and managing HIV at an early stage will help reduce the number of persons who are under-diagnosed and under-treated," said Ms. Gebbie, who added that ineffective care results in unnecessary illnesses and shorter life spans.
According to Dr. Lee, the guidelines will mostly benefit primary care practitioners who until now have had limited contact with HIV infected patients or who have not felt confident enough to treat them, as well as people living with HIV and parents or caregivers of HIV-infected children.
The guidelines were developed by a private-sector panel of physicians, dentists, nurses, social workers, physician assistants, and a man and a woman living with HIV.
"We have synthesized important information needed to effectively evaluate and manage selected aspects of early HIV infection, and put it in "clinician-friendly" formats," said Wafaa El-Sadr, M.D., M.P.H., chief of infectious diseases at Harlem Hospital Center in New York, and co-chair of the 19-member expert panel. Dr. El-Sadr said that future guidelines should address other aspects of HIV care.
"With early treatment we have the opportunity to extend life for all those living with HIV, and to assist them in leading productive and healthy lives," said Dr. El-Sadr.
The panel's other co-chair, James M. Oleske, M.D., M.P.H., director of allergy, immunology and infectious diseases in the pediatrics department of the New Jersey Medical School in Newark, said, "It is especially important to treat HIV-infected infants aggressively, since the disease progresses more rapidly in children than in adults."
Dr. Oleske said the guidelines include special recommendations for women, adolescents and children, because women and adolescents constitute the fastest growing segments of the estimated 40,000 to 60,000 new cases of HIV infection every year in the United States.
The guidelines recommend that the provider try to coordinate all aspects of medical care, as well as obtain needed support and case management services, when available.
The guidelines recommend that:
DISCLOSURE OF HIV STATUS
The practitioner should disclose the presence of HIV to a patient or in the case of children, to parents or caretakers, in person. Counseling should include discussion of the psychosocial and medical effects of the illness, available therapies and support services.
Patients should also be told about federal, state and local reporting requirements and of potential advantages and disadvantages of voluntary disclosure to family, friends and others.
MEDICAL EVALUATION AND MANAGEMENT
Detailed medical history-taking, including sexual and substance use history, is crucial and should emphasize review of HIV test results and previous infections.
Practitioners closely monitor patients' count of CD4 cells beginning with the initial medical evaluation, and every six months thereafter for those with counts above 600 and at least every three months for patients whose counts are between 600 and 200. Monitoring of CD4 count below 200 is dependent on the availability of other interventions.
Preventive therapy for "Pneumocystis carinii" pneumonia (PCP) begin when a patient's CD4 cell count drops below 200 or he or she has an episode of the disease or other specific symptoms.
Pregnant women's CD4 cell count be measured when they begin a prenatal care program or at delivery if they have not had prenatal care.
Patients be screened for "Mycobacterium tuberculosis" and preventive therapy or treatment be started, if warranted. Methods to improve adherence with treatment of tuberculosis should be employed.
All HIV-infected and sexually active adults and adolescents be checked for the presence of syphilis and other sexually transmitted diseases in the initial medical evaluation and regularly thereafter.
Patients be offered antiretroviral therapy with zidovudine (ZDV, formerly known as AZT) whose CD4 counts are below 500. Patients should be informed about the potential benefits and risks of early therapy with ZDV, and other options for antiretroviral therapy should be discussed. Pregnant women should be told of possible benefits as well as risks to both themselves and their unborn babies.
Women be given regular pelvic examinations that include Pap smears.
Adolescents be assessed based on their level of sexual and physical maturity, and that drug dosages should be adjusted accordingly.
The provider conduct an oral examination at each visit and recommend that a dentist examine the patient at least two times a year.
The practitioner also conduct an eye examination and recommend the patient see a qualified eye doctor according to a schedule that varies with their age and symptoms.
Contraceptive, family planning, and prenatal counseling be given to all HIV-infected women, with the focus on the patient, and that her psychological state, medical and social support network be assessed.
HIV-infected mothers be informed of the need for contingency planning for future care of their children.
Patients be provided with access to appropriate clinical trials including women, as well as pregnant women and adolescents.
The provider should obtain information regarding available case management programs and provide patients access to them.
Two accompanying booklets -- for persons living with HIV and for caregivers of HIV-infected children -- urge readers to learn all they can about HIV infection, see their practitioner regularly, and work in partnership with their provider regarding their care.
The booklets, which are available in English and Spanish, also recommend that women talk with their provider about family planning, pregnancy, breast feeding and related matters.
The panel also called for women -- including women who are pregnant -- adolescents and children to be included in clinical trials and experimental protocols.
According to AHCPR Administrator J. Jarrett Clinton, M.D., M.P.H., the guidelines will be widely disseminated to primary care physicians and other practitioners, and the consumer guides will be made available to HIV screening sites, community and migrant health centers, public health departments, and other settings.
Copies of "Early Evaluation and Management of HIV Infection," an accompanying quick reference guide, and the consumer booklets, may be obtained free of charge, through a joint effort with the Centers for Disease Control and Prevention, by calling 1-800-342- 2437 (AIDS), 1-800-344-7432 (SIDA) for those who speak Spanish, and 1-800-AIDS-TTY for the deaf. Persons with telephone-equipped facsimile can get the quick reference guide, consumer booklets, and an overview of the guidelines by calling AHCPR Instant Fax (301-594-2800) 24 hours a day.