You arrive for your ED shift and are presented with 3 HIV-infected patients with various chief complaints. The first patient is a 28-year-old man with 1 day of right flank pain, nausea, vomiting, and hematuria. He had a kidney stone a year ago with identical pain, and a point-of-care ultrasound shows asymmetric hydronephrosis; however, a nonenhanced CT scan demonstrates hydronephrosis and hydroureter without a stone. You wonder if the CT eliminates an impacted stone or if there is another explanation.
The second patient is a 42-year-old HIV-infected woman complaining of as many as 3 episodes a day of diarrhea for the past 3 weeks. She denies pain, melena, rectal bleeding, and fevers. Her laboratory test results are unremarkable. You wonder if additional testing is needed and whether sending her home is appropriate.
The third patient presents because her family has noticed that she has been acting increasingly “sad.” She denies any suicidal or homicidal ideation, but does corroborate that since initiation of an SSRI antidepressant drug 6 months ago, she has not noticed any improvement in her mood. In the absence of suicidal ideation, you wonder if she can be sent home.
You are reminded that caring for the HIV-infected patient is not so simple, and you realize quickly that you are dealing with 3 very different presentations related to the same disease and must prioritize where to begin.
The human immunodeficiency virus (HIV) causes a progressive failure of the immune system, ultimately leading to acquired immunodeficiency syndrome (AIDS) in the absence of treatment. Although under different nomenclature, AIDS was first described in the early 1980s when clusters of patients developed opportunistic infections (OIs) not seen in patients with intact immune systems. HIV has spread to every country in the world, creating a global pandemic. In 2012, there were 35.3 million people living with HIV worldwide and 2.3 million new diagnoses that year.1
The development of highly active antiretroviral therapy (HAART) in 1996 dramatically increased life expectancy for HIV-infected patients. Due to the effectiveness of HAART, by the early 2000s, life expectancy of HIV-infected patients in developed countries was equivalent to that of comparable persons who were not HIV-infected.2,3
Current guidelines from the United States Department of Health and Human Services recommend the treatment of all HIV-infected patients with antiretroviral medications (ARVs).4 These current recommendations are based on evidence that ARVs reduce the risk of disease progression in all patients with CD4 T lymphocyte (CD4) count < 350 cells/mm3, CD4 count 350 to 500 cells/mm3, and CD4 count > 500 cells/mm3. This recommendation is a change from prior guidelines, which recommended therapy only for patients with lower CD4 counts. The guidelines are also based on evidence that treatment decreases the risk of transmission, and that patients with undetectable HIV viral loads are at exceedingly low risk for transmitting the virus to others.5
In addition to improving life expectancy, HAART has also changed the epidemiology of conditions affecting HIV-infected patients. In the beginning of the epidemic, HIV patients generally presented with infectious complications of their advanced disease. These included OIs such as Pneumocystis jiroveci pneumonia and Kaposi sarcoma. Now, patients more commonly present with complications unrelated to OIs, including cardiovascular, hepatic, and kidney disease, as well as HIV-related malignancies and adverse effects from medication.5,6 The spectrum of presenting complaints is associated with patient compliance with treatment. OIs are still seen in patients with undiagnosed infection presenting with advanced disease and those with financial, social, or other barriers to medication compliance.
This changing epidemiology of HIV complications poses a particular challenge for emergency clinicians, who should be familiar with these presentations as well as the presentation of OIs. This issue of Emergency Medicine Practice reviews the emergency complications of long-term HIV infection, especially noninfectious conditions and complications common in the HAART-adherent HIV patient.
HAART: Highly active antiretroviral therapy
HIV: Human immunodeficiency virus
NNRTI: Nonnucleoside reverse transcriptase inhibitor
NRTI: Nucleoside reverse transcriptase inhibitor
NtRTI: Nucleotide reverse transcriptase inhibitor
OI: Opportunistic infection
PEP: Postexposure prophylaxis
PI: Protease inhibitor
PubMed and the Cochrane Database of Systematic Reviews were searched for English-language articles related to the management of HIV/AIDS. Attention was focused on articles relevant to the emergency clinician, those published after 1996 (to coincide with the advent of HAART), and on articles that discussed the effects of chronic HIV infection and HAART adverse events. Search terms included HIV, AIDS, combination antiretroviral therapy, highly active antiretroviral therapy, and immune reconstitution inflammatory syndrome. Because of the large number of articles retrieved in these searches, the initial focus was on review articles with cross-referencing primary literature cited in the bibliographies. Relevant guidelines by the World Health Organization, the United States Department of Health and Human Services, and the American College of Emergency Physicians were also reviewed.
Now, nearly 20 years after the advent of HAART, considerable literature exists on the subject of HIV both in terms of the OIs patients experience and the chronic effects of longstanding illness and treatment. This literature provides strong evidence to support the practice recommendations made in this article.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study are included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.
David L. Gutteridge, MD, MPH; Daniel J. Egan, MD
February 1, 2016
March 1, 2019
Upon completion of this article, participants should be able to:
Date of Original Release: Feburary 1, 2016. Date of most recent review: January 10, 2016. Termination date: Feburary 1, 2019.
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Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ACEP Accreditation: Emergency Medicine Practice is approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAFP Accreditation: This Medical Journal activity, Emergency Medicine Practice, has been reviewed and is acceptable for up to 48 Prescribed credits by the American Academy of Family Physicians per year. AAFP accreditation begins July 31, 2014. Term of approval is for one year from this date. Each issue is approved for 4 Prescribed credits. Credit may be claimed for one year from the date of each issue. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
AOA Accreditation: Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2A or 2B credit hours per year.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Infectious Disease/HIV CME credits and 0.5 Pharmacology CME credits, subject to your state and institutional approval.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common mediocolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration–approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
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