Lactic Acidemia in Infection with Human Immunodeficiency Virus

CDC/HRSA/NIH/HIVMA of the IDSA Recommendations for Incorporating HIV Prevention into the Medical Care of HIV-Infected Persons The following summarizes the most important features of the new guidelines for HIV prevention intended for providers (www.aidsinfo.nih.gov). The challenge is the rate of 40,000 new infections per year for the past decade. The goal is to reduce this by 50%. Patients should be screened for behavior associated with HIV transmission on the initial visit and periodically thereafter at a minimum of once yearly. Initial and subsequent visits should also be accompanied by a history for symptoms suggestive of STDs, including urethral discharge, vaginal discharge, intermenstrual bleeding, genital or anal ulcers, anal pruritus, burning with urination, and, in women, low abdominal pain. There should be an HIV prevention message provided at each visit or periodically with a frequency of at least twice yearly. Methods to reduce sexual transmission of HIV include sexual abstinence, consistent and correct use of condoms and ‘‘sex only with a partner of the same HIV serostatus. ’’ HIV-infected patients who engage in high-risk sexual practices with persons who are seronegative or have an unknown serologic status should be counseled on the use of condoms. Screening for STDs should include syphilis serology; women should be screened for trichomoniasis, and sexually active women less than 25 years should be screened for cervical C. trachomatis infection. There should be ‘‘consideration’’ of screening HIVinfected men and women for gonorrhea and for screening HIV-infected men for gonorrhea and chlamydia infection using urine-based nucleic acid amplification tests (NAATs). Screening should be repeated annually and at frequencies of up to 3 to 6 months for asymptomatic persons at high risk. Some experts also recommend type-specific serologic tests for HSV type 2. Women of child-bearing age should be questioned regarding the possibility of pregnancy, should have pregnancy tests performed if indicated, and should be referred for appropriate prenatal care, reproductive health care, or appropriate counseling as indicated. Viral load: The risk of heterosexual HIV transmission in untreated patients increases approximately 2.5-fold for each 10-fold increase in plasma viral load (N Engl J Med. 2000;342:921). This suggests that HAART should reduce the probability of transmission, but there is no level considered safe. It is noted that some reports suggest that drug-resistant strains are less easily transmitted (Nat Med. 2001;7:1016), but data are limited. Postexposure prophylaxis: There are a few data on efficacy for nonoccupational exposure, although one report suggests benefit (Schecter M et al. 9th CROI. Seattle; 2002. Abstract 15). The recommendation is not supportive of antiretroviral agents for prophylaxis if there is nonoccupational HIV exposure because ‘‘avoiding exposure remains the best approach. and potential availability of post-exposure prophylaxis should not be used as a justification for. risky behavior. ’’ Injection drug use: Patients with IDU should enter substance abuse treatment programs including methadone maintenance and should be given referrals to such programs. Those who continue to inject drugs should use sterile equipment and never reuse or share needles, syringes, or other injection equipment. They should be provided information on obtaining sterile syringes and needles as with needle-exchange programs. Contact tracing: Patients should be queried at the initial visit to know if their sex and needle-sharing partners are aware of their exposure to HIV. They should be encouraged to speak with health department specialists about partners who have not been informed to arrange a referral for HIV testing. STD screening: The following tests are recommended for the screening for STDs. What are the minimum tests: (1) history of HIV risk, current risk behavior, and information about knowledge that those placed at risk know it; (2) genital and rectal exam; (3) current risk and method to reduce risk; (4) need to disclose risk to sex