By Dan Vergano, Medical Tribune News Service
Citing recent change in patient treatment, federal health officials have released new guidelines for the treatment of the opportunistic infections that can accompany HIV.
Because HIV attacks the immune system, its victims can suffer from a host of diseases, particularly pneumonia and bacterial infections. However, with new discoveries about the immune system and use of more potent drug therapies since the 1997 release of the last set of opportunistic infections guidelines, physicians have updated those recommendations to reflect new knowledge about treating HIV patients. Because patients are being treated with potent drug combinations to stop or at least markedly slow the immune cell destruction caused by HIV, many patients do not need to take preventive drugs, so-called prophylaxis medications, to prevent opportunistic infections.
"The most important question is whether patients stop taking prophylaxis after their CD4 [immune cell] counts increase," said Dr. Henry Masur, of the National Institutes of Health in Bethesda, Md., co-chairman of the 1999 Guidelines for the Prevention of Opportunistic Infections in Persons Infected with HIV. Published by the Public Health Service and Centers for Disease Control and Prevention (CDC), the recommendations convey indications for taking patients off preventive drugs as their immune system recovers and information about new diseases. Hepatitis C and herpesvirus 8, newly included diseases that prey on HIV victims with particular intensity, were less well known when the earlier guidelines were issued.
"The bottom line is that physicians can rely on CD-4 counts," for stopping prophylaxis for many illnesses, said Masur. Since the beginning of the AIDS crisis, physicians have debated the merits of using the numbers of these immune cells, a subset of the so-called T-cells that police the bloodstream looking for invaders, as a marker of patient health. With the advent of protease inhibitors and other HIV-fighting drugs, doctors turned to the question of whether patients with reconstituted levels of T-cells were truly safe from opportunistic infections. "We gathered 150 experts in the field to create these recommendations, so they do represent a consensus on accepting CD4 counts," said Masur.
While HIV has dropped from No. 1 to No. 5 as a cause of death among people aged 25 to 44, roughly 40,000 new cases of the disease occur nationwide every year, according to the National Institute of Allergy and Infectious Diseases. Today, new HIV patients are more likely to be injection-drug users and immigrants, with fewer gay men, said Masur. Still, "the patients all get the same illnesses, so treatment of opportunistic infections remains the same."
Typical updates to the recommendations include notification of physicians that a two-month regimen of anti-tuberculosis drugs works as well as the six-month treatment regimen now commonly used. "That change represents a big convenience for patients, along with better compliance rates," said Masur.
"The guidelines really represent a thorough and excellent resource for physicians not used to treating HIV," said Tim Teeter, associate director for treatment support at the San Francisco AIDS Foundation, an organization with approximately 2,500 clients who are infected with HIV.
"The one drawback of the guidelines is they don't include screening guidelines for routine diseases," added Teeter.
The guidelines were released as an addendum to the federal Morbidity and Mortality Weekly Report, and will be republished in journals for physicians at a later date, according to the CDC.
