This HIV Standard of Care chart is reproduced from ACT UP/Philadelphia’s HIV Standard of Care published in May, 1993. This is the fourth version with a fifth version expected soon. This chart is meant as a minimum standard of care for adults (children require a different standard) who are HIV positive -- a minimum level by which patients can determine and measure the quality of their care. HIV Standards of Care differ by region, treatment philosophy and patient population. POZ will present different Standards of Care in future issues.
| WHEN PATIENTS TEST HIV POSITIVE | |
| ANY LEVEL OF T4 CELLS | |
| TESTS TO BE PERFORMED | TREATMENT OR INOCULATION |
| T4 count and T8 ratio as baseline | Repeat every six months if over 500 |
| Anergy Skin Testing | Pneumovax inoculation, if not previously |
| Syphilis Test (use MHATP) | Over treat with Benzathine Penicillin |
| All patients | Flu shot once a year (October) |
| All patients | H. Influenza inoculation, if not previously |
| Hepatitis B negative? | If not, consider Hepatitis B vaccination |
| Baseline Chemscreen / Baseline Toxoplasmosis Titer | If positive, follow carefully, monitor for symptoms |
| Tuberculosis PPD test | If positive at 5mm., treat one year with INH+ Rifampin |
| Baseline Ophthalmic eye tests | Treat if symptomatic for CMV or other problems |
| Herpes Zoster outbreak | Treat aggressively with Zovirax* |
| Vaginal exam | Every 6 months, treat for candidiasis, if present, with topical cream; oral drugs if refractory |
| Pap Smear | If positive, immediate colposcopy, otherwise repeat smears every 3-6 months; if colposcopy is positive, therapy as appropriate |
| Baseline dental exam | Repair obvious gum and tooth problems |
| Baseline Psychatric exam | Some new “positives” need treatment for depression |
| Do your own reading and research | Educate yourself for the many decisions to be made |
T4 ABSOLUTE COUNT* >500 | |
| TESTS TO BE PERFORMED | TREATMENT, INOCULATION OR FOLLOW-UP |
| T4/T8 | Repeat every 6 months; take test same time of day; send to same lab |
| HPV (women) | Continue pap spear every 3-6 months. If positive, immediate colposcopy; if this is positive, therapy as appropriate |
| Office visit to primary physician every 4-6 months | Visual exam to include inspection of mouth skin |
| Dental exam | Exam and cleansing every 4-6 months |
| Psychiatric | Continue counseling or join a support group |
T4 ABSOLUTE COUNT* 500-200 | |
| TESTS TO BE PERFORMED | TREATMENT OR FOLLOW-UP |
| HIV Infection | Start anti-retroviral duo therapy with DDI & AZT. Move on to AZT & DDC as next step, use d4T or Alpha Interferon as backups |
| T4/T8 tests | Every 3 months -- constant time and lab |
| PCP | If <300 t4=“” cells=“” and=“” symptomatic=“” test=“” for=“” active=“” infection=“” by=“” induced=“” sputum=“” or=“” broncoscopy=“” if=“” asymptomatic=“” do=“” not=“” begin=“” prophylaxis=“” until=“” 200=“” percentage=“” is=“” below=“” 15=“” td=“”> |
| CMV | Eye exam immediately if symptoms occur |
| HPV (women) | Pap smear every 3-6 months; colposcopy if positive; therapy if appropriate |
| Candidiasis (oral, esophageal) | Local clotrimazole therapy (Mycelex®); fluconazole (Diflucan®) or ketoconazole (Nizoral®) if refractory |
| Dental | 2 or 4 times per year visits; repair longstanding problems. Expect some mouth ulcers or dry mouth conditions |
| Skin problems, including foot fungus | See dermatologist; treat topically, aggressively |
| Expect Sinusitis problems | Treat aggressively with decongestants, antihistamines. Take care to have any pneumonia symptoms checked |
| Nutrition inventory & Chemscreen | Treat nutritional deficiencies through counseling and vitamins |
| Office visit every three months | Treat other problems immediately |
| Psychiatric | Continue therapy or support group |
T4 ABSOLUTE COUNT* 200-100 | |
| TESTS TO BE PERFORMED | TREATMENT OR FOLLOW-UP |
| HIV Infection | Continue therapy if working; switch to other combinations (AZT/DDC or AZT/DDI); frequent amylase levels if on DDI; watch for anemia if on AZT. Treat anemia with dose reduction or transfusions or EPO injections; folic acid tabs and B-12 injections can be helpful. Do not use Alpha Interferon as backup as it can lower T4 count at these levels. PCP prophylaxis Bactrim (double strength 3x per week) or aerosol pentamidine (with posturing). Add Dapsone to pentamidine twice per week as adjunct if previous PCP patient. Bactrim is now viewed as a preferred therapy. Use Atovaquone (566c80) as a backup. |
| HPV (women) | Pap smear every 3 months; colposcopy every 6 months |
| Candidiasis | Treat locally with topicals; fluconazole (safer) or ketoconazole (cheaper) if refractory |
| Vaginal Candidiasis | Vaginal exam every 3 to 6 months; treat aggressively with local clotrimazole cream; fluconazole if refractory |
| CMV | Continue eye exams; treat with Gancyclovir if proven CMV infection |
| Toxoplasmosis Titer | Once a year; if positive, consider pyrimethamine prophylaxis; or with Bactrim combination (prophylaxis is as yet unproven) |
| TB | Any suspicion of TB should be x-rayed and cultured; treat very aggressively with ING and Rifampin, usually along with other drugs (PZA, etc.) |
| Office Visit | Visual exam to include inspection of mouth and skin every 3 months |
| Fevers | Identify cause and treat. (Most people use too little Tylenol®) |
| Diarrhea | Treat with Immodium; if continues more than 2 weeks identify cause and treat aggressively; eliminate milk products. If continues may treat with Humatin if cryptosporidiosis is suspected |
| Peripheral Neuropathy | Best available treatment is acupuncture (really!), but some success with Tegretol or Elavil. Experimentation with gel insoles can be helpful for feet. Try using Mexiletine |
| Dental Exam | Exam and cleaning 4-6 months. Fix problems |
| Nutrition and Vitamins | Correct deficiencies; add vitamin supplements |
| Psychiatric | Continue therapy and/or support group |
T4 ABSOLUTE COUNT* <100 | |
| TESTS TO BE PERFORMED | TREATMENT OR FOLLOW-UP |
| HIV Infection | Continue combination therapy; high dose Acyclovir (800 TID) also has survival benefit at these levels |
| PCP | Continue prophylaxis (Bactrim or Pentam with Dapsone). Use Atoquavone (566c80) as a backup; Trimetrexate with Leucovorin rescue is being used as a salvage (last ditch) therapy |
| CMV | Use Gancyclovir or foscarnet if actual CMV is proven. Eye exam every 3 months. WAtch for CMV gut problems |
| Toxoplasmosis Titer | If positive, use Prophylax with pyrimethamine, Bactrim or combination |
| MAI/MAC | MAI blood culture every 3 months. If positive, tret with clarithromycin or azithromycin usually with Rifabutin, or traditional multiple drug combination therapies. If wasting occurs, treat for MAI aggressively; consider prophylaxis with Rifabutin, adding clarithromycin or azithromycin later on |
| Cryptosporidiosis | Aggressive testing and treatment; consider Humatin prophylaxis |
| Candidiasis | Treat aggressively with fluconazole; Sporanox® backup |
| Cryptococcal meningitis | Treat aggressively wityh Amp B+5FU; prophylaxis with fluconazole. Prophylax all patients with fluconazole to prevent cryptococcal meningitis |
| HPV (women) | Pap smear every 3 months; colposcopy every 6 months or if positive, consider aggressive therapy |
| Wasting | Consider treatment for MAI presumptively; also use Megace or Marinol; consider Trental (TID) prophylaxis |
| Office Visit | Monthly to bimonthly. Treat all other problems aggressively |
*T4 count is CD4 cell count. Practitioners should also count percentage of Lymphocytes and treat accordingly. The 20% level is frequently considered a “trigger” for aggressive therapy even if T4 count is more than 200. Many physicians consider percentage as important as absolute T4 count. Delayed Hypersensitivity Skin Tests, which are under-administered in the U.S., are useful as an adjunctive test of immune function.
Source: HIV Standard of Care, ACT UP/Philadelphia, Version 4; published May, 1993
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