Ronald H. Goldschmidt

Centers for Disease Control and Prevention 2006 Human Immunodeficiency Virus Testing Recommendations and State Testing Laws

grams are not part of academic hospitals. Because hospitals are not financially accountable for their patients after discharge, only those hospitals with strong commitments to quality are likely to institute programs designed to ensure continuity of care between hospitalists and patients’ primary care physicians. Evidence suggests that hospitalist programs can be effective, but internal changes for efficiency do not assure better outcomes after discharge. We need empirical evidence regarding performance of a representative sample of hospitalist programs, regardless of the sponsorship under which they operate. Assuming that all programs are as effective as the literature may miss important opportunities for improving patients’ experiences and outcomes.

Treatment of AIDS and HIV-related conditions--1997.

Extraordinary developments in antiretroviral therapy against the human immunodeficiency virus (HIV) have profoundly changed the way patients, their families, their physicians, and society now view HIV disease. Only one decade after discovery of the virus, new medications and pharmacologic strategies appear to be able to retard the proliferation of the virus and slow the progression of disease. Although long-term studies of the clinical impact of antiretroviral therapy are not yet available, all indications are that treatment of this chronic disease will be dramatically more promising during the next decade. The prospect of markedly slowing the progression of HIV disease and the acquired immunodeficiency syndrome (AIDS) challenges all clinicians to provide their patients with the most helpful guidance and the most effective therapies. These challenges include selecting antiretroviral strategies, offering prophylaxis against opportunistic infections, treating the major complications of AIDS, and providing comprehensive primary care. This Current Report-HIV is an update of our annual treatment guidelines. 1 It is based on our clinical experience at San Francisco General Hospital, a review of the medical literature, and experience gained from answering calls to our National HIV Telephone Consultation Service. Its purpose is to provide treatment recommendations for most of the medical problems of adults and adolescents with HIV disease and AIDS.

Families Of Homosexual Men: Their Knowledge And Support Regarding Sexual Orientation And HIV Disease

Background: The number of homosexual men (gay) with the human immunodeficiency virus (HIV) who will become ill in the next few years is expected to rise dramatically. Many will need and desire support from their families of origin. Understanding the history of family relationships can be crucial for the optimal care of these patients and their families. Little is known, however, about the relationship between gay men and their families of origin. Methods: A convenience sample of gay men (n = 265) from three northern California cities was surveyed to determine family member knowledge of their sexual orientation and HIV status and perceived family supportiveness regarding issues of HIV disease and acquired immunodeficiency syndrome (AIDS). Fifty-five percent of the sample were HIV negative, 14 percent were HIV positive, 8 percent had received a diagnosis of AIDS, and 23 percent had not been tested. Results: Approximately 70 percent of family members knew a son’s or brother’s sexual orientation. Fewer family members (50.9 percent) knew a son’s or brother’s HIV status than knew his sexual orientation. Untested gay men reported the least family knowledge of both sexual orientation and HIV status. There was, however, considerable variation in knowledge among members of the same family, with mothers and sisters knowing HIV status more frequently than fathers and brothers. The amount of supportiveness regarding issues of HIV disease within the family also varied considerably. Conclusions: It is important for the family physician caring for the gay male patient, his family, or both to understand that the pattern of knowledge and supportiveness among family members concerning sexual orientation and HIV status is selective, even within the same family. The physician needs to assess family members’ knowledge and attitudes to plan an overall care strategy.

Teleconsultation for Clinicians Who Provide Human Immunodeficiency Virus Care: Experience of the National HIV Telephone Consultation Service

OBJECTIVE To examine the infrastructure, successes, and challenges of a teleconsultation service for human immunodeficiency virus (HIV) clinicians. MATERIALS AND METHODS The HIV Warmline is a telephone consultation service providing free, live HIV/AIDS management advice to U.S. clinicians. We present descriptive data about callers, patients, and consultation topics gathered by electronic query of the HIV Warmline database for 2009. Caller satisfaction survey results for 2009 are also presented. RESULTS The HIV Warmline has provided more than 37,000 consultations since its inception in 1992. The service provides consultations to clinicians from all 50 states, from a variety of professional backgrounds, and with a wide range of HIV experience levels. The majority of call topics concern antiretroviral therapy. Callers are generally pleased with the service, giving a mean Likert scale rating of 4.7 on satisfaction survey questions. CONCLUSION The experience of the HIV Warmline can serve as a model for other programs planning to develop remote consultation systems. HIV teleconsultation has been relatively simple to implement and can be useful for many types of clinicians. HIV teleconsultation should continue to be evaluated as a way to improve HIV care, especially in areas without easy access to HIV expertise.

Treatment of AIDS and HIV- Related Conditions: 2000

Managing human immunodeficiency virus (HIV) disease and the acquired immunodeficiency syndrome (AIDS) has changed dramatically during the past few years. Potent combination antiretroviral therapy has produced dramatic improvement in the clinical status of many persons living with HIV disease, decreased the incidence of opportunistic infections, and reduced mortality from AIDS. For the patient, the family, and the primary care clinician, the major challenges are achieving suppression of viral replication to obtain clinical benefits, preventing the development of drug resistance, maintaining adherence to complicated medication regimens, and avoiding toxicities and drug-drug interactions. Excellent care of persons with HIV disease requires applying the principles of primary care and chronic care management to a disease that is somewhat different from other primary care diseases. Not only are HIV disease and AIDS unique in their potential lethality and infectiousness, l but suboptimal antiretroviral therapy can lead to irreversible drug resistance. Multidisciplinary care, therefore, has great advantages in managing HIV infection and AIDS. Collaboration among a team consisting of a primary care clinician, pharmacists, case workers, nurses, and AIDS experts can offer the best opportunity to provide excellent comprehensive care. Pharmacists can be especially helpful in assessing and improving treatment adherence. This Current Report-HIV updates our annual treatment guidelines. The recommendations (fable 1) are based on our experience at San Francisco Gen-

Sulfadiazine-induced crystalluria and renal failure in a patient with AIDS.

Cerebral toxoplasmosis is one of the most treatable opportunistic infections of the central nervous system in patients with the acquired immunodeficiency syndrome (AIDS).l,2 A combination of sulfadiazine and pyrimethamine is the therapy of choice, producing a favorable clinical response in 68 to 95 percent of patients receiving this regimen.3,4 Reports of sulfadiazine-induced crystalluria and renal failure were common during the 1940s and 1950s, before more soluble sulfonamides, such as trimethoprim-sulfamethoxazole (TMP/SMX) , became available. Recently, case reports of sulfadiazine nephrotoxicity have reappeared as widespread use of this regimen for human immunodeficiency virus (HIV)-related cerebral toxoplasmosis increased.5-17 We report a patient with AIDS and central nervous system toxoplasmosis who developed nonoliguric renal failure caused by sulfadiazine-induced crystalluria.

Oral health care issues in HIV disease: Developing a core curriculum for primary care physicians

Background: Given the high occurrence of oral manifestations in patients infected with human immunodeficiency virus (HIV), the relative ease in recognizing these manifestations on physical examination, and their potential impact on the health care and quality of life in these patients, it is critical to provide adequate training for primary care physicians in this area. Methods: Based on a review of the published literature and the consensus of a national panel of primary care physicians and dentists with clinical and research expertise in this area, a core curriculum was developed for primary care physicians regarding oral health care issues in HIV disease. Results and Conclusions: We describe the process of developing the core curriculum of knowledge, skills, and attitudes regarding oral health care issues in HIV disease. The final curriculum is in a format that allows for easy accessibility and is organized in a manner that is clinically relevant for primary care physicians.

Type 2 diabetes in adolescents. How to recognize and treat this growing problem.

PREVIEW At the same time they are reporting the current obesity epidemic, US physicians are also seeing a dramatic increase in the prevalence of type 2 diabetes in adolescent patients. In this article, Drs Laurencin, Goldschmidt, and Fisher summarize the prevalence and risk factors, clinical presentation, diagnosis, and treatment of type 2 diabetes in adolescents. They also offer interventional strategies for both lifestyle change and pharmacologic management.

Individualized Strategies in the Era of Combination Antiretroviral Therapy

Combination antiretroviral therapy can produce unprecedented improvements in survival, laboratory markers, opportunistic infections, and quality of life in persons infected with the human immunodeficiency virus (HIV). Potent drug combinations that include a protease inhibitor are now considered standard therapy for persons with HIV infection. For these regimens to be successful, clinicians must devote special attention to explaining the correct use of these agents, their risks and benefits, their toxicities and drug interactions, and the importance of good adherence. Although many primary care clinicians are not as familiar with these drug combinations as they are with the treatment of other complex diseases, antiretroviral management of HIV-infected persons is within the purview of most family physicians and other primary care providers. Recent guidelines released by the Department of Health and Human Services (DHHS)l and the International AIDS Society2 provide therapeutic principles and specific recommendations for the use of antiretroviral drugs in adults and adolescents infected with HN. Both these guidelines are markedly similar in their recommendations; a version of the DHHS guidelines is available on the Internet at www.hivatis.org. Final recommendation by the DHHS will be published in the Morbidity and Mortality Weekly Report in 1998. These and other3 recommendations provide helpful guidelines for antiretroviral treatment.

Preexposure Prophylaxis in the United States: An Evolving HIV Prevention Opportunity

Remarkable progress in preventing new human immunodeficiency virus (HIV) infections has occurred during the past few years. That progress is principally measured by the accelerated rate at which biomedical interventions are being implemented, a trend that promises to greatly impact the HIV epidemic into the future. The first intervention, preexposure prophylaxis (PrEP), is the topic of an article in this issue of Clinical Infectious Diseases. The other powerful biomedical intervention, dubbed “treatment as prevention,” has been around for years, initially in prevention of maternal-to-child transmission, but now is supported by stronger proof of effectiveness [1]. Along with measures such as expanded routine HIV testing, postexposure prophylaxis (PEP), and safer sexual and injection drug use practices, a long-awaited decrease in new HIV transmissions has become more possible than any time in the history of HIV since the dramatic declines that followed the adaptation to safer sexual practices much earlier in the epidemic. The study by Wu et al [2], in this issue of CID, provides a look at the uptake of PrEP into practice as reflected by the increase in prescriptions of co-formulated tenofovir disoproxil fumarate (TDF)/emtricitabine (Truvada) for PrEP. The study measured claims data from an extremely large employer-sponsored health insurance database. Although studies looking at billing claims data are imperfect measures of overall clinical use and the population studied is covered by private health insurance plans, the authors do account for the most important variables and confounders. The study design could not account for prescribing changes that might have occurred when the individual carriers added PrEP as an indication for TDF/emtricitabine to their approved formularies. In addition, the current study does not assess uptake among the various racial and ethnic groups in which uptake has been slow. Nevertheless, this study allows the reader a view of the principal findings: a dramatic uptake in PrEP usage in 2014, and few PrEP prescriptions for women. The nearly identical increase in uptake during 2014, at the Kaiser system in San Francisco [3] and among Medicaid recipients in New York [4], provides additional support for the first finding. The time frame for the study (2010– 2014) spans most of the short history of PrEP, from the first major clinical trial in December 2010[5] through the 2012 US Food and Drug Administration approval of TDF/emtricitabine for PrEP and the 2014 revised Centers for Disease Control and Prevention (CDC) PrEP guidelines [6]. It is not surprising that the spike in uptake was not until 2014, when the usual factors that produce acceptance of a new intervention were in place. For clinicians, those factors included sufficient clinical trials results supporting the effectiveness of PrEP; reports of real-world experience confirming PrEP as an accepted prevention tool; approval of the drug for the specific indication; and national guidelines spelling out indications, laboratory monitoring protocols, treatment approaches, and follow-up schedules. Perhaps equally important as clinician acceptance was patient acceptance. Prior to 2014, concerns surrounding the appropriate place for PrEP as an adjunctive or even a sole prevention strategy had been percolating, especially within the community of men who have sex with men (MSM). The controversy, as well as the anticipation, was considerable. Issues such as effectiveness, safety, appropriateness as a prevention measure, cost, and coverage were dissected. Among the most divisive issues was concern about risk compensation (increase in unsafe sexual activities accompanying the sense of PrEP-related protection). The prolonged dialogue, however, raised awareness of this new intervention, especially among MSM. This probably is reflected in the claims data results, which showed that when PrEP prescribing took off, fully 97.5% of prescriptions were for men. The small proportion of PrEP prescriptions for women almost certainly reflects that such a community dialogue and “vetting” of PrEP as a viable prevention measure did not exist among women as it did among MSM. E D I T O R I A L C O M M E N T A R Y