Refugee Health Vancouver is a practical resource to support clinicians who provide care to refugees in British Columbia.
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|Image retrieved from US CDC, Electron microscopic image of HIV, seen as spheres atop white blood cells.|
For twenty years, the accuracy of serologic screening has steadily improved with successive generations of assays. Thus, HIV diagnosis has become minimally burdensome for the health care practitioner.
Note: Newly presenting patients who report history of HIV infection should be confirmed by serologic testing. Confirmation of diagnosis is important, as some reports of infection appear inaccurate.
The US Center for Disease Control has estimated that early detection of HIV could prevent 32 000 cases of new HIV (in the United States) each year. This is a fifty percent reduction. According to a 2006 study published in the Lancet 40% of HIV positive patients receive testing and diagnosis within one year of an AIDS defining illness. Looking to the evidence of HIV natural history, this then implies that 40% of HIV diagnosis occurs at least seven years after initial infection.
A review of 1302 "late testers" (patients with an AIDS diagnosis within one year of first positive test) demonstrated that these patients had a total of 7988 encounters with the health care system from 1997 to 2005 without HIV testing, an average of 6.5 visits/patient. These encounters were viewed as "missed opportunities" since early detection contributes to both individual and population health.
A subsequent retrospective study of 44,491 HIV-infected patients from 13 US and Canadian clinical cohorts found that the median CD4 count at diagnosis increased from 256 cells/mm3 to 317 cells/mm3 during the period from 1997 to 2007; although the median CD4 cell count at presentation improved, it was still below the threshold at which treatment is currently recommended.
Careful clinical evaluation should be completed at the time of initial assessment of an HIV positive individual. This will include blood work, review of systems, full physical exam. Special attention should be paid towards the patients understanding of his/her illness, emotional state, social supports, and willingness to partake in treatment. Exploration of issues of transmission must be discussed at length, as knowledge is variable around the world. HIV case workers may be useful where available. Special attention should be paid to comorbidities. These effect choice of ART.
Antiretroviral therapy has dramatically changed the course of HIV since its introduction over two decades ago. Opportunistic infections and other AIDS defining illness have dramatically declined.
For detailed review of HIV primary care please refer to the following 2 most up-to-date resources:
The decision to initiate antiretroviral therapy is complex. Guidelines have changed over the years, trending towards earlier therapy. Risks of toxicity, resistance, and patient burden should be openly discussed with each patient. Today, we know that viral suppression can restore and improve immune system function. Patients must adhere to life long therapy for maximum benefit, a task that is sometimes difficult to achieve in Canada's most affected populations: injection drug users, sex workers, Canada's aboriginal populations, refugees, and men who have sex with men.
Trends toward earlier treatment result from:
We now know that untreated viremia creates an uncontrolled inflammatory state affecting all organ systems. End organ damage is common and inevitable. We are learning that comorbid conditions are likely developing due to this chronic inflammatory state. Mortality from non-AIDS events now exceeds AIDS defining opportunistic diseases in individuals on ART.
Initiate ART regardless of CD4 count if:
Effective treatment should suppress viral load to less than 50 copies/mL (PCR)
This is still unknown.
Changes in assay methodology may result in detectable and sporadic viral load.
Vitamin D deficiency is common in the setting of HIV. The evidence is unclear regarding whether this is a viral effect or iatrogenic. Guidelines recommend supplementation.
Aberg, JA, Kaplan, JE, Libman, H, et al. Primary care guidelines for the management of persons infected with human immunodeficiency virus: 2009 update by the HIV medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 2009; 49:651.
Daar, ES, Little, S, Pitt, J, et al. Diagnosis of primary HIV-1 infection. Los Angeles County Primary HIV Infection Recruitment Network. Ann Intern Med 2001; 134:25.
Simon, V, Ho, DD, Abdool Karim, Q. HIV/AIDS epidemiology, pathogenesis, prevention, and treatment. Lancet 2006; 368:489.
Losina, E, Schackman, BR, Sadownik, SN, et al. Racial and sex disparities in life expectancy losses among HIV-infected persons in the united states: impact of risk behavior, late initiation, and early discontinuation of antiretroviral therapy. Clin Infect Dis 2009; 49:1570.
Althoff, KN, Gange, SJ, Klein, MB, et al. Late presentation for human immunodeficiency virus care in the United States and Canada. Clin Infect Dis 2010; 50:1512.
M Thompson, J Aberg, P Cahn, J Montaner, et al. Antiretroviral Treatment of Adult HIV Infection – 2010 Recommendations of the International AIDS Society – USA Panel. JAMA, July 21, 2010 – 304, (3) 321-333
Palella F, Armon C, Buchacz K, et al. CD4 at HAART initiation predicts long-term CD4 responses and mortality from AIDS and non-AIDS causes in the HIV outpatients study. In: 17th Annual Canadian Conference on HIV/AIDS Research. San Francisco, CA: CrOI; 2010. Abstract 983.
Harrison KM, Song R, Zhang X. Life expectancy after HIV diagnosis based on national HIV surveillance data from 25 states, United States. J Acquir Immune Defic Syndr 2010;53(1): 124-130.
Lohse N, Hansen AB, Pederson G, et al. Survival of persons with and without HIV infection in Denmark, 1995-2005. Ann Intern Med 2007;146(2):87-95.
Reekie J, Mocroft A, Sambatakou H, et al; Euro-SIDA Study Group. Does less frequent routine monitoring of patients on a stable, fully suppressed cART regimen lead to an increased risk of treatment failure? AIDS 2008;22(17):2381-2390.
Mueller NJ, Fux CA, Ledergerber B, et al; Swiss HIV Cohort Study. High prevalence of severe vitamin D deficiency in combined antiretroviral therapy-naive and successfully treated Swiss HIV patients. AIDS 2010; 24 (8): 1127-1134
Translated educational handouts on health issues.
Dentists, physiotherapists and other community resources who speak other languages, accept IFH or offer reduced fees.
An overview of the main countries from which Canada receives refugees, with a focus on political and health issues.