Professional Documents
Culture Documents
HONGKONG
AIDSUNIT
香港衛生署愛滋病服務組
July 1995
Hong Kong
Contents
Foreword 5
Preface 6
1
• CD4 lymphocyte count; Other virological,
immunological, serological and blood tests
2
• General management - nutrition, lifestyle
modification and others; Treatment and
prophylaxis of common HIV-related diseases
5.2 Antiretroviral therapy 99
• Zidovudine; Didanosine & zalcitabine; Other
antiretroviral agents; Combination therapy;
Current strategy and future direction;
Recommended dosages, monitoring and common
side effects of registered antiretrovirals in Hong
Kong
3
Appendix I-A: Global AIDS statistics 132
Appendix I-B : Cumulative HIV/AIDS statistics in 133
Hong Kong
Appendix II : Organizational structure of Hong Kong's 134
AIDS programme
Appendix III : Services provided by the AIDS Unit, 135
Department of Health
Appendix IV : Classification for HIV Infection and 138
surveillance case definition for AIDS in
adolescents and adults in Hong Kong
(1995)
Appendix V : Classification system for HIV infection in 140
children less than 13 years of age in Hong
Kong (1995)
Appendix VI : List of locally-prepared documents on 144
HIV/AIDS
Appendix VII: Ethical Guidelin e s o n A I D S b y t h e 147
HKMA/BMA Joint Ethics Advisory
Committee
Appendix VIII: Disinfection procedures to prevent 149
transmission of HIV in health care
settings
Appendix IX: List of infectious diseases requiring special 152
dispo sal procedures for dead bodies
Appendix X : Advice to staff of funeral parlours and 153
relatives on the safe handling of dead
bodies with infectious diseases
Appendix XI : Useful telephone numbers 154
Appendix XII: Abbreviations & Glossary 156
Appendix XIII: Suggested general readings 159
Appendix XIV: HIV/AIDS report form 160
4
Foreword
The average local doctor or dentist has only a very limited knowledge about
this disease and there is hardly any published text on this subject that is suitable for
the health care worker in Hong Kong settings. We first got some idea about AIDS,
the disease, the virus, its management and prevention in 1987 when the AIDS
Counselling Service of the Medical & Health Department produced its "Information
on AIDS for Doctors and Dentists" which was subsequently reviewed in 1992.
The publication of this AIDS manual aptly replaces the two previous volumes.
It sets out systematically the updated information on the disease and the virus, the
clinical picture and management protocol. Especially important is the inclusion of
recommended guidelines for prevention of transmission in clinical practice and for
the first time recommended guidelines for the infected health care worker as
formulated by the Advisory Council on AIDS.
5
Preface
The HIV epidemic in Hong Kong is now in its second decade. Although there
has not been any explosive increase in the incidence of the infection, reported
statistics has recorded a steady rise in the number of cases. It is reasonable to
project that more HIV-infected patients will be encountered in the future, requiring
more input from medical and social services personnel. Health care providers who
have not managed HIV/AIDS patients before should expect to face HIV positive
patients in the coming years.
Dr. KH Wong
Dr. SS Lee
6
How to use this Manual
Chapter 2 depicts the dimension of the HIV epidemic, both globally and locally.
AIDS programme and strategy development in Hong Kong is introduced, as are its
components - prevention, surveillance and care of people with HIV/AIDS. An
overview of the local response to the disease can be grabbed. It would, however, be
necessary to refer to the local document “ S t r a t e g i e s f o r A I D S p r e v e n t i o n , c a r e
a n d c o n t r o l i n H o n g K o n g ” published by the Advisory Council on AIDS for
greater details if necessary.
7
transmission? What should be done in case of occupational exposure? How should
we respond to the issue of HIV infection and health care workers?. Colleagues can
find information relevant to their professional practice.
AIDS Unit
Department of Health
8
1. BASIC SCIENCE OF HIV INFECTION
The virus causing acquired immunodeficiency syndrome (AIDS) in human being was
first discovered in 1983, which was then called lymphadenopathy associated virus (LAV),
human T-lymphotrophic virus type III (HTLV-III) or AIDS-related virus (ARV). The name
human immunodeficiency virus (HIV), now widely used, was adopted by an international
committee subsequently formed for its nomenclature. We actually refer to HIV type 1 (HIV-1)
in most of the instances when using the term HIV, as there is another serotype - HIV type 2
(HIV-2), which was discovered in 1986. HIV-2 can cause the same spectrum of diseases,
including AIDS, as HIV-1, although it is considered less virulent than HIV-1. HIV-1 was
responsible for most of the infections of the epidemic worldwide whereas HIV-2 is mostly
prevalent in West Africa, though also found in other places. In Hong Kong, one case of
HIV-2 infection has been reported so far.
Virology of HIV
After entry into the cell, RT copies the RNA to proviral DNA within activated
lymphocyte, which is then inserted into the host genome and subsequently replicates with
it. This contributes to the chronic latent nature of HIV infection and makes the virus
extremely difficult to eradicate. Genes on the viral RNA codes for all the viral proteins; more
important ones include the g a g gene for core protein, pol gene for polymerase or RT and
9
other enzymes, and env gene for envelope proteins. There are several other unique genes for
HIV, for instance, the t a t a n d rev genes which are important for viral replication. Based on
the variance in the g a g and env sequences, at least 8 subtypes (termed A-H) of HIV-1 have
been isolated. The recent discovery of subtype O from patients of Cameroonian origins have
caused much public concern as it may escape detection by conventional assays. The
genomic organisation (40-45% homology) and function of gene products of HIV-2 are similar
to HIV-1. However, its nucleotide sequence is more similar to simian immmunodeficiency
virus (SIV) rather than HIV-1. SIV is found in some African monkey species but the chronic
infection is largely asymptomatic.
Some other cell types can also be infected by HIV, e.g. monocytes, macrophages,
follicular dendritic cells, Langerhans' cells and glial cells of brain. In fact, macrophages and
dendritic follicular cells are the major reservoirs for HIV replication. HIV is usually only
found in small concentration in plasma and T lymphocytes during the asymptomatic period.
As disease progresses, the concentration increases. Also, the viral phenotype may change
to the syncytium inducing (SI) strains which induce T cells to form syncytia and kill the cells
rapidly.
Immunology of HIV
10
hampered by the virus, and it transfers the
virus to other CD4 cells. There is a great
variety of interaction between HIV and
different components of immune system.
Knowledge of these immune changes and
the immunopathogenesis of HIV is central to
the development of immunomodulatory or
vaccine therapy for the infection.
Current vaccine development focusses on the use of HIV proteins and peptides as
vectors, development of recombinant proteins, as well as the application of traditional
approach with whole live attenuated or killed virus as immunogens. Recent studies
suggested that protection may be offered by stimulating HIV-specific cell-mediated
immunity, or the functioning of both cytotoxic T lymphocytes and neutralising antibodies,
rather than by antibodies alone (more research done in the past). This area will be the focus
of basic science research in the future. Antigens from conserved region of viral genome has
been used to overcome the problem of diversity of viral strains. For optimal effect, a cocktail
of multiple viral antigens may have to be used in combination. However,
11
potential problems, e.g. antagonism of different antigens and recognition of all the antigens
by body's immunological mechanisms, have to be tackled.
Besides the issue of immunogenicity, the safety and efficacy of the candidate vaccines
have to be tested in clinical studies. The difficulty of implementing any large scale, good
quality human trials cannot be overcome without concerted efforts, good planning and
international co-operation. Phase III trials for HIV vaccine is unlikely to be underway in the
near future, in view of the technical problems anticipated. On the other hand, therapeutic
vaccines may boost the beneficial immune response to HIV. It may, therefore, have a role for
those already infected with the virus in significantly reducing viral burden, slowing disease
progression and possibly minimising risk of transmission. Also, in short of a highly effective
vaccine, even one with only partial efficacy may be invaluable in places with high
prevalence of HIV infection. Of note, however, is that even when a safe and effective
vaccine is available soon - which is very unlikely if not impossible - its value in curbing the
spread of the HIV epidemic will still be limited by its accessibility and affordability. This
underscores the importance of sustained efforts and commitment in strengthening the global
HIV prevention programmes.
12
1.2 Laboratory tests for HIV
The diagnosis of HIV infection is made by means of laboratory tests, amongst which
HIV antibody test is the most widely used one. The antibody test is also useful in providing
epidemiological information on the prevalence and incidence of HIV infection in a
community, as well as safeguarding blood and blood products. In some circumstances,
however, other tests for HIV such as the detection of HIV p24 antigen, the virus itself or
viral genetic material are indicated. A simplified version of the serological profile of HIV
infection is shown in Fig. 2.
Lately, kits for screening both HIV-1 and HIV-2 infection have become available, by
using antigens from both viruses. The screening assays are generally very accurate, with
sensitivity and specificity rates of close to or over 99%. However, their predictive values
depend also on the prevalence of HIV infection in the population tested. For low
seroprevalence populations like Hong Kong, many false positive results may be detected
relative to the identification of truly infected individuals. Testing for HIV antibody has the
advantage that when serum is unavailable in certain settings, saliva or urine samples can be
used alternatively, particularly for the purpose of epidemiological surveillance.
13
It should be noted that a positive screening (ELISA) result needs to be confirmed.
Western Blot (WB) test is the most commonly used confirmatory test in the local setting.
WB looks for antibody responses to specific proteins of HIV, which were separated
electrophoretically. All HIV positive results issued by the Virus Unit of the Department of
Health are being confirmed by supplemental test. When interpreting WB results, it is
recommended to follow the criteria set by the Centers for Disease Control and Prevention
(CDC) in USA, i.e. a test is considered positive if any two of p24, gp41 or gp120 bands are
present. A partial response with some reaction but not meeting the criteria for positivity is
called "indeterminate result". This may occur in early phase of HIV infection, in which case a
positive result is usually obtained upon repeating the test. Partial responses may represent
non-specific cross-reactions. People with persistently indeterminate results for six months or
more may be considered negative for the infection, if they do not have definite risk factors or
HIV-related symptoms.
14
HIV antigen test
T he use of HIV p24 core antigen detection to diagnose HIV infection is limited by the
unsatisfactory sensitivity of the assays and unavailability in routine laboratories (because
of the cost) to date. Nevertheless, the test may still be diagnostically useful at the time of
seroconversion and for infants born to HIV positive mother. Also, it serves as a prognostic
marker for HIV disease progression towards a later stage of the infection. An ELISA-based
antigen-capture technique is usually used to detect free antigen in excess of antibody to
p24.
The development of and subsequent easy availability and widespread use of HIV
antibody tests have made possible early detection of patients infected with HIV. If the test is
used properly, after informed consent and counselling in the case of voluntary testing, it
should be an invaluable procedure for those being tested. For example, although there is
currently no cure for the infection, an early diagnosis will definitely facilitate the monitoring
and management of different stages of HIV disease. With proper intervention, disease
progression is slowed and asymptomatic phase prolonged. Many studies have confirmed
the association between late presentation and poorer patient survival. Early detection of
HIV-infected people is also beneficial from the public health angle as further spread of the
virus can be minimised. Notwithstanding these advantages, possible psychosocial impacts
and other consequences to the tested persons, and more so of the positive subjects, should
always be considered (section 6.1) when the test is performed.
15
2. EPIDEMIOLOGY, SURVEILLANCE & CONTROL
OF HIV/AIDS
The acquisition of HIV via blood-borne route occurs in situations like transfusion of
HIV-contaminated blood or blood products, sharing of contaminated needles or syringes in
injecting drug users, and through needle-stick injury in health care setting. On a global
scale, needle sharing among drug users constitutes the most important channel for its
spread through contaminated blood. Perinatal transmission, also called vertical transmission,
is the passing on of infection from a mother to her infant. This can happen before and during
birth, or through breast-feeding.
16
evidence to suggest transmission of HIV by mosquito bites. Several instances of household
transmission have been reported recently - via blood-borne contact. However, interpretation
of these rare, isolated events has to be put into the correct perspective against the global
HIV epidemic. Into the second decade of the epidemic, such occurrence actually provides
the best epidemiological proof for the three usual documented modes of HIV transmission.
The specific modes of HIV transmission carry the implication that there are behaviours
which put people at risk of infection. This is supported by evidence that most of the known
infections are sexually acquired, or are results of intravenous drug use (via sharing of
needle).
17
Intravenous drug use i s a n o t h e r i m p o r t a n t f o r m o f h i g h r i s k b e h a v i o u r c o n t r i b u t i n g
to the spread of HIV infection. Although the average risk of HIV transmission via needle
sharing is not high, spread among drug users can explode once the virus enters a
community with high frequency of needle or syringe sharing. Infected drug users can also
play a crucial role in perpetuating HIV to other communities through sexual and vertical
transmission. Substance abuse and HIV infection have been described in the USA as the
'twin epidemic', literally illustrating the epidemiological significance of the intertwining
problems. Prevention of HIV spread among drug users can be achieved by the
encouragement and ensurance of use of new injection equipment and avoidance of sharing
of needles and syringes (harm reduction). The strategy should be in place together with the
common goal of drug detoxification and rehabilitation.
Haemophilia i s a r a r e h e r e d i t a r y c o n d i t i o n c h a r a c t e r i s e d b y t h e d e f i c i e n c y o f
certain clotting factors, of which Haemophilia A (or Factor VIII deficiency, a sex-linked
genetic disease) is the commonest. Clotting factor replacemnent is the standard treatment for
haemophilia patients, especially those suffering from severe deficiency. Worldwide, vast
majority of HIV infection among haemophiliacs occurred in the late seventies / early eighties,
when safer blood products were not available and HIV-contaminated ones were
unknowingly given to the patients. HIV-infected haemophiliacs suffer from the
complications and stigmatisations associated with both conditions.
Blood transfusion m a y a l s o r e s u l t i n H I V i n f e c t i o n i f c o n t a m i n a t e d b l o o d i s u s e d .
With the implementation of HIV screening, the chance of such occurrence has become
remote. In Hong Kong, universal screening of donor blood has been undertaken by the
Hong Kong Red Cross Blood Transfusion Service since August 1985. There is, however,
still the minimal chance of HIV infection occurring if an infected donor gives blood during
the 'window period' before HIV antibody becomes detectable (section 1.2). People who have
practised high risk behaviours (sexual or drug-taking) should be advised to refrain from
donation.
18
2.2 The HIV/AIDS epidemic
Global scene
19
The true dimension of HIV infection is even
more difficult to be ascertained, because of
its asymptomatic nature, the long incubation
period from infection to overt disease, and
Global HIV cases by exposure the varied accessibility to HIV testings. The
category WHO has estimated that there are now a
* heterosexual : 60-70% cumulative 18 million adults infected with
* homosexual : 5-10% HIV, the greatest proportion being in
* injecting drug use : 5-10% Subsaharan Africa (over 11 million),
* perinatal : 5-10% followed by South East Asia (3.5 million),
* blood/blood product transfusion : North America (1.1 million), Latin America (2
3-5% million), Europe (about 0.5 million) and
Australia (over 25 thousand). No place is or
will be immune of HIV infection, and the
fastest growth of the epidemic has recently
been noted in countries of South East Asia,
such as Thailand, India and Myanmar.
About 1.5 million children have been
infected by HIV thus far. By the year 2000,
the WHO projects that as many as 30-40
million people might have become infected
by the virus, with 90% in the developing
countries. As a result, more than 10 million
children will be orphaned by AIDS.
Globally, sexual contacts accounted for 70-80% of all infections, with the majority
being heterosexually (60-70%) rather than homosexually (5-10%) acquired. The importance
of each risk factor, however, varies from country to country. For example, HIV spreads
predominantly by heterosexual contacts in Africa, with a male to female cases ratio of about
1:1. In North America, Europe and Australia, majority of the known cases were related to
homosexual activity. There is evidence, however, that the epidemiological pattern is
changing with increasing incidence of heterosexual transmission, and more women are
becoming infected recently. Heterosexual contact is also the main route of HIV transmission
in South East Asia.
20
Hong Kong situation
To date, only 10 % of the reported HIV infection have occurred in women. The rate of
increase of HIV infection in females was, however, particularly rapid in the past two years.
With the increasing trend of heterosexual transmission, it is likely that more women will
become infected by the virus. Locally, two cases of perinatal transmission has been
reported, the first case in mid-1994. Again, more similar cases would be expected in parallel
with the rising trend of heterosexual transmission and of women becoming infected with
HIV.
The prevalence of HIV infection among drug users in Hong Kong has remained low, as
evidenced by the low reported number (2% of the total HIV cases) and surveillance data
collected through unlinked anonymous screening.
Overall, cumulative HIV infection has increased by 20% - 30% per year in the last
couples of years. According to the projection made in 1994, the cumulative infection by the
year 2000 may range from 8000 to 12000, depending on its rate of spread. The annual
incidence of clinical AIDS will be about 200-300 in the coming years, rising to 350-450 by
2000 (Fig 4). Even though the HIV prevalence is relatively low (<0.1%) now, it is predicted
that the infection will grow steadily in the coming years. Because of its impact on young
people, AIDS may become the cause of 20% of all deaths between the age of 20 and 49 at
the turn of the century.
21
2.3 AIDS programme & strategy in Hong Kong
Historical development
22
D u r i n g t h e intensification phase ( 1 9 8 7 - 1 9 8 9 ) , p u b l i c e d u c a t i o n w a s h i g h o n t h e
agenda. A committee on education and publicity on AIDS and a publicity working group
were formed to initiate, implement and coordinate publicity and education programmes.
These were put forth through the aid of various government departments as well as
community organisations. Media publicity was strengthened, with television spots (API)
being produced by the Government Information Service, focussing on various aspects of
HIV/AIDS. The AIDS Counselling and Health Education Service of the Medical & Health
Department was expanded to become an operational arm of the committee, which organised
educational activities targeting various community groups.
T h e t h i r d p h a s e - consolidation - b e g a n f r o m 1 9 9 0 . A c e n t r a l A d v i s o r y C o u n c i l o n
AIDS, appointed by the governor, was established in March 1990. The council has served to
develop AIDS strategy and streamline the operations of Hong Kong's AIDS prevention,
care and control programme. Community participation was encouraged. Both the Hong
Kong AIDS Foundation and the AIDS Concern were formed during this same period. In
early 1993, the AIDS Trust Fund was set up to provide ex-gratia payment to HIV-infected
haemophiliacs and transfusion recipients, and to fund educational and AIDS care projects.
The Advisory Council on AIDS is now underpinned by three committees - Committee on
Education & Publicity on AIDS (CEPAIDS), Scientific Committee on AIDS (SCA), and the
AIDS Services Development Committee (ASDC). Secretarial support is provided by the
Department of Health's Special Preventive Programme. In 1994, the Council published its
policy in a document titled Strategies for AIDS Prevention, Care & Control in Hong Kong .
Services provided to people with HIV/AIDS were reviewed; and the HIV surveillance system
was strengthened through the initiation of studies on scenarios and behaviours.
The structure of the existing AIDS programme in Hong Kong is depicted in Appendix
II. Both government departments / policy branches and voluntary agencies participate and
contribute to the overall AIDS programme. The AIDS Unit of the Department of the Health,
operative under the Special Preventive Programme, remains an important operational arm for
initiating and undertaking a good range of AIDS-related activities, and its services are listed
in Appendix III.
23
patients is promoted, besides educating
people on how to protect themselves from
the infection. It is noted that sustained
avoidance of high risk behaviours cannot be
achieved without a supportive social
environment, e.g. public perception of safer
sex and the use of condoms. Relevant AIDS
education programmes have to be
undertaken consistently, coordinated and
integrated with other health and social
activities as necessary.
24
Except for UAS, the person tested is and should be counselled and informed of the
testing, and that support services should be available for those detected positive (section
6). UAS is the testing of specimens for markers of infection after elimination (unlinking) of all
personal information from each specimen. International guidelines on undertaking UAS for
public health surveillance of HIV infections were established by the WHO in 1989, and the
system has been adopted in Hong Kong since 1990. UAS has been conducted on neonates,
tuberculosis patients, prisoners as well as drug users.
25
3. CLASSIFICATION, NATURAL HISTORY &
ASSESSMENT OF HIV INFECTION
The clinical course of HIV infection is best depicted as a continuum, from acute
infection to the development of AIDS and eventual death. The acute infection may be
subclinical or symptomatic. Afterwards, the disease enters its chronic phase of varying
duration but is usually characterised by the presence of a prolonged period of asymptomatic
infection. Gradually, as the immune system is progressively depleted, the infected patient
begins to experience symptoms arising largely from its complications.
26
In 1993, the CDC revised the classification system (Appendix IV-A) for HIV infection
by incorporating also the CD4 lymphocyte count because of its clinical and prognostic
significance. Staging is therefore made by considering both the clinical condition and the
CD4 level. There are three clinical categories: category A consists of either asymptomatic
HIV infection, PGL or acute infection; c a t e g o r y B refers to symptomatic HIV infection but
not yet clinical AIDS; and category C includes the AIDS-indicator conditions. Similarly,
t h e r e a r e t h r e e c a t e g o r i e s b a s e d o n t h e a b s o l u t e C D 4 c o u n t : c a t e g o r y 1 f o r c o u n t ≥ 500
cells/ul; c a t e g o r y 2 for 200-499 cells/ul; and c a t e g o r y 3 for <200 cells/ul. For both clinical and
CD4 categories, the 'higher' options take precedence. Depending on different combinations
of the two categories, there are nine possibilities of the stages. Further to this revision, the
CDC has also expanded the AIDS surveillance case definition by adding three clinical
c o n d i t i o n s ( Mycobacterium tuberculosis infection of any site - pulmonary or extrapulmonary,
invasive cervical cancer and recurrent pneumonia) to the 1987 list of 23 diseases and also
including the immunological criteria of CD4 count <200/ul or CD4 percentage <14.
The new classification system is primarily intended for the staging of people with
HIV/AIDS in the United States. It provides a framework in enabling clinicians to have a fast
and clear idea about the rough extent of clinical and immunological manifestations of an
HIV-infected patient. The expanded AIDS case definition, especially the CD4 level criteria, is
however not adopted worldwide. This is not surprising as disease pattern varies from place
to place, and so are the requirements for health care provision. For example, tuberculous
infection is highly prevalent in Hong Kong, and it may be difficult to differentiate between
tuberculosis arising from HIV infection or coexistence of the two diseases. On the other
hand, disease like Penicillium marneffei infection occurs not uncommonly in severely
immunosuppressed HIV positive patients in Hong Kong but not in the west. In practice,
Penicillium infection has been included as an AIDS-defining illness by the Department of
Health in Hong Kong. Lastly, the CD4 count enumeration may not be freely available in
some countries, and its inclusion as a diagnostic criterion carries other implications like that
of confidentiality in reporting.
In 1995, the Scientific Committee of the Advisory Council on AIDS formulated its
new classification system for HIV infection and surveillance definition for AIDS in Hong
Kong. The 1993 CDC classification system was recommended for clinical monitoring of
disease. As for surveillance definition, a modified approach has been adopted (Appendix IV-
B). An HIV-infected patient who has either one of the 25 indicator diseases established in
the 1993 CDC surveillance definition or Penicillium marneffei infection is considered as
suffering from AIDS, irrespective of the CD4 count or whether the latter test has been
performed. Of note is that in order for pulmonary TB (with or without involvement of the
drainage lymph nodes) to be treated as an AIDS indicator illness, the patient's CD4 count
must be < 200/ul and/or his CD4% < 14.
27
Primary HIV infection
28
candidiasis, nausea, vomiting and diarrhoea.
In addition, other manifestations such as
aplastic anaemia, hepatitis, pneumocystis
pneumonia with respiratory failure and
rhabdomyolysis may rarely occur. The acute
illness is usually self-limiting and lasts for 1
to 2 weeks. Its association with more rapid
progression to AIDS has been described.
Treatment is basically symptomatic.
29
Early HIV infection & persistent generalised lymphadenopathy
The presence of PGL does not appear to adversely influence the prognosis of HIV
disease. Instead, its disappearance may herald progressive lymphopaenia and deterioration
of immune function. It has recently been found that the period of clinical latency of HIV
infection is not parallelled by a viral latency. More sensitive laboratory techniques, notably
the polymerase chain reaction (PCR) and in-situ hybridisation, have shown that there is an
enormous infiltrate of lymphoid organs by HIV, at all stages of the infection. The minimal
viral burden and replication detected in peripheral blood during early HIV disease is sadly
enough not a true reflection of the state of overall HIV replication and host cell destruction.
With time, activated CD4 cells and macrophages that are infected with HIV are progressively
eliminated and free HIV virions are released into the circulation, which in turn encourage
further CD4 cell activation and viral replication. The vicious cycle continues until the
lymphoid system is so depleted that it breaks down and huge amount of virus then enters
the peripheral circulation. Disease progression is generally evident by that time.
30
Symptomatic HIV infection & clinical AIDS
As immunodeficiency progressively
worsens, the body becomes increasingly
vulnerable to various opportunistic
infections and/or cancers. The infected
patient finally enters the stage classifiable as
AIDS, when he/she suffers from more and
more morbidity and finally mortality. Specific
clinical manifestations of HIV infection
occurring over time are discussed in greater
details in subsequent chapters. The rate of
progression of HIV disease varies
substantially from patient to patient. From
the results of cohort studies of homosexual
men, it is known that about 50% of the
infected patients develop clinical AIDS in 10
years. The cumulative risk increases with
time lapse after acquisition of the infection.
Studies of transfusion-related HIV infection
has suggested a faster rate of
progression. In
31
contrast, progression in HIV-infected
haemophiliacs is in general thought to be
slower, except for those who are older (age
>35 years ) at time of seroconversion. The
rates of progression of HIV infection in
injecting drug users and women are not
clearly defined. Nonetheless, they are
believed to be similar to patients with other
risk factors of HIV transmission. It is not
known yet whether all HIV-infected persons
will develop AIDS, though this is highly
likely if given adequate time for the disease
to progress. Recent studies suggested that
there was a small sub-group of patients who
could be classified as non-progressors in
view of the stable CD4 counts and absent
clinical complications. The prevalence varied
from cohorts to cohorts, and was likely to be
only about 5% after a period of 7 to 10 years.
32
Median survival of patients after AIDS diagnosis has improved over the years, more
so in the developed countries, although the overall outlook is still poor. In places with the
best figures, AIDS patients now survive for a mean of 18 to 24 months. In Hong Kong,
survival of AIDS patients have also improved in recent few years. Possible reasons for the
improved survival are: earlier diagnosis and treatment of life-threatening conditions;
effective prophylaxis of secondary infections especially PCP; advances in antiretroviral
therapy and other forms of treatment. It should be noted, however, that with increasingly
effective prophylaxis of opportunistic infections and potent antiviral therapy, clinical AIDS
may be deferred to the truly terminal stage of HIV infection with complications inamenable to
modern management. The survival time after AIDS may also be affected by the case
definiton of AIDS adopted.
Others
* secondary infections as cofactors
* time lapse after infection
33
3.2 Clinical assessment of HIV-infected patients
T h e c o m p l e x i t y o f p r o b l e m s r e s u l t i n g f r o m H IV i n f e c t i o n d e m a n d s a c o m p r e h e n s i v e
clinical, laboratory and psychosocial assessment to be made for management to be
optimised. This should be implemented throughout the course of the infection, although
emphasis placed on each modality may vary according to the different stages of HIV
disease, as well as the interplay amongst them. Health care professionals and other service-
providers shall be prepared to face the challenge.
W i t h t i m e , m o r e d i v e r s i f i e d HI V - r e l a t e d s y m p t o m s a n d s i g n s m a y p r e s e n t , a n d t h e s e
should be actively looked for. When the patient is started on antiretroviral therapy or
opportunistic pathogen prophylaxis, they may be seen every 4 to 6 weeks if the condition is
stable, after initial intensive monitoring. The condition may need to be reviewed more
frequently if there is evidence of clinical or immunological deterioration. Obviously, when a
patient is severely immunocompromised or has developed clinical AIDS, he/she requires
more frequent care and attention which, however, have to be individualised and tailored to
one's specific needs.
34
Clinical markers of disease progression
Several clinical presentations are common in the course of HIV infection e.g. cough
and fever, diarrhoea and neurological problems. The differential diagnoses depend on
individual clinical setting and the stage of HIV disease. Detailed clinical history and
complete physical examinations are clearly a must for making a provisional diagnosis to work
upon; nevertheless, investigations are usually necessary afterwards. The general approach
to some of the common clinical problems associated with HIV/AIDS are outlined below.
35
Presentation Diagnostic approach
36
Presentation Diagnostic approach
37
Presentation Diagnostic approach
38
3.3 Laboratory assessment of HIV-infected patients
39
CD4 lymphocyte (T-helper or T4 cell)
CD4 count & HIV-related count is unquestionably the single most
complications# important laboratory marker in the
management of HIV-infected individuals. A
CD4 <50/ul
* Cryptosporidiosis
* Cytomegalovirus disease
* Mycobacterium avium complex
* Primary CNS lymphoma
40
* guides medical management level may fare well for a prolonged duration.
* surrogate marker for clinical Although a useful and widely employed
end-points of HIV infection marker, its interpretation should often be
treated with caution. Unfortunately direct
viral quantitation by, for example,
polymerase chain reaction, is currently only
a research tool. Nevertheless, CD4 count is
probably one of the best laboratory
indicators for immunological assessment as
well as for monitoring the efficacy of
antiretroviral therapy. In Hong Kong, CD4
enumeration by flow cytometry is available
at the Pathology Institute of the Sai Ying
Pun Polyclinic operated by the Department
of Health. As a general recommendation, the
CD4 level of HIV positive patients is
checked every 3 months unless the count is
rapidly falling and thus requires closer
monitoring.
41
the blood. A low or loss of antibody to p24
core antibody may be secondary to
increased production of. HIV antigen and
development of immune complexes.
β2- m i c r o g l o b u l i n i s a s u b u n i t o f t h e c l a s s I m a j o r h i s t o c o m p a t i b i l i t y c o m p l e x w h i l e
neopterin is a product of stimulated macrophages. Their serum level are raised as a result of
i m m u n e a c t i v a t i o n . A l t h o u g h h i g h l e v e l s o f β2- m i c r o g l o b u l i n a n d n e o p t e r i n a r e a s s o c i a t e d
with a poor prognosis, they are in general non-specific markers. Supplementing the
information (CD4, CD8 and their ratio) from T-cell subset tests, these virological and immune
markers may be measured every 6 to 12 months, depending on needs and resources
available. Skin tests for cell-mediated immunity (CMI) may provide additional clues to the
immunological status of the patient.
Serological tests are often used in the diagnostic workup for several opportunistic
infections. These include antibodies to CMV, toxoplasma and HSV (herpes simplex virus),
and cryptococcal antigen. Baseline documentation is useful and these tests are later
repeated when necessary. Also, infections sharing the same risk factors as HIV, such as
hepatitis B and C and syphilis can be surveilled regularly by serology.
Other blood tests useful in the management of HIV infection are: complete blood
counts with differentials, and liver function tests. For patients on antiviral therapy, a closer
laboratory monitoring for adverse effects is needed. For example, blood counts, creatine
kinase and liver function may be checked every month for zidovudine-treated patients
whereas amylase and urate level are also measured for patients on ddI or ddC.
Besides all these monitoring and surveillance tests, it is essential that patients at
their first consultation should have HIV antibody test repeated to ensure that the result is
correct.
42
4. ORGAN/SYSTEM INVOLVEMENT &
SPECIAL CLINICAL ISSUES OF HIV INFECTION
Oral problems
Kaposi's sarcoma (KS) may involve the palate, gingiva or tongue, and appears as
purple macule, papule or even fungating mass. Biopsy could establish the diagnosis if
there is uncertainty.
43
Retrosternal discomfort, dysphagia & odynophagia
CMV often leads to large and solitary oesophageal ulcer. Histology may show the
characteristic large (cytomegalic) cells containing intranuclear or cytoplasmic inclusions.
T h e i n t r a n u c l e a r i n c l u s i o n m a y b e s u r r o u n d e d b y a s p a c e , g i v i n g t h e a p p e a r a n c e o f a n o wl's
eye” halo. Immunoperoxidase stain for early antigen may also assist in the diagnosis.
Idiopathic oesophageal ulceration usually occurs in those patients who have already
developed AIDS. It mainly situates in the mid to distal oesophagus and is single and less
than 1 cm in about 40% of the cases. It may respond dramatically to steroid. In resistant
cases, thalidomide may be useful. Other causes such as reflux oesophagitis, which may be
exacerbated by non-steroidal anti-inflammatory drugs (NSAIDs) or even zidovudine, can
also be the cause of oesophageal symptoms.
44
Diarrhoea - gastrointestinal infections & other diseases
45
and goes. Previously the diagnosis was usually made by electronic microscopy of duodenal
or jejunal biopsy tissue. Microsporidia (but not the species) can now be identified by light
microscopy examination of the stool with special technique.
Cytomegalovirus can affect any site of the gastrointestinal tract. The commonest
manifestation of enteric CMV disease is colitis. It is characterised by diarrhoea, fever, lower
abdominal pain, and possibly haemorrhage. The presentation can mimic acute abdomen.
Complications like toxic dilatation, haemorrhage and perforation have been reported. The
diagnosis is usually made by upper and/or lower gastrointestinal endoscopic examination
with biopsy. AIDS-associated enteropathy is postulated as the cause for patients who
exhibit villous atrophy and malabsorption in the absence of identifiable pathogens. The
exact mechanisms of this entity remain controversial. In clinical practice, chronic diarrhoea
has to be distinguished from ano-rectal discharge from infections by sexually transmitted
agents like Neisseria gonorrhoea, herpes simplex virus and Chlamydia trachomatis , commonly
c a l l e d t h e “ Ga y b o w e l s y n d r o m e ” .
Hepatobiliary diseases
Cholecystitis/Cholangiopathy
Cytomegalovirus
Cryptosporidium
Kaposi's sarcoma
46
Parenchymal liver disease can be caused by a variety of infections or neoplasia.
Cytomegalovirus or mycobacteria (MAI or MTB) can cause biochemical abnormality with or
without pain, fever or hepatomegaly. Lymphoma and Kaposi's sarcoma can both infiltrate
the liver. Hepatitis viruses, especially B, C, and to a lesser extent A, are agents to consider in
frank hepatitis as they share similar risk factors as HIV and are thus more prevalent in this
group of patients. The host's immune response plays an important role in the pathogenesis
of liver damage in viral (especially hepatitis B virus) hepatitis. Such damage, and thus
symptomatology, may be more severe when the patient is still immunologically competent.
Drug-induced liver damage has also to be excluded as several drugs commonly used in the
setting of HIV infection can cause deranged liver functions, e.g. zidovudine, ketoconazole
and rifabutin. Serological testing, ultrasonic examination of the hepatobiliary system and
liver biopsy are useful investigations. Both histology with usual and special stains, as well
as culture, are necessary in tissue examination.
A c a l c u l o u s c h o l e c y s t i t i s a n d A I D S c h o l a n g i o p a t h y a r e u s u a l l y a e t i o l o g i c a ll y l i n k e d t o
CMV or Cryptosporidium infection, though rarely they can be due to Kaposi's sarcoma.
Recurrent right upper quadrant pain, fever or jaundice can be the presenting symptom.
Ultrasonogram may reveal a thickened-wall gall-bladder with narrowed lumen, without
stones and sometimes with dilated intrahepatic ducts. Endoscopic retrograde cholangio-
pancreatography (ERCP) can both be diagnostic and therapeutic. It shows extrahepatic duct
dilatation in case of cholangiopathy, with a picture similar to sclerosing cholangitis.
Symptomatic relief may be obtained with sphincterotomy if there is no response to specific
therapy for CMV or Cryptosporidium. Systemic chemotherapy may be considered if the
pathology is due to Kaposi's sarcoma. Cholecystectomy may be necessary when other
measures failed.
47
4.2 Respiratory manifestations
Procedure for sputum induction illness in over half of the AIDS patients in
* fast ≥ 4 hours before induction many series, and the life-time risk was once
* thoroughly clean mouth by estimated to be nearly 80%. In Hong Kong,
brushing & gargling it has remained the commonest AIDS event
* use 3% hypertonic saline & over the past decade. The chance of getting
ultrasonic nebuliser PCP is much higher when one’s CD4 count
* instruct patient to inhale & falls below 200/ul, and the diagnosis must be
exhale with mouth through the considered in all patients presenting with
mouthpiece pneumonia. The taxonomic position of P.
* expectorate coughed-up sputum carinii remains unclear as a protozoan or
(not saliva) into the container fungus though recent research was more in
favour of the latter.
level.
48
A high index of suspicion is essential
for diagnosing PCP as this could well be the
first presentation of previously unknown
HIV positive patients. Definitive diagnosis
can usually be established with
microbiological examination whereas
histological evidence is necessary in
difficult cases. Induced sputum with
hypertonic saline for P. carinii i s a relatively
simple and efficient method of arriving at the
diagnosis, with a sensitivity of >90%
reported in some studies. However, the
potential risk of arterial desaturation has to
be borne in mind. Giemsa or silver stain are
used for detection of the trophozoite or cyst.
Monoclonal antibody examination can
improve the yield. In case of sputum
negativity, one may proceed to
bronchoscopic examination with
bronchoalveolar lavage (BAL), which has a
diagnostic yield of over 95% for PCP.
Transbronchial biopsy may be indicated if
BAL is negative or when other pathogens
e.g. cytomegalovirus or mycobacteria are
also suspected.
anti-pneumocystis therapy can significantly reduce the risk of death by half. Intravenous
pentamidine has to be used in case of intolerance to co-trimoxazole. With pentamidine, side
effects like renal impairment, pancreatitis, hypotension, hypoglycaemia followed by
hyperglycaemia and also electrolyte disturbances may occur. Other alternative drugs for
mild to moderate PCP include dapsone and trimethoprim, clindamycin and primaquine, and
atovaquone. Trimetrexate has been used as a salvage therapy for severe cases intolerant of
or unresponsive to both parenteral co-trimoxazole and pentamidine.
Preventive therapy, either primary (indicated when CD4 count is less than 200/ul or
patient has developed AIDS) or secondary (after an episode of PCP) , has been shown to be
very effective in reducing future occurrence of PCP. Again, co-trimoxazole is the first-line
drug if the patient can tolerate it. It has the additional advantage of protecting against
toxoplasmosis. In Hong Kong, the drug has been used in the public service for PCP
prophylaxis since 1989. The choice of second-line drugs for prophylaxis differs from places
49
to places. The options are aerosolised or intravenous pentamidine, oral dapsone with or
without pyrimethamine, and pyrimethamine-sulfadoxine (Fansidar).
Tuberculosis
HIV infection has re versed the declining trend of tuberculosis (TB) in developed
countries like USA. Tragically, it has also worsened the already severe problem of TB in
developing countries, especially Africa. Tuberculosis has once again become a major public
health issue globally as a result of the AIDS epidemic. In Hong Kong, roughly 10% of the
AIDS patients had disseminated tuberculosis as their initial AIDS-defining disease.
Mycobacterium tuberculosis ( M T B ) is a virulent pathogen and it causes disease relatively early
in the course of HIV infection, when the median CD4 count is about 350/ul. In places where
tuberculosis is endemic, development of TB in HIV positive patients is often via
reactivation of latent infection. Compared with non HIV-infected subjects, the frequency and
the progression rate of clinical tuberculous disease is much higher in HIV-infected people.
50
The BACTEC radiometric culture
system is a new, rapid and sensitive method
Treatment of tuberculosis for diagnosing mycobacterial disease. The
* good response to treatment growth and identification of species are
* combination chemotherapy with usually achieved within 2 to 3 weeks, being
4 drugs (isoniazid, rifampicin, faster for MAI than MTB. This enhances
pyrazinamide and ethambutol) the speed and efficiency of diagnosis and
for 2 months, followed by the application of control measures for
isoniazid & rifampicin tuberculosis. The rising prevalence of
* total duration of 9 months or more multidrug-resistant tuberculosis (MDR-TB)
* regimen for MDR-TB depends on with several major outbreaks in USA among
prevailing susceptibility or HIV-infected people have resulted in rapidly
determined sensitivity fatal disease in some cases. MDR-TB will
continue to be a big worry both
epidemiologically and management wise in
the future.
The response of HIV positive TB patients to treatment has been shown to be as good
as non HIV-infected ones. Early diagnosis and prompt treatment are essential both for the
health of the patient as well as for preventing the spread of tuberculosis in the public health
control programme for the disease. Longer duration of the standard anti-TB therapy is
recommended: a mininum of 9 months in total after initial 2 months with at least four drugs.
For disseminated disease or resistant strains, treatment has to be continued for one year or
more. Rifampicin, isoniazid, pyrazinamide and ethambutol are commonly used. Streptomycin
is less commonly used because of the need to be given through injection. Good drug
compliance is prudent. Isoniazid prophylaxis for selected candidates has been shown to
decrease the incidence of disease in some overseas studies. Treatment of MDR-TB can be a
problem; the regimen should consist of at least two drugs that the strain is sensitive to.
Apart from TB, patients with HIV may also be affected by atypical mycobacterial
infection, which often occurs in advanced stage of HIV disease, with preceding AIDS
diagnosis. The commonest atypical mycobacterium is Mycobacterium avium intracellulare
(MAI), also called Mycobacterium avium complex (MAC). MAI is ubiquitous in the
environment, commonly found in soil, water and foodstuff.
51
The respiratory and gastrointestinal
tracts are possible portals of entry for MAI.
Localised disease can occur but
Disseminated MAI disseminated MAI infection is much more
fever significant which characteristically occurs
malaise with a CD4 count of less than 100/ul.
night sweats Disseminated disease may present as fever,
weight loss weight loss, night sweats, diarrhoea,
diarrhoea abdodminal pain, hepatomegaly, anaemia or
abdominal pain an elevated serum level of alkaline
lymphadenopathy phosphatase. Chest X-ray may show
hepatosplenomegaly nodular, diffuse, or patchy infiltrates, with or
anaemia without hilar or mediastinal
pancytopaenia lymphadenopathy. MAI is recoverable by
raised alkaline phosphatase blood culture in more than 80% of patients
with disseminated infection. However, MAI
bacteraemia can be intermittent, especially
with a lighter load of organism. Repeated
culture may therefore be necessary before a
diagnosis can be made. The BACTEC
culture system has hastened the process of
obtaining positive culture, the result of
which is commonly available within 7 to 14
days. Bone marrow, liver, and lymph node
are other potential sites for isolation of MAI.
Sometimes the organism is only found in
sputum or faeces, the presence of which
may represent colonisation only. However,
the chance of subsequent dissemination in
such circumstances can be high.
Besides causing morbidity, studies have suggested that disseminated MAI infection
also adversely affects survival. Treatment is indicated to alleviate symptoms, improve
quality of life and hopefully improve survival. Life-long therapy is needed to reduce the
bacterial burden in the body and to suppress bacteraemia. Combination antimycobacterial
agents is used, consisting of at least two and usually 3 to 4 drugs. Clarithromycin, a new
macrolide, is one potent drug against MAI and should preferably be used. Other drugs
employed may include rifabutin, rifampicin, ethambutol, clofazimine, ciprofloxacin and
amikacin. Potential drug interactions have to be watched out for as affected AIDS patients
are usually taking multiple drugs.
52
Bacterial, viral, fungal & parasitic infections
Bacterial infections of the respiratory tract are commoner in patients with HIV infection
than the general population, particularly in drug users. The phenomenon is caused by the
underlying impaired immunological function at the level of B cell, macrophage, and
neutrophil. Pneumonia and sinusitis (often chronic) are common presentations whereas
increased incidence of bronchiectasis and bronchitis have been reported. For community-
acquired pneumonia, the most important organisms identified are Streptococcus pneumoniae
and Haemophilus influenzae, followed by Staphylococcus aureus, Mycoplasma pneumoniae a n d
gram-negative bacteria (though often n o s o c o m i a l ) i n c l u d i n g Pseudomonas aeruginosa. Clinical
presentations may be similar to those of immunocompetent people. Unlike opportunistic
infections, they occur in relatively early stage of the HIV infection. Bacteraemic spread and
recurrence are, however, common, especially with pneumococcal infection. Moreover,
Pseudomonas aeruginosa i n f e c t i o n of the lung and other sites have been increasingly reported
as a serious and recurrent complication of AIDS. The antimicrobial therapy used for bacterial
infections are similar to those occurring in HIV negative patients.
Viral infe c t i o n o f t h e l u n g i s p r o b a b l y
Pulmonary infections in HIV uncommon. The pathogenic importance of
CMV pneumonitis in HIV infection is
Mycoplasma pneumoniae
Pseudomonas aeruginosa Cryptococcus neoformans lung infection
53
respiratory specimens, lymph node or bone
marrow. Other fungi such as Aspergillus and
Candida species are rarely implicated as
pulmonary pathogens. Amphotericin is the
gold standard of therapy for these infections
though several azole drugs are also useful
for certain specific fungal infections of the
lung. Toxoplasma gondii can cause
pneumonia, albeit uncommon. Fever and
dyspnoea are common features. Serological
test for anti-toxoplasma antibody is usually
positive. Similar to fungal pneumonia, the
organism can often be recovered from
bronchoalveolar lavage with or without lung
biopsy.
54
Chronic lymphoid interstitial pneumonitis was previously an AIDS-defining illness in
children with HIV infection. Its aetiology remains unclear and diagnosis is made by biopsy.
On the other hand, non-specific interstitial pneumonitis has been described in some patients
presenting with pulmonary symptoms without identifiable pathogens. In this case, chest X-
ray shows diffuse interstitial infiltrates and histology reveals mixed mononuclear infiltration.
Penicillium marneffei
The pathogen is a dimorphic fungus that is only found in Southeast Asia including
southern China. Human beings and bamboo rats are the hosts. Both healthy and
immunocompromised subjects who reside in or have travelled to the afflicted areas can be
infected. In patients with HIV/AIDS, penicilliosis generally occur with profound
immunosuppression, as evidenced by the fact that all local infected patients had a CD4
count less than 100/ul.
The patients typically present with systemic symptoms of fever, weight loss and
anaemia. Other common findings include lymphadenopathy, hepatosplenomegaly,
pulmonary and gastrointestinal symptoms, as well as skin manifestations such as papular
molluscum contagiosum-like lesions. Diagnosis is usually made by a positive blood or bone
marrow culture. Occasionally, the fungus may also be recovered from skin biopsy as well as
culture of respiratory specimens. Prompt diagnosis is important as treatment with
amphotericin B can be life-saving in the acute phase. Lifelong maintenance therapy with
antifungals like itraconazole is necessary to suppress the infection after acute treatment.
Some authors have also used itraconazole as initial therapy.
55
4.3 Neurological manifestations
The neurological system, both central and peripheral nervous systems, can be affected
by opportunistic infections, tumours, HIV itself and drugs. Alternatively, the pathology can
be classified according to the anatomical site of involvement, which ranges from
asyptomatic HIV infection of the brain, meningitis, focal brain disease, o n - f o c a l’ brain
disease, myelopathy, peripheral neuropathy, myopathy to retinitis. Clinical presentations of
different underlying neurological diseases can be remarkably non-specific and overlapping.
Yet, a correct diagnosis is crucial for initiating appropriate intervention, particularly when a
treatable cause is the culprit. Neurological complications are associated with significant
morbidity and mortality, especially when the implicating disease is life-threatening or that
can result in major functional disability.
C. neoformans can often be identified by Indian ink stain of the cerebrospinal fluid
(CSF). Protein and glucose level of the CSF may be normal or mildly abnormal, and there is
often only a mild lymphocytic pleocytosis. Diagnosis is confirmed by culture while a
positive CSF or serum cryptococcal antigen is also supportive of the diagnosis. Chest X-ray
is necessary to look for pulmonary involvement. Disseminated cryptococcal disease can
present with skin lesions resembling molluscum contagiosum and in this case blood culture
may be positive. Poor prognostic factors of cryptococcal meningitis include positive
extraneural culture, high CSF cryptococcal antigen titers, low CSF leucocyte (<20 cells/mm3)
and most importantly, abnormal mental state at presentation. In selected mild cases,
treatment with fluconazole may be adequate. However, for severe or resistant meningitis,
amphotericin is the standard treatment, at least for the initial period. Life-long maintenance
therapy with an anti-fungal agent like fluconazole is required to prevent relapse.
Other causes of meningitis in HIV setting are much less common. Tuberculous
meningitis may occur with disseminated MTB infection. CSF cytology may reveal lymphoma
56
cells in case of lymphomatous meningitis. HIV per se can also cause an aseptic meningitis
which usually occurs during relatively early stage of the infection. Neurosyphilis is always a
possibility to consider in patients presenting with neurological symptoms. It is important to
check syphilis serology and ask for relevant history to assist in the diagnosis.
57
There is usually clinical and radiographic response within 2 to 3 weeks, a phenomenon
which virtually confirms the diagnosis. If not, other or concurrent pathology has to be
excluded and a brain biopsy may be indicated. Lifelong maintenance treatment with
pyrimethamine, sulphadiazine and folinic acid supplement is necessary. Co-trimoxazole for
PCP prophylaxis has been shown to protect against cerebral toxoplasmosis.
58
It usually reveals non-enhancing
asymmetrical white-matter lesions without
mass effect. Brain biopsy is required for a
definitive diagnosis. The disease runs
variable course but is often fatal. There is as
yet no treatment of proven value although
cytosine arabinoside has been shown to
have some therapeutic effects in a number of
anecdotal reports.
H I V e n c e p h a l o p a t h y o r AIDS dementia
complex (ADC) usually occurs in
AIDS dementia complex (ADC) symptomatic HIV-infected patients. It is
* occurs in late HIV disease characterised by a subcortical dementia
* affects concentration, thinking, developing over weeks or months. During
balance, fine movement and the workup, it is important to rule out
social interaction opportunistic complications of the brain,
* exclude other causes of dementia psychiatric problems such as depression or
* may respond to high dose anxiety and chronic drug use e.g.
zidovudine benzodiazepine intoxication which can mimic
AIDS dementia complex. All three areas of
cognitive, motor and behavioural functions
may be affected, resulting in poor
concentration, mental slowing, tremor, poor
coordination, ataxia, and apathy. Early stage
may only reveal subtle physical signs like
impaired rapid alternate movements of
fingers and abnormal tandem gait. Cerebral
atrophy is evident on CT scan. CSF usually
shows mild mononuclear pleocytosis, raised
59
protein and markers of immune activation - β
A d i s t a l s e n s o r y a x o n a l neuropathy is
the commonest form of peripheral
neuropathy caused by HIV. Patients
Sensory peripheral neuropathy experience tingling or numbness sensation
* pins and needles in feet over the feet which may gradually spread
* motor disability uncommon proximally. Motor function is preserved
* symptomatic treatment with except that rarely walking is impaired by
amitriptyline, NSAIDs, narcotics severe feet pain. Treatment is symptomatic
and amitriptyline may be tried. Other
confounding causes of peripheral
neuropathy e.g. drugs like ddC has to be
excluded.
P a t i e n t s w i t h HIV myelopathy u s u a l l y p r e s e n t w i t h a s u b a c u t e f o r m o f p r o g r e s s i v e
spastic paraparesis without a definite sensory level. Decreased proprioception and vibration
are the commonest sensory abnormalities. Often ADC is also present. Exclusion of other
spinal cord pathology from infection or tumour is aided by MRI scan or myelogram with or
without simultaneous CT scan. Zidovudine may be tried but is usually of no therapeutic
value.
H I V - r e l a t e d myopathy r e m a i n s p o o r l y d e f i n e d i n t e r m s o f p a t h o g e n e s i s , t i m i n g o f t h e
disease and therapy. Steroid may ease the myopathy but pose the risk of worsening the
immunosuppression due to HIV. In HIV patients with features of myopathy, it is important to
consider zidovudine as the cause. This usually manifests as wasting of buttock muscles
with leg weakness. Improvement or resolution may result with early cessation of the drug.
60
Neurological diseases due to cytomegalovirus
Cytomegalovirus is a common
Polyradiculopathy pathogen in patients with AIDS, usually
Myelitis affecting gastrointestinal tract, nervous
Encephalitis system and eye but it can involve virtually
Chorioretinitis any organ of the body. CMV disease occurs
as a result of reactivation of latent virus due
to progressive impairment of cell-mediated
immunity. Neurological complications of
CMV take the form of polyradiculopathy,
myelitis, encephalitis, and most commonly
chorioretinitis.
CMV polyradiculopathy is
characterised by subacute onset of
ascending asymmetrical leg weakness,
CMV polyradiculopathy
numbness and pain, progressing to flaccid,
* ascending leg pain & paralysis
areflexic paraparesis or paraplegia. Sphincter
with areflexia
dysfunction, sacral paresthesia and low
* neutrophilia in CSF
back pain are common features since
* can have marked but delayed
myelitis may also be present. Patients often
response to ganciclovir
have severe immunosuppression and
* lifelong maintenance therapy
history of opportunistic infections. CSF
examination reveals polymorphonuclear
pleocytosis and moderately reduced glucose
level. Imaging studies may be necessary to
exclude compressive lesions of the spinal
cord. Prognosis is poor without treatment.
However, early therapy with ganciclovir
and/or foscarnet can give dramatic
response. Initial deterioration or delayed
improvement for weeks or even months may
occur with correct treatment. Anti-CMV
maintenance therapy has to be continued
indefinitely.
C M V encephalitis i s a s u b a c u t e p r o c e s s t h a t d e v e l o p s o v e r d a y s t o 1 o r 2 w e e k s . T h e
clinical presentation is progressive personality change, obtundation, headache, fever and
fits. CT brain scan is usually unremarkable. MRI scan may show non-specific periventricular
contrast enhancement due to tissue necrosis. Again polymorphonuclear pleocytosis may be
found in CSF. Treatment is with ganciclovir but the efficacy is unknown.
61
CMV retinitis is a frequent
complication in AIDS patients with
CMV retinitis advanced immunosuppression. It is
* symptoms of floater, blurred increasing in incidence and importance. It is
vision, and visual field loss the commonest opportunistic infection in
* characteristic though non-specific patients who had already progressed to
retinal changes AIDS in Hong Kong. Sometimes it is the
* essentially a clinical diagnosis primary presenting AIDS-defining illness.
Retinitis usually begins unilaterally, but not
uncommonly it progresses to involve both
eyes because of CMV viraemia. Patients
present with floaters, blurring of vision or
less commonly, visual field loss.
Fundoscopic examination typically shows
Management of CMV retinitis
areas of retinal oedema, and perivascular
* induction treatment with IV
haemorrahge and exudate (classically
ganciclovir or foscarnet, depending
on tolerance and response
described as cottage cheese and catsup
appearance). Initially, these changes may be
* may use combination treatment
found in the periphery of the retina. If left
in case of poor response
untreated, the abnormalities progress to
* lifelong suppressive therapy
involve the macula and optic disc.
All patients with AIDS or CD4 count below 100/ul should be regularly monitored for
development of CMV retinitis, although the disease can also occur at earlier stage of HIV
infection. The diagnosis is made clinically and prompt treatment with antivirals like
ganciclovir is necessary. The major side effect of ganciclovir is bone marrow suppression,
which can substantially limit its tolerance, especially in patients receiving concomitant
zidovudine treatment. Products like G-CSF may be useful to counteract its most profound
toxicity of neutropaenia. Foscarnet has been shown to be at least as effective as ganciclovir
in treating CMV retinitis and apparently gives a survival benefit, possibly through its anti-
HIV effect. It has a different spectrum of side effects compared with ganciclovir, and is in
general less well tolerated than ganciclovir. Ganciclovir resistance has been described, and it
is possible that the same can happen with foscarnet.
In case of poor response to treatment with either agent, the alternate drug or a
combination of the two should probably be tried although there is yet no good study to
support this approach. Lifelong maintenance therapy is needed after 3 weeks of induction
treatment, to lower the chance of relapse. Insertion of long term venous access device has to
be considered as both drugs need to be administered intravenously. Clinical trials on the use
of oral ganciclovir is now in progress. Initial results showed that it is effective for
maintenance therapy, though an earlier relapse is expected compared with intravenous
ganciclovir. Expense is another disadvantage for this convenient alternative.
62
4.4 Skin manifestations
Minor skin conditions can be of increased severity if they occur together with HIV
i n f e c t i o n . O n e e x a m p l e i s seborrhoeic dermatitis w h i c h i s v e r y c o m m o n i n H I V - i n f e c t e d
people and is characterised by thick, scaly plaques with inflammation. Apart from commonly
affecting the nasolabial and glabellar regions, more extensive involvement of face and trunk
63
m a y b e s e e n . Psoriasis i s a l s o i n c r e a s e d i n f r e q u e n c y a n d s e v e r i t y i n H I V p o s i t i v e p a t i e n t s ,
a s w e l l a s skin infections l i k e f o l l i c u l i t i s , f u r u n c l e , w a r t a n d s u p e r f i c i a l f u n g a l i n f e c t i o n s .
64
4.5 Sexually transmitted diseases & HIV
The incidence and prevalence of STDs in a population are valuable indices of the
underlying HIV problem or the potential risk for its spread. Surveillance of HIV infection
among people with high risk sexual behaviours can be achieved by offering HIV tests at
STD clinics.
65
For recurrent disease, patients may have prodromal symptoms of tingling and paraesthesia
when the herpes is relapsing, in which case early treatment may abort the attack.
In the management of active herpes, the pain may partially be alleviated by bathing the
lesions in warm saline. Adjuntive analgesic is usually necessary. Acyclovir, the specific
anti-herpes drug, is still largely effective in treating overt HSV infection in patients with HIV,
although some AIDS patients may fail to respond because of viral resistance. Foscarnet has
been shown to be effective in acyclovir-resistant infections. Similarly, acyclovir prophylaxis
is of value in preventing symptomatic relapse of herpes in HIV-infected patients.
Syphilis
Incidence of neurosyphilis is increased in patients with HIV. There are various forms of
presentation - asymptomatic, meningovascular, parenchymatous or polyradiculopathic.
Serum and CSF syphilis serology is essential in investigating HIV-infected patients with
neurological symptoms although it can be unreliable in neurosyphilis occurring in HIV
positive patients. In a series of 42 patients, 21% had a negative VDRL reaction. Other CSF
abnormalities and clinical correlation are especially important in these cases. Because of the
high chance of treatment failure, procaine penicillin with or without probenicid or soluble
66
penicillin should be given for 2 to 3 weeks, depending on the stages. Benzathine penicillin
may also be used in early stages of syphilis. Monitoring of syphilis serology can be useful
to follow up response to treatment and future relapse.
67
4.6 Malignancy & HIV
Kaposi's sarcoma
68
its characteristic appearance. Sometimes biopsy is indicated for doubtful cases but false
negative result may occur due to its deep-seated location in the submucosa.
Malignant lymphoma
For AIDS patients with low CD4 level and pre-existing opportunistic infections, they
usually tolerate conventional chemotherapy (e.g. CHOP or MBACOP) poorly and their
survival may be similar to or even worse than patients receiving less intensive therapy.
69
Patients in an early stage of HIV infection respond better to systemic chemotherapy and
may warrant a more aggressive approach. Prophylaxis with intrathecal methotrexate is often
indicated as progression to CNS involvement is common. The role of G-CSF in improving
management and survival in HIV-related NHL has yet to be established.
Hodgkin's disease h a s a l s o b e e n r e p o r t e d t o b e a s s o c i a t e d w i t h H I V i n f e c t i o n b u t i t s
incidence and importance have not been adequately assessed. They are treated with
regimen of MOPP (mechlorethamine, vincristine, procarbazine, prednisolone) or ABVD
(adriamycin, bleomycin, vinblastine, dacarbazine). The dose may have to be reduced
compared with standard recommendation.
70
4.7 Other HIV-related diseases
HIV and its related complications can affect virtually every organ of the body, giving
various clinical, biochemical, haematological and pathological manifestations. The majority
of the commoner or classical diseases has been dealt with in previous sections. The other
manifestations, which are usually rarer except for some haematological problems, are
discussed below.
Haematological problems
Anaemia i s c o m m o n i n l a t e s t a g e o f
HIV infection, which presents as anaemia of
chronic disorder. Many opportunistic
Anaemia & neutropaenia
complications and HIV itself can cause bone
* caused by HIV, secondary
marrow suppression. Anaemia with or
infections, tumours and drugs
without neutropaenia occurs in 5-10% of
* identify and treat treatable causes
patients taking zidovudine. Correction of the
* blood transfusion, erythropoietin,
primary treatable causes for anaemia is
G-CSF/GM-CSF
imperative,
71
in addition to supportive measures like blood
transfusion or erythropoietin treatment. Apart
from lymphopaenia , a m i l d d e g r e e o f
neutropaenia i s s o m e t i m e s s e e n i n p a r a l l e l
with progression to AIDS. Profound
neutropaenia is, however, often the result of
HIV-related complications or therapy. Again,
amelioration of the underlying culprit is
essential though the adjunctive therapeutic
or prophylactic use of the cytokines G-CSF
and GM-CSF in neutropaenic AIDS patients
is growing.
T h e adrenal g l a n d i s t h e c o m m o n e s t
affected endocrine organ. Cytomegalovirus
Adrenal insufficiency in HIV infection causing adrenalitis is well
* CMV adrenalitis is the commonest recognised while disseminated
cause mycobacterial (tuberculosis and atypical)
* serum cortisol level and short infection, cryptococcus, toxoplasma,
synacthen test for diagnosis pneumocystis, lymphoma and KS can also
* hydrocortisone and fludrocortisone involve the adrenals. Involvement is usually
replacement subclinical but overt adrenal insufficiency
with clinical and biochemical changes
occurs uncommonly in severely affected
cases, especially when the patient is under
stress. Glucocorticoid with or without
mineralocorticoid replacement should then
be considered.
Thyroid f u n c t i o n i s a b n o r m a l i n s o m e
HIV-infected patients. The serum T3 level is
usually not as low as similarly ill patients
suffering from other diseases. The raised
resting energy expenditure may contribute
to the AIDS wasting syndrome, which is
different from that resulting from simple
starvation. In patients with AIDS, fat
tissue is not preferentially depleted. Instead,
patients lose muscle along with fat.
72
This loss of lean body mass has been found
to correlate inversely with survival and
Weight loss & wasting in HIV functional status. Hyperalimentation,
* caused by reduced nutrient intake, unfortunately, can only build up fat stores
malabsorption, hypermetabolism and not lean tissue in AIDS patients who are
and metabolic disturbances losing weight. Metabolic dysregulation, with
* difficult to regain after loss, more not yet clear mechanisms but possibly
so for lean tissue mediated through cytokines, may be a major
* wasting is associated with cause of the wasting. As weight and lean
morbidity and mortality muscle loss tend to occur in prominent
* minimise weight and muscle mass bouts with incomplete recovery during
loss by ensuring adequate nutrient secondary infections, it is important to
intake and treating active diseases prevent this by aggressively treating active
energetically diseases and also giving full nutritional
support (both calorie and protein) as early
as necessary. The role of anabolic agents,
cytokine-inhibitors, and exercise to replete
lost muscle mass are still experimental. The
hypertriglyceridemia characteristic of AIDS
has no correlation with the degree of
wasting.
Decreased libido and hair loss have been reported in HIV positive men. Reduced
testosterone concentrations may be found in those who have progressed to AIDS, usually
w i t h i n a p p r o p r i a t e l y l o w g o n a d o t r o p h i n l e v e l . Gonadal f u n c t i o n i n w o m e n w i t h H I V i n f e c t i o n
h a s n o t b e e n a d e q u a t e l y s t u d i e d . T h e pancreas i s a l s o v u l n e r a b l e t o o p p o r t u n i s t i c
infections, cancers, and drug toxicity in patients with HIV disease. For example,
cytomegalovirus, lymphoma, and drugs like pentamidine, didanosine and co-trimoxazole can
all cause pancreatitis with resultant permanent damage.
Cardiac i n v o l v e m e n t i s u n c o m m o n a n d
is often subclinical in HIV infection. Likely
Cardiac lesions in HIV pathogenic processes include opportunistic
* pericarditis ± pericardial effusion infections and tumours, resulting in
* myocarditis pericardial effusion, pericarditis, myocarditis,
* endocarditis endocarditis or a combination of them. KS,
mycobacterial disease, cryptococcal and
nocardial infection can cause pericardial
disease. Lymphoma, KS, cytomegalovirus,
Toxoplasma gondii, and cryptococcus are
common causes of myocarditis and
cardiomyopathy. Non-bacterial thrombotic
endocarditis has also been reported. Direct
involvement by HIV of the heart is also
possible.
An HIV-associated nephropathy
73
characterised by severe nephrotic syndrome
Renal problems in HIV and renal insufficiency progressing rapidly
* HIV-related nephropathy e.g. to end stage renal failure has been well
focal/global glomerulosclerosis described. The kidneys are normal in size
* sepsis, dehydration, tumour or and tissue changes include focal or global
drugs glomerulosclerosis, with mesangial deposits
of C3, IgM and sometimes IgG. It has a
predilection for black persons. Other
nephropathies, such as diffuse mesangial
hyperplasia and a variety of immune-
complex-mediated glomerulopathies may
also occur in patients with HIV. Renal
impairment in HIV-infected patients can be
the result of nephrotoxic drugs like foscarnet
and amphotericin B, disseminated infection
with direct involvement of the kidney or
septicaemic shock, intravascular volume
depletion from diarrhoea, vomiting or poor
oral intake and rarely invasion by cancer e.g.
lymphoma.
H I V i n f e c t i o n i s a l s o a s s o c i a t e d w i t h s o m e rheumatological m a n i f e s t a t i o n s . A r t h r i t i s
m a y r e s u l t f r o m a m o d i f i e d f o r m o f R e i t e r’ s s y n d r o m e , p s o r i a t i c a r t h r o p a t h y o r H I V - r e l a t e d
arthropathy. Other connective tissue disorders that have been reported include Sicca
syndrome, lupus-like syndrome, polymyositis and vasculitis. They, however, usually lack
the typical antibodies found in classical diseases.
74
4.8 Women & HIV
Although most HIV-infected adults in the world are men, women of reproductive age
are the fastest growing population to becoming infected. Globally, the ratio of male to female
HIV infection is approaching one and may soon be reversed. Epidemiologically, heterosexual
transmission followed by injecting drug use are the commonest risk factors for HIV infection
in women. In some places, AIDS is one of the leading causes of death for young women.
The understanding of HIV in women, both in clinical and social contexts, is only beginning
to receive attention. A majority of HIV positive women in the world do not have access to
optimal care and support.
75
The natural history and clinical
manifestations of HIV infection in women
Clinical spectrum of HIV have not been as well studied as those for
Infection in women men. It is believed, however, that there is
* similar to men but less KS little gender difference with the exception of
* gynaecological lesions common - certain unique gynaecological complications
recurrent vaginal candidiasis, occurring in women. Also, KS is much rarer
cervical intraepithelial neoplasia, in women and essentially only occurs in
and carcinoma of cervix female partners of infected bisexual men.
Candida infection of the mucosa is the most
frequently observed opportunistic infection.
Vaginal candidiasis can occur at an early
stage of HIV infection. Recurrent or
refractory episodes should alert health care
workers to the possibility of an underlying
HIV infection. Genital herpes is also a
common clinical problem. Cervical intra-
epithelial neoplasia (CIN) is a disease to be
looked out for, which is related to human
papillomavirus. CIN progresses more quickly
to cervical cancer in HIV positive than HIV
negative women, especially for patients with
advanced HIV disease. The frequency of
Management
pelvic inflammatory disease and its
* physical, psychological and
complications may be higher compared with
social aspects
HIV negative people. Pregnancy does not
* treatment and prevention of
seem to hasten the progression of HIV
opportunistic infections
disease. Similarly, asymptomatic HIV-
* regular monitoring for cervical
infected pregnant women are not at an
neoplasia
increased risk for adverse outcome of
* antiretroviral therapy as
pregnancy.
indicated
Regimens for the treatment and prophylaxis of secondary infections in women are the
same as in male patients. Regular screening for cervical neoplasia with pap smear should be
part of the monitoring programme for an HIV positive woman. Besides clinical management,
psychosocial problems, needless to say, have to be properly addressed. To a certain extent,
women are often socially oppressed. There is also the problem that HIV positive women are
76
more likely marginalised people of the society - drug users or commercial sex workers
(prostitutes) or both and the provision of health care services to these communities requires
additional efforts. Moreover, to look after a child with HIV infection will surely add to the
burden and stress. It is clear that caring for HIV-infected women can never be
comprehensive without a good social support for their day-to-day living.
77
The interplay between HIV infection
and pregnancy can be complex and intricate.
HIV and pregnancy Worldwide, efforts have been made to try
* One does not adversely affect the reducing the incidence of perinatal
outcome of the other when in transmission. However, measures can only
coexistence be implemented when one knows that HIV is
* antenatal testing may be indicated complicating the pregnancy. In some places,
with full pre-test and post-test antenatal HIV testing is offered to pregnant
counselling women who or whose sex partner gives a
* HIV-infected mother should be history of higher risk behaviours. This may
counselled to make informed be valuable particularly for areas with high
decision about continuing HIV prevalence. Management of babies born
pregnancy or not to HIV-infected mother is certainly facilitated
* use of zidovudine during pregnancy by the knowledge of the HIV status. It
and delivery is safe and effective in enables the mother to benefit from active
reducing vertical transmission clinical intervention and the option of
* avoid breast feeding if possible continuing the pregnancy or not. Pre-test
counselling, however, with thorough
explanation of the implication of the test and
positive result, should be an integral part of
the testing procedure, which is conducted
voluntarily. Strict confidentiality has to be
ensured in the system.
HIV positive women should be counselled about the pros and cons of continuing or
discontinuing the pregnancy. Issues to be considered are: risk of transmission to the infant,
possible course of HIV disease in an infected child, care of the baby and family support, and
likely psychological stress from the pregnancy or its termination. Her partner may need to be
involved for making decision about the pregnancy and full support should be rendered
subsequently, where appropriate, whatever the decision is. Close monitoring of HIV status
should be continued during the pregnancy. Primary or secondary PCP prophylaxis is to be
given whenever appropriate. The use of zidovudine should be considered according to
established protocol. It should be commenced after the first trimester if indicated regarding
the woman’ s HIV disease status, or to reduce chance of perinatal transmission if pregnancy
is to be continued. High dose intravenous zidovudine is to be given during labour to
augment its protective effect, and syrup zidovudine be provided to the newborn for say,
a n o t h e r s i x w e e k s a f t e r b i r t h ( s e e “ Gu i d e l i n e s o n m a n a g e m e n t o f H I V i n f e c t i o n i n c h i l d r e n ”
by Scientific Committee of Advisory Council on AIDS, 1995). Invasive procedures such as foetal
scalp blood sampling should be avoided as far as possible to minimise the risk of
transmission during the intrapartum period. Similarly, breast feeding is not recommended if
there is availability of safe alternative - artificial milk, to minimise chance of transmission
after delivery. Following pregnancy, HIV positive women need to be further counselled
about future procreation and contraception. The condition should be kept under periodic
review. Also, there should be regular follow-up of the HIV disease.
78
4.9 Paediatric HIV/AIDS
P r i o r t o a p p ly i n g H I V a n t i b o d y s c r e e n i n g t o d o n a t e d b l o o d a n d i n a c t i v a t i o n o f b l o o d
products by heat or detergents, transmission of HIV in children was largely through
transfusion of contaminated blood or blood products. The progression of HIV disease in
transfusion-acquired patients was fastest when the immune system was very immature (in
young child) or degenerative (in case of elderly) at time of infection and when whole blood
was received. Since mid 1980s, transfusion-related HIV infection has become exceedingly
rare in countries where appropriate measures for safeguarding blood and blood products
were adopted, including Hong Kong. Perinatal transmission (mother to infant) has then
emerged as the major cause of HIV transmission in children.
Clinical manifestations
Highly suggestive of HIV infection Due to the diagnostic difficulty and different
* Pneumocystis carinii p n e u m o n i a spectrum of clinical presentations compared
* lymphoid interstitial pneumonia with adults, the Centers for Disease Control
* oesophageal candidiasis or and Prevention (CDC) has proposed a
persistent oral candidiasis separate classification system for HIV
* parotitis infection in children under 13 years old,
which was revised in 1994 (Appendix V).
79
non-suppurative parotitis clearly warrants
an HIV antibody test. Neurological
involvement is common in advanced HIV
disease. This is usually manifested as
developmental delay, loss of milestones and
features of encephalopathy.
Cardiomyopathy and nephropathy can also
occur. Paediatric AIDS patients usually run
a rapidly downhill and fatal course,
particularly when complication like
Pneumocystis carinii pneumonia has
developed.
80
Similar to adults, surrogate markers are useful clues to diagnosis, and serve as guides
to management of HIV infection in children. CD4 cell is the main target of HIV and its count
demands regular monitoring. It should be noted, however, that infants have a higher
baseline CD4 count than adults. A different reference range is needed. Besides a lowered
CD4 level, a reduced CD4 to CD8 ratio is also a common indicator of the underlying disease
process. Serum β2- m i c r o g l o b u l i n and neopterin may be raised. Polyclonal
Management
81
with a low age-specific CD4 count or
percent. Lifelong prophylaxis is needed for
previous episode of PCP. Co-trimoxazole
thrice weekly is the preferred regimen. It may
also protect against recurrent bacterial
infections.
82
shall be used in place of live oral (Sabin)
vaccine as the latter may still be excreted for
many months in the stool of immunised
infants. Even if vaccinated against certain
disease, the protection can never be
assumed to be complete for patients with
HIV infection.
83
4.10 Idiopathic CD4+ T-lymphocytopaenia
S i n c e 1 9 8 9 , s e v e r a l i n v e s ti g a t o r s i n t h e
world have independently reported cases of
ICL CD4+ T-lymphocytopaenia with
*not new; rare, heterogenous disease opportunistic infections or Kaposi's sarcoma
*not caused by a virus but no evidence of HIV infection. The
*progressive CD4 depletion phenomenon caused much public concern,
uncommon notably during the VIIIth International
Conference on AIDS in July 1992 in
Amsterdam, when the media reported the
development of a potential epidemic of a
new viral AIDS-like disease. Extensive
investigations by the World Health
Organization and the Centers for Disease
Control later concluded that there was no
evidence for a new epidemic. The syndrome
has probably been in existence for a long
time, and only become apparent with the
wider availability of CD4 count testing.
For surveillance purpose, a provisional case definition was devised by the CDC for
suspected cases during the global investigative exercise: (a) a documented absolute CD4+
T-lymphocyte count of less than 300/ul or less than 20% of total lymphocyte on more than
one occasion; (b) no serologic evidence of HIV infection and (c) no defined
immunodeficiency or therapy associated with T cell depletion. In June 1993, the CDC
reported that a total of 125 cases have been cumulated in USA, including 14 children. The
term "Idiopathic CD4+ T-lymphocytopaenia (ICL)" was used by some researchers during the
investigation.
84
5. MANAGEMENT OF ADULT HIV INFECTION
The clinical management of HIV infection encompasses many components. They are
(1) optimisation and maintenance of health, (2) regular monitoring for HIV disease
progression, (3) prophylaxis of opportunistic infections, (4) early diagnosis and aggressive
treatment of HIV-related complications, (5) antiretroviral therapy, (6) psychosocial support
for the patients and their families/partners and (7) prevention of future HIV transmission.
This section deals with the general aspects on health maintenance, antiviral therapy and
outlines the recommended protocols on treatment and prevention of common secondary
infections and neoplasms. The other aspects of the management are covered in details
elsewhere in the manual.
T h e l o n g l a t e n c y of H I V i n f e c t i o n i m p l i e s t h a t a g r e a t m a j o r i t y o f i n f e c t e d p e o p l e
remain largely asymptomatic for a prolonged period of time. The objective of management at
this level is to, as far as possible, maintain optimal health. Apart from intercurrent infections,
other factors which may be important in affecting the course of the disease are nutrition,
stress, smoking, co-infection with sexually transmitted diseases, extra or new HIV load, use
of illicit drugs and the availability of psychosocial support. Obviously, refraining from the
potential risk factors means a change in lifestyle. In this regard, information, education, peer
support and other backup services have to be offered as necessary. A good patient-carer
relationship is essential and the client should be encouraged to play an active and
responsible role in the overall management of his/her infection and its related problems. A
positive but realistic approach towards the positive status is probably the best way to go
by.
85
Although there is no evidence that
nutritional intervention can reverse the
immune dysfunction due to HIV, it is
possible however that poor nutrition can
Nutrition in HIV disease precipitate or aggravate secondary
* malnutrition is common which infections. It has been suggested that
can significantly affect the quality nutritional status as reflected by lean body
of life and survival mass is a significant determinant of survival
* nutritional assessment and in patients with AIDS. Intake of adequate
support is prudent, especially in and nutritious food should be emphasised
advanced stage of HIV infection starting from the asymptomatic stage and
* input from dietitian with dietary should be continued throughout the course
manipulation and supplementation of HIV disease. Nutritional assessment and
as necessary dietary advice from dietitian may be
necessary. Several parameters can be used
to assess the nutritional status, e.g. body
weight, % of loss from usual body weight,
body mass index, triceps skin fold and mid-
arm circumference, and also biochemical
data like that of serum albumin level. Serial
readings are more informative than isolated
single values.
When HIV disease progresses with the emergence of anorexia, weight loss, chronic
diarrhoea, malabsorption or other opportunistic complications, nutritional support becomes
an increasingly important part of the management plan. In tackling some specific problems in
the course of the disease, dietary manipulation can be a useful adjunct, e.g low-fibre, low-fat
and low-residue diet is required for patients with chronic diarrhoea resulting from enteric
infections. Nutritional supplementation through enteral or even parenteral feeding may be
used as necessary at times of poor oral intake, especially when there is concurrent active
major infections or malignancies.
86
T h e m e ri t s o f h e a l t h y l i f e s t y l e a p p l y
equally well to people with HIV infection.
Healthy lifestyle Appropriate exercise can upkeep one’ s
* refrain from smoking and health status if it is undertaken consistently
recreational drugs and regularly. HIV positive persons should
* safer sex practice be encouraged to have daily exercise that is
* avoid stress and overworking, physically and socially affordable. Though
maintain good mental health poor mental health with, for instance,
* regular exercise and adequate rest depression or anxiety, may not adversely
affect disease progression, it is reasonable
to include maintenance of healthy mental
state in the management plan. Social
stigmatisation, disturbed relationship with
partner or family, personality problem with
difficulty in coping with the disease may all
contribute to upsetting one's mental health.
Besides psychosocial support, counselling
and psychotherapy, drugs are needed in
case of overt psychiatric disorders e.g. major
depression.
Smoking has been suggested to be associated with a faster rate of progression of HIV
disease. Contracting sexually transmitted diseases e.g herpes simplex infection, infection by
a new and/or different HIV strain, use of recreational drugs may also adversely affect the
outcome. The avoidance of these 'risk' factors may demand change of certain behaviours
that have already been 'deep-seated' for a long time. Efforts should be made to educate and
offer support for the necessary behaviour changes. The aim shall be to reduce the harm if
they cannot be avoided in total. For example, cigarette consumption is to be reduced if to
quit smoking is not feasible in the meantime. Realistic and individualised advice for adopting
and maintaining safer sex practice is beneficial for the client and also helps in preventing
further spread of HIV in the community.
87
Treatment and prophylaxis of common HIV-related diseases
Opportunistic complications,
especially infections, remain the leading
Treatment of HIV-related cause of morbidity and mortality in patients
Opportunistic infections with HIV infection. In addition to
* effective agents available for antiretroviral therapy, treatment and
most diseases prophylaxis of secondary infections is the
* major factor in determining the mainstay of medical management. Based on
quality of life and survival of new knowledge and application of standard
patients with HIV/AIDS as well as newer antimicrobials, better
* chronic maintenance therapy treatment outcome has become evident in
often necessary to prevent the recent years. Maintenance treatment
relapse or suppress the infection (secondary prophylaxis) of many
opportunistic infections is necessary as it is
usually impossible to eradicate the
pathogens in the milieu of a defective
immune system. The role of primary
prevention is investigated and PCP
prophylaxis is a brilliant example of the value
and success of this approach.
88
Disease Drug Duration Comment/Side
effects
Refractory
candidiasis may
need IV
Amphotericin B
* investigational approach/regimen
89
Disease Drug Duration Comment/Side
effects
Cryptococcosis
Treatment 1. Amphotericin B 8-10 weeks in Amphotericin B for 2
0.5-0.8mg/kg/D ± 5FC total weeks followed
2. Fluconazole 400mg/D by fluconazole
should be the right
treatment for most
patients
Maintenance 1. Fluconazole 200mg/D lifelong
2. Amphotericin B 1mg/kg Renal impairment,
per week nausea, fever, chills,
3. *Itraconazole hypokalaemia and
bone marrow
* primary *Fluconazole 50-200mg/D suppression are
prophylaxis possible side effects
of Amphotericin B
* investigational approach/regimen
90
Disease Drug Duration Comment/Side
effects
Cytomegalovirus
Disease
Treatment 1. Ganciclovir 5mg/kg 21 days Bone marrow
twice/D toxicity especially
2. Foscarnet 60mg/kg leucopaenia, and
3 times/D phlebitis are side
(adjust dose for both drugs effects of
if renal impairment) ganciclovir
* investigational approach/regimen
@ experimental drug
91
Disease Drug Duration Comment/Side
effects
Lymphoma
Primary CNS Radiotherapy
* investigational approach/regimen
92
Disease Drug Duration Comment/Side
effects
Mycobacterium
Tuberculosis
Treatment Four drugs combination of Four drugs for 2 Monitor for
Isoniazid 300mg/D months, then hypersensitivity
Rifampicin 450-600mg/D continue reaction, liver
Pyrazinamide 1.5-2g/D isoniazid and toxicity, peripheral
Ethambutol 20mg/kg/D rifampicin for at neuropathy and
+ Pyridoxine 10-50mg/D least 9 months optic neuritis
Monitor for
gastrointestinal
upset, liver
impairment, low
blood counts, optic
neuritis and tissue
pigmentation
Primary *Rifabutin, Clarithromycin
Prophylaxis
* investigational approach/regimen
93
Disease Drug Duration Comment/Side
effects
Penicilliosis
Treatment Amphotericin B Few reports
0.5-0.8 mg/kg/D for 4 regarding optimal
weeks, followed by treatment and
itraconazole 400mg maintenance
twice/D for 3 months regimens
Pneumocystis
Carinii
Pneumonia
Treatment 1. Co-trimoxazole IV/po 21 days Co-trimoxazole is the
(20mg/kg/D TMP) in preferred regimen if
four divided doses patient can tolerate,
2. Pentamidine IV but its use is
4mg/kg/D associated with high
3. Atovaquone 750mg frequency of adverse
three times/D (mild to effects e.g.
moderate cases) hypersensitivity rash
4. *Dapsone (100mg/D) + and fever, nausea,
trimethoprim vomiting, liver
(20mg/kg/D in 3-4 toxicity
divided doses)
5. *Primaquine (15mg/D) For severe PCP with
+ clindamycin (450- pO2 <70mm Hg,
600mg 4 times/D) adjunctive
6. *Trimetrexate IV prednisone within 72
4 5 m g / m 2/ D w i t h hours of starting
leucovirin anti-PCP therapy will
reduce death
(40mg twice/D for 5
days, 20mg twice/D
for 5 days, 20mg/D
for 11 days, then tail
off rapidly)
* investigational approach/regimen
94
Disease Drug Duration Comment/Side
effects
Intravenous
pentamidine can
cause hypotension,
pancreatitis,
hypoglycaemia,
hyperglycaemia,
renal impairment and
marrow toxicity
* investigational approach/regimen
@ experimental drug
95
Disease Drug Duration Comment/Side
effects
Corticosteroid may
be used to reduce
severe cerebral
oedema
* investigational approach/regimen
@ experimental drug
96
Disease Drug Duration Comment/Side
effects
* primary 1. Co-trimoxazole
prophylaxis 2. *Dapsone (200mg) plus
pyrimethamine 75mg
per week
* investigational approach/regimen
97
5.2 Antiretroviral therapy
Viral penetration & uncoating (ii) reverse transcription of HIV RNA into
CD4 analogues, HIV-antibodies, and DNA, (iii) subsequent transcription of viral
Vaccines mRNA from proviral DNA and (iv) the final
stage of assembly and release of viral
98
Zidovudine
99
The potential benefits of zidovudine in
Toxicity of zidovudine HIV positive patients could be offset by its
* anaemia, leucopaenia and rarely toxicity. Side effects of zidovudine include
thrombocytopaenia an early occurrence of gastrointestinal upset
* nausea, vomiting and anorexia with nausea, vomiting and anorexia, and
* myalgia and myositis bone marrow toxicity which often present
* malaise, insomnia and headache later. Even though the incidence of anaemia
* rash and leucopaenia has been reduced by the
* liver derangement lower dose (500-600mg/day) used
nowadays, these adverse effects may be
disturbing to some patients, particularly with
prolonged administration. Use of zidovudine
is also associated with rash, headache,
insomnia, myalgia, myopathy and deranged
liver function. When used in HIV-infected
children, bone marrow suppression may also
occur, albeit a better tolerance than in
adults. Zidovudine therapy in children has
been reported to lead to weight gain and
improvement in cognitive function as well as
immunological and virological markers.
100
prolonged therapy. Interestingly enough, the resistance of some zidovudine-resistant
strains was reportedly reduced by a didanosine resistance mutation.
Zalcitabine was approved by the FDA in 1992 for use in combination with zidovudine
in treating advanced HIV disease with clinical or immunological deterioration. This was
based on a trial which demonstrated improvement of immunological and virological markers
with the combination regimen. A recent study showed that zalcitabine monotherapy was at
least as effective as didanosine in a group of patients with advanced disease, and possibly
carried a slight survival benefit. Resistance to zalcitabine has also been reported and there
could be cross-resistance with didanosine.
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Other antiretroviral agents
Although zidovudine, didanosine and zalcitabine are useful drugs in suppressing HIV
replication, they are by no means effective in controlling the infection. Acting as reverse
transcriptase inhibitors, they cannot inhibit viral replication in chronically infected cells
harbouring HIV genome. Other newer agents are being actively developed and tested for
safety, toxicity and efficacy. Various drugs with different sites of action have come into
place recently. The better known or promising ones are non-nucleoside reverse transcriptase
inhibitors, inhibitors of TAT (transactivator of transcription) protein, protease inhibitors and
glycosidase inhibitors. Newer nucleoside analogues, e.g. stavudine (d4T) and lamivudine
(3TC) have also been studied.
Stavudine h a s b e e n a p p r o v e d b y t h e F D A i n 1 9 9 4 f o r u s e i n p a t i e n t s w i t h a d v a n c e d
HIV disease who are intolerant of other approved antivirals, or when the latter fail. The
benefit shown to date is, however, only with the surrogate markers. Peripheral neuropathy
(15-21%) is the main limiting toxicity. Raised transaminase level can also occur. No cross
resistance with AZT has been demonstrated for d4T.
Lamivudine h a s b e e n r e s e a r c h e d f o r u s e i n c h r o n i c h e p a t i t i s B i n f e c t i o n w i t h s o m e
preliminary positive effects. Its anti-HIV activity is synergistic with zidovudine in in vitro
condition. Recently, this synergistic effect was also demonstrated in clinical trials which
showed sustained and greater improvement in CD4 level as well as viral load (follow-up for
24 weeks) when compared with zidovudine monotherapy. Whether this encouraging
immunological and viral results can be translated into clinical benefit is not known.
Nevertheless, lamivudine apppears to be a promising agent for use in combination antiviral
therapy.
In some pilot studies, protease inhibitors, either used singly or in combination with
zidovudine, appear to be potent and safe. The HIV protease (also called proteinase)
processes viral core and polymerase proteins to make infectious virions. When it is blocked
by specific inhibitors, noninfectious viral particles are produced. The glycosidase inhibitors,
through their blockage of glycosylation pathways, prevent glycoproteins formation in the
late stage of HIV life cycle. These agents have been shown to be effective in vitro. Finally,
gene therapy, vaccine therapy and cytokine therapy (with, say, interleukin-2) are also
potential candidates for treating HIV infection.
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Combination therapy
103
Current strategy and future direction
If there is zidovudine intolerance or failure, either didanosine (125 or 200mg twice daily)
or zalcitabine (0.75mg thrice daily) monotherapy is indicated. Alternatively, combination
therapy by adding didanosine or zalcitabine to zidovudine can be tried when disease
progression occurs in patients tolerating zidovudine. Stavudine can be considered if
patients fail or are intolerant of the other antivirals. In arriving at any of the treatment
decisons, the patient should be adequately counselled and encouraged to make the most
appropriate choice.
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Several questions, however, remain to be answered - (i) which combinations of drugs
are least toxic while most durably efficacious, (ii) will combination delay or limit the
emergence of multiple resistant strains and (iii) how important is the mode of drug
administration e.g. simultaneous, alternating, intermittent or sequential. Different agents that
are active against both acute infection of new cells and HIV replication in infected cells
should probably be encouraged in the combination approach. The chronic nature of HIV
infection underscores the need for prolonged therapy. In this regard, new, safe and more
effective drugs have to be continually developed. Finally, the patient should always be
involved in making decision regarding his/her antiretroviral therapy, at present and also in
the future. Clear information shall be given, alternatives thoroughly discussed and support
rendered to backup their informed decisions.
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6. PRIMARY CARE & PSYCHOSOCIAL SUPPORT
OF HIV/AIDS
Counselling is an indispensable
component of a succcessful intervention
Aims of HIV/AIDS counselling and care programme for people with
1. provide psychosocial support HIV/AIDS. The reasons are: there is as yet
2. prevent spread of infection no cure for the disease but prevention of
further spread is feasible; the infection
carries with it at least as many social
meanings as the physical ones, if not more.
The psychosocial consequences can in fact
cause more sufferings for HIV-positive
people than the medical complications.
HIV/AIDS counselling aims at (1) providing
psychosocial support for people infected
and affected by the disease and (2)
preventing further HIV transmission. These
obviously cannot be achieved without a
trusting relationship between the client and
the care-provider or counsellor, a tailored
and personally relevant health education
and behavioural change programme, and a
comprehensive support system.
Pre-test counselling
In light of the possible medical, social, emotional, financial, insurance and personal
implications of being identified HIV positive, pre-test counselling should be offered to all
subjects undergoing voluntary antibody testing. HIV test should never be regarded as a
routine medical test. Explicit informed consent shall be obtained. The meaning and
limitations of the HIV test, interpretations of positive or negative results, actual testing
process and issues of confidentiality and notification (not a notifiable disease) should be
explained. For example, it should be emphasised that the test only detects past exposure to
and infection by the virus but not AIDS, and that false negative result may arise during the
window period. The risk of acquiring HIV has to be assessed, both in contexts of sexual and
drug taking behaviours and the possible occupation-related aspects for health care workers.
Preventive education tailored to the individual situation is necessary.
P o t e n t i a l c o n s e q u e n c e s o f a p o s i t i v e r e s u l t s h a l l b e d i s cu s s e d t h o r o u g h l y . T h e y a r e :
the natural course of HIV/AIDS; psychological impacts to the infected person, his partner,
family and friends; accessibility of medical serivces; local insurance policy; social
stigmatisation and discrimination; and possible restrictions in employment. The client
should be prepared that the result may indeed be positive. The social responsibility of HIV
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positive people in preventing further spread of infection should be explained. In contrast to
the negative impact being identified positive, the benefits of early diagnosis and
management should also be given. An HIV-infected person is also better able to plan his
future when he is certain of the diagnosis. Pre-test counselling also provides the
opportunity to clear misconception, relieves distresses which may arise from HIV/AIDS, and
assess the possible reaction and coping strategy with a positive diagnosis.
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It is unlikely that a patient can take in much information at this news-breaking stage.
Another appointment later, after stabilisation of the patient's emotion, is necessary to
discuss things in more detail and to plan ahead the future management. Some of the issues
to be covered include health implications, access to psychosocial support services, rights
and responsibilities, confidentiality, household infection control measures and safe
practices regarding sex and drug use. The involvement of partner or the closest person is
ususally important and useful.
Various forms of counselling and psychotherapy may be needed in the continuing care
of the patients, to address issues like loss of self-control, social discrimination, family
relationships, friendships, sexuality, changes in lifestyle, grief, bereavement and death. Self-
help support group for sharing of experience and mutual support can be an important outlet
for some individuals. In some cases, the operation of support groups can be facilitated by a
counsellor. Buddy system provides companionship and help from a volunteer who
functions as a friend. Practical support for activities of daily living, e.g. cooking, clothes
washing, house cleaning and shopping, may require other forms of community
mobilisations, e.g. support of home-help service. Other social issues, such as financial
hardship, employment and housing also need to be addressed. Of course, the patients'
spouse/partner, other family members or close friends may become the principal carers. In
turn, support for them is necesary as they may be faced with enormous stress in the process
of providing care, especially when the patient is progressing to late stage of the infection.
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6.2 Confidentiality
In Hong Kong, the government and the medical profession have adopted ethical codes
of practice and policies enforcing strict compliance with the rule of confidentiality. Such
codes are considered reasonable standard of care, the negligence of which may be treated as
evidence resulting in legal claims. Consent should always be sought from the patient before
conveying medical information (including one’ s HIV status) to other people, including other
health care professionals.
There are certain grey areas in the maintenance of confidentiality. One example is that
when a patient knowingly continues to place others at risk of HIV infection through the
practice of high risk behaviours. If the person at risk is identified, and especially when
he/she is also a patient of the same doctor, the latter may have a duty to warn of the risk.
Health care workers are required to act reasonably to counsel the patient about possible risk
of infection and also minimising the risk of transmission.
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6.3 Primary care of HIV/AIDS
T h e h e a lt h c a r e p r o f e s s i o n h a s n e v e r
been an absolutely ‘ s afe ’ working
Health care profession environment throughout its history. Health
* inherent known and unknown risk care workers have been, are and will
of the work continue to be exposed to risk of acquiring
* professional obligation to provide different diseases and injuries, while they
quality care to all patients are delivering or contributing care to
patients. As long as they are pursuing with
this mission, they should understand that
the risk can be minimised by good strategy,
but never to zero. It is, however, the ethical
obligation of health care professionals to
provide the best possible care to all patients,
irrespective of factors like race, sex, and also
disease of the patients, just to name a few.
Refusal to care for patients on the ground of
unaccepatable personal risk or dislike
towards certain people is morally and
professionally inappropriate.
Sadly enough, even in the second decade of the HIV/AIDS epidemic, we are still
seeing HIV positive patients being denied of care and treatment by health care workers.
Perceived risk of being infected while providing care for patients with HIV is definitely a
concern for some people. The reluctance of some workers may be further explained by their
judgemental attitude towards the disease and also the patients, as the infection is thought to
b e a s s o c i a t e d w i t h ‘ im m o r a l’ b e h a v i o u r s . T h e p u b l i c w i l l n a t u r a l l y n o t b e c o n v i n c e d a b o u t
the low risk of transmission of HIV in health care setting if the workers themselves refuse to
care for patients infected with HIV. Personal values leading to inacceptance of things such
as homosexuality and substance abuse are difficult to tackle. It is important, therefore, to
provide education starting early in the professional training. Health care workers should also
try to counsel those colleagues who are uncomfortable in providing care to HIV-infected
people.
Nursing care
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Caring for HIV-infected patient s i s a
very challenging but rewarding task. The
Care of HIV-infected patients variable course of the infection from
* demonstrates the importance of progression of asymptomatic disease to
holistic and multidisciplinary bouts of life-threatening illnesses, highly
approach complex psychosocial factors entangled
* stimulates new and better models with the disease and the lack of a cure at
of care to serve as reference for present have all contributed to the
other patients difficulties and dilemma when providing
HIV/AIDS care. The nursing experiences
gained in responding to the needs of
patients with HIV have shed light to the
development of alternative and innovative
models of nursing care for patients in
general. A holistic approach with attention
to physical, psychosocial and spiritual
needs of patients is the goal to work at, and
patients should be actively involved as
appropriate in their own care. Nurses can
also play a role in the preventive education
of and advocacy for HIV/AIDS within their
profession and the society.
The basic nursing skills for direct care of patients with HIV infection is no different
from those for patients suffering from other diseases. During hospitalisation, there is no
need for routine isolation of HIV-infected patients. However, they may require single room
for the following conditions:
• Bleeding
• Great chance to bleed
• Profuse diarrhoea
• Incontinence
• Disturbed level of consciousness
• Unco-operative patients
• Post-operation with open or draining wound
• Poor patient hygiene with contamination of environment by blood, secretion or
excretion
• Suffering from an opportunistic infection that is contagious e.g TB
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Role of primary care physicians
Diagnosis of HIV infection requires a screening test and confirmatory test. Since 1989,
the Virus Unit of the Department of Health has been providing free confirmatory tests to
other laboratories with positive screening results. A high index of clinical suspicion is
needed for diagnosing HIV/AIDS, which can be confirmed with laboratory investigations.
The HIV testing has, however, to be done with pre-test counselling (section 6.1).
In the past decade, HIV/AIDS has evolved from a hospital-based medical specialty to a
subject of primary care concern. Except for those with late and fulminant diseases, HIV
positive patients can often be managed on an outpatient basis. Advice on a healthy life
style e.g. adequate nutrition, rest and exercise, is important. They should also be
encouraged to refrain from risk behaviours that can both activate their infection and pass on
the virus to others. Regular follow-up and monitoring of one's health is essential. Attention
to emotional and social aspects of the disease, with appropriate intervention and support,
should also be paid. Early collaboration with services of the specialist clinic will be
beneficial. It is crucial that primary care physicians are involved in the fight against spread
of HIV/AIDS and care of people infected and affected by the disease. In order to achieve
this, they have to have broadened awareness of the disease, as well as knowledge about its
common problems and management.
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7 . H I V T R AN S M I S S I O N I N H E A L T H C A R E S E T T I N G
7.1 Introduction
The issue of patients infected by HIV while receiving treatment in health care setting
has raised much public concern. This was fuelled after the report in 1992 of five patients who
were infected with the virus after undergoing dental procedures in the clinic of a dentist in
Florida, USA. The strong public response to an isolated rare event has, once and again,
reminded us that HIV infection carries with it much more social meanings than medical
implications. Other investigations undertaken in USA, UK and Australia in the recent few
years on patients of several HIV-infected surgeons, obstetricians and gynaecologists have
not identified any transmission. These patients have all undergone operations or other
invasive procedures by their doctors, before the positive HIV status of the doctors was
revealed.
In 1993, another incident of patients being infected in health care setting was reported
in Australia. This time HIV transmission has probably occurred from patient to patient: an
HIV-infected patient had passed the virus to four patients who underwent minor surgical
treatments in a private clinic in Sydney. The report has not received wide media attention in
Hong Kong. There was recently another report of possible nosocomial transmission of HIV
to an infant, and transmission to patients in a dialysis centre.
To date, these few reports represented the only known incidences of HIV transmission
from health care workers or patients to other patients. After thorough investigation of the
case of Florida dentist by a committee, it can only conclude that the most likely route of
transmission was from the infected dentist to the patients, but the exact mechanism was still
unknown. The Sydney case has probably resulted from patient-to-patient transmission,
possibly due to breakdown of infection control at some point of the surgery. The risk of HIV
transmission to patient in health care setting has been difficult to be calculated, as it is a
heterogenous situation affected by many variables and confounding factors. Yet, the risk is
likely to be much lower than that of transmission to health care workers from HIV-infected
patients. Nevertheless, these instances further demonstrated the importance of ensuring
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quality infection control practices and procedures in preventing communicable diseases, in
particular blood-borne ones, in health care establishments.
The prevalence of HIV infection appears to be low in Hong Kong (<0.1%). Because it is
often impossible to know when an individual has been infected with HIV or other blood-
borne pathogens, and in light of the high prevalence of hepatitis B virus infection in the
community, guidelines and practices that reduce health care workers ’ exposure to blood and
b o d y f l u i d s o f all p a t i e n t s s h o u l d b e d e v e l o p e d . A p p r o p r i a t e w o r k p r a c t i c e s , i n c l u d i n g
protective barriers to prevent parenteral, mucous membrane and non-intact skin exposure to
blood and certain body fluids (amniotic fluid, pericardial fluid, pleural fluid, peritoneal fluid,
synovial fluid, cerebrospinal fluid, semen and vaginal secretion) of all patients, should be
adopted. The risk of HIV transmission from faeces, nasal secretion, sputum, sweat, tears,
urine and vomitus without overt blood staining is extremely low or non-existent. As all
available evidence indicates that percutaneous injury with sharps is the most common mode
of blood-borne pathogen transmission in health care settings, all sharps and potential
sharps should be handled with extreme care.
Health care workers who consider themselves at increased risk of HIV infection should
arrange confidential testing. Those who are infected must seek appropriate medical advice
to ensure they pose no risk to patients.
The following recommendations outline work practices and barrier techniques that
should be adopted in in-patient and out-patient settings, including Accident and Emergency
Department and ambulatory care settings. The recommendations are based on current
available information. Infection Control Committees of all health care institutions are urged
to familiarise themselves with these recommendations and adapt them in light of local
circumstances and requirements. The adopted precautions should then be widely
disseminated to all health care workers.
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(i) Gloves
Gloves should be worn for direct contact with blood and body fluids, as well as
contact with mucous membrane and non-intact skin of all patients. They should also be
worn when handling contaminated items or surfaces.
If gloves are worn, they should be changed after contact with each patient and before
administering care to another patient, whenever torn and when a needle-stick or other injury
occurs.
General purpose utility gloves such as rubber household gloves may be used for
housekeeping chores involving potential blood contact, as well as for instrument cleaning
and decontamination procedures. Utility gloves should be decontaminated and reused if
still in satisfactory condition.
Masks and protective eyewear or face shields should be worn when the splashing of
blood and body fluids is anticipated.
(iii) G o w n s a n d A p r o n s
Gowns or aprons should be worn during procedures that are likely to cause the
spattering or splashing of blood and body fluids.
(b) Hands
Hands and other skin surfaces should be washed with soap and water immediately and
thoroughly if contaminated with blood or other body fluids.
(c) Rooms
A single room may be indicated for a patient with profuse bleeding that is likely to
cause environmental contamination, or when patient hygiene is poor, for example, when a
patient contaminates the environment with blood, secretion or excretion.
Individuals with known HIV infection often suffer from other infectious diseases, such
as tuberculosis. They should be placed on isolation precautions as recommended by the
Infection Control Committee of individual hospital.
(d) Sharps
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Precaution should be taken to prevent injuries caused by needles, scalpels and other
sharp instruments or devices during procedures, when cleaning instruments, during
disposal of used needles and handling sharp instruments after procedures.
All used sharps should be placed in a puncture-resistant sharps box which should be
located in the area where it is used. Do not overfill the sharps box.
Used sharps box should be placed in red plastic bag and disposed of as medical waste.
(e) Specimens
All patients ’ specimens should be placed in sturdy leak-proof containers with secure
lids to prevent leaking during transport. Care should be taken when collecting and handling
specimens to avoid contamination of the outside of the containers and the laboratory
request slips accompanying the specimens. When the primary container is subject to
leakage, or the specimen is to be transported between institutions, a secondary leakproof
container such as a zip lock clear plastic bag should be used. Request slips should be
placed outside of the secondary container.
In case of penetrating injury or mucocutaneous exposure to blood and body fluids, the
injured or exposed areas should be washed with copious amount of running water. Minor
penetrating injury should be encouraged to bleed.
H I V i s s e n s i t i v e t o h e a t . S t u d i e s s h o w e d t h a t i t i s i n a c t i v a t e d b y m o i s t h e a t a t 6 0 oC in
30 minutes. It is also inactivated rapidly after exposure to commonly used chemical
disinfectants at concentration much lower than those used in routine hospital practice.
Depending on the amount of blood and mucus present on the surface to be cleaned and
disinfected, a solution of sodium hypochlorite (household bleach) in concentration ranging
from 1,000 ppm (1:50 dilution) to 10,000 ppm (1:5 dilution) available chlorine is effective.
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sensitive items, immersion in 1,000 ppm hypochlorite solution for at least 10 minutes should
be effective. For metal devices which might be corroded by repeated exposure to
hypochlorite solution, 2% glutaraldehyde for 10 minutes is recommended.
Spills of blood and body fluids should be cleaned up as soon as possible. They
should be removed with disposable absorbent material held in a gloved hand. The spill site
should then be wiped down with paper towel soaked in 10,000 ppm hypochlorite solution.
This should be rinsed off to reduce the risk of surface damage, particularly if used on metal
surface.
No special precautions are necessary for dishes, drinking glasses and eating utensils.
Individuals with known or suspected HIV infections should have their meals served with
ordinary eating utensils. These can be cleaned together with those used by other patients
in accordance with the institutional policy. There is no need to use disposable items.
Environmental surfaces such as wall, floor and other surfaces have not been
associated with the transmission of HIV. Common housekeeping procedures are adequate
for cleaning environmental surface.
(h) Laundry
All used linen should be bagged at the location where it is used. Linen should not be
sorted or rinsed in patient care areas. There is no need to use disposable linen for HIV-
infected patients.
Linen soiled with blood or body fluids should be disinfected with 1,000 ppm
hypochlorite solution for 30 minutes and then bagged and sent to the laundry.
Alternatively, untreated soiled linen can be placed in alginated bags for treatment in the
laundry.
Linen should be washed with detergent in hot water. The temperature of the items in
the machine should be maintained at over 800 C for at least 10 minutes.
Blood, excretion and secretion may be carefully poured down a drain connected to the
sewer system.
Precautions for Invasive Procedures
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precautionary measures may be required. In general, when performing “ exposure-prone”
procedures, or procedures which are predicted to last longer than 3 hours, and result in
blood loss greater than 300 ml, in addition to the procedures adopted routinely to prevent
cross-infection, the following barrier protection should be used :
(a) Patients with suspected or known HIV infection who require haemodialysis or
peritoneal dialysis can be dialysed in any hospital based or free standing dialysing
unit that uses standard infection control precautions. A single room is preferable for
HIV infected patient undergoing haemodialysis.
(b) Haemodialysis machines should be disinfected with 500 - 750 ppm hypochlorite
solution for 30-40 min. or 4% formalin overnight.
(a) All endoscopists must wear gloves, gown, mask and protective eyewear.
(d) The endoscope should be cleaned and disinfected at the beginning of the first
procedure of the day and after each procedure.
(e) In between cases, after thorough cleaning which should include irrigating and
brushing of channels, the endoscope and all internal channels should be soaked in 2%
glutaraldehyde for at least 5 min. (at least 30 min. for bronchoscopy).
(f) After the glutaraldehyde soak, the channels should be rinsed with sterile water
followed by wiping the insertion tube with 70% alcohol.
(g) Use autoclavable biopsy forceps and cytology brushes. A separate pair of biopsy
forceps and cytology brush should be used for each patients. Do not use a needle to
remove biopsy materials from biopsy forceps.
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Blood, blood contaminated saliva and gingival fluids from all patients should be
considered infective and appropriate barriers should be used during dental procedures in all
health care settings. Procedures adopted routinely for all practices must be adequate to
prevent cross-infection.
• Blood, serum, unfixed tissue and tissue fluids from all patients should be considered
potentially infective. Minimal risk of HIV transmission is presented by urine, saliva
and faeces without overt blood staining, though they may contain other pathogens.
• Laboratory access should be restricted to authorised staff only.
• Eating, drinking, smoking and the application of cosmetics should be prohibited in the
laboratory.
• Labora tory coats, gloves or other protective clothing should be worn to prevent
contamination of exposed skin and soiling of clothing. Protective clothing should be
changed if visibly contaminated with blood or body fluids, and should always be
removed before leaving the laboratory.
• Care should be taken when opening specimen containers to prevent splashing or
spattering. Routine procedures with blood and body fluids can be performed on an
open bench. However, processing of specimens which are likely to create splash
should be carried out with gloved hands in a biological safety cabinet. Alternatively,
laboratory personnel should wear protective barriers including gloves, masks,
protective eyewear to prevent the contamination of skin or mucous membrane.
• Centrifuges with sealed buckets, safety cups or sealed heads should be used to
prevent the escape of liquids or aerosols.
• M e c h a n i c a l p i p e t t i n g d e v i c e s m u s t b e u s ed f o r t h e m a n i p u l a t i o n o f a l l l i q u i d s i n t h e
laboratory. Mouth pipetting must not be allowed.
• Laboratory and quality control reagents containing or derived from blood or blood
products should be considered potentially contaminated.
• Needles and syringes should be used only when necessary and in a situation in
which there is no alternative. The use of plastic pipettes should be encouraged. Care
should be taken to prevent injuries caused by needles, scalpels, glass slides and other
sharp or breakable instruments or devices. Needles should not be recapped or
manipulated by hand. Disposable needles and other sharp items should be placed in
a puncture-resistant sharps box for disposal after use. These containers should be
located as close as practical to areas where they will be used.
• Laboratory work surfaces should be decontaminated with 1,000 ppm hypochlorite
solution on a daily basis and following spillage of blood or body fluids. For large
spills of cultured or concentrated infectious agents, the contaminated area should be
first flooded with 10,000 ppm hypochlorite solution before cleaning, and then wiped
down with disposable towels in a gloved hand.
• Automated machines should have designs to avoid splashing or be adequately
screened. There should be a closed system from specimen presentation to safe
discharge of effluent, and should accept periodic disinfection readily.
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• As far as possible, equipment should be decontaminated before they are sent for
mechanical or electrical servicing.
• Tissue or serum specimens to be stored should be clearly and permanently labelled as
potentially hazardous.
• Infective waste from the laboratory should be autoclaved before disposal or sent for
incineration.
Although most organisms in the dead body are unlikely to infect healthy persons,
some infectious agents may be transmitted where workers are in close contact with blood,
body fluids and tissues of dead body who died with infectious diseases. To minimise the
risks of transmission of known and also unsuspected infectious diseases, dead bodies
should be handled in such a way that workers' exposure to blood, body fluids and tissues is
reduced. A rational approach should include staff training and education, safe working
environment, appropriate work practices, the use of recommended safety devices and
vaccination against hepatitis B.
There is a need to maintain the confidentiality of patient's medical condition even after
the death of the patient, particularly when stigmatising conditions, like human
immunodeficiency virus (HIV) infections, are involved. At the same time, there is obligation
to inform personnel who may be at risk of infection through contact with deceased person to
take appropriate measures to guard against infection. The discrete use of labelling such as
‘ Danger of Infection’ on the dead body is considered appropriate.
The following outline work practices which are recommended when handling and
disposing dead bodies. These have been formulated by a working party comprising
representatives of the Department of Health, Hospital Authority, Urban Services Department
and Regional Services Department. Hospitals, public mortuaries and funeral parlours are
urged to adapt them in light of local circumstances and requirements. The adopted
precautions should be widely disseminated to all staff involved.
I.1 For all dead bodies other than those with infectious diseases as listed in Appendix
VIII
1. Nursing and other personnel who handle dead bodies must wear protective clothing
consisting of gown/apron and gloves. They should cover all cuts and abrasions with
waterproof bandages or dressings.
2. Wound, drainage and needle puncture holes should be disinfected with 1% household
bleach (1:5 dilution and must be freshly prepared) and dressed with non-permeable
material.
3. Extreme caution should be exercised when removing intravenous catheters and other
devices which are sharp. They should be disposed into puncture resistant containers.
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4. All body orifices should be plugged with swabs soaked in 1% household bleach (1:5
dilution).
5. The body should be cleaned and dried.
6. A f t e r i d e n t i f y i n g a n d a t t a c h i n g t o t h e b o d y t h e n e c e s s a r y i d e n t i t y l a b e l s , th e b o d y
should be wrapped with mortuary sheet before being placed on mortuary trolley and
transported to the mortuary.
7. After removing protective clothing and gloves, hands should be washed thoroughly.
I.2 Precautions for handling dead body with infectious disease as listed in Appendix VIII
1. To obviate the need for the undertaker to handle the body, following I.1.1 - I.1.5, it is
preferable for the ward staff to dress the deceased. The relatives should be informed
beforehand so that they can bring the necessary clothing in advance.
2. Identify the body and attach to the body the necessary identity labels. The body
should be placed in a robust, transparent plastic bag made of polyethylene of not less
t h a n 1 5 0 µm t h i c k . The open end of which should be closed tightly with tapes and
bandage strips. Pins are not to be used.
3. The outside of the plastic bag should be wiped with 0.1% household bleach (1:50
dilution).
4. The bagged body should be wrapped with mortuary sheet before being placed on
mortuary trolley and transported to the mortuary.
5. Warning labels such as `Danger of Infection' should be attached to body/body bag,
mortuary sheet and accompanying paperwork.
6. D i s p o s a b l e i t e m s s h o u l d b e d i s c a r d e d i n t o r e d p l a s t i c w a s t e ba g w h i c h s h o u l d b e
securely tied up and sent for incineration.
7. Used linen or protective clothing should be autoclaved or soaked in 0.1% household
bleach (1:50 dilution) for 30 mins.
8. E q u i p m e n t s h o u l d b e a u t o c l a v e d o r d e c o n t a m i n a t e d w i t h d i s i n f e c t a n t so l u t i o n s i n
accordance with established disinfectant policy.
9. All surfaces which may be contaminated should be disinfected with 0.1% household
bleach (1:50 dilution) or 1% printol.
10. A f t e r r e m o v i n g p r o t e c t i v e c l o t h i n g a n d g l o v e s , h a n d s s h o u l d b e w a s h e d t h o r o u g h l y .
11. The mortuary staff-in-charge should be informed that there is potential risk of infection
if there is possibility of contact with blood, body fluids or tissues.
II Precautions in mortuary
1. All staff should be trained in the prevention of infections. A high standard of personal
hygiene should be adopted.
2. Smoking, drinking and eating is forbidden in post-mortem room, body storage and
viewing areas.
3. The mortuary must at all times be kept clean and properly ventilated. Lighting must be
adequate. Surfaces and instruments should be made of materials which could be easily
disinfected and maintained.
122
4. Staff who handle dead bodies must wear protective clothing consisting of gown, apron,
gloves and boots. They should cover all cuts and abrasions with waterproof bandages
or dressings.
5. All bodies must be identified and correctly labelled.
6. Any dead body which is contaminated with blood or body fluids should be placed in a
disposable plastic bag as soon as possible.
7. B o d i e s s h o u l d b e s t o r e d i n c o l d c h a m b e r s m a i n t a i n e d a t a p p r o x . 4 °C . Storage
compartments should be easily accessible for both regular cleaning and maintenance.
8. Since all bodies who come to autopsy are a potential source of infection, at all times,
pathologists and other support staff should observe universal precautions in the
performance of any autopsy.
9. All efforts should be made to avoid sharps injury, both in the course of examination and
afterwards in dealing with waste disposal and decontamination.
10. Soiled linen, environmental surfaces, instruments and transport trolley should be
decontaminated in accordance with established policy.
11. Single use gloves, protective aprons and other waste materials must be disposed of in
red plastic bags for incineration.
12. A f t e r r e m o v i n g p r o t e c t i v e c l o t h i n g a n d g l o v e s , h a n d s s h o u l d b e w a s h e d t h o r o u g h l y .
II.2 Additional precautions for handling dead body with infectious diseases as listed in
Appendix VIII
2. Mortuary staff should ensure that good liaison is maintained between themselves and
those who collect bodies for disposal. It is essential that staff of funeral parlours and all
others involved in handling the body are informed that there is a potential risk of
infection if there is possibility of contact with blood and body fluids.
3. Advice should be given to staff of funeral parlours and relatives regarding the safe
handling of the body (appendix IX).
123
1. When handling bodies, do not smoke, eat, drink or take actions that will bring the hands
into contact with mouth, eyes or nose.
2. Make sure that any cuts, wounds or abrasions are covered by waterproof bandages or
dressings.
3. Hepatitis B vaccination is recommended for all staff who are lik ely to come into contact
with dead bodies.
4. Make sure that a supply of disposable gloves, protective clothing and disinfectant such
as household bleach is readily available.
5. Put on disposable gloves and protective clothing/uniform when handling dead b odies.
6. Hands must be washed after removing gloves and protective clothing.
7. Any spilled blood or body fluids must be wiped with 1% household bleach (1:5
dilution).
8. Protective clothing or uniform must be kept apart from outdoor clothing.
124
7.3 Occupational exposure to HIV
125
Management of occupational exposure to HIV
A mechanism of reporting exposures should be available for every institution and the
information/record should be treated with strictest confidence. For the purpose of
documentation and planning for intervention, assessment should be made regarding the
type, site, mechanism, circumstance, severity, and source of exposure. The source patient
shall, if possible, be evaluated and being offered informed consent to HIV and/or HBV
testing as appropriate.
For significant exposure to proven or potential HIV, the injured person should receive
counselling and baseline HIV antibody testing as soon as possible. Follow-up HIV testing is
usually done at six months after exposure. Exposed persons should be advised to return for
evaluation if symptoms of seroconversion develop. Psychological reactions to the exposure
can be extremely diverse and severe, which may, however, only be evident on careful
questioning and assessment. Clinicians and experts in managing psychosocial stress are
important personnel in tackling these problems, and on-going counselling should be
available. Issues on the protection of third parties, such as sexual partners, and blood/organ
recipient in the event of blood/organ donation, should be discussed and advised.
126
assessment, potential side effects of zidovudine and its unproven efficacy. The possibility
of zidovudine resistance in source patients being heavily treated with zidovudine has to be
considered. If the individual person decides to have prophylaxis, it is logical to institute
zidovudine (1000mg daily) as early as possible. It is given for six weeks if tolerable and
acceptable by the person. The person should be monitored for AZT toxicity (while on
prophylaxis) as well as evidence of HIV seroconversion beyond the course of AZT
prophylaxis.
127
7.4 HIV infection and the health care workers
- recommended guidelines
( formulated by the Advisory Council on AIDS in April 1994 )
1. BACKGROUND
1.1 A I D S ( A c q u i r e d I m m u n o d e f i c i e n c y S y n d r o m e ) i s c a u s e d b y a r e t r o v ir u s n a m e d H I V ,
the human immunodeficiency virus. The syndrome, characterised by development of
complications like opportunistic infections or tumours, was first described in 1981 in the
USA. The human race is now hard hit by the pandemic. An estimated total of 15 million
people worldwide have already been infected so far.
1.2 HIV is transmitted largely through three routes : (a) sexual contact with an HIV-infected
person, (b) exposure to contaminated blood and needles, and (c) perinatally from an infected
mother to her baby. Worldwide over three-quarters of the infection have been contracted
through sex, and largely heterosexual contacts.
1.3 HIV infection has been reported to occur in health care settings by exposure to
contaminated blood through cutaneous injuries or mucous membranes. The estimated risk of
contracting the virus after such injuries or exposure to infected blood is 0.4%.
1.4 The chance of HIV transmission from an infected health care worker to his/her client is
much lower. The CDC ( Centre for Diseases Control ) in Atlanta has reported that six
patients of an HIV positive dentist in Florida were infected since 1990. There is still
controversy as to how the transmission has occurred but this is the only case documented
s o f a r . I n o t h e r ‘ lo o k - b a c k’ s t u d i e s o f o v e r 1 5 0 0 0 c l i e n t s o f 3 2 H I V - i n f e c t e d h e a l t h c a r e
workers, including dentists and surgeons, none was found to have caught the virus.
1.5 Taken the extremely low risk of HIV transmission in the health care setting, universal
precaution in handling blood and other body fluids was generally advocated as the most
effective measure in further minimising the chance of infection. HIV has been isolated from
blood, semen, saliva, tears, urine, vaginal secretion, cerebrospinal fluid, synovial fluid,
breast milk and amniotic fluid of infected individuals. However only blood, blood products,
semen, vaginal secretion and breast milk have been linked to HIV transmission.
2. GENERAL PRINCIPLES
2.1 The most effective means of preventing HIV transmission in health care setting is
through adherence to universal precautions, thereby decreasing the risk of direct exposure
to blood and/or body fluids.
2.2 Voluntary instead of mandatory HIV testing is the best way of encouraging people
(including health care workers) at risk of infection to seek counselling and appropriate
treatment.
128
2.3 Health care workers should consider receiving counselling and HIV antibody testing if
they have reason to suspect that they have been infected.
2.4 Health care workers are generally not required to disclose their HIV status to their
patients or employers. Disclosure, if any, should be made on a need-to-know basis and with
consent of the worker. Maintaining confidentiality is one way to prevent interference with
individual privacy. It is also essential in encouraging the health care workers ( either
infected or at risk of infection ) to receive proper counselling and management.
2.5 Currently there is no justification for restricting practice of health care workers on the
basis of the HIV status alone. Restriction or modification, if any, should be determined on a
case-by-case basis.
3. GUIDELINES
T h e b e s t w a y o f p r e v e n t i n g b l o o d - b o r n e d i s e a s e s i s t o t r e a t a l l b l o o d ( a n d certain
body fluids ) as potentially infectious. Universal precautionary measures should be adopted
w h e n h a n d l i n g b l o o d , a m n i o t i c fluid, pericardial fluid, pleural fluid, peritoneal fluid, synovial
fluid, cerebrospinal fluid, semen and vaginal secretion. The risk of HIV transmission from
faeces, saliva, nasal secretion, sputum, sweat, tears, urine and vomitus without overt blood
staining is extremely low, and good simple hygienic measures should be sufficient.
Rapid advancement in medicine and technology has meant that it is essential to keep
updated on issues relating to infection control practice. Infection control committees should
efficiently serve the functions of developing, promulgating and updating infection control
policies in each institution and for each clinical specialty.
129
(c) Infection control training
The subject of infection control should be made an integral part of undergraduate, pre-
registration or pre-employment training for all health care workers who may come into
contact with blood/body fluids. Similarly, regular courses tailored to the infection control
needs of individual specialties, should be organised by professional bodies,
universities/polytechnics as well as relevant government depart ments. It should be made
known that those who fail to use appropriate infection control techniques to protect patients
may be subject to charges of professional misconduct by the relevant governing body.
3.2 HIV counselling & related services for health care workers
Information and counselling should be made easily available for health care workers
who may have been exposed to HIV through risk behaviour, exposure to contaminated
blood/blood products or occupational accidents. The importance of voluntary, confidential
a n d a n o n y m o u s c o u n s e l l i n g a n d H I V t e s ti n g s h o u l d b e u n d e r l i n e d .
3.3.1 Confidentiality
In general, health care workers are not required to disclose their HIV status to their
employers or clients. HIV infection and AIDS are not notifiable diseases by law in Hong
Kong, and reporting is on a voluntary basis. There are, however, occasions where the HIV
status has to be made known on a need-to-know basis, and this will normally be with the
consent of the infected worker. For example, doctors or specialists involved in evaluating an
infected health care worker may need to know his HIV status. In exceptional circumstances,
breach of confidentiality may be warranted, for instance when an HIV infected health care
worker refuses to observe the restrictions and patients have been put at risk.
The status and rights of an HIV-infected health care worker as an employee should be
safeguarded. If work restriction is required, employers should make arrangement for
alternative work, with provision for retraining and redeployment.
An HIV-infected health care worker should seek appropriate counselling and to act
upon it when given. It is unethical if one fails to do so as patients are put at risk. The
attending doctor of an HIV-infected health care worker should seek the advice of the expert
panel formed by the Director of Health on the areas of management and possible need for
job modification. The doctor who has counselled an HIV-infected colleague on job
modification and who is aware that the advice is not being followed and patients are put at
risk, has a duty to inform the Medical / Dental Council for appropriate action.
130
Referral to the expert panel should be made by the health care worker's attending
physician. Formed by the Director of Health, the panel shall decide on whether job modi-
fication, limitation or restriction is warranted. A case-by-case evaluation would be
undertaken considering multiple factors that can influence risk and work performance.
The issue of HIV transmission in health care setting has caused much public concern
despite the minimal risk incurred. Focussing on health care setting in fact deflects the
society from proper attention to the major transmission routes through sex and drug abuse.
The health care profession has the duty of constantly reassuring the public, and to educate
the clients on how HIV can and cannot be contracted. More importantly, the public looks on
the health care profession as an example of how AIDS should be dealt with. By adhering to
the guidelines for prevention of HIV infection in the health care setting, public fear can be
allayed.
131
Appendix I-A
Continent No.
Africa 418051
Americas 580129
Asia 23912
Europe 141275
Oceania 6444
World Total 1169811
* The estimated cumulative AIDS cases in adults and children is 4.5 million while that of HIV
infection among adults and children is 18.5 million and 1.5 million respectively. The largest
number of HIV infection has ocurred in Sub-saharan Africa (>11 million), followed by South
and South-east Asia (3.5 million).
132
Appendix I-B
No. (%)#
Total AIDS
SEX Male 518 (90) 136 (92)
Female 55 (10) 12 (8)
* The estimated cumulative HIV and AIDS cases is 3000 and 250 respectively. The projected
number by the year 2000 is 8000-12000 and 1650-1800 for HIV and AIDS respectively.
# Percentage may not add up to 100 due to rounding off of figures.
133
Appendix II
Organizational Structure
of Hong Kong AIDS Programme
Hong Kong
Government
Planning/Evaluation
Subcommittee Working Groups
on
Department of
Health
Information Services Department
Education
Department
[Hospital Authority]
Social Welfare Department
Council of Social Service
Non-governmental organizations :
(on AIDS) :
134
Hong Kong AIDS
Foundation
AIDS Concern
AIDS Memorial Quilt
Project
Society for AIDS
Care
HIV Information & Drop-in Centre
135
Appendix III
The Service is composed of two systems - the AIDS counselling hotline and the
infoline. The AIDS hotline (Tel: 2780 2211) utilises an interactive voice processing
system. Callers may choose to listen to recorded AIDS or STD messages (24-hour
computerised system), or talk to experienced nurse-counsellor directly by selecting the
right number. HIV antibody tests and/or face-to-face counselling could be arranged if
required. Counsellors are available between 8 am to 8 pm, from Monday to Friday. All
information is kept in strictest confidence.
The service provides in-depth face-to-face counselling, and HIV antibody tests
to people at risk of infection. It is free, strictly confidential and anonymous.
Appointment has to be made in advance.
136
a new initiative developed together with Lions International Hong Kong. A newsletter
is published 3 times a year covering various issues relating to HIV infection.
The service keeps a collection of a good variety of both local and overseas
education materials, for medical professionals and the public who are interested in
AIDS care, education and publicity. Materials available include books, journals, audio-
visuals, pamphlets, posters and resource kits.
The Unit has been actively involved in research relating to various aspects of
HIV/AIDS with local perspective and relevance. Some topics that have been covered
include clinical manifestation and management, epidemiology, AIDS-related
behaviours/attitudes, and effectiveness of local health education activities.
137
Appendix IV
Category A
Asymptomatic HIV infection
Persistent generalised lymphadenopathy
Acute (primary) HIV infection with accompanying illness or history of acute HIV infection
138
#C a t e g o r y C :AIDS indicator conditions
Candidiasis of bronchi, trachea, or lungs
Candidiasis , oesophageal
Cervical cancer, invasive
Coccidioidomycosis, disseminated or extrapulmonary
Cryptococcosis, extrapulmonary
Cryptosporidiosis, chronic intestinal (> 1 month's duration)
Cytomegalovirus disease (other than liver, spleen, or nodes)
Cytomegalovirus retinitis ( with loss of vision )
Encephalopathy, HIV-related
Herpes simplex: chronic ulcer(s) ( > 1 month's duration ); or bronchitis, pneumonitis, or
oesophagitis
Histoplasmosis, disseminated or extrapulmonary
Isosporiasis, chronic intestinal ( > 1 month's duration )
Kaposi's sarcoma
Lymphoma, Burkitt's ( or equivalent term )
Lymphoma, immunoblastic ( or equivalent term )
Lymphoma, primary, of brain
Mycobacterium avium complex or M kansasii, disseminated or extrapulmonary
Mycobacterium tuberculosis; extrapulmonary or pulmonary/cervical lymph node (only if
CD4 <200/ul)
Pneumonia, recurrent
Penicilliosis, disseminated
Mycobacterium, other species or unidentified species, disseminated or extrapulmonary
Pneumocystis carinii pneumonia
Progressive multifocal leukoencephalopathy
Salmonella septicaemia, recurrent
Toxoplasmosis of brain
Wasting syndrome due to HIV
#M o d i f i c a t i o n of the CDC 1993 AIDS surveillance case definition: (1) Penicilliosis has been
added and (2) pulmonary or cervical lymph node tuberculosis included only if CD4 <200/ul
*adapted from the 1993 CDC revised classification system for HIV infection and expanded
surveillance case definition for AIDS among adolescents and adults (MMWR 1992;Vol 41:1-
4,15), and endorsed by the Advisory Council on AIDS in July 1995.
139
Appendix V
Clinical categories
Immunologic N: No signs/ A: Mild signs/ B: Moderate C: Severe
categories symptoms symptoms signs/ signs/
symptoms symptoms
1: No evidence of
suppression N1 A1 B1 C1
2: Evidence of
moderate N2 A2 B2 C2
suppression
3: Severe N3 A3 B3 C3
suppression
Age of child
<12 mos 1-5 yrs 6-12 yrs
Immunologic category uL (%) uL (%) UL (%)
1: No evidence of ≥ 1,500 ( ≥ 25) ≥ 1,000 ( ≥ 25) ≥ 500 ( ≥ 25)
suppression
2: Evidence of moderate 750- 500- 200-
suppression 1,499 (15-24) 999 (15-24) 499 (15-24)
3: Severe suppression <750 (<15) <500 (<15) <200 (<15)
140
Clinical categories for children with human immunodeficiency virus (HIV) infection
Children who have no signs or symptoms considered to be the result of HIV infection
or who have only one of the conditions listed in Category A.
Children who have symptomatic conditions other than those listed for Category A
or C that are attributed to HIV infection. Examples of conditions in clinical Category B
include but are not limited to :
100,000/mm3) p e r s i s t i n g ≥3 0 d a y s
• Bacterial meningitis, pneumonia, or sepsis (single episode)
• Candidiasis, oropharyngeal (thrush), pers isting (> 2 months) in children >6
months of age
• Cytomegalovirus infection, with onset before 1 month of age
• Diarrhoea, recurrent or chronic
• Hepatitis
• Herpes simplex virus (HSV) stomatitis, recurrent (more than two episodes
within 1 year)
• HSV bronchitis, pneumonitis, or oesophagitis with onset < 1 month of age
• Herpes zoster (shingles) involving at least two distinct episodes or more
than one dermatome
• Leiomyosarcoma
• Lymphoid interstitial pneumonia (LIP) or pulmonary lymphoid hyperplasia
complex
• Nephropathy
• Nocardiosis
• Persistent fever (lasting > 1 month)
• Toxoplasmosis, onset before 1 month of age
• Varicella, disseminated (complicated chickenpox)
Children who have any condition listed in the 1987 surveillance case definition for
acquired immunodeficiency syndrome, with the exception of LIP.
141
Conditions included in clinical Category C for children infected with human
immunodeficiency virus (HIV)
• Serious bacterial infections, multiple or recurrent (i.e. any combination of at least two
culture-confirmed infections within a 2-year period), of the following types :
septicaemia, pneumonia, meningitis, bone or joint infection, or abscess of an internal
organ or body cavity (excluding otitis media, superficial skin or mucosal abscesses, and
indwelling catheter-related infections)
• Candidiasis, oesophageal or pulmonary (bronchi, trachea, lungs)
• Coccidioidomycosis, disseminated (at site other than or in addition to lungs or cervical
or hilar lymph nodes)
• Cryptococcosis, extrapulmonary
• Cryptosporidiosis or isosporiasis with diarrhoea persisting > 1 month
• Cytomegalovirus disease with onset of symptoms at age > 1 month (at a site other than
liver, spleen, or lymph nodes)
• Encephalopathy (at least one of the following progressive findings present for at least
2 months in the absence of a concurrent illness other than HIV infection that could
explain the findings) : a) failure to attain or loss of developmental milestones or loss of
intellectual ability, verified by standard developmental scale or neuropsychological
tests; b) impaired brain growth or acquired microcephaly demonstrated by head
circumference measurements or brain atrophy demonstrated by computerised
tomography or magnetic resonance imaging (serial imaging is required for children <2
years of age); c) acquired symmetric motor deficit manifested by two or more of the
following: paresis, pathologic reflexes, ataxia, or gait disturbance
• Herpes simplex virus infection causing a mucotaneous ulcer that persists for > 1
month's duration; or bronchitis, pneumonitis, or oesophagitis for any duration affecting
a child >1 month of age
• Histoplasmosis, disseminated (at a site other than or in addition to lungs or cervical or
hilar lymph nodes)
• Kaposi's sarcoma
• Lymphoma, small, noncleaved (Burkitt's), or immunoblastic or large cell lymphoma or B-
cell or unknown immunologic phenotypes
• Lymphoma, primary, of brain
• Mycobacterium avium complex or M kansasii, disseminated (at a site other than or in
addition to lungs or cervical or hilar lymph nodes)
• Mycobacterium tuberculosis; disseminated or extrapulmonary; if pulmonary or cervical,
patients need to be in immunologic category of severe suppression
• Mycobacterium, other species or unidentified species, disseminated (at a site other than
or in addition to lungs or cervical or hilar lymph nodes)
• Pneumocystis carinii pneumonia
• Progressive multifocal leukoencephalopathy
• Salmonella (nontyphoid) septicaemia, recurrent
• Toxoplasmosis of brain with onset >1 month of age
• Wasting syndrome in the absence of a concurrent illness other than HIV infection that
could explain the following findings: a) persistent weight loss 10% of baseline OR b)
142
downward crossing of at least two of the following percentile lines on the weight for
age chart (e.g. 95th, 75th, 50th, 25th, 5th) in a child ≥ 1 year of age OR c) <5th percentile
f o r w e i g h t - f o r - h e i g h t c h a r t o n t w o c o n s e c u t i v e m e a s u r e m e n t s , ≥3 0 d a y s a p a r t P L U S a )
c h r o n i c d i a r r h o e a ( i . e . a t l e a s t t w o l o o s e s t o o l s p e r d a y f o r ≥3 0 d a y s ) O R b ) d o c u m e n t e d
fever(for ≥3 0 d a y s , i n t e r m i t t e n t o r c o n s t a n t )
• Penicilliosis, disseminated
*adapted from the 1994 CDC revised classification system for human immunodeficiency
virus infection in children less than 13 years old (MMWR 1994;43RR-12), and endorsed by
the Advisory Council on AIDS in July 1995.
143
Appendix VI
2. Virus inactivation for clotting factor concentrates - Scientific Working Group on AIDS 1991
3. Disease notification in the context of HIV/AIDS - Scientific Working Group on AIDS 1992
5. Procedures for management of needlestick injury or mucosal contact with blood or body
fluids : recommended guidelines for HIV and hepatitis B prevention - Scientific Working
Group on AIDS and Scientific Working Group on Viral Hepatits Prevention 1992, revised in
1995 ( H e p a t i t i s C p r e v e n t i o n i n c l u d e d )
7. HIV & AIDS : Information for primary care doctors - Committee on Education and Publicity
on AIDS 1992
8. Proposed revised specification for clotting factor concentrates - Scientific Working Group
on AIDS 1993
144
9. Recommended guidelines for undertaking anonymous screening for public health
surveillance of HIV infection in Hong Kong - Scientific Working Group on AIDS 1993
10. HIV infection and health care workers : recommended guidelines - Advisory Council on
AIDS 1994
12. HIV antibody testing : recommended measures to generate quality results - Scientific
Committee on AIDS 1994
13. The choice of safe clotting factor concentrates for treatment of haemophilia in Hong
Kong : recommended guidelines - Scientific Committee on AIDS 1994
2. Information on AIDS for doctors and dentists - Medical & Health Department 1987,
Department of Health 1992
3. Information on AIDS for nurses - Medical & Health Department 1988, Department of Health
1993 [Chinese & English]
9. Guidelines on infection control practice in clinics and maternity homes - Infection Control
Committee of Department of Health 1993
145
10. Guidelines on infection control practice in dental clinics - Infection Control Committee of
Department of Health 1994
1. Strategies for AIDS prevention, care and control in Hong Kong - July 1994
2. A review of services provided to people with HIV/AIDS in Hong Kong - AIDS Services
Development Committee July 1994
4. *Report of the study group on HIV infection of haemophiliacs through blood products
in Hong Kong (submitted to the Health & Welfare Branch) - May 1993
5. *Estimation and projection of HIV infection and AIDS cases in Hong Kong - report of
the AIDS Scenario & Surveillance Research Project, initiated and monitored by the
Scientific Committee on AIDS 1994
7. Classification system for HIV infection and surveillance case definition for AIDS in
adolescents and adults in Hong Kong - Scientific Committee on AIDS 1995
146
Appendix VII
The following statements on treatment of AIDS patients was adopted at the 40th
World Medical Assembly in September 1988. The Joint Ethics Advisory Committee of the
Medical Association and the British Medical Association (Hong Kong Branch) has adopted
them as its position and would like to advise members accordingly.
"Patients with AIDS and those who test positively for the antibody to the AIDS virus
must be provided with appropriate medical care and should not be treated unfairly or suffer
from arbitrary or irrational discrimination in their daily lives. Physicians have a long and
honored tradition of tending to patients afflicted with infectious diseases with compassion
and courage. That tradition must be continued throughout the AIDS epidemic.
A I D S p a t i e n t s a r e e n t i t l e d t o c o m p e t e n t m e d i c a l c a re w i t h c o m p a s s i o n a n d r e s p e c t f o r
human dignity. A physician may not ethically refuse to treat a patient whose condition is
within the physician's current realm of competence, solely because the patient is
seropositive. Medical ethics do not permit categorical discrimination against a patient based
solely on his or her seropositivity. A person who is afflicted with AIDS needs competent,
compassionate treatment. A physician who is not able to provide the care and services
required by persons with AIDS should make an appropriate referral to those physicians or
facilities that are equipped to provide such services. Until the referral can be accomplished,
the physician must care for the patient to the best of his or her ability."
The HKMA/BMA Joint Ethics Advisory Committee discussed the position on AIDS
and Confidentiality and has reached the following opinion :
147
C. AIDS Testing
(published in HKMA Newsletter, November/December 1989)
The HKMA/BMA Joint Ethics Advisory Committee has discussed the issue of
whether consent is required for testing for HIV antibody and would like to present the
following views for members' consideration :
1. I t i s g e n e r a l l y a c c e p te d a n d w e l l u n d e r s t o o d w i t h i n t h e p r o f e s s i o n t h a t a d o c t o r
should treat a patient only on the basis of the patient's informed consent. A
patient's consent may be given implicitly, for example by agreement to provide a
specimen of blood for routine multiple analysis. Under other circumstances, explicit
consent may be required, for example before undergoing a specific operative
procedure.
2. Whether implicit or explicit consent is required for HIV antibody testing depends
on what patients actually consent to when presenting themselves to the medical
practitioner for medical treatment. One view is that when patients present
themselves for treatment, consent is implied for the medical practitioner to carry out
the necessary investigations which are necessary for management and are in the
best interest of the patient. Another view is, because HIV infection has such
serious social and financial consequences, HIV antibody testing should not be
regarded as a "routine test" and explicit consent should be sought. Whichever
view prevails, the doctor in carrying out such tests must act in the best interest of
the patient.
(Remarks : The Committee noted that the legal adviser of BMA concluded that as
the law stood at present the consent of the patient was essential and that it would
be unwise for doctors to adopt a course that would expose them to the possibility
of criminal and civil proceedings.)
148
Appendix VIII
steam and pasteurisation at temperature 65o C for 30 minutes or 80o C for 10 minutes are also
effective.
In routine situations, the most useful chemical disinfectants are hypochlorite, ethyl
alcohol and glutaraldehyde.
149
Uses of Hypochlorites and Strength of Solutions
* Care is required in preparation of the solution as the amount of available chlorine in stock
solution varies with the country of manufacture, e.g. household bleach 'clorox' in USA and Canada
(5.25% available chlorine), Eau de Javel in France (15% available chlorine), 'Chloros' in the United
Kingdom (10-15% available chorine).
# Approximate values
150
Usual concentration: 2%
Uses:
• Disinfection of equipment that cannot be heat-s terilised.
Phenolics have some virucidal activity and results of in vitro tests have shown
that lysol is capable of inactivating HIV. For blood spillage onto surfaces or
contaminated heat-sensitive articles, use may be made of 2% phenolic disinfectants.
For general enviromental hygiene practice, 1% phenolic disinfectant is recommended.
(d) Hydrogen peroxide and ethylene oxide are also capable of inactivating HIV.
References :
3. Recommended Infection-control pra ctices for Dentistry. MMWR 1986; Vol 35:No. 15.
6. Guidelines for Prevention of Transmission of HIV and HBV to Health-care and Public
S a f e t y W o r k e r s . MMWR 1989; Vol 38:No. S-6.
151
Appendix IX
1. Anthrax
3. Plague
4. Rabies
6. Other infectious diseases as deemed necessary by the physician i/c, the infection
control officer or microbiologist
152
Appendix X
This is to inform you that the deceased had suffered from infectious
diseases. The body had been enclosed in a plastic bag. For safe handling of the body, you
are advised to adopt the followings :
(2) The body should not normally be removed from the plastic bag.
(4) Viewing of the face without physical contact should be permitted. The
plastic bag should be resealed afterwards.
(5) Avoid direct contact with blood or body fluids from deceased's body.
(6) Persons handling the body should wear disposable gloves and protective
clothing. After use, these gloves and clothing should be soaked in
freshly prepared household bleach (1:50 dilution) for 30 min. before
washing or disposal.
(7) Hands must be thoroughly washed after removing gloves and protective
clothing.
(8) Relatives who are worried about having already exposed to the infection
should contact the physician i/c for counselling.
153
Appendix XI
treatment is free; no referral or appointment is needed; all information is kept confidential; HIV
testing is offered for people suspected/confirmed of having STDs
154
7. Hong Kong AIDS Foundation office 2560 8528
helpline 2513 0513
1 0 . AIDS Project, the Hong Kong Council of Social Service 2864 2963
14. Horizons Gay and Lesbian Hotline 2893 0208, 2893 0209
(every Tuesday & Thursday 7:30 - 10:30 pm)
155
Appendix XII
β 2-microglobulin A protein that forms part of the MHC Class I molecule. An elevation
o f β2 - m i c r o g l o b u l i n i n s e r u m m a y i n d i c a t e d i s e a s e p r o g r e s s i o n .
Cytomegalovirus.
CMV
Dideoxycytidine (Zalcitabine), a reverse transcriptase inhibitor. See
ddC Chapter 5.2.
156
ELISA Enzyme - linked Immunosorbent Assay.
A common immunoassay system, usually used for antigen or
antibody detection.
A common technique used to screen for HIV antibody.
gp Glycoprotein.
Gp 120 is a glycoprotein with molecular weight of 120,000, found on
the surface of HIV.
IFN Interferon.
A naturally-occuring or synthetic protein molecule that has
antiviral/immunomodulatory effects.
KS Kaposi's sarcoma.
A vascular tumour that is common in HIV-infected homosexuals. see
Chapter 4.
Oral candidiasis.
OC
Opportunistic infection.
OI
Abbreviation for HIV core protein. p24 means a protein with MW of
p 24,000.
PCP Pneumocystis carinii p n e u m o n i a .
A very common AIDS-defining illness which however has effective
prophylaxis.
RT Reverse transcriptase.
An enzyme critical for the replication of RNA virus.
ZDV Zidovudine.
See AZT.
158
Appendix XIII
2. Gu i d e l i n e s f o r P r e v e n t i o n o f T r a n s m i s s i o n o f H I V a n d H B V t o h e a l t h - c a r e a n d p u b l i c -
s a f e t y w o r k e r s . MMWR 1989; Vol 38: No. S-6.
3. AIDS Pocket Picture Guide 1989. I Williams, A Mindel, IVD Weller. Triton Biosciences
Inc.
6. R e c o m m e n d a t i o n s f o r p r e v e n t i n g T r a n s m i s s i o n o f H IV a n d H e p a t i t i s B v i r u s t o p a t i e n t s
during Exposure - Prone Invasive Procedures. MMWR 1991; Vol. 40:no. RR-8.
7. 1993 revised classification system for HIV infection and expanded case definition for
AIDS among adolescents and adults. MMWR 1992; Vol 41: no. RR-17
8. The Medical Management of AIDS. 3rd edition 1993. Merle A. Sande and Paul A.
Volberding. W.B. Saunders.
9. HIV infection and AIDS - The Ethical Considerations. June 1993 General Medical
Council.
1 0 . A I D S - i m a g e s o f t h e e p i d e m i c . W o r l d H e a lt h O r g a n i z a t i o n 1 9 9 4
11. The HIV/AIDS Pandemic - 1994 overview. Global Programme on AIDS, World Health
Organization WHO/GPA/TCO/SEF/94.4 1994.
12. Recommendations of the US Public Health Service Task Force on the use of zidovudine
to reduce perinatal transmission of HIV. MMWR 1994; Vol 43: no. RR-11
13. 1994 revised classification system for HIV infection in children less than 13 years of age.
MMWR 1994; Vol 43: no. RR-12
159
Appendix XIV
DEPARTMENT OF Health
HIV/AIDS Report Form
161
Figure 1. Simplified serological profile of HIV infection
Figure 2. Route of transmission of reported HIV cases in Hong Kong (1984 – June 1995)
162
Figure 3. Route of transmission of reported HIV cases in Hong Kong (1984 – June 1995)
Figure 4. Estimated and projected annual AIDS cases in Hong Kong according to different HIV scenarios
163