Care of Patients With HIV Infection: Diagnosis and Monitoring.

Appropriate screening for HIV infection is the cornerstone of HIV-related care. There have been several recent changes in testing technology and screening recommendations. The US Preventive Services Task Force recommends universal HIV screening at least once for adolescents and adults ages 15 to 65 years, and additional screening for patients at higher risk, although evidence is insufficient to determine optimum rescreening intervals. All pregnant women should be screened for HIV infection in the first trimester, and pregnant women at high risk should be screened again in the third trimester. The Centers for Disease Control and Prevention recommends use of an algorithm using fourth-generation tests for screening; this decreases the window period between infection and detection to as few as 14 days, thereby reducing the number of false-negative results. Home HIV testing kits, which require follow-up confirmatory testing, also are available. Clinicians should be aware of HIV-specific laws in their states, including those criminalizing HIV exposure and transmission. Thorough medical and laboratory evaluations are essential at initiation of care for patients with HIV infection, along with appropriate follow-up monitoring, as recommended in various guidelines.

Care of Patients With HIV Infection: Medical Complications and Comorbidities.

Care of patients with HIV infection starts with diagnosis as soon as possible, preferably at or near the time of acute infection. Opportunistic infections, malignancies, and other conditions develop progressively over time, particularly in untreated patients. The AIDS-defining opportunistic infections most common in the United States include Pneumocystis jirovecii pneumonia, Candida esophagitis, toxoplasmic encephalitis, tuberculosis, disseminated Mycobacterium avium complex, cryptococcal meningitis, and cytomegalovirus retinitis. Specific prophylaxis regimens exist for several opportunistic infections, and effective antiretroviral therapy reduces the risk of most others. Other AIDS-defining conditions include wasting syndrome and HIV encephalopathy. AIDS-defining malignancies include Kaposi sarcoma, systemic non-Hodgkin lymphoma, primary central nervous system lymphoma, and invasive cervical cancer. Although not an AIDS-defining condition, anal cancer is common in patients with HIV infection. Other HIV-related conditions include thrombocytopenia, recurrent bacterial respiratory infections, HIV-associated nephropathy, and HIV-associated neurocognitive disorder.

Care of Patients With HIV Infection: Antiretroviral Drug Regimens.

The advent of combination antiretroviral drug regimens has transformed HIV infection from a fatal illness into a manageable chronic condition. All patients with HIV infection should be considered for antiretroviral therapy, regardless of CD4 count or HIV viral load, for individual benefit and to prevent HIV transmission. Antiretroviral drugs affect HIV in several ways: entry inhibitors block HIV entry into CD4 T cells; nucleotide and nucleoside reverse transcriptase inhibitors prevent reverse transcription from RNA to DNA via chain-terminating proteins; nonnucleoside reverse transcriptase inhibitors prevent reverse transcription through enzymatic inhibition; integrase strand transfer inhibitors block integration of viral DNA into cellular DNA; protease inhibitors block maturation and production of the virus. Current guidelines recommend six combination regimens for initial therapy. Five are based on tenofovir and emtricitabine; the other uses abacavir and lamivudine. Five include integrase strand transfer inhibitors. HIV specialists should assist with treating patients with complicated HIV infection, including patients with treatment-resistant HIV infection, coinfection with hepatitis B or C virus, pregnancy, childhood infections, severe opportunistic infections, complex drug interactions, significant drug toxicity, or comorbidities. Family physicians can treat most patients with HIV infection effectively by choosing appropriate treatment regimens, monitoring patients closely, and retaining patients in care.

Care of Patients With HIV Infection: Primary Care.

With the advent of antiretroviral therapy and improved access to care, the average life expectancy of patients with HIV infection receiving optimal treatment approaches that of patients in the general population. AIDS-related opportunistic infections and malignancies are no longer the primary issues; instead, traditional age- and lifestyle-related conditions are a growing concern. Patients with HIV infection are at higher risk of cardiovascular disease, diabetes, hypertension, and some non-AIDS-related cancers than patients in the general population. Family physicians need to be knowledgeable about screening for and managing chronic comorbid conditions as this population ages. Health maintenance, including appropriate vaccinations, prophylaxis against opportunistic infections, and routine screening for sexually transmitted infections, remains an important part of care. As HIV infection becomes a chronic condition, emerging strategies in prevention, including preexposure prophylaxis, fall within the scope of practice of the family physician.

Xanthohumol, a prenylflavonoid derived from hops induces apoptosis and inhibits NF-kappaB activation in prostate epithelial cells.

There is increasing evidence that certain natural compounds found in plants may be useful as cancer chemopreventive or chemotherapeutic agents. Limited in vitro studies indicate that several prenylated flavonoids present in the hop plant (Humulus lupulus) possess anticarcinogenic properties. The purpose of this study was to investigate the anti-tumorigenic effects of xanthohumol (XN), the major prenylflavonoid in hops, on prostate cancer and benign prostate hyperplasia. BPH-1 and PC3 cell lines were used in our study to represent both non-tumorigenic hyperplasia and malignant prostate cancer. In both BPH-1 and PC3 cells, XN and its oxidation product, XAL, decreased cell viability in a dose dependent manner (2.5-20 microM) as determined by MTT assay and caused an increase in the formation of early and late apoptotic cells as determined by Annexin V staining and multicaspase assays. XN and its oxygenated derivative also induced cell cycle changes in both cells lines, seen in an elevated sub G1 peak at 48h treatment. Western blot analysis was performed to confirm the activation of proapoptotic proteins, Bax and p53. XN and its derivative caused decreased activation of NFkappaB. This work suggests that XN and its oxidation product, XAL, may be potentially useful as a chemopreventive agent during prostate hyperplasia and prostate carcinogenesis, acting via induction of apoptosis and down-regulation of NFkappaB activation in BPH-1 cells.