Intervention for hyperlipidemia associated with protease inhibitors.

In the past 3 years, treatment for HIV infection has significantly improved the prognosis for HIV-infected persons. The administration of protease inhibitors for the treatment of HIV infection has had a significant role in the reduction of AIDS-related complications. Recent findings have indicated that protease inhibitors may significantly increase lipids to levels that pose a health risk that may be greater than the illness itself. This article reviews the initial findings of a study that investigated the impact of interventions for the treatment of protease inhibitor-related hyperlipidemia. The purpose of the study was to determine if initiation of interventions based on the National Cholesterol Education Program Guidelines would be effective in lowering protease inhibitor-related hyperlipidemia without disrupting the effectiveness of the HIV therapy. A total of 45 HIV-infected individuals who were taking a protease inhibitor and had abnormally elevated lipids were enrolled into this study. Mean serum cholesterol level prior to initiation of a protease inhibitor regimen was 170 mg/dl as compared to a mean cholesterol at time of enrollment of 289 mg/dl and triglycerides of 879 mg/dl. Interventions included diet and exercise and the prescription of gemfibrozil alone or in combination with atorvatstatin. During the course of the study, overall intervention significantly reduced serum cholesterol level to 201 mg/dl (p. 01) over a study period of ten months. Case studies of five medical events related to hyperlipidemia are included. Currently, 26 participants continue in the study. Sixteen participants discontinued protease inhibitor therapy during the course of the study and thus ended their participation.

Lipid abnormalities associated with protease inhibitors.

Treatment for HIV infection in the past 3 years has significantly improved the prognosis of people infected with HIV. Protease inhibitors have played a critical role in this improved prognosis. Recent findings indicate, however, that protease inhibitors may cause significant alterations in lipid metabolism. This study reviewed the incidence of lipid abnormalities associated with the use of three different protease inhibitor therapies and identified that 56% of those who were assessed had abnormal elevated lipids. Following initiation of the protease inhibitor, a significant increase in cholesterol was found in 80% of the patients on norvir/saquinavir, 51% of patients on indinavir, and 47% of patients on nelfinavir. These lipid alterations have added a new and unexpected health risk for HIV-infected persons. The risks of therapy with protease inhibitors may have a greater life-threatening potential than the disease itself. This article will review the published findings suggestive of protease inhibitor hyperlipidemia and will highlight the findings of these events in a clinical setting. The purpose of this article is to alert the nursing community of this potential serious side effects and to make recommendations that may be put into practice so that complications may be reduced.

HIV RNA quantitation: marker of HIV infection.

Assessment of the status and prognosis of an HIV-infected individual traditionally has been difficult for the clinician. The use of markers of disease progression such as CD4+ has been found to not be a complete indicator of the status of an HIV-infected individual. As a result, determining appropriate therapy for the treatment of this viral infection has been both unpredictable and challenging. Recent development of a laboratory assay has brought a new tool in the management of HIV. The assay is a quantitation of the amount of detectable HIV RNA and estimates the amount of HIV viral load or HIV viral burden present in the blood. Since the development of this assay, HIV RNA quantitation has rapidly become an important surrogate marker of HIV infection. In addition, this quantitation is used to determine the effectiveness of anti-HIV therapies. Understanding the differences and results of quantitative assays is imperative in the management of HIV-infected patients. This article summarizes the events leading to the creation of quantitative assays, explanations and comparisons of the current quantitative assays, and nursing considerations for the implications and uses of viral load markers.

Psychological effects of participation and nonparticipation in a placebo-controlled zidovudine clinical trial with asymptomatic human immunodeficiency virus-infected individuals.

Psychological effects of participation in Protocol 019, a zidovudine placebo-controlled clinical trial, were investigated. Forty-six Protocol 019 subjects and 27 control asymptomatic human immunodeficiency virus-seropositive subjects were assessed at entry, 2 months, 6 months, and after trial modification. At baseline there were no psychological differences. Most Protocol 019 and control subjects were depressed on at least one psychological measure; fewer were anxious. Both groups had improvement over time. By 6 months, Protocol 019 subjects had decreased Beck Depression Inventory (BDI) scores, state anxiety, stress reaction, and symptoms of depression and anxiety. Controls had decreased scores on only the BDI. Over time, the percentage meeting modified DSM III-R criteria for anxiety decreased in both groups and the proportion of Protocol 019 subjects meeting DSM III-R depression criteria decreased. After protocol modification, study subjects were less depressed and distressed than controls. Protocol 019 subjects reduced depression symptoms but controls did not. Clinical trial participation was not deleterious and may have yielded some relative psychological benefit.

'Duty to warn' vs. 'patient confidentiality': the ethical dilemmas in caring for HIV-infected clients.

An ethical dilemma that health professionals working with HIV-infected clients currently face is the issue of maintaining patient confidentiality vs. the professional's duty to warn persons at potential risk for acquiring the virus. Multiple factors are involved when trying to resolve what a health professional's obligations are when he or she becomes aware of a risk to another individual. Professional standards require that patient confidentiality be maintained in order to promote a helping relationship. Yet, the well-being of the one at risk must be considered. Legal precedents with other sexually transmitted diseases have been established that place the burden upon the clinician to warn in order to prevent litigation. Yet, an action on the part of the clinician should not be carried out just to prevent litigation. Actions that are taken should consider what is healthiest for all parties involved. Two cases are presented that cite specific instances in which a sexual partner was put at risk. A flow chart is presented that should assist in decision-making.

Treatment of cytomegalovirus retinitis with intravitreal ganciclovir. Long-term results.

Long-term management of cytomegalovirus (CMV) retinitis by intravitreal injection of ganciclovir was evaluated in ten patients with acquired immune deficiency syndrome (AIDS). Patients were unable to tolerate systemic ganciclovir because of severe neutropenia (8 cases), catheter-induced sepsis (1 case), or the need to continue therapy for human immunodeficiency virus (HIV) with zidovudine (ZDV) (1 case). All patients had a favorable response to initial treatment. Cytomegalovirus retinitis progressed in four fellow eyes in which treatment was deferred. Vision improved or remained stable in all but one eye. Patients were followed for a mean of 4 months and received an average of 16.6 intravitreal injections in each eye. Relapse occurred late in the course while on maintenance treatment in five eyes (33%). There was no evidence of toxicity from repeated intravitreal injections. Treatment was very well tolerated. The only severe complication in a total of 249 injections was a single case of Staphylococcus epidermidis endophthalmitis which responded to intravitreal antibiotic treatment. Intravitreal ganciclovir is an effective alternative to systemic ganciclovir in those patients with severe neutropenia and in those patients who desire to remain on systemic ZDV.