the outcomes of a therapeutic decision are most likely to be optimized when the decision takes into account the factors that make each patient different

set the legitimately expected clinical effects of therapy BEFORE starting therapy; use those objectives to monitor drug effects and to signal the need for changes in therapy

each patient is unique in response to particular drugs: therefore, each patient poses unique challenges to the health care provider

the elderly patient is at risk of entering a vicious cycle in which the patient is more likely to receive drugs, more likely to develop adverse drug reactions, and potentially more likely to receive even more drugs to treat the unrecognized adverse drug effect

the renal function of a patient must be known to prescribe drugs wisely; understand a drug's route of clearance, as well as the route of clearance of any active or toxic metabolites, before prescribing it

because liver disease produces so many alterations in physiology, it is difficult to accurately predict he effects of liver disease on a particular drug's kinetics

failure to establish a firm diagnosis makes therapeutic plans difficult, especially in critically ill patients; when empiric drug treatment is necessary, it is even more important that data be carefully gathered and form the basis of sound decisions

aggressive, early, broad-spectrum empiric treatment before a diagnosis is made may be either essential or foolish; aggressive, invasive and thorough efforts to establish a firm diagnosis before beginning treatment may be essential or foolish; the clinician must consciously balance the risks and benefits of treatment and diagnostic studies in the dynamic state posed by the patient’s disease and the unique interaction of features in each patient

even when a drug has been used for years for recognized indications, we should not be surprised when new data surface documenting a new form of drug-induced toxicity; in fact, it is likely that increased experience with a drug will not only lead to new indications of the drug's use, but also provide data that older indication may not be justified

although a clinician's recent personal experience is important, it can lead to the clinician's overestimating the frequency of his/her most recently recognized adverse drug reaction and underestimating what he/she has not recently seen

choosing appropriate endpoints of efficacy may not be straightforward, but should be done prospectively as often as possible; targets and goals can change as our understanding of the disease or the drug change over time; patients may stress endpoints related to cost, functional status, or overall satisfaction, even as clinicians traditionally select endpoints related to pharmacological effect and quantitative evidence of reduction in the severity of illness

only when the clinician approaches each drug prescription as the beginning of a therapeutic experiment of uncertain outcome, and not as a concluding act to an office visit, will the chances that the experiment will be as safe, effective and productive as possible be maximized

transmission: sex, blood, vertical transmission, occupational exposure

PrEP --> vulnerable people use as part of an HIV drug regimen on a daily basis to prevent HIV (Truvada, Descovy)

prevention opportunities: abstinence, correct & consistent condom use, male circumcision, PrEP/PEP, treatment of STIs, decreased sexual partners, decreased sharing of needles, prevention of mother-to-child transmission

meningoencephalitis or aseptic meningitis, peripheral neuropathy or radiculopathy, facial palsy, Guillain-Barre syndrome, brachial neuritis, cognitive impairment or psychosis

everyone should be tested for HIV at least once in their lifetime; all pts 13-64 & pts with TB or seeking treatment for STI

200<CD4<500 --> toward lower end of range the incidence of minor HIV-related infections and other symptoms increases (oral/mucosal candidiasis, herpes zoster, dermatitis, fatigue, diarrhea); very symptomatic pts may develop an OI at this level

100<CD4<200 --> AIDS diagnosis based upon CD4 count under 200 due to higher risk of Pneumocystis jiroveci pneumonia (PCP)

CD4<100 --> increasing high risk for all opportunistic infections

CD4>500 --> associated with few, if any, symptoms and no opportunistic infections

HIV is a virus; AIDS is the syndrome that results from the virus damaging the immune system

currently, a combination of at least 3 antiretroviral drugs administered chronically

8 classes: nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, protease inhibitors, entry inhibitors (fusion, CCR5, attachment, post-attachment), integrase inhibitors

CD4 count --> the major indicator of immune function; check every 3-6 months

causes of failure: patient factors, drug resistance, suboptimal adherence, ARV toxicity & intolerance, pharmacokinetic problems, provider experience

long term prognosis --> related to the degree of control of the virus and degree of immunosuppression when therapy started; if started early and adhered to without problems, survival approaching that of uninfected population

dry cough, fever, SOB, chest tightness, diffuse infiltrate on chest xray, arterial blood O2 desaturation

treatment: trimethoprim-sulfamethoxazole, atovaquone, pentamidine

treatment: amphotericin B IV, LP, fluconazole maintenance therapy daily, no ART or steroids for at least first 2 weeks

fever, weight loss, constitutional symptoms, respiratory complaints, AMS, hepatosplenomegaly, adenopathy, cytopenias

diagnosis: blood/tissue culture, tissue histology, urine/serum antigen testing

treatment: amphotericin B (acute), itraconazole (mild acute), itraconazole (chronic)

treatment: multi-drug regimen based upon clarithromycin/azithromycin; ethambutol +/- rifamycin and macrolide; >12 months

diagnosis: presence of antibodies, abnormal imaging (ring-enhancing lesions), tissue histology

treatment: sulfadiazine + pyrimethamine; clindamycin + pyrimethamine; clarithromycin/azithromycin/atovaquone + pyrimethamine; dapsone + pyrimethamine

already being treated for OI (TB, MAC, cryptococcal disease), then start HAART, and have clinical deterioration/recurrence of symptoms

other: hep C, hep B, herpes, HPV, JC virus, syphilis & other STIs, cancer (kaposi, lymphomas, anal/genital), psychiatric disease, substance use