Determining Prognosis: Patients with End-Stage AIDS (Reading & Sharing)

The human immunodeficiency retrovirus causes acquired immunodeficiency syndrome (AIDS), in which immunity is profoundly reduced through destruction of CD4 T lymphocytes and macrophages. The CD4 recognize infected cells and foreign antibodies, activate antibody-producing lymphocytes, and orchestrate cell-mediated immunity in which infected cells and foreign antigens are destroyed. When viral loads climb and CD4 counts drop, the immune system cannot resist the development of opportunistic infections and malignancies. AIDS is defined as a CD4 count < 200/ul or occurrence of AIDS defining conditions. AIDS is a syndrome once considered rapidly fatal. However, HIV has become a chronic disease as antiretroviral drugs and drugs controlling opportunistic infections have successfully prolonged life: over 35.3 million people across the globe are living with HIV, of whom 1.3 million are North Americans. Overall, the impact of antiretroviral on survival has made it difficult to use traditional prognostic indicators, and the clinical course of HIV/AIDS is fluctuating, with considerable variation among patients, and is marked by a number of opportunistic infections requiring treatment. Effective prevention strategies, earlier diagnosis, and the use of antiretroviral therapy (ART) have all improved survival rates. Despite this, there remain approximately 20,000 AIDS deaths per year in the United States. A viral load of more than 100,000 copies of a CD4 count below 25 cells/mcl may predict a terminal condition if a patient is declining in function, choosing to forgo medication, antiretrovirals are no longer effective, or life-threatening complications have developed.

Clinical Course: HIV is transmitted by sexual contact, exposure to contaminated blood products and bodily fluids, or perinatal transmission from mother to child. The acute phase of HIV infection is characterized by a febrile illness, much like a typical flu. Followed by an asymptomatic second phase lasting 4-5 years, and then a more chronic symptomatic phase in which patients develop persistent lymphadenopathy and AID-defining malignancies. The final stage is clinical AIDS, defined as a CD4 count <200/ul or occurrence of AIDS-defining conditions. The World Health Organization (WHO) Staging: (www.who.int)

• Primary HIV infection: Asymptomatic, acute retroviral syndrome
• Clinical Stage 1: Asymptomatic, persistent generalized lymphadenopathy
• Clinical Stage 2: Moderate unexplained weight loss, recurrent respiratory tract infection, herpes zoster, angular cheilitis 烂嘴角, recurrent oral ulcerations, papular pruritic eruptions, fungal nail infections, seborrhoeic dermatitis
• Clinical Stage 3: Severe weight loss ( >10% of presumed or measured body weight), unexplained chronic diarrhea for longer than 1 month, unexplained persistent fever (intermittent or constant for longer than 1 month), persistent oral candidiasis, oral hairy leukoplakia, pulmonary tuberculosis (TB), severe presumed bacterial infections (e.g., pneumonia, empyema, pyomyositis, bone or joint infection, meningitis, bacteremia), acute necrotizing ulcerative stomatitis, gingivitis, or periodontitis, unexplained anemia (<8 g/dl), neutropenia (<500 /mm3) and or chronic thrombocytopenia (<50,000 /mm3)
• Clinical Stage 4: HIV wasting syndrome, pneumocystis pneumonia, recurrent severe bacterial pneumonia, chronic herpes simplex infection (>1 month’s duration or visceral at any site), esophageal cndidiasis, extrapulmonary TB, kaposi’s sarcoma, cytomegalovirus (CMV) infection, central nervous system toxoplasmosis, HIV encephalopathy, extrapulmonary cryptococcosis (including meningitis), disseminated non-tuberculous mycobacterial infection, progressive multifocal leukoenxephalopathy, chronic cryptosporidiosis, chronic isosporiasis, visceral herpes simplex infection, disseminated mycosis (extrapulmonary, histoplasmosis, coccidiomycosis), lymphoma (cerebral or B-cell non-hodgkin), symptomatic HIV-associated nephropathy or cardiomyopathy, recurrent septicemia (including non-typhoidal salmonella), invasive cervical carcinoma, atypical disseminated leishmaniasis.
  • Types of infections
    • Bacterial: Streptococcus pneumoniae, mycobacterium avium-intracellulare (MAI) and mycobacterium avium complex (MAC), tuberculosis (TB, salmonellosis, syphilis, and bacillary angiomatosis
    • Viral: cytomegalovirus (CMV), viral hepatitis, herpes simplex virus (HSV), human papillomavirus (HPV), and progressive multifocal leukoencephalopathy (PML)
    • Fungal: Candida albicans, histoplasma capsulatum, and cryptococcal meningitis
    • Parasitic: pneumocystis carinii pneumonia (PCP), toxoplasmosis, and cryptosporidium

Factors supporting hospice referral: (both 1 and 2 should be present, factors from 3 lend support to the documentation)

1. CD4+count 100,000 copies/ ml, plus one of the following:
   • CNS lymphoma (Prognosis <6 months) 
   • untreated, or persistent despite treatment, wasting (loss of at least 10% of lean body mass) (Prognosis <6 months)
   • mycobacterium avium complex (MAC) bacteremia, untreated, unresponsive to treatment or treatment refused (Prognosis <6 months)
   • progressive multifocal leukoencephalopathy (Prognosis <6 months)
   • systemic lymphoma, with advanced HIV disease and partial response to chemotherapy
   • visceral Kaposi’s sarcoma unresponsive to therapy (Prognosis <6 months)
   • renal failure in the absence of dialysis (Prognosis <6 months)
   • cryptosporidium infection (Prognosis <6 months)
   • toxoplasmosis, unresponsive to therapy (Prognosis <6 months)
2. Decreased performances status, as measured by a Karnofsky Performance Scale value of 50% or less
3. Additional factors to document:
   • chronic persistent diarrhea for 1 year
   • persistent serum albumin <2.5 gm/dl
   • concomitant, active substance abuse
   • age > 50 years
   • advanced AIDS dementia complex
   • toxoplasmosis (tok-so-plaz-MOE-sis)弓形蟲感染症
   • CHF, symptomatic at rest
   • advanced liver disease
   • absence of, or resistance to, effective antiretroviral, chemotherapeutic andprophylactic drug therapy related specifically to HIV disease

References:

Corridor (2006). Hospice Quickflips: A Guide for Hospice Clinicians

HIV Transmission: Statistical Modelling

Yennurajalingam, S., & Bruera, E. (2016). Oxford American Handbook of Hospice and Palliative Medicine and Supportive Care (2nd. Ed.)

Zerwekh, J. V. (2006) Nursing care at the end of life: Palliative care for patients and family.

How Close Are We to Curing HIV/AIDS?