HIV Infection

Rationale

AIDS (acquired immunodeficiency syndrome) represents one of the most difficult challenges in clinical medicine today. The majority of cases in the USA currently occur among members of three risk groups (homosexual men, intravenous drug users, and hemophiliacs who have received factory VIII concentrate in the past). The remaining cases occur in either sexual partners of high risk individuals, infants born of high risk mothers, or recipients of tainted blood products. Given there is not a proven cure for this disorder, AIDS remains an important training problem for third year medical students.

Prerequisites

Prior knowledge, skills and attitudes acquired during the pre-clinical (basic science) years should include:

1. knowledge of the worldwide epidemiology, biology and immunology of HIV infection
2. understanding of universal precautions

Specific Learning Objectives

1. Knowledge: Students should be able to define and describe:
   1. CDC AIDS case definition
   2. symptoms and signs of HIV-related opportunistic infections
      1. P. carinii
      2. Candidiasis
      3. Cryptococcosis
      4. Cryptosporidiosis
      5. Cytomegalovirus
      6. Mycobacterium avium complex
      7. Mycobacterium tuberculosis
      8. Toxoplasmosis
   3. symptoms and signs of HIV-related opportunistic infections
      1. Kaposi’s sarcoma
      2. Non-Hodgkin’s lymphoma
      3. Cervical carcinoma
   4. what constitutes hospice care
   5. relationship of CD4 count to opportunistic infections
2. Skills: Students should demonstrate specific skills including:
   1. history-taking skills: Students should be able to obtain, document and present an age-appropriate medical history, that differentiates among etiology of disease including:
      1. HIV infection risk factors:
         • sexual contacts
         • parenteral exposure to infected blood by needle sharing or transfusion
         • occupational exposures
         • other STDs that establih increased risk for HIV infection
         • HIV serology results and CD4 lymphocyte counts
         • HIV-related opportunistic infections
      2. fever, sweats, weight loss, wasting
      3. dyspnea, diarrhea or headache
      4. neuropsychiatric complaints
      5. vaginal candidiasis, cervical dysplasia and neoplasia, or pelvic inflammatory disease
      6. travel
      7. demonstrate the ability to obtain a diet history to assess:
         • number of meals eaten per day
         • use of supplements
   2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including assessing for:
      1. lesions of Kaposi’s sarcoma
      2. lymphadenopathy
      3. retinitis
      4. oral candidiasis
      5. sinusitis
      6. hairy leukoplakia
      7. gingivitis
      8. pulmonary infiltrates
      9. pelvic inflammatory disease
      10. mental status alterations
      11. cognitive function deficits
      12. focal neurologic deficits
      13. muscle wasting of extremities and temporal muscles
   3. differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings in an HIV-positive patient who presents with:
      1. fever
      2. dypsnea
      3. diarrhea
      4. headache
      5. altered mental status
   4. laboratory interpretation: Students should be able to recommend and interpret diagnostic and laboratory tests, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences
      1. laboratory and diagnostic tests should include, when appropriate:
         • specific tests for HIV (with appropriate application of sensitivity and specificity)
         • hematologic abnormalities of HIV infection
         • CD4 lymphocyte count as a predictor of disease
         • induced sputum and LDH for the diagnosis of PCP
         • chest x-ray for P. carinii
         • serum and cerebral spinal fluid cryptococcal antigen
   5. communication skills: Students should be able to:
      1. counsel and educate patients about HIV exposure prevention
      2. educate about HIV exposure and seroconversion rates
      3. council and educate patients about complications of HIV drug therapy
   6. basic procedural skills: Students should be able to perform:
      1. gram stain of infected body fluids
      2. urinalysis
   7. management skills: Students should be able to develop a treatment plan for patients with HIV infection including:
      1. prophylactic antiviral regimens for HIV positive persons
         • P. carinii prophylaxis
      2. assessing PPD status and treatment for TB
      3. scheduling pneumococcal and H. influenza vaccines
      4. ordering nutritional supplements to manage and prevent malnutrition
      5. identify community health resources available for the care of AIDS patients
      6. students should also be able to access and utilize appropriate information systems and resources to help delineate issues related to HIV infection
3. Attitudes: Students should be able to:
   1. consider the bioethical and social issues concerning patient confidentiality of HIV infection
   2. understand and have tolerance towards alternative life styles
   3. maintain a non-judgmental attitude