Human Immunodeficiency Virus 1

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Contents 1 More Specific Terms 2 Introduction 3 Epidemiology 4 Pathology 5 Clinical-manifestations 6 Laboratory 7 Complications 8 Management 9 More General Terms 10 Additional Terms 11 References

More Specific Terms

• HIV/AIDS in the elderly

Introduction

• RNA virus encoding a reverse transcriptase, with subsequent insertion of nascent DNA into cellular genome, thus causing latent & persistent infection.

Epidemiology

• predominant HIV1 strain in US & Europe is group M subtype B
• HIV1 group M subtype B originated in central Africa & spread Haiti in about 1966 (1962-1970) [20]
• spread to the US (& elsewhere around the world) emerged after a single migration of HIV1 out of Haiti in about 1969 (1966-1972) [20]
• 1.2 million people in the US infected with HIV1 (2009) [3]
• majority of cases in US occur in men who have sex with men; heterosexual transmission is 2nd most common cause [3]
• 10% of new diagnoses in patients >= 50 years of age

• 48% of older infected adults diagnosed when CD4 count < 200 cells/ uL
• men who have sex with men account for 40% of diagnosed older adults

Pathology

• HIV binds to CD4 in the presence of a coreceptor - either CCR5 or CXCR4, on the cell surface of T-helper lymphocytes, monocytes, macrophages & other cells

• alternative coreceptors: APLNR, CCR2, CCR3, CCR8, CCR9, CX3CR1, CXCR7, GPR1, GPR15

• with disease progression, CD4+ lymphocytes decline; below 200 cells/ mm3, there is an increased risk of opportunistic infections
• early symptomatic HIV infection generally occurs when the CD4 count begins to decline & the CD4/CD8 ratio inverts
• disease generally progresses over a period of 10-14 years
• ongoing viral replication throughout the entire course of infection, including asymptomatic periods
• 100 million to 10 billion new virions produced daily
• > 99% of virions produced from acutely infected CD4+ cells
• 1/2 life of virus in plasma is estimated to be about 1.2 days
• initially, several hundred million CD4 cells are produced daily in response to rapid viral replication
• acutely infected individuals are viremic & contagious [14]
• eventually, the immune system fatigues with increased viremia, decreased CD4 production, & opportunistic infection
• low-lvel virus replication within chronically infected monocytes, macrophages & dendritic cells
• B-cell dysfunction occurs early in HIV infection
• defective neutrophil chemotaxis, phagocytosis & bactericidal activity
• also see resistance to HIV1

Clinical-manifestations

• primary infection

• often asymptomatic
• acute retroviral syndrome

• cutaneous manifestations of early disease

• genital warts
• genital Herpes
• psoriasis
• mild seborrheic dermatitis

• persistently enlarged glands may be 1st sign of AIDS
• signs/symptoms may increase in severity with time [21]

• swollen lymph nodes
• fever, chills, night sweats
• diarrhea
• weight loss
• cough
• dyspnea
• fatigue
• skin lesions
• blurred vision
• headache

Laboratory

• specific HIV-1 antibodies* are not detectable until 4-12 weeks after initial infection

• screening with ELISA* for antibody to HIV-1 (99% sensitivity & specificity)
• Oraquick Rapid HIV-1 Antibody Test available 2003
• HIV Ag/Ab Combo assay to detect both HIV p24 antigen & antibodies FDA-approved 6/21/10
• p24 antigen testing is generally positive just after onset of symptoms of seroconversion, before development of antibodies
• confirmatory HIV1 western blot* for antibodies to virus- specific proteins: a positive HIV1 western blot consists of the presence of bands for:
• p24; b) gp41 & c) gp120 or gp160
• seronegative HIV1 infections are rare, but potentially lethal [3]

• quantitative HIV-1 RNA levels

• reverse-trancriptase polymerase chain reaction ( RT-PCR)
• branched chain DNA (bDNA) assay
• nucleic acid sequence-based assay (NASBA)
• high levels of HIV-1 RNA (500,000- 21 million copies/ mL) are detected in plasma before the detection of specific anti-HIV-1 antibodies
• the high level of viremia decreases 100-10,000 fold coincident with the development of the specific anti-HIV-1 humoral immune response - it is thought that cytotoxic T-cells are responsible for this decline in HIV1 viral load
• post- seroconversion viral load ( HIV RNA determined by PCR) is the best predicator of long-term prognosis
• post- seroconversion HIV RNA > 30,000 copies/ mL are associated with a high risk of disease progression
• identification of acute HIV infection with quantitative HIV-1 RNA levels combined with aggressive early treatment may

• reduce severity of chronic infection
• prevent transmission to sexual contacts [14]

• HIV1 viral load
• independent predictor of disease progression [3]
• poorly predicts decline in CD4 count [17]
• responds to initiating or changing therapy within 4-8 weeks (>= 1 log decrease in HIV RNA)
• a decrease in HIV RNA of more than 1 log is associated with treatment benefit
• frequent monitoring of HIV-1 RNA levels for the 1st year to detect treatment failure [26]
• routine every 3-4 months & monthly after change in therapy

• complete blood count ( CBC) with differential

• lymphopenia may develop during acute seroconversion
• atypical lymphocytosis may follow resolution of symptoms associated with seroconversion

• serum chemistries (every 6-12 months)

• renal function tests
• serum transaminases
• serum glucose
• lipid panel

• serology

• serologic testing for syphilis
• Toxoplasma gondii IgG
• Cytomegalovirus ( CMV) IgG
• hepatitis B serology & hepatitis C serology

• CD4 count

• best predictor of risk of disease progression
• average rate of decline is 80-90/ uL/year
• viral load does NOT predict decline [17]
• routine every 3-4 months [3]

• tuberculin skin testing annually [3] unless PPD+ or with active tuberculosis
• Papanicolaou (Pap) smear for women
• glucose-6-phosphate dehydrogenase ( G6PD) in erythrocytes (baseline)
• HIV1 resistance testing, all HIV1 patients [3,26]

• * informed consent for testing must be obtained & arrangements should be made for a follow-up visit to discuss results; results of HIV testing should not be given over the phone

Complications

• see complications in patients with HIV disease

Management

• antiretroviral therapy

• indications

• all HIV- infected patients [36]
• older recommendations

• start antiretroviral therapy if symptomatic, regardless of CD4 cell count [26]
• asymptomatic patients should start at CD4 counts of <= 500/ mm3 [26,30]
• CD4 count < 200/ mm3 [11] (200-350/ mm3 [6], 350/ mm3 [21,27])
• post- seroconversion HIV RNA load of > 5000 copies/ mL (10,000-100,000 copies/ mL [6])
• rapid rate of CD4 count decline, HIV viral load of > 100,000 copies/ mL, hepatitis B or hepatitis C coinfection, HIV-associated neuropathy or cardiovascular risk factors even if CD4 count is > 350/ mm3 [22]

• initial therapy should consist of a 3- drug combination, individualized according to the results of HIV1 resistance testing
• multiple agents are used to prevent emergence of viral resistance (at least 3 agents)
• see AIDS for antiretroviral regimens
• goal of therapy is to achieve viral RNA levels below limits of detectability, formerly < 500-5000 copies/ mL
• treatment diminishes CSF viral load [19]
• early antiretroviral treatment protects sex partners [32]
• antiretroviral therapy as effective in the elderly as in younger patients [35]

• prophylactic antiretroviral therapy

• exposure to potentially infectious tissue or body fluids
• see post-exposure HIV prophylaxis
• pre-exposure chemoprophylaxis

• once daily oral tenofovir/emtricitabine ( Truvada) may be 75% effective [29]
• limit to sexually active men who have sex with men
• screen for other STDs
• limit to 1 tablet/day with no more than 90 day supply <see MMWR> [29]
• not effective for women [31]

• medication compliance is an issue

• treatment failure or emergence of resistance in > 50% of cases when medication compliance < 90%
• goal is > 95% compliance [5]
• direct observation benefits are not sustained past the period of direct observation [34]

• health maintenance including routine immunizations & cancer screening for the most part as per uninfected persons

• immunizations (unless immune or CD4 < 200 mm3)

• pneumovax at 1st visit
• hepatitis B vaccine
• measles-mumps-rubella vaccine ( MMR)
• influenza virus vaccine annually

• aggressive cardiovascular risk reduction for patients on antiretroviral therapy [3]
• tuberculin skin testing annually unless PPD+ or with active tuberculosis (see AIDS)

• follow-up every 6 months in early HIV infection
• experimental therapies

• interleukin-2 (IL-2) may be of some benefit in increasing CD4 counts & diminishing viral loads in HIV positive patients
• HIV vaccine stimulating cytotoxic lymphocyte responsiveness to the HIV GAG protein show promise (results in monkeys) [7]
• transfection with short interfering double-stranded RNA ( siRNA) shows promise [8]
• CMV/HIV1IV virus vaccine may be effective on infected mucosal cells early in the course of HIV1 infection [33]

• case reporting required in California (local health department) [9]
• patient education

• a stable partnership is associated with a better prognosis [10]

• prognosis:

• non-HIV related deaths becoming more common [16]
• although HIV1 has been transformed from a fatal disease to a chronic disease, life expectancy is diminished for even the healthiest HIV patients (72 years most favorable estimate) [23]
• seropositive HIV1 patients able to maintain an HIV RNA viral load of < 50 copies/ mL without antiretroviral therapy are called 'elite controllers'
• excess mortality in untreated HIV even with CD4 counts of > 350/ uL [28]

More General Terms

• Retroviridae (retrovirus)
• chronic infection (chronic infectious disease)

Additional Terms

• Acquired Immuno-Deficiency Syndrome (AIDS)
• acute retroviral syndrome
• antiretroviral therapy (ART)
• complications in patients with HIV disease
• depression & HIV/AIDS
• HIV infection during pregnancy
• HIV laboratory testing
• HIV1/hepatitis C-coinfection
• HIV1/malaria coinfection
• human immunodeficiency virus-2 (HIV-2)
• infectivity of HIV
• perinatal transmission of HIV
• post-exposure HIV prophylaxis
• resistance & susceptibility to HIV1
• safe sex (prevention of HIV1 & other STDs)
• screening for HIV1
• surgery in HIV patients

References

Also see antiretroviral therapy and HAART 

1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 720-26
2. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 180
3. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, American College of Physicians, Philadelphia 1998, 2006, 2009
4. Journal Watch 20(16):128, 2000 Davey RT et al Immunologic and virologic effects of subcutaneous interleukin 2 in combination with antiretroviral therapy: A randomized controlled trial. JAMA 284:183, 2000 PMID: [1]
   - Blankson J & Siliciano RF Interleukin 2 treatment for HIV infection. JAMA 284:236, 2000 PMID: [2]
5. Prescriber's Letter 8(1):3 2001 (subscription needed) [3]
6. Journal Watch 22(1):1, 2002 Phillips AN et al HIV viral load response to antiretroviral therapy according to the baseline CD4 cell count and viral load. JAMA 286:2560, 2001 PMID: [4]
   - Hogg RS et al Rates of disease progression by baseline CD4 cell count and viral load after initiating triple-drug therapy. JAMA 286:2568, 2001 PMID: [5]
   - Pomerantz RJ. Initiating antiretroviral therapy during HIV infection: confusion and clarity. JAMA 286:2597, 2001 PMID: [6]
7. Journal Watch 22(5):42, 2002 Shiver JW et al Replication-incompetent adenoviral vaccine vector elicits effective anti-immunodeficiency-virus immunity. Nature 415:331, 2002 PMID: [7]
   - Barouch DH et al Eventual AIDS vaccine failure in a rhesus monkey by viral escape from cytotoxic T lymphocytes. Nature 415:335, 2002 PMID: [8]
   - Lifson JD & Martin MA One step forwards, one step back. Nature 415:272, 2002 PMID: [9]
8. Journal Watch 22(16):128, 2002 Novina CD et al siRNA-directed inhibition of HIV-1 infection. Nat Med 8:681, 2002 PMID: [10]
   - Pomerantz RJ RNA interference meets HIV-1: will silence be golden? Nat Med 8:659, 2002 <PubMed> PMID: [11]
9. Internet> [12] Action Report, Medical Board of California, 85:9 (April) 2003
10. Young J Stable partnership and progression to AIDS or death in HIV infected patients receiving highly active antiretroviral therapy: Swiss HIV cohort study. BMJ 328:15,2004 <PubMed> PMID: [13] <Internet> [14]
11. Journal Watch 24(17):136, 2004 Yeni PG, Hammer SM, Hirsch MS, Saag MS, Schechter M, Carpenter CC, Fischl MA, Gatell JM, Gazzard BG, Jacobsen DM, Katzenstein DA, Montaner JS, Richman DD, Schooley RT, Thompson MA, Vella S, Volberding PA. Treatment for adult HIV infection: 2004 recommendations of the International AIDS Society-USA Panel. JAMA. 2004 Jul 14;292(2):251-65. PMID: [15]
12. Smith DK, Grohskopf LA, Black RJ, Auerbach JD, Veronese F, Struble KA, Cheever L, Johnson M, Paxton LA, Onorato IM, Greenberg AE. Treating Opportunistic Infections Among HIV-Exposed and Infected Children: Recommendations from CDC, the National Institutes of Health, and the Infectious Diseases Society of America. MMWR Recomm Rep. 2005 Jan 21;54(RR-2):1-112. PMID: [16]
13. Smith DK, Grohskopf LA, Black RJ, Auerbach JD, Veronese F, Struble KA, Cheever L, Johnson M, Paxton LA, Onorato IM, Greenberg AE Antiretroviral Postexposure Prophylaxis After Sexual, Injection-Drug Use, or Other Nonoccupational Exposure to HIV in the United States Recommendations from the U.S. Department of Health and Human Services MMWR Recomm Rep. 2005 Jan 21;54(RR02):1-20. [17]
14. Journal Watch 25(11):88, 2005 Pilcher CD, Fiscus SA, Nguyen TQ, Foust E, Wolf L, Williams D, Ashby R, O'Dowd JO, McPherson JT, Stalzer B, Hightow L, Miller WC, Eron JJ Jr, Cohen MS, Leone PA. Detection of acute infections during HIV testing in North Carolina. N Engl J Med. 2005 May 5;352(18):1873-83. PMID: [18]
15. Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, Clark JE; Centers for Disease Control and Prevention (CDC). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006 Sep 22;55(RR-14):1-17; quiz CE1-4. Corresponding NGC guideline withdrawn Dec 2011 PMID: [19]
16. Sackoff JE et al, Causes of death among persons with AIDS in the era of highly active antiretroviral therapy: New York City Ann Intern Med 2006, 145:397 PMID: [20]
    - Aberg JA The changing face of HIV care: Common things really are common. Ann Intern Med 2006, 145:463 PMID: [21]
17. Rodriguez B et al, Predictive value of plasma HIV RNA level on rate of CD4 T-cell decline in untreated HIV infection. JAMA 2006, 296:1498 PMID: [22]
18. Bartlett JA et al, An updated systematic overview of triple combination therapy in antiretroviral-naive HIV-infected adults. AIDS 2006, 20:2051 PMID: [23]
19. Spudich S et al, Treatment benefit on cerbrospinal fluid HIV-1 levels in the settings of systmeic virological suppression and failure. J Infect Dis 2006, 194:1686 PMID: [24]
20. Gilbert MTP et al, The emergence of HIV/AIDS in the Americas and beyond. Proc Natl Acad Sci USA 2007, 104:18566 PMID: [25]
21. Stevens LM et al, HIV Infection: The Basics, JAMA Patient Page JAMA 2008, 300(5):614
22. Hammer SM et al; International AIDS Society-USA. Antiretroviral treatment of adult HIV infection: 2008 recommendations of the International AIDS Society-USA panel. JAMA. 2008 Aug 6;300(5):555-70. PMID: &dopt=Abstract
23. Antiretroviral Therapy Cohort Collaboration. Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies. Lancet. 2008 Jul 26;372(9635):293-9. PMID: &dopt=Abstract
24. Aberg JA et al Primary Care Guidelines for the Management of Persons Infected with Human Immunodeficiency Virus: 2009 Update by the HIV Medicine Association of the Infectious Diseases Society of America Clinical Infectious Diseases 2009;49:651-681 <PubMed> PMID: [26] <Internet> [27]
25. Antiretroviral therapy for HIV infection in adults and adolescents World Health Organization Nov. 2009 [28]
    - Use of antiretroviral drugs for treating pregnant women and preventing HIV Infection in infants World Health Organization Nov. 2009 [29]
    - HIV and infant feeding: Revised Principles and Recommendations World Health Organization Nov. 2009 [30]
26. Thompson MA et al Antiretroviral Treatment of Adult HIV Infection 2010 Recommendations of the International AIDS Society- USA Panel JAMA. 2010;304(3):321-333 <PubMed> PMID: [31] <Internet> [32]
27. Smith RD et al. HIV transmission and high rates of late diagnoses among adults aged 50 years and over. AIDS 2010 Aug 24; 24:2109. PMID: [33]
28. Study Group on Death Rates at High CD4 Count in Antiretroviral Naive Patients. Death rates in HIV-positive antiretroviral-naive patients with CD4 count greater than 350 cells per µL in Europe and North America: A pooled cohort observational study. Lancet 2010 Jul 31; 376:340 PMID: [34]
29. Grant RM et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med 2010 Nov 23; <PubMed> PMID: [35] <Internet> [36]
    - Michael NL. Oral preexposure prophylaxis for HIV - Another arrow in the quiver? N Engl J Med 2010 Nov 23; <PubMed> PMID: [37] <Internet> [38]
    - Prescriber's Letter 18(1): 2011 Truvada for Pre-Exposure Prophylaxis of HIV Infection Detail-Document#: [39] (subscription needed) [40]
    - Centers for Disease Control and Prevention (CDC) Interim Guidance: Preexposure Prophylaxis for the Prevention of HIV Infection in Men Who Have Sex with Men Morbidity and Mortality Weekly Report (MMWR) January 28, 2011 / 60(03);65-68 <PubMed> PMID: [41] <Internet> [42]
30. The HIV-CAUSAL Collaboration When to Initiate Combined Antiretroviral Therapy to Reduce Mortality and AIDS-Defining Illness in HIV-Infected Persons in Developed Countries: An Observational Study Ann Intern Med April 19, 2011, 154:509-515 <PubMed> PMID: [43] <Internet> [44]
    - Baker JV and Henry K If We Can't Get What We Want, Can We Get What We Need? Optimizing Use of Antiretroviral Therapy in the Current Era Ann Intern Med April 19, 2011, 154:563-565; PMID: [45]
31. FHI statement on the FEM-PrEP HIV prevention study [press release]. Durham, NC: Family Health International; Apr 18 , 2011 [46]
32. NIH News Release, May 12, 2011 Treating HIV-infected People with Antiretrovirals Protects Partners from Infection [47]
33. Hansen SG et al. Profound early control of highly pathogenic SIV by an effector memory T-cell vaccine. Nature 2011 May 26; 473:523. PMID: [48]
    - Johnson RP. Persistence pays off. Nature 2011 May 26; 473:456. PMID: [49]
34. Berg KM et al. Lack of sustained improvement in adherence or viral load following a directly observed antiretroviral therapy intervention. Clin Infect Dis 2011 Nov 1; 53:936 PMID: [50]
35. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
36. AIDSinfo, Centers for Disease Control and Prevention (CDC) [51]
    - Guidelines for the use of antiretroviral agents in HIV-1- infected adults and adolescents [52]
37. New York State Department of Health AIDS Institute HIV Clinical Resource [53]
    - diagnostic, monitoring, and resistance tests for HIV [54]
    - Anxiety disorders in patients with HIV/AIDS [55]
    - personality disorders in patients with HIV/AIDS [56]
38. National Guideline Clearinghouse
    - Adolescents & adults:
    - Guidelines for the use of antiretroviral agents in HIV-1- infected adults and adolescents Department of Health and Human Services (U.S.) ngc-guideline: [57]
    - Primary care guidelines for the management of persons infected with human immunodeficiency virus: recommendations of the HIV Medicine Association of the Infectious Diseases Society of America. ngc-guideline: [58]
    - Antiretroviral therapy for HIV infection in adults and adolescents. World Health Organization (WHO) ngc-guideline: [59]
    - Primary care approach to the HIV-infected patient. (New York State Department of Health) ngc-guideline: [60]
    - Identification and ambulatory care of HIV-exposed and -infected adolescents. (New York State Department of Health) ngc-guideline: [61]
    - HIV infection. (Finnish Medical Society Duodecim) ngc-guideline: [62]
    - Diagnosis and management of acute HIV infection. New York State Department of Health. ngc-guideline: [63]
    - Gynecologic care for women with human immunodeficiency virus. American College of Obstetricians and Gynecologists (ACOG) ngc-guideline: [64]
    - Transitioning HIV-infected adolescents into adult care. New York State Department of Health ngc-guideline: [65]
    - Infants & children:
    - Antiretroviral therapy for HIV infection in infants and children: towards universal access. World Health Organization (WHO) ngc-guideline: [66]
    - HIV post-exposure prophylaxis for children beyond the perinatal period. (New York State Department of Health) ngc-guideline: [67]
    - Oral health management of children and adolescents with HIV infections. ngc-guideline: [68]
    - Guidelines for the use of antiretroviral agents in pediatric HIV infection. Centers for Disease Control and Prevention ngc-guideline: [69]
    - Growth, body composition, and metabolism. New York State Department of Health ngc-guideline: [70]
    - Guidelines for the use of antiretroviral agents in pediatric HIV infection. Department of Health and Human Services (U.S.) ngc-guideline: [71]
    - Bacterial infections. In: Guidelines for prevention and treatment of opportunistic infections among HIV-exposed and HIV-infected children. ngc-guideline: [72]
    - Fungal infections. In: Guidelines for prevention and treatment of opportunistic infections among HIV-exposed and HIV-infected children. ngc-guideline: [73]
    - Mycobacterial infections. In: Guidelines for prevention and treatment of opportunistic infections among HIV-exposed and HIV-infected children. ngc-guideline: [74]
    - Parasitic infections. In: Guidelines for prevention and treatment of opportunistic infections among HIV-exposed and HIV-infected children. ngc-guideline: [75]
    - Viral infections. In: Guidelines for prevention and treatment of opportunistic infections among HIV-exposed and HIV-infected children. ngc-guideline: [76]
    - Disclosure of HIV to perinatally infected children and adolescents. New York State Department of Health ngc-guideline: [77]
    - Diagnosis of pediatric HIV infection in HIV-exposed infants. New York State Department of Health ngc-guideline: [78]
    - Elderly:
    - Medical care for menopausal and older women with HIV infection. New York State Department of Health ngc-guideline: [79]
    - Sexually-transmitted disease
    - HIV infection: detection, counseling, and referral. Sexually transmitted diseases treatment guidelines 2010 Centers for Disease Control and Prevention ngc-guideline: [80]
    - Gonococcal and chlamydial infections. New York State Department of Health ngc-guideline: [81]
    - Human immunodeficiency virus (HIV). In: Sexually transmitted infections: UK national screening and testing guidelines. British Association for Sexual Health and HIV (BASHH) ngc-guideline: [82]
    - Infectious disease:
    - Mycobacterial infections. New York State Department of Health ngc-guideline: [83]
    - Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. ngc-guideline: [84]
    - Acute respiratory illness in immunocompromised patients American College of Radiology ngc-guideline: [85]
    - Laboratory:
    - Diagnostic, monitoring, and resistance laboratory tests for HIV. (New York State Department of Health) ngc-guideline: [86]
    - United Kingdom national guidelines on HIV testing 2008. British Association of Sexual Health and HIV ngc-guideline: [87]
    - Mental Health
    - Cognitive disorders and HIV/AIDS: HIV-associated dementia and delirium. (New York State Department of Health) ngc-guideline: [88]
    - Depression and mania in patients with HIV/AIDS. Mental health care for people with HIV infection. (New York State Department of Health) ngc-guideline: [89]
    - Working with patients' personalities and styles. Mental health care for people with HIV infection. (New York State Department of Health) ngc-guideline: [90]
    - Guidelines for the prescribing of medication for mental health disorders in people with HIV infection. (Royal College of Psychiatrists) ngc-guideline: [91]
    - Suicidality and violence in patients with HIV/AIDS New York State Department of Health ngc-guideline: [92]
    - Mental health disorders among substance-using HIV-infected patients. New York State Department of Health ngc-guideline: [93]
    - Severe and persistent mental illness in HIV-infected patients. New York State Department of Health ngc-guideline: [94]
    - Prophylaxis & prevention:
    - HIV prophylaxis following occupational exposure. New York State Department of Health ngc-guideline: [95]
    - HIV prophylaxis following non-occupational exposure including sexual assault (New York State Department of Health) ngc-guideline: [96]
    - UK guideline for the use of post-exposure prophylaxis for HIV following sexual exposure. British Association for Sexual Health and HIV ngc-guideline: [97]
    - Prevention with positives: integrating HIV prevention into HIV primary care. New York State Department of Health ngc-guideline: [98]
    - Screening:
    - Screening for HIV in health care settings: a guidance statement for the American College of Physicians and HIV Medicine Association. ngc-guideline: [99]
    - Pregnancy:
    - Public Health Service Task Force recommendations for use of antiretroviral drugs in pregnant HIV-infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States. ngc-guideline: [100]
    - Management of HIV in pregnancy. Royal College of Obstetricians and Gynaecologists (RCOG) ngc-guideline: [101]
    - Preconception care for HIV-infected women. New York State Department of Health ngc-guideline: [102]
    - Acute HIV infection in pregnancy. New York State Department of Health ngc-guideline: [103]
    - HIV testing during pregnancy and at delivery. New York State Department of Health ngc-guideline: [104]
    - Women
    - Menstrual disorders in HIV-infected women. New York State Department of Health ngc-guideline: [105]
    - Nutrition
    - HIV/AIDS evidence-based nutrition practice guideline. American Dietetic Association ngc-guideline: [106]
    - Homeless
    - Adapting your practice: treatment and recommendations for homeless patients with HIV/AIDS. ngc-guideline: [107]
    - Transgender
    - Care of the HIV-infected transgender patient. New York State Department of Health ngc-guideline: [108]
    - Substance abuse:
    - Medical care of HIV-infected substance-using women. (New York State Department of Health) ngc-guideline: [109]
    - Screening and ongoing assessment for substance use. (New York State Department of Health) ngc-guideline: [110]
    - Aspects of primary care for the HIV-infected substance user. (New York State Department of Health) ngc-guideline: [111]
    - Reducing the risk of HIV infection associated with illicit drug use. (American Academy of Pediatrics) ngc-guideline: [112]
    - Clinical management of alcohol use and abuse in HIV-infected patients. New York State Department of Health ngc-guideline: [113]
    - Other
    - Trauma and post-traumatic stress disorder in patients with HIV/AIDS. New York State Department of Health) ngc-guideline: [114]
    - Smoking cessation in HIV-infected patients. (New York State Department of Health) ngc-guideline: [115]
    - (1) Neoplastic complications of HIV infection. (2) July 2007 addendum. (New York State Department of Health) ngc-guideline: [116]

human immunodeficiency virus-1