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HIV and the chronically mentally ill

Posted: Jan 21, 2008

QUESTION:

I am a general internist at a state psychiatric hospital. I have a patient with chronic paranoid schizophrenia. When he first presented he had a very low CD4 count of 2 and viral load of 750,000. Compliance was an issue initially but he has been compliant for the past 2 years and his viral load has been undetectable for over the past year and a half. His CD count has risen to right at 200. He fluctuates between 175 and 225. He is on medication observation and we document his compliance. He is on Kaletra and Epzicom When he first presented he had PCP and CMV pneumonia. He is maintained on Valcyte and Bactrim since stays right at 200.

When would it be safe to stop the Bactrim and Valcyte?

Is this the best response we are likely to see?

Also my facility is about 200 miles away from the nearest ID specialist. Our patients are forensic (criminally insane). The last patient we sent to the ID specialist attacked his nurse and now he won't see our patients.

I utilize the CDC Warmline and discuss the management of each our small population of HIV patients with one of their consultants with all of the HIV patients. Do you think this is acceptable? I want to make sure they are getting the highest level of care possible.

The management of our patients is quite challenging give the polypharmacy and the refractory natures of their mental illness. Do you know any resources that specialize in the management of the HIV positive patients with refractory mental illnesses?

Clozaril therapy is thought to be contraindicted in this patient population but we have a patient who was on Clozaril and done well on that Clozaril (Clozaril is a drug of last resort). She has since been found to be HIV positive- CD4 still in the 800-900 range. Do you think we need to stop the Clozaril? Her CBC is monitored weekly and she has had no neutropenia. I have not found any literature concerning this scenario.


  

RESPONSE FROM:   

    Thanks for your post and sorry for the delay in my response.

    WIth your patient's CD4 count of approximately 200, one could definitely stop the valaganciclovir and if the percentages are all above 15%, the Bactrim too.

    I'd continue to expect slow increases in CD4 numbers in your patient.

    Clozaril isn't contraindicated for your schizophrenic patient population (at least as far as I know), but rather should be used with caution in persons with myelosuppression. If your HIV patients have normal CBCs, then the medication should be acceptable. Clearly, periodic monitoring for adverse effects would be indicated.

    As for your resources, your correct that polypharmacy can be a daunting issue. Using a variety of web- or computer-based engines, one can be on alert to relevant interactions. Given the complexities of your patients, it is usually preferable to have HIV specialist's assistance; the CDC's site is certainly one excellent resource. Know that you're welcome to contact me (either through the forum or via email) if I can be of help.

    Best of luck, BY




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