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dence of hepatotoxicity Recent analysis suggests also that HIV-infected individuals at high risk for tuberculosis should receive a course of isoniazid prophylaxis regardless of the PPD status This may include homeless individuals and injection drug users Although not yet widely available, a blood test (QuantiFERON Gold test) can be used to assess prior tuberculosis exposure Blood samples are mixed with synthetic antigens representing M tuberculosis Patients infected with M tuberculosis produce interferon-gamma in response to contact with the antigens Unlike the PPD, the patient does not have to return for a second visit The test is less likely to result in false-positive results than a PPD Unfortunately, HIV-infected persons may not produce sufficient interferon-gamma, in which case the test may be falsely negative Because of recent increases in the number of cases of syphilis among MSM, including those who are HIV infected, all such men should be screened for syphilis by rapid plasma reagin (RPR) or Venereal Disease Research Laboratories (VDRL) test every 6 months Increases of syphilis cases among HIV-infected persons are of particular concern because these individuals are at increased risk for reactivation of syphilis and progression to tertiary syphilis despite standard treatment Because the only widely available tests for syphilis are serologic and because HIV-infected individuals are known to have disordered antibody production, there is concern about the interpretation of these titers This concern has been fueled by a report of an HIV-infected patient with secondary syphilis and negative syphilis serologic testing Furthermore, HIVinfected individuals may lose fluorescent treponemal antibody absorption (FTA-ABS) reactivity after treatment for syphilis, particularly if they have low CD4 counts Thus, in this population, a nonreactive treponemal test does not rule out a past history of syphilis In addition, persistence of treponemes in the spinal fluid after one dose of benzathine penicillin has been demonstrated in HIV-infected patients with primary and secondary syphilis Therefore, the CDC has recommended an aggressive diagnostic approach to HIVinfected patients with reactive RPR or VDRL tests of greater than 1 year or unknown duration All such patients should have a lumbar puncture with cerebrospinal fluid cell count and cerebrospinal fluid VDRL Those with a normal cerebrospinal fluid evaluation are treated as having late latent syphilis (benzathine penicillin G, 24 million units intramuscularly weekly for 3 weeks) with follow-up titers Those with a pleocytosis or a positive cerebrospinal fluid-VDRL test are treated as having neurosyphilis (aqueous penicillin G, 2 4 million units intravenously every 4 hours, or procaine penicillin G, 24 million units intramuscularly daily, with probenecid, 500 mg four times daily, for 10 days) Some clinicians take a less aggressive approach to patients who have low titers (less than 1:8), a history of having been treated for syphilis, and a normal neurologic examination Close follow-up of titers is mandatory if such a course is taken For a more detailed discussion of this topic, see 34 The efficacy of pneumococcal vaccine is debated, but since it is safe, HIV-infected individuals should receive it Patients without evidence of hepatitis B surface antigen or surface antibody should receive hepatitis B vaccination Live vaccines, such as yellow fever vaccine, should be avoided Measles vaccination, while a live virus vaccine, appears relatively safe.

Many scientists have abandoned the quest for a fully protective HIV vaccine and are focusing on developing a vaccine that would reduce the chances of HIV transmission given a particular exposure

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In the era prior to the development of highly effective antiretroviral treatment, cohort studies of individuals with documented dates of seroconversion demonstrate that AIDS develops within 10 years in approximately 50% of untreated seropositive persons With currently available treatment, progression of disease has been markedly decreased In addition to antiretroviral treatment, prophylactic regimens can prevent opportunistic infections and improve survival Prophylaxis and early intervention prevent several infectious diseases, including tuberculosis and syphilis, which are transmissible to others Recommendations are listed in Table 31 3 Because of the increased occurrence of tuberculosis among HIV-infected patients, all such individuals should undergo PPD testing Although anergy is common among AIDS patients, the likelihood of a false-negative result is much lower when the test is done early in infection Those with positive tests (defined for HIV-infected patients as > 5 mm of induration) need a chest radiograph Patients with an infiltrate in any location, especially if accompanied by mediastinal adenopathy, should have sputum sent for acid-fast staining Patients with a positive PPD but negative evaluations for active disease should receive isoniazid (300 mg daily) with pyridoxine (50 mg daily) for 9 months to a year An alternative regimen of rifampin plus pyrazinamide for 2 months is no longer recommended because of the high associated inci-

For all HIV-infected individuals: CD4 counts every 3 6 months Viral load tests every 3 6 months and 1 month following a change in therapy PPD INH for those with positive PPD and normal chest radiograph RPR or VDRL Toxoplasma IgG serology CMV IgG serology Pneumococcal vaccine Influenza vaccine in season Hepatitis B vaccine for those who are HBsAb-negative Haemophilus influenzae type b vaccination Papanicolaou smears every 6 months for women Consider anal swabs for cytologic evaluation yearly for patients with history of receptive anal intercourse For HIV-infected individuals with CD4 < 200 cells/mcL: Pneumocystis jiroveci 1 prophylaxis (see Table 31 6) For HIV-infected individuals with CD4 < 75 cells/mcL: Mycobacterium avium complex prophylaxis For HIV-infected individuals with CD4 < 50 cells/mcL: Consider CMV prophylaxis

namespace Example_5_12_ _ _ _The_while_Loop { class Program { public static void Main( ) { int counterVariable = 0; // while the counter variable is less than 10 // print out its value while (counterVariable < 10) { Console.WriteLine("counterVariable: {0}", counterVariable); counterVariable++; } } } }

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