Book Review

Management of the HIV-Infected Patient

N Engl J Med 1997; 336:1533-1534May 22, 1997

Article

Management of the HIV-Infected Patient
Edited by Suzanne Crowe, Jennifer Hoy, and John Mills. 437 pp., illustrated. New York, Cambridge University Press, 1996. $85. ISBN: 0-521-45269-4

Paradox in the emerging specialty of AIDS care is that the rapidity and complexity of changes in therapeutics have created the need for textbook-length compendiums of new information, yet the same pace of change risks making any such book less than up to date by the time it is published.

Dramatic changes in treatment have been particularly evident over the past year, with the management of HIV infection revolutionized in ways surpassing even the symbolic importance of the introduction of zidovudine in 1987 as the first HIV-specific antiretroviral agent. Quantitative plasma assays of viral load, combination antiretroviral therapy, and the potent new class of protease-inhibitor drugs have rapidly become standards for the routine management of HIV infection. Reducing plasma HIV RNA to undetectable levels has become a new criterion for the effectiveness of treatment, and researchers have begun to discuss the possible eradication of HIV from infected hosts. In view of these recent events, one could reasonably argue that 1996 has been the most important year to date in the development of treatments for HIV infection.

To be useful, a textbook of AIDS medicine must incorporate rapidly changing information and reflect current (and anticipated) practice. In this respect, Management of the HIV-Infected Patient succeeds admirably in some areas and less so in others. The book was published in 1996, and most of the chapters appear to have been written before mid-1995. Regrettably, the timing of publication has meant that recent developments in certain key areas could not be included. Current information on the use of viral-load measures, protease inhibitors, combination antiretroviral therapy, and certain other treatments (e.g., use of the new macrolides, which have become standard for the treatment of and prophylaxis against Mycobacterium avium–complex infection) is lacking, simply because it was not available when the book was assembled. The editors have attempted to address this problem by adding a final chapter on late-breaking developments, but it cannot fully account for the magnitude of recent changes in HIV management.

The book's editors and many of the contributors are internationally recognized authorities in their specialties, and a number of the chapters are useful and well presented. This is particularly true of the chapters on areas in which clinical care has not been radically transformed over the past year, such as clinical manifestations and opportunistic infections. Useful discussions are provided in the chapters on neurologic, hematologic, hepatobiliary, and dermatologic disease, as well as many of the chapters on opportunistic infection, including those on herpesvirus infections, cytomegalovirus infection, tuberculosis, Pneumocystis carinii infection, Toxoplasma gondii infection, cryptococcosis, fungal infections, and cryptosporidiosis and microsporidiosis. Chapters on HIV-related neoplasia, drug interactions (albeit without the important protease-inhibitor interactions), and advice for the HIV-infected traveler add interesting and relevant information for clinicians. The chapters on natural history, patient evaluation, and antiretroviral therapy, however, are not sufficiently up to date to warrant their use as current guides for clinical practice.

Beyond the omissions that result from the lag time between writing and publication, this book is lacking in one other area of special relevance to HIV care in many urban centers, especially in the United States and Europe: there is virtually no mention of injection-drug use as a clinical condition with important and immediate consequences for the management of HIV infection. In addition to the well-described coexisting conditions and spectrum of disease seen in HIV-infected injection-drug users, drug-using behavior has a great impact on the clinical management of HIV infection, with implications for adherence to medication regimens, abuse of prescription drugs, coexisting psychiatric illness, and the coordination of care with drug-abuse treatment. These are areas in which clinicians caring for HIV-infected drug users need to develop expertise, or else the clinical outcomes are likely to be suboptimal.

One could predict that the next year or two are unlikely to produce the same dramatic changes in HIV care that occurred over the past year, although with the benefit of hindsight, this prediction may prove to be incorrect. If it is correct, then a quickly produced second edition of this textbook, with updates of the chapters in greatest need of revision (and perhaps selected additional material, as noted above), would have appeal. The expertise and the infrastructure have already been assembled; the challenge will be to convey new knowledge in a timely manner. If the time lag for a revised edition is long and irreducible, it may signal the need for formats other than printed textbooks to disseminate information in this rapidly changing field.

Peter A. Selwyn, M.D., M.P.H.
Yale University School of Medicine, New Haven, CT 06510