15.1 (15.1) HIV/AIDS

Question 1

Why is there a substantial rise in prevalence of persons living with HIV/AIDS?

Answer 1

Increase in life expectancy of people living with HIV (now with antiretroviral therapy can live near normal life expectancy)

+

Minimally changed incidence of new HIV infections (40k/year in US)

Question 2

Name 3 most-common routes of HIV transmission.

Answer 2

Men who have sex with men (MSM)
Heterosexual sex
Injections drugs

Question 3

Why do minorities, women and older people are more likely to present with more advanced disease? Name 3 reasons.

Answer 3

Increasing heterosexual transmission
Delayed diagnosis
Barriers in access and linkage to care

Question 4

What happens to HIV patients as they age?

Name 3 reasons.

Answer 4

“Premature ageing”:

• Progressive decline of immune system due to virus
• Poorer response to HAART
• Development of geriatric syndromes (frailty, falls, etc.)
• Accumulating comorbidities (e.g. end stage liver disease, OA, cancer, etc.)

FS:
- HIV (inflammation and immunosuppresion)
- HIV meds
- HIV and non HIV comorbs

Question 5

List five factors that contribute to complex palliative care needs for those living with HIV/AIDS

Answer 5

Figure 15.1.2

HIV infection (chronic immune dysfunction and inflammation)

drug toxicity (renal, hepatic, metabolic, etc.)

non-AIDS specific comorbidities

aging population (age related morbidity, premature aging)

Social environmental stressors (poverty, unstable housing)

psych issues (substance use, mental health)

Question 6

List 3 factors associated with increased life expectancy of HIV infection patients

Answer 6

1. Early diagnosis
2. Linkage and retention in care (including rapid initiation of ART)
3. Adherence to ART regimens

Question 7

Goal of ART (antiretroviral therapy)

Answer 7

Suppress HIV replication

Question 8

List 2 lab values used to monitor HIV status in patients

Answer 8

CD4 T-lymphocyte count
viral load

Question 9

List 4 classes of drugs used to treat HIV

Answer 9

nucleoside reverse transcriptase inhibitor (NRTI)
non-nucleoside reverse transcriptase inhibitor (NNRTI)
protease inhibitor (PI)
integrase strand transfer inhibitor (INSTI)

Question 10

How do comorbidities affect those with HIV compared to non-HIV infected individuals. List three possible reasons for this

Answer 10

They are accelerated in their progression in HIV/AIDS patients:

direct toxicity from HIV virus

virus related chronic inflammatory processes

chronic immunosuppression

toxicity from ART

increasing rates of smoking in HIV/AIDS patients

FS:
Viral inflammation
Viral immunosuppresion
ART toxicity

Question 11

List six types of chronic comorbidity that people with HIV/AIDS experience

Answer 11

neurocognitive disorders (HIV dementia, HIV encephalopathy)*

psychiatric comorbidities (MDD, GAD, substance use)*

Cardio (esp atherosclerosis and CHF) *

pulmonary disease (infections, COPD, lung ca)*

liver (NASH, HCV co-infection)*

renal disease (HIV nephropathy, drug related nephrotoxicity)*

GI (malabsorption, wasting)

metabolic bone disease (osteoporosis, osteonecrosis)

malignancy (HIV related and non HIV related)*

premature frailty*

hypogonadism (low testosterone)

substance abuse

Question 12

3 common lung infections

Answer 12

Pneumocystis jirovecci pneumonia (“PJP” - seen only in setting of low CD4 counts)

Pneumococcal pneumonia

TB

Question 13

List three AIDS defining malignancies

Answer 13

Kaposi’s sarcoma
non-hodgkin’s lymphomas (Burkitt’s and primary CNS lymphoma)
invasive cervical cancer

Question 14

List criteria for frailty (how many must be met?)

Answer 14

3 of the following 5:

unintentional weight loss of >4.5kg in past year

exhaustion (self reported)

low physical activity
weak grip strength
slow walk time

Question 15

List 3 contributors to wasting in HIV population

Answer 15

inadequate nutrient intake secondary to oral and upper GI problems*

poor appetite

malabsorption

hormonal disorders such as hypogonadism, hypothyroidism*

altered metabolism secondary to HIV or opportunistic infections*

economic constraints*

Question 16

List three definitions of wasting*

Answer 16

unintentional loss of greater than 10%
BMI 20 or less
unintentional loss of greater than 5% in 6 months that persisted x 1 year

Question 17

List three treatments for wasting other than ART initiation

Answer 17

megesterol acetate
dronabinol
synthetic androgens (oxandrolone)
recombinant human growth hormone

Question 18

3 principles to managing pain in HIV patients

Answer 18

1. Pain is subjective and should be taken SERIOUSLY
2. Patients with psych illness may cause frustration - watch for COUNTER-TRANSFERANCE
3. Aberrant opioid related behaviours have DDX beyond substance use (psych history, criminal intent, anxiety, etc.)
4. MULTI-MODAL approach (including PT, CBT, neural blockage)

Question 19

Role of opioids for HIV pain

Answer 19

Limited evidence although may be useful for selected and monitored patients

Question 20

What is the most common cause of neuropathic pain in the HIV infected population? What are the two evidence based treatments for this?

Answer 20

HIV distal sensory polyneuropathy (length dependent degeneration of small and large nerve fibres)

gabapentin and high dose topical capsaicin

Question 21

What type of ARTs are cytochrome p450 inhibitors? What type of ARTs are cytochrome P450 inducers? List three common medications used in palliative care that are CYP3A4 substrates

Answer 21

CYP450 - enzymes involved with metabolizing majority of drugs. CYP3A family is the most abundant subfamily of the CYP isoforms in the liver. There are at least four isoforms: 3A4, 3A5, 3A7 and 3A43 of which CYP3A4 is the most important (highest activity in liver and small intestine). https://www.medsafe.govt.nz/profs/puarticles/march2014drugmetabolismcytochromep4503a4.htm

Table 15.1.3 - good one to review

CYP450 Inhibitors (increase substrates) - PIs (darunavir) along with abx, antifungal, antidepressants, antipsychotics, steroids, grapefruit (FS: inhibitors more common)

CYP450 Inducers (decrease substrates) - NNRTIs (efavirenz) along with antimycobacterial, anticonvulsants

CYP3A4 substrates (levels increase with inhibitors and decrease with inducers) - methadone, oxycodone, codeine, fentanyl, NSAIDs, TCAs, SSRIs, benzos (FS: TOMC and TOMF)

Question 22

How does poorly controlled symptoms contribute to ART usage

Answer 22

Patients with poorly controlled symptoms may be less compliant with ARTs

Question 23

In the US, what are 3 most common reasons HIV infected patients die

Answer 23

36% end stage HIV
19% non AIDs defining cancer
18% bacterial pneumonia or sepsis
13% liver failure or cirrhosis

Question 24

In late-stage AIDS - what 2 factors are more predictive of mortality compared to CD4 count and viral load

Answer 24

Age
Markers of functional status

Question 25

List 4 types of opportunistic infections in patients with HIV

Answer 25

PJP - pneumocystis jirovecii pneumonia*
TB*
toxoplasmosis encephalitis
MAC (mycobacterium avian complex)*
CMV
Candida*

cryptococcus infection
progressive multifocal leucoencephalopathy

Question 26

A patient receives a diagnosis of AIDS and appears end stage. You are consulted to assess for hospice eligibility. What treatment should be offered to patient before this assessment can be made and why?

Answer 26

Trial of ART - Lazarus syndrome - dying patients can experience a quick and dramatic return to fully functional lives

Question 27

List two outcomes of early involvement of palliative care in the treatment of those with HIV/AIDS

Answer 27

improves QOL
favourably impact treatment adherence

Question 28

Name 3 reasons to continue ART and 3 reasons to stop ART at late-stage disease

Answer 28

3 reasons to continue ART:
- Avoid increasing symptoms
- Protect against infections
- Protect against HIV encophalopathy or HIV dementia
- Patient and family preference

3 reasons to stop ART:
- Reduce drug-drug interactions
- Reduce anxiety related to adherence
- Reduce pill burden
- Reduce lab monitoring and dose adjustment
- Barrier to enter hospice

Question 29

Name the 4 stages of chronic HIV/AIDS condition

Answer 29

a. Asymptomatic stage

b. Early symptomatic HIV infection

c. AIDS characterized by a CD4 cell count <200 cells/microL or presence of any AIDS-defining condition

d. Advanced or late HIV infection characterized by a CD4 cell count <50 cells/microL

UpToDate – The natural history and clinical features of HIV infection in adults