15.1 (15.1) HIV/AIDS Flashcards
Why is there a substantial rise in prevalence of persons living with HIV/AIDS?
Increase in life expectancy of people living with HIV (now with antiretroviral therapy can live near normal life expectancy)
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Minimally changed incidence of new HIV infections (40k/year in US)
Name 3 most-common routes of HIV transmission.
Men who have sex with men (MSM)
Heterosexual sex
Injections drugs
Why do minorities, women and older people are more likely to present with more advanced disease? Name 3 reasons.
Increasing heterosexual transmission
Delayed diagnosis
Barriers in access and linkage to care
What happens to HIV patients as they age?
Name 3 reasons.
“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
List five factors that contribute to complex palliative care needs for those living with HIV/AIDS
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)
List 3 factors associated with increased life expectancy of HIV infection patients
- Early diagnosis
- Linkage and retention in care (including rapid initiation of ART)
- Adherence to ART regimens
Goal of ART (antiretroviral therapy)
Suppress HIV replication
List 2 lab values used to monitor HIV status in patients
CD4 T-lymphocyte count
viral load
List 4 classes of drugs used to treat HIV
nucleoside reverse transcriptase inhibitor (NRTI)
non-nucleoside reverse transcriptase inhibitor (NNRTI)
protease inhibitor (PI)
integrase strand transfer inhibitor (INSTI)
How do comorbidities affect those with HIV compared to non-HIV infected individuals. List three possible reasons for this
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
List six types of chronic comorbidity that people with HIV/AIDS experience
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
3 common lung infections
Pneumocystis jirovecci pneumonia (“PJP” - seen only in setting of low CD4 counts)
Pneumococcal pneumonia
TB
List three AIDS defining malignancies
Kaposi’s sarcoma
non-hodgkin’s lymphomas (Burkitt’s and primary CNS lymphoma)
invasive cervical cancer
List criteria for frailty (how many must be met?)
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
List 3 contributors to wasting in HIV population
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*
List three definitions of wasting*
unintentional loss of greater than 10%
BMI 20 or less
unintentional loss of greater than 5% in 6 months that persisted x 1 year
List three treatments for wasting other than ART initiation
megesterol acetate
dronabinol
synthetic androgens (oxandrolone)
recombinant human growth hormone
3 principles to managing pain in HIV patients
- Pain is subjective and should be taken SERIOUSLY
- Patients with psych illness may cause frustration - watch for COUNTER-TRANSFERANCE
- Aberrant opioid related behaviours have DDX beyond substance use (psych history, criminal intent, anxiety, etc.)
- MULTI-MODAL approach (including PT, CBT, neural blockage)
Role of opioids for HIV pain
Limited evidence although may be useful for selected and monitored patients
What is the most common cause of neuropathic pain in the HIV infected population? What are the two evidence based treatments for this?
HIV distal sensory polyneuropathy (length dependent degeneration of small and large nerve fibres)
gabapentin and high dose topical capsaicin
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
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)
How does poorly controlled symptoms contribute to ART usage
Patients with poorly controlled symptoms may be less compliant with ARTs
In the US, what are 3 most common reasons HIV infected patients die
36% end stage HIV
19% non AIDs defining cancer
18% bacterial pneumonia or sepsis
13% liver failure or cirrhosis
In late-stage AIDS - what 2 factors are more predictive of mortality compared to CD4 count and viral load
Age
Markers of functional status
List 4 types of opportunistic infections in patients with HIV
PJP - pneumocystis jirovecii pneumonia*
TB*
toxoplasmosis encephalitis
MAC (mycobacterium avian complex)*
CMV
Candida*
cryptococcus infection
progressive multifocal leucoencephalopathy
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?
Trial of ART - Lazarus syndrome - dying patients can experience a quick and dramatic return to fully functional lives
List two outcomes of early involvement of palliative care in the treatment of those with HIV/AIDS
improves QOL
favourably impact treatment adherence
Name 3 reasons to continue ART and 3 reasons to stop ART at late-stage disease
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
Name the 4 stages of chronic HIV/AIDS condition
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
