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ICM > 2: HIV > Flashcards

2: HIV Flashcards

1
Q

describe worldwide HIV epidemic in terms of numbers and access to treatment

A
  • total number w/ HIV/AIDS increased worldwide

- less than 1/3 of people who need antiretroviral drugs have access to them

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2
Q

what method of contracting HIV has the highest transmission rate? the rest of the ways to contract HIV have what type of transmission rates?

A

transfusion of contaminated blood - 90%

rest of the methods are all

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3
Q

CDC testing guidelines

A
  • “opt out testing”
  • don’t need specific informed consent
  • persons at high risk should be screen at least annually
  • prevention counseling not required, but strongly recommended for high risk persons
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4
Q

why are E Europe and Central Asia numbers still rising?

A

heroin/IV drug use

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5
Q

historical indications for HIV testing (long list)

A
  • sexually active gay men
  • persons w/ multiple partners
  • current or past injection-drug users
  • recipients of blood products b/w 1978 and 1985
  • persons w/ current or past STIs
  • commercial sex workers and their contacts
  • persons sexually assaulted
  • persons w/ occupational exposures
  • pregnant women/women of childbearing age
  • children born to HIV-infected moms
  • sexual partners of those at risk of infection
  • persons who consider themselves at risk/request testing
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6
Q

first good protease inhibitor

A

Indenovir

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7
Q

clinical indications for testing (long list)

A
  • TB
  • syphilis
  • recurrent shingles
  • unexplained chronic constitutional sx
  • unexplained generalized adenopathy
  • unexplained chronic diarrhea or wastin g
  • unexplained encephalopathy
  • unexplained thrombocytopenia
  • thrush or chronic/recurrent vaginal candidiasis
  • HIV-associated opportunistic diseases
  • suspected primary HIV syndrome
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8
Q

significance of the release of HAART (the protease inhibitors) in 1996

A

60-80% reduction in deaths from AIDS in US

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9
Q

four H’s are risk groups:

A

heroin addicts
homosexuals
hemophiliac
Haitians

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10
Q

common signs/sx of primary HIV infection:

  • those presenting in 50-90% of patients (6)
  • those presenting in 25-50% of patients (3)
  • those presenting in
A

50-90%

  • fever
  • fatigue
  • rash
  • myalgia/arthralgia
  • pharyngitis
  • night sweats

25-50%

  • N/V/D
  • low wbc/plts
  • weight loss
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11
Q

how long is the eclipse period of HIV infection?

A

10-12d (from time of initial infection to viral detection)

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12
Q

when does one start making Ab’s to HIV?

A

after about 3w (period of seroconversion - from initial infection to first creation of Ab’s)

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13
Q

testing for HIV: how are viruses detected (what component do they test for)?

A

HIV RNA in plasma

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14
Q

other options in the primary HIV ddx

A
  • EBV mono
  • CMV
  • HSV
  • flu
  • rubella
  • viral hepatitis
  • toxoplasmosis
  • syphilis
  • disseminated GC
  • rickettsial disease
  • lyme disease
  • streptococcal infection
  • early TSS
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15
Q

clinical clues for primary HIV infection (7)

A
  • mucocutaneous ulcerations
  • rash
  • abrupt onset: “10 sx/signs in 24h”
  • GI sx
  • antedecent high risk exposure
  • prolonged sx

-cough/URI: diagnosis less likely

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16
Q

what test is used to detect HIV Abs?

A

ELISA (highly sensitive)

  • if result is (-), HIV AB reported as (-)
  • if result is (+), ELISA repeated
    • if repeat (+), Western blot (more specific) for confirmation
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17
Q

what happens when western blot results are indeterminate?

A

means 1 of 3 characteristic bands present - recommend supplemental testing

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18
Q

what can an indeterminate western blot indicate?

A

presence of recent HIV-1 infection or HIV-2 infection, which is endemic in West Africa

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19
Q

can you use a low CD4+ count to diagnose HIV?

A

no - not diagnostic and cannot be used instead of HIV Ab testing

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20
Q

are there any rapid tests for HIV?

A

yes - blood and oral swabs can give results in 20 min

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21
Q

what should you determine in a newly diagnosed HIV history? (8)

A
  • HIV risk behaviors (sexual and drug use)
  • knowledge of HIV infection
  • emotional response to diagnosis
  • family and social situation
  • employment and insurance status
  • travel history
  • exposure to TB, syphilis, other STIs, and viral hep (A,B,C)
  • status of immunizations
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22
Q

labs to run on a newly diagnosed HIV patient (12)

A
  • CBC and differential counts
  • BUN/creatinine, liver fxn tests, fasting glucose/lipid profile
  • CD4 count and HIV viral load
  • HIV genotype test
  • syphilis testing (RPR or VDRL)
  • anti-HAV, HBsAg, HBcAb (HBsAB if prior immunization), anti-HCV
  • toxoplasmosis (IgG) serology
  • PPD
  • chlamydia and GC assays in persons at risk
  • consider anal pap smear in persons at risk
  • G6PD quantitative testing (if needing pneumocystic prophylaxis)
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23
Q

what is the main surrogate marker for monitoring HIV disease progression?

A

CD4 count

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24
Q

normal range of CD4

A

350-1100/mm3

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25
Q

what is the average decline in CD4 count per year without treatment?

A

75-100/mm3 - but variability b/w patient and in a given patient over time

26
Q

what are factors that can transiently affect the value of CD4?

A
  • intercurrent illnesses

- inter- and intra-lab variability

27
Q

what are the clinical uses of CD4 count?

A
  • to determine need for antiretroviral therapy
  • to determine need for antimicrobial prophylaxis
  • to assess prognosis
28
Q

prognostic indication of high early viral load

A

sx are worse for patients - knocks down the CD4s faster and indicates clinically that the meds will have a rough time

29
Q

how do you measure viral RNA loads in plasma?

A

PCR or branched DNA techniques

30
Q

what is the lower limit of detection of ultrasensitive PCR assay

A
31
Q

what does a high level of viral RNA in plasma correlate to?

A

CD4 cell count decline and clinical disease progression

32
Q

what is the normal variability of HIV viral load?

A

0.3 log (3- to 5-fold)

33
Q

what are the clinical uses of monitoring HIV viral load?

A
  • monitor antiretroviral therapy

- to assess prognosis

34
Q

patient presentation with CD4 > 500/mm3

A
  • most asymptomatic
  • bacterial infections (pneumococcus, staph)
  • pulmonary TB
  • shingles
  • other dermatologic conditions
35
Q

patient presentation with CD4 200-500/mm3

A
  • many asymptomatic
  • generalized adenopathy
  • thrush
  • Kaposi’s sarcoma
36
Q

patient presentation with CD4

A
  • PCP
  • toxoplasmosis
  • cryptococcus
37
Q

patient presentation with CD4

A
  • CMV and Mycobacterium avium complex infections
  • increased risk of lymphoma
  • highest mortality
38
Q

indications of when to start HIV treatment (5)

A
  • AIDS-defining condition

- CD4 count

39
Q

targets of HIV drugs

A
  • RT inhibitors
  • integrase inhibitors
  • protease inhibitors
  • fusion/entry inhibitors
40
Q

HIV meds: NRTIs

A
  • abacavir
  • didanosine
  • emtricitabine
  • lamivudine
  • stavudine
  • tenofovir
  • zidovudine
41
Q

HIV meds: PIs

A
  • atazanavir
  • darunavir
  • fosamprenavir
  • indinavir
  • lopinavir
  • nelfinavir
  • ritonavir
  • saquinavir
  • timpranavir
42
Q

HIV meds: NNRTIs

A
  • delavirdine
  • efavirenz
  • etravirine
  • nevirapine
43
Q

HIV meds: integrase inhibitor

A

raltegravir

44
Q

HIV meds: fusion inhibitor

A

enfuvirtide

45
Q

HIV meds: CCR5 antagonist

A

maravioc

46
Q

how many meds are administered at once? why? which ones?

A

usually 3 drugs at a time - virus can’t make resistance to 3 at a time
-often two NRTIs with an integrase inhibitor

47
Q

what other non-infectious disease state should be watched for in HIV treatment?

A

inflammatory disease

48
Q

preferred initial treatment: NNRTI based

A

EFV/TDF/FTC

  • don’t use EFV in first trimester of pregnancy or in women trying to conceive or not using effective/consistent BC
  • 3TC can be used in place of FTC and vice versa
49
Q

preferred initial treatment: PI based

A

ATV/r + TDF/FTC
DRV/r (QD) + TDF/FTC
-3TC can replace FTC

50
Q

preferred initial treatment: II based

A

RAL + TDF/FTC

-3TC can replace FTC

51
Q

preferred initial treatment: pregnant women

A

LPV/r (BID) + ZDV/3TC

-3TC can replace FTC

52
Q

drug resistance testing before initiation of ART

A
  • transmitted resistance in 6-16% of HIV patients
  • w/ no therapy, resistance mutations may decline over time and become undetectable by current assays, but may persist and cause treatment failure when ART is started
  • ID resistance mutations to optimize tx outcomes
  • genotype recommended for all at entry to care
  • recommended for all pregnant women
53
Q

drug resistance testing in patients with virologic failure

A

-perform while patient is taking ART, or

54
Q

list the complications of HIV treatment (5)

A
  • lipodystrophy syndrome
  • lactic acidemia/acidosis
  • premature osteopenia and osteoporosis
  • avascular necrosis of hips
  • peripheral neuropathy
55
Q

describe lipodystrophy syndrome

A

-body morphology changes and metabolic complications - this is why II > PI in terms of Rx: prevents buffalo humps, skinny arms, and temporal fat

56
Q

describe the lactic acidemia/acidosis that can be caused by HIV tx

A

peripheral neuropathy, pancreatitis, myopathy, steatosis with liver failure

57
Q

describe vaccinating people with HIV

A
  • avoid live vaccines
  • benefits increased if given early in disease
  • pneomococcal: boost after 5y
  • Hep A and B: if Ab(-)
  • flu: yearly, avoid intranasal prep
  • HPV: to males and females age 9-26
  • H. influenzae: if asplenic
  • varicella: if no immunity to varicella + CD4 >200
  • tetanus: as w/ general pop (Tdap once)

-MMR and zoster: typically avoided

58
Q

what occupations have the most HIV exposures?

A
  • nurses
  • ancillary staff
  • surgeon
  • dental workers
  • EMS
59
Q

what is the risk of seroconversion with needle stick exposure for each of the following: HBV, HCV, HIV

A

HBV: 30%
HCV: 3%
HIV: 0.3%

60
Q 
rates of perinatal HIV transmission for each of the following viral loads at time of delivery: 
>100,000
40,000-100,000
3000-40,000
400-3000
A

> 100,000: 32%
40,000-100,000: 21%
3000-40,000: 11%
400-3000: 6%

ICM (26 decks)

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