21. Diagnosis and Management of HIV II Flashcards
22 year old women is in the eighth week of pregnancy, referred for new HIV diagnosis, 2 year old daughter removed from custody because of mom’s alcoholic tendencies, oral thrush on exam, which of the following should occur?
being mom on HIV treatment or give baby post-exposure prophylaxis or do not breast feed or all of the above
can be transmitted from mother to baby, occurs during vaginal delivery process or close to delivery process when the placenta is disrupting from mom and there is mixing of maternal blood, or there is possible exposal through mucosal membranes, in utero transmission is through the placenta, vaginal transmission also transmits, breast feeding also transmits postnatally <1 month of birth with 0.7% risk so breast feeding is limited in acutely infected individuals, is preventable by testing and treatment
HIV maternal transmission
patient comes in with loss of vision, HIV+ positive male with CD4 count of 350 (19%), had thrush 2 months ago, rash 1 week ago, and treated with predisone, had headache for several days, exam shows rash to the face, limbs, torso, palms & soles, CT head is normal, lumbar puncture shows opening pressure at 16 cm, 52 L & 3 N, protein 87, and glucose 48, syphilis Ab screen positive, TPPA positive, RPR 1:256 positive, which of the following statements about secondary syphilis is true?
mostly a problem in women, spares the eye, rarely involves oral mucosa, occurs at any CD4 count
macular papular rash, palmar plantar rash, mucous patches, condyloma lata raised and mucoid, has a lot of organisms so is very infectious, needs to be treated with benzapine penicillin
secondary syphilis
20 year old male with a past medical history of asthma who had COVID 2 weeks ago and a bout of thrush for which he received nystatin S&S, presents to the ED with odynophagia, 25lb weight loss, cough, fever, and shortness of breath, has sex with men, negative HIV screening test a year ago, on exam is thin with temp at 38.8C, HR 100, RR 18, blood pressure at 105/71, oxygen saturation at 96 on room air, no thrush, lungs without crackles or wheezes, epigastric abdominal tenderness, chest x-ray shows infiltrates, was also complaining about shortness of breath prompting CT angiogram for pulmonary embolism which shows decreased air space bilaterally, HIV Ab/Ab positive and HIV-1 Ab positive, HIV-1 viral load 120,226 cpm, CD4 count 19 at 3%, hepatitis B immune, hepatitis A and C antibody negative, nasopharyngeal swab was positive for SARS-CoV-2, negative for other respiratory viruses, which of the following would not be appropriate for this patient?
bronchoalveolar lavage or empiric therapy for pneumocystis or empiric therapy for esophageal candidiasis or prophylaxis for CMV
pneumocystic jirovecii, most common AIDS defining illness, CD4<200, empiric therapy with trimethoprim-sulfamethoxazole, differential diagnosis includes tuberculosis, histoplasma, coccidiodes, cryptococcus, cytomegalovirus, pyogenic bacteria, recall that CD4<200 can prompt pneumocystis infection
pneumocystis jirovecii infection
prevention of first episode, done for pneumocystis, start if CD4<200 and stop when CD4>200, and toxoplasma Ab positive, start when CD4<100 or stop when CD4>100-200
primary prophylaxis
maintenance therapy to prevent relapse after initial treatment, includes pneumocystis, toxoplasma, myobacterium avium complex, cytomegalovirus, cryptococcus, and histoplasma, treat until the CD4 count is high enough
secondary prophylaxis
sputum tuberculosis nucleic acid test negative, AFP smear negative, blood beta-d-glucan highly elevated, bronchoscopy with bronchiolar alveolar lavage strongly positive for pneumocystis, low number of polymorphonuclear cells, negative for fungi, bacteria, AFB, and nocardia patient was diagnosed with HIV/AIDS, started on biktarvy before discharge, given TMP/SMX IV then oral for pneumocystis, oral fluconazole for presumptive candida esophagitis, no antiviral given for COVID
diagnosis and treatment of previous case
combination antiretroviral therapy, cART, 2 or 3 active drugs, dolutegravir is an integrase inhibitor used plus one other potent HIV drug which may be sufficiency, goal is to prevent HIV-associated disease by suppression of HIV replication to undetectable viral load and improve immune system by restoring CD4 cell numbers, also stop HIV transmission
HIV treatment
undetectable viral loads are untransmittable
treatment as prevention
protease inhibitors, fusion inhibitors, attachment inhibitors to CCR5, nucleoside reverse transcriptase inhbitors, non-nucleoside reverse transcriptase inhibitors, integrase inhibitors
antiretroviral drug classes
integrase inhibitor based regimens combined with nucleoside reverse transcriptase inhibitors, negative HLAB5701 needs to be present to use abacavir
new starts for treatment-naive in 2022
combination single tab of TAF, emtricitabine, and bictegravir
biktarvy
atypically inflammatory disorder associated with immune recovery, manage with nonsteroidals or some corticosteroids like predisone, more common with tuberculosis
immune reconstitution inflammatory syndrome -IRIS-
two HIV drug combination (tenofovir and emtricitabine) protectsagainst HIV infection, efficacy is 95% when taken everyday, cost-effective, but doesn’t protect against other STIs, cabotegravir is an extended release injectable suspension given intramuscularly every 2 months
pre-exposure prophylaxis
men who have sex with men engaging in risky sex or recent ATI, heterosexual population with risk sex and recent STIs, and IV drug use, HIV uninfected, no acute HIV symptoms of signs, good kidney function, known hepatitis B status
tenofovir/emtricitabine candidacy
descovy, different form of tenofovir which has less toxicity than the original which can damage kidneys or lead to bone loss
HIV prevention pill
42 year old HIV man reports bleeding from his anus and enlarging anal lesion, had anal warts fulgurated by local GI doctor last year, history of AIDS CD4 nadir at 55 cells/mm3, now receiving cART therapy, with CD4 count of 355 19% and HIV viral load <50 copies/mL, has HIV associated lipodystrophy, type II diabetes mellitus, mixed hyperlipidemia, and hypertension, prior history of AIDS increases risk for?
dyslipidemia, cardiovascular disease, squamous cell carcinoma of the anus, or all of the above
have declined over recent years, non-HIV related deaths have remained stable
HIV related deaths
central obesity, hypertension, high triglycerides, low HDL, insulin resistance, lipodystrophy, fat atrophy of the face and arms, low of visceral fat
HIV associated metabolic syndrome
earlier age compared to HIV, may arise from or mimic a wart, do not need to have anal intercourse, HPC vaccine is the primary prevention
HPV-related anal squamous cell carcinoma
lung cancer, anal cancer, this patient population as a group is are more likely to smokers, will have baseline elevated levels of inflammatory cytokines which predispose to cardiovascular disease
HIV cancers with elevated rates
pandemic continues, test and treat, pre-exposure prophylaxis is a cost-effective prevention strategy is the way forward
HIV conclusion
