#9 HIV CLinical case Flashcards
Guidelines for monitoring AIDS
Screen any pts, aged 13-64 once at any healtcare setting
Any pregant person at initial visit and in the 3rd treimester
Annually if : IVDU, commercial sex, more then one sex partner since last HIV test
Statistics show: testing reduces transmission:
54% of infections are caused by 25% of people unaware they are infected vs… 75% are aware of infection and cause only 46% of transmission
What are the Benefits of Testing
- diagnosis allows indi to get antiretroviral tx = decreased mortality
- 32% of new HIV cases also diagnosed w/in 1 year
- missed opportuniteis is don’t test in clinic~~~ most HIV+ have had previous visits to clinic
Acute retroviral syndrome
______wks post infection see primary response to infection
2-6
- Symptoms seen in 80% for acute retroviral syndrome:
a. fever (80%)
b. Arthralgia/myalgia (54%)
c. anorexia/weight loss (54%)
d. rash and lympadenopathy
e. fatigue and malaise
f. pharygitis and oral ulcers
1% of ind tested for infectious mono were + for acute HIV!!! Not mono (did a test of blood samples)
when we did a blood test for mono
Comon symptoms of acute retroviral syndrome
anrthalgia/anorexia/rash
During acute retroviral syndrome we see: High levels of _______
viremia
During viremia of acute retroviral syndrome we see what in regard to viral load and infectious aspect?
widespread seeding of other lymph tissues w/ high viral lode and really infectious
22xs more infectious to others than in chronic HIV phase
What do we see happen to CD4 cells or HIV CD8-T cells?
Decreased CD4 cells circulating
HIV specific CD8-T cell reponse contains infection
~~during acute retroviral syndrome
The Antibody test shows up:
negative until 4-6 wks post infection
For the AntiB test we use ELISA, its affordable and fast and we can detect IgM in the blood from
(detect IgM for HIV from week 3 until 24 weeks)
If an ELISA comes back +… what do we do
follow up with Western Blot
Benefits of antigent test:
Antigen test: detect infection after 10-14 days but very expensive
What are we ‘looking for’ in the antigen test
the specific antiG and timeframe
looks for HIV viral load/RNA
p24 antigen detection (only detected week 2-4)
Whats a fast and cheap way to do HIV RNA testing?
Pooled HIV RNA testing: samples of 20-90 pts: cheaper and faster and increases yield of HIV testing by 10% compared to antiB testing alone
Resistance of HIV prior to tx:
d/t inhereted strain mutation from person you got it from
Goals of HIV tx
a. undetectable viral lode (less then 20 copies/uL)
Increase CD4T cells
eliminate HIV-related symptoms
HIV tx follow Tcell counts every ___ months
Current consensus: start tx if CD4 is below ______ cells/mm3 or you can offer tx at any CD4 level
3 months
500 cells/mm3
Antiretroviral tx recommendation
- 3 meds and 2 classes of drugs
- Classes
a. Nucleoside reverse transctiptase inhibitors (NRTIs)~~ most commonly chosen
b. Nonnucleoside reverse transcriptase inhibitor (NNRTI)
c. Protease inhibitor (PI)
d. Integrase inhibitor or fusion inhibitor or CCR5 R antagonist
- Classes
Integrase inhibitor or fusion inhibitor or ______R antagonist
CCR5
Preferred guidelines: use 2 NRTI’s and then another based on
genetics of virus and pt response
We didn’t see a decline in death age d/t HIV until we had
the 3 drug tx regimen in 1996
Perinatal transmission
1. HIV infected pregnant woman: has \_\_\_\_\_chance she would infect her baby 2. Mom on AZT orally, IV during labor and the baby receiving it orally—\_\_\_\_\_ chance
25%
8%
Standard of care for pregnant women: HAART to mother –_______ + IV AZT at labor and AZT to baby X6 wks and formula feed~~~ see 0-1%
2nd trimester
HIV viral loads
Determines liki-hood of transmission:
as viral load increases, so does the likilhood of transmission: especially male to female
When people go off meds……
their viral loads increase as does their chance for transmitting the virus
Saw NO transmission when viral load is less then _______
1500
Test and tx strategy:
1. Universal HIV testing and immediate ARVs
Expected results:
see 1/1000 in in 10 yrs with a prevalance of under 1% in under 50 yrs → goal is put on immediate HAART once HIV +
→ this would reduce 8 million deaths d/t AIDS
HIV exposure
Main modes Transmission
Needle sharing (67%),
receptive anal sex,
percutaneous needle stick,
receptive penile vaginal intercourse, insertive anal intercourse,
instertive penile-vaginal intercourse (6.5%), receptive oral an instertive oral
Largest cause of HIV transmission
needle sharing
receptive anal sex
percutaneous needle stick
rule of 3’s
Hep B = 30% Hep C = 3% HIV = .3%
for transmission per 1 exposure
Pecuratnous injury (needlestick or cut) OR contact of mucous membrane or non-intact skin WITH
a. blood and tissue (other potentially fluids—CSF, synovial, vaginal, pericardial, amnionic, semen or vag)
What will NOT cause transmission
NOT infectious for HIV unless bloody: feces, nasal secreations, urine, sweat, tears, vomit, saliva
factors associated with injury more likely to cause transmission:
deep injury, visible blood on device, intravascular devic,e terminally ill
ARBs for post-exposure prophylaxsis (PEP)
1. started in health care settins d/t 400,000 needlesticks/yr
- -started in healthcare setting
- -initiate 2-3 drug therapy within 72 hours
- -saw that HIV seroconverters were 80% less likely to have taken PEP
Post-exposure prophy in non health-care related is applicable for:
for sexual exposure to HIV (nonoccupational, nPEP)
~~feasible, especially dedicated prograoma and its timely ARVs and expensive
Pre-exposure prophylaxsis (PrEP):
- an HIV uninfected ind uses antiretroviral meds ahead of HIV exposure
- presence of HIV antiretrovirals in blood/tissue, makes difficult for HIV to establish infection
- an HIV uninfected ind uses antiretroviral meds ahead of HIV exposure
- presence of HIV antiretrovirals in blood/tissue, makes difficult for HIV to establish infection
use PrEP
Prescribing PrEP
a. Before:
assess sexual risk/ Screen for HIV and STIs
Inination or PrEP:
reinforce adherence, discuss additional risk reduction methods
On PrEP how do we monitor our patients
Every 3 months: HIV testing and STI testing and assess medication adherence
every 6 moths: monitor kidney fnx and assess sexual risk
Every 3 months:
every 6 moths:
- HIV testing and STI testing and assess medication adherence
- monitor kidney fnx and assess sexual risk
3 RCTs of PEP
a. iPrEx in men-men saw 44% protection with iPrEx
b. Partners that PrEP in hetorsexual couples saw 75% HIV protection
c. TDF2 in male and femal saw 56% HIV protection
Adherence and efficacy in PrEP trials
a. saw a clear dose response between evidence of PrEP use and efficacy
b. higher the tenofovir levels, the lower the incidence of spread
c. if you take tenofovir you see 90% reduction in transmission
