#9 HIV CLinical case Flashcards by Meghan May

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

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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

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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

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Acute retroviral syndrome

______wks post infection see primary response to infection

2-6

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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

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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

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Comon symptoms of acute retroviral syndrome

anrthalgia/anorexia/rash

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During acute retroviral syndrome we see: High levels of _______

viremia

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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

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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

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The Antibody test shows up:

negative until 4-6 wks post infection

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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)

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If an ELISA comes back +… what do we do

follow up with Western Blot

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Benefits of antigent test:

Antigen test: detect infection after 10-14 days but very expensive

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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)

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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

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Resistance of HIV prior to tx:

d/t inhereted strain mutation from person you got it from

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Goals of HIV tx

a. undetectable viral lode (less then 20 copies/uL)
Increase CD4T cells
eliminate HIV-related symptoms

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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
1. 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

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%

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):

1. an HIV uninfected ind uses antiretroviral meds ahead of HIV exposure 2. 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