HIV Flashcards
When to do POCT
Rapid turnaround needed
Community site (high risk areas)
Urgent source case testing in exposure incident
Venepuncture refused
How long for 4th gen HIV test to be positive
45 days
How long for POCT to be positive?
90 days
Risk factors for HIV
Sti Partner HIV pos MSM Female contacts of MSM Trans woman who has sex with men and no test in past year PWID Partners who PWID High prevalence country >1% High risk sex - group, chemsex Injections/ transfusions, transplants in high risk countries Sex workers or those who paid for sex Sexual assault by the above
Settings where HIV testing should be routine
GUM Antenatal Drug dependency programmes TOp TB/ hep c/ b lymphoma services Sx or signs of HIV indicator condition Accessing healthcare in high prevalence >2/1000 and extremely high >5/1000 Sex partners of those with HIV
Hiv testing in other settings - where?
Dialysis Organ and blood donation Hosp admission and: Sx or part of differential High risk country or group MSM and no test in past year Trans woman and no test in past year Sex with someone from high risk country High risk sex e.g chemsex Sti PWID Partner HIV pos Prisons
AIDS defining thoracic conditions which need test
Candidiasis (bronchial/tracheal/pulmonary)
Herpes simplex bronchitis/ pneumonia
Mycobacterium avium complex, mycobacterium kansasii, other mycobacterium
Pneumocystis carinii pneumonia
Recurrent pneumonia (2 or more in 12 months)
TB (pulmonary or extra pulmonary )
AIDS defining gastro conditions needing HIV testing
Atypical disseminated leishmaniasis
Cryptosporidosis diarrhoea >1/12
Isosporiasis >1/12
Oesophageal candidiasis
Neuro aids deifning conditions need test
Cervebral toxoplasmosis Cryptococcal meningitis Primary cerebral lymphoma Progressive multi focal leukoencephalopathy Reactivation of American trypanosomiasis
Dermatology aids defining
Herpes simplex ulcer >1/12
Kaposis sarcoma
Oncology aids defining
Cattleman’s disease
Non Hodgkin’s lymphoma
Cervical ca
Ophthalmology aids deifning
CMV retinitis
Infective retinal diseases including HSV and toxoplasma
Aids defining infective causes
Cryptococcosis extrapulmonary
Histoplasmosis
Penicilliosis
Salmonella septicaemia recurrent
Medical conditions associated with an undiagnosed HIV prevalence >1/1000
Anal cancer dysplasia Candidemia Cervical dysplasia CAP GBS Hep a b or c Herpes zoster Malignant lymphoma Mononucleosis like illness Ms like disease Oral hairy leukoplakia Peripheral neuropathy Lung ca primary Seborrhic dermatitis Severe psoriasis Sti Su cortical dementia Chronic diarrhoea unexplain Unexplained fever Unexplained lymphadenopathy Unexplained oral Candida Unexplained weight loss Leukocytopenia thronbocytopenia > 4 weeks
What to discuss in giving HIV diagnosis
Not aids Good prognosis Art option U=u Keep working, have kids, normal life expectancy Support network Specialist hiv team PN Routes of tanmsision Condoms Pep/ prep for partners Prosecutions for reckless transmission Reg stis Encourage disclosure to partner s
Annual hiv test for who?
Heterosexuals with new partner
PWID
Sex workers
MSM
3 monthly HIV test for
MSM - condomless anal sex with partner of unknown status over past 12/12
MSM and drug use during sex in past 6/12
Over 10 sexual partners in last 12/12
Multiple or anonymous partners since last test
Prep users
Follow up for sts or anogenital ct/GC
Antenatal hiv testing when?
Booking
If refuse reoffer
If refuse third offer at 36 weeks
Reoffer at 34-36 weeks for those with risk factors
POCT if present for first time in labour and send venous
Risk of vertical transmission of unknowingly positive HIV mother
20-35%
Factors increasing risk of vertical HIV transmission
Maternal viral load
Obs factors - mode, duration of ROM, del pre 32 weeks
Infant prematurity
Breast feeding
Ways to reduce maternal transmission of HIV
Don’t breastfeed
Art for mum and baby
No FBS or FSE
Mode of del
Primary infection with HIV time frame
1-4 weeks from acquisition until auffiencent antibodies to be detected on testing
Highly infectious time
Primary HIV 1 Sx
40-90% get them
Last 7-10 days
Fever, malaise, arthralgia, loss of aperitif, rash, myalgia, pharyngitis, oral ulcers, weight loss
Neuro Sx of primary hiv infection
Headache Menigism Cranial nerve palsies Transient heniplegia or dysarthria High viral loads in CSF
Years after HIV acquired and immune system weakened. First manifestations?
Frequent minor infections viral or recurrent vaginal or oral Candida
Dry skin, seborrhoeic derm, thanks psoriasis
Anaemia or thrombocytopenia
Systemic fatigue weight loss nigjts sweats
As becomes more profound - oral hairy leukoplakia or multidermatomal shingles
Impact of HIV on kidneys
Glomerulonephritis
HIV associated nepheopathy
CV impact of HIV
Increased atherosclerosis
Dilated cardiomyopathy
Pericarditis and pericardial effusions
Pulmonary HTN
Hiv impact on liver
Faster progression of cirrhosis in Hep b and c
Higher rates of fatty liver
Bone impact of HIV
Osteopenia and osteoporosis
High rates of vit D deficiency
Osteonecrosis
Neuro impact of HIV
Peripheral neuropathy
Bell’s palsy
Cognitive impairment
Disease progression gene factors
Mutation in CCR5 - hiv uses it to gain entry to CD4 cells
HLA -B27 and 57 - resistance to disease progression
HIV 2
West Africa
Less transmissible
Less pathogenic
Natural hx similar but lower viral loads and slower progression
Baseline ix when hiv pos
HIV serology 1vs2 CD4 count and CD4 % HIV viral load Resistance testing at baseline - HLA-B27 and 57 test (for hypersensitivity reaction) Renal, liver, bone profile Hba1c Urine dip Urine PCR FBC Hep B and C Vaccinate against Hep B A, varicella and measles if not already Sti screen inc sts Women - annual smear. Rubella if no prev vaccine Over 40’s - qrisk2 Over 50 - FRAX
When to measure CD4 count
> 500 annually
350-500 6/12
<350 - 3/12
Annual hiv viral load, FBC, renal, liver bone profiles lipids ans sti screen
What to check pre starting art
CD4 in past 3/12
Viral load and full bloods inc urine PCR if urine pos for protein in past 6/12
Review resistance testing
Check tropism test for CCR5 antagonist are considered
Post art starting when follow up bloods?
4 week, 3/12 and 6/12 Renal and liver Urine dip HIV viral load If CD4 < 350 when starting art - 3/12ly
How to assess birological response to art?
HIV viral load should fall by 10fold within 4 weeks
If not do further load after 4 weeks
If not undetectable by 6/12 or rises- virological failure? Incomplete virological response? Rebound or blip?
Once established on art when check bloods?
Every 6/12 viral load If CD4 < 200 3/12 If CD4< 350 annually If >350 on 2 occasions over at least 1 year - stop monitoring Annual blood screens
Once established on ART when to routine screening tests
Smear yearly
Sti screen yearly and every visit for MSM at risk
Qrisk2 annually for those over 40
Frax 3 yearly for those over 50
How many months post HIV acquisition can define primary infection
6/12
Times when expedited initiation of ART recommended
Neuro involvement
Aids deifning illness
CD4 <350
PRimary HIVinfevtuon diagnosed within 12 weeks of a prev neg test
Art
Two NRTI backbones recommended
Nneucleotide reverse transcriptase inhibitors
Tenofovir and Emtricitabine (truvada)
Alternative abacavir and lamivudine (kivexa)
Name the classes of the 6 preferred 3rd agents for ART
Non neucloside reverse transcriptase inhibitors (nnrtis) : rilpivirine
Integrase inhibitors: raltegravir, dolutegravir, elvitegravir
Protease inhibitors: atazanavir/ritonavir or darunavir/ ritonavir
Strep pneumoniae
Gram positive Pneumonia and otitis media and sinusitis Invasive when in CSF or blood Carried in 10-15% of most peoples noses Carriage rates double in HIV Causes consolidation Can spread to brain meningitis
Risk factors for invasive pneumococcal disease
Extremes of age No spleen Diabetics Alcoholics Chronic renal pulmonary or liver or cv disease Immunodefin ie cancer or HIV
CXR findings of strep pneumoniae pneumonia
Lobar consolidation
Differential is PCP, TB and fungal infections
Bacterial causes of penimonia in HIV 1
Staph aureus E. coli H. Influenza Klebsiella Pseudomonas aeruginosa
Pneumococcal prevention in HIV
Give to HIV positive regardless of CD4 or art use
Co trimoxazole for all with CD4 less than 200 against PCP. Also reduces risk of pneumonia and invasive baceterial disease
Influenza A vaccination
Smoking cessation
TB findings on CXR
Primary TB - pulmonary lesion (usually hilar lymphadenopathy also)
Cavitation and patchy consolidation
Particularly in upper lobes
Can get pleural effusions
With HIV primary TB can progress to?
Progressive primary TB
Post primary TB (=reactivation)
Sites of extrapulmonary TB
Brain Lymph nodes Pericardium Renal and Gu tract Joints GI tract
When to start ART when TB presenting condition
CD4 < 100 ASAP
100-350 - ASAP but can wait until 2/12 post TB Rx
>350 mins physician decision
Hiv diagnosed in pregnancy. What aiming to get undecteavle by? Gestation
36 weeks
Diagnosed with hiv in pregnancy - what to give baby?
4 weeks of AZT (zidovudine) mono therapy
No breastfeeding
If mum viral load >1000 what to do for delivery?
C/s
Stat nevirapine, raltegravir and IV AZT in labour
Baby triple therapy for 4 weeks
Hiv mode of delivery depending on viral load
If <50 nvd
If 50-400 consider c/s
If >400 - section
What to give if VL over 1000 in labour or if not known of consider if VL 50-1000
Zidovudine IV
Neonatal pep when to start?
Within 4hours max
If mother in ART for >10 weeks and VL <50 on/after 36 weeks -
2 weeks zidovudine
If mother on ART less than 10 weeks and BL less than 50 now but was previously higher what give?
4 weeks zidovudine
If maternal VL >50 on dah of delivery
4 weeks of combo prep AZT 3TC, NVP Zidovudine Lamivudine Nevirapine
When to test neonate for HIV?
Non breastfeeding - 48 hours, 6 weeks, 12 weeks, 18-24 months
BF- 48 hours, 2weeks, monthly whilst breastfeeding and 4 and 8 weeks post stopping
When to give neonate cotrimoxazole prophylaxis?
1month old if HIV PCR positive at any stage or confirmed HIV pos. only stop if exclude HIV
