HIV Flashcards

1
Q

Define

A

Aetiology: present in vaginal fluid, semen, blood, breast milk -> transmission through sexual contact, BB, vertical

Less transmission through vaginal mucosa than through anal mucosa

Decision to treat with PEP based on guidelines (i.e. only ‘considered’ if penetrative vaginal intercourse)

  • HIGHEST risk of transmission if mother is newly diagnosed at the beginning of pregnancy or near delivery (as viral load is extremely high in acute phase of infection)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Risk factors

A

Risk factors:

  • vertical risk if high viral load
  • low CD4 count
  • prolonged rupture of membranes (>4h)
  • breastfeeding
  • chorioamnionitis
  • preterm delivery

Reduced transmission risk: low/ undetectable viral load at the time of delivery, ART, C-section delivery, XS formula feeding

Epidemiology: increasing prevalence as people are living longer, most prev in black-African heterosexual women in the UK

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Signs and symptoms

A

Asymptomatic: 1-4 weeks for seroconversion (from primary infection)

General S/S of HIV/AIDS – fever, rash, lethargy, oral ulcers, lymphadenopathy, sore throat, etc.

AIDs-defining diseases – PCP, Kaposi’s sarcoma, MAC, oesophageal candidiasis, CMV retinitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Investigations

A

BLOOD testing;

Routine HIV testing in antenatal booking  regular viral load, CD4 count

Baseline indication tests – FBC, UE, LFT, lactate, blood glucose

  • WANT TO CHECK FOR HAEMOGLOBINOPATHY

Do a full STI screen

Full Hep Screen needed

  • Hep C and HIV together

Additional blood tests

  • Varicella zoster
  • Measles
  • Toxoplasmosis
  • (Parvo virus and rubella)

Neonates test +ve for HIV antibodies due to passive transfer from mother -> diagnosis of HIV in the neonate requires direct viral amplification by PCR (carried out at birth, on discharge, 6 weeks, 12 weeks and 18 weeks)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Management

A

Monitoring:

  • 2x CD4 counts (at baseline and at delivery)
  • 8x Viral load (measured every 2-4 weeks, at 36 weeks and after delivery)
  • Check LFTs when starting at with each routine blood test
  • Check for co-infection with HBV and HCV

The risk of vertical transmission is affected by maternal viral load, obstetric factors and infant feeding

 Management of mother:

ART:

  • Maternal = continual (do not stop)
  • Zidovudine if uncomplicated/NO SYMP women

HAART has slightly tetragenic but allows for vaginal delivery if the viral load is low

cART - 2 x NRTI, 1 x NNRTI

Integrase inhib is used when above doesn’t suppress high viral load

SHOULD HAVE COMMENSED BY 24 WEEKS

Neonate = first 2-4 weeks of life for the baby – see below

Delivery (different for PROM/PPROM, but this is too in-depth to be important here):

Undetectable (<50 copies/mL) at 36 weeks -> vaginal delivery

Detectable viral load (>50 copies/mL) at 36 weeks -> ELCS at 38w

ELCS at 38w if… HIV/HCV co-infection, >50 HIV/mL OR on zidovudine monotherapy

If pre-labour SROM (>34wks) –> IOL (<50 copies/mL) or Emergency CS (>50 copies/ml)

If SROM <34 wks –> IM steroids, optimise viral load, MDT discussion about timing and mode of delivery

[Intrapartum zidovudine – only if detectable viral load]

Avoidance of breastfeeding (+ offer cabergoline to women to supress lactation + free formula)

Invasive prenatal diagnostic testing should be deferred until HIV viral load suppressed to < 50 RNA copies/mL

If not on cART and invasive diagnostic test cannot be delayed, women should commence ART (including raltegravir) and be given a single dose of nevirapine 2-4 hours prior to procedure

Foetal blood sampling is contraindicated (even if undetectable)

Do NOT stop ART post-partum

Management of infants:

  • Cord clamped as soon as possible and baby bathed immediately after birth
  • Zidovudine monotherapy for 2-4w (low/medium risk) OR 4w PEP combination (high risk)
  • Women not to breastfeed
  • Give all immunisations including BCG (unless a moderate-high risk of transmission)
  • Confirm or deny diagnosis of HIV in the neonate with direct viral amplification by PCR
  • (normally carried out at birth, on discharge, 6 weeks, and 6 months) and antibody test at 18m
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Summary

A

Summary:

ART: all women should be offered ART regardless of whether they were previously taking it - joint HIV and obs referral (or HIV specialist clinic)

Delivery: vaginal delivery is recommended if viral load <50/mL at 36 weeks, otherwise C-section

Neonatal ART: zidovudine (oral or IV) is usually administered orally to the neonate if maternal viral load is <50/mL; otherwise, triple ART should be used. Continue therapy for 2-4 weeks

Breastfeeding: all women in the UK should be advised NOT to breastfeed

Suppress lactation with cabergoline

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Complications

A

Complications and Prognosis

  • Transmission to baby (depending on viral load)
  • HIV-related infections and complications
  • Progression to AIDS
  • GOOD prognosis if viral load is suppressed
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

PACES

A

PACES Counselling:

Refer them to an HIV/obs clinic where you will see them every 2 weeks

Stress the importance of good compliance with HAART (want to start by 24 wks)

  • Risk of vertical transmission is greatly reduced if the viral load remains low

Viral load measurement every 2-4 weeks and at 36 weeks

Viral load <50 copies/mL at 36 weeks -> safe vaginal delivery

Viral load >50 copies/mL at 36 weeks -> ELCS

Explain neonatal treatment with oral zidovudine for 2-4w if viral load is <50 otherwise triple ART

No breastfeeding in the UK

Will check HIV diagnosis in neonate by PCR at birth, discharge, 6 wks and 6 months

MDT imp

  • Test partner if they are HIV positive
    https: //www.hiv-druginteractions.org/checker

PrEP and PEP:

PrEP = two-drug ART (i.e. 2x NRTI)

PEP = three-drug ART for 1 month (i.e. HAART for 1 month; 2x NRTI + 1x INI)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly