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GORGAS > HIV > Flashcards

HIV Flashcards

1
Q

What three genes define a retrovirus?

A

Gag
Pol
**

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2
Q

Primary Infection cell entry?

A

Virus targets CD4 cells, macrophages and dendritic cells
Can also invade mucosa
GP120 binds to CD4 receptor and appropriate co-receptor CXCR4 or CCR5
GP41 promotes fusion of viral and cellular membranes

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3
Q

How does HIV integrate genetic material?

A

Reverse transcriptase copies viral RNA into double stranded DNA
This is site of action for NRTI (AZT, 3TC, D4T etc) and NNRTI (NVP, EFZ)

CDNA enters cell nucleus and integrates into human DNA- this is site of action for integrate inhibitors

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4
Q

What is transcription?

A

When an infected cell is activated, viral replication begins
Tat and rev genes get activates
Tat amplifies transcription of RNA
Rev promotes RNA transport to cytoplasm

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5
Q

What is translation?

A

Other viral proteins are translated and new viral particles assembled
Protease inhibitors act at this level

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6
Q

What is defined as AIDS?

A

When CD4 <200 or <14%

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7
Q

What is the reservoir for HIV?

A

Lymphoid tissue
95% of plasma detectable virus is derided from the activated infected cells
ARV cannot eradicate all infected cells

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8
Q

Who is screened for HIV?

A

High risk groups: prisoners, IVDU, MSM, sex workers
Healthcare workers

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9
Q

What is ELISA of HIV?

A

ELISAs now on 4th generation
Capacity to detect Ag (p24) and antibodies simultaneously
Can now detect HIV in acute symptomatic phase

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10
Q

When can you detect viral load?

A

11-12 days

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11
Q

When can you do an ELISA?

A

in 3-4 weeks

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12
Q

When do you do RNA testing?

A

To differentiate between HIV-1 or HIV-2

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13
Q

What % women or girls make up people living with HIV globally?

A

54%

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14
Q

What countries of world are women disproportionately affected?

A

Eastern and Southern africa, but problem globally

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15
Q

How many cases of HIV in children are due to transmission vertically?

A

> 90%

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16
Q

How is HIV transmitted maternal to child?

A

In utero: likely due to disruption of placental integrity and placental inflammation also genital tract infections

Intrapartum: Exposure of neonatal membranes to viremic body fluids, microtransfusions and any VD with instruments

Postpartum: Not fully understood, likely earlier in breastfeeding

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17
Q

When does HIV vertical transmission commonly occur?

A

Mostly in third trimester and during delivery

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18
Q

Main risk factors for vertical transmission?

A

Mainly maternal HIV viral load

New maternal HIV infection during pregnancy, likely related to higher plasma viral load levels

Other risk factors include; maternal STIs, Anaemia etc

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19
Q

How to prevent vertical transmission?

A

ALL pregnant women need HIV, Syphillis and HBsAg in first trimester
High burden settings, women should get testing in 3rd trimester and consider Postpartum period testing

Can offer Prep to serodicordant couples during pregnancy and/or postpartum.
This typically is Tenofovir disproxil fumerate (TDF) or dapivrine ring

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20
Q

How much do you want to reduce maternal viral load to reduce risk of vertical transmission?

A

You want <1000 copies/ml
Ideally lower viral load before pregnant
ART can reduce vertical transmission to <1%

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21
Q

What is choice of ART to prevent vertical transmission?

A

2 x NRTI and 1x Integrase Inhibitor
Dolutegravir, Tenofovir, lamivudine or emtricitabine
You can keep women on their orginial ART combo

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22
Q

Risk of using Dolutegravir in pregnancy

A

Neural Tube defects, but this is minimal
Benefit far outweighs the risk and is preferential over efavirenz

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23
Q

Do you alter mode of delivery to prevent VT?

A

Vaginal delivery perfectly safe

Only offer C-section in developed countries if VL>1000 copies

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24
Q

When do you start infant prophylaxsis?

A

Ideally within 6hrs of birth
Type and duration will be a risk assessment

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25
Q

What is considered high risk for VT?

A

A mother not receiving ART
If born to Mum recieveing <4weeks of ART at delivery
If maternal VL >1000 copies in 4 weeks before delivery
Incidental maternal HIV during pregnancy or breastfeeding

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26
Q

What drug regimen for neonate to prevent VT? Duration?

A

AZT in combination with NVP for 6 weeks
Continue combo or NVP alone for additional 6 weeks if BREASTFEEDING

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27
Q

HIV negative female in first trimester, but now positive is she high or low risk?

A

High

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28
Q

HIV positive in first trimester and starts ART, VL undetectable before delivery

A

Low risk

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29
Q

High risk infant who is breastfeeding prevention of VT?

A

AZT and Nevirapine daily for 6 weeks
Then needs AZT and NVP for additional 6 weeks or NVP alone for 6 weeks
If Mum cannot tolerate ART whilst breastfeeding continue NVP until one month after cessation of breastfeeding

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30
Q

Low risk infant breastfeeding tx to prevent vertical transmission?

A

NVP daily 6 weeks

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31
Q

Tx to prevent VT in formula fed infant who is high risk?

A

AZT twice daily and NVP daily for 6 weeks

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32
Q

Tx to reduce VT in formula fed low risk infant?

A

NVP daily for 4-6weeks or AZT twice daily for 4-6weeks

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33
Q

Main side effect of AZT

A

Anaemia

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34
Q

Risk factors for VT when breastfeeding?

A

Increased maternal VL
Acute HIV infection
Low maternal CD4
Breast infections
Mixed feeding

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35
Q

For mothers with HIV what are breastfeeding recommendations?

A

6 months Exclusive breastfeeding with maternal ART and infant prophylaxsis (12 weeks)
Then continue maternal ART and can do mixed feeding for next 24 months

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36
Q

When do you consider co-trimoxazole in infants in prophylactic VT?

A

Recommended for HIV exposed infants 4-6weeks of age and continue until HIV infection has been excluded in neonate after complete cessation of breastfeeding
This is to prevent OIs

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37
Q

Symptoms of HIV in neonates and infants?

A

Fevers, generalised LAD, failure to thrive, candida, diarrhea, CNS risk, recurrent invasive bacterial infections
Babies progress rapidly, by 12-18months, majority are showing signs

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38
Q

How do you test infants for HIV in infants <18 months?

A

Only with virologic testing (NAT)
This is HIV DNA or RNA testing
(Babies inherit maternal IgG abs which could be positive)

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39
Q

What would NAT positive at birth likely indicate?

A

Likely a prenatal infection, infection at deliver, NAT can take several days or weeks to turn positive

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40
Q

When do you start ART in children?

A

Straight away and in every child if HIV positive

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41
Q

What children are considered to have severe disease
<5 and >5yrs old?

A

<5 and not on ART and clinically stable is considered advanced disease
For >5yrs advanced disease is defined as WHO stage 3 or 4 or CD4 count <200

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42
Q

How do you monitor response to tx in children? How often?

A

Viral load, should be measured at 6 months, 12 months and then every 12 months

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43
Q

Kids with HIV and vaccines?

A

Generally get all their childhood vaccines

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44
Q

What is HIV DNA test?

A

Virologic test used in infants <18months
Poor sensitivity at birth, this increases to 90% by 4 weeks and 100% at 3-6 months

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45
Q

What can affect NAT results in neonates

A

Maternal ART
Neonatal prophylactic ARV

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46
Q

How do you test for HIV in children >18 months

A

Serology testing can be used, same as adults

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47
Q

What should you be mindful of in children who start on ART very early?

A

If started on ART at 3-6months can get blunted antibody production and falsely test negative on serologic tests!

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48
Q

Timeline of testing for HIV in infants?

A

Exposed at 0-2 days: NAT
If exposed at 4-6 weeks to 18 months: NAT

If this is negative, infant remains at risk until cessation of breastfeeding
Repeat NAT at 9 months
Repeat NAT at 18 months or 3 months after cessation of breastfeeding (whatever is later)

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49
Q

What is the difference of HIV serology testing in infants <12 months vs infants >18months

A

For infants <12 months it’s a SCREENING test for EXPOSURE, needs confirmation with a virology test

For infants >18 months it is DIAGNOSTC just like adults and you need a repeat serology for confirmation

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50
Q

What are the two types of NAT testing?

A

HIV DNA
HIV RNA

Both need confirmed with 2nd test
Interpret HIV RNA negative test with caution if infant on ART

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51
Q

What can you use to monitor treatment if VL unavaible in children?

A

CD4 count and clinical sx

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52
Q

Tx of HIV positive neonates and children?

A

Neonates: AZT (Zidovudine) and Lamivudine (3TC) and raltegravir (RAL)
Children: Dolutegravir (DTG), Lamivudine (3TC) and abacavir (ABC)

Kids learning ABC at school

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53
Q

What do you do if during monitoring VL is >50 to <1000 copies?

A

Provide enhanced adherence counselling, repeat VL after 3 months. Maintain the same ARV regimen

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54
Q

What do you do if VL during monitoring is >1000 copies?

A

If on NNRTI, need regimen switched

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55
Q

What vaccines HIV positive children must get?

A

Pneumococal
HPV
measles
BCG

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56
Q

Do you screen children for CRAG?

A

Not routinely only when 10-19yrs (adolescents)

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57
Q

When do you give co-trimoxazole in HIV infected infants and children?

A

recommended for all infants, children and adolescents regardless of CD4 count or clinical stage. Priority is children <5yrs

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58
Q

Necessary conditions for discontinuing co-trimoxazole in HIV postivie children?

A

ONLY in settings where there is low prevalence of malaria and other bacterial infections
child is >5yrs
clinically stable and or virally suppressed on ART for at least 6 months
CD4 count >350

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59
Q

When do you hold giving the BCG vaccine to neonates who are HIV positive?

A

Delay until ART started and immunolgically stable

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60
Q

What vaccine do you have to be cafeful with?

A

Rubella if severe immunodeficiency!

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61
Q

What do you do in breastfed neonate when mother declines or cannot tolerate ART?

A

Continue neonatal prophylaxsis throughout breastfeeding until 1 week after cessation

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62
Q

What are the normal CSF parameters on LP?

A

Opening pressure-<20
WBC <5
Protein 15-45
Glucose->60% serum glucose

Low glucose: TB, bacterial, crypto, ca

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63
Q

How long until starting ARVs with crypto meningitis?

A

4 weeks + clinical improvement

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64
Q

What is the most common cause of meningitis in AIDS?

A

Cryptococcus neoformans

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65
Q

What is the best test for crypto meningitis?

A

CRAG (CSF more than serum)
India ink used as well (black background with white circular fungus)

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66
Q

Tx of Cryptococcal men?

A

Reduce opening pressure by 50%, keep repeating therapeutic LPs
Induction tx:
Preferred: single dose liposomal ampho B plus 14 days flucytisone and fluconazole
Alternative is IV ampho B (1 week) + flyucitosine (14 days) + fluconazole (8 weeks)

Consolidation:
8 weeks fluconazole 800mg and then maintenance fluconazole 200mg
Monitor renal function when using fluconazole

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67
Q

If CDA<100 what do you do in terms of crypto meningitis?

A

Do a POC test, if positive do an LP an if this is positive treat
If LP negative, give prophylaxsis with fluconazole

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68
Q

Do you perform toxo IgG or IgM?

A

IgG, never do IgM
IgG shows they have been exposed it is used in conjunction with imaging

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69
Q

What is toxoplasmosis?

A

Caused by toxoplasma gondii
CD4<100, patients are seropositive IgG
CNS toxoplasmosis involves altered mental status, seizure, focal neurological deficits
Ring enhancing lesions on imaging

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70
Q

Tx of toxoplasmosis?

A

Do not use steroids!
Pyrimethamine and sulfadiazine
Alternatives (high dose cotrimox)

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71
Q

What are the most common causes of mass lesions in CNS?

A

Toxoplasmosis
Lymphoma
Tuberculoma

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72
Q

What causes multiple brain lesions in HIV opportunistic infections?

A

Toxo
TB and Lymphoma can be multiple or single

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73
Q

What is special about PML lesion?

A

Does not cause mass effect

74
Q

What are enhancing vs non-enhancing lesions?

A

Enhancing: toxoplasmosis (ring), lymphoma (ring or diffuse), tuberculoma (diffuse)
Non enhancing: crypto and PML

75
Q

What the common lung pathologies in AIDs?

A

PCP
MTB
Bacterial Pneumonia
Fungal infections

76
Q

What is the number one cause of pneumothorax in HIV patients?

A

PCP

77
Q

What is PCP?

A

Penumocystis Jivorecii (PCP)
Very common in ADIs, common if CD4 <200 or thrush
Normal CXR in 25% (CT much more sensitive)
Get diffuse Bilateral infiltrates that look like bat wings

78
Q

PCP vs TB in HIV?

A

PCP happens in late disease
CD4<200 with thrush typically
Get diffuse interstitial alveolar infiltrates with pnuemothorax, cysts and nodules

TB can present early or late disease
In early HIV its upper lobe infiltrates, cavities
Advanced HIV get pleural effusions, military TB

79
Q

What lung pathology has normal CXR in HIV patients?

A

PCP
TB
Fungal
Bronchitis

80
Q

What typically causes nodules or cavities in lung pathology?

A

Tumors, endocarditis, KS, TB, fungus, Nocardia

81
Q

When do you start ARVs in TB?

A

Within 2 weeks
Wait 4-8 weeks if TB meningitis

82
Q

What ARVs are preferred?

A

Dolutegravir
Efavirenz as alternative
(avoid PIs as interaction with rifampicin, can use rifabutin)

83
Q

What are some examples of PIs?

A

Lopinavir
Ritonavir
Indinavir

84
Q

Examples of NRTI?

A

Abacavir (ABC)
Emtricitabine (FTC)
Lamivudine (3TC)
Zidovudine (AZT)

85
Q

Examples of NNRTIs

A

Efavirenz (EFV)
Nevirapine (NVP)
Etravirine

86
Q

Examples of INSTIs

A

Dolutegravir (DTG)
Raltegravir (RAL)

87
Q

What are esophageal diseases in HIV?

A

CD4<100
Candida, CMD, HSV, TB
Treat empirically with fluconazole

88
Q

What do you get in cystoisospora belli?

A

IgE rise

89
Q

HIV and relationship with malaria?

A

Associated with more severe malaria
Drug interactions common

90
Q

What are symptoms of visceral leish?

A

Fever, weight loss, hepatosplenomegalu and pancytopenia

91
Q

How do you tx visceral leish

A

Lipsomal ampho B and miltefosine

92
Q

How do visceral leish tests differ in HIV patients?

A

Negative skin test
Serology only picks up 50%
Need to do PCR of blood or tissue

93
Q

How does chagas present in HIV patients?

A

Reactivation with low CD4
Meningoencephalitis or brain abscess
Myocarditis
Erythema nodosum

94
Q

Dx of chagas in HIV?

A

Ideally 2 separate serologies (eg western blot and ELISA)
CSF microscopy

95
Q

Tx of chagas

A

Benznidazole or nifurtimox

96
Q

What does resistance to neviraprine commonly mean?

A

Also resistant to efavirenz

97
Q

How do you define treatment failure?

A

Ideally want CD4 and VL
VL is better indicator
VL<50, nothing needs to be done
VL 50-1000, enhanced adherence counselling
If VL 1000 and on NNRTI, need to change regimen
If >1000 need to switch regimen

98
Q

What are 2nd line regimens if tx failure?

A

-If non DTG based regimen, switch to DTG plus NRTI
-If already on DTG, switch to PI in combo with NRTI

99
Q

What is a common side effect of tenofovir?

A

Renal toxicity (fanconni syndrome)

100
Q

What do you need to check in Abacavir?

A

HLA-B5701
If this is positive, do not use abacavir

101
Q

What drug increases risk of MI?

A

Abacavir

102
Q

What are renal manifestations of HIV?

A

Glomerulonephropathies
ATN
Ig A nephropathy
Coninfection with HCV

103
Q

How do you manage dyslipidemia in PLHV?

A

Quit smoking
Healthy lifestyle
Consider statin

104
Q

What is the most common type of HIV worldwide? Europe/America?

A

HIV 1 is split into 4 groups- M (major) and N (New)
M then has subgroups, C is the most common worldwide and B is the most common in Europe and America

HIV 2 is less transmissible and Predominantly found in W Africa

105
Q

How is most HIV spread?

A

Sexual, up to 80% of the cases

106
Q

What are risks of HIV in vertical transmission/ Blood transmission/ occupational exposure?

A

Mother to child tx is 15-40% if the woman is not on ART, this goes down to less than 2% if they are on ART
Blood transfusion is 90% if the donor is HIV positive
IVDU is <1%

107
Q

How does acute HIV present?

A

Mono like syndrome
90% of people have fever then have symptoms like fatigue/rash/headache

108
Q

What HIV tests are positive in acute infection?

A

Viral load will be positive
4th generation ELISA, not 3rd gen!
Western blot will be negative

109
Q

Time from acute infection to late disease?

A

Roughly 7 years

110
Q

Most common cause of death in PLWH in developing world?

A

TB

111
Q

Who stage 1:

A

Mostly asymptomatic
Can be a bit generally unwell

112
Q

WHO stage 2?

A

Weight loss <10%
Recurrent URTIs
Recurrent oral ulcers
Some skin changes such as saborrehic dermatitis, shingles, fungal nail infections

113
Q

WHO stage 3:

A

Chronic diarrehea
Weight loss >10%
>1month of fever
Thrush, hairly leurkoplakia
Pulmonary TB or lymphatic TB
Bed ridden <50% month
Unexplained anaemia, thrombocytopenia or neutropenia
Severe bacterial infections such as pneumona, pyomyositis, osteomyelitis
Acute necrotising ulcerative gingivitis

114
Q

WHO Stage 4:

A

Wasting defined as weight loss >10% plus chronic diarrhoea or prolonged fever
Extrapulmonary TB
Recurrent severe bacterial Pneumonia
Bed ridden >50% of previous month
HIV encephalopathy, HIV assoc nephropathy
Kaposis sarcoma, CNS or NH lymphoma, invasive Cervical ca
Any of the classical OI: PCP, toxo, crypto, MAC, esophageal candida, PML, Disseminated mycosis, chronic cryptosporidosis, chronic herpetic ulcers, CMV

115
Q

What are the goals of ART?

A

Reduce Viral load ideally to undetectable <20-30 copies
Increase CD4 count
Sustain low viral load for as long as possible
Prevent further transmission

116
Q

What makes up the backbone of most HIV regimens?

A

Typically two NRTIs plus either an NNRTI/ Protease Inhibitor or Integrase inhibitor

117
Q

Examples of NRTI?

A

Tenofovir
Abacavir
Zidovudine
Emtricitabine
Lamivudine

118
Q

Examples of NNRTIs?

A

Efavirenz or Nevirapine

119
Q

Examples of Protease Inhibitors?

A

Often boosted with ritonavir:
Lopinavir/ritonavir
Atazanavir
Atazanavir

120
Q

Examples of Integrase Inhibitors?

A

Dolutegrair
Raltegravir
Bictegravir

121
Q

Side effects of NRTIs?

A

Lactic Acidosis (mitochondrial disorders)
Lipodystrophy
Neuropathy and GI disturbance

Tenofovir: Renal problems
Abacavir: Hypersensitivity reaction, need to check HLA-B5701, includes rash/GI disturbance/fever
Zidovudine: Anaemia, lipodystophy

122
Q

Side effects and draw backs of NNRTIs?

A

Not active against HIV type 2
Efavirenz– vivid dreams, Rash and hepatoxicity
Nevirapine– Rash and hepatotoxicity, men cannot start unless CD4< 400 and <250 in women

123
Q

Side effects of PIs?

A

GI disturbance, hepatotoxicity and dyslipidemia

Lopinavir/Ritonavir mainly causes diarrhea
Atazanavir can cause jaundice

124
Q

Main side effect of Dolutegravir?

A

Weight gain
Generally very well tolerated drug

125
Q

Main HIV ART regimen?

A

Tenofovir + Lamivudine+Dolutegravir

126
Q

What should your initial assessment of newly positive HIV patient include?

A

BMI
WHO staging
TB symptom screening
CRAG (if CD4 <200)
Serology hep B and hep C
Screen for other co-morbidities or OIs
Suitability to starting ART

127
Q

How do you monitor ART and HIV patients?

A

Initially CD4 and VL, repeat at 6 months and then every 12 months
Can stop looking at CD4 if patient stable
VL is main thing you want to monitor

128
Q

What is treatment failure classed as?

A

Clinical– New or recurrent WHO stage 4 after 6 months of ART, TB can indicate failure
Virological failure, VL >1000 copies, repeated at 3 months and after 6 months
Immunological: Fall of CD4 to baseline or persistently <100

Consider Why? Adherence or resistance?

129
Q

What vaccines do HIV patients get?

A

HBV and influenzez
Pneumonia as well
MMR and VZV if CD4 is preserved
Consider YF and BCG

130
Q

What do you do if someone’s VL is >1000 copies at check up?

A

Switch off NNRTI if on one
Provide adherence counselling and repeat VL at 3 months, if >1000 then regimen needs switched

131
Q

What ART has significant interactions with TB drugs?

A

Lopinavir/Ritonavir

Dolutegravir or Efavirenz good in TB

132
Q

When do you screen CRAG?

A

When CD4 <100
If positive need an LP, if LP negative treat with fluconazole 800mg 10 weeks
If negative, give low dose fluconazole as prophylaxsis

133
Q

What ART do you want a patient who has HBV and HIV on?

A

Tenofovir and Lamivudine or Emtricitabine

134
Q

When do you give co-trimoxazole?

A

When CD4<350 or <200 in developed setting
Prevents toxoplasma and PCP
Also reduces risk of malaria and other bacterial infections

135
Q

Who gets Isoniasid therapy?

A

Screen for active vs latent TB
Everyone gets 6-9 months INH regardless of CD4 count
If high prevalence of TB, need 36 months

136
Q

Most common cause of CNS mass in HIV patients?

A

Toxoplasma Gondii

137
Q

How dose Toxoplasma present?

A

Ring enhanced lesions seen on CT
Altered mental status, focal neurology such as weakness and seizures

138
Q

Tx of Toxoplasma?

A

Pyrimethamine and Sulfadiazine

139
Q

How does PML present?

A

Subacute, clumsy, weakness, difficulty speaking
White matter lesions with no mass effect on CT
Caused by JC virus, no tx need to start ART!

140
Q

Most common cause of retinitis?

A

CMV causes ‘cheese and ketchup lesions’
Tx is valgancyclovir and intravitreal gancyclovir injections

141
Q

What should you suspect in HIV patients with oral thrush?

A

PCP

142
Q

How do you treat PCP?

A

Co-trimoxazole for 21 days
Consider steroids if low oxygen sats

143
Q

What causes oral hairy leukoplakia? Treatment?

A

Caused by EBV, need to start ART

144
Q

What causes Kaposis sarcoma? Tx?

A

Human herpes virus 8
Chemo and ART

145
Q

What can mimic Kaposis sarcoma?

A

Bacillary angiomatosus caused by bartonella henslae
Tx is doxycycline

146
Q

Match the clinical presentations to disease:
-Altered mental status, acute focal abnormality and seizure
-Stength ok, but slow mentation
-Pain in feet and reduced DTR
-Cauda equina syndrome
-Subacute progressive deficits
-ICP elevation

A

-Toxoplasmosis
-HIV dementia
-Sensory neuropathy
-CMV radiculitis
-PML
-Cryptococcal meningitis

147
Q

When do you suspect HIV assoc lymphoma?

A

Confusion/weakenss/focal signs and seizures
Suspect if no response to toxoplasmosis treatment

148
Q

What causes syphillis? Tx?

A

Treponema Pallidum
Tx is pen G

149
Q

What other co-morbidities does HIV increase risk of?

A

Osteoporosis and osteopenia
MI and stroke
Dyslipidemia
Cervical and anal cancer
HIV assoc dementia
HIV associated nephropathy

150
Q

How does HIV increase risk of CVD?

A

Dyslipidemia
Lipodystrophy
Chronic inflammation
Vasuclar and endothelial dysfunction

151
Q

Most common type of renal abnomrlaity in HIV?

A

HIV assoc nephropathy
-proteinuria, enlarged kidneys, much more common in Black’s
Need SRT, steroids and ACEi

152
Q

What does P24 antigen correlate to?

A

Viral load
Decreases in asymptomatic period

153
Q

Which HIV tests in acute period?

A

Viral load
P24 will be positive after about 10 days
Antibodies are detectable within 4-6 weeks
4th generation ELISA includes P24 so will be positive in acute infection window

154
Q

What do you do if screening of CRAG unavaible?

A

Initiate fluconazole if CD4 <100

155
Q

Do you use steroids in induction phase of treatment of Cryptococcal meningitis?

A

NOT recommended

156
Q

Most common cause pf Pneumonia in HIV patients?

A

Strep Pneumoniae
Just like non HIV!

157
Q

What OIs typically occur at
CD4 <200
CD4< 100
CD4 <50

A

<200: PCP, histoplasmosis, cocci, candida
<100: Toxoplasmosis and crypto
<50: MAC, CMV and PML

158
Q

How does TB present in HIV patients?

A

Early disease: Upper lobe infiltrates, cavities and bronchogenic spread
Advanced: Pleural effusions, miliary TB

159
Q

If Dolutegravir regimen failing, what do you switch to?

A

Boosted PI eg lopinovir/ritonavir plus an NRTI

160
Q

What are the main issues with efavirenz?

A

Resitance
It has a long half life so essentially becomes monotherapy ART if adherence issues

161
Q

Most common resitance genes assoc with NNRTIs?

A

K103N and Y181C

162
Q

What can you do to anti TB drugs in HIV patients if not wanting to change ART?
If do change ART, what is suitable?

A

Change rifampicin to rifabutin, decrease dose of rifabutin in half to avoid toxicities
You cannot give rifabutin with TAF, Bictegravir or elvitegravir

Or modify ART: Switch to Efavirenz or double dose of lopinavir/ritonavir

163
Q

What do you do in IRIS assoc TB infected HIV patients?

A

4 week course of steroids
No need to interrupt ART or anti-TB drugs

164
Q

How do you modify anti-fungals when pt on ART?

A

Replace itraconazole to posiconazole or voriconazole
Or increase itraconazole dose
Extend duration of Ampho B induction

165
Q

How do different ART drugs affect itraconazole?

A

Efavirenz reduces itraconazole
Lopinavir/ritonavir increases itraconazole levels
Integrase Inhibitors do not interact with TB drugs

166
Q

How does ART affect anti-malarials?

A

Efavirenz increases Artesunate and amodiaquine
Efavirenz decreases atemether/lumefantrine
PIs decrease artemether and increase lumefantrine (monitor for toxicity with QTc)

PIs decrease atovaquone/proguanil efficacy, consider other prophylaxsis

167
Q

How does HIV affect parasitaemia?

A

2 fold higher prevalence of parasitaemia, inversely correlated with CD4 count
Increase prevalence of parasitaemia and parasitaemia density
2-3 fold increase in parasitaemia in HIV positive

168
Q

How does HIV affect clinical malaria?

A

2 fold increase in clinical malaria
Inversely correlated with CD4 count

169
Q

How does HIV increase risk of severe malaria?

A

Increased risk of severe malaria (12x) in stable country
Always test for HIV in a stable country when adult presents with severe malaria

170
Q

How does HIV postivie children with severe malaria increase risk of?

A

Increased prevalence/severity of anemia
Increased transfusion requirements
Increased prevalence of coma, hypoglycemia
Increased prevalence of concomittant bacteremia

171
Q

Does HIV infected individuals with severe malaria increase risk of death?

A

YES

172
Q

How is haemoglobin/Anaemia affected in malaria infected HIV individuals?

A

Greater impact on haemoglobin decline and slower recovery
Higher incidence and longer recovery time from Anaemia

173
Q

Summaries effect of HIV on malaria

A

Increased prevalence and density of parasitaemia
Severity of malaria increased
Treatment efficacy not affected
Haemoglobin levels lower
HIV individuals use more anti-malarials

174
Q

How does malaria affect HIV?

A

Temporary decline of CD4- can be cumulative with recurrent malaria infections, see an excess decline of CD4 count
Increases viral load
Has not yet been shown to impact morbidity/mortality

175
Q

What can help prevent malaria in endemic countries?

A

Co-trimoxazole, this is not a treatment!

176
Q

Can malaria impact transmission of HIV?

A

Where HIV prevalence high, seems that malaria increases risk of transmission
Not proven in low prevalence HIV settings

177
Q

Summarise impact of malaria on HIV?

A

Transient increase VL
Transient decrease CD4
Faster progression to AIDS not been demonstrated
Reduces specificity of HIV RDTs

178
Q

What are the interactions between HIV and malaria in pregnant women?

A

Increases severity of Anaemia
Worse birth outcomes
Higher maternal HIV RNA
Higher prevalence/intensity of placental and peripheral parasitaemia

179
Q

What anti-malarial do you avoid with efavirenz? zidovudine?

A

Do not give artesunate/amodiaquine increases risk of hepatitis with efavirenz and nevirapine
Do not give artesunate/amodiaquine with AZT increases risk of neutropenia

180
Q

What do NNRTIs and PIs do to artemesinin?

A

Reduce concentration of artemesinin
PIs increase concentration of partner drug

181
Q

What anti-malarial do you avoid in HIV patients being treated with co-trimoxazole?

A

Artesunate and sulfadoxine Pyrimethamine

GORGAS (33 decks)

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