HIV Flashcards
What are the two types of HIV 1 and 2
HIV 1: 4 groups M(Major), N(New), O, P
M has C and B
HIV2: Less pathogenic and less transmissble, only in W. Africa
What is the risk of transmitting HIV to a child in HIV infected women without prophylaxis?
15-40% without ppx
<2% if ART is used
15-29% due to breast feeding
HIV transmission risk if donor is HIV positive
90%
What are forms of PREP you can use?
Tenofovir-based oral PREP, Dapivirine ring for women, Cabotegravir long-acting injection since 2022
What tests should you run in acute HIV infections?
HIV Viral Load, p24 viral antigen, Ag/Ab 4th generation ELISA. Western blot/Serology will be negative in the first week
Common clinical manifestations with C4 counts 100-200
PCP, Histoplasmosis, Extrapulmonary TB, ML
Common clinical manifestations in patients with CD4<100
Cryptococcosis, Toxolasmosis, Cryptosporidiosis, Candida, Microsporidiosis, CMV, MAC, CNS lymphoma
Definition of WHO Clinical 1
ASymptomatic, Generalized LAD
WHO Clinical Stage 2
Weight loss <10%, Recurrent oral ulces, angular cheilitis, pruritic papular eruptions, seborrheic dermatitis, shingles, fungal nail infections, recurrent upper respiratory infections
Definition of WHO stage 3
Weight loss >10%, chronic diarrhea , >1 month of fever, thrush, oral hairy leukoplakia, pulmonary or lymphatic TB, PNA, pyomyositis, osteomyelitis, acute necrotizing ulcerative gingitivits, anemia, neutropenia, thrombocytopenia, bed ridden for <50% of previous month
WHO Clinical stage 4 definitions
Wasting defined as weight loss>10%, chronic diarrhea, prolonged fever; may have OIs of PCP, toxo ,crypto, MAC, esophageal candida, PML, disseminated mycosis, chronic crypto, isosporiosis, chronic herpetic ulcers, CMV; extra pulmonary TB, recurrent severe bacterial pneumonia, kaposis, CNS or NH lymphoma, HIV encephalopathy, bed ridden >50% of previous month
How do you understand HIV infection in children
CD4% is helpful (not CD4); Recurrent invasive bacterial infections common and OIs are more agressive
NRTIs Class toxicities
Mitochondrial toxicity (lactic acidosis, neuropathy), lipodystrophy, GI disturbances
TDF
NRTI-Tenofovir. Preferred agent in WHo
-Once a day, Can have renal problems
-Can be active against HBV
What are the common NRTIs
Tenofovir, Lamivudine (3TC), emtricitabine (FTC) , Zifovudine (AZT), Stavudine, Didanosine, Abacavir
AZT side effect
zidovudine (AZT)-anemia, mitochondrial toxicity
d4T
Stavudine -twice a day, tolerated in the first few months but very toxic to use; lactic acidosis risk is high *DO NOT USE
Didanosine side effects
neuropathy, pancreatitis. DO NOT use with d4T
Abacavir side effects
hypersensitivity reaction -Test for HLA b5701 before. Rash is common
HIV drugs that cause lipodystrophy
NRTIs, but mostly d4T and AZT (Stavudine) and Zidovudine
Most common side effects of NNRTIs
Rash and hepatotoxicity
Efavirenz
WHO preferred NNRTI. Side effects of vivid dreams, rash, hepatotoxicity; use with TB and in pregnancy
Nevirapine
NNRTI. CD4 restrictions *must check CD4 first; Men CD4>400, Women CD4>250
Which drug class has a high rate of resistance
NNRTI (efavirenz), especially hard to stop without supervision because of prolonged half life
What are the general side effects of PIs
GI, Hepatotoxicity, dyslipidemia; metabolized by p450
Atazanavir
PI -boosted preferred, used in limited settings; 5-7% develop jaundice; cannot use with PPI
Lopinavir/Ritonavir
PI-can get diarrhea
Side effect of INdinavir
Kidney stones, renal toxicity
Common integrase inhibitors
Raltegravir, Elvitegravir, Dolutegravir, Bictegravir, Cabotegravir
Raltegravir
Integrase Inhibitor; Can use with TB, just need to increase dose ; good for neonates and childdren
Bictegravir
integrase inhibitor, but interacts with rifampin (do not use in TB)
Dolutegravir
Preferred WHO ; Integrase inhibitor; increase with Tb; can cause weight gain
First line HIV treatment
2 NRTIs + Integrase inhibitor (Tenofovir, lamiduvine, dolutegravir) Can also do efavirenz instead of dolutegravir
When do you start ART in OIs
TB: within 2 weeks
Crypto meningitis: 4-6 weeks
What are theh preferred medications in HIV-TB Coinfection
Dolutegravir or efavirenz (PIS should be avoided for rifampin interaction p450 metabolism)
Treat HIV with HBV
Start ART and regimen should have contain TDF/TAF AND 3TC
What is the definition of treatment failure in HIV
Clinical: new or recurrent WHO stage 6 months after ART (Or TB-WHO Class 3)
Immunological: Fall of CD4 to baseline, persistent CD4 below 100
Virological failure: VL>1000 after 6 months of ART
definition of primary ppx
use of drugs to prevent infection before it has happened (i.e. PCP, toxoplasma)
secondary ppx definition
use of drugs to prevent relapse of a previously seen infection
If clinical screening for TB is negative, what to do with ART and ppx
IPT should be offered for at least 6 months, but 36 months is recommended
What vaccines are recommended in HIV
HBV, Influenza; sometimes pneumonia HPV HAV Meningococcus ; live attenuated vaccines are contraindicated unless CD4 is preserved
22 year old woman with 1 week of headaches and fever, no weakness or seizure. HIV is positive. lumbar puncture shows 15 WBC, protein is 75, 100% LM, Glu is normal
Cryptococcoal meningitis
Management of cryptococcal meningitis
liposomal amphotericin B plus 14 days of flucytosine plus fluconazole
What is the length of conslidation therapy in crypto meningitis
8 weeks of fluconazole 800mg , then maintenance therapy is fluconazole 200mg ; postpone ART
Toxoplasma gondii : prevelance, acquired through, how to test, Treatment
Prevalence is high in Europe and Africa; usually oral ingestion but symptoms are usually from reactivation of latent infection, so test for IgG toxo; Focal neuro deficits, CT with ring enhancing lesion; treat with pyrrimethamine and sulfadiazine (or high dose bactrim), then 2ndary ppx
Toxoplasmosis
PML: Caused by what, CD4?, Sx, Findings on MRI, how to diagnose, how to treat
progressive multifocal leukoencephalopathy (PML); caused by JC virus , CD4 is <100, Subacute motor cognitive and visual symptoms, focal signs; white matter lesions on MRI, no mass effect, no enhancement; JC Virus will be + PCR in CSF, Start ART
22year old woman with 1 week of decreased vision, floaters in the left eye. HIV positive.
CMV Retinitis
Most common cause of retinitis in HIV? How to test? What do the lesions look like? Tx?
CMV Retinitis, CMV IgG+, 2/3rds have unilateral lesions, cheese and ketchup lesions; PO Valganciclovir + intravitreal GCV Injections (if sight threatening); PO valganciclovir for non-life threatening
difference between CMV and Toxo retinitis
In toxo: Encephalitis coexists in 50% of AIDS patients; photophobia floaters and decr visions are similar in both; uveitis is more common in Toxo; lesions are BILATERAL in toxo (unilateral, ketchup and cheese in CMV)
TB manifestations in HIV -CXR
early HIV: Upper lobe cavities
Advanced HIV: Miliary, pleural effusion, miliary pattern, disseminated disease
PCP: full name, CD4?, sx, CXR, Tx
Pneumocystis jirovecii , CD4<200, gradual onset fefver dry cough, dyspnea; Pneumothorax, diffuse interstitial infiltrates ; treat with TMP?SMX and if PaO2 <70, steroids
Third most common OI in endemic areas with a similar presentation to histo (fungal)
Talaromyces marneffei in SE Asia
How do you treat oral candida
2 weeks of clotrimazole , nystatin suspension (topical)
PO: Fluconazole x 2 weeks
What is oral hairy leukoplakia and how do you treat
caused by EBV, Raised lesion in the lateral borders of the tongue, hairy appearance, does not rub off; tx with ART
cystoisospora (secretory diarrhea, eosinophilia), Cyclospora (secretory diarrhea), Cryptospordium (secretory diarrhea), microsporidium (diarrhea, cholangitis, hepatitis, sinusitis)
HIV Neuro:
1. Strength OK but slow mentation
2. Cauda equina
3. Pain in feet, decreased DTRs
4. Seizures, focal decifits
5. Subacute progressive deficits
6. ICP Elevation
- HIV dementia
- CMV Radiculitis
- Sensory neuropathy
- Toxo
- PML
- Crypto
Most common non viral STD in HIV
Trichomoniasis-Treat with flagyl
In HIV, what mimics KS?
Bartonella, skin bone liver-bacillary angiomatosis
Treatment of visceral leish in HIV
Liposomal amphotericin and miltefosine
Woman 21year old has white patches in the mouth and papular pruritic eruption with no CD4 available. What WHO Stage? What tx?
Oral thrush: Stage 3
Tx: Start ARTs
What to know about HIV2?
They are not susceptible to NNRTI
There is a lower risk of transmission
They are mostly found in some areas of Western Africa
The prevelance is NOT increasing
RIsk of acquiring HIV after needle stick, not on ART.
<1% (approx 0.3)
Patient with pulmonary TB in HIV. What WHO stage?
Stage 3-start ARTs immediately
Which PI is associated with lower risk of metabolic side effects?
Atazanavir
Patient has a chronic middle ear infection, discahrge from the ear, chronic sinusitis. What WHO stage?
Stage 2
Patient admitted for acute weakness of one side of hte body-responding to bactrim. What WHO stage?
stage 4-toxo
Patient with herpes zoster HIV, what WHO stage
stage 2
Patient with KS in HIV. What WHO stage?
stage 4
What NOT to use with liver problems
nevirapine
Avoid what in anemia
zidovudine
Avoid what with renal problems
tenofovir
Avoid what in TB
Efavirenz
What are the best meds to use in chronic HBV
Tenofovir + lamivudine or Emtricitabine
What are the side effects of dolutegravir
hepatotoxicity if pre -existing liver disease, sleep disturbances, CNS problems, weight gain
What is definition of viral failure in HIV treatmetn
persistently detectable viral load >1000 copies/mL after 6 months of ART
What is the definition of clinical failure in HIV?
Occurrence of new or recurrent WHO stage 4 condition
risks for developing IRIS
Low CD4, high TB burden (can give RIPE+Steroids)
patient on ART x 3 years , no OIs. Then develops recurrence of prurigo, zoster, weight loss. Next steps?
Stage 2 WHO->make sure adherence and then can switch but is not necessary in stage 2
how do you diagnose HIV in low resource settings
2 or 3 positive RDTs successfully performed
