HIV Flashcards
what contributed to the decline of HIV/AIDs
safer sex programs
greater outreach to high-risk populations
who are the populations at risk of HIV/AIDS
- men who have sex with men
- transgender people
- people who inject
- sex workers
- heterosexuals
- healthcare workers
what are the ways HIV can be transmitted
- blood
- semen
- pre-seminal fluid
- rectal fluids
- vaginal fluids
- breast milk
- in utero
- during birth
NOT in saliva, sweat, tears, vomit, urine, nasal secretions
what has the highest and lowest HIV transmission rates
- anal receptive intercourse
- blood transfusion
describe the 6 steps of how HIV invades a cell
- fusion of HIV to host cell surface
- HIV RNA and viral proteins enter host
- viral DNA formed by reverse transcriptase
- viral DNA transported across nucleus and integrates into host DNA
- new viral DNA is used as genomic RNA and to make viral proteins
- new viral DNA and proteins move to cell surface and a new, immature HIV forms and is released
what is the first cell to come into contact with the HIV cell
dendritic cell
best when it’s a mature DC
what are the 3 steps of transferring of virus from DCs to CD4+ T cells
- DCs capture and bind HIV
- HIV traffics within DC
- HIV is transferred to CD4+ T cells via trans-infection
what are the 4 stages of HIV infection
- viral transmission/HIV acquisition
- acute HIV infection/acute retroviral syndrome (symptomatic)
- chronic HIV infection
- can be asx
- often follows early symptomatic HIV infection
- AIDS - advanced HIV infection
what must happen in order to be considered AIDS
CD4 ct <200 cells/uL OR presence of AIDS defining condition
a CD4 ct of <50 cells/uL means ?
advanced HIV infection
4 step stages of acute HIV infection
- viral penetration of mucosal epithelium
- infection of submucosal CD4 T cells, dendritic cells, and monocytes
- spreads to lymph nodes
- HIV viremia
acute retroviral syndrome can be asx for an average ____
10 years
s/s of acute retroviral syndrome
- nonspecific viral syndrome - fever, chills, diaphoresis, pharyngitis, lymphadenopathy, myalgias/arthralgias, cephalgia, fatigue
- spontaneous resolution
- infection latent until progression to AIDS
who should be tested for HIV?
- known or suspected sexual or hematologic exposure
- sexually active people
- known drug abuse, especially IVDU
- accidental needle stick
- pregnancy
- recent STI
CDC recommends routine screening ages 13-64 at least once
7 HIV tests
- serum HIV ELISA
- HIV rapid antibody test (10-20min)
- serum western blot
- serum p24 antigen
- serum HIV DNA PCR
- CD4 ct
- serum viral load (HIV RNA)
if the HIV test comes back positive, what are the next steps?
- confirm with western blot
- another ELISA
other testing for HIV
- pregnancy
- serum hepatitis B serology
- serum hepatitis C serology
- CBC w/ diff
- BMP or CMP
- UA, LFTs, fasting plasma glucose, lipid profile
- human leukocyte antigen-B*5701 testing
- order only when prescribing abacavir if positive - PPD, CXR
how to do lab monitoring for HIV pts
- offer ART regardless of CD4 ct
- monitor CD4 cts every 3-6 months
- monitor HIV viral load every 3-6 months
what is used for pre-exposure prophylaxis (PrEP)
tenofovir (truvada, drug class NRT1)
what is the prevention of perinatal transmission of HIV
- HIV testing of all pregnant women
- initiation of ART if HIV positive and likely C-section delivery based on viral load
- avoid breast feeding
what are the associated diseases of HIV? what are the tx of choice?
- TB - isoniazid + pyridozine (w/ sputum cx)
- syphilis - PCN
usual presentation of TB
upper lobe consolidations/cavitary lesions
+/-mediastinal or hilar adenopathy
how do you screen for syphilis
- rapid plasma reagin (RPR)
- venereal disease research laboratory (VRDL) test every 6 months
if someone presents with a small, painless sore on their genitals that healed by itself within 3-6 weeks, what type of syphilis do they have?
primary
if someone presents with nonpruritic, maculopapular rash on their palms and soles, what type of syphilis do they have?
secondary
5 additional measures to prevent HIV
- safe sex practices to avoid other STIs
- avoiding consumption of raw foods (toxoplasma, salmonella, campylobacter)
- avoid cleaning cat litter (toxoplasma)
- avoid cat scratches/bites (bartonella)
- avoid drinking tap water (crytosporidium
what is the perinatal HIV tx
- ART (if HIV positive)
- zidovudine (retrovir)
if a healthcare worker got exposed via need stick, what are the next steps
- HIV antibody testing and HIV viral load at baseline, 6 weeks, 3 months, 6 months
- ART ASAP and continued x 4wks
- triple therapy = tenofovir + emtricitabine + dolutegravir/raltegravir
what is started in all patients regardless of CD4 ct and must be tested for resistance before initiating
antiretroviral therapy (ART)
what is HAART
highly-effective antiretroviral therapy
combo therapy with at least 3 meds from two different classes to avoid resistance
what are the 6 classes of antiretroviral therapy
- nucleoside reverse transcriptase inhibitors (NRTI)
- nucleotide reverse transcriptase inhibitors (NRTI)
- non-nucleoside reverse transcriptase inhibitors (NNRTI)
- protease inhibitors
- entry inhibitors/fusion inhibitors
- integrase inhibitors
what antiretroviral therapy class has most of its agents complicated by peripheral neuropathy and often components of fixed dose antiretroviral combos?
nucleoside reverse transcriptase inhibitor
what antiretroviral therapy class stops the conversion of HIV RNA to HIV DNA by blocking reverse transcriptase
NRTIs
- nucleoside
- nucleotide
NNRTIs
what antiretroviral therapy class commonly leads to renal failure
nucleotide reverse transcriptase inhibitor
what must you monitor when taking nucleotide reverse transcriptase inhibitor
creatinine
usually leads to renal failure
what antiretroviral therapy class is usually well-tolerated and does not need special monitoring
NNRTIs
what antiretroviral therapy class blocks new HIV from maturing, therefore suppressing HIV replication
protease inhibitors
what antiretroviral therapy class is usually used to “boost” other regimens
protease inhibitors
what antiretroviral therapy class blocks HIV envelope from fusing with the CD4 membrane
entry/fusion inhibitors
what antiretroviral therapy class is used as add-on therapy for pts with multidrug resistance
entry/fusion inhibitors
what antiretroviral therapy class slows HIV replication by blocking HIV integrase enzyme needed for viral multiplication
integrase inhibitors
4 things to monitor for antiretroviral therapy
- resistance testing prior to initiating therapy, and during therapy if viral suppression is suboptimal
- adherence is key - stress importance/choose tolerable regimen
- lab monitoring for toxicity every 3-4 months
- CD4 ct and HIV viral load 1-2 months after regimen initiation/change, every 3-6 months once stable
5 tx goals for HIV
- reduce HIV-related morbidity and mortality
- prevent transmission
- prevent viruses from multiplying
- give immune system a chance to recover and fight infections and HIV-related cancers
- reduce risk of HIV transmission (including infected mother to unborn child)
3 definitions for AIDS
- outcome of chronic HIV infection and subsequent depletion of CD4 cells
- CD4 ct <200 OR presence of any AIDS defining condition regardless of CD4 ct
- advanced HIV infection CD4 ct <50
14 AIDS defining conditions
- mucocutaneous candidiasis
- oral
- fungal rash - oral hairy leukoplakia
- genital herpes
- herpes zoster/shingles
- molluscum contagiosum
- CAP
- pneumocystis jiroveci pneumonia
- esophageal candidiasis
- kaposi’s sarcoma
- wasting syndrome
- mycobacterium avium infection
- cryptococcal meningitis
- cytomegalovirus retinitis
- toxoplasmosis
complaint of unpleasant taste or mouth dryness with pseudomembranous or erythematous plaques
mucocutaneous candidiasis - oral candidiasis
usually seen as an inguinal rash
tinea cruris - fungal rash of mucocutaneous candidiasis
caused by Epstein-Barr virus that leaves white lesions on the lateral aspect of the tongue
oral hairy leukoplakia
small, grouped vesicles on penile shaft, labia, perianal skin, or buttocks
genital herpes
common manifestation of HIV that leaves painful, vesicular lesions occurring along dermatome
herpes zoster/shingles
often seen in children
umbilicated fleshy papules
molluscum contagiosum
most common cause of pulmonary disease in HIV infected pts
CAP
- p. pneumonia
- h. flu
- p. aeruginosa
most common opportunistic infection with AIDS
AIDS defining condition
fever, cough, dyspnea, hypoxemia
CXR -diffuse or perihilar infiltrates
pneumocystis jiroveci penumonia
common AIDS complication
AIDS defining condition
dysphagia, or difficulty swallowing
commonly diagnosed via EGD
esophageal candidiasis
AIDS defining condition that leaves purplish, nonblanching lesions
kaposi’s sarcoma
decreased caloric intake - anorexia, N/V
malabsorption
increased metabolic rate
disproportionate loss of muscle mass
wasting syndrome
spread by inhalation
encapsulated budding yeast found in soil and pigeon poop
gram stain of CSF with budding, encapsulated fungi
cryptococcal meningitis
rapidly progressive visual loss with retinal perivascular hemorrhages and white fluffy exudate
most common retinal infection in AIDS pts
cytomegalovirus retinitis
most common space-occupying lesion in HIV affect pts leading to HA, focal neurologic deficits, altered mental status, seizures, causing CNS damage
toxoplasmosis
if the CD4 <200 what could be the opportunistic infection
pneumocystis
if the CD4 <150 what could be the opportunistic infection
histoplasmosis
if the CD4 <100 what could be the opportunistic infection
- toxoplasmosis
- cryptococcus
if the CD4 <50 what could be the opportunistic infection
mycobacterium avium complex (MAC)
why monitor CD4 cts every 3-6 months?
- reflects degree of immune dysfunction
- reflects efficacy of therapy
why monitor HIV load every 3-6 months
- assesses level of viral replication
- provides prognostic information about disease progression
- reflects efficacy of therapy
Post-exposure prophylaxis for sexual and drug use exposures to HIV, and needlesticks is offered within ?
72h of exposure
how do you choose antiretroviral therapy?
- Prior treatment experiences
- Medication side effects
- Underlying conditions
- Convenience of formulation
- Genotypic resistance testing
- Results of resistance testing
→ 15 - 20% of treatment naive patients resistant!
which ART is metabolized by cytochrome P450 system → high potential for drug interaction
protease inhibitor
which ART allows for more rapid decrease in viral load versus other regimens
integrase inhibitors
May flare as part of Immune Reconstitution Inflammatory Syndrome
Kaposi’s sarcoma
Causes disseminated infection in late-stage HIV (CD4 count <50/mcL), with persistent fever, weight loss, usually a positive blood culture
MYCOBACTERIUM AVIUM INFECTION
Starts as pulmonary nodules and/or infiltrates that spread to CNS
CRYPTOCOCCAL MENINGITIS