HIV Flashcards
What is Aids defined as ?
The outcome of chronic HIV infection and consequent depletion of CD4 cells.
Defined as CD4 count <200 cells/microL
or
the presence of any AIDS defining condition regardless of the CD4 count.
According to the WHO, name some populations that are most at risk for HIV
Men who have sex with men
Transgender people
People who inject drugs
Sex workers
Heterosexuals
Healthcare workers – needlesticks (3 per 1000)
How is HIV trasnmitted?
Blood, semen, pre-seminal fluid, rectal fluids, vaginal fluids, and breast milk
____ type of T cell is most relevant to HIV/AIDs
CD4 helper T cells
Why is it HIV hard to treat?
reverse transcriptase is error prone so the virus is constantly mutating
_____ are increased in blood smear of patients with HIV
monocytes
What is the first stage of HIV known as?
acute retroviral syndrome
What are some s/s of acute retroviral syndrome?
Nonspecific viral syndrome (fever, chills, diaphoresis, pharyngitis, lymphadenopathy, myalgias/arthralgias, cephalgia, fatigue)
What PE should you do if you suspect HIV?
HEENT, lymph, abdomen, skin
What labs should you order if you suspect HIV?
HIV testing, CBC, CMP, UA, Screen for additional STDs
Who should be tested for HIV?
Known or suspected sexual or hematologic exposure
Those with promiscuous sexual history (heterosexual or homosexual)
Known drug abuse, especially IVDU
Accidental needlestick
Pregnancy
Recent sexually transmitted infection
CDC recommends routine screening ages 13 - 64 years at least once in their lifetime
Name some of the HIV tests?
Serum HIV enzyme-linked immunosorbent assay (ELISA)
HIV rapid antibody test - screening test; 10-20 min
Serum Western Blot
T/F: All patients positive for HIV should be offered ART, regardless of their CD4 count
TRUE
How often should you check the CD4 count and HIV viral load?
Monitor CD4 counts every 3 - 6 months in patients taking ART consistently
What is the PrEP drug?
Truvada
If an HIV positive women becomes pregnant, what things do you want to consider?
Initiation of ART if HIV positive
likely C-section delivery based on viral load
Avoidance of breastfeeding if HIV+
Start zidovudine (Retrovir)
What is the protocol if a healthcare worker is exposed to HIV?
HIV antibody testing and HIV viral load at baseline, 6 weeks, 3 months, and 6 months
ART ASAP and continued x 4 weeks
tenofovir 300mg plus emtricitabine 200mg (combo drug - Truvada) plus dolutegravir (Tivicay) or raltegravir (Isentress) = triple therapy*
_____ is found in 5% of all HIV positive patients
TB
80% of secondary syphilis rashes occur where?
on the palms and soles of the hands and feet
What are the recommended vaccines that need to be up to date on a patient with HIV?
Pneumococcal vaccine
Inactivated influenza vaccine annually in season
Hepatitis A vaccine
Hepatitis B vaccine
Tdap vaccine
HPV vaccine for patients <45 years of age
Haemophilus influenzae type b vaccine
Do not administer ____ vaccines to a HIV positive pt
LIVE vaccines
What is the primary goal of ART?
suppression of HIV replication
What is the recommended medication therapy schedule like?
Combination therapy with at least three medications from two different classes to avoid resistance → combination is termed HAART (highly-effective antiretroviral therapy)
What are some classes of ART therapy?
Entry inhibitors
Fusion inhibitors
Non-nucleoside reverse transcriptase inhibitors (NNRTI)
Nucleoside and nucleotide reverse transcriptase inhibitors (NRTI)
Integrase inhibitors
Protease inhibitors
_____ was the first approved antiretroviral medication for HIV; often not well tolerated due to anemia
zidovudine/ZDV/AZT (Retrovir)
Nucleoside/Nucleotide Reverse Transcriptase Inhibitor, what is a major complication?
peripheral neuropathy
What are some examples of Nucleoside/Nucleotide Reverse Transcriptase Inhibitor?
(Truvada, Atripla, Stribild)
efavirenz (Sustiva)
etravirine (Intelence)
nevirapine (Viramune)
rilpivirine (Edurant)
doravirine (Pifeltro)
Name some examples of NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTIs
How do NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTIs) work? Are they well tolerated?
inhibit reverse transcriptase
well tolerated
What class?
Protease inhibitors
What are some key points to know about protease inhibitors?
Suppress HIV replication
Administered as combination therapy
Metabolized by cytochrome P450 system → high potential for drug interaction
Used to “boost” other regimens
____ function to block the entry of HIV into cells by blocking fusion to cell membrane or blocking receptors, Used as add-on therapy for patients with multidrug resistance
ENTRY/FUSION INHIBITORS
maraviroc (Selzentry)
- CCR5 antagonist
and
enfuvirtide (Fuzeon)
– Fusion Inhibitor
Are both included in what class?
ENTRY/FUSION INHIBITORS
raltegravir (Isentress HD)
cabotegravir (Vocabria)
dolutegravir (Tivicay, Tivicay PD
All fall in what category?
INTEGRASE STRAND TRANSFER INHIBITORS (INSTIs)
Slow HIV replication by blocking the HIV integrase enzyme needed for viral multiplication.
Allow for more rapid decrease in viral load versus other regimens
Integrase Inhibitors
fostemsavir (Rukobia)
What class?
Attachment Inhibitor
ibalizumab-uiyk (Trogarzo)
What class?
Post-attachment Inhibitor:
lenacapavir (Sunlenca)
What class?
Capsid Inhibitor
cobicistat (Tybost)
What class?
Pharmacokinetic Enhancer
When do CD4 count and HIV viral load need to be monitored?
checked every 1-2 months after regimen initiation/change
Every 3-6 months once stable
What is advanced HIV infection defined as ?
defined as CD4 count <50 cells/microL
What is AIDS defined as?
Defined as CD4 count <200 cells/microL
or
the presence of any AIDS defining condition regardless of the CD4 count.
Complaint of unpleasant taste or mouth dryness
Pseudomembranous (removable white plaques) or erythematous (red friable plaques) in the mouth
What am I?
MUCOCUTANEOUS CANDIDIASIS (oral thrush)
What is the treatment for MUCOCUTANEOUS CANDIDIASIS (oral thrush)?
clotrimazole 10 mg troches one PO 5 times a day x 14 days
fluconazole 100 mg po daily x 3 - 7 days
What is a MUCOCUTANEOUS CANDIDIASIS - fungal rash caused by? What is the treatment?
Tinea cruris
ketoconazole 2% cream bid
clotrimazole 1% cream bid
ORAL HAIRY LEUKOPLAKIA is caused by _____
Epstein-Barr virus
White lesion on lateral aspect of the tongue that cannot be rubbed off
Has corrugated appearance with fine or thick “hairy” projections
What am I?
What is the treatment?
ORAL HAIRY LEUKOPLAKIA
No specific treatment - resolves with ART
What is the treatment for genital herpes?
Treated for 5 - 10 days with:
acyclovir 400 mg po TID
famciclovir 500 mg po BID
valacyclovir 1000 mg po BID
Painful, vesicular lesions occurring along dermatome
What am I?
What is the treatment?
Herpes Zoster/Shingles
Treated for 7 - 10 days with:
famciclovir 500mg po tid
valacyclovir 500mg po tid
What is a way to prevent HERPES ZOSTER / SHINGLES?
Consider live attenuated zoster vaccine - Zostavax (ZVL) or inactivated Shingrix (RZV) for patients >50 years old with CD4 count >200 mcL
Caused by a pox virus
Seen in children, but common in HIV - infected adults
Umbilicated fleshy papules
Treated topically with liquid nitrogen
What am I?
What is the treatment?
MOLLUSCUM CONTAGIOSUM
imiquimod (Aldara) topical - off label
_____ is the most common cause of pulmonary disease in HIV infected patients
COMMUNITY ACQUIRED PNEUMONIA (CAP)
COMMUNITY ACQUIRED PNEUMONIA (CAP) is caused by what 3 bacteria?
Pneumococcal pneumonia
Haemophilus influenzae
Pseudomonas aeruginosa
Fever, cough, dyspnea, hypoxemia
Classic CXR findings - diffuse or perihilar infiltrates
Most common opportunistic infection with AIDS
Fungal in origin
AIDS-defining condition
What am I?
PNEUMOCYSTIS JIROVECI PNEUMONIA
How do you diagnose PNEUMOCYSTIS JIROVECI PNEUMONIA?
Dx through Wright-Giemsa stain of sputum, or direct fluorescence antibody testing of sputum
Serum lactate dehydrogenase elevated in 95%; positive serum beta-glucan test
What is the treatment for PNEUMOCYSTIS JIROVECI PNEUMONIA?
Rx: trimethoprim-sulfamethoxazole DS (Bactrim DS) po TID x 21 days + prednisone 80 mg taper x 21 days
Prophylaxis started for CD4 count <200 cells/mcL
Common AIDS complication / AIDS-defining condition
Typically caused by C. albicans
Dysphagia, or difficulty swallowing
Commonly diagnosed via EGD
What am I?
What is the treatment?
ESOPHAGEAL CANDIDIASIS
fluconazole 100 - 200 mg po qd x 14 - 21 days
Name some aids defining conditions?
PNEUMOCYSTIS JIROVECI PNEUMONIA
ESOPHAGEAL CANDIDIASIS
KAPOSI’S SARCOMA
Purplish, non-blanching lesions, either papular or nodular
Caused by _____ sarcoma associated herpesvirus, also known as HHV8
Lesions appear anywhere - inspect for occult lesions
May flare as part of Immune Reconstitution Inflammatory Syndrome
What am I?
What is the treatment?
KAPOSI’S SARCOMA
Resolve with effective ART
What are some treatments for wasting syndrome?
proper ART
megestrol acetate (Megace – appetite stimulant) 80mg po QID,
dronabinol (appetite stimulant / antiemetic) 2.5 - 5mg po BID,?
medical cannabis
anabolic steroids (testosterone)
What is the treatment for MYCOBACTERIUM AVIUM INFECTION? When should you treat a pt?
clarithromycin 500mg po bid plus ethambutol (EMB) 15mg/kg/day
Treated for at least 12 months after which may be discontinued if CD4 counts have exceeded 100 cells/mcL for 6 months while on antiretroviral therapy
Prophylaxis offered for all patients with CD4 count <50 cells/mcL (clarithromycin or azithromycin)
Encapsulated budding yeast found in soil and pigeon dung
Spread by inhalation
Starts as pulmonary nodules and/or infiltrates that spread to CNS
Gram stain of CNS fluid with budding, encapsulated fungi
What am I?
What is the treatment?
CRYPTOCOCCAL MENINGITIS
Treated with IV liposomal amphotericin B with PO flucytosine (Ancobon - antifungal), followed by PO fluconazole to complete one year of therapy
Most common retinal infection in AIDS patients
Retinal perivascular hemorrhages and white fluffy exudates
Rapidly progressive visual loss with involvement of optic nerve or retinal detachment
What am I?
What is the treatment?
CYTOMEGALOVIRUS RETINITIS
IV ganciclovir x 7 - 10 days plus valganciclovir 900 mg po BID x 21 days, then 900 mg/day maintenance
Causes CNS disease
Most common space-occupying lesion in HIV affected patients
Headache, focal neurologic deficits, altered mental status, seizures
Multiple contrast-enhancing lesions on CT scan
What am I?
What is another way to diagnose?
What is the treatment?
TOXOPLASMOSIS
Most have positive Toxoplasma serologic testing (may not mean active disease)
Treated with pyrimethamine (anti-parasitic) combined with sulfadiazine (antibiotic) and leucovorin (folic acid)
You should test for ______ at all CD4 counts
Tuberculosis
Need to test for _____ at a CD4 count at or below 250
Coccidiomycosis: Annual IgG and IgM serologic screening
Prophylactic fluconazole if positive until CD4 > 250 for > 6 months
Need to test for _____ at a CD4 count at or below 200
Pneumocystis
TMP-SMX in all patients for prophylaxis
Discontinue when CD4 > 200
Need to test for _____ at a CD4 count at or below 150
Histoplasmosis
Need to test for _____ at a CD4 count at or below 100
Toxoplasmosis: Bactrim
Cryptococcus
Need to test for _____ at a CD4 count at or below 50
Mycobacterium avium complex (MAC): check blood cultures
treat with azithromycin
