HIV Flashcards
Describe the demographics of HIV disease in the US in terms of gender, race, age and sexual preference
-1.2 million living with HIV/Aids in the US
- AA>white>hispanic (hispanic F>white F)
- AA have highest risk of infection but White men are more common in CO
- M>F
- nearly half of PLWHA in CO are over 50y/o
- MSM>heterosexual contact>IVDU>MSM and IVDU> perinatal
CDC estimates that approximately ___ people in the United States are newly infected with HIV each year
50,000
*Two thirds of these new infections occurred in gay and bisexual men
____ men and women were highly affected and were estimated to have an HIV incidence rate that was 8 and 16 times higher, respectively, than the incidence rate among ____ men and women
Black/African American
White
antivirals were created around
1996
MSM comprise of __ cases of HIV
2/3rds
*most women who have HIV are heterosexual
____ persons have died of AIDS in U.S
About __ in __ aren’t aware of their infection
Over 670,000
1 in 6
Describe the HIV1 and 2
-HIV-1 predominates in most of the world
- HIV-2 in West Africa and in countries with socioeconomic ties to West Africa (e.g., southern Europe, Brazil.
Clinically indistinguishable
HIV = obligate intracellular parasite, like every good virus
HIV belongs to a family called ___ and its genetic material is ___
retroviruses (retroviridae)
HIV’s genetic material = ssRNA
Human genome = dsDNA
how does HIV make its genetic material compatible with human genetic material to turn T-cells into virus factories?
viral reverse transcriptase
Describe how one becomes infected
Free virus binding and fusion Infection reverse transcriptase integration transcription assembly budding immature virus breaks free of the infected cell maturation
__ looks for any cell line that has a __ receptor on it
Gp 120
CD4
People with ____ cannot get infected with HIV
No functional CCR5
Targets for HIV based on CD4 receptors
- brain glial cells
- thymus bone/BM
- colon, duodenum,
- lymphocytes, blood
- lymph nodes
- lung, alveolar
- skin, Langerhan cells
Describe the transmission of HIV
- Anal receptive intercourse carries the greatest infection risk
- Oral receptive intercourse controversial
- Body fluids with high HIV titer: blood, semen, vaginal fluid, breast milk
- Body fluids with low HIV titer: sweat, tears, urine, saliva, feces (N.B. low does not equal zero)
Concurrent infection with ___ increases risk for HIV transmission
STDs, e.g., syphilis, HSV-2
*ulcerations= great risk for HIV to get in
What are body fluids with high and low HIV titer
High: blood semen, vaginal fluid, breast milk
Low: sweat, tears, urine, saliva, feces (N.B. low does not equal zero)
What STD may facilitate transmission of HIV
- Primary syphilis chancre
- Herpes simplex-2
*on penis or vulva
What are surrogate makers for HIV
- T4 lymphocytes (aka T cells or CD4)–> the more CD4 the better your immune system)
- Viral load
What happens with T4 over the course of HIV
Normal T4=600-1200/ml blood or >32%
-HIV takes out the general immune system (T4)–> drops over years –> therefore increase risk for opportunistic infections
What is considered AIDS in terms of T4 count
If T4 < 200 and/or <14%, a person is then classified as AIDS (acquired immunodeficiency syndrome)
How is viral load used as a surrogate marker
“Undetectable” <20 copies/ml
The higher the viral load, the “healthier” the virus
__ measures the relative “health” of the virus
Viral load (VL)
How can VL be used to monitor ART
If the medication is working, the VL should go down from baseline values, optimally, to <50 copies/ml for as long as possible
No one really dies of HIV per se, they die from ___ that can no longer be controlled with antibiotics, or cancers or other complications
overwhelming infection
*As T4 decreases and the immune system weakens, the threats from multiple opportunistic infections increases
AIDS-indicator conditions
- pneumocystis pneumonia
- Kaposi’s sarcoma
- esophageal candidiasis
- Cryptococcosis
- non-hodgkins lymphoma
*CD4+ cell count <200/mm3 or percent <14%
Signs of HIV infection prior to development of AIDS:
- generalized lymphadenopathy
- oral candidiasis (can scrape off)
- oral hairy leukoplakia (caused by EBV, cannot scrape off)
- herpes zoster/shingles
the most common opportunistic is ___. You are at increased risk if ____
PCP (Pneumocystis carinii pneumonia aka Pneumocystis jiroveci)
*a common soil fungus
Increased risk if T4<200/uL or 14%
- can cause respiratory distress and death
- Dx w/ sputum specimen
Prophylactic medication for PCP
trimethoprim-sulfamethoxazole as long as T4<200/uL or <14%.
What are sx of Kaposi’s Sarcoma?
- skin lesion
2. large pleural effusion due to pulmonary KS
EBV can cause:
- Mono
- Ring-enhancing lesion with edemaPrimary CNS lymphoma at autopsy
*Ring-enhancing lesion with edemaPrimary CNS lymphoma at autopsy
Mycobacterial Opportunistic Infections:
- Tuberculosis (TB)–> MOST COMMON OI on a global basis
2. M. avium complex (MAC)
When is a HIV pt at increased risk for Mycobacterium TB and mycobacterium avium (MAC)
- Tuberculosis (TB)– when T4 <500/uL
- M. avium complex (MAC):
when T4 <50/uL, with bacterima
Presentation of M. avium complex (MAC) and TB
MAC: GI presentation- wt. loss, abdominal pain, diarrhea–> disseminated MAC in intra-abdominal LAD
TB: pulmonary and extrapulmonary (cervical LAD)
How do you prevent toxoplasmosis
Toxoplasmosis (for IgG antibody-positive patients) also prevented by Bactrim.
Begin when T cells < 100/uL
How do you prevent MAC
Begin prophylaxis with azithromycin when T cells
< 50/uL
Goals of ART
- Maximally and durably suppress plasma HIV viral load
- Reduce HIV-associated morbidity and prolong survival
- Improve quality of life
- Restore and preserve immunologic function
- Prevent HIV transmission
Classes of of currently approved drugs
- Nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs)
- Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
- Protease inhibitors (PIs)
- Entry inhibitors
- Fusion inhibitors
- Integrase inhibitors
AVT take-home points
- Medication can be offered to anyone, regardless of CD4 count (immune status)
- Proven reduction in infectivity for patients on medications
- Multiple current recommended regimens are effective and durable (combo regimen, 1 pill QD)
- Getting people diagnosed, into care, and engaged in care are the big hurdles
Describe Post-exposure prophylaxis risk assessment
ask about:
- Sexual activity, type of sex
- Condoms?
- Insertive or receptive (top or bottom) - HIV status of partner known?
- Last HIV test for patient?
- Number of partners
- Drug use?
- Meth, cocaine, heroin
- Mode of use: smoked, injected, snorted, booty-bumped
- Needle sharing?
Common sx of acute HIV infection
- Fever
- fatigue
- wt. loss
- pharyngitis
- myalgias
- rash
- lymphadenopathy
- night sweats
- diarrea
**flu like
DDX of acute HIV infection
- Infectious mononucleosis
- “Viral syndrome”
- Streptococcal pharyngitis
- Secondary syphilis
- Viral meningitis
- Primary herpes simplex or 7. CMV infection
- Drug reaction
- Viral Hepatitis
- Disseminated gonococcal infection
How do you test for acute HIV infection
- Standard EIA test (HIV Ab and Western Blot) frequently negative in acute infection
* *4th gen NAAT testing now preferred - HIV viral load better for EARLY diagnosis
- Viral loads usually very high in acute infection (often >1 million)
Describe the sequence of HIV laboratory markers
- get infected–> HIV RNA plasma peaks in 10 days (VL test)
- then HIV-1 p24 Antigen a could days latter (VL 4th generation immunoassay)
- HIV antibody goes up around 23 days (Ab detection)
* ADD TOO SLIDE 49
Describe “Non-occupational Post-Exposure Prophylaxis” \
- Within 72 hours of a high-risk sexual encounter
- Usually consists of triple drug therapy for 1 month
- HIV tests done at baseline, 6 weeks, 3 months, and 6 months
PrEP (Pre-Exposure Prophylaxis) is good for what type of person
good for someone who participates in high risk activity
ie. local bath house, states there are multiple male sexual partners plus IV methamphetamine use
What is PrEP
Truvada (73% reduction in most adherent)
**ADHERENCE IS CRITICAL
What are the users barriers to PrEP uptake
- Unaware of HIV risk, PrEP availability, or how to access it
- No or delayed access to clinical preventive care
- Uninsured or unable to pay
- Adherence challenges
- Concern about disclosure and stigma
What are the providers barriers to PrEP uptake
- Unaware of intervention
- Uncertain how to deliver the intervention
- Wary of complexity and time involved
- Discomfort with assessing candidacy
- Uncertain how to bill for intervention
PrEP is recommended as one prevention option for the following adults at substantial risk of HIV acquisition
- Sexually active MSM
- Sero-discordant couples
- Recent bacterial STI
- High number of sex partners
- Hx of inconsistent or no condom use
- Commercial sex work - Heterosexually active men and women
- Sero-discordant couples
- Recent bacterial STI
- High number of sex partners
- Hx of inconsistent or no condom use
- Commercial sex work
- Living in high prevalence area - Injection drug users
- HIV uninfected
- Adequate renal fxn (Creatinine clearance ≥ 60 mL/min)
What ar additional recommended actions for someone on PrEP
- screen for hep B
- If HBV uninfected and susceptible → vaccine (MSM in United States should be vaccinated against HBV)
- If HBV-infected, treat for HBV (potentially with TDF/FTC [Truvada]) - screen and tx STDs
How do you prscribe PrEP
- Co-formulated FTC 200 mg/TDF 300 mg, 1 tablet daily (Truvada)
- No more than 90-day supply
- Renewable only if HIV testing confirms the patient remains HIV-uninfected
- Anticipate, at minimum, quarterly HIV testing
How should you counsel someone w/ PrEP
- Continued behavioral risk reduction
- Condom use is still recommended, Other STDs are still present - Importance of PrEP adherence
- Adverse events:
- Very well tolerated and safe
- May experience mild nausea in first few wks
Describe the F/U for PrEP
- 1 month, 2 month, then every 3 months
- HIV testing
- Every 3 months; document negative result - Evaluate and support adherence
- Continued risk-reduction counseling
- Condom use is still emphasized
- Assess for STD symptoms at each visit
- Screen asymptomatic patients every 3 months - Renal safety
- Test creatinine and UA at 1 and 2 months, then every 3 months while on PrEP
How do you discontinue PrEP
- HIV testing
- If HIV positive, stop PrEP
- Get resistance testing
- Establish linkage to HIV care
- Choose new ART regimen
- If HIV negative, risk-reduction support services - If person has chronic hepatitis B infection
- Check liver function tests (case reports of hepatitis flares after discontinuing TDF/FTC
Describe PrEP reimbursement
Public and private insurance so far is paying for PrEP, sometimes with a significant co-pay and sometimes not
ADAP funds cannot be used to pay for PrEP but that will be changing in Colorado in 6 months
For the uninsured (e.g., undocumented) Gilead will pay for 12 months
Describe what you should do if you have an occupational health care exposures
- Baseline testing on HCW
- Within 2 hrs start (ASAP)
- 28-day regimen:
Tenefovir
Emtricitabine
Dolutegravir - Follow-up in 3 days with ID
What are occupational health care exposures
- Needlestick, hollow-bore needle
- splitting
- biting
- urine, semen, saliva
- intact skin vs obvious cuts
- mucous membrane exposure
If you’re seeing mono-like symptoms, think about ___
acute HIV infection
*If a patient has unexplained thrush, herpes zoster or lymphadenopathy, think about HIV
___ transmission is common, and is the major risk factor for females
Heterosexual
Opportunistic illnesses are related to ___ NOT ___
CD4 T-cell count, not to viral load
Benefit of starting therapy at __ has now been demonstrated
CD4 >500/uL
*START WHEN YOU CAN!!
*be on therapy for life–> drug holidays increases risk for complications and CV dz
Treatment is typically with ___
3 active drugs, often in combination preparations
PLWHA have higher rates of __ and ___, and these problems help fuel the epidemic
mental illness and substance abuse
HIV/___ co-infection is common; liver-related mortality is high and greater than for mono-infected patients
HCV
*HIV can also cause cardiovascular disease
___ has returned as a major epidemic in MSM, especially HIV+ MSM
Syphilis
*HIV is an STD: think about it in patients with gonorrhea, chlamydia, herpes, etc.
