HIV Flashcards
3 stages of HIV infection
Stage 1: Acute HIV infection
* 2-4 weeks after infection * Flu-like illness * Very viremic
Stage 2: Clinical latency
* Years to decades (if on ART) after infection * Usually asymptomatic * Not as viremic
Stage 3: AIDS
* CD4 count < 200 cells/mm * Opportunistic infections * If no treatment ~3y survival
USPSTF Screening Recommendations for HIV
One time screening for all adolescents and adults
Repeat screening in setting of risk factors
Annual screening for those at high risk
Every pregnancy
Available HIV tests
4th generation antigen/antibody test
* IgG and IgM antibodies * p24 antigen for early detection of HIV-1 (capsid protein of virion) * Converts 14-20 days after infection
NAT
* Qualitative or quantitative (viral load) * Converts about 10 days after infection
Rapid tests
* Capillary blood or oral swab * Most are antibody tests with 23-90 day conversion
HIV reporting requirements
Labs will notify state health department
States de-identify data and report to CDC
If positive rapid test, order confirmatory tests
If no confirmatory test done, report
Health department may contact you to follow up
What is PrEP?
Pre-exposure prophylaxis with Truvada (emtricitabine 200 mg / tenofovir disoproxil fumarate 300mg) 1 tab q day
Rectal protection in 7 days, vaginal protection in 20 days
Can be used during pregnancy/breastfeeding
Don’t abruptly stop if you have HBV
Good candidates for PrEP
- Any HIV negative person at high risk
- Sexual transmission
- Anyone with a partner living with HIV
- Sexually active within high prevalence area or social network
- Exchange sex for money/commodities
- Incarceration
- Diagnosis of STI
- Partner/s with unknown HIV status and any other risk factor
- People who use injection drugs
Testing needed before initiating PrEP
- HIV 4th generation
- HBV surface antibody and antigen
- Renal function
- STI’s
- Pregnancy test if indicated
Recheck creatinine clearance and STI screen every 6 month or PRN. HIV testing q 3 months
Post exposure prophylaxis (PEP)
Must start within 72 hours but earlier the better
Indicated: source person is known to be HIV positive and significant transmission risk
Case by case: significant transmission risk and source person HIV unknown
NOT indicated: > 72h after exposure or no substantial transmission risk
Prescribe: tenofovir disoproxil fumarate 300mg with emtricitabine 200 mg (it’s Truvada again!) once daily plus raltegravir 400 mg BID or dolutegravir 50 mg daily
Initial evaluation post HIV diagnosis
CD4 cell count with percent
Quantitative HIV RNA (viral load)
HIV resistance testing (repeated if defer treatment)
CBC, BMP, lipid panel, UA and creatinine clearance
Screenings for: TB, hepatitis, syphilis, CT, GC, TV, cervical dysplasia and anal dysplasia for high risk individuals
Vaccines: pneumococcal, influenza, varicella, HAV, HBV, HPV, MMR if needed
Pap screening guidelines for PLHIV
ASCCP guidelines do not apply to PLHIV
Do cervical pap at time of diagnosis and 6 months later
If normal, do annual repeat cervical pap
If normal x 3 years, space to q.3 years
If abnormal, do colpo and directed biopsy
Anal pap is indicated if any history of:
* Receptive anal intercourse * Prior abnormal cervical pap * Genital warts
Contraception
All methods are safe for WLHIV
Increased partner risk with nonoxynol-9 spermicides
May have small decrease in efficacy due to drug interactions with some ARV’s and systemic hormonal methods
Of note, Depo users may have slight increased risk of acquisition
Depo start in people at high risk for HIV recentely changed from 1 to 2
Intrapartum
if VL < 1,000 copies - plan for vaginal delivery, no need for zidovudine
if VL > 1,000 copies - plan on C/S around 38 weeks. IV zidovudine for 3 hours before CS (crosses placenta =
PEP/PrEP for baby)
Infant prophylaxis
Initiate as soon as possible after birth
Regimen depends on risk:
* Low risk - zidovudine * Higher risk - combined ART
Continued for 4 – 6 weeks
Breastfeeding
WHO, CDC, and AAP all recommend against WLHIV breastfeeding
Risk-benefit ratio favors formula when it is available
* In some countries, risk of malnutrition/infection/lack of formula outweighs risk of HIV acquisition
If a WLHIV breastfeeds, if at all possible:
* Maintain viral suppression with ART * Exclusively breastfeed * Consider infant PrEP
Serial infant testing and start ART if any positive HIV result
