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Systems: Infection AB > HIV > Flashcards

HIV Flashcards

1
Q

How is HIV spread?

A
  • Sexual transmission
  • Injection drug misuse
  • Blood products
  • Vertical transmission
  • Organ transplant
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2
Q

When can a patient be tested for HIV without giving consent?

A

Unconscious patients can be tested if you think it is in the patient’s best interest

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3
Q

What does the HIV do?

A

Infects and destroys cells of the immune system especially Th cells that have CD4 receptors on their surface

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4
Q

Where are CD4 receptors found?

A
  • Lymphocytes
  • Macrophages
  • Monocytes
  • Cells in the brain and skin
  • Other
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5
Q

What happens in HIV?

A
  • CD4 count declines & HIV viral load increases
  • Increasing risk of developing infections and tumours
  • The severity of these illnesses is greater the lower the CD4 count (normal CD4 > 500)
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6
Q

When are most AIDS diagnoses made?

A

When the CD4 count <200

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7
Q

What is the pragmatic approach to HIV?

A

Consider symptomatic and asymptomatic disease

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8
Q

What is clinical stage 1 of HIV?

A
  • Asymptomatic

- Persistent generalised lymphadenopathy

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9
Q

What is clinical stage 2 of HIV?

A
  • Weight loss
  • Minor mucocutaneous manifestations
  • HZV infection
  • Recurrent URTI
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10
Q

What is clinical stage 3 of HIV?

A
  • Significant weight loss
  • Unexplained chronic diarrhoea
  • Unexplained prolonged fever
  • Thrush
  • Oral hairy leukoplakia
  • Pulmonary TB
  • Severe bacterial infections
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11
Q

What is clinical stage 4 of HIV?

A
  • Wasting syndrome
  • Encephalopathy
  • Progressive multifocal leukoencephalpathy
  • Cryptococci’s, extrapulmonary
  • Many others…
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12
Q

What types of infection are you more prone to with a CD4 count <350?

A
  • Thrush

- Skin changes

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13
Q

What types of infection are you more prone to with a CD4 count<200?

A
  • PCP
  • TB
  • Cryptosporidiosis
  • Kaposis lymphoma
  • Toxoplasmosis
  • Cryptococcal meningitides
  • CMV MAC
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14
Q

Is it AIDS or HIV?

A
  • Certain infections and tumours that develop due to a weakness in the immune system are classified as AIDS illnesses. If you have no symptoms then you have HIV infection only.
  • Virtually everyone with an AIDS illness should recover from it and then be put on antivirals to keep them free from any future illness.
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15
Q

Respiratory: AIDS defining conditions

A
  • TB

- Pneumocystis

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16
Q

Neurology: AIDS defining conditions

A
  • Cerebral t toxoplasmosis
  • Primary cerebral lymphoma
  • Cryptococcal meningitis
  • Progressive multifocal leucoencephalopathy
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17
Q

Dermatology: AIDS defining conditions

A

Kaposi sarcoma

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18
Q

Gastroenterology: AIDS defining conditions

A

Persistent cryptosporidiosis

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19
Q

Oncology: AIDS defining conditions

A

NH lymphoma

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20
Q

Gynaecology: AIDS defining conditions

A

Cervical cancer

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21
Q

Ophthalmology: AIDS defining conditions

A

Cytomegalovirus retinitis

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22
Q

What is the natural history of HIV?

A
  • Acute infection: seroconversion
  • Asymptomatic
  • HIV related illnesses
  • AIDS defining illness
  • Death
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23
Q

What happens when HIV antibodies first start to develop?

A

Primary HIV/Seroconversion

  • Approximately 30 - 60% of patients have a seroconversion illness
  • Abrupt onset 2-4 weeks post exposure, self limiting 1-2 weeks
  • Symptoms generally non-specific and differential diagnosis includes a range of common conditions (can present like glandular fever)
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24
Q

What do symptoms of seroconversion include?

A
  • Flu-like illness
  • Fever
  • Malaise and lethargy
  • Pharyngitis
  • Lymphadenopathy
  • Toxic exanthema
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25
Q

What is the treatment for HIV?

A
  • Not currently curable

- Combined ART taken as a combined pill once a day

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26
Q

What are the principles of antiretroviral therapy?

A
  • Different classes of drugs acting on different stages in HIV lifecycle
  • Combination antiretroviral therapy (cART) means at least 3 drugs from at least 2 groups
  • Adherence needs to be over 90% - support patient
  • cART can lead to a normal life but side effects can be significant eg metabolic, lipodystrophy,
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27
Q

Where do the treatments act?

A
  • Reverse transcription inhibitors
  • Integrase inhibitors
  • Protease inhibitors
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28
Q

When should ART be commenced?

A

-Consider starting all patients at diagnosis regardless of CD4
If CD4 < 350 cells/mm3 encourage patients to start treatment
-If CD4 < 200 need to start as soon as possible
-Any pregnant woman:start before third trimester

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29
Q

What should pregnant women know about their delivery?

A

They can have a vaginal delivery if their viral load is undetectable

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30
Q

What ART is first line?

A

Three drug combination with treatment adjustment if VL not adequately suppressed after 4-6 weeks of therapy

31
Q

What is the current life expectancy?

A

Life expectancy according to CD4 Nadir (lowest CD4 before starting therapy) in patient diagnosed aged 20

  • CD4< 100 age 52
  • CD4 100-200 age 62
  • CD4 >200 age 70+
32
Q

How long must patients be on treatment?

A
  • Once treatment is started it must be maintained for the rest of life.
  • It may need to change from time to time
  • Always a need fro antiviral therapy
33
Q

Why do treatments fail?

A

Poor adherence leads to viral mutation and resistance

Incomplete suppression

  • Inadequate potency
  • Inadequate drug levels
  • Inadequate adherence
  • Pre-existing resistance
34
Q

What types of antiviral drugs are there?

A
  • Nucleoside reverse transcriptase inhibitors
  • Non-nucleoside reverse transcriptase
  • Protease inhibitors
  • Integrase inhibitors
35
Q

What are the possible side effects of nucleoside reverse transcriptase inhibitors?

A
  • Lipodystrophy
  • Marrow toxicity
  • Neuropathy
36
Q

What are the possible side effects of non-nucleoside reverse transcriptase inhibitors?

A
  • Skin rashes
  • Hypersensitivity
  • Drug interactions
37
Q

What are the possible side effects of protease inhibitors?

A
  • Lipodystrophy
  • Drug interactions
  • Diarrhoea
  • Lipodystrophy
  • Hyperlipidaemia
38
Q

What are the possible side effects of integrase inhibitors?

A

Rashes

39
Q

How can lipodystrophy be treated

A

Change drugs (less likely with newer agents)

Cosmetic procedures

  • Facelift
  • Liposuction
  • Fillers
40
Q

What are the challenges of HIV care in 2018?

A
  • Osteoporosis
  • Cognitive impairment
  • Malignancy
  • Cerebrovascular disease
  • Renal disease
  • Ischaemic heart disease
  • Diabetes mellitus
  • The ageing patient
41
Q

How can HIV be prevented?

A
  • Behaviour change and condoms
  • Circumcision
  • Treatment as prevention (VL undetectable = untransmissable (pregnancy))
  • Pre-exposure prophylaxis (PrEP)
  • Post-exposure prophylaxis for sexual exposure (PEPSE)
42
Q

What is the future of HIV care?

A
  • Therapeutic vaccines
  • Long-acting injectable drug treatments
  • Cure – “kick-kill” strategies
43
Q

What is the epidemiology of HIV in Europe?

A
  • M > F
  • Variation between countries as to predominant route of spread
  • UK is a low prevalence area
44
Q

What is the main route of transmission within the UK?

A
  • Sexual

- Transmission by IVDU is actually <1% in the UK

45
Q

What is the predominant form of HIV?

A

HIV-1

46
Q

Describe the basic virology of HIV?.

A
  • HIV-1 attaches to cells with CD4 on surface (Th) lymphocyte cells with certain chemokine receptors
  • Integrase facilitates integration into host cell DNA
  • Contains protease enzyme, needed for mature virus progeny
47
Q

How is virus diversity produced?

A
  • Retroviruses use reverse transcriptase to convert RNA to DNA
  • There is lack of accuracy during replication fiving rise to virus diversity
48
Q

What family does HIV belong to?

A

A group of retroviruses called lentiviruses

49
Q

What does the virus require for replication?

A
  • Host cell

- RNA must be transcribed into DNA

50
Q

What is the genome of retroviruses made of?

A

2 single chains of RNA

51
Q

What specific form of HIV is responsible for the global HIV epidemic?

A

HIV-1 Group M

52
Q

Briefly describe how a virus replicates?

A
  • Binding and entry to host cell
  • Reverse transcription
  • Integration
  • Transcription
  • Assembly
  • Release and protease
53
Q

What is type of testing is used to diagnose HIV?

A

Antibody/antigen testing

54
Q

Why are lab tests carried out in the management of HIV infection?

A
  • Viral load
  • HIV resistance testing
  • Avidity testing
  • Subtype determination
  • Tropism testing
  • Drug levels
55
Q

What is the diagnostic window?

A
  • The period of time between exposure and seroconversion when markers of infection (antibodies) are not detectable
  • Testing during this period can give false negatives
  • Length of window varies
56
Q

What antibody/antigen testing is carried out?

A
  • 4th generation ELISA assays which allow simultaneous detection of antibody and antigen
  • Window period is 1 month
57
Q

What is HIV genome detection (viral load) used for?

A
  • Used to monitor the effectiveness of HIV treatment
  • Used for diagnosis in presence of maternal antibody
  • Detection of HIV RNA (range of 40 to >10 million genome copies / ml blood)
58
Q

How does resistance develop?

A
  • Acute infection
  • Chronic infection
  • Successful antiretroviral therapy
  • Therapy failure
  • Treatment interruption
  • Salvage therapy and failure
59
Q

How is HIV resistance testing carried out?

A
  • Sequencing of the polymerase and protease genes

- Identification of specific mutations that confer resistance to antiretroviral drugs

60
Q

What is HIV resistance testing used for?

A
  • Baseline at diagnosis
  • Suboptimal treatment response
  • Treatment failing
  • Want to change treatment for another reason
61
Q

What does tropism testing tells us?

A

Which co-receptor does the virus use to enter CD4 cells, required before using a CCR5 antagonist

62
Q

What does drug level testing tell us?

A

Compliance

63
Q

Do you have to tell your work when diagnosed with HIV?

A
  • If an HIV test is not required for your work then no
  • You may need to have an HIV test for a visa to work abroad
  • If involved in healthcare, you need to avoid exposure-prone procedures (EPPs) (may not apply if on effective treatment)
64
Q

How is HIV infection monitored?

A
  • CD4 lymphocyte count
  • HIV viral load
  • Clinical features
65
Q

What is the risk of transmisson of BBV to healthcare workers?

A

Percutaneous exposure (sharp instrument accidentally penetrating the skin) to:

  • HBV surface antigen positive blood up to 30% = (1:3)
  • HCV RNA positive blood ~ 3% = (1:30)
  • HIV positive blood ~ 0.3% = (1:300)
Mucocutaneous exposure (blood or other body fluid splashes into the eyes, nose or mouth or onto broken skin) to: 
-HIV positive blood <0.1% = (1:1000)
66
Q

What bodily fluids should be handled with the same precautions as blood?

A
  • Cerebrospinal fluid.
  • Pleural, peritoneal, pericardial fluid.
  • Breast milk.
  • Amniotic fluid.
  • Vaginal secretions, semen.
  • Synovial fluid.
  • Any other body fluid containing visible blood.
  • Unfixed tissues and organs.
  • Saliva – dental procedures
  • Exudate/tissue fluid from burns or skin lesions
67
Q

What is the risk with HIV and bodies?

A

-HIV may be recovered for many days after
death.
-Little risk unless leakage of blood or body fluids.

68
Q

What actions should be taken after blood/body fluid exposure?

A

First Aid:

  • Wash off splashes on skin with soap & running water.
  • Encourage bleeding if the skin has been broken
  • Wash out splashes in the eye, nose or mouth.
  • REPORT to senior manager or doctor AND to OHS.
69
Q

The risk of infection following blood/body fluid exposure is assed by considering…

A
  • The source of contamination
  • The extent of injury and the type of sharp (if any) causing it
  • The likelihood of B/C/HIV in the source
  • The vaccination history

Ideally the source should be tested with informed consent

70
Q

How is occupation exposure to HIV managed?

A
  • Should receive post-exposure prophylaxis

- Truvada and Kaltre within 48-72 hours of exposure and continued for 28 days

71
Q

How should HBV occupation exposure be managed?

A
  • Known responders who have completed course of vaccination= no prophylaxis or a booster
  • Non-responders= consider booster and reassure
  • Incomplete prophylaxis= complete vaccine schedule, accelerated course if severe risk
72
Q

How is HCV prevented following occupation exposure?

A
  • No vaccine available
  • No immunoglobulin available for PEP
  • No anti-viral therapy licenced for PEP

-Early treatment decreases risk of chronic infection →
important to test after exposure

73
Q

How can exposure to BBV in the health care setting be prevented?

A
  • Good basic hygiene with regular hand washing
  • Cover existing wounds or skin lesions
  • Take simple protective measure to avoid contamination of person and clothing with blood
  • Protect mucous membrane of eyes, mouth and nose from blood splashes
  • Prevent puncture wounds, cuts and abrasions in the presence of blood
  • Avoid sharps usage
  • Safe sharps handling and disposal
  • Clear up bodily spillages and disinfect surfaces
  • Follow procedure for the safe disposal of contaminated waste

Systems: Infection AB (12 decks)

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