HIV Flashcards
factors influencing the efficacy of PEP?
delayed initiation transmission of resistant virus variable genital tract drug penetration poor / non-adherence further high risk sexual exposures
factors increasing the risk of HIV transmission
high viral load of source
breaches in mucosal barrier - ulcers / trauma
menstruation / other bleeding - theoretical
ejaculation
non-circumcision
discordant VL in genital tract
HIV prevelence in sex workers
- western european
- central european
- eastern european
- Male CSW
- western european <1%
- central european 1-2%
- eastern european 2.5 - 8%
- Male CSW 14%
which medications are usually used for PEPSE
Truvada = tenofovir and emtricitabine OD
AND
Raltegravir BD 400mg
Timeframe from exposure for starting PEPSE
72 hours
ideally within 24 hours
At what risk of transmission is PEPSE indicated
> 1:1000 recommended
1:1000 - 1:10,000 consider
<1:10,000 not required
Is PEPSE required if the source is HIV +ve with an undetectable VL?
No - as long as on ART and taking reliably
<200 copies / ml
sustained for min 6m
risk of HIV transmission per exposure for receptive anal intercourse on average
with ejaculation
without ejaculation
receptive anal 1:90
with ejaculation = 1:65
without ejaculation = 1:170
risk of HIV transmission per exposure for insertive anal intercourse on average
not circumcised
Circumcised
insertive anal intercourse on average 1:666
not circumcised 1:909
Circumcised 1:161
Risk of HIV transmission per exposure for receptive vaginal sex
and insertive vaginal sex
Receptive vaginal sex = 1:1,000
Insertive vaginal sex 1:1219
If the source is known HIV +ve what is the risk of HIV transmission from:
- human bite
- semen splash to eye
- oral sex - insertive or receptive
- blood transfusion
- needlestick injury
- sharing injecting equipment
- human bite <1;10,000
- semen splash to eye <1;10,000
- oral sex - insertive or receptive <1;10,000
- blood transfusion 1:1
- needlestick injury 1:333
- sharing injecting equipment 1:149
If HIV transmission risk falls into the ‘consider PEPSE’ category - what factors would suggest it should be offered?
Source or patient has a diagnosed STI
breaches in the mucosal barrier - ulcers, trauma etc
Primary HIV infection in the source
Victim of sexual assault / trauma
more than one high risk exposure within 72 hours
menstruation or other bleeding
calculation for estimating HIV risk of transmission
risk the source is HIV positive x risk per exposure
management of a patient requiring PEPSE in ED
Sexual history
+
medical history
medication history incl OTC / alternative / recreational
smoking / alcohol
4th gen POCT
U+Es, LFTs
urine ACR
UPT if required + EC
1st dose hep B vaccine
management of a patient requiring PEPSE in GUM clinic
Sexual history medical history medication history incl OTC / alternative / recreational smoking / alcohol 4th gen POCT Send 4th gen serum sample bloods for STS, Hep B, Hep C STI screen U+Es, LFTs urine dip for proteinuria - if present send urine ACR UPT if required + EC hep B vaccine
What advice should you give a patient starting PEPSE?
rational for PEPSE
Drugs not licenced for PEPSE but commonly used
full course = 28 days
continue if baseline bloods return as +ve
usually minimal SE - sometimes GI upset or allergy
Baseline liver and renal function taken
Avoid further high risk sexual exposures - but if this occurs in the last 48 hours of course need to continue for another 48hr
safe sex, risk reduction advice
drug and alcohol advice
PEPSE not 100% effective
Return if develops rash or flu-like illness
take first dose immediately then remainder at same time daily
FU HIV test and PN
Initial FU after starting PEPSE
review bloods at 48 hours Check compliance and SE any symptoms of STIs 2 weeks STI test 3m repeat bloods for STS and HIV Plan for remaining Hep B vaccines - 3m and 12m
Management of <16yo requiring PEPSE
assess as per adult guidelines
if >13 and >35kg can use adult dose
and refer to HIV transition team or paeds HIV team for follow up
If <13yr or <35kg refer to CHIVA guideline and refer to paeds HIV team - medication and dose will be weight and age dependent
Management of a pregnant woman requiring PEPSE
Pregnancy does not alter the decision to start PEPSE
Calculate risk and offer if >1:10,000 and within 72 hours
POCT + 4th gen serum test
SHS incl HBV, HCV, STS
serum U+Es, LTFS
Urine dip
explain PEPSE medications unlicensed in pregnancy
recommendations for missed doses of PEPSE
always reinforce importance of adherence
<24 hours since last dose - take missed dose immediately and next at usual time
12-48 hours since last dose - continue PEPSE
> 48 hours since last dose - stop PEPSE
Management of a further high risk sexual exposure in the last 2 days of a patient taking PEPSE
Continue PEPSE for 48 hours after the last high risk sexual exposure
When should patients taking PEPSE be advised to return for an urgent review
if they develop a rash
or flu-like illness
may represent HIV seroconversion
Management of a patient who has a +ve baseline HIV test after PEPSE has already been started
continue PEPSE
review by HIV specialist
Alternative for raltegravir in PEPSE for patients who cannot take it
Dolutegravir (integrase inhibitor)
If a HIV +ve patient has a CD4 count <200/mm3 what should they recieve in addition to ARVs?
CD4 count < 200/mm3
should receive prophylaxis against Pneumocystis jiroveci pneumonia
= co-trimoxazole
Why is abacavir not recomended for PEPSE?
Hypersensitivity reaction in 8% of pateints
NRTI
What class of drug is Abacavir?
NRTI = Nucloside reverse transcriptase inhibitor
what is in truvada and what class of drug is it?
Tenofovir and Emtricitabine
Class = NRTI = Nucloside reverse transcriptase inhibitor
SE of Nevirapine and what class of drug is it?
Hepatotoxicity in 10%
some require transplant, can cause death
NNRTI = Non-Nucloside reverse transcriptase inhibitor
SE of Efavirenz and what class of drug is it
CNS side effects
drowsiness, dizziness, headache, insomnia, strange dreams, reduced concentration, seizures
NNRTI = Non - Nucloside reverse transcriptase inhibitor
What is in kaletra and what class of drug is it?
Lopinavir and Ritonavir
Protease inhibitor = PI
SE of kaletra (Lopinavir and Ritonavir)
Nausea and vomiting
diarrhoea
hyperlimidaemia
therefore co-administered with antiemetic and anti-diarrhoeal in PEPSE - no longer first line for PEPSE
SE of Maraviroc and what class of ARV is it?
few SE
well tolerated
CCR% receptor antagonist
Signs of PCP infection
CXR: bilateral interstitial pulmonary infiltrates (can present with other x-ray findings e.g. lobar consolidation or may be normal)
Exercise-induced desaturation.
Sputum often fails to show PCP
Bronchoalveolar lavage (BAL) often needed to demonstrate PCP (silver stain shows characteristic cysts)
Symptoms of PCP
dyspnoea
dry cough
fever
very few chest signs
HIV +ve patient - CD4 <200
Treatment of PCP
co-trimoxazole
IV pentamidine if severe
steroids if hypoxic ( reduce risk of respiratory failure and death)
What additional baseline
investigations do pregnant women who are newly diagnosed with HIV require (BHIVA)
No additional baseline investigations
Those routinely offered
If a HIV positive pregnant woman is not on ART when should it be commenced?
- As soon as able in 2nd T where baseline VL
≤30,000 copies/mL - Start of 2nd T or ASAP thereafter if baseline VL 30,000–100,000 copies/mL
- Within 1st T if VL >100,000 copies/mL and/or CD4
count < 200 cells/mm
All women should have commenced ART by week 24
A woman who presents after 28 weeks should start ART without delay
If ART commenced in pregnancy what should be started?
Start Tenofovir DF or Abacavir
with Emtricitabine or Lamivudine
Third agent - efavirenz or atazanavir
Management of an untreated HIV +ve woman presenting in labour at term
STAT dose - Nevirapine 200 mg
Commence oral zidovudine 300 mg and lamivudine 150 mg BD
And raltegravir 400 mg BD
And IV zidovudine for the duration of labour
Management of a women presenting in labour or with spontaneous rupture of the membranes (SROM) without a documented HIV test result?
Advised to have an urgent HIV test.
4th gen POCT and send serum sample
Act immediately on a postitive result - initiate interventions to reduce vertical transmission
recommended investigations on diagnosis of new HBV infection in a pregnant F with HIV co-infection?
Confirm viraemia
Quantitative HBV DNA, ‘e’ antigen status
AND hepatitis A, C and D tests
Test to assess hepatic inflammation/fibrosis and liver function
Which ARVs are recommended for treatment of pregnant women with HIV and HBV co-infection?
Tenofovir DF and emtricitabine or lamivudine should form the backbone
What is the recommendation regarding delivery route for a pregnant woman with HIV and HBV co-infection
Vaginal delivery can be recommended
IF the HIV VL is fully suppressed on ART,
Irrespective of HBV viral load
Management of an infant born to a woman with HBV
Neonatal immunisation +/- hepatitis B immunoglobulin commenced within 24 hours of delivery
BHIVA recommendations on invasive pre-natal diagnostic tests for women who are HIV +ve
Deferred until HIV viral load suppressed to <50 HIV RNA copies/mL
Can ECV be offered to HIV +ve pregnant women
Yes - if on ART and plasma viral load <50 HIV RNA
copies/mL.
HIV +ve pregnant women can be offered a vaginal delivery if the VL is less than……
plasma viral load of <50 copies/mL at 36 weeks
planned vaginal delivery should be supported
Recommended delivery method for HIV +ve pregnant women with a plasma viral load of 50-399 copies/ml at 36 weeks?
Consider pre-labour CS Take into account the actual viral load VL trajectory Duration on treatment Adherence issues Obstetric factors Patient preference and views
Recommended delivery method for HIV +ve pregnant women with a plasma viral load of ≥400 copies/ml at 36 weeks?
VL ≥400 HIV copies/mL at 36 weeks,
pre-labour CS recommended
For a HIV +ve patient with SROM in what timeframe should delivery be aimed for?
In all cases of term pre-labour SROM in HIV +ve women
Aim for delivery within 24 hours
When is Intrapartum intravenous zidovudine infusion recommended?
- women with a HIV VL >1000 copies/mL who present in labour or with SROM or are admitted for Pre-labour CS
- untreated women presenting in labour /with SROM and current VL is not known
- Consider in women on ART with a plasma HIV VL between 50 and 1000 copies/mL.
BHIVA advice re PEP for infants of HIV +ve mothers
2/52 zidovudine monotherapy if infant = V Low risk
- mother on ART > 10 weeks
AND
- 2 documented HIV VL <50 during pregnancy at
least 4 wk apart
AND
- Maternal VL <50 HIV at /after 36/40
Extend to 4 weeks zidovudine monotherapy:
• If the criteria above not all fulfilled but maternal HVL <50 HIV or infant born <34 weeks but most recent maternal VL <50 H
If infant at HIGH RISK - Use combination PEP = zidovudine, lamivudine and nevirapine
- maternal VL is >50 on day of birth, uncertain or unknown VL
when should neonatal PEP should be commenced?
As soon as possible after birth
At least within 4 hours
Maximum duration of infant PEP advised by BHIVA
4 weeks
Factors which reduce vertical transmission of HIV
Reduce risk from 25-30% to 1-2%
- maternal antiretroviral therapy
- mode of delivery (caesarean section)
- neonatal antiretroviral therapy
- infant feeding (bottle feeding)
Toxoplasmosis accounts for what % of cerebral lesions in patients with HIV
50%
Symptoms of toxoplasmosis in patients with HIV
constitutional symptoms
headache
confusion
drowsiness
CT findings of toxoplasmosis in HIV +ve patient
CT: single or multiple ring enhancing lesions#mass effect may be seen
management of toxoplasmosis
management: sulfadiazine and pyrimethamine
What stains with India ink
Cryptococcus neoformans
Most common cause of diarrhoea in HIV +ve patients
Cryptosporidium = most common cause of diarrhoea in patients with HIV infection.
Mycobacterium avium intracellulare and giardiasis are known causes of diarrhoea in HIV patients but are not as common
in what % of patients is HIV seroconversion symptomatic
in 60-80%
typical presentation of HIV seroconversion illness
Occurs 3-12 weeks after infection
sore throat lymphadenopathy malaise, myalgia, arthralgia diarrhoea maculopapular rash mouth ulcers rarely meningoencephalitis
