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General (Long) > HIV > Flashcards

HIV Flashcards

1
Q

Risk factors for HIV infection? (4)

A

Vertical

Transfusion

IVDU

MSM/Sexual

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2
Q

Clinical presentations of HIV - P in PRICMCP?

A
  1. Initial symptoms that led to a diagnosis
  2. Dx date
  3. Has the patient had a seroconversion illness (≥50%): symptoms similar to glandular fever - fever, lymphadenopathy, rash, arthralgia, myalgia, N+V, meningism, oral candida.
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3
Q

What are the complications of HIV & it’s treatment you need to ask in history?

A
  • Infection: ask from top - have you ever had following infections that were thought to be caused by HIV? - brain (toxo, cryptococcal), eye (CMV retinitis), oral/food gullet/bowel (candida, oesophageal candida, CMV colitis), lungs (PJP, MAC), skin (chicken-pox/Herpes Zoster)
  • Malignancy: KS, NHL, primary CNS lymphoma
  • Accelerated atherosclerosis: CVD, CVD (+vascular/HIV dementia)
  • Kidney: nephrotic syndrome - either HIV nephropathy or drug-induced
  • Psychiatric: both disease & treatment side effects
  • Drug side effects: lipodystrophy, metabolic*** (lipid, diabetes - PIs, OP - tenofovir), hepatotoxicity, renal toxicity, psychic, PN.
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4
Q

HIV long PRICMCP?

A

P: initial symptoms, seroconversion illness (not associated with prognosis), date dx. Was there an AIDS-defining illness (e.g. PJP, KS, NHL. disseminated MAC, Toxoplasma, oesophageal candida, CMV).

R: Vertical, Transfusion, Sexual, IVDU.

I: current CD4 & VL (what were the lowest points - nadir?). Genotyping (?resistance, if so to what). How was the dx confirmed? Any LP, MRI/CT, BM biopsy (what did it show?)

C:

  • Infection: ask from top - have you ever had following infections that were thought to be caused by HIV? - brain (toxo, cryptococcal), eye (CMV retinitis), oral/food gullet/bowel (candida, oesophageal candida, CMV colitis), lungs (PJP, MAC), skin (chicken-pox/Herpes Zoster)
  • Malignancy: KS, NHL, primary CNS lymphoma
  • Accelerated atherosclerosis: CVD, CVD (+vascular/HIV dementia)
  • Kidney: nephrotic syndrome - either HIV nephropathy or drug-induced
  • Hepatitis: from drugs
  • Neuro-Psychiatric: both disease & treatment side effects, peripheral neuropathy**
  • Drug side effects: lipodystrophy, metabolic*** (lipid, diabetes - PIs, OP - tenofovir), hepatotoxicity, renal toxicity, PN.

M: Current & previous regime, compliance, treatment failure/resistance? It is a big issue if the patient does not know their drug…!***

C:

  • has the disease been under control? current CD4, VL, recent infective episodes
  • current inpatient (or outpatient) issue / current complication
  • Sexual contact***: contact traced? family & friends aware of diagnosis, have you disclosed sexuality, HIV status
  • impact - work, life, family - do you face discrimination?
  • Finance - how are they coping

P:

  • Understanding of disease, why adherence is so important, life-style change (due to CV risk), awareness of drug interaction (hence not to start without talking to physician)
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5
Q

When would you start the infection prophylaxis?

A

CD4 <200 → Bactrim for PCP and CNS toxo.

CD <50 → Azithromycin for MAC

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6
Q

OIs when CD count 200-500? (4)

A

TB

Pneumococcal pneumonia

Oral candida

VZV

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7
Q

OIs when CD4 50-200? (5)

A

PJP

Toxoplasma CNS

Cryptococcus

KS

NHL

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8
Q

OIs when CD4 <50? (3)

A

Disseminated MAC

CMV retinitis/colitis

Cryptosporidiosis

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9
Q

What investigations would you like to review for this patient with HIV?

A

T: HIV antibodies, HIV RNA VL, CD4 counts. Western blot (confirmatory).

E: concurrent diseases (Hep A/B/C), risk of latent infections (CMV Ab, syphilis Abs, Toxoplasma Abs), TB (quantiferon/TST), CD4+<200: Hep C RNA, Cryptococcal Ag, Stool for cyst/ova/parasites

CD4+<100: CMV PCR, Mycobacterial blood cultures, ECG, fundoscopy with pupils dilated.

Septic work-up to exclude potential OIs (blood culture, CXR, CRP, urine) + further investigations guided by symptoms (previous CSF, CXR/CT, flexi-biopsy…etc).

S: review previous CD4/VL trends (is the patient progression or non-progressor?, resistance testing

T: FBC, EUC, LFTs, HBA1C, fasting lipids, HLA B5701 (Abacavir), Genotype testing

S: MMSE does not work as HIV-dementia is subcortical. Luria test + Heel-toe walk → if abnormal, refer to neuropsych, ECG (ischaemic changes), TTE, urine MCS, ACR, PCR (nephritis/nephrotic), HbA1C, lipid profile, DEXA, CTB (microvascular ischaemic changes / vascular dementia)

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10
Q

How accurate is HIV Ab testing (i.e. ELISA or EIA)?

A

Sensitivity 99%

Specificity 90% in low-risk populations (FP due to recent vaccinations, other viral infections or autoimmune disease).

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11
Q

What is the earliest detectable test? So why would you do Ab testing?

A

HIV PCR RNA is the earliest detectable test.

Ab testing is still needed as the level of RNA may still be below the detectable range.

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12
Q

When would you start the HAART on this patient with newly diagnosed HIV?

A

Current guideline suggest that ALL should be treated regardless of CD4 counts or viral load.

This is based on START study → demonstrated that earlier treatment was a/w better composite outcome, prevention benefit, and public health.

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13
Q

Which drug would you avoid if the HIV patient has…

  1. IHD
  2. Significant psychiatric conditions
  3. Renal impairment
A
  1. IHD: Avoid abacavir
  2. Significant psychiatric conditions: avoid Efavirenze
  3. Renal impairment: avoid Tenofovir
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14
Q

What are the big 4 major side effects (groups) that are associated with HAART use?

A
  1. Cardiovascular
  2. Metabolic (DM, lipids, osteoporosis)
  3. Neuropsychiatric (PN, dementia)
  4. Renal (renal impairment, stone, FSGS, nephrotic syndrome)

Also lipodystrophy (facial, central adiposity, buffalohump)

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15
Q

How would you manage PCP in HIV?

Presentation:

Diagnosis:

Management:

A

Presentation: pneumonia

Diagnosis: CXR/CT - bilateral interstitial infiltrates

Management: Bactrim +/- steroids (if hypoxic)

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16
Q

How would you manage CMV in HIV?

Presentation:

Diagnosis:

Management:

A

How would you manage PCP in HIV?

Presentation: CMV retinitis or colitis

Diagnosis: biopsy + PCR

Management: Ganciclovir then Valganciclovir maintenance

17
Q

How would you manage Cerebral Toxoplasma in HIV?

Presentation:

Diagnosis:

Management:

A

How would you manage Cerebral Toxoplasma in HIV?

Presentation: neurological symptoms

Diagnosis: multiple ring-enhancing lesions on CTB, Toxoplasma Ab

Management: Sulfadiazine + Pyrimethamine (otherwise Bactrim - 2/3rd line)

18
Q

When would you cease Bactrim prophylaxis?

A

Once the CD4 count is >200 for at least 3 months.

19
Q

When would you give Acyclovir or Fluconazole/Ketoconazole prophylaxis in HIV?

A

As a secondary prevention (after one episode has already occurred)

20
Q

Differential diagnoses for neningism/focal neurology/seizures in patient with HIV? (5) what is your approach to investigating this?

A

Infection: Toxoplasma (CD4 200-500), TB (any CD4), Cryptococcus & other usual (e.g. HSV, EBV)

Malignancy: CNS lymphoma

Disease progression: HIV-encephalopathy

Others: Progressive multifocal leukoencephalopathy (PML)

Approach

Bloods: inflammatory markers, CD4/VL, cryptococcal, Toxoplasma serology.

CSF: raised protein, low glucose, HIV viral load (if high consider HIV-encephalopathy) cryptococcal/toxoplasma serology, mycobacterial culture, MCS, cytology, flow-cytometry, PCR for Ig-heavy chain (CNS lymphoma), PCR for JCV (PML).

Also do usual screen: EBV, HSV, VZV.

Imaging: MRI/CTB with contrast: ring-enhanced lesions, SOL.

Neurocognitive assessment.

21
Q

How would you manage disseminated MAC in HIV?

Presentation:

Diagnosis:

Management:

A

How would you manage disseminated MAC in HIV?

Presentation: insidious fever, diarrhoea

Diagnosis: AFB and Blood culture

Management: anti-mycobacterials: ethambutol, azithromycin, rifabutin.

22
Q

How would you manage Cryptococcal in HIV?

Presentation:

Diagnosis:

Management:

A

How would you manage Cryptococcal in HIV?

Presentation: headache, fever, meningism

Diagnosis: serum + CSF cryptococcal Ag + CSF culture

Management: Fluconzaole or Amphotericin B

23
Q

Management of Kaposi’s sarcoma in HIV? (3)

A
  1. HAART is the 1st line (1B) - i.e. optimal tx of HIV is essential. For some, this is all they need
  2. For limited disease-causing symptoms or cosmetic disfigurement - local chemotherapy (intralesional) or RTx
  3. Systemic chemotherapy (e.g. liposomal daunorubicin) is indicated for extensive cutaneous or visceral disease (symptomatic). Also indicated in IRIS (i.e. rapidly progressive KS within weeks after initiation of ART).
24
Q

What is IRIS?

A

Immune Reconstitution Inflammatory Syndrome, where there is paradoxical worsening of pre-existing infectious process following the initiation of ART.

25
Q

How would you manage IRIS in HIV? (3)

A

Must measure the balance between the benefit of early ART vs. induction of potentially serious IRIS. Usually starts from 1 week to a few months.

Risk is higher if CD4/HIV RNA VL is very low prior to commencing ART.

Approach:

  1. Treat the OI as early as possible
  2. Delay initiating ART for 2 weeks, but in setting of certain OIs (e.g. meningitis), ART may have to be delayed for longer: speak to ID.
  3. If already on ART, can generally be continued and commence Anti-microbials ASAP.
26
Q

Would you recommend organ transplant (say, kidney) for this patient with HIV? Could there be an issue?

A

HIV is not a contraindication.

Must have a serological control.

Overall survival similar to non-HIV patients

However but the rejection rate is higher.

27
Q

What is your approach to treatment failure in HIV patient? (4)

A
  1. Confirm compliance with family + optimize (check side effects, understanding)
  2. Exclude mal-absorption (from celiac disease, PPI)
  3. Exclude drug interaction: is patient taking any OTC, herbal, other medications?
  4. Viral genotype / resistance testing (tells you which drugs you can’t use) - however, do not stop the drug even if they are resistant (high-risk of clinical events)
28
Q

What is your approach to HIV and Hep B (a particularly good regime?) or C co-infection?

A

Monitor carefully for cirrhosis and HCC

Non-pharmacological Mx - e.g. moderation of ETOH consumption

Involve experts - however, principles are

Hep B: use Tenofovir based regime (active against both HBV and HIV) → Truvada (Tenofovir + Emtricitabine) is very effective so try and include this drug into the regime.

Hep C: use same DAAs, they have same outcome as HIV -ves.

29
Q

How would you manage HIV-TB coinfection?

A

Latent disease (TST >5mm is positive or Quntiferon) → treat with INH

Active disease: specialised area so consult ID but the principles are

  1. Start anti-TB ASAP
  2. The timing of commencing ART depends on CD4 and other clinical features. Generally aim to commence ART within the first 2 months of anti-TB therapy. However if CD4 count is low (<50), can consider commencing simultaneousl.y
30
Q

Pregnancy and HIV - approach?

A

The aim is to minimize vertical transmission whilst achieving/maintaining disease control for the mother (given complication of disease will be detrimental to fetus)

In general, the patient should be on ART regardless of CD4 or VL.

Consider pregnancy-safer drugs: TDF, emtricitabine (i.e. Trvada) + Dolutegravir or Darinavir.

Both partners (HIV +Ve and -ve) should have Post-exposure prophylaxis.

Infant need to be treated for 6 weeks.

Vaginal delivery is OK, unless VL <1000 copies (if so for c-section)

No breast feeding

31
Q

Is this HIV patient on contraceptive pill? Any concerns?

A

Potential drug-drug interaction may make OCP ineffective, can also affect drug concentration.

Patients should be educated on drug-drug interaction, provide written advice.

32
Q

Why do you want to do a viral genotype testing for HIV for treatment naive patient?

A

Because the prevalence of HIV drug resistance is about 6-16%. So must do a pre-treatment viral genotype testing.

33
Q

How does this patient’s comorbidities influence your choice of ART? (patient has a significant IHD, CKD, osteoporosis, depression/pSavesychosis, and on methadone program). (3)

A

Avoid Tenofovir as it is a/w tubulopathy (CKD) → phosphaturia → osteomalacia + osteoporosis.

Avoid Efavirenz (worsens HIV-associated dementia + neuropsychiatric)

Avoid PIs or Abacavir if Cardiovascular disease (worsens metabolic state) - use INSTIs

34
Q

What is your approach to managing this patient with HIV in the long-run?

A

Goal: suppression of VL, restoration of CD4, treatment adherence, minimise complications.

Confirm dx: review HIV VL, CD4, genotype testing.

A: screen & treat ***depression + neuropsych as these affect adherence that is critical.

S: screen for complications of disease & treatment

  • Cardiac: ECG (ischaemic changes), lipid profile, HbA1C (or OGTT), previous TTE/Angio
  • Metabolic: DEXA, Vitamin D, Calcium.
  • Renal: EUC, ACR, PCR looking for evidence of tubulopathy (tenofovir), hypophosphataemia
  • Neuropsych: previous neuropsychiatric assessment, if not examine for sub-cortical dementia (fine-motor control looking for slowing - e.g. Luria test + heel-toe walk)

T: non-pharm

  • Educate: risk of non-adherence → treatment failure, CV risk, drug-drug interactions, written information, HIV Australia
  • Preventing transmission*****: barrier contraception, inform partner of HIV+ve status, PEP
  • Infection prophylaxis: HIV patients has x150 risk of pneumococcal pneumonia
  • CV risk modification: diet (salt restriction, high fibre, avoid sat-fat, Mediterranean), weight loss, mod-exercise 5/7, smoking cessation*** - as they thnk they will die of HIV, moderation of ETOH
  • OP: calcium + vitamin D replacement, denosumab/bisphos if OP
  • Adherence: continued support, regularly check their understanding, warn side effects, write down side effects
  • Malignancy screening: age-appropriate + HPV/Anal cancer surveillance

T: Pharm

  • Manage HTN, dyslipidemia, DM
  • Infection prophylaxis: Bactrim (CD4<200), Azithrom (CD4<50), secondary if previous fungal
  • Usual regime: 2xNRTIs + INSTI (or PI). Usually 3-drugs, ask why if not on 3.
  • Close monitoring of OIs and appropriate treatment

Involve: family support, counselling, SW (financial support), neuropsychiatric assessment, HIV clinic

Complications + Ensure follow-up

  • 3 monthly CD4/VL monitor + for virologic failure
  • Depression, ongoing education, insight, social issues
  • Monitor for cardiovascular, metabolic, renal and neuropsychiatric complications as above.
35
Q

Which groups of non-HIV medications should you most lookout for complications in HIV long-case?

A
  1. Fluticasone: severe Cushing’s, OP, neuropsychiatric
  2. PPI: impairs drug absorption*** common, high-yield problem
  3. Methadone*** (some drugs, e.g. Efavirenz increases clearance of Methadone - acute withdrawal symptoms)
  4. Anti-arrhythmic (Amiodarone, Flecainide)
36
Q

What are the side effects of NRTIs? (3) Examples?

A

Zidovudine, Didanosine, Lamivudine, Stavudine, Abacavir.

BM supporession

Pancreatitis

Peripheral neuropathy

37
Q

Side effects of NNRTIs? (2)

A

Efavirenz, Nevirapine

Neuropsychiatric***

Hepatitis

38
Q

Side effects of protease inhibitors? (3)

A

PIs = -navirs.

Lipodystrophy

Insulin resistance & diabetes

Hepatitis

General (Long) (15 decks)

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