HIV/AIDS Flashcards
1
Q
Treatment of HIV
A
- Treatment with antiretrovirals to prevent progression to AIDS
- With good adherence, patients may have near normal life expectancy
2
Q
Risk factors for development of AIDS
A
- Inadherence to treatment regimen (results in antiretroviral resistance)
- Inability to maintain close follow up with HIV treatment team
- Social factors and comorbidities contributing to complex medical problems, barriers to care, and symptom burden (mental illness, addictions, Hep B and C)
3
Q
Natural history of HIV infection
A
Transmission
- Blood
- Semen/vaginal secretions
Infection
- Targets CD4 cells (T cells especially, Monocytes, macrophages, dendritic cells) for replication
- Acute infection - cell death via HIV-induced cell lysis and activation of CD8 T cells
- Chronic infection – chronic immune activation due to HIV replication, which results in more CD4 apoptosis and reduced replacement by the thymus as thymocytes are also destroyed by HIV
- Acute seroconversion phase (weeks)
- Asymptomatic, or acute retroviral syndrome (flu like symptoms)
- Initial decline in CD4 count followed by recovery, typically back to normal levels - Clinically latent phase (years)
- Rapid turnover of viral and CD4 cells, gradual decline in CD4 count
- Asymptomatic or persistent generalized lymphadenopathy - Early symptomatic phase
- Cutaneous manifestations (e.g. herpes zoster, fungal nail infections, oral candidiasis, oral leukoplakia, seborrhoeic dermatitis)
- Unexplained weight loss
- Recurrent URTIs
- May see anemia, leukopenia, thrombocytopenia, lymphopenia - Advanced phase (CD4 < 200)
- Systemic manifestations (may involve every body system)
- AIDS defining illnesses (opportunistic infections, reactivation of latent viral/parasitic infections, esophageal candidiasis, heme malignancies, CMV, toxoplasmosis, Kaposi’s sarcoma, resp (Pulmonary TB, PJP, pneumonia) and GI tract disorders)
- HIV wasting syndrome
4
Q
Impact of treatment on progression of HIV infection
A
- Treatment at any point typically leads to some improvement in CD4 count and symptoms
- Antiretroviral treatment now typically offered to all HIV patients, regardless of CD4 count
- Watch for IRIS and ensure prophylaxis offered if patients meet CD4 threshold
5
Q
Characteristics of Advanced Phase HIV infection
A
Advanced phase (CD4 < 200)
- Systemic manifestations (may involve every body system)
- AIDS defining illnesses (opportunistic infections, reactivation of latent viral/parasitic infections, esophageal candidiasis, heme malignancies, CMV, toxoplasmosis, Kaposi’s sarcoma
- Resp (Pulmonary TB, PJP, pneumonia)
- GI tract disorders
- HIV wasting syndrome
6
Q
Characteristics of Early Phase HIV Infection
A
Early symptomatic phase
- Cutaneous manifestations (e.g. herpes zoster, fungal nail infections, oral candidiasis, oral leukoplakia, seborrhoeic dermatitis)
- Unexplained weight loss
- Recurrent URTIs
- May see anemia, leukopenia, thrombocytopenia, lymphopenia
7
Q
Pathophys of HIV infection
A
Transmission
- Blood
- Semen/vaginal secretions
Infection
- Targets CD4 cells (T cells especially, Monocytes, macrophages, dendritic cells) for replication
- Acute infection - cell death via HIV-induced cell lysis and activation of CD8 T cells
- Chronic infection – chronic immune activation due to HIV replication, which results in more CD4 apoptosis and reduced replacement by the thymus as thymocytes are also destroyed by HIV
8
Q
AIDS defining Illness
A
AIDS
- CD4 count < 200 OR:
- HIV related encephalopathy
- CMV retinitis with vision loss
- PJP pneumonia
- Invasive cervical CA
- Kaposi’s sarcoma
- Lymphoma
- CNS toxoplasmosis
9
Q
Immune reconstitution Syndrome
A
- Occurs upon initiation of ART, where the immune system suddenly ‘recognises’ a previously acquired opportunistic infection
- Results in overwhelming inflammatory response - can be fatal
- Manage by beginning prophylaxis against opportunistic infections if CD4 threshold met BEFORE initiation of ART (e.g. Septra for PJP with CD4 <200, azithro for mycobacterium avium with CD4 <100)
10
Q
How does HCV impact clinical picture of HIV
A
- HCV co-infection common amongst patients with HIV infection (HCV more readily transmitted through contaminated blood, but less likely to be transmitted sexually)
- HIV and HCV co-infection means progression of liver injury is more likely to occur, with time from infection to cirrhosis shorter
- HIV makes treatment with interferon-alpha and ribavirin even less successful, but newer agent direct acting antivirals may be used (watch for drug interactions with ART)
- Social factors that make treatment adherence difficult for HIV also make adherence challenging for HCV treatment
11
Q
How to navigate opioid prescribing in patients with history of addictions
A
- Clearly defined contract between patient and prescriber regarding conditions under which analgesic will be provided
- Grounds for termination of the contract (e.g. diversion, unauthorised dose escalation)
- Requirement for periodic random urine screening, if appropriate
- Understanding that any deviation fromt he terms will result in immediate discontinuation of the prescription without any further negotiation
- Consider consulting with a chronic pain physician with experience in managing addictions, if appropriate
12
Q
Complexities in the HIV population
A
- Higher rates of comorbidities
- More likely to have at least one chronic condition (COPD, CHF, PVD, end stage renal disease in particular)
- As a result of: Direct toxicity due to the virus, Chronic inflammation, Chronic immunosuppression, ART toxicity with long term use, High risk health behaviours - Higher rates of psychiatric comorbidity
- Mental health and alcohol/substance misuse
- Results in reduced adherence to ART, potential for increase in existential distress at end of life, and difficulties for healthcare providers in prescribing safely - Higher rates of metabolic bone disease
- Likely due to hypogonadism, ART, direct inflammatory effects of HIV, smoking/alcohol - Higher rates of malignancies (both HIV and non-HIV related)
- Higher rates of neurocognitive disorders
- ART related and due to HIV - Premature frailty
13
Q
Long term toxicity of ART
A
Renal health
- Long term use of ART linked to increased risk of chronic kidney disease
- Some studies have shown that for every year of use of certain ART agents (especially NRTIs), risk of CKD increases
Neurocognitive Functioning
- Aside from HIV-associated neurocognitive dysfunction, ART (especially NNRTIs) is associated with worsened neurocognitive functioning, particularly in older patients
Cardiovascular and Liver Disease
- HIV patients are already at increased risk of CV and liver disease
- Risk may be exacerbated by ART
14
Q
Side effects of ART
A
- Peripheral neuropathy
- IHD
- Nephrotoxicity
- Neurotoxicity
- Depression
- Sleep disturbances
- N/V
- Xerostomia
15
Q
Drug interactions with ART
A
- HIVdruginteractions.org
- In short, many, many interactions with drugs commonly used in Palliative Care
- Opioids, steroids, NSAIDs, SSRIs, TCAs, Antipsychotics, Benzos
Protease Inhibitors (atazanavir, etc.) are particularly troublesome
A few notes:
- Ativan and tylenol do not interact with any ART drugs
- Dexamethasone results in decreased exposure to most ART drugs
- Duloxetine and venlafaxine are not felt to have significant interactions
- Codeine appears to be the opioid with the least interactions
