HIV - collins Flashcards
what year were routine HIV screenings recommended
2006
what year was PrEP(pre-exposure prophylaxis) approved
2012
what are the risk factors for HIV
concomitant STDs
alcohol and drug use
sexual intercourse (receptive anal intercourse»other modes)
Needles
what is the etiology of new HIV diagnoses
68% Male-to-male sexual contact
23% heterosexual contact
6% IVDU
What are the symptoms of HIV
often asymptomatic
can have acute retroviral syndrome (50-70%)
- mild=vague flu-like illness
- severe= meningitis, encephalitis, thrombocytopenia
what are HIV screenings and when are they done
CDC recommends at least one time screening for all pts 13-64
at least once yearly for high-risk patients
more frequently might be preferred for high risk patients
screening completed via “opt-out” testing
- pts notified HIV screen will be completed with routine blood work
- testing is the default - must elect NOT to be tested
what are HIV tests
Nucleic acid tests (NATs) - detect HIV RNA
Antigen/antibody testing - detects HIV p24 antigen AND HIV IgM and IgG
Antibody only testing - detects HIV IgM and IgG
what is the window period
time between acute infection and ‘detectable’ infection
What is the Nucleic Acid Test (NAT)
expensive
most acute HIV or indeterminate test - no HIV abx yet
Detectable 10 days post-exposure
positive = presence of HIV RNA
when are the treatments for HIV recommended
initiate in any pt age >18 regardless of CD4 count
initiate immediately on diagnosis(or ASAP)
should obtain baseline/screening labs on initiation of treatment
what baseline/screening labs should be obtained on the initiation of treatment for HIV
Viral load (HIV RNA)
CD4 count
HIV genotyping
BMP/CMP for baseline (liver and kidney function)
lipids
CBC
Glucose
Urinalysis
Pregnancy testing
what co-infections screening should be obtained for HIV
STI (syphilis, chlamydia, gonorrhea; + trichomonas in F)
Latent TB
Hep A and B
HCV
Coccidiodimycosis
What is the first line treatment for HIV
ART (anti-retroviral therapy)
generally a 3 drug combo (1InSTI + 2 NRTIs)
What is the second line treatment for HIV
2NRTIs+ 1 from another class (PI, NNRTI, II)
what is INSTI
integrase inhibitors
What is PI
Protease Inhibitors
what is NRTI
Nucleoside/Nucleotide Reverse Transcriptase Inhibitors
What is NNRTI
Non-Nucleoside Reverse Transcriptase Inhibitors
What are the side effects of HIV treatments
N/V/D
Difficulty sleeping
Dry mouth
Headache
Rash
Dizziness
Fatigue
Fever
Osteopenia/osteoporosis
Peripheral neuropathy
Pancreatitis
Hepatitis
Anemia
Neutropenia
Nephrotoxicity
what is the goal of HIV treatment
virologic suppression
Defined as < 50 copies/mL
takes about 24 weeks to achieve
what should rise with Virologic suppression
CD4 count
check every 6 months for first 2 years
then, if suppressed, check yearly
What is Immune Reconstitution Inflammatory Syndrome (IRIS)
occurs after initiation of ART (higher risk if worse disease)
secondary to rapid increase in CD4 count - can now mount inflammatory response
appearance of worsening opportunistic infections
must rule out new or worsening opportunistic infections
what is the treatment of IRIS
supportive +/- steroids if severe
what are reasons to adjust ART
side effects
toxicity
simplify regimen for compliance
virologic failure (HIV RNA >200 on 2 consecutive occasions)
what is the best way to prevent HIV
no vaccine available
prevention: cessation of IVDU/needle sharing, safe sex practices (regular screenings, condom use, limited partners, avoid concurrent ETOH/drug use), sex education, ART as prevention
What is PrEP
pre-exposure prophylaxis
indicated for any high risk patients who request - inconsistent condom use, recent PEP or STI, HIV + partner, needle sharing
how is PrEP taken
once daily oral (truvada or Descovy(not indicated in vaginal sex))
IM injection (cabotegravir) every 2 months
monitoring every 3 months for screenings
what are the oral PrEP medications
Truvada (tenofovir DF and emtricitabine)
Descovy (tenofovir A and emtracitabine) - not indicated for receptive vaginal sex
what are the IM injection PrEP medications
Cabotegravir (apretude) every 2 months - good option if patient preference and if troubles with adherence
what needs to be monitored every 3 months with PrEP use
HIV screening
Pregnancy screening
ready for SUD treatment?
clean needle access
creatinine
STIs
Annual HCV screening
What is PEP
Post-exposure prophylaxis
for prevention of HIV in negative pts AFTER EXPOSURE to HIV
must be started within 72 hours of exposure
how is PEP adminitered
Orally for 28 days
Tenofovir DF + emtracitibine (truvada) daily
AND either Raltegravir (BID) or dolutegravir (daily
What are screenings needed prior to the administration of PEP
HIV rapid test (if HIV + DONT start PEP)
pregnancy test
LFTs
BUN/creatinine
STI screen (if sex related exposure)
Hep B screen
HCV screen
requires repeat HIV screening at 30d and 90d to rule out seroconversion
what are the complications of HIV
may have fever, weight loss, night sweats (can occur w/o OI)
wasting syndrome - loss of muscle > fat
neuropathy
arthritis, rhematologic diesases, osteopenia/osteoporosis
CAD
progression to AIDs - OI or Opportunistic diseases
What is AIDS
acquired immunodeficiency syndrome
late-stage HIV (mean time of about 10 years between initial HIV infection and AIDS)
what defines AIDS
CD4 count less than 200 cells/mcL
OR
Presence of an ‘AIDS defining’ infection/malignancy (OI)
prior to ART, what was the most common OI in aids patients
Pneumocytis jirovecii (PCP)
CD4 < 200
symptoms are similar to pneumonias - cough, SOB, hypoxia, fever
what is present of PCP pneumonia x-ray
diffuse or perihilar infiltrates on CXR
used to be called pneumocysitc carinii
how is PCP pneumonia diagnosed
sputum testing
how is PCP pneumonia treated
TMP-Sulfa (Bactrim) x 21 days
what is toxoplasmosis
CNS infection
CD4 <100
ssx: HA, focal neuro deficits, seizures, AMS
Ring-enhancing lesion (Contrast enhancing) on CT
usually setting of + Serologic tests (IgM, IgG)
what is the treatment of Toxoplasmosis
pyrimethamine + sulfadiazine X 6 weeks
+/- leucovorin
OR TMP-Sulfa (Bactrim) - prophylaxis
What is Mycobacterium Avium Complex (MAC)
infection with Mycobacterium avium and Mycobacterium intracellular
CD4 <50 - rare since ART improvements
pulmonary infection in health individuals (elderly, pre-existing lung dz)
Disseminated MAC in HIV + patients (fever, night sweats, weight loss, fatigue, SOB, abd pain, diarrhea, anemia)
how is MAC diagnosed
sputum culture (+ acid fast bacillus (AFB))
how is MAC treated
clarithromycin (or azithromycin) + ethambutol + rifampin
What is Cryptococcal Meningitis
Infection with Cryptococcus (usually neoformans)
fungal infection
sx: headache and fever (Meningeal irritation less likely)
How is Crytococcal meningitis diagnosed
+ serum cryptococcal antigen (CRAG)
+ india ink stain CSF
what is the treatment of cryptococcal meningitis
IV liposomal Amp B + flucytosine X 2 weeks
then Fluconazole 400mg X 8 weeks, then Fluconazole 200mg X 1 Year
what is CMV retinitis
infection of the retina with cytomegalovirus
rule out all HIV + pts with visual changes
perivascular hemorrhages and white fluffy exudates - not cotton wool spots
What are Opportunistic diseases in AIDS
HIV-related encephalopathy
Invasive cervical cancer
Kaposi’s sarcoma
Lymphomas
Progressive multifocal leukoencephalopathy(PML)
Wasting. syndrome
What is Kaposi’s sarcoma
infection with Kaposi’s sarcoma herpes virus (KSHV) - aka HHV-8
most commonly CD4 < 200
purplish macules, papules or nodules
can present anywhere on skin/MM
how is Kaposi’s sarcoma diagnosed
biopsy
how is kaposi’s sarcoma treated
ART if not widespread
Add chemo if ART is widespread
What are the typical first line HIV treatment regimens
Bictegravir + Tenofovir + emtricitabine (BIC/TAF/FTC)
Doultegravis + abacavir + lamivudine (DTG/ABC/3TC)
Doultegravir OR Raltegravir + tenofovir/emtricitabine (DTG/TAF/FTC or 3TC)
what does the india ink stain test
Cryptococcus neoformans
What is the prophylaxis treatment for TB
if not active disease (negative CXR) - start isoniazid (INH)
what is the prophylaxis treatment for cocidiodomycosis
fluconazole if positive screening
what is the prophylaxis treatment for PCP
trimethoprim-sulfamethoxazole (Bactrim) 80/400mg or 160/800mg
what is the prophylaxis treatment for toxoplasmosis
Bactrim 160/800mg
