HIV infection and HIV treatment Flashcards
persistent sore throat and new onset rash and diarrhea with negative rapid strep and has headache and nausea and diarrhea
Acute HIV
acute HIV presentation
acute fever, headache, sore throat, nausea, diarrhea and enlarged lymph nodes. may be mistaken for other viral illnesses and seems like the flu
Gonoccocal pharyngitis infection
genitourinary symptoms that can occur by itself. Seen with joint or tendon pain or peripheral rash (not truncal) and varies from maculopapular to pustular.
EBV infectious mononucleus presentation
<21 yrs old and sore throat with malaise and LAD see rash if given antibiotics like amoxicillin
when does symptoms for an acute HIV infection occur?
2-4 weeks post exposure
mononucleosis like syndrome of fever lymphadenopathy, sore throat, and arthralgias and generalized macular rash and GI symptoms
acute HIV infection
what labs are seen on acute HIV infection?
presence of p24 antigen present.
HIV antibody testing may be negative (not yet seroconverted)
HIV1/2 antibody differentiation immunoassay will be positive. OR can have positive HIV RNA nucleic acid amplification testing shows viral load is elevated >100K
CD4 count may be normal
management of HIV infection
combination of anti-retroviral therapy partner notification consideration of secondary prophylaxis.
when to start ART therapy for patients with HIV?
even if newly diagnosed, start combination antiretroviral therapy.
offer treatment regardless of CD4 count as this can fall precipituously with HIV infection.
DO NOT NEED resistance testing to be done at time of initiation of ART. must be done eventually but this does not delay starting ART.
infectious mononucleosis presentation
malaise myaglia, generalized rash (maculopapular, urticarial and petechial) but rash is only seen after amoxicillin. they also have fever, pharyngitis and LAD and atypical lymphocytes.
bone lucency, marked body cavity LAD and uncontrolled HIV need to consider
lymphoma 4% of HIV pts have lymphoma at time of diagnosis.
risk factors for developing lymphoma and HIV
HIV direct effects when CD4 count <100, immunosuppressive state, coinfection with oncogenic viruses (EBV)
most common lymphoma related to HIV
Burkett’s lymphoma and diffuse large non hodgkin lymphoma
Pre exposure prophylaxis or PrEP consists of:
2 drug antiretroviral therapy with tenofovir + emtricitabine.
why do we like PrEP therapy?
helps decrease risk for HIV acquisition by >90% and is offered to those with substantial risk for new HIV infections
who gets PrEP?
sexual behaviors - HIV positive partner with detectable viral load,
men who have sex with men,
individuals with high prevalence areas (sub Saharan Africa) with recent bacterial sexually transmitted infection,
sex exchange for money,
inconsistent condom use,
higher number of partners
IV drug abuse - HIV positive injecting partner or sharing of injecting equipment
how to monitor PrEP therapy?
need required follow up every 3 months with HIV testing, risk reduction counseling, medication adherence and side effect assessment. Need lipid panel, CMP (cr level) every 6 months. check urine GC/chlaymydia/trichonella, test for hepatitis, urine testing and PCR. Need to check for pregnancy q3 months.
how to qualify for PrEP therapy?
negative fourth generation HIV testing, no manifestations of acute HIV, normal renal function and documented Hep B infection or Hep B vaccination status. needs pregnancy test.
Pt presents with new skin changes when HIV presentation and CD4 coutns are less than 400. What are those skin changes
new seborrheic dermatitis. Can also need to screen for HIV when they have recurrent herpes zoster infections and sudden severe psoriasis
guidelines for starting treatment with pregnant women who have HIV And why?
start ART as soon as possible regardless of initial viral load or CD4 counts to minimize maternal risks of HIV infection and reduce risk for perinatal transmission
when is drug resistance testing done for pregnant women with HIV?
done after ART is started. ART can be modified based on drug resistance results.
Often are HIV RNA viral load is checked? CD4 cell count checked?
check HIV RNA load at initial visit, every 2-4 weeks after initiation or change of therapy until undetectable and t_hen every 3 months_
check CD4 count every 3-6 months
Resistance testing is done once if not previously performed
Recommendations on pregnant women getting a amniocentesis?
viral load <1000 copies/ml
what are recommendations for intrapartum care with HIV pts: what procedures to avoid? which type of delivery?
avoid artificial rupture of membranes (ROM),
fetal scalp electrode,
operational vaginal delivery
Viral load<1000 copies/ml: ART and vaginal delivery
Viral load >1000 copies/ml: ART + zidovudine+ c section
post partum care recommendations for pt with HIV for ART
mom must continue ART
infant (maternal viral load _<1000 copies/m_l) gets zidovudine only
infant (maternal viral load _>1000 copies/m_l) gets multidrug ART
ART must include:
combo drug and must include: 3 drugs from 2 classes
at least
2 nucleoside reverse transcriptase inhibitor (NRTI) + Protease inhibitor
2 nucleoside reverse transcriptase inhibitor (NRTI) + integrase inhibitor
what is given to infant after delivery by HIV positive mom?
they get post exposure prophylaxis after delivery to decrease viral transmission. Therapy and dosing varies based on maternal viral load and specific infant risk factors.
Can HIV positive moms breast feed?
Moms who live in areas where formula is available (US) should not breastfeed as HIV can be transmitted through breast milk
Moms who live areas where there is no formula access they continue ART and breast feed for 6 months to minimize infant morbidity and mortality from infectious diseases.
what blood abnormality can be seen with HIV pts?
what about AIDS pts?
thrombocytopenia up to 10% as initial symptom and seen up to 40% in disease course. thus all thrombocytopenia pts should get HIV testing.
People who have CD4<200 and HIV (AIDS) can see increased incidence of monoclonal gammopathy and plasma cell dyscrasias
Can see MGUS.
If concerned for acute HIV infection and positive ELISA but indeterminant western blot then check:
HIV RNA PCR or repeat western blot in 1 month.
acute conversion will have high viral load. The indeterminant western blot may be seen with early conversion.
goal for HIV treatment
`undetectable viral load <50
u = u or undetectable means untransmissible
also will help prevent complications of HIV
if there is incomplete suppression of viral load (or limited compliance) check HIV genotype resistance assay
pregnant woman’s ART
must be 3 regimen two NRTI’s and integrase strand transfer inhibitor or protease inhibitor.
if already on efavirenz then can continue taking this while pregnant
efavirenz - known to cause neural tube defects has now been disproven.
post exposure prophylaxis is:
PEP must be started within 72 hrs** of exposure **otherwise not recommended.
3 drugs for 28 days tenofovir, emtricitabine, and raltegravir.
Test pt at baseline, then at 4-6 weeks and then 3 months post exposure
IRIS - immune reconstitution inflammatory syndrome which is
this is a paradoxical worsening of a pre-existing chronic infection or unmasking of an unrecognized infection within weeks or a few months of ART for HIV.
Think of the immune system waking up and realizing that there’s a virus or infection going on.
Seen in late stage HIV
Sometimes to prevent life-threatening complications we start to treat underlying infection and delay ART for 5 weeks with TB and crytococcal meningitis only.
do we ever stop ART in IRIS?
only if there’s a severe or life threatening complication do we stop ART temporarily and add steroids.
Who is at most risk for IRIS in an HIV pt
when pts who’s CD4 count <100 prior to ART treatment IRIS severity is greatest with those who have high pretreatment HIV RNA levels and have a strong virologic (rapid decline in HIV RNA) and immunological (rapid rise in CD4 count) response to therapy.
How to diagnose IRIS?
diagnosis of exclusion must rule out other causes bacterial superinfection drug allergy/toxicity and patient non compliance
several opportunistic infections are associated with IRIS including:
TB crytococcus
CMV
Hep B and C
HSV
Human herpes virus 8
John Cunningham polymavirus
Pneumocystis (PCP)
how do we treat IRIS?
this is treated with treating the underlying infection ART can be continued without interruption
How do we test for TB in someone with advanced HIV who has signs of active TB on imaging ?
IGRA is not reliable. it can have an indeterminant test because there’s no immune system to mount the regular reaction so need repeat testing after ART. may also not mount a response to TST.
If concerned about active TB, need to get sputum testing for acid fast bacilli and culture
how do we test for HIV? screening is with:
initial ELISA- this screens serum for HIV antibodies + antigen screening at the same time as initial ELISA test
Basically looking at HIV antibodies (ELISA for HIV1/HIV2) and HIV p24 antigen
rationale: pts in window period where they are infected but not producing antibodies at high enough level to be detected will be missed. The antigen/antibody combination had a low false positive rate.
confirmatory testing is: with a HIV1/2 antibody differentiation immunoassay - if intermediate, then get HIV RNA testing by PCR.
if HIV1/HIV2 antibody differentiation immunoassay is positive- confirms infection.
If negative HIV1/HIV2 antibody differentiation get HIV RNA testing by PCR. If that is positive, then it confirms HIV infection.
prior to starting PrEP what should be done?
Counsel pt on continuing to use barrier methods, medication toxicity and continued risk for other STI’s. Testing should be done for HIV, hep B, kidney function and pregnancy prior to PrEP
If someone is on PrEP for HIV what labs should be done?
monitor for HIV, STI’s and pregnancy q3months follow Cr and BMP every 6 months
people who test positive with PrEP for HIV need to get:
continue tenofovir and emtricitabine but needs: ritonavir boosted darunavir or doltegravir
How do we confirm HIV testing is positive if HIVp24 antigen or initial ELISA HIV antibody is positive?
confirmatory testing: with a HIV1/2 antibody differentiation immunoassay - if intermediate then get HIV RNA testing (by PCR).
if HIV1/HIV2 antibody differentiation immunoassay is positive = infection.
If negative or intermediate, HIV1/HIV2 antibody differentiation get HIV RNA testing by nucleic acid amplification testing.
If positive, then it confirms HIV infection,
Do we still use the HIV western blot for testing?
no we don’t.
it’s not as fast and not as accurate as using the HIV/HIV2 antibody differentiation assay
also do not use PCR for HIV RNA as a screening test; used as a way to track medication compliance and effectiveness.
screening frequency for HIV
everyone average risk: once
screen yearly if higher risk people:IVDA and sex partners, prostitutes, ppl with >1 sexual partner since last HIV test,
every 3-6 month testing: asymptomatic men who have sex with men, individual risk factors, local HIV epidemiology and policies.
HIV complications of disease itself:
accelerrated aging,
neurocognitive impairment
worsens HLD (esp with boosted protease inhibitor based)
check A1c, fasting glucose, and lipid levels at baseline and q3months after starting and changing ART
CKD- seen with HIV nephropathy, check BMP q6 months
Reduced bone density; needs DEXA scan in men >50 yrs old and post menopausal women and pts with fragility fractures, high risk for falls and chronic steroid use.
also increased risk for liver dx - coinfection with Hep B and C.
HLD and HIV
worsens HLD (esp with boosted protease inhibitor based)
check A1c, fasting glucose, and lipid levels at baseline and q3months after starting and changing ART
bone density and HIV
Reduced bone density;
needs DEXA scan in
men >50 yrs old
post menopausal women
pts with fragility fractures
high risk for falls
chronic steroid use.
Hiv and renal dx
CKD- seen with HIV nephropathy, check BMP q6 months
no tenofovir - can increase CKD - tubular nephrotoxicity which manifests as proteinuria
pts who are coinfected with hep b or c and HIV positive should get:
tenofovir (TDF or TAF)
+ emtricitabine or lamivudine based regimen which treats both viruses
also need to treat Hep C
which HIV ART needs genetic testing prior to prescribing?
abacavir needs genetic testing for HLA B 5701 in case there’s risk for DRESS.
dont start it until testing results return.
pts with HIV infection have increased incidence of
stroke and CAD.
HIV infection - chronic inflammatory state and untreated HIV have a higher risk for cardiovascular events compared to pts on ART.
Someone overdoses on isoniazid. What to give them to prevent complicatoins?
give Vitamin B6
Drug competes with pyridoxal phosphate which involves with the synthesis of GABA and this results in lower GABA and decreases seizure threshold.
Pts having seizures may develop hyperthermia and rhabdomyolysis. Giving B6 (pyridoxine) helps increase the level of GABA in the brain.
