HIV - Schoenwald Flashcards
1
Q
HIV is a disease of _____ immunity.
A
Cell mediated
2
Q
Function of CD4 cells?
A
Antigen presenting cells - help make antibodies
3
Q
HIV transmission can be broken down into what 3 categories?
A
Blood
Sexual intercourse/Mucosa
Perinatal
4
Q
T/F? HIV can be spread through breast milk. and intrapartum.
A
True
5
Q
Antiretroviral therapy in a pregnant mother reduces the risk of transmission to the child by how much?
A
Reduces risk by 2/3
6
Q
What antiretroviral is traditionally used for prevention of mother to child transmission?
A
AZT= Zidovudine (NRTI)
7
Q
AIDS is defined by?
A
HIV + AIDS defining illness
OR
HIV with CD4 count < 200
8
Q
What is the most common presentation of HIV?
A
**Asymptomatic pts
WITH (+) SCREENING TEST
9
Q
Name a common co-infection (STI) with HIV
A
Syphilis “these 2 go hand in hand”
ALWAYS test new syphilis pts with HIV
10
Q
Symptoms of HIV?
What viral load do they occur at
A
- Fever,
- night sweats
- LAD (cervical),
- unexpected wt loss
Occur at ANY CD4 ct. (MC <200)
11
Q
What type if pneumonia is typically only found in immunocompromised patients, and is an AIDS defining illness?
A
Pneumocystis jiroveci (PCP)
12
Q
Pneumocystis jiroveci is classified as a ______.
A
Fungus
13
Q
What is the gold standard test for PJP?
A
Silver stain on sputum sample.
14
Q
Classic x ray appearance of PJP?
A
Bilateral hilar infiltrate
butterfly pattern
15
Q
Symptoms of PJP?
A
- Fever
- Dry cough
- SOB
- SEVERE HYPOXIA
- Fatigue
16
Q
Treatment for PJP?
A
High dose TMP/SMX
15-20mg/kg IV QD divided Q6-8hr dose.
+/- prednisone if paO2<70mmHg
17
Q
When should HIV patients have prophylaxis for PCP?
A
If CD4 < 200
18
Q
What medication is used for PJP prophylaxis?
A
Trimethoprim/sulfamethoxazole PO
19
Q
What medication should be used for PJP prophylaxis in patients with sulfa allergies?
A
Dapsone or inhaled pentamidine
20
Q
Purple, brownish lesions common is AIDS patients?
A
Kaposi’s sarcoma
21
Q
Kaposi’s sarcoma is caused by?
A
Human herpes virus 8
22
Q
Treatment for Kaposi’s sarcoma?
A
Reconstituting the immune system can get rid of them.
23
Q
Name 3 early indicators of HIV infection.
Are they AIDs defining illnesses
A
TB Shingles oral hairy leukoplakia Thrush “TOTS”
These are not AIDs defining illnesses
24
Q
What is a retrovirus?
A
A RNA virus that depends on reverse transcriptase (RNA-dependent DNA polymerase) to replicate
25
What is the most common type of HIV in the US?
HIV 1
26
Where is HIV 2 found?
West Africa
27
Which type of HIV is more virulent?
HIV 1
28
HIV enters CD4 cells via what receptors?
| Which is the main receptor?
CCR5 and CXCR4 chemokine receptors
| CCR5
29
Acute HIV infection usually occurs within what time frame after exposure?
within 2 weeks of exposure
30
The most current screening test for HIV is?
| What does it check?
COMBO or 4th generation testing (EIA)
Checks Ag-AB (Ag not on old ELIZA test)
Ie HIV AB &p24 AG
31
What test do you do after a (+) EIA/COMBO/4th gen to Confirm?
After EIA, CONFIRM with:
| HIV RNA by PCR (by/ viral load)
32
What test is used to measure viral load?
Ultrasensitive quantitative RNA by PCR
33
What ID/medical screenings need to be done after a (+) EIA/COMBO & HIV RNA by PCR?
```
SYPHILIS
TB, Toxoplasmosis (opportunistic infections)
Hepatitis
also,
CMP, CBC, LFTs, PAP
```
34
Combination or 4th generation testing (EIA) can show positivity how long after exposure?
2-6 weeks
35
When should HIV drug resistance testing be considered?
If viral load > 1000 copies/mL
36
Antiretroviral consists of medications of 4 classes. Name them.
Protease inhibitors (PI)
Nucleoside reverse transcriptase inhibitors (NRTI)
Non-nucleoside reverse transcriptase inhibitors (NNRTI)
Integrase inhibitors (INSTI)
37
A goal of antiretroviral therapy is suppression of viral load to _____.
<50 copies/mL
38
```
Antiretroviral therapy typically consists of a backbone and a base. Which class of medications are the backbone.
Which are the base?
```
Backbone - typically two NRTIs
| Base - either NNRTI or PI or integrase inhibitor
39
Name 4 commonly used complete combination pills.
```
"GOAT"
Genvoya
Odefsey
Atripla
Triumeq
```
40
What complete combination is injectable once per month?
Cabenuva (cabotegravir + ripivirine)
41
Atripla is a combination of what medications?
Backbones: Tenofovir Disoproxil + Emtricitabine.
Base: Efavirenz (NNRTI)
42
Genvoya is a combination of what medications?
Backbones:
Tenofovir Alafenamide + Emtricitabine
Base: Elvitegravir, (INSTI)
Booster: cobicistat
“New Gen still likes Elvis”
43
Odefsey is a combination of what medications?
Backbones: tenofovir alafenamide + emtricitabine
Base: Rilpivirine (NNRTI)
44
What medications are approved for PrEP?
Descovy
Truvada
Cabotegravir
45
Truvada is a combination of what medications?
Backbones:
Tenofovir disoproxil
emtricitabine
46
Backbones of Descovy?
Backbones:
Tenofovir alafenamide
emtricitabine
47
Descovy and Truvada are what class of medications?
NRTIs
48
What is a commonly used NNRTI?
Efavirenz-Sustiva
49
Recommend screening for what STD in HIV (+) pts
Syphilis
50
What is the difference between tenofovir disoproxil and tenofovir alafenamide?
Disoproxil is older and has higher risk of renal failure and osteoporosis
51
Protease inhibitors all end in?
-navir
52
What is the preferred protease inhibitor
Darunavir
53
Integrase strand transfer inhibitors end in?
-egravir
54
According to the most recent guidlines, when should HIV treatment be considered?
* *ALL HIV (+) PATIENTS should be considered for treatment, regardless of CD4 count.
* *START EARLY
55
What should patients be screened for before starting Abcavir (In Triumeq)?
Why?
HLA-B*5701
| To reduce the risk of a hypersensitivity reaction.
56
What are some of the most common side effects of PI's (group w/most S/E)?
```
Facial wasting
HLD
Lipodystrophy
Hepatotoxicity
GI intolerance
increased bleed in hemophiliacs
DDI
```
57
What are some s/e of NRTIs
Lactic acidosis
Hepatic steatosis
Lipodystrophy
58
What is IRIS - Immune Reconstitution Syndrome
| When does it happen?
Condition caused by an inflammatory reaction in response to rapid increase of CD4 counts
-Occurs after initiation of ART
59
What testing should be done for HIV patients every 6-12 months?
CD4 and viral load
Anal Pap smears
Cervical pap smears
60
Patients should have prophylaxis for toxoplasmosis at CD4 counts _____.
<100
61
What medication is used for prophylaxis of toxoplasmosis
TMP/SMX or Dapsone + pyrimethamine
62
Patients should have prophylaxis for mycobacterium avium complex (MAC) at CD4 counts _____.
<50
63
T/F: Immune Reconstitution Syndrome is a diagnosis of exclusion
True
64
What medications are commonly used for pre exposure prophylaxis (PrEP)?
Truvada (only men)
or Raltagravir
or Cabotegravir
65
How long are post exposure prophylaxis (PEP) meds given?
1 month
66
Post exposure prophylaxis (PEP) should be started how soon after exposure?
ASAP, but generally within 72 hours.
67
Failure rate of PrEP?
1-6%
68
HIV status should be checked how often in PrEP patients?
3mo!!
Cabotegravir needs an earlier f/u 1mo after initialtion.
69
What PrEP med would would you choose for a patient with renal impairment?
Descovy - it has tenofovir alafenamide rather than tenofovir disoproxil
70
What opportunistic infection presents with an influenza like illness and is diagnosed by IgM/IgG serology?
Coccidioidomycosis
Coccidioides immitis
(San Joaquin Valley fever)
71
Treatment for Coccidioidomycosis
| (Coccidioides immits)?
No tx normally
Fluconazole/DifluCan if pt is having persistent or severe infection.
72
Is Coccidioides immits an AIDS defining illness?
No
73
Histoplasmosis is linked to exposure to ________ along the Ohio River Valley?
How is it diagnosed?
```
Bird droppings and bat guano
Ag test (serum, CSF, urine) or tissue Bx
```
74
Treatment for Histoplasmosis?
itraconazole for mild-moderate and amphotericin B for severe disease
75
Is histoplasmosis an AIDS defining illness?
Yes
76
Blastomycosis is linked to exposure to _______ along the Ohio River Valley?
Dust
“Blasts from InDUSTrial sites”
77
T/F? Disseminated Blastomycosis only occurs in AIDS and immunosuppressed patients.
False - can happen to anyone
| “Blast for both parties”
78
Diagnosis of Histoplasmosis is done by?
Serum, urine, or CSF antigen test
OR
tissue biopsy.
79
Diagnosis of blastomycosis is done by?
Biopsy and culture
| “Bx for Blasto”
80
Treatment for blastomycosis?
Itraconazole for mild-mod dz
| amphotericin B for severe disease
81
Toxoplasmosis is associated with exposure to?
Cat litter boxes
82
IS toxoplasmosis in HIV usually primary infection or reactivation?
Reactivation
83
When is toxoplasmosis usually a primary infection?
In pregnancy
84
Characteristic findings on brain MRI in toxoplasmosis?
***Punched out lesions
85
Risk to HCW with needle stick?
LOW
| 1:300
86
Common AIDS defining Illnesses
- **Candidiasis of Esophagus
- Candidiasis of bronchi, trachea, or lungs
- Coccidioidomycosis, DISSEMINATED
- Histoplasmosis, DISSEMINATED
- Kaposi Sarcoma
- Burkitts lymphoma
- Primary Lymphoma of brain (99% in AIDS)
- Pneumocystis carnii PNA (PJP/PCP)
87
T/F? PJP PNA pts often present without severe hypoxia
False
| PJP often present w/severe hypoxemia
88
People with deletions in what chemokine receptor are less likely to become infected with HIV?
CCR5
89
What does the HIV virus do to the cell during the latent state?
How long can the Latent State of HIV last?
Integrates HIV genome into host cell genome.
| Could be up to 10yrs
90
What happens to CD4 count with increased length of HIV infection?
CD4 count ↓ w/ ↑ length of infect
91
What is Acute Retrovirus Syndrome (Acute HIV) MC mistaken for?
MONO
| Flu like symptoms
92
Diff B/W Mono & HIV
Rash 5-10% time MONO
Rash >80% of time in Acute HIV
Maculopapular rash & mucosal ulcerations
93
SxS of ARS (Acute HIV)?
- HIGH fever
- Fatigue
- LAD
- Pharyngitis
- Rash
94
MC Infections w/CD4 200-500
- Thrush
- Oral Hairy Leukoplakia**
- TB
- Shingles
“200 TOTS”
95
MC infections w/CD4 <200
- Candida esophagitis**
- HSV**
- PCP**
“CHP”
96
MC infections W/CD4 <100
- Cryptococcus
- Histoplasmosis
- Aspergillus
97
MC infections w/CD4 <50
- M avium complex
| - CMV
98
T/F: HIV is a chronic illness that we can manage
True
99
T/F? Rapid testing (saliva) is as sensitive as combo 4th gen Ab-Ag (EIA) testing?
False
| EIA then HIV RNA by PCR is test of choice
100
T/F? ELIZA looks for Both HIV AB & p24 AG
False. That is Combo 4th gen testing (EIA)
Eliza only looks for ABs
P24 is a structural protein that makes up most of the HIV viral core
101
What is it called when a TB test is negative because the CD4 count is <50?
anergy
102
Who should be tested for HIV?
| What does the CDC recommend?
CDC recommends opt-out testing but…….
- Anyone 13-64 that:
- IVDU and their sex partners
- Persons who exchange sex for money or drugs
- Sex partners of HIV infected persons
- Anyone who has sex
103
Triumeq is a combo of what drugs?
Backbones:
Lamivudine
Abacavir
Base: Dolutegravir (INSTI)
“LA Dodgers are triumphant”
104
Common 1st line regiments of ART
Preferred: 2 NRTI's + 1 INSTI
Historic: 2 NRTI's + 1 NNRTI (ie Atripla)
or
Triumeq (check for Abacavir rash) (lamuvidine+ Abacavir + dolutegravir)
or
Dovato (Lamivudine+dolutegravir)
105
T/F: End organ damage can occur at any stage of HIV infection?
True
106
How to use CD4 count levels to guide ART Tx (1st 2yrs)?:
- check CD4 Immediately before starting ART
- check baseline 2x in Q3-6mo,
- check baseline Q3-6mo for 2yr after
107
Common S/E for PI's
```
*Facial Wasting
Hyperlipidemia
Lipodystrophy
Hepatotoxicity
GI intolerance
Possibility of ↑ bleeding risk
for hemophiliacs
Drug-drug interactions
```
108
Common S/E from NRTI's
Lactic acidosis
Hepatic steatosis
Lipodystrophy
(highest incidence with Stavuine)
109
Common S/E from NNRTI's
- Rash, including Stevens-Johnson syndrome
- Hepatotoxicity (Nevirapine)
- DDI
Sustiva (CNS Effects-sleepwalking)
110
How long can HIV be dormant?
10yr
111
Blood transfusion risk if blood infected?
95%
112
What is HIV?
Virus present w/o AIDS defining illness
113
T/F: If Dx with AIDS and CD4 comes up (>200), pt now has HIV?
False, will still have AIDS even if CD4 count comes up.
114
T/F: Are all opportunistic infections AIDS defining Illnesses?
False. ie Thrush, oral hairy leukoplakia, shingles
115
What stage of HIV infection MOST LIKELY presents with symptoms?
Is this the most common presentation?
ACUTE HIV
2wks post exposure
No, MC presentation with symptoms is years later with opportunistic infection.
116
Locations of Kaposi Sarcoma?
- Body wide
| - inside mouth
117
How many cases of HIV in US?
| What percent of HIV pts are unaware?
1mil
| 20%
118
What groups are most affected by HIV?
Gay and bisexual men
119
What groups have the highest number of new HIV dx?
Black gay & bisexual men
120
What tests are performed after confirmation of EIA/Combo/4th gen & HIV RNA by PCR?
- CD4 count (baseline)
- Ultrasensitive quantitative RNA by PCR
- Rapid Testing (not as sensitive as combo/EIA)- saliva, SUDS in ER- serum test)
“CUR”
121
Name 3 Historic NRTI's and 2 newer choices
```
Historical:
Zidovudine (AZT)- preggers
Lamivudine (3TC)
Abacavir (ABC)
“ZAL”
```
Newer Choices:
Emtricitabine (FTC)
Tenofovir (TAF)
“ET”
122
Benefits of early HIV tx
1. Earlier ART prevents HIV-related End-Organ Damage
2. decreases HIV-assoc inflammation
3. Potential decrease in risk of complications (Nephropathy, Liver dz from Hep, CVD, Malignancies, Neurocognitive decline, Blunted immune respone of old age)
123
T/F: Start Cabotegravir PO (Vocabria) with Cabotegravir IM (Cabenuva) Q1wk to start before sole Cabenuva IM tx
Yup, that's what you do
124
S/E of ART
```
High potential for adverse effects
- rash
- diarrhea
- pancreatitis
- HLD
- Lipodystrophy
- inc CVD risk
CNS effects (distrubances)
```
125
Vaccinations for Prophylactic HIV mgmt
- pneumococcal
- Hep A&B
- TDaP
- Meningitis
- FLu
- COVID
- SHingles
- HPV (all <26yo. 26-45 shared decision)
126
HIV mgmt checklist post-2yrs(5)?
If CD4 <200?
If CD4 <50?
- CD4 & viral load (Q6-12mo)
- PPD/Quantiferon
- RPR (syphilis coinfect)
- Toxoplasmosis (AB- reactivation infection)
- Anal/Cervical PAP (Q6-12mo)
If CD4 <200 (PCP prophylaxis)
If CD4 <50 (MAC prophylaxis)
127
T/F: you can give Cabotegravir for PEP
False, only indicated for PrEP
128
If source of HIV (+) exposure is known, what is used for PEP?
PEP with the effective agent utilized by the person
129
How much does PrEP decrease risk of HIV by?
92-99%
130
(+) screenings for PrEP from assessing risk behavior in heterosexual men?
These pts need discussion &/or use of PrEP
- Bacterial STI in 6mo
- 1+ partners w/unk HIV status
- Don't use condoms
- HIV known partner
131
Pearls for PrEP (3)
- Check HIV status prior to initiation & Q3mo after
- check for SxS acute HIV (ie Fever, Rash, LAD)
- Check for other STIs Q3-6mo
- Check renal function (CrCl >30)
- Check Hep B immunity
132
T/F: PrEP reduces risk of other STIs
Nope!
133
T/F: Descovy PrEP is for men & transgender women only
True
| "Descovy=dicks only'
134
Cabotegravir dosing for PrEP
dose 600mg=3mL injection
2nd dose 4wks later
then 8wks
135
How often is follow up for PrEP?
**1st FOLLOW UP IS 1mo FROM 1st VISIT
**CHECK HIV STATUS EVERY 3mo!!
136
F/U for PrEP
```
Q3mo
HIV testing
Medication monitoring/stress adherance
Counseling/behavioral risk reduction
Assess renal function, if normal, then Q6mo
Oral/rectal STD screening if appropriate
Pregnancy testing if appropriate
```
137
F/U for Cabotegravir PrEP
138
T/F: It is better to start Zidovudine early (14wks or later) in pregnancy for best outcomes?
Trueee
139
T/F: Coccidioidomycosis is often asx and should be treated with Diflucan always
False. Cocci is often asx
| but should only use Diflucan if immunosuppressed.
140
1. _____ is a disseminating dz in immunocomrpomised pts/AIDS
| 2. ______ is a disseminating dz possible in ALL pts
1. Histoplasmosis
2. Blastomycosis
“Histo dissem in HIV”
“Blasto for Both”
141
What is a reactivation infection?
Reactivation is the mechanism whereby a latent virus that has infected a host cell switches to a lytic stage, undergoing productive viral replication and allowing the virus to spread.
142
During the eclipse period, what viral marker goes up first? How do we detect this marker?
RNA (before p24 AG)
HIV RNA by PCR (NAT)
This is also the confirmatory test for EIA
143
3 Drugs that have tenofovir alafenamide?
Genvoya
Odefsey
Descovy
"Ala= GOD"
144
2 Drugs that have tenofovir disoproxil?
Atripla
Truvada
"DAT"
145
PEP Rx?
Truvda
| Raltegravir
146
How often do we check STDs in PrEP pts?
Q3-6mo
147
SxS Histoplasmosis
Many infections “asymptomatic”
| usually pulmonary symptoms if presenting
148
SxS Blastomycosis
Many infections “asymptomatic”; usually start as pulmonary infections with CUTANEOUS DISSEMINATION
149
SxS Toxoplasmosis
focal neurologic findings
| fever
