HIV Small Group

Question 1

1. Compare and contrast the ELISA, Western Blot, and viral load tests used to diagnose children and adults with HIV infections.

Answer 1

ELISA is used as a screening test it is sensitive but not specific. Western blot (done by electrophoresis) is a confirmatory test that is very sensitive; both test for antibodies against HIV; if needed can be repeated out to 6mo to wait for seroconversion

viral load tests are PCR tests that test the levels of viral DNA (used more for prognostic and treatment monitoring purposes)

Question 2

2. Explain the principles of treating HIV infection with Antiretroviral therapy, including when to start ART.

Answer 2

ART should be started as soon as diagnosis is confirmed, ART should be administered as a multi-drug regimen to prevent provoking resistance; goals of treatment is to bring viral loads down to undetectable and to allow CD4+ counts to rebound

3 drug prophylaxis for needle stick best within 72 hours (2hrs ideal)
PREP for serodicordant couples ie. is 2 drug regimen to prevent transmission

Question 3

3. Explain how HIV is transmitted person to person.

Answer 3

transmission via sexual contact, fetal maternal transplacental, birthing process or through breast milk and from contaminated needles or blood products

Question 4

1. Describe the initial evaluation of a person with HIV infection and explain the purpose of the tests that are routinely obtained in this situation.

Answer 4

a. CD4- base line, check risk for opportunistic infection
b. Viral load- base line prognostic and tx. strategy
c. RPR- check for syphyillis (FTA-Ab to double check)
d. Chlymydia/gonhaerria: UA, urethera swab
e. PPD, Inf gold
f. Hep B, C: Core antibodies (core-have they had in the past, surface- if they’ve had it or been vaccinated)
g. Immunization hx
h. Genotype, resistance testing , longer you have HIV, decreased ability to check as time goes on
i. Pap cervical and anal: due to risk of HPV cancers
j. CBC, (‘penias’)UA (HIV neurophathy , dictate meds, CMP (liver) Creatinine, check for HBV, HCV
k. Toxoplasma Ab, risk of reactivation and counseling on infection
l. Fasting lipid, glucose- metabolic syndrome increases with treatment
m. Pregnancy test

Question 5

2. Describe the clinical manifestations of a person with primary HIV infection and explain the consequences of missing the diagnosis at an early stage of HIV infection.

Answer 5

consequences: worse prognosis, more opportunistic infections, risk to transmit to other people, less opportunities to test resistance

clinical manifestations of acute retroviral syndrome:
rash
decreased appetite
fever
headache
fatigue
malaise, or a general "unwell" feeling
sore throat
night sweats
ulcers that appear in the mouth, esophagus, or genitals
swollen lymph nodes
muscle aches

Question 6

3. Given clinical scenarios that include viral loads and CD4 T-cell counts, describe the goals of antiretroviral therapy as they relate to clinical virology, and immunologic parameters.

Answer 6

pregnancy: maintain viral load as low as possible for whole pregnancy but especially during birthing, if concern for exposure during birth, prophylaxis meds to baby; IV AZT during labor and delivery

man out of work: additional risk factors of adherance or transmission, consider risk of mental health or AODA complicating factors

serodiscordant partners: PREP can be used if adherence is solid, best prevention is keeping viral load in infected partner as low as possible

accidental needle stick: PEP, prevent conversion due to needle stick with post-exposure prophylaxis, 4wks treatment

Question 7

4. Describe the major factors that must be taken into account when a specific ART regimen is chosen.

Answer 7

1. adherence: poor adherence can lead to developing resistance, long drug half-life difficult (resistance in mono therapy if other therapies are stopped)
2. viral resistance: unknown drug resistance can lead to break through of viral loads
3. drug interaction: drugs that are p450 metabolized can be effected by drugs like simvistatin
4. adverse drug reactions: metabolic syndrome common adverse effect, protease inhibitors lead to diarrhea, cistiva: vivid dreams, rash/itching common
5. other clinical context: patients co-morbidities and their mental health

(cost can usually be covered by public funding/ Ryan White funding for people who cannot cover the cost, also co-pay cards and cost assistance payment programs with drug Co)