Lecture 1: HIV/AIDS Flashcards
What race/ethnicity group & sexual group has the highest overall lifetime risk of HIV diagnosis
African American MSM
Which state has the highest lifetime risk of HIV diagnosis
D.C
Screening for HIV
- what 2 group should be screen for HIV
Screening for HIV
- ALL pregnant women
- pts 15-65 y/o (& younger if at risk)
Screening/Testing for HIV
- what is the main screening test used today
- what is the assoc confirmation test
Screening/Testing for HIV
- screening test = 4th gen immunofluorescence assays HIV 1 & 2
- confirmation test = multispot HIV-1/2 differentiation assay
Screening/Testing for HIV: what test is used
- if indeterminate results found on multispot HIV-1/2 differentiation assay
- to Dx acute retroviral infxn
- to monitor infectivity & tx effectiveness in HIV pts
Viral RNA by PCR
What type of virus is HIV
- name and type (RNA vs DNA)
- retrovirus
- RNA virus
How does HIV replicate in humans
- what enzyme is responsible?
HIV = RNA virus
- converts RNA –> DNA by RT (reverse transcriptase) –> incorporated into host nucleus –> replicates
What are the 2 major methods of transmission of HIV
Others: vertical (during birth/breastfeeding), received blood products before 1985, mucosal contact w/infected blood, needle stick
Major transmission methods for HIV
- Sexual contact
- IV drug use
What is the major site for T-cell loss + early HIV replication
- what happens to the CD4 cell count during primary HIV infection
GALT = gut assoc lymphoid tissue
(most CD4 memory cells there)
- rapid depletion of CD4 count during primary HIV infection
HIV Primary Infection
- what is the name of the condition that occurs 2-4 wks after infection and is a/w flu like Sxs (fever, fatigue, malaise, generalized rash & LAD
other name for it
Acute Retroviral Syndrome or Acute Seroconversion
occurs 2-4 wks after infection and is a/w flu like Sxs (fever, fatigue, malaise, generalized rash & LAD
describe the typical rash in primary HIV infection
blanching maculopapular rash
Baseline evaluations: HIV Dz staging
- what 3 things are you testing to determine pt’s initial dz stage
- After baseline evaluations how often do you monitor a pt’s dz status & ART?
Baseline evaluations: HIV Dz staging
- 3 things testing fo at baseline =
- CD4 cell count
- HIV RNA viral lod
- Resistance testing (genotype, +/- phenotype) - monitor pt’s dz status & ART Q3-6 months
What annual evaluations are done for co-infections that are common in HIV (3 things)
- which on of the 3 is also done at baseline
Annual evaluations for Co-infxns common in HIV
- STIs
- TB - also done at baseline
- Cancer
What vaccines should you give a person w/any CD4 count levels for prevention and ppx of HIV (6)
Vaccines
- flu
- TDa
- pneumococcal
- Hep A + B
- Herpes suppression
- HPV
Infection prevention & OI ppx
- When pts have CD4 < 200 what are they at risk for & ppx for it?
- When pts have CD4 < 50 what are they at risk for & ppx for it?
Infection prevention & OI ppx
- CD4 < 200 = at risk for PJP –> give Bactrim as ppx
- CD4 < 50 = at risk for MAC – give Azithromycin
HIV Tx
1. what is the goal of ART for HIV &what indicates that this goal reached (& what does this mean in terms of transmission)
HIV Tx
1. goal of ART = total HIV suppression
- indicated by UNDETECTABLE viral load
means can transmit virus
HIV Tx w/ART
- why should all pts be started on ART ASAP
- does their CD4 count matter?
- How is treating HIV, prevention of it
HIV Tx w/ART
- ALL HIV pts should be started on ART ASAP –> to decr morbidity/mortality &prevent transmission
(deferred tx = incr risk) - CD4 count DOESNT MATTER
- Tx HIV –> PREVENT transmission to others
HIV Life Cycle
- what are the first 2 steps for the HIV life cycle
1&2 = binding & fusion
HIV Life Cycle
What step in HIV life cycle do the NRTIs and NNRTIs work?
3 Reverse Transcription
What does RT (Reverse Transcriptase) do
RT - converts single stranded HIV RNA –> double stranded HIV DNA so can be incorp into host
HIV life Cycle: #3 Reverse Transcription & Drug action
- What is the main NRTI & its 2 types
- what 3 options used in combo w/it?
HIV life Cycle: #3 Reverse Transcription & Drug action
- Main NRTI = Tenofovir (AF or DF)
- Tenofovir combined w/ Emtricitabine, Abacavir, or Lamivudine
HIV Life Cycle: #4 Integration
- what is the role of integrase–> & what type of virus results?
- What do the integrase inhibitors do?
- 3 examples of integrase inhbitors?
HIV Life Cycle: #4 Integration
- inetgrase incorp HIV DNA into host DNA –> provirus (inactive)
- Integrase inhibitors prevent HIV DNA from being incorp
- Integrase inhibitors “RED”
- Raltegravir
- Elvitegravir
- Dolutegravir
HIV Life Cycle: #5 Transcription
- what enzyme is used to make copies of the HIV genomic material after the host cell is activated
(host or viral enxzyme?)
HIV Life Cycle: #5 Transcription
- host RNA polymerase used to make copies of HIV genomic material
HIV Life Cycle: #6 Assembly
- what class of drugs work here?
- what drugs in this class is used as booster for other drugs in the class & other HIV meds
HIV Life Cycle: #6 Assembly
- protease inhibitors work at this step
- Ritonavir + Cobicstat = boosters
HIV Life Cycle: #7 Budding
- when the virus buds out from host cell what part of the cell’s outer envelope does it steal & why is this necessary for viral spread
HIV Life Cycle: #7 Budding
- steals glycoproteins from outer envelope –> needed to bind to CD4 rec & co-rec –> infect other cells
HIV Life Cycle: #8 Maturation
- what becomes active that triggers the HIV life cycle to start again & produce more HIV
HIV Life Cycle: #8 Maturation
- viral proteinase becomes active –> triggers the HIV life cycle to start again & produce more HIV
HIV Tx
- what 5 things do you check before choosing Tx regimen?
HIV Tx: check before choosing Tx
- HBV (& C) status
- CD4 count
- viral load
- drug resis w/genotyping
- HLA-b5701
HIV Tx
- if someone is HLA-b5701 (+) what drug should NOT be given
- if someone is Hep B (+) what drug is NEEDED
HIV Tx
- HLA-b5701 (+) –> DONT GIVE Abacavir
- Hep B (+) –> MUST have combo w/ tenofovir
1st line Tx for HIV
- what 2 drug classes are combined
& how many of each are pts receiving
1st line Tx for HIV
Combo of: 1 integrase inhibitor + 2 NRTIs
1st line Tx for HIV (specific)
- what are the 3 drug options that every pt gets
- plus what other 2 combinations
1st line Tx for HIV (specific)
- every pt = integrase inhbiitor “RED”
- Raltegravir, Elvitegravir, Dolutegravir - plus
- tenofovir AF or DF w/emtricitabine or…
- abacavir w/ lamivudine
HIV Tx: Special considerations
- what drug should be avoid in Pregnancy for 1st 8 wks b/c teratogenic
- if pt has HBV what drug MUST be used
- what if that drug cant be used alt can be added? - HCV & HIV
- what is the pro of treating both
- what is the con w/ treating HCV (what can reactivate)
HIV Tx: Special considerations
- preg –> avoid efavirenz in 1st 8 wks (teratogenic)
- HBV –> MUST use tenofovir
- alt = add entecavir - Tx HCV + HIV = slow dz progression of other dz
- Tx HCV –> can reactivate HBV
What drug has the S/E of renal damage, joint necrosis and osteoporosis
Tenofovir DF
PEP: post exp ppx
- how soon MUST you take these meds, what window is best?
- 3 drug combo given for 4 weeks?
PEP
- must take w/in 72 hrs (w/in 2 hrs = best)
- 3 drug combo
- Raltegravir + tenofovir DF w/Emtricitabine
PrEP: Pre exp ppx
- what is the only diff in drug regimen vs PEP?
- what 4 groups are mainly at risk for getting HIV and should be offered PrEP
- how long does it take to be eff in rectal vs vaginal tissues
- what test must be confirmed (-) before starting PrEP
- If pt on PrEP presents w/Sxs of acute HIV infxn what should you do?
PrEP
- no Raltegravir
(Tenofovir DF w/Emtricitabine) - MSM, IVDA, sex workers, h/o unprotected sex
- rectal tissues = 1 wk, vaginal tissues = 3 wks
- (-) 4th gen Ag/Ab test before starting PrEP
- pt on PrEP presents w/Sxs of acute HIV infxn –> D/C PrEP til (-) status confirmed
HIV/AIDS complications: Oropharyngeal infections
- what 5 conditions a/w HIV/AIDS
HIV/AIDS complications: Oropharyngeal infections
- Oral ulcers
- Oral candidiasis
- Oral hairy leukoplakia
- Peridontal dz
- Kaposi’s Sarcoma
HIV/AIDS complications: Oropharyngeal infections #1 oral ulcers
- 3 main causes
- 2 main ways to Dx
HIV/AIDS complications: Oropharyngeal infections #1 oral ulcers
- causes = HSV, CMV, Apthous stomatitis
- 2 main ways to Dx = cultures, Bx
HIV/AIDS complications: Oropharyngeal infections
pt comes in w/pseudomembranous tongue & angular cheilitis, the white substance on his tongue scrapes off and he notes burning and altered taste.
Dx?
Tx?
HIV/AIDS complications: Oropharyngeal infections
Dx = oral candiasis
Tx = Nystatin or fluconazole
HIV/AIDS complications: Oropharyngeal infections
- how does oral hairy leukoplakia differ from oral candidiasis
HIV/AIDS complications: Oropharyngeal infections
oral hairy leukoplakia
- does NOT scrape off tongue
- no burning or altered taste
HIV/AIDS complications: Oropharyngeal infections
pt comes in w/ marginal erythema of gums, gingival regression & palatal necrosis
Dx?
Dx = Periodontal dz
HIV/AIDS complications: Oropharyngeal infections
pt w/ high CD4 count comes in w/ maculopapular rash w/nodules and plaque like lesions
Dx?
Tx?
what is the viral cause?
Dx = Kaposi's Sarcoma (CA of endothelium) Tx = HAART (HIV Tx) Cause = herpes virus (spp = HHV 8)
HIV/AIDS complications: Cutaneous infxns
- what are the 5 types
HIV/AIDS complications: Cutaneous infxns
- VZV
- HSV
- Seborrheic keratosis
- Bacillary angiomatosis
- Molluscum contagiosum
HIV/AIDS complications: Cutaneous infxns
- what dz is caused by bartonella
- what dz caused by poxvirus and a/w small, flesh colored umbilicated lesions
- what dz a/w velvety wart lesions w/greasy stuck on appearance
- what dz a/w dermatomal outbreaks, several dermatomes affected & disseminated dz
- what dz a/w gential lesions –> ulcers; complications of radiculomyelitis & proctitis
HIV/AIDS complications: Cutaneous infxns
- Caused by bartonella = Bacillary angiomatosis
- caused by poxvirus and a/w small, flesh colored umbilicated lesions = Molluscum contagiosum
- velvety wart lesions w/greasy stuck on appearance = seborrheic keratosis
- dermatomal outbreaks, several dermatomes affected & disseminated dz = VZV (shingles)
- a/w gential lesions –> ulcers; complications of radiculomyelitis & proctitis = HSV
HIV/AIDS complications: Pulm infxns
- 2 main dz
HIV/AIDS complications: Pulm infxns
- PJP - Pneumocystis Jiroveci PNA
- Myobacterial Infxn (TB)
HIV/AIDS complications: Pulm infxns #1 PJP
- what type of infxn is it?
- what CD4 count incr pts risk?
- what test is diagnostic & which gives definitive dx?
- what is both the Tx and ppx for it?
HIV/AIDS complications: Pulm infxns #1 PJP
- fungal infxn
- CD4 < 200 = incr risk
- diagnostic test = bronchoscopy,
definitive = bronchoalveolar lavage - Tx & ppx = Bactrim
HIV/AIDS complications: Pulm infxns
- pt comes in c/o fever, sweats fatigue and non-productive cough that has developed over the last few weeks. He also states he has exertional dyspnea and chest tightness.
CXR reveal bilat diffuse infiltrates
Dx?
Dx = PJP
HIV/AIDS complications: Pulm infxns #2 TB/mycobacterium
2 ways to Dx
HIV/AIDS complications: Pulm infxns #2 TB/mycobacterium
Dx = sputum or bronchoscopy
HIV/AIDS complications: Ocular infxns
pt presents w/ fever, blurry vision & floaters w/progressive vision loss over past few days. On fundo exam you see coalescing white exudates w/flame hemorrhages & edema?
Dx & Tx
What on pathology is diagnostic for this d/o?
Why is this an urgent condition (what can it progress to w/out Tx)?
HIV/AIDS complications: Ocular infxns
Dx = CMV Retinitis & Tx = intraocular cyclovir
Pathology = owl eye inclusions
Urgent condition b/c w/out Tx –> retinal detachment & permanent vision loss
HIV/AIDS complications: CNS infxns
- 4 d/o in this category
HIV/AIDS complications: CNS infxns
- PML (Progressive Multifocal Luekoencephalopathy)
- Toxoplasmosis
- CMV
- Cryptococcus Meningitis
HIV/AIDS complications: CNS infxns
- what d/o a/w polyradiculopathy, meningeal signs and flaccid paralysis, + owl eye appearane on Bx
- what d/o a/w HA, confusion, behav/mood changes, encephalitis + chorioretinitis and caused by a parasite a/w cats?
- what d/o a/w rapidly progressive focal neural deficits such as hemiparesis and visual field defects + white matter lesions on MRI
- what d/o a/w HA, AMS, seizures + neck stiffness, and caused by fungus and can be dx w/india ink stain
HIV/AIDS complications: CNS infxns
- polyradiculopathy, meningeal signs and flaccid paralysis, & owl eye appearane on Bx = CMV
- a/w HA, confusion, behav/mood changes, encephalitis & chorioretinitis and caused by a parasite a/w cats = Toxoplasmosis
- a/w rapidly progressive focal neural deficits such as hemiparesis and visual field defects + white matter lesions on MRI = PML
- a/w HA, AMS, seizures + neck stiffness, and caused by fungus and can be dx w/india ink stain = Cryptococcus meningitis
HIV/AIDS complications: GI infxns
- 2 types in this category
HIV/AIDS complications: GI infxns
- CMV
- Cryptosporidum
HIV/AIDS complications: GI infxns
- which d/o a/w persistent diarrhea + dx by examine stool
- which d/o can affect/cause inflam of entire GI system (esophagitis, gastritis, colitis), odonophagia, diarrhea, proctitis, fever abd pain and Dx = endo/colonoscopy w/Bx
HIV/AIDS complications: GI infxns
- a/w persistent diarrhea + dx by examine stool = Cryptosporidum
- can affect/cause inflam of entire GI system (esophagitis, gastritis, colitis), odonophagia, diarrhea, proctitis, fever abd pain and Dx = endo/colonoscopy w/Bx = CMV
HIV/AIDS complications: Disseminated infxns
pt c/o fever, sweats, wt loss, fatigue, SOB and diarrhea. On exam you note HSM, RUQ pain and adenopathy. Labs reveal anemia
Dx?
PPx?
MAC (Mycobacterium Avium Complex)
ppx = Azithromycin
HIV/AIDS complications: Prevention/PPx
- what is the ppx for both Toxoplamosis and PJP
- MAC ppx
- TB ppx drug?
HIV/AIDS complications: Prevention/PPx
- ppx for Toxoplamosis and PJP = Bactrim
- ppx for MAC = Azthiromycin
- ppx for TB = INH
HIV/AIDS complications
pt started on ART 4 wks ago presenting today w/ worsening clinical status. CD4 count is 30 and there has been a rapid decline in viral load since starting tx
Dx?
dx = IRIS (Immune Reconstitution Inflammatory Syndrome)
HIV & Aging: Medication issues in older pop
- what can HIV meds cause/worsen
- HIV meds have signific _____
- what is major med problem in elderly
HIV & Aging: Medication issues in older pop
- HIV meds cause/worsen comorbidities
- HIV meds = signific drug interactions
- Polypharmacy = prob in elderly
HIV & Aging: Comorbidities
- 3 or more of the following: exhaustion, slowed walking speed, low activity level, weakness and wt loss
means pts have what type of comorbidity?
HIV & Aging: Comorbidities
3+ = fragility phenotype
HIV & Aging:
- What dz contributes to most deaths among HIV pts
CVD = biggest RF for mortality in HIV pts
HIV & Aging:
- What dz is a complication of HIV ART, especially with the DF formulation of tenofovir
Kidney/Renal dz
HIV & Aging:
- fully effective HIV Tx has lead to increased prevalence of what 3 things
fully effective HIV Tx has lead to increased prevalence of
- insulin resistance
- glucose intolerance
- DM
HIV & Aging:
- lipodystrophy/buffalo hump is a/w what type of HIV drug
HIV & Aging:
- lipodystrophy/buffalo hump a/w older PIs (Protease inhib)
HIV & Aging:
- what drug is a/w decr bone mineralization & osteoporosis
HIV & Aging:
- tenofovir DF = a/w decr bone mineralization & osteoporosis
HIV & Aging: specific med effects
NRTIs, NNRTIs and PIs all affect lipids
- which one also incr risk of heard dz
note: tenofovir = unique AEs in previous cards
HIV & Aging: specific med effects
- incr risk of heart dz w/PIs
HIV & Aging: polypharmacy
what 3 types of drugs CANNOT be given w/PIs
HIV & Aging: polypharmacy
- statins (Sim, Lova, Pita)
- St. John’s Wart
- BZs
