Medical Management of HIV/AIDS Flashcards
How do you define a case definition of AIDS?
HIV infection and
CD4 count < 200 (adults) and/or
CD4 cells < 14% total lymphocytes and/or
AIDS-defining conditions
What are some AIDS-defining conditions?
Life-threatening opportunistic infections
Unusual cancers (B cell lymphomas of CNS, Kaposi’s sarcoma)
Invasive cervical carcinoma
Pulmonary TB
Recurrent pneumonias
What is an essential aspect of health counseling for HIV in primary care?
Prevention of infection
What is the prevalence of HIV infection in US estimated to be?
1.2 million
What is the incidence of new HIV infections in the US?
50,000/year
What are the 2 types of post-exposure prophylaxis?
Occupational exposure & sexual encounter exposure
How does post-exposure therapy work?
Take it within 72 hours of potential exposure; follow a 28-day regimen of anti-retroviral therapy.
Why are PCPs managing the care of many HIV patients today?
It has become a chronic, rather than acute, disease. Many patients are living into their 70s, 80s. Early prognosis was about 2 years. Current prognosis today can be as long as a few decades.
What kind of care should be provided for HIV patients?
ART and routine preventive care recommended for all patients.
What are you using when you assume that everybody’s blood and bodily fluids which you are about to handle are contaminated?
Universal precautions
Abstinence & avoidance of IV drug use, testing (especially if at risk), monogomous relationship with HIV(-) partner, condom use, clean needle use by IVDAs, screening for anti-HIV antibodies in blood, and ART of pregnant women are all examples of what?
Prevention of HIV transmission
What is high risk heterosexual contact?
Multiple partners, prostitution
What are clinical manifestations of HIV/AIDS?
Acute retroviral syndrome Manifestations during chronic period Opportunistic infections Unusual cancers End-organ damage due to HIV itself
We generally have B cell lymphomas floating around, but if you find a rise in them in the ______, your patient is severely ______.
…..CNS…..immunocompromised.
Within what time frame would you expect to see manifestations of acute retroviral syndrome?
Within 6 weeks
What clinical and serological findings would you expect to see within first 5-6 weeks of HIV infection?
ARS
Antibodies are not detectable yet
Viral RNA & p24 are detectable
What clinical and serological findings would you expect to see after 6 weeks of HIV infection?
ARS
Antibodies are detectable
Viral RNA and p24 persist
What tests should you perform to confirm HIV diagnosis?
ELISA, followed by Western Blot
What is p24?
Structural protein that makes up most of the HIV viral core/capsid
When would you expect to see high levels of p24 in blood serum of newly infected individuals?
During the short period between infections and seroconversion.
What is the time frame for recent HIV infection?
6 weeks - 6 months
How do you diagnose HIV?
Usually, have detectable HIV RNA or p24 antigen with negative/indeterminate HIV antibody test result. If diagnosis is made by HIV RNA testing, confirmatory serologic testing should be performed in 3-6 months.
What is the problem with combination HIV Ag/Ab tests?
Do not differentiate between Ag & Ab positivity. If reactive retest with Ab assay. If negative/indeterminate, check HIV RNA if acute HIV is suspected.
What is the problem with home HIV tests?
Only detect HIV antibodies; will not detect (antigens) for very early infection.
What are the goals of HIV management?
Keep the patient as healthy as possible.
Prevent further transmission.
What can you do to help keep the patient as healthy as possible?
ART
Screening, prevention, treatment for opportunistic infections & cancers as necessary
Regular preventive care - especially for cardiovascular function, lipid panels, cancer screenings, osteoporosis screenings, diabetes, kidney & liver function
How can you help prevent further transmission?
Contact tracing
Patient education
What would you include in the work up of a newly diagnosed HIV-infected patient that you wouldn’t necessarily include for your average healthy patient?
Baseline CD4 cell count (repeated every 4-6 months)
Baseline viral load (check every 6-12 months)
Check for viral resistance patterns
Baseline CBC & differential, UA, BUN, total protein & albumin, serum liver enzymes, electrolytes, creatinine, fasting lipid profile, blood glucose
Screen for diabetes, osteoporosis, cervical & colon cancer
Vaccinations! - pneumo, influenza, varicella, HAV, HBV
Screen for other STDs, particularly gonorrhea, chlamydia, syphilis, Trichomonas vaginalis
Screen for TB infection & viral hepatitis (Histoplasma, Toxoplasma, CMV if patient is at risk)
Counseling on ways to prevent transmission and maintain health at EVERY office visit
As long as the CD4 count is at _____, you can vaccinate your patient.
200
What are the immunologic/virologic assessments for newly diagnosed HIV-infected patients that you should perform?
CD4 count
Viral load
Viral resistance testing
How often should you check your patient’s CD4 count?
Repeat after initiation of ART and regularly thereafter.
How often should you check your patient’s viral load?
Repeat after initiation or change in ART and regularly thereafter.
How often should you check your patient’s viral resistance testing?
Repeat if viral load increases while on ART.
How might a newly infected HIV patient have a resistant strain?
Infected partner had one.
If virus becomes resistant, viral load can go _____ without seeing _____ ______ ______ ______.
…..up…..symptoms of disease progression.
How do you measure viral load?
PCR
What is considered a high viral load?
100,000 copies/mL or greater
What is considered a low viral load?
10,000 copies/mL or greater
What is considered an undetectable viral load?
below 400 or 50 copies/mL, depending on test
What does it mean to say that viral load is a prognostic indicator?
High viral load predicts more rapid progression to AIDS.
If the initial viral load is high, how crucial is it to begin ART?
Very
What is the goal of ART in terms of viral load?
Reduce it to < 20-75 copies/mL of blood
CD4 count is the major indicator of what?
Immune function
What is an adequate response of CD4 cells to ART?
50-150 cells/micro-L per year
When CD4 count decreases to a certain level, prevention of some opportunistic infections can be accomplished in what way?
Administration of prophylactic antimicrobials
What prophylaxis would you give to a patient with low CD4 counts who is at risk for pneumocystis, toxoplasma, and mycobacterium avium infections?
Pneumocystis (CD4 < 200/cmm) & Toxoplasma (CD4 < 50/cmm) - TMP/SMX Mycobacterium avium (CD4 < 50/cmm) - asithromycin or clarithromycin
Your treatment-naive patient is asymptomatic and has a CD4 count < 350 cells/mm^3. ART recommendation?
Strongly recommended
Your treatment-naive patient has a CD4 count 350-500 cells/mm^3. ART recommendation?
Strongly recommended
Your treatment-naive patient has a CD4 count > 500 cells/mm^3. ART recommendation?
Moderately recommended
What are the classes of drugs being prescribed to treatment-naive patients?
NRTI, NNRTI, PI, INSTI, FI, chemokine receptor antagonist
Why is ART treatment so important?
It can encourage a longer latency.
What are potential benefits of early ART?
Slow progression (immune dysfunction secondary to chronic T cell activation, inflammation, T cell immune deficiency; HIV-related end-organ disease)
Reduction in viral load can decrease risk of transmission
All pregnant HIV-infected patients should receive ART to reduce risk of transmission to neonate
What are the goals of ART?
Improve quality of life
Improve adherence to ART
Reduce toxicities
Reduce risk of virology failure
What are potential disadvantages of early ART?
Some drugs have strong toxicities
Patients not exhibiting any symptoms could feel worse on drugs
Fear that resistance will wipe out all drug effectiveness (not really a true concern these days)
How do you determine which drugs to chose after determining CD4 count, measuring viral load, and performing resistance testing?
Determine viral tropism
HLAB 5701 testing - prior to initiation of abacavir due to risk of hypersensitivity reaction
What are some toxicities that may be caused by ART?
Lactic acidosis Hepatotoxicity Lipodystrophy Nephrotoxicity Hyperlipidemia
