Module 11: HIV & Primary Care Flashcards
1
Q
Types of HIV
A
- HIV-1
- More common worldwide
- Easier perinatal transmission - HIV-2 (RARE in US)
- Less easily transmitted
- Less Pathogenic
- Less likelihood perinatal transmission
2
Q
HIV Vs AIDS
A
- HIV
- Breaks down body’s defense
- Infects specific WBC’s
- Weakens immune system - AIDS
- Attacks the immune system
- Reduces WBC’s
- Symptoms or illnesses that result from HIV infection
3
Q
Stages of HIV & AIDS
A
- Stage 0 — Early diagnosis; CD4 >/=200 or >/=14% —
- Stage 1 or 2 — No AIDS defining condition
- Stage 3 — CD4=200 or =14% OR Having an AIDS defining condition (Ex. Thrush, toxoplasmosis, meningitis
- AIDS diagnosis needs to be STAGE 3**
- AIDS diagnosis stays even when CD4 goes back up above 200
4
Q
HIV/AIDS
-Goal of Care?
A
- Diagnose
- Establish Care
- Retention in Care
- Viral Suppression
5
Q
HIV/AIDS
-Risk Factors
A
- Unprotected Sex — Vaginal & anal
- Needle sharing
- Perinatal Transmission (HIV-1)
- Substance Abuse Hx
- Accidental Needle stick
- Blood transfusion (prior to 1985)
- STI’s — Increase susceptibility with GC
- Mental Illness
6
Q
HIV/AIDS
-Patho
A
- Binding & entry
- Reverse transcription (RNA converted to DNA)
- Integration — into host cell DNA
- Synthesis of viral proteins
- Budding from the cell — start the process w/ new cells
Each part of the process can be blocked** Meds
7
Q
HIV/AIDS
-Natural Course of HIV
A
- Viral Transmission — Person to person
- Acute retroviral syndrome — Primary infection occurs (S/Sx resemble mono) — highest viral load **
- Recovery and Seroconversion — Antibody (infection) development takes 4 wks to 3 months — high risk pt should test q3 months
- Asymptomatic Chronic HIV Phase — Lasts from 3 months to 15 years
- Symptomatic Infection — Physical symptoms start to manifest — Seen in Primary care — Mono like symptoms
- Death
8
Q
HIV/AIDS
-Common S/Sx during Acute HIV infection?
A
6 days to 6 weeks after transmission and lasts 3 wks — may spontaneously resolve
- Fever 90-96%
- Adenopathy 50-74%
- Sore throat 70%
- Rash 70%
- Myalgia
- HA
- Night sweats
COUGH is NOT part of Acute HIV infection***
9
Q
HIV/AIDS
-Initial Hx
A
ROS
Constitutional — Fever
HEENT — Sinus pain, sore throat, thrush, lymphadenopathy (acute infection), Hemoptysis
GI — Painful swallowing (Fungal esophagitis) N/V/D, Hematochesia
Neuro — Unilateral HA’s, Visual disturbances (CMV retinitis), CNS
Cognitive — AIDS related dementia? Memory
SENSITIVE Diagnosis. Pay attention
10
Q
HIV/AIDS
-Exam
A
- Skin — Kaposi Sarcoma
- HEENT — Sinus tenderness, purulent drainage. Fundoscopic exam (CMV Retinitis), Mouth (Leukoplakia) Lymphadenopathy
- Chest — Consolidation, effusion; Xray if lung sounds normal w/ clinical suspicion
- Abdomen — Enlargement or tenderness of liver or spleen
- Rectum/Genitalia — PAP for invasive cervical carcinoma; endoscopy sigmoidoscopy (Colon lesions); Anal Pap and DRE (Anal CA Screen)
- Neuro — Detailed mental status exam; peripheral neuropathy; myopathy; CMV
11
Q
HIV/AIDS
-Initial Labs
A
- CBC w/ Diff — Anemia of chronic dz; lymphopenia
- CMP — LFT’s & Renal issues
- UA — Proteins and ketones
- Hepatitis Serologies — Hep A-C
- Gonorrhea/Chlamydia
- RPR — Syphilis test — If pt has had syphilis RPR will always be positive. Titer will tell status
- Cytomegalovirus/toxoplasmosis
- HLA B 5701 — If POSITIVE, Abagavir can cause SJS
12
Q
HIV/AIDS
-Additional Labs
A
- HIV Viral Load — Highest in acute phase
- CD4 T-cell count/Percentage (200/14)
- Quantiferon or T-spot (TB test)
- CMV IgG
- G6PD — Test for those Predisposed to hemolysis w/ sulfa drugs
- Dilated retina exam (MANDITORY w/ CD4 <50)
13
Q
Antiretroviral Therapy (ART) -5 major Classes?
A
- Nucleoside Reverse Transciptase Inhibitors (NUKES)
- Non-nucleoside Reverse Transcriptase Inhibitors
- Protease Inhibitors
- Fusion inhibitors/Entry Inhibitors
- Integrase Inhibitors
14
Q
Antiretroviral Therapy (ART) -When to Start?
A
- Recommended for ALL HIV-infected individuals, especially
- Pregnancy
- Hx of AIDS-defining illness
- HIV-associated nephropathy (HIVAN) — common in African Americans
- Hepatitis B Coinfection — ART can treat hep b
- Age >50 years — Harder to bounce back with older age
15
Q
Antiretroviral Therapy (ART) -Benefits of new ART meds?
A
- Increased potency, durability, simplicity, safety
- Decrease emergence of resistance
- Decrease toxicity w/ earlier therapy
- Increase subsequent treatment options
- Risk of uncontrolled viremia at all CD4 levels
- Decrease transmission
16
Q
Antiretroviral Therapy (ART) -Benefits of Early therapy
A
- HIV-Associated Nephropathy (HIVAN) — Meds reduce this risk
- Liver disease progression from Hep B or C — ART’s treat Hep B
- Malignancies — reduce likelihood of AIDS defining and non-AIDS defining conditions
- Neurocognitive decline
- Blunted Immunological response owing to ART initiation at older age
- Persistent T-cell activation and inflammation
17
Q
Antiretroviral Therapy (ART) -When to Consider Deferral??
A
- Clinical or personal factors may support deferral — potential mental health
- Significant barriers to adherence
- If co-morbidities complicate or prohibit ART
18
Q
Antiretroviral Therapy (ART) -Unique S/E’s
A
- Peripheral Neuropathies & Pancreatitis
- Hypersensitivity w/ Abacavir — HLA-test if positive DO not use abacavir
- CNS Toxicity (EFV)
—Dizziness, aggravation of mental health complications, vivid dreams - Metabolic complications
—Lipid abnormalities, altered glucose metabolism, body fat redistribution, mitochondrial toxicity, neuropathies
19
Q
Antiretroviral Therapy (ART) -Immune Reconstitution Inflammatory Syndrome (IRIS)
A
- Practical Definition
- Paradoxical worsening of a pre-existing infection of a previously undiagnosed condition - Paradoxical IRIS
- Improvement of known infection w/ treatment but deteriorate w/ ART - Unmasking IRIS
- Detection of previously unknown pathogen that shows a prominent clinical expression w/ immune recovery
20
Q
Prophylaxis Regimens
-Prevention of Opportunistic Infection?
Pneumocystis Jiroveci pneumonia?
A
- Pneumocystis Jiroveci Pneumonia CD4 < 200
—No Sulfa Allergy — Treat with BACTRIM
—Sulfa Allergy — G6PD test — Dapsone 100mg or Aerosolized Pentamidine
21
Q
Prophylaxis Regimens
-Prevention of Opportunistic Infection?
Mycobacterium Avium Complex
A
- Mycobacterium Avium Complex — CD4 <500
—Zithromax 1G weekly OR Clarithromycin 500mg BID
22
Q
Prophylaxis Regimens
-Prevention of Opportunistic Infection?
Toxoplasmosis IgG Positive and no active disease
A
- Toxoplasmosis IgG positive and no active disease (CD4<100)
—Bactrim 1 tab daily
23
Q
Prophylaxis Regimens
-Follow up Labs
A
- 1 month after initiating therapy
—CBC w/ diff; CMP; CD4+; CD4%; HIV viral load - 3-6 months
—Lipid panel and HbA1C q6 months - Goal is <40 copies or undetectable
- W/ each visit, check mouth, lymph nodes, skin, vitals, feels and emotions and well-being
24
Q
HIV
-Prevention/Behavior Modification
A
- Consistent condom use
- Monogamy vs partner reduction
- Safer sex and drug practices
- Opiate substitution — methadone
- Prevention message every clinic visit
- Screen and treat for mental health
25
HIV
| -Vaccinations/Immunizations
1. Hepatitis — Serology to check immunity
- Hep A - 0 and 6 months; screen at risk
- Hep B - 0, 1, & 6 months —check titer 1 month post vaccine
- Delay re-vaccination if CD4 is <200
- 3 series twinrix vaccine for both Hep A & B (0, 1, & 6 months)
2. Pneumonia -PCV-13 & PPV-23
- NO PPV 23 if CD4 <200**
- PCV 13 then give PPV-23 8 wks after
3. Parter HPV w/ Hep vaccine due to same schedule of vaccination
4.
26
HIV
| -Routine Screenings
1. Gonnorrhea, Chlamydia, Syphilis, Hepatitis Serologies
—Baseline
—At least annually for all sexually active patients
—High risk every 3-6 months
2. DM, Dyslipidemia
—Baseline
—W/in 3 months of starting new ART regimen
—Annually
27
HIV
| -Metabolic Co-Morbidities
1. Dyslipidemia
2. Diabetes Mellitus
3. HTN
28
HIV + Comorbidities
| -Clinical Implications
1. Physical changes
2. Hypertriglyceridemia
3. Low HDL cholesterol
4. Modest increases in LDL cholesterol
5. Increased diastolic BP
6. Increased Metabolic Syndrome profile
7. Increased Cardiovascular risk
29
HIV & Dyslipidemia
| -Meds of choice
1. Statins
- Rosuvastatin
- Atorvastatin
- Pravastatin
30
HIV and DM
1. 3.8% increase in prevalence of DM in HIV pt’s over 3 yr period
2. Treat to A1c of =7 with HIV pt’s
3. ART + Metformin can cause Lactic Acidosis
4. Nephrotoxicity — MONITOR GFR and Creatinine**
31
HTN and HIV
| -Considerations
1. Concern for CCB and BB w/ regimens that include a protease inhibitor
—Can increase levels of anti-HTN, HIV drug, or QT or PR interval prolongation
—Dose adjustment, and close monitoring needed
32
Common Problems in HIV care
1. Folliculitis
2. Candida —Oral, esophageal, rectal, vaginal
3. HSV
4. Herpes Zoster
5. Anal fistula
6. Genital warts
7. P. Jirovecii Pneumonia (PCP), Toxoplasmosis, Mycobacterium Avium complex, histoplasmosis capsulatum, coccidioidomycosis, kaposi sarcoma
33
Related HIV Issues
1. Mental Health
2. Costs of Care
3. Stigma
4. Support systems
5. Polysubstance abuse
6. Correctional care
7. Lifestyle context
34
Drug-Drug Interactions with ART
1. Vitamins & Tums— Decrease absorption of ART — Take 4 hrs apart
2. OCP’s w/ protease — Result in OCP failure & ART toxicity — can lead to pregnancy
3. PPI’s
4. Antibiotics — PI’s and azythromycin lead to QT prolongation — Also CDIFF** Gastric acid suppression
5. Steroids — can reduce non-nuc ART meds
35
HIV
| -Special Considerations
1. Pregnancy — Contraception and preconception care
2. Children — Advisory committee on immunization practices for HIV-infected infants and children
3. Adolescents — Transition to adult care
4. Transgender Care — address specific biological, psychological, and social needs
36
HIV
| -Occupational Risk Exposures in Health Care Personnel
1. Percutaneous injury (needle stick or cut)
2. Contact of mucous membrane or non intact skin
WITH
3. Blood, tissue, CSF, Synovial, pleural, pericardial, peritoneal, or amniotic fluid — Semen or vaginal secretions
37
HIV
| -Fluids that are NOT considered Infectious for HIV
1. Feces, Nasal secretions, saliva, sputum, sweat, tears, urine, vomitus
38
Initiating Post-Exposure Prophylaxis (PEP)
1. PEP should be started asap, preferably w/in hours, rather than days following exposure
2. When uncertain, start the basic regimen rather than delay
3. 3 drug combo regimen for 1 month are recommended in ALL casses of occupational exposure**
39
PEP Evaluation
1. Re-evaluate exposed HCP w/in 72 hrs of exposure, especially as new info about exposure or source patient is available
2. If source is negative, DC the PEP
40
PEP Baseline Labs?
1. HIV antibody test
2. Hep B & C
3. CBC, CMP, HCG
4. After initiating ART
— Check HIV antibody test at 6, 12, and 24 wks
— Check Hep C at 12 & 24 wks
5. Check drug toxicities — HIV antibody test, CBC, CMP, and HIV RNA
MONITOR all side effects
41
Pre-Exposure Prophylaxis
| -Guidelines
1. Truvada and Descovy**
2. Sexually active gay and bisexual men w/out HIV
3. Sexually active heterosexual men and women w/out HIV
4. Sexually active transgender persons w/out HIV
5. Persons w/out HIV who inject drugs
6. Persons on non-occupational PEP and report continued risk behavior
42
Pre-Exposure Prophylaxis
| -Monitoring
1. At least every 3 months
—Repeat HIV testing & assess for s/s of acute infection
—Pregnancy testing for women who may become pregnant
—S/E, adherence, HIV risk behavior
2. At least every 6 months
—Creatinine clearance
—STI testing for sexually active adolescents and adults
3. At least every 12 months
—Eval need to continue PrEP as component of HIV prevention
