WEEK 1: CLINICAL COURSE OF HIV Flashcards

1
Q

HIV medicines help people with HIV live longer, healthier lives. One of the main goals of ART is to reduce a person’s viral load to an undetectable level.

What is an undetectable viral load?

A

An undetectable viral load means that the level of HIV in the blood is too low to be detected by a viral load test.

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2
Q

There are three stages of HIV infection. State them.

A

(1) acute HIV infection
(2) chronic HIV infection
(3) acquired immunodeficiency syndrome (AIDS).

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3
Q

Why is ART is very effective at preventing HIV from multiplying?

A

Because an HIV treatment regimen includes HIV medicines from at least two different HIV drug classes, ART is very effective at preventing HIV from multiplying.

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4
Q

What are the seven stages of the HIV life cycle?

A

1) binding: When HIV attacks a CD4 cell, the virus binds (attaches itself) to molecules on the surface of the CD4 cell: first a CD4 receptor and then either a CCR5 or CXCR4 coreceptor.

2) fusion: After HIV attaches itself to a host CD4 cell, the HIV viral envelope fuses with the CD4 cell membrane. Fusion allows HIV to enter the CD4 cell. Once inside the CD4 cell, the virus releases HIV RNA and HIV enzymes, such as reverse transcriptase and integrase.

3) reverse transcription: HIV releases and uses reverse transcriptase (an HIV enzyme) to convert its genetic material—HIV RNA—into HIV DNA. The conversion of HIV RNA to HIV DNA allows HIV to enter the CD4 cell nucleus and combine with the cell’s genetic material—cell DNA.

4) integration: Once inside the host CD4 cell nucleus, HIV releases integrase, an HIV enzyme. HIV uses integrase to insert (integrate) its viral DNA into the DNA of the host cell.

5) replication: Once HIV is integrated into the host CD4 cell DNA, the virus begins to use the machinery of the CD4 cell to create long chains of HIV proteins. The protein chains are the building blocks for more HIV.

6) assembly: During assembly, new HIV RNA and HIV proteins made by the host CD4 cell move to the surface of the cell and assemble into immature (noninfectious) HIV.

7) budding: During budding, immature (noninfectious) HIV pushes itself out of the host CD4 cell. (Noninfectious HIV can’t infect another CD4 cell.)

Once outside the CD4 cell, the new HIV releases protease, an HIV enzyme.

Protease breaks up the long protein chains in the immature virus, creating the mature (infectious) virus.

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5
Q

What is a latent HIV reservoir?

A

A latent HIV reservoir is a group of immune system cells in the body that are infected with HIV but are not actively producing new virus.

HIV attacks immune system cells in the body and uses the cells’ own machinery to make copies of itself. However, some HIV-infected immune cells go into a resting or latent state.

While in this resting state, the infected cells do not produce new virus. HIV can hide inside these cells for years, forming a latent HIV reservoir but, at any time, cells in the latent reservoir can become active again and start making more virus.

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6
Q

Do HIV medicines work against latent HIV reservoirs?

A

HIV medicines prevent HIV from multiplying, which reduces the amount of the virus in the body (called the viral load). Because the HIV-infected cells in a latent reservoir are not producing new copies of the virus, HIV medicines have no effect on them.

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7
Q

What is HIV testing?

A

HIV testing determines if a person is infected with HIV.

HIV testing can detect HIV infection, but it cannot tell how long a person has had HIV or if the person has AIDS.

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8
Q
A
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9
Q

Why is HIV testing important?

What should one do if they are HIV negative?

What should one do if they are positive?

A

Knowing your HIV status can help keep you—and others—safe.

If you are HIV negative:

A negative HIV test result shows that you do not have HIV. Continue taking steps to avoid getting HIV, such as using condoms during sex and, if you are at high risk of getting HIV, taking medicines to prevent HIV (called pre-exposure prophylaxis or PrEP). For more information, read the HIV info fact sheet on The Basics of HIV Prevention.

If you are HIV positive:

A positive HIV test result shows that you have HIV, but you can still take steps to protect your health. Begin by talking to your health care provider about antiretroviral therapy (ART). People on ART take a combination of HIV medicines every day to treat HIV infection. ART is recommended for everyone who has HIV, and people with HIV should start ART as soon as possible. ART cannot cure HIV, but HIV medicines help people with HIV live longer, healthier lives.

A main goal of ART is to reduce a person’s viral load to an undetectable level. An undetectable viral load means that the level of HIV in the blood is too low to be detected by a viral load test. People with HIV who maintain an undetectable viral load have effectively no risk of transmitting HIV to their HIV-negative partner through sex.

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10
Q

Who should get tested for HIV?

Age?

A

Everyone 13 to 64 years of age get tested for HIV at least once as part of routine health care.

As a general rule, people at higher risk for HIV should get tested each year.

Sexually active gay and bisexual men may benefit from getting tested more often, such as every 3 to 6 months.

If you are over 64 years of age and at risk, your health care provider may recommend HIV testing.

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11
Q

Outline factors that increase the risk of HIV infection.

A

Factors that increase the risk of HIV include:

*Having vaginal or anal sex with someone who is HIV positive or whose HIV status you do not know

*Injecting drugs and sharing needles, syringes, or other drug equipment with others

*Exchanging sex for money or drugs

*Having a sexually transmitted disease (STD), such as syphilis

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12
Q

Should pregnant women get tested for HIV?

What is perinatal transmission?

State other synonyms.

A

CDC recommends that all pregnant women get tested for HIV so that they can begin taking HIV medicines if they are HIV positive. Women with HIV take HIV medicines during pregnancy and childbirth to reduce the risk of perinatal transmission of HIV and to protect their own health.

When a mother with HIV passes the virus to her infant during pregnancy, labor and delivery, or breastfeeding (through breast milk).

Maternal-Child Transmission, Mother-to-Child Transmission (MTCT), Vertical Transmission

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13
Q

What are the types of HIV tests?

A

Antibody tests check for HIV antibodies in blood or oral fluid. HIV antibodies are disease-fighting proteins that the body produces in response to HIV infection. Most rapid tests and home use tests are antibody tests.

Antigen/antibody tests can detect both HIV antibodies and HIV antigens (a part of the virus) in the blood.

NATs look for HIV in the blood.

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14
Q

What is window period?

A

The window period is the time between when a person may have been exposed to HIV and when a test can accurately detect HIV infection.

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15
Q

HIV testing can be confidential or anonymous.

Describe the two tests.

A

Confidential testing means that your HIV test results will include your name and other identifying information, and the results will be included in your medical record.

HIV-positive test results will be reported to local or state health departments to be counted in statistical reports.

Health departments remove all personal information (including names and addresses) from HIV test results before sharing the information with CDC.

CDC uses this information for reporting purposes and does not share this information with any other organizations, including insurance companies.

Anonymous testing means you do not have to give your name when you take an HIV test. When you take the test, you receive a number. To get your HIV test results, you give the number instead of your name.

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16
Q

What is ART?

ART is recommended for everyone with HIV, and people with HIV should start ART as soon as possible.

How is the treatment offered?

A

Treatment with HIV medicines is called antiretroviral therapy (ART).

People on ART take a combination of HIV medicines (called an HIV treatment regimen) every day.

A person’s initial HIV treatment regimen generally includes three HIV medicines from at least two different HIV drug classes.

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17
Q

What is an investigational HIV drug?

A

An investigational HIV drug is an experimental drug that is being studied to see whether it is safe and effective.

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18
Q

What are the 5 types of investigational HIV drugs are being studied?

A

Some types of investigational HIV drugs being studied include:

*Microbicides: A drug, chemical, or other substance used to kill microorganisms. The term is used specifically for substances that prevent or reduce the transmission of sexually transmitted diseases, such as HIV.

*Immune modulators: Immune modulators are a class of drugs that help to activate, boost, or restore normal immune function after HIV has damaged the immune system.

*Latency-reversing agents: Latency-reversing agents reactivate latent HIV within CD4 cells, allowing ART and the body’s immune system to attack the virus.

*gp120 attachment inhibitors: Attachment inhibitors are a class of antiretroviral (ARV) drugs that interfere with the early interaction between the gp120 protein on the outer surface of HIV and the CD4 receptor on the host cell (CD4 T lymphocytes [CD4 cells]). This prevents HIV from binding to and entering CD4 cells. Attachment inhibitors are part of a larger class of HIV drugs called entry inhibitors.

*Rev inhibitors: Rev is the name of an HIV protein that helps to transport HIV’s genetic information within an infected immune cell. HIV uses the Rev protein to replicate and produce new virus. Rev inhibitors are drugs that interfere with the Rev protein’s activity to prevent HIV from multiplying in the body.

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19
Q

How are clinical trials of investigational drugs conducted?

A

Clinical trials are conducted in phases. Each phase has a different purpose and helps researchers answer different questions about the investigational drug.

Phase 1 trial: Initial testing in a small group of people (20–80) to evaluate the drug’s safety and to identify side effects.

Phase 2 trial: Testing in a larger group of people (100–300) to determine the drug’s effectiveness and to further evaluate its safety.

Phase 3 trial: Continued testing in large groups of people (1,000–3,000) to confirm the drug’s effectiveness, monitor side effects, compare it with standard or equivalent treatments, and collect information to ensure that the investigational drug can be used safely.

Phase 4 trial: Ongoing tracking that occurs after a drug is approved by the FDA for sale in the United States. The purpose of the tracking is to seek more information about the drug’s risks, benefits, and optimal use.

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20
Q

What is a therapeutic HIV vaccine?

A

A therapeutic HIV vaccine is a vaccine that is designed to improve the body’s immune response to HIV in a person who already has HIV.

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21
Q

How is a therapeutic HIV vaccine different from a preventive HIV vaccine?

A

A preventive HIV vaccine is given to people who do not have HIV, with the goal of preventing HIV infection in the future.

The vaccine teaches the person’s immune system to recognize and effectively fight HIV in case the virus ever enters the person’s body.

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22
Q

What is a Preventive HIV Vaccine?

A

A preventive HIV vaccine is given to people who do not have HIV, with the goal of preventing HIV infection in the future.

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23
Q

What is a clinical trial?

A

A clinical trial is a research study done to evaluate new medical approaches in people. HIV and AIDS clinical trials help researchers find better ways to prevent, detect, or treat HIV and AIDS.

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24
Q

Outline the classes of HIV medicines.

A
  1. Nucleoside Reverse Transcriptase Inhibitors (NRTIs): NRTIs block reverse transcriptase, an enzyme HIV needs to make copies of itself.

EXAMPLE: Tenofovir Disoproxil Fumarate (tenofovir DF, TDF)

  1. Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs): NNRTIs bind to and later alter reverse transcriptase, an enzyme HIV needs to make copies of itself.
  2. Protease Inhibitors (PIs): PIs block HIV protease, an enzyme HIV needs to make copies of itself.
  3. Fusion inhibitors block HIV from entering the CD4 T lymphocyte (CD4 cells) of the immune system.
  4. CCR5 Antagonists: CCR5 antagonists block CCR5 coreceptors on the surface of certain immune cells that HIV needs to enter the cells.

6.Integrase Strand Transfer Inhibitor (INSTIs): Integrase inhibitors block HIV integrase, an enzyme HIV needs to make copies of itself.

  1. Attachment Inhibitors: Attachment inhibitors bind to the gp120 protein on the outer surface of HIV, preventing HIV from entering CD4 cells.
  2. Post-Attachment Inhibitors
    Post-attachment inhibitors block CD4 receptors on the surface of certain immune cells that HIV needs to enter the cells.
  3. Capsid Inhibitors
    Capsid inhibitors interfere with the HIV capsid, a protein shell that protects HIV’s genetic material and enzymes needed for replication.
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25
Q

What is HIV drug resistance?

A

Once a person gets HIV, the virus begins to multiply in the body. As HIV multiplies, it sometimes changes form (mutates). Some HIV mutations that develop while a person is taking HIV medicines can lead to drug-resistant HIV.

Once drug resistance develops, HIV medicines that previously controlled the person’s HIV are no longer effective. In other words, the HIV medicines cannot prevent the drug-resistant HIV from multiplying. Drug resistance can cause HIV treatment to fail.

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26
Q

Can drug resistance HIV be transmitted?

A

Drug-resistant HIV can spread from person to person (called transmitted resistance). People with transmitted resistance have HIV that is resistant to one or more HIV medicines even before they start taking HIV medicines.

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27
Q

What is drug-resistance testing?

What is its importance?

A

Drug-resistance testing identifies which, if any, HIV medicines that will not be effective against a person’s HIV. Drug-resistance testing is done using a sample of blood.

People with HIV should start taking HIV medicines as soon as possible after their HIV is diagnosed. But before a person starts taking HIV medicines, drug-resistance testing is done.

Drug-resistance test results help determine which HIV medicines to include in a person’s first HIV treatment regimen.

Once HIV treatment is started, a viral load test is used to monitor whether the HIV medicines are controlling a person’s HIV. If viral load testing indicates that a person’s HIV treatment regimen is not effective, drug-resistance testing is repeated. The test results can identify whether drug resistance is the problem and, if so, can be used to select a new HIV treatment regimen.

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28
Q

How can a person taking HIV medicines reduce the risk of drug resistance?

A

Taking HIV medicines every day and exactly as prescribed (called medication adherence) reduces the risk of drug resistance. Skipping HIV medicines allows HIV to multiply, which increases the risk that the virus will mutate and produce drug-resistant HIV.

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29
Q

What is HIV treatment adherence?

A

For people with HIV, treatment adherence means:

Starting HIV treatment
Taking HIV medicines every day and exactly as prescribed (also called medication adherence)
Keeping all medical appointments

30
Q

How soon should a person start treatment after testing positive for HIV?

A

It is best to see a health care provider as soon as possible after testing positive for HIV. Once in medical care, people with HIV should start taking HIV medicines as soon as possible.

31
Q

Why is medication adherence important?

A

Taking HIV medicines every day prevents HIV from multiplying, which reduces the risk that HIV will mutate and produce drug-resistant HIV.

Skipping HIV medicines allows HIV to multiply, which increases the risk of drug resistance and HIV treatment failure.

Poor adherence to an HIV treatment regimen also allows HIV to destroy the immune system. A damaged immune system makes it hard for the body to fight off infections and certain cancers.

32
Q

What is HIV treatment failure?

State factors that contribute to HIV treatment failure.

A

When an antiretroviral (ARV) regimen is unable to control HIV infection.

Factors that can contribute to HIV treatment failure include:

Drug resistance, drug toxicity, or poor adherence to antiretroviral therapy (ART).

33
Q

What is a drug interaction?

A

A drug interaction is a reaction between two (or more) drugs or between a drug and a food, beverage, or supplement.

34
Q

There are three types of drug interactions. Describe them.

A
  1. Drug-drug interaction: A reaction between two (or more) drugs.
  2. Drug-food interaction: A reaction between a drug and a food or beverage.
  3. Drug-condition interaction: A reaction that occurs when taking a drug while having a certain medical condition.

For example, taking a nasal decongestant if you have high blood pressure may cause an unwanted reaction.

35
Q

Do HIV medicines ever cause drug interactions?

A

Drug interactions, especially drug-drug interactions, can complicate HIV treatment.

For example, some HIV medicines may make hormonal birth control less effective, so women using hormonal contraceptives may need to use an additional or different method of birth control to prevent pregnancy.

36
Q

Can drug-food interactions affect people taking HIV medicines?

A

Food can affect the absorption of some HIV medicines and increase or reduce the concentration of the medicine in the blood.

Depending on the HIV medicine, the change in concentration may be helpful or harmful.

Directions on how to take HIV medicines specify whether to take the medicine with food or on an empty stomach. Some HIV medicines can be taken with or without food, because food does not affect their absorption.

37
Q

Outline conditions that cause drug interactions in people living with HIV and AIDS.

A

Conditions, such as kidney disease, hepatitis, and pregnancy, can affect how the body processes HIV medicines.

The dosing of some HIV medicines may need to be adjusted in people with certain medical conditions.

38
Q

Which vaccines are recommended for people with HIV?

A

The following vaccines are recommended for people with HIV:

Hepatitis B
Human papillomavirus (HPV)
Influenza (flu)
Meningococcal
Pneumococcal (pneumonia)
Tetanus, diphtheria, and pertussis (whooping cough). A single vaccine called Tdap protects adolescents and adults against these three diseases.

39
Q

What is PrEP?

What is PEP?

A

PrEP stands for pre-exposure prophylaxis and PEP stands for post-exposure prophylaxis.

Prophylaxis means “treatment or actions taken to prevent a disease.”

PrEP is a treatment plan to prevent HIV before a person is exposed.

PEP is a treatment plan for after a person is exposed. Should be taken within 72 hours.

40
Q

State the drugs used for PrEP.

A

Both TDF (Tenofovir disoproxil fumarate) and FTC (Emtricitabine) are nucleos(t)ide analogue reverse transcriptase inhibitors (NRTIs) which must be taken up into cells and sequentially phosphorylated in the cell to the pharmacologically active diphosphate (DP) and triphosphate (TP) anabolites.

They block reverse transcriptase enzyme.

41
Q

What are long-term non-progressors?

A

Long-term non-progressors are people with HIV who do not take antiretroviral therapy and still maintain normal CD4 counts indefinitely.

They have properties within their immune systems that control the virus.

Long-term non-progressors (LTNPs) are HIV-infected individuals who remain symptom-free over long -term and do not progress to AIDS.

42
Q

Does Clinical latency mean no viral replication?

A

No, clinical latency does not mean no viral replication. It means that the virus is still active but reproduces at very low levels.

43
Q

Viral diversity decreases during latent HIV infection. T or F

A

F
As the virus replicates, there are mutations so diversity increases.

44
Q

Once exposed to single ARV, viral rebound occurs within weeks or months. Why?

A

There are mutations which result in drug resistance, so the virus increases again as it is not suppressed.

45
Q

Describe 2 phases of HIV viral decay, following exposure to ARV treatment.

A

Phase 1: Rapid decline
Phase 2: Slow decline

46
Q

How does viral load affect clinical progression during the latent HIV infection?

A

Higher viral load, worse clinical progression.

47
Q

What is the normal CD 4 count.

When do symptoms occur?

When is it AIDS?

A

500-1500

Less than 500

Less than 200

48
Q

A 24-year-old goes to routine screening. CD4 count is 200. Before HIV, it is 620. How long has he had HIV?

A

The approximate number of cells lost per year is 150.

Around 4-8 years

49
Q
  1. Same man above has a GF who Tests HIV positive. 4 years ago, her cd4 count was 900. Now it’s 600. What can you say about the clinical course of HIV in her vs him. What might explain thisdifference.
A

Man has the worst progression, started with a low CD4 count and has lessCD4 count after 4 years.

Could be explained by some genetic factors and lifestyle.

50
Q

1.Describe factors associated with decline in viral load associated with acute infection.

A

*Appearance of CD8+ T CELLS
*Use of ART

51
Q

How long it takes for HIV specific antibodies to be detected in serum?

A

About 3 months, varies.

52
Q

How do ART initiation in acute HIV infection impact the clinical course of HIV?

A

Prevent replication of the virus by inhibiting Reverse transcriptase and proteases. Lowers viral load.

53
Q

Are new infection caused by multiple homogeneous/heterogeneous virions?

A

Homogenous virions

54
Q

Name at least 3 factors associated with efficiency of HIV infections.

A

*Route of infection
*Pre-existing genital ulceration diseases caused by STDs.
*Level of viremia, viral load

55
Q

How long can clinical latency last following acute clinical infection?

A

8-12 years

56
Q

What are elite controllers and long-term non-progressor differences?

A

The difference is that elite controllers have undetectable levels of virus (<50 copies/ml) while long-term non-progressors have low but detectable levels of virus (<2000 copies/ml)

57
Q

Outline typical manifestation of acute HIV infection.

A

*Diarrhea
*Fever
*Vomiting
*Nausea
*Headache
*Sore throat
*Chills and sweats
*Rash
*Loss of appetite
*Fatigue
*Lymphadenopathy
*Pharyngitis

58
Q

How long will the first symptoms occur following exposure?

A

2-4 weeks

59
Q

What is the proportion of patients that recall their acute phase symptoms?

A

50-70% after a lot of probing.

60
Q

How long do symptoms last in acute phase?

A

1-2 weeks

61
Q

What cells rapidly decline then arises following acute phase?

A

CD4+ T lymphocytes

62
Q

How long does it take for detection of HIV-RNA following acute infection?

A

3 Weeks: Burst of Viral replication.

63
Q

An associated protein used to assess HIV.

A

p24

64
Q

Majority of virions seen in HIV infection.

A

HIV-1, HIV-2 least

65
Q

Describe HIV under the following.
1. Family
2.Genus
3. Species

A

Family: Retroviridae
Genus: Lentivirus
Species
HIV-1: most common species worldwide
HIV-2: restricted almost completely to West Africa

66
Q

Describe the structure of HIV.

A

Envelope: The outermost layer of HIV is the viral envelope. This envelope is derived from the host cell membrane during the process of viral budding, and it contains viral glycoproteins (gp120 and gp41) that are essential for attachment and entry into host cells. These glycoproteins are involved in binding to specific receptors on the surface of host immune cells, such as CD4 and CCR5/CXCR4 co-receptors.

Lipid Bilayer: The viral envelope surrounds a lipid bilayer, which provides the structural integrity for the virus. This lipid bilayer is embedded with viral glycoproteins and helps the virus to fuse with the host cell membrane during the entry process.

Capsid: Inside the viral envelope is the capsid, a cone-shaped protein structure. The capsid is composed of p24 protein and contains the viral RNA genome. It protects the genetic material and plays a crucial role in transporting the viral genome into the host cell’s cytoplasm.

Genetic Material: HIV contains two identical copies of a single-stranded RNA genome. This genome encodes all the information required for viral replication. HIV is a retrovirus, so it carries the enzyme reverse transcriptase, which is necessary to convert its RNA genome into DNA once inside the host cell.

Matrix Protein: Between the capsid and the envelope, there is a matrix protein (p17) that helps to stabilize the structure of the virus and plays a role in viral assembly and release.

Reverse Transcriptase, Protease, and Integrase: Inside the viral core, HIV carries enzymes like reverse transcriptase, which converts its RNA genome into DNA upon entering the host cell, protease, which is involved in the maturation of viral proteins, and integrase, which integrates the viral DNA into the host cell genome.

67
Q

List all cells with CD4 receptor.

A

T lymphocytes
Macrophages
Dendritic cells
Langerhans cells
Microglial cells

68
Q

HIV has 9 genes encoding a total of 15 proteins.

Describe what the following genes code for?

  1. pol gene
    2.gag gene
    3.en gene
  2. tat gene
  3. rev gene
A

Function of structural proteins

  1. pol gene codes for a polyprotein which consists of
    Protease: cleavage of gag and gag-pol proteins during maturation of the virion [4]
    Reverse transcriptase: converts viral RNA to dsDNA.
    Integrase: helps insert the viral genes into the host genome
  2. gag gene codes for gag protein, which consists of
    Matrix protein (p17 protein)
    Nucleocapsids
    Capsid proteins (p24 capsid protein)
  3. env gene codes for gp160 which gets cleaved into envelope glycoproteins
    gp120: attaches to host CD4+ T-cells
    gp41: assists in fusion and entry of the virus into the host cell
  4. tat gene (trans-activator of transcription) codes for tat protein which promotes viral transcription
  5. rev gene: codes for the rev protein, which regulates translocation of unspliced and incompletely spliced mRNAs
69
Q

What is meant by that the HIV genome is pseudodiploid?

A

The containment of two copies of single-stranded RNA within a virion but the production of only a single DNA provirus is called pseudodiploidy.

70
Q

Outline vaccines that should be prioritized in HIV positive people.

A

In addition to routine vaccinations, the following vaccines should be prioritized in this population:
Hepatitis A vaccine
Hepatitis B vaccine
Human papilloma virus vaccine
Influenza vaccine (annually)
Meningococcal vaccine
Pneumococcal vaccine
Herpes zoster vaccine
COVID vaccine

71
Q

Outline exceptions to the routine immunization schedule in HIV.

A

The routine ACIP immunization schedule is applicable to individuals with HIV with the following exceptions:

  1. Varicella vaccine, MMR vaccine, and dengue vaccines
    Contraindicated in individuals with CD4 percentage < 15% or CD4 count 200 cells/mm3 or an AIDS-defining condition.
  2. Influenza vaccine
    Live attenuated influenza vaccine is contraindicated in all individuals with HIV.
    Inactive influenza vaccine should be given instead.