Week 2 - HIV

Question 1

What are 3 examples of horizontal transmission of HIV?

Answer 1

• sexual contact
• percutaneous contact (needles)
• mucous membrane exposure to blood or bodily fluids

Question 2

What are 3 examples of vertical transmission of HIV?

Answer 2

• mother to infant transplacentally in utero
• during birth
• via breastfeeding

Question 3

What is the acute stage of HIV characterized by?

Answer 3

flu-like symptoms 2-4 weeks after being infected

high viral load

Question 4

What is the chronic stage of HIV characterized by?

Answer 4

Viral load increases, CD4 T-cell count decreases

Question 5

What is the diagnostic criteria for AIDS?

Answer 5

HIV +

CD4 T-cell count < 200 cell/min or the development of an opportunistic infection

Question 6

What labs do children with HIV need every year?

Answer 6

HIV quantitative PCR
CD4 T-cells
CBC /diff
UA
CMP
Lipase
Lipid
Quantiferon Tb Gold
***HIV genotype - if viral load was detectable at last test or if patient reports poor adherence

Question 7

What are clinical manifestations that should make you suspect HIV as a differential diagnosis?

Answer 7

Persistent fevers
Loss of appetite
Frequent diarrhea
Poor weight gain/rapid weight loss
Chronic swollen lymph nodes
Chronic fatigue
Oral thrush
Recurring or unusual infections

Question 8

What are 5 high transmission risk situations for a newborn?

Answer 8

1. Most recent maternal HIV viral load is > 1,000 copies/mL
2. Mother did not receive antiretroviral (ARV) therapy during labor or pregnancy
3. Mother only received intrapartum ARVs (no prenatal ARV)
4. Mother w/ known high-level antiretroviral resistance
5. Mother dx w/ acute HIV during current pregnancy

Question 9

What labs do you order for a newborn with an HIV positive or HIV status unknown mother?

Answer 9

1. HIV-1 qualitative RNA RCR by NAAT
2. CBC with differential

DO NOT send HIV antibody (this will come back positive due to presence of maternal antibodies)

Question 10

What is initial management for a newborn with an HIV positive or HIV status unknown mother?

Answer 10

Zidovudine in the first 12 hours of life, 4mg/kg PO BID

Question 11

How do you reduce the risk of vertical transmission through breastmilk?

Answer 11

Don’t breastfeed. Use formula or donor milk.

If mother must breastfeed, ONLY exclusive breastfeeding. Mixed feeding increases risk more than exclusive. Mother and baby (until 6 week old) should also be on ARTs.

Question 12

Male circumcision reduces risk of HIV acquisition. True or false?

Answer 12

True

Question 13

What is the recommended 3 drug regimen for HIV?

An example of this 3 drug regimen?

Answer 13

1. Non-nucleoside reverse transcriptase inhibitor (NNRTI)
2. boosted PI or dual NRTI/NNRTI backbone
3. integrase strand inhibitor (INSTI)

Ex: tenofovir DF + emtricitabine + raltegravir

Question 14

What is the preferred diagnostic for HIV during infancy?

Answer 14

HIV PCR (DNA or RNA)

Question 15

What is the recommended immunization schedule for children with HIV?

Answer 15

• Routine immunizations per CDC guidelines
• 23-valent pneumococcal polysaccharide vaccine recommended for HIV-infected children at 2yo and adolescents and adults with CD4 count >/= 200/mm3
• MMR 1st dose at 12 months of age, 2nd dose at 4-6yo
• Varicella-zoster given only to asymptomatic, non immunosuppressed children beginning 12mo
• Inactivated split influenza virus vaccine given annually at or after 6mo

Question 16

What is the most common opportunistic infection (manifestation of AIDS) for children with HIV?

Treatment?

Answer 16

P. jiroveci pneumonia (PCP)

TMP/SMX (Bactrim)

Question 17

What are the risk factors for infant HIV?

Answer 17

• Untreated HIV infected mom (increases even more for vaginal births)
• Maternal drug use
• Premature ROM more than 4 hours before onset of labor
• Low birthweight
• Premature birth < 34 weeks

Question 18

PrEP vs nPEP?

Answer 18

Pre-exposure prophylaxis (PrEP) for certain high risk individuals - 2 drug combo taken daily

nPEP for post exposure prophylaxis

Question 19

For a high risk of HIV infant, what do you do before giving newborn IMs?

Answer 19

Bathe the newborn

Question 20

When do you start TMP/SMX for a newborn with high risk of HIV?

When do you stop?

Answer 20

At 4-6 weeks follow up appt. This is also when the zidovudine is stopped.

> /= 4 months f/u appt

Question 21

When do you get a HIV antibody lab for a newborn?

Answer 21

12-18 months

Question 22

When is nPEP not recommended?

Answer 22

> /= 73 hours after exposure

< 72 hours after exposure and:

• Unknown source OR HIV status and risk status unknown (unquantifiable risk)
• HIV status unknown; 0 risk factors below (low risk)

Question 23

When is nPEP recommended?

Answer 23

< 72 hours after exposure and source is HIV positive with at least one risk factor

Question 24

What are the risk factors for high risk of HIV source exposure?

Answer 24

• Injection drug user
• Men sex with men
• Commercial sex workers (or exchange of money or drugs for sex)
• Individuals with multiple sex partners
• Individuals with prior convictions for sexual assault
• Individuals with a history of incarceration
• Sexual activity with a member of a high risk group

Question 25

How long should nPEP be consistently taken?

Answer 25

28 days

Question 26

What lab tests should an exposed person be taking?

Answer 26

HIV Ag/Ab, Hepatitis B serology, Hepatitis C antibody, Syphilis serology, CT/GC, Pregnancy,

*** For those prescribed ART
serum creatinine
alanine transaminase, aspartate aminotransferase

*** For those w/ confirmed HIV
HIV viral load
HIV genotypic resistance