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clinical decision making- summer > HIV-1 schoenwald > Flashcards

HIV-1 schoenwald Flashcards

1
Q

HIV is a disease of cell mediated immunity– ____ cells

A

CD4 cells* (T cells)

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2
Q

HIV cases are presented with opportunistic infections i.e. ____

A

PCP

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3
Q

HIV transmission: list 3 routes and ex’s of each

A
  1. Blood (ie transfusion/injections (drugs)
  2. Sexual intercourse (heterosexual** male to male MC)
  3. Perinatal (ie intrapartum and breast feeding)
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4
Q

___:___ is the risk from sharing needles in IVD

A

1:150

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5
Q

___:___ is the risk to hcw w/ needlestick

A

1:300. (hcw=healthcare worker)

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6
Q

Blood transfusion with infected blood risk?

Perinatal risk w/ antiretriviral?

A
  • 95%

- 13-40%

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7
Q

HIV=

A

presence of virus without AIDS defining illness

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8
Q

AIDs (list 2 definitions)

A
  • HIV + with AIDS defining illnesses (as listed in Current Medical Diagnosis and Treatment)
  • **HIV + with CD4 count <200
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9
Q

List Ex’s of AIDS defining illnesses

A

-THRUSH is NOT an AIDs defining illness BUT–> Candidiasis of bronchi, trachea, or lungs or esophageal is
-Kaposi’s sarcoma
-Pneumocystis carinii (jirovicci) PNA
Burkitt’s lymphoma
-

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10
Q

HIV Sx:

HIV MC presentation?

A
  • can be asymptomatic for years
  • +/- Fever, night sweats, unexpected weight loss, LAD

-MC: asymptomatic and found via screening tests, **commonly presents w/ opportunistic infxn THEN found to have HIV

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11
Q

Recommended to screen anyone with new dx of ______ for HIV

A

Syphilis

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12
Q

_____ HIV most likely to have sx

A

acute

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13
Q

Pneumocystis jiroveci (humans):

  • classified as: ?
  • gold standard dx test?
  • Newer tests ?
A
  • a fungus
  • Gold standard**= silver stain on sputum sample
  • newer= PCR based methodology
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14
Q

Pneumocystis Jiroveci:

-Chest X ray reveals** ______

A

**Bilateral hilar infiltrate

-CT scan shows brown glass opacity

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15
Q

Pneumocystis pneumonia Sx: (list)

A

Fever
Dry cough
Shortness of breath-desaturation of oxygen
fatigue

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16
Q

Pneumocystis tx ?

A

High dose trimethoprim/sulfamethoxazole
15-20 mg/kg IV q day divided into q 6-8 hour dosing

-Prednisone 40 mg PO BID added if paO2<70mm/HG

**PEARL: often present w/ severe hypoxemia

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17
Q

PCP prophylaxis at CD4 count of _____

A

<200
first line: Trimethoprim/sulfamethoxazole po

-Dapsone or inhaled pentamidine are alternates if sulfa allergic

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18
Q

Kaposi’s Sarcoma= Human herpes virus __

A

8**

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19
Q

Kaposi’s SarcomaSx?

-tx?

A
  • **Purplish, brownish lesions
  • Can be body wide, including inside of mouth

tx: reconstitute the immune system

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20
Q

HIV:

-can be a retrovirus that depends on ______

A

reverse transcriptase–RNA dependent DNA polymerase to replicate

  • *HIV 1 most prevalent in US
  • HIV 2 is rare in the US, but less virulent– most confined to west africa
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21
Q

when HIV enters the body, it enters ____ cells via _____ receptors

A

CD4 cells via chemokine receptors(CCR5 and CXCR4)

  • **people w/ CCR5 deletions are less likely to become infected
  • once in cell–> HIV replicates and causes cell fusion/or death
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22
Q

HIV latent state (describe)

-what happens to CD4 count

A

integration of HIV genome into cell genome

**CD4 count falls with increasing length of infection

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23
Q

HIV: list ex’s of S/Sx

A 
Asymptomatic
Fever, night sweats and weight loss
Presence of opportunistic infection
Kaposi’s sarcoma
Lymphoma
-Oral lesions such as hairy leukoplakia
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24
Q

Acute HIV aka _____

-describe sx?

A

Acute Retroviral Syndrome (time frame of first 12 weeks post exposure to HIV infxn)

  • Non specific “flu-like Sx”
  • Fever, fatigue, pharyngitis, LAD, Body wide maculopapular Rash*
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25
Q

Who should be tested for HIV?

A
  • 13 and 64yo
  • Injection drug users and their sex partners
  • Persons who exchange sex for money or drugs
  • Sex partners of HIV infected persons
  • MSM or heterosexual persons who themselves or whose sex partners have had sex with more than one sex partner since their most recent sex partner
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26
Q

testing for HIV?

A

-combination aka 4th generation testing (EIA) is reccomended over ELISA for screening

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27
Q

Describe mechanism for Combination HIV testing

A
  • Measurses HIV AB and p24 Ag

- Confirmation is HIV RNA by PCR

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28
Q

Other HIV testing methods?

A
  • CD4
  • Ultrasensitive quantitative rna by PCR (viral load)
  • Rapid testing
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29
Q

ELISA (aka the old test of choice for HIV)–> looks for _____

vs

combination or 4th generation–> looks for both ____ and _____

A

antibody only*
-and it takes 4-12 weeks for antibody to develop

-HIV antibody and p 24 antigen
2-6 weeks from exposure to positivity —>Now test of choice for testing, confirm with NAT-(HIV rna by pcr)

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30
Q

How to measure a Pt’s response to HIV tx?

A
  • CD4 count

- Viral load (VL) –> Drug resistance= VL >1000

31
Q

HIV Pts:

-what other screening tests should be performed?

A
  • Hep A,B, and C
  • TB and Toxoplasmosis
  • STDs (syphilis, chlamydia, gonorrhea, etc)
32
Q

HIV tx:

-list Ex’s

A
  • *HAART= highly active antiretroviral therapy– now referred to as antiretroviral therapy**
  • -> Protease inhibitors, nucleoside reverse transcriptase inhibitors (NRTI), non nucleoside reverse transcriptase inhibitors (NNRTI) and integrase inhibitors standard
33
Q

Goals of HIV therapy (list top 5)

A
  • Suppression of viral load to <50 copies per ml
  • Restoration of immune function (CD4 count)
  • Prevention of HIV transmission
  • Prevention of drug resistance
  • Improvement in quality of life
34
Q

HIV regimen:

-backbone=

A

2 nucleoside reverse transcriptase inhibitors (NRTIs)

35
Q

HIV regimen:

-base=

A

traditionally included either a non-nucleoside reverse transcriptase inhibitor (NNRTI) or Protease Inhibitor (PI), or integrase inhibitor reltegravir

36
Q

Nucleoside Reverse Transcriptase Inhibitors (NRTIs):

Newer choices?

A
  • Emtricitabine (FTC)
  • Tenofovir (TAF)

Less Use 2° ADRs

  • Didanosine (ddI)
  • Stavudine (d4T)
  • Abacavir (ABC)
37
Q

Non-nucleoside Reverse Transcriptase Inhibitors (NNRTIs)

-1st line choices?

A

Nevirapine (NVP)
Delavirdine (DLV)
Efavirenz (EFV)

38
Q

HIV meds:

-Tenofovir has 2 formulations–> list? (why is the newer formulation better?)

A

Tenofovir disoproxil(old) higher risk of causing renal failure and osteoporosis

**Tenofovir alafenamide-(new) lessened renal and bone risks

39
Q 
Protease Inhibitors (PIs) (-"navir drugs"**)
-list the ones that are STILL recommended
A
  • Ritonavir (RTV)
  • Lopinavir (LPV)
  • Atazanavir (ATV)
  • Darunavir (DRV) preferred= 1st line (KNOW)
40
Q

Integrase Strand Transfer Inhibitors (INSTIs) (-egravir drugs) list ex’s

A

Use 2 nucleoside inhibitors and add in 1 integrase strand transfer inhibitors like: Raltegravir or Elvitegravir

41
Q

HIV combination meds (once daily dosing) (list Ex’s of common combination pills)

A
  • Atripla: (Tenofovir disoproxil/emtricitabine/efavirenz
  • Stribild: (elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil
  • Genvoya: elvitegravir/cobicistat/emtricitabine/ tenofovir alafenamide
  • Complera: emtricitabine/rilpivirine/tenofovir disoproxil fumarate
  • Odefsey: emtricitabine/rilpivirine/tenofovir alafenamide
42
Q

When should treatment be started:
-historically based on ______ count
VS
MOST recent guideline?

A

*CD4 count –>500- monitor
<500 consider initiation of treatment
<350 treatment initiated

  • January 2020: states that all HIV + should be considered for initiation of treatment
  • -Continuation of 1st recommendation in 2016 (ANYTIME someone is dx w/ HIV they should be offered tx)
43
Q

Initial Treatment: Choosing Regimens

-3 main categories?

A

-1 II + 2 NRTIs
-1 PK-boosted PI + 2 NRTIs
-1 NNRTI + 2 NRTIs
–Combination of II, boosted PI, or NNRTI + 2 NRTIs is preferred for most patients
NRTI pair should include 3TC or FTC

44
Q

MC regimen**

A

2 NRTIs (FTC + TAF) + 1 NNRTI (ex.EFV) (historic option)
OR
+ 1 INSTIs (ex. RAL) (preferred)
OR
+ “boosted”PI (DRV)
OR
*boosted with ritonavir or cobicistat

45
Q

Untreated HIV is assoc. w/ development of _____ and ______

A

*AIDS and non-AIDS-defining conditions

46
Q

Earlier Aids related therapy (ART) may prevent:

A

HIV-related end-organ damage; deferred ART may not reliably repair damage acquired earlier
-ALSO: more evidence that HIV in of itself causes enough inflammation to cause end organ damage

47
Q

which NRTIs are MC used?

A

**Emtricitabine (FTC) &
Tenofovir (TAF)

+ ! **INSTI– Raltegravir (RAL)- 1st line (preferred to do INSTI + 2 NRTIs)

OR
+
1 NNRTI (ie Efavirenz (EFV)) (historic choice)

48
Q

Benefits of Early therapy:

Potential decrease in risk of many complications, including–> list Ex’s

A

HIV-associated nephropathy

Liver disease progression from hepatitis B or C

Cardiovascular disease

Malignancies (AIDS defining and non-AIDS defining)

Neurocognitive decline

Blunted immunological response owing to ART initiation at older age

Persistent T-cell activation and inflammation

49
Q

Describe CD4 monitoring with HIV therapy:

A
  • check @ baseline (x2) and every 3-6 months
  • immediately before initiating ART
  • Every 3-6 months during first 2 yrs of ART or if CD4 <300
  • After 2 yrs on ART w/ HIV RNA consistently surpressed:
  • -CD4 300-500: Q 12 months
  • -CD4 >500: optional
  • -more frequent testing if on meds that lower CD4 count
50
Q

What screening assessment is needed prior to Pt starting ABC (abacavir)?

A

**HLA-B*5701 (MUST screen for all newly diagnosed HIV PTs) either they are + or -.

**Positive Pts should NOT recieve ABC (abacavir)

-Positive status should be recorded as ABC allergy–> this drug can cause a severe hypersensitivity rxn (HSR) that can result in death

51
Q

High potential for adverse effects w/ ART meds: (list ex’s)

A 
Rash
Diarrhea
Pancreatitis
Hyperlipidemia and lipodystrophy
Increased cardiac risk
CNS effect-psychological disturbances
52
Q

Adverse Effects: PIs (protease inhibitors) list Ex’s

A 
Hyperlipidemia 
Lipodystrophy 
Hepatotoxicity
GI intolerance
Possibility of increased bleeding riskfor hemophiliacs
Drug-drug interactions
53
Q

Adverse Effects of NRTIs (lsit ex’s)

A

Lactic acidosis and hepatic steatosis (highest incidence with d4T, then ddI and ZDV, lower with TDF, ABC, 3TC, and FTC)

-Lipodystrophy(higher incidence with d4T)

54
Q

Adverse Effects of NNRTIs

A

Rash, including Stevens-Johnson syndrome

Hepatotoxicity (especially NVP)

Drug-drug interactions

55
Q

IRIS=

A

immune reconstitution syndrome= occurs after initiation of HAART

  • Inflammatory reaction in response to rapid reconstitution of CD4 counts
  • –Can “unmask” underlying opportunistic infection

*Diagnosis of exclusion

56
Q

HIV management: (list all tests)

A
  • Cd4 and viral load Q 6-12 months
  • PPD/Quantiferon gold testing
  • RPR
  • Toxoplasmosis antibody
  • Anal PAP smears,Cervical PAP smears (6-12 months)
  • If CD4 ct < 200-PCP prophylaxis,<50 MAI prophylaxis
57
Q

Pathogen: PCP

-Indication: CD4

A

<200

-Bactrim

58
Q

Pathogen: Toxo

–Indication: CD4

A
  • CD4 <100 and IgG +

- Trimethoprim-sulfa or Dapsone + Pyrimethamine

59
Q

Pathogen: MAC

-Indication: CD4

A

CD4 <50

-Clarithro/Azith

60
Q

Pathogen: TB

  • Indication: ____
  • Regimen= ?
A

+PPD(5mm)

-INH (9 months)

61
Q

Vaccinations for all HIV PTs

A 
Pneumococcal
Hepatitis A and B
Tetanus, diphtheria, pertusis
Meningitis
Influenza
COVID-19
Shingles in >50 years of age

-HPV?-definitely in those aged 26 years and younger

62
Q

Postexposure prophylaxis

A

Antiretroviral therapy decreases risk of converting to infection
Begin within 72 hours of exposure

–If source is HIV +, prophylax with agents known to be effective against that patient’s virus

  • -Generally given for 1 month
  • Truvada/Raltagravir**

(think health care workers that were exposed via needle stick, or someone that had sex with an HIV Pt, or rape victims**)

63
Q

Pre exposure prophylaxis: List meds**

A
  • Can reduce risk of HIV infection by 92%(8-2-2017)(JAMA 2019)
  • Truvada:tenofovir/emtricitabine–Daily dosing
64
Q

Recommended PREP by MSM:

-describe this demographic

A
  • Adult man without acute or established HIV infection
  • Any male sex partners in past 6 months
  • Not in a monogamous partnership with a recently tested, HIV-negative man

AND at least one of the following:

  • -Any anal sex without condoms (receptive or insertive) in past 6 months
  • -Any STI diagnosed or reported in past 6 months

–Is in an ongoing sexual relationship with an HIV-positive male partner

65
Q

Recommended PREP by MSM:

-regimen?

A
  • Tenofovir/emtricitabine (Truvada) once daily
  • Tenofovir alafenamide/emtricitabine (Descovy) approved for PrEP Oct 2019
  • -Check HIV status every 3-6 months
66
Q

PrEP Pearls

A
  • Assess HIV status prior to initiation and every 3 months after initiation
  • PrEP does NOT reduce the risk of other STIs**
  • Check renal function**
  • Check Hep B immunity!!!!** KNOW for boards
67
Q

F/U: what tests are required at every 3-month visit?

A

HIV testing

Medication monitoring/stress adherence

Counseling/behavioral risk reduction

Assess renal function, if normal, then q 6 months

Oral/rectal std screening if appropriate
Pregnancy testing if appropriate

68
Q

Perinatal transmission:

-what med should be administered to the pregnant mother w/ HIV?

A

**AZT,Zidovudine administered during pregnancy, labor and delivery , vertical transmission decreased by 2/3.

-Can start as early as 14 weeks into the pregnancy.

69
Q

List 4 Ex’s of Miscellaneous Opportunistic infxns

A
  • Coccidioidomycosis
  • Histoplasmosis
  • Blastomycosis (HIV defining illness)
  • Toxoplasmosis
70
Q

Coccidioidomycosis:

  • Sx?
  • Dx?
  • Tx?
A

-Coccidioides immitis
aka “San Joaquin Valley fever”

sx: 40% present with influenza-like illness
high fever, night sweats common
dx: serology (IgM/IgG)

tx: no tx indicated unless specific risk factors (immunosuppression)–> tx=diflucan**

71
Q

Histoplasmosis:

  • Sx?
  • Dx?
  • Tx?
A

-Histoplasma capsulatum–>Linked to bird droppings or **bat guano exposure along Ohio River Valley

  • Many infections “asymptomatic”; usually **pulmonary symptoms if presenting
  • Disseminated disease common in AIDs/ immunocompromised states

-dx: antigen test (serum/urine or CSF) or tissue bx

-Tx: itraconazole (mild/mod dz)
and Amphotericin B (severe dz)

72
Q

Blastomycosis:

  • Sx?
  • Dx?
  • Tx?
A

**Linked to soil exposure along Ohio River Valley, especially dust exposure (ex. construction)

  • Many infections “asymptomatic”; usually start as pulmonary infections with cutaneous dissemination
  • -Disseminated disease possible in all Pts

-Dx: bx & culture

-Tx: itraconazole (mild/mod dz)
and Amphotericin B (severe dz)

73
Q

toxoplasmosis:

  • Sx?
  • Dx?
  • Tx?
A

aka toxoplasma gondii

  • Assoc w/ cat boxes**
  • Usually reactivation in setting of HIV, not primary infection
  • Sx: focal neurologic findings, fever, Characteristic lesion on MRI-punched out lesion

tx: If you have HIV/AIDS, the TOC for toxoplasmosis is also pyrimethamine and sulfadiazine, with folinic acid (leucovorin).

74
Q

Histo vs blasto: what is the differentiator?

A
  • Histo= immunosuppression (AIDS defining illness)

- Blasto= no immunosuppression

clinical decision making- summer (3 decks)

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