Clinical HIV

Question 1

Describe the incidence/prevalence of HIV in the US

Answer 1

Incidence is decreasing

Prevalence is increasing- average life span 50+ years

Question 2

Describe the acute phase of HIV

Answer 2

Fever, diffuse maculopapular erythematous rash, painful pharyngitis, diffuse lymphadenopathy, thrombocytopenia, myalgia, ulcers….

Question 3

What is the risk of transmission of HIV during the acute phase?

Answer 3

High risk of transmission

Question 4

What is the best way to detect an acute HIV infection?

Answer 4

Combined antigen/antibody assay: detection of p24 antigen + HIV antibodies

HIV RNA PCR is another way to detect HIV prior to seroconversion.

Question 5

How do we track the response to ART?

Answer 5

HIV RNA PCR

Question 6

What is a major advantage of starting ART as soon as someone is diagnosed with HIV?

Answer 6

Reduces rates of transmission by up to 96%
50% fewer serious illnesses and deaths compared to waiting until CD4+ counts are 350-500 or AIDS

Benefits are seen even in patients with low viral loads and high CD4+ counts

Question 7

What yearly monitoring must be done for someone being treated with ART for HIV?

Answer 7

Check CD4+ and viral load every 6+ months once the levels are suppressed/stable
Check chemistries regularly, CBC to monitor side effects
Yearly screening for TB/STI’s, or more frequently if patient is high risk

Question 8

Complications of HIV including neuropathy, Bell’s palsy, and thrombocytopenia occur at which CD4+ counts?

Answer 8

> 500

Question 9

Complications of HIV including herpes zoster, tuberculosis, bacterial pneumonia and non-CNS lymphoma occur at what CD4+ counts?

Answer 9

200-500

Question 10

Complications of HIV including thrush, PJP (pneumocystis jirovecii pneumonia), KS, Cryptococcus, MAC, CMV, PML, CNS lymphoma and toxoplasmosis occur at which CD4+ counts?

Answer 10

<200

Question 11

How do you treat PJP?

Answer 11

Bactrim: TMP-SMX + prednisone with significant hypoxia

Question 12

How do you prevent PJP in HIV patients?

Answer 12

You give them prophylactic TMP-SMX until their CD4+ has stabilized >200 for >3 months

Question 13

At what CD4+ count does toxoplasmosis tend to occur?

Answer 13

At CD4+ <100, especially when CD4+ counts are <50

Question 14

What causes CNS lymphoma in HIV?

Answer 14

Nearly always due to EBV reaction

Question 15

What CD4+ leaves you at risk for CNS lymphoma?

Answer 15

<100

Question 16

What differentiates an infection with cryptococcus from other opportunistic HIV infections that alter mental acuity?

Answer 16

Skin lesions

Cryptococcus = fever, headache, altered mentation, pneumonia, skin lesions

Question 17

How do you treat a cryptococcus infection?

Answer 17

Amphotericin B + 5-Flucytosine

Followed by fluconazole

Question 18

Under what CD4+ count does CMV retinitis occur?

Answer 18

<50

Question 19

Describe CMV retinitis and how its treated

Answer 19

Reactivation of latent infection –> retinal disease with floaters as an initial symptom.

Treat with gancyclovir

Question 20

When does immune reconstitution inflammatory syndrome occur?

Answer 20

After ART initiation when CD4+ counts rise - it’s not related to an uncontrolled infection, but to an improved response from the ART. Prednisone may be helpful.

Basically everything gets worse for a minute.