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Flashcards in HIV Deck (107):

HIV is a _____________



HIV-1 and HIV-2 ... Which is more transmissible?



When should you consider HIV-2?

Pts from West Africa and/or AIDS patients with and indeterminate or negative HIV, as the tests may not pick it up


What is the time to seroconversion in HIV?

Most patients seroconvert to positive HIV serology within 4 to 10 weeks after exposure using newer diagnostic tests, and ≥95 percent seroconvert within six months [27-29]. The median time from exposure to positive serology in one study was 63 days (uptodate)

Currently, as divided by CD4 status: CD4 500: 1.19 years; CD4 350: 4.19 years; CD4 200: 7.93 years. (Pubmed: "Time from human immunodeficiency virus seroconversion to reaching CD4+ cell count thresholds...)


Blood exposure and sex are the risks for acquiring an HIV infection. Name some factors that increase risk of infection

Herpes, Trichomonas, Smoking


A pt is newly diagnosed with HIV infection. What is something you'll want to know about the virus BEFORE beginning treatment?



HIV is arranged in an icosahedral symmetry structure. The outer capsule surrounds RNA dimers. The proteins of this capsule are called capsid proteins (CA) and the major capsid protein is _______

p24 -This can be measured in the serum to detect early HIV infection


How do you determine whether or not a pt has AIDS?

HIV infection plus one or more of the following: CD4 count <200; a CD4+ T-cell percentage of total lymphocytes of less than 15%; or an AIDS-defining illness


What are the AIDS-defining illnesses?

Candidiasis of bronchi, esophagus, trachea or lungs; Coccidioidomycosis that has spread; extrapulmonary Cryptococcosis, Cryptosporidiosis for longer than 1 month, CMV outside of the liver, spleen or lymph nodes, HIV-related encephalopathy, Herpes simplex including ulcers lasting more than a month or bronchitis, pneumonitis or esophagitis, Histoplasmosis, Isosporiasis, Kaposi's sarcoma, Lymphoma that is Burkitt type, immunoblastic or that is primary and affects the brain or central nervous system, Mycobacterium avium complex or disease caused by M kansasii, Mycobacterium tuberculosis, Pneumocystis pneumonia, progressive multifocal leukoencephalopathy, Salmonella septicemia that is recurrent, Toxoplasmosis of the brain, Wasting syndrome caused by HIV, invasive cervical cancer, recurrent pneumonia


What are CD4 counts in normal, healthy individuals?

~ 1000 cells/uL blood


In HIV-infected pts, how fast do CD4 counts decline?

by about 60 cells/uL blood/year


A 24 y.o. woman with HIV is diagnosed with MAC infection. She is started on a treatment regimen of clarithromycin with ethambutol. She needs to be educated that which of the following is a potential complication of this therapy?
A. Anemia
B. Azotemia
C. Methemoglobinemia
D. Mucositis
E. Optic neuritis

E - Optic neuritis is associated with the use of ethambutol. Anemia is associated with many of the drugs used to treat AIDS-related opportunistic infections, including TMP/SMX, pentamidine, amphotericin B, ganciclovir, and valganciclovir. Amphotericin B is associated with azotemia and trimethoprim with methemoglobinemia. Trimetrexate can cause mucositis.


The American College of Obstetricians and Gynecologists (ACOG) recommends which of the following regarding delivery to prevent HIV transmission to the infant?
A. Cesarean delivery only for those women who have not received HAART during therapy.
B. Cesarean delivery if the infant has not been delivered within 3 hours of membrane rupture
C. Determination of type of delivery based on maternal viral load
D. Scheduled cesarean section at 38 weeks' gestation



A 32 y.o. man who is HIV+ has a seizure. In the E.D., he is confused and unsure of what happened. His partner reports that he had been complaining of HA in the days preceding the event. CT scan of the head demonstrates 5 peripheral contrast-enhancing lesions. What is the most likely Dx?
A. AIDS dementia complex
B. Central nervous system lymphoma
C. Cryptococcal meningitis
D. Progressive multifocal leukoencephalopathy
E. Toxoplasmosis

E. The most common space-occupying lesion in pts with HIV is toxoplasmosis. This condition may present with HA, focal neurologic deficits, seizures, and/or mental status changes. The typical appearance on brain imaging is that of multiple contrast-enhancing lesions in the periphery, particularly the basal ganglia. CNS lymphoma is more typically a single lesion. AIDS dementia complex is a Dx of exclusion, without a characteristic appearance. Cryptococcal meningitis is made by examination of CSF. PML imaging shows nonenhancing white matter lesions without mass effect.


Which class of antiretroviral drugs is most likely to affect serum lipid profiles?
A. Entry inhibitors
B. Integrase inhibitors
C. Nonnucleoside reverse transcriptase inhibitors
D. nucleoside/nucleotide reverse transcriptase inhibitors
E. Protease inhibitors

E. Protease inhibitors are most likely to increase cholesterol and triglycerides; thus lipid profiles should be monitored carefully in patients taking them.


A surgical PA suffers a deep puncture wound during surgery on an HIV+ pt. The pt, who is on a multi-drug regimen, has a viral load of 120,000 copies. Which of the following drugs is contraindicated for the PA because of its potential for hepatotoxicity in the setting of HIV prophylaxis?
A. Abacavir
B. Indinavir
C. Lamivudine
D. Nevirapine
E. Zidovudine

D. Nevirapine should be avoided for HIV prophylaxis as reports have linked it to hepatotoxicity in the prophylactic setting.


Which of the following vaccines is contraindicated in a person with HIV infection and a low CD4 count?
A. Herpes zoster
B. Inactivated influenza
C. Measles
D. Pneumococcal
E. Tetanus-diptheria

A - The HZV vaccine is contraindicated in HIV+ persons who have evidence of immune suppression. The inactivated influenza vaccine should be given annually. Although measles is a live vaccine, it appears to be appropriate for an HIV+ person who has no protection against the measles. The pneumococcal and DTP vaccines form an important part of health-care maintenance for HIV+ persons.


A 36 y.o. woman with HIV is admitted with new-onset seizures. The CT scan of the head reveals multiple ring enhancing lesions of the brain. Which of the following is the best therapy for the likely condition?
A. Rifampin, isoniazid, ethambutol
B. Ganciclovir
C. Penicillin
D. Sulfadiazine with pyrimethamine



How does a 'protease inhibitor' (PI) work on HIV?

Protease is a vital HIV enzyme that cleaves gag and pol proteins from their larger precursor molecules (post translational modification). Protease deficient HIV virions can not form their viral core and are non-infectious. Therapy with protease inhibitors increases CD4 cells and reduces HIV levels.



Protease inhibitor (1st generation)



Protease inhibitor



Protease inhibitor



Protease inhibitor



Protease inhibitor


How do 'integrase inhibitors' work on HIV?

Integrase inhibitors inhibit the enzyme integrase, which is responsible for integration of viral DNA into the DNA of the infected cell.



Protease inhibitor



Protease inhibitor



Protease inhibitor



Protease inhibitor



Protease inhibitor



Integrase inhibitor


How do Non-Nucleoside reverse transcriptase inhibitors (NNRTI) work?

Non-Nucleoside reverse transcriptase inhibitors (NNRTI) inhibit reverse transcriptase by binding to an allosteric site of the enzyme; NNRTIs act as non-competitive inhibitors of reverse transcriptase.



Non-Nucleoside reverse transcriptase inhibitor (NNRTI)



Non-Nucleoside reverse transcriptase inhibitor (NNRTI)



Non-Nucleoside reverse transcriptase inhibitor (NNRTI)



Non-Nucleoside reverse transcriptase inhibitor (NNRTI)


How do the Nucleoside reverse transcriptase inhibitors (NRTI) and Nucleotide reverse transcriptase inhibitors (NtRTI) work?

NRTIs and NtRTIs work to inhibit reverse transcription by acting as competitive substrate inhibitors



Nucleoside/nucleotide analogue (NRTI)



Nucleoside/nucleotide analogue (NRTI)



Nucleoside/nucleotide analogue (NRTI)



Nucleoside/nucleotide analogue (NRTI)



Nucleoside/nucleotide analogue (NRTI)



Nucleoside/nucleotide analogue (NRTI)



Nucleoside/nucleotide analogue (NRTI)



Nucleoside/nucleotide analogue (NRTI)



Entry inhibitor



Entry inhibitor


Guidelines for antiretroviral therapy change often, but what, historically, has been a typical combination? (which classes of antiretrovirals)

Typical combinations include 2 NRTIs (Nucleoside Reverse Transcriptase Inhibitors) + 1 PI (Protease Inhibitor) or 2 NRTIs + 1 NNRTI (Non-Nucleoside Reverse Transcriptase Inhibitor



zidovudine + lamivudine



abacavir + zidovudine + lamivudine



lopinavir + ritonavir



abacavir + lamivudine






efavirenz + tenofivir/emtricitabine



rilpivirine + tenofovir/emtricitabine



elvitegravir + cobicistat + tenofivir/emtricitabine


Before beginning abacavir, pts should be tested for what?

HLA-B*5701 status


For an HIV+ person, what constitutes a positive PPD?

induration of >5 mm - should prompt a CXR


At what CD4 count level will you encounter an A1 level of recommendation to initiate ART therapy in treatment-naive patients?

CD4 <350


According to HHS antiretroviral therapy 2013 guidelines- what preferred regimen for ARV-Naive patients has a pill-burden of only one?






As of 2012, what drug is approved for pre-exposure prophylaxis?



A 28 y.o. man is HIV+ by ELISA and Western Blot, but has never had an opportunistic infection. Of the following lab values, which, if present, is consistent with the Dx of AIDS in this man?

A. CD4 count of 175/mL
B. HHV-8 titer of 1:160
C. HSV-2 titer of 1:80
D. Platelet count of 10,000
E. Total white count of 1500/mL



A 26 y.o. African-American man with HIV has a CD4 lymph % of 12. Prior to beginning prophylactic therapy for PCP, which of the following drugs requires testing for G6PD deficiency?

A. Aerosolized pentamidine
B. Atovaquone
C. Dapsone



A 35 y.o. man with AIDS has had unintended weight loss of nearly 30lb over the last 6 months. This loss has been primarily in muscle mass. He has little appetite but no nausea, diarrhea, or evidence of oral candidiasis. He reports interest in resuming his former weight-training regimen. Which of the following is the most appropriate pharmacologic agent to help him gain weight?

A. Dronabinol
B. Megestrol acetate
C. Odansetron
D. Prochlorperazine
E. Testosterone enanthate

E. Anabolic steroids, most commonly testosterone enanthate or cypionate, increase lean body mass in pts with AIDS, particularly in those who do weight training.


A 29 y.o. man who is taking combination ART develops severe right-sided flank pain and dysuria. He is also nauseated, which he attributes to the severity of the pain. He is unable to sit still and paces about the room. Dipstick urine is remarkable for 3+ hematuria. Which of the following drugs is most likely to be responsible for this clinical picture?

A. Abacavir
B. Delaviridine
C. Didanosine
D. Indinavir
E. Nelfinavir

D. A common SE of indinavir is kidney stones.


Common SE of abacavir?

Rash and fever


Common SE of delaviridine?



Common SE of Didanosine?

Peripheral neuropathy, pancreatitis, dry mouth, hepatitis


Most common SE of nelfinavir?



What black box warnings are associated with abacavir?

Hypersensitivity reactions (carriers of HLA-B*5701 allele are at higher risk of hypersensitivity

Lactic acidosis/ Severe Hepatomegaly


What Black Box warnings are associated with Truvada?

Lactic acidosis/ Severe Hepatomegaly
NOT approved for Hep B infection!!
Only prescribe for pre-exposure prophylaxis use in HIV-negative patients


An HIV+ patient who also has an HBV infection is in for his yearly physical. He laments that his current drug regimen is difficult. He says that he has a friend who is also HIV+, and he only takes one pill a day. "Atripla, I think is the name. Can I take that one instead? It would make taking my pills so much easier on me..." Can this patient consider a switch to Atripla?

No. Atripla is not approved for HBV infection (Atripla contains truvada). This is a black-box warning. If the pt is persistent, and you want to give it a try, then maybe call the HIV doc. experience with this stuff... just going by what I'm reading here!


What is the dosage of TMP/SMX for PCP prophylaxis?

1 DS PO qd
Can stop if CD4 >200 for 3 months (primary prophylaxis) or for 6 months (secondary prophylaxis)


T/F Circumcision leads to a decreased risk in acquiring HIV

True. Circumcision leads to a decrease in acquisition rate by 60%. The foreskin has an enormous number of cells at risk for HIV, most of any part of the body.


A 42 y.o. man with AIDS has had a gradual onset of "my feet always going to sleep on me." This tingling and burning keeps him awake much of the night and he "can't cope much longer" because of he sleep deprivation. He drinks no alcohol nor does he use any illicit drugs. His PE reveals no gross or motor sensory deficits. His thyroid function tests and vitamin B12 levels are WNL and syphilis screen is negative. Of the following, what is that recommended intial therapy?

A. Didanosine
B. Gabapentin
C. Ibuprofen
D. Stavudine

B. No inflammatory process, hence ibuprofen is not indicated. Didanosine and stavudine are the most common causes of peripheral neuropathy.


A 38 y.o. man with HIV has had a fever and a sever generalized HA for the past several hours. On exam, he is noted to be alert and oriented and gives a coherent history that is corroborated by his partner. He has no papilledema or meningismus. What is the most likely Dx?

A. AIDS dementia complex
B. CNS lymphoma
C. Cryptococcal meningitis
D. Progressive focal leukoencephalopathy
E. Toxoplasmosis

C. Pts with Crypto meningitis have, most typically, HA and fever, but fewer than 20% have meningismus. They also usually have normal mental status. AIDS dementia complex is characterized by difficulty in performing cognitive tasks, diminished motor speed, and waxing and waning of manifestations of dementia. CNS lymphoma and toxoplasmosis present w/ HA, focal neurological deficits, seizures, and/or altered mental status. Pts w/ PML primarily have focal neurological deficits such as aphasia, hemiparesis, and cortical blindness


A 25 y.o. G1 woman who is HIV+ arrives to the hospital in early labor. Membranes are intact and the cervix is 50% effaced and 3 to 4 cm dilated. Fetal HR is 150. Which of the following procedures is contraindicated during labor?

A. Amniotomy
B. Oxytocin
C. External monitoring
D. Operative delivery
E. Fetal scalp electrodes



Which of the following is an antiretroviral which acts by binding to the viral envelope, thereby interfering with HIV fusion with the host cell plasma membrane?

A. Atazanavir
B. Didanosine
C. Enfuviritide
D. Lopinavir
E. Nevirapine



An HIV+ man develops elevated cholesterol and trig levels while taking ARV therapy that includes 2 nucleoside analogs and a protease inhibitor. Which of the following therapies is contraindicated because of interactions with protease inhibitors?

A. Atorvastatin
B. Gemfibrozil
C. Lovastatin
D. Pravastatin

C. Lovastatin and Simvastatin should be avoided in pts taking PIs because of drug interactions. In general, pts should be started on atorvastatin or pravastatin


A 25 y.o. woman with HIV delivers a 6lb infant at 39.5 weeks' gestation. She rec'd 3 drug prophylaxis during her pregnancy. Of the following, what is the most appropriate course of action for the infant?

A. Combination therapy for 1 to 2 weeks
B. Indefinite therapy with zidovudine
C. No additional prophylaxis needed
D. Treat only if 2 separate HIV-PCR tests are pos

A. Zidovudine or other ARV prophylaxis during pregnancy with additional prophylaxis for the infant during the first 1 to 2 weeks of life decreases vertical transmission to less than 1%.


At how many months of age should an asymptomatic HIV+ infant receive her first MMR vaccine?

12 months


A 28 y.o. woman has been recently diagnosed with HIV. She has no evidence of opportunistic infection and her CD4 count is

6 months


An infant is born to an HIV+ mother who received 3 drug treatment during pregnancy. Which of the following, if positive, indicates HIV infection in the infant?

A. HIV ELISA an Western Blot on cord blood
B. HIV ELISA and Western Blot at 1 month
C. HIV ELISA and Western Blot at 6 months
D. HIV ELISA and Western Blot at 12 months
E. HIV ELISA and Western Blot at 24 months

E. The median age at which infants no longer show the maternal antibody for HIV is 10 months; by 18 months, they all do not.


What is the 'Ecclipse Phase"?

The time between infection and detectable HIV RNA


What is the "Window period"?

Time between infection and detectable HIV antibodies


At what CD4 count should you prophylactically treat for Toxoplasma encephalitis and what is the prophylaxis?

CD4 <100 ; TMP/SMX


At what CD4 count should you prophylactically treat for MAC complex and what is the prophylaxis?

CD4 <50 ; Azithromycin


A 34-year-old HIV-infected woman with a CD4 count of 18 cells/mm3 and an HIV RNA load of 226,000 copies/ml (on no medications) presents with a 10-day history of fatigue, non-productive cough, fever, and dyspnea on exertion. A diagnosis of Pneumocystis pneumonia is suspected and TMP-SMX is ordered. What is the criteria for giving the patient corticosteroids?

PaO2 35


What is the preferred therapy for Toxoplasma encephalitis with HIV/AIDS?

Pyrimethamine + Sulfadiazine + Leucovorin


A 28-year-old woman with AIDS is newly diagnosed miliary pulmonary tuberculosis. She is started on directly observed 4-drug therapy: isonizid + rifabutin+ pyrazinamide+ ethambutol. She has a CD4 count of 7, and HIV RNA greater than 500,000 copies/ml.
After 2 weeks, she has marked improvement in her dyspnea and fever. Four weeks later she starts on Tenofovir-Emtricitabine-Efavirenz (Atripla) and the rifabutin dose was increased appropriately). Now 8 weeks after starting therapy for tuberculosis, she presents with a cavitary lung lesion, cervical lymphadenopathy, and fever.

What syndrome is demonstrated here, and what would you recommend doing at this point?

IRIS ; Start corticosteroids (taken from slides "HIV primary care part 2" from ID module)


What are the 4 indications for initiating ARV therapy regardless of CD4 count?

Clinical AIDS, Pregnancy, Chronic HBV, HIVAN


What is HIVAN?

HIV-associated nephropathy (HIVAN) refers to kidney disease developing in association with HIV infection. The most common, or "classical", type of HIV-associated nephropathy is a collapsing focal segmental glomerulosclerosis (FSGS), though other forms of kidney disease may also occur with HIV.[1] Regardless of the underlying histology, renal disease in HIV-positive patients is associated with an increased risk of death.


A 34-year-old woman was diagnosed with HIV about 18 months ago. She is seen in the clinic for follow up. Her CD4 counts have been 670, 550, 570, 490, and 470 cells/mm3. She has no active medical, mental health, or substance abuse issues. She works full time and her social situation is stable. She has a boyfriend who is not infected with HIV. Would you recommend starting ARV therapy?

Yes. The new "start" is 500. Also- the boyfriend is not infected.


A CD4 count of 500 or below is "Recommended" to start ARV therapy (according to 2011 DHHS guidelines) At what CD4 count do the guidelines say that ARV therapy is "Strongly recommended"?



What is the preferrred (2011 DHHS) initial therapy regimen for ARV?

2 NRTIs + 1 NNRTI or 1 PI or 1 Integrase Strand Transfer Inhibitor (INSTI)


What commonly used ARV medication do we need to avoid using in pregnancy? (especially in the first trimester)



A 33-year-old HIV-infected woman with a CD4 count of 582 cells/mm3 is 8 weeks pregnant. She is on no medications. What ARV regimen would you recommend starting her on?

Lopinavir-Ritonavir (2x daily) + Zidovudine-Lamivudine (AI)
(PI based regimen)


Which antiretroviral druga are contraindicated for postexposure prophylaxis in health care workers?

Nevirapine and abacavir


T/F You need written consent to obtain an HIV test

F. As far as I can tell, verbal consent is enough. Some states have their own laws regarding consent and HIV testing.


What labs should be obtained in the initial evaluation of a newly diagnosed HIV pt?

CBC w/ Diff; CMP, G6PD, RPR or VDRL, Toxoplasma IgG, Hep B and C serologies, CD4 count, HIV RNA level, HIV genotype, PPD

Consider: CMV IgG, Hep A IgG, baseline CXR


What are common adverse events associated with Nucleoside/nucleotide Reverse Transcriptase Inhibitors?

Lactic acidosis with hepatic steatosis (higher incidence with stavudine), lipodystrophy


What is the common event linked to NNRTIs?



What are the common adverse events linked to PIs?

Fat misdistribution, GI intolerance, hyperglycemia, lipid abnormalities


Which ARV is associated with CNS symptoms as adverse effects?



Define HIV Seroconversion

Seroconversion is the period of time during which HIV antibodies develop and become detectable.
Seroconversion generally takes place within a few weeks of initial infection.
It is often, but not always, accompanied by flu-like symptoms including fever, rash, muscle aches and swollen lymph nodes. These symptoms are not a reliable way to identify seroconversion or to diagnose HIV infection.


Which ARV drug should you be sure to give to a pregnant woman?

Zidovudine - "If you want a kid, give Zid"