HIV

Question 1

types

Answer 1

HIV 1 and 2
2 is less aggressive and takes long to cause disease and not easily spread

Question 2

Patho

Answer 2

CD4 triggers immune response like inflammatory and T cell and B cell response
Without cannot trigger immune responses
HIV triggers potent and systemic immune and inflammatory response, increased risk for CAD, CA, VTE, fragility, neurocognitive disorders

Question 3

HIV vs AIDS

Answer 3

CD4 count less than 200 AND AIDS defining illness
Once you have AIDS you always have AIDS even if CD4 count goes back up

Question 4

AIDS defining illness

Answer 4

PCP
toxoplasmosis
PML
Kaposi sarcoma
Lymphoma
Disseminated MAC
TB, esophageal or trachea candida
CMV
Histoplasmosis
Cervical CA
Recurrent bacterial infection

Question 6

Signs of undiagnosed HIV or progression to AIDS

Answer 6

Thrush
Cervical dysplasia
Cervical carcinoma in situ
Fever of 38.5 degrees greater than 1 month
Oral hairy leukoplakia
HZV
ITP, PID
Peripheral neuropathy
Vaginal yeast that are persistent, frequent or poorly responsive

Question 7

Screening

Answer 7

All persons age 16-64 years old
All patients initiating TB tx
All patients seeking tx for STDs
Annual screen for high risk
Any person who blood or body fluids are the source of occupational exposure
All pregnant women
Consent no longer needed but recommended

Question 8

DX

Answer 8

P24 antigen-decrees coral vital protein P24, can be detected as early as 10 days post infection disappears about 45 days post, is detectable in late stage of AIDS
HIV antibody with western blot confirmation- antibodies to HIV, have to wait 12 weeks post exposure but 99% sensitivity and specificity
4th generational immunoassay-recommended, combo antigen and antibody, two types, architect (acute), determine HIV, if positive then HIV1/2 antibody differentiation should be done, if negative then do viral load
Rapid antibody test- oraquick-confirmed with 4th generation

Question 9

Test to manage HIV

Answer 9

CD4 count-significant change is 30% or 3 % percentage value
HIV viral load-baseline, Q1-2 months after starting or changing therapy, and monthly until at goal and 3 months thereafter
Resistant testing-genetic profile
HLA-B 5701-hypersensitivity to abacavir prior to starting if positive do not give
Co receptor tropism assay-which co receptor the virus binds to on CD4 cell, if initiating CCR5 inhibitor

Question 10

Acute HIV infection

Answer 10

Infection following initial HIV infection
1-6 weeks post exposure and resolves, may last 3-14 days
Fever, lymphadenopathy, pharyngitis, rash, myalgia, diarrhea, HA, n/v, hepatosplenomegaly, weight loss, thrush, neuro ss
dx with 4th generation and viral load
Symptom management
Anti retro viral therapy
Highly infectious!

Question 11

Nucleoside reverse transcriptase inhibitors (NRTI)

Answer 11

Inhibits reverse transcriptase by binding to reverse transcriptase
Standard dosing
Renal dosing or weight base may be needed
drug-abacavir (hypersensitivity rxn!!), didanosine, stavudine, emtricitabine, lamivudine, tenofovir, zidovudine
Common ADE- hepatitis B exacerbation, immune suspension or platelet suppression

Question 12

Non nucleoside reverse transcriptase inhibitors (NNRTI)

Answer 12

Inhibit reverse transcription by binding to reverse transcriptase they bind to different sites on reverse transcriptase than NRTI
Standard dosing
CYP450 metabolite
Drugs- efavirenz, delavirdine, etravirine, nevirapine, rilapivirine
ADE- psych, HLD, rash, SJS, MDD, insomnia, HA, prolong QT, heptotoxic, teratogenic

Question 13

Protease inhibitors

Answer 13

Prevent protease from cleaving larger immature viral proteins into smaller functional proteins this leaves the virus immature and unable to infect cells
Standard dosing
No PPO or anatacids
C3A4 metabolite
SE-HLD, hyperglycemia, fat maldistribution, increased bleeding in hemophilia, liver issues
Drugs- atazanavir, darunavir, fosamprenavir, indiavir, lopinavir/ritonavir, saquinavir, tipranavir

Question 14

Fusion inhibitor

Answer 14

Drug-enfuviritide
Used only as salvage therapy
Binds to gp120 viral protein and prevents it from fusing to target cell
SC BID
SE- infection site rxn, increased rate of PNA, hypersensitivity

Question 15

CD4 post attachment inhibitor

Answer 15

Drug-ibalizumab
HIV 1 with MDRO who fail other meds
Binds to CD4 cell and changes it so that the viral protein GP120 and HIV co receptors cannot attach to the cell
SE-n/d, dizziness, rash

Question 16

CCR5 inhibitors

Answer 16

Drug- maraviroc
Selectively and reversible binds to CCR5 co receptors located on human CD4 cells
Renal and liver dosing
CYP3A metabolite
SE-abd pain, cough, dizziness, pyrexia, rash, URI, hepatotoxic, orthostatic hypotension

Question 17

Integrase inhibitors

Answer 17

Drug-raltegravir, bicetegravir, raltegravir, dolutegravir, elvitegravir, cabotegravir (inj)
Inhibits the catalytic activity of integrase thus preventing integration of the pro viral gene DNA into human DNA
1st line TX
SE: n/v/d, SJS, rash, rhabdo, insomnia, HA, SI, MDD

Question 18

What to start

Answer 18

INSTIs with 2 NRTIs-1st if cannot then
Integrate inhibitor based therapy first or booster PI with 2 NRTI; NNRTI with 2 NRTIs

Question 19

Contraindications

Answer 19

Monotherapy
2 or 3 NRTI based regiment
Efavirenz and dolutegravir in pregnancy
Combined carefully!!
Some may be ineffective if in combo, some may increase ADE, or decrease combination of others

Question 20

Pre exposure prophylaxis

Answer 20

recommended for men who have sex with men, HIV discordant couple, IVDU, heterosexual men and women at increased risk
Eligibility-negative HIV antibody, absence of HIV infection, confirm risk, normal renal function, hepatitis B screen and immunize, hepatitis C screen, screen for other STD, assess pregnancy plan and test for pregnancy Q 3 months
Truvada (tenofovir & emtricitabine)
3 months supply with testing every 3 months, renal function Q6months, STI testing, Q3 month pregnancy test, counsel on risk reduction, DC if HIV positive
Protection wanes 7-10 days after last dose so they can get infected during this period!

Question 21

Non occupational post exposure prophylaxis

Answer 21

After sexual exposure or exposure via IVDU, transfusion or high risk exposure
For HIV negative patients only
Initiate ART within 72 hours of exposure and continue for 28 days
Adults and those older than 13 normal renal tenofovir and emtricitabine with raltegravir or dolutegravir
If renally impaired zidovudine and lamivudine with raltegravir or dolutegravir

Question 22

Occupational post exposure prophylaxis

Answer 22

Percutaneous risk- 0.3%, mucous membrane contact 0.09%
2 NRTIs plus one of the following- integrase inhibitor, boosted PI, NNRTI, recommend regiment is emtricitabine, tenofovir, raltegravir
Consult ID for risk benefit ratio
FU post 72 hrs post exposure
HIV antibody testing at initial, 6 weeks, 12 weeks, and 6 months with 4th generational assay

Question 24

Adolescents and HIV

Answer 24

Initiate post puberty adolescents guidelines (tanner stage 4/5) if younger use peds guidelines

Question 25

PCP

Answer 25

Environmental reservoirs Subacute progressive exertional SOB, fever, non productive cough, chest discomfort that worsens over a period to month, weight loss, anorexia, night sweats Hypoxic, LDH greater than 500, PCP PCR, CXR, CT scan, cytology to confirm Can do bactrim DE IV or PO TIR or QID for 21 days, steroids if 02 less than 90%, 21 days tapering dose Prevention given for CD4 less than 200 or % less than 14, HX of oral candidiasis or AIDS illness-order bactrim DS 1 PO daily

Question 26

Toxoplasmosis

Answer 26

Focal encephalitis with fever, HA; confusion, motor weakness, may lead to seizures or coma DX with toxo IgG antibody, CT or MRI of Brain or biopsy, LP TX- pyrimethanine, sulfadiazine, plus leucovorin, steroids anti seizures Prevention-bactrim DS 1 PO daily when CD4 less than 100

Question 27

Disseminating mycobacterium about complex (MAC)

Answer 27

Systemic Fever, weight loss, night sweats, diarrhea, abdominal pain, lymphadenopathy: hepatosplenomegaly DX- elevated alkaline phos, anemia, blood culture, abdominal CT, CXR, liver biopsy, lymph node biopsy TX- clarithromycin and ethanbutol for 6-12 months may be lifelong if immune system does not rebuild with ART, clinical improvement in 2-4 weeks Prevention- CD4 less than 50, clarithromycin 500 my PO BID if azithromycin 1200 mg once a week

Question 28

CMV

Answer 28

Colitis, esophagitis, pneumonitis, encephalitis Retinitis- unilateral but can progress to bilateral and loss of vision and blindness, requires ophthalmology referral-TX valganciclovir PO, IV gabciclovir, foscarnet, cidofovir Prevent with condoms

Question 29

Candida infections

Answer 29

Mouth, esophagus, vagina Can have down entire GI tract assess for dysphagia Prophylaxis not recommended Fluconazole orally 1-2 weeks Esophagitis- fluconazole 200 mg daily PO or IV for 2-3 weeks or PO itraconazole

Question 30

Crypotcoccosis

Answer 30

Fungal that infects CNS causing meningitis, also affects lungs, kidney, bone or prostate May be inhaled from bird droppings Fever, malaise, HA, photophobia, nuchal rigidity, lethargy; AMS, personality changes, memory loss, skin changes on unbillicus, pulmonary infections DX with LP, blood antigen TX- amphotericin B and flucytosine IV, fluconazole may be started and given for one year

Question 31

Other complications of HIV

Answer 31

Lymphomas can occur with CD4 counts below 200, hodgkins and primary site CNS, kaposi sarcoma HIV dementia, myelopathy, neuropathy Peripheral neuropathy Retinopathy Pulmonary HTN and emphysema Anemia Neutropenia, thrombocytopenia Inspired glucose and lipid metabolism Lipodystrophy Myocarditis, cardiomegaly, AS, CM, sudden death, AF, CKD Skin manifestations Progressive multifocal leukoencephalopathy HIV induced enteropathy HIV pancreatitis Fatty liver and fibrosis AIDS cholangiopathy Diarrhea