HIV

Question 1

What virus causes HIV infection?

Answer 1

A Lentivirus, genus Retroviridae, single stranded RNA

Question 2

What is the binding site for CD4 cells?

Answer 2

Envelope protein GP 120

Question 3

What occurs at the cellular level in HIV infection?

Answer 3

Helper cells are damaged. They normally are responsible for presenting antigen to B cells and stimulating them with cytokines as well as cytotoxic T cells.
IL1 secretion is reduced as well as chemotaxis and cytotoxicity,

Question 4

How does HIV enter the body?

Answer 4

Via dendritic cells inn the vagina and surface lymphatics.

Question 5

What is the role of reverse transcriptase?

Answer 5

It permits the viral RNA to enter the nucleus of the immune cells and become part of the cells’ DNA. Replication of the immune cells results in production of the HIV RNA which kill the immune and other cells. Inflammation worsens the process.

Question 6

What time period is required for HIV dissemination throughout the entire body?

Answer 6

One week.

Question 7

How long does it take to destroy the immune system?

Answer 7

8 to 10 years.

Question 8

How many CD4 cells are destroyed daily?

Answer 8

200,000,000,

Question 9

How many virions are destroyed/ cleared daily?

Answer 9

10,000,000.

Question 10

What does ART(combination of multiple drugs) do?

Answer 10

It blocks viral replication, resulting in a change in the balance of replication and destruction. The result is and increase in CD4 cells, then memory cells and finally naïve cells.

Question 11

What are the opportunistic infections (OI) in Africa?

Answer 11

CNS Cryptococcosis, TB, Esophageal Candidiasis, PCP, Amebiasis, CMV Retinitis, CNS Toxo

Question 12

What are the OI in developed countries?

Answer 12

PCP, Esophageal Candidiasis, MAC Infection, CMV Retinitis, CNS Cryptococcosis, CNS Toxo

Question 13

At what CD4 count level do the above OI appear?

Answer 13

CD4 of 200 or less

Question 14

At what CD4 level does Bacterial Pneumonia and Orall Thrush appear?

Answer 14

CD4 count between 500 and 200

Question 15

What is the treatment for PCP? If sulfa allergic

Answer 15

TMP-SMX3 to 4 X per day, if sulfa allergic use escalating doses of TMP-SMX

Question 16

When is Prednisone used?

Answer 16

if hypoxic with PaO2 <70, Tapered over 20 days

Question 17

What infections are frequently concomitant ?

Answer 17

PCP and TB

Question 18

How does an infection with Toxoplasmosis occur?

Answer 18

Usually from reactivation of oocysts ingested from undercooked pork, lamb and beef

Question 19

What is the treatment of Toxoplasmosis?

Answer 19

Pyrimethamine + Sulfadiazine + Folinic Acid; steroids are not helpful

Question 20

When do you suspect disseminated Cryptococcal infection?

Answer 20

When CD4 ct is less than 100

Question 21

What are the sx of CNS infection?

Answer 21

Progressive severe HA with stiff neck

Question 22

What physical findings are associated with this infection?

Answer 22

6th nerve palsy due to elevated ICP
Molloscum like skin lesions
Non inflammatory Meningitis

Question 23

How to make the dx of Cryptococcal Meningitis?

Answer 23

India Ink of CSF is + 75-95% of the time

CRAG

Question 24

What is the treatment of CNS Cryptococcal Meningitis?

Answer 24

Amphotericin B plus
5 Fluocytosine or Fluconazole
Fluconazole is continued for 10 weeks at 800 mg orally once per day the reduced to 200 mg once daily which is continued indefinitely

Question 25

What % of Esophageal Infections are caused by Candidiasis?

Answer 25

50-70%

Question 26

What conditions do you consider when Esophagitis is not associated with systemic sx?

Answer 26

Candidal Esophagitis | Pill Esophagitis-AZT and DDC

Question 27

What conditions cause Esophagitis with systemic sx?

Answer 27

CMV Candida Neoplasm Idiopathic Ulcer

Question 28

What causes Bacillary Angiomatosis (BA)?

Answer 28

Bartonella Hensleae ( Cat Scratch Disease) and Bartonella Quintana ( cause of Endocarditis and Trench Fever)

Question 29

What do the skin lesions of Bacillary Angiomatosis (BA)resemble?

Answer 29

Kaposi's Sarcoma. The Warthin-Starry Silver Stain helps to distinguish them from each other.

Question 30

What is the treatment of BA?

Answer 30

Macrolides or Doxycycline

Question 31

What is Immune Reconstitution Syndrome?

Answer 31

Seen when CD4 count is less than 100. ART administered and immune system improved which recognizes previously unrecognized antigens. Presents with elevated ICP>250, treated with daily lumbar punctures removing 10 to 30 cc of CSF. The Iris event is a cytokine storm The risk is 3 to 6x after 2 weeks of ART. It is treated with 1.5 mg/kg daily for 2 weeks then .75mg.kg for 2 weeks

Question 32

What are some prophylaxis considerations in HIV?

Answer 32

``` When CD 4 count is below: 200- PCP 100- Toxoplasmosis 50- MAC, Cryptococcosis and Candida also consider the presence of Hepatitis C and D. ```

Question 33

What are the 5 steps in managing HIV ( in Africa)?

Answer 33

1. Confirm HIV + 2. Stage illness- check CBC, VDRL, CD4 count and CXR 3. Prophylax all those who are HIV+ with TMP-SMX 4. Counsel all prior to staring therapy 5. Start ART

Question 34

What is ART?

Answer 34

2 NRTIs + 1 NNRTI

Question 35

What are the NRTIs?

Answer 35

Zidovudine (AZT or ZDV), Lamivudine (3TC)

Question 36

What are the NNRTIs?

Answer 36

Nevirapine (NVP) Stavudine (D4T) Efaverez (EFV)

Question 37

What is the alternative to ART?

Answer 37

Alluvia (Lopinavir + Ritonavir)

Question 38

What labs are checked at the monthly visit?

Answer 38

A CD4 count and a viral load. It is expected that the CD4 count will rise >50% over a 6 month period.

Question 39

What are the complications of HIV infection?

Answer 39

Cardiac- Pericarditis, Cardiomyopathy, Atherosclerosis Renal- Nephrotic SYndrome (HIVAN) Neurologic- Dementia, Neuropathy Oncology- Kaposi's Sarcoma (due to Herpes Virus) , Lymphoma

Question 40

Why do the complications occur?

Answer 40

Endothelial Damage cause vascular dysfunction Elevated IL6 levels, C Reactive Protein, Protein S and C and Triglycerides Reduced HDL and LDL Chronic Inflammation

Question 41

What labs are checked at the monthly visit?

Answer 41

A CD4 count and a viral load. It is expected that the CD4 count will rise >50% over a 6 month period.

Question 42

What are the complications of HIV infection?

Answer 42

Cardiac- Pericarditis, Cardiomyopathy, Atherosclerosis Renal- Nephrotic SYndrome (HIVAN) Neurologic- Dementia, Neuropathy Oncology- Kaposi's Sarcoma (due to Herpes Virus) , Lymphoma

Question 43

Why do the complications occur?

Answer 43

Endothelial Damage cause vascular dysfunction use Carotid Intimal Thickness to measure Elevated IL6 levels, C Reactive Protein, Protein S and C and Triglycerides Reduced HDL and LDL Chronic Inflammation

Question 44

What are the risks of HAART?

Answer 44

``` Interaction with Statins via P450-3A4 Hypertension after 5 years Type 2 DM Lipodystrophy Hyperlipidemia Myocardial Infarction ```

Question 45

What drugs cause Hyperlipidemia?

Answer 45

Protease Inhibitors- Lopinavir , Staduvidine and Ritonavir | NRTI- Abacavir

Question 46

What are the 4 stages of HIV/

Answer 46

1. Generalized Lymph Nodes, no sx 2. Weight Loss with Mucocutaneous Disease 3. Greater than 10% Weight Loss- Chronic Diarrhea, Fever, TB, ANUG, Hairy Leukoplakia 4. Wasting- opportunistic infections(CD4<100)

Question 47

Who are the priority patients with HIV infection?

Answer 47

Pregnant Women Children Those who are obviously Ill

Question 48

What is a PIMA?

Answer 48

A POC test with CD4 count in 15 minutesl

Question 49

What is PEP?

Answer 49

Start 24-36 hrs post exposure and use for 4 weeks. retest at 6 weeks, 12 weeks and 6 mos. The cances of acquiring HIV from a needle stick is 0.33%.The drugs used are Truvada or Combivir for low risk and for high risk 2 NRTIs + Ritonovir (PI) or Kaletra (Lopinavir +Ritonovir)

Question 50

When to start HIV therapy in children?

Answer 50

``` Under 24 mos. and/or stage 3 or 4 btwn 24 mos and 5 yrs, when CD4 <750 5 yrs+ when CD4 <350 All HIV exposed- TMP-SMX TB exposed, active or inactive- start INH ```

Question 51

What is PREP?

Answer 51

Truvada (Tenofovir + Emtricibine) for discordant sexual partners.

Question 52

What is PEP?

Answer 52

Start 24-36 hrs post exposure and use for 4 weeks. retest at 6 weeks, 12 weeks and 6 mos.

Question 53

What increases risk of transmission in pregnancy?

Answer 53

``` Preterm <34 weeks Birth Weight , 2500 gms ROM > 4hrs Low Maternal CD4 count Maternal use of recreational drugs ```

Question 54

What are the treatments for HIV in pregnancy?

Answer 54

1) AZT BID, add NVP for 1 dose at onset of albor if less than 4 weeks of therapy then AZT+ 3TC during L and D and for 7 days post partum 2) Triple drug therapy starting at 14 weeks

Question 55

What are the treatments for HIV in pregnancy?

Answer 55

1) AZT BID, add NVP for 1 dose at onset of labor if less than 4 weeks of therapy then AZT+ 3TC during L and D and for 7 days post partum 2) Triple drug therapy starting at 14 weeks

Question 56

What is the infant regimen?

Answer 56

NVP for 4 to 6 weeks or until 1 week post stopping breast feeding NVP or bid AZT for 4 to 6 weeks