Flashcards in HIV Deck (26):
1. What is the most common mode of transmission in the world? in the US?
2. How are neonates exposed to HIV?
1. world: heterosexual contact; US: male-male sexual contact
2. contact w/ mother's infected blood through the vagina
1. What enhances sexually transmitted HIV?
2. Other modes of transmission (4)
1. advanced disease, other STDs, and receptive anal intercourse
2. Mother to child
3. IV drug abuse
4. Blood (almost 0 due to screening)
Diagnosis of HIV
1. What is the primary screening test?
2. What is the confirming test?
3. How long does it take to develop antibodies?
4. What other viral detection methods are not used?
1. HIV-1 Antibody by EIA
2. Western blot; detects Ab against specific HIV envelope and core proteins
3. 1-3 months
4. culture (impractical), PCR (for quantification)
Signs and Symptoms of Acute Retroviral Syndrome
Fever, lymphadenopathy, pharyngitis, rash, myalgia or arthralgia, diarrhea, headache, nausea and vomiting, hepatosplenomegaly, weight loss, thrush, neuro symptoms;
LOOKS LIKE MONO
Acute Retroviral Syndrome
1. What symptom distinguishes HIV from mononucleosis?
2. What other symptom may be present?
1. mucocutaneous ulceration involving mouth, esophagus, or genitals
2. erythematous maculopapular rash with lesions on the face and trunk and sometimes extremities (including palms and soles)
Acute Retrovial Syndrome: Neurological Symptoms (6)
1. Meningoencephalitis or aseptic meningitis (uncommon)
2. peripheral neuropathy or radiculopathy
3. Facial palsy
4. Guillain-Barre syndrome
5. Brachial neuritis
6. Cognitive impairment or psychosis
Acute HIV Infection: Lab Testing
1. What 2 things are looked for in screening?
2. What is used to confirm?
1. HIV RNA and HIV Ab (may be indeterminate or negative)
Acute HIV Infection: Treatment
1. Decrease the severity of acute disease, alter the viral set-point, reduce rate of mutation, preserve immune function, reduce risk of viral transmission
2. drug-related toxicity, earlier emergence of drug resistance, limitation of future treatment options, potential need for indefinite treatment, adverse effects on quality of life
Presence of HIV + one of the following: invasive candida, Pneumocystis carinii pneumonia, Kaposi's sarcoma, Mycobaterium (TB, MAC), Wasting syndrome, or CD4<14% lymphocytes
Natural History of HIV progression
1. What % has it in 5 years?
2. 10 years?
3. 11 years?
4. What 2 factors increase the incidence of developing AIDS?
4. low T cells; increased viral load
Preventable complications of AIDS: PCP Prophylaxis
1. What are indications for prophylaxis?
2. What is the preferred regimen?
1. History of PCP, CD4 < 200 or < 14%; HIV associated thrush
Preventable complications of AIDS: MAC Prophylaxis
1. Indication for prophylaxis
3. When can prophylaxis be discontinued?
Preventable complications of AIDS: Toxoplasmosis Prophylaxis
1. CD4 < 100
2. Bactrim DS
Goals of Antiretroviral Therapy (8)
1. improve quality of life
2. reduce HIV-related mortality and morbidity
3. restore and/or preserve immune function
4. maximal and durable suppression of viral load
5. preservation of future treatment options
6. rational sequencing of therapy
7. maximizing adherence
8. use of resistance testing in selected clinical settings
Before Initiating ART, what 6 things need to happen?
1. confirm HIV results
2. complete H and P
3. CBC, chemistry profile
4. CD4 cell count, plasma RNA measurement
5. Resistance Testing (genotype)
6. Assess "readiness" for treatment and adherence (accept dx and must take drugs every day)
Additional Tests to do before initiation ART (9)
1. RPR or VDRL
3. Chest X-ray
4. Hep A, B, C serology
5. Toxoplasma IgG
6. Fasting glucose and lipids
7. Gynecologic exam w/ pap smear
8. testing for chlamydia and gonorrhea
9. Opthalmology exam (CD4 < 100/ul)
What are some things to consider in initiating ART in asymptomatic HIV? (5)
1. willingness of pt to begin and the likelihood of adherence
2. Degree of immunodeficiency
3. Plasma HIV RNA
4. Risk of disease progression
5. Potential benefits and risks of therapy
What is the treatment recommendation for each pt?
1. Symptomatic AIDS, pregnant, neuropathy?
2. Asymptomatic HIV w/ CD4< 350
3. Asymptomatic HIV w/ CD4> 500
1. treat w/ any CD4 T cell and plasma HIV RNA count
2. Treat w/ any value of plasma HIV RNA
3. 50% say treat
1. Benefits of Deferrred ART Therapy
2. Risks of Deferred Therapy
3. What therapy is never recommended?
1. avoid negative effects on quality of life, avoid drug-related toxicity, preserve future drug options, delay development of drug resistance, decrease total time on meds
2. possibility of irreversible immune system depletion, increased possibility of progression to AIDS, possible increased risk of HIV transmission
Adherence to ART
1. What does it determine?
2. What is associated with virologic failure?
3. What is required for optimal suppression?
4. What is common?
1. degree and duration of viral suppression
2. poor adherence
3. 90-95% adherence
4. suboptimal adherence is common
What factors predict inadequate adherence? (8)
1. regimen complexity and pill burden
2. poor doctor-pt relationship
3. active drug use or alcoholism
4. unstable housing
5. mental illness (especially depression)
6. lack of pt education
7. medication adverse effects
8. fear of medication adverse effects
What factors predict good adherence (7)?
1. emotional and practical supports
2. convenience of regimen
3. understanding the importance of adherence
4. belief in efficacy of medications
5. feeling comfortable taking medications in front of others
6. Keeping clinic appointments
7. severity of symptoms or illness
ART Adverse Effects (7)
1. Lactic acidosis/ hepatic steatosis
4. fat maldistribution (not specific to any 1 drug)
6. increased bleeding in hemophiliacs
7. osteonecrosis, osteopenia, osteoporosis
ART SE: Fat Maldistribution
5. may be associated with?
2. no uniform definition
3. not understood
4. switching to other agents may slow progression
5. dyslipidemia, insulin resistance, lactic acidosis
ART SE: Hyperlipidemia
3. associated with which drugs?
1. elevations in total cholesterol, LDL, and TGs
3. all PIs (except ATV), d4T, EFV
4. uncertain; concern for CV/pancreatitis
5. consider ARV switch; lipid-lowering agents