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LMCC Part II > HIV/AIDS > Flashcards

HIV/AIDS Flashcards

1
Q

What are the three clinical categories of HIV

A

A–> asymptomatic HIV infection; persistent generalized LAD; acute primary HIV infection

B–> symptomatic with conditions that are either attributed to HIV/defective cell mediated immunity or have clinical course complicated by HIV

C–> symptomatic with AIDS defining illnesses

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2
Q

what are the AIDS defining illnesses

A

PJP

kaposi sarcoma

recurrent bacterial pneumonia

candidiasis of esophagus or pulmonary system

(there are others)

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3
Q

what are the two types of HIV

A

HIV 1–> predominant type in most of the world except West Africa where type 2 predominates

HIV 2–> infection results in a similar clinical course to HIV 1 but degree of immune suppression and disease progression is slower

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4
Q

what is HIV

A

retrovirus that preferentially infects CD4 T lymphocytes

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5
Q

what % of new infections are in women

A

50%

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6
Q

how has the epidemiology of AIDS changes

A

estimated number of AIDS cases has remained the stable but number of cases among MSM, heterosexual adults and adolescents has increased, while cases among IVDU have decreased

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7
Q

risk factors for HIV transmission

A 
viral load
lack of circumcision
sexual risk 
presence of ulcerative STD
host and genetic factors
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8
Q

how is HIV transmitted

A

unprotected anal or vaginal sex
rarely oral sex
sharing of HIV contaminated needles and paraphernalia
vertical transmission
transfusion of contaminated blood or blood products
accidental exposures of health care workers

*it is NOT transmitted by casual contact, kissing, mosquito bites, toilets and shared utensils

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9
Q

what is the natural history of HIV in an UNTREATED patient

A

most patients, even without ARVs, survive for 10-12 years after acquiring HIV infection and are asymptomatic much of that time

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10
Q

what are the stages of HIV 1 infection

A
  1. viral transmission
  2. primary HIV infection
  3. seroconversion
  4. clinical latent period with or without persistent generalized LAD
  5. early symptomatic HIV infection
  6. AIDS
  7. Advanced HIV infection characterized by CD4 count below 50
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11
Q

how do you diagnose AIDS

A

AIDS indicator condition and CD4 count below 200 regardless of presence or absence of symptoms

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12
Q

what are two predictors of disease progression in HIV

A

CD4 cell counts

HIV viral RNA counts after 8-12 months of transmission (set point)

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13
Q

how do you diagnose HIV

A

serological detection of anti-HIV Ab, antigen or viral RNA is required

by 6 months after infection, anti0HIV Abs are present in 95% of people

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14
Q

what is the window between infection and seroconversion

A

3-6 weeks

*for recently exposed individuals (in the above window period) diagnosis can be made by detection of HIV in plasma (antigen testing)–a repeat ELISA at 6 weeks and 3 months is still indicated

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15
Q

what is the primary screening test for HIV

A

ELISA HIV antibody test

if the test is reactive, then repeat in duplicate. if either or both of those is reactive then the test is considered positive and a western blot or indirect immunofluorescence assay is done for confirmation

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16
Q

in which patients is a viral antigen test for HIV indicated

A

screening blood donors

screening neonates born to HIV infected mothers

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17
Q

what is HIV viral RNA detection testing used for

A

monitor disease progression and ARV therapy response

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18
Q

when should routine HIV testing occur

A

at the time of the initial visit

all testing must be voluntary, confidential and done with the patients consent

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19
Q

how should HIV testing be done if a specific exposure has occurred

A

baseline antibody testing should be obtained with repeats at 6, 12 and 24 weeks (same as exposed health care worker)

if patient has possible symptoms of primary HIV, viral load testing should be performed in addition to antibody testing

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20
Q

what are the most common causes of false positive testing in low risk patients

A

recent immunization

repeat serologic testing

HIV viral RNA level in 1-3 months

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21
Q

list 4 goals of HIV therapy

A
  1. durable suppression of HIV viral load to less than 50 copies/mL
  2. improvement in quality of life
  3. preservation of future therapeutic options
  4. restoration of immune function (as indicated by CD4 cell count)
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22
Q

list two potential risks of HIV therapy

A
  1. higher risk of long term antiretroviral dug toxicities due to a considerable increase in the duration of antiviral exposure
  2. evolution of drug resistance if therapy fails to completely suppress viral replication (thus need to stress compliance)
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23
Q

in which patients should you absolutely start ARV therapy

A

pregnant women

patient with HIV associated nephropathy

patient coinfected with HBV

patient with CD4 cell count below 350

patient with history of AIDS defining illness

24
Q

how should you manage an HIV positive patient with a CD4 count above 350

A

assess clinical scenario, patient readiness, age, comorbidities, potential impact on quality of life and adherence factors

then decide if ARV therapy should be pursued

25
Q

what classes of drugs are available for treatment of HIV

A

nucleoside and nucleotide transcriptase inhibitors (NRTIs)

non nucleoside reverse transcriptase inhibitors (NNRTIs)

protease inhibitors (PIs)

fusion inhibitor

integrase inhibitor

CCR5 antagonist

fixed dose combinations including:
Combivir
Trizivir
Epzicom
Truvada
26
Q

how many ARVs are generally included in HIV therapy

A

at least 3 active ARVS

base is either an NNRTI or a PI

backbone typically consists of two NRTIs

27
Q

how do you pick an ARV regimen for a patient

A

should be individualized, and should be based on a number of factors including:

comorbid medical conditions
drug interactions
adverse effects
pregnancy potential
genotyping etc
28
Q

how should viral load change after initiation of ARV therapy

A

should decrease 3-4 fold within 2-8 weeks and continue to decrease thereafter

goal is to have undetectable viral load at 6 months

29
Q

when should HIV viral load be undetectable after initiation of ARV therapy

A

within 6 months

30
Q

when should you change treatment for HIV

A

treatment failure

adverse effect

noncompliance due to adverse effects

31
Q

what are some signs of a failing ARV regimen

A

unable to achieve or maintain suppression of viral replication below 50 copis

increasing viral load

decreasing CD4 cell count

clinical deterioration

32
Q

what are some adverse events that can arise from ARV therapy

A

lactic acidosis

lipodystrophy

hyperlipidemia

peripheral neuropathy

GI symptoms

renal insufficiency

rash

33
Q

other than ARV, what treatments can be offered to the HIV positive patient

A

prophylaxis for opportunistic infections when indicated by CD4 count

immunizations early in disease

34
Q

at what CD4 count should you start prophylaxis for PJP

A

less than 200

35
Q

at what CD4 count should you start prophylaxis for toxoplasmosis

A

less than 100

36
Q

at what CD4 count should you start prophylaxis for MAC

A

less than 100

37
Q

at what CD4 count should you start prophylaxis for CMV

A

less than 50

38
Q

at what CD4 count should you start prophylaxis for TB

A

if PPD has 0.5 mm induration

39
Q

what type of sexual activity is greatest risk for HIV transmission

A

receptive anal intercourse (8fold higher risk)

–risk is 1.5% per act with an infected individual

40
Q

what steps can be taken to reduce risk of transmission from mother to child in vertical transmission

A

c section for delivery

prenatal ARV therapy

ARV therapy in the newborn immediately after birth

avoid breastfeeding (unless local conditions make this unsafe)

41
Q

how do prior or current STD infections raise risk for transmission of HIV

A

G and C increase HIV transmission risk by 3 fold

syphilis by 7 fold

herpes by up to 25 fold during an outbreak

42
Q

how does acute seroconversion with HIV present

A

flu like illness–> fever, malaise, generalized rash

43
Q

what is often a presenting complaint for HIV

A

generalized LAD

44
Q

how does AIDS manifest

A

recurrent, severe, occasionally life threatening infections and/or opportunistic maligancies –> thus, HIV should be suspected when unusual infections present in apparently health individuals

45
Q

what are some sequelae of HIV itself

A

AIDS associated dementia/encephalopathy

HIV wasting syndrome (chronic diarrhea and weight loss with no identifiable cause)

46
Q

are there any findings specific to HIV infection

A

no

the physical findings are those of the presenting infection or illness

generalized LAD is common, weight loss may be apparent

47
Q

what might clue you in to HIV infection in a presenting patient

A

evidence for risk factors (MSM, IVDU, vertical transmission, multiple sexual partners)

minor opportunistic infections i.e herpetic lesions on the groin, widespread oral candidiasis

48
Q

given that opportunistic infections and cancers can arise on people without HIV but with other immune disorders etc, what other etiologies should you consider in someone presenting with an infection or malignancy associated with HIV

A

chemotherapy
immune disorders
severe combined immune deficiency
severe malnutrition

i.e a young adult undergoing chemotherapy

49
Q

what are the most effective methods, on an individual level, for preventing HIV

A

avoidance of sexual contact outside a monogamous relationship

the use of safer sex practices for all other sexual encounters

abstinence from nonmedical parenteral drug use

50
Q

what % of new HIV infections were transmitted by HIV infected persons undergoing treatment with viral suppression

A

0%

based on march 2019 CDC reporting

(51% of the US HIV positive population is undergoing treatment with viral suppression, and they transmitted 0% of new infections)

51
Q

what are some prevention methods that people can use with their partners, or if they are in high risk populations, to help prevent HIV transmission

A

condom use

pre-exposure prophylaxis (PrEP)

52
Q

prevention methods for HIV

A

abstinence when possible

reduction in number of sexual partners

using barrier contraception

treatment of concurrent STDs

testing of self and partner for HIV infection and other STDs

53
Q

what is the most well known risk factor that predisposes to HIV transmission

A

concomitant infection with other STDs as they may cause mucosal ulcerations or tears

54
Q

what risk factor in women (a med) may increase risk of transmission of HIV

A

OCP

55
Q

who should be considered for PrEP (per 2014 CDC guidelines)

A

anyone who is in an ongoing sexual relationship with an HIV infected partner

a gay or bisexual man who has had sex without a condom or has been diagnosed with an STI within the past 6 months and is not in a mutually monogamous relationship with a partner who recently tested HIV negative

a heterosexual man or woman who does not always use condoms when having sex with partners known to be at risk for HIV and is not in a mutually monogamous relationship with a partner who recently tested HIV negative

anyone who, in the preceeding 6 months, has injected illicit drugs and shared equipment or been in a treatment program for illicit drug use

  • daily oral PrEP has been shown to be safe and effective in reducing the risk of sexual HIV transmission in adults, adolescents and discordant couples
  • acute and chronic HIV infection must be excluded by symptom history and HIV testing immediately before PrEP is prescribed
  • oral PrEP for coitally timed or other noncontinuous daily use is not recommended
56
Q

how does compliance affect efficacy of PrEP

A

among those who took their PrEP as prescribed (daily) 90% of days, HIV transmission risk was reduced by 73%

in those who used it less than 90% of the time, risk was only decreased by 21%

57
Q

what are the long term monitoring guidelines for HIV

A

in patients on ARVs, do the following every three months:
basic chemistry profile
LFTs
CBC-D

fasting glucose every 6 months

fasting lipids every 12 months

in patients on a stable regimen whose viral load is suppressed and whose CD4 count is well above the threshold for opportunistic infection risk, CD4 count may be monitored every 6-12 months (3-6 months if these conditions are not met)

LMCC Part II (52 decks)

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