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Flashcards in HIV infection Deck (160):
1

normal CD4 count

500

2

immunosuppressed CD4 count

200

3

HIV transmission

-blood/blood products
-body fluids/ sexual transmission

4

blood/blood products that transmit HIV

-transfusion (RBC + Clotting factors)
-IVDU (sharing needles)
-Lab/ Health care workers/ needle stick
-vertical transmission

5

Body fluids/ sexual transmission of HIV

-MSM
-heterosexual

6

where are the majority of deaths + those with HIV in children?

Africa

7

percent of those HIV infected do not know their status

1/3

8

who should be screened annually?

people at high risk

9

HIV ab testing should be performed routinely in all patients age

13-64

10

clinical manifestatios of acute HIV infections in order of most prominent to least

fever
fatigue
myalgia
skin rash
headache
pharyngitis
cervical adenopathy
arthralgia
night sweat
diarrhea

11

myalgia

pain in a muscle or group of muscles

12

arthralgia

pain in a joint

13

inquire new partners

-within last 3 mos
-past testing
-sexual risk
-exposure/assault
-needle sharing

14

screening test for HIV use 4th generation use

immunoassays that combine HIV antigen + HIV antibody

15

inquire about new partners

-within last 3 mos
-past testing
-sexual risk
-exposure/assault
-needle sharing

16

remember the window period

earliest positive= 15-20 days

prior to that window, may test negative despite symptoms of acute HIV

17

diagnosis of acute HIV requires detectable plasma RNA

-test RNA early if symptomatic
-

18

4th generation diagnostic HIV tests= window

IgM + IgG antibody and p24 antigen

19

4th generation HIV test target of detection

IgM + IgG antibody and p24 antigen

20

4th generation window to take positive tset

15-20 days

21

HIV viral load test target of detection

RNA

22

HIV viral load test approximate time to positivity

10-15 days

23

HIV II

rare

24

how many years does it take to develop advanced disease

8-12 years

25

untreated HIV can be

very progressive + infectious

26

What does HIV target that declines infection?

CD4 cells

27

HIV is most common in people with

lower CD4 counts

28

acute antiretroviral infection

seroconversion

29

evolution of untreated HIV leads to

acute antiretroviral infection (seroconversion)

30

acute antiretroviral infection

-viral syndrome in most, but may be mild
-within 2 weeks, develop Mono-like syndrome

31

established HIV

start ART (acute antiretroviral infection) at any CD4 count, even if asymptomatic
-CD4>350 -500 cells
-symptomatic

32

untreated, progressive HIV

-opportunistic infections/malignancies
-risk for OIs depends on exposure

33

opportunistic infections/malignancies

-cell mediated immune deficit
-exposure to opportunistic pathogens
-epidemiology of frequent OIs
(diagnostic methodology + tx)

34

risk for Opportunistic Infections depends on exposure

-geography/prior exposure
-practices/habits
-degree of immunosupression

35

pneumonias, shingles, candida

36

early opportunistic infectious, CD4 count

>200

37

Late opportunistic infections : CD4 count

>200

38

What kind of population do early Opportunistic infections affect?

in healthy population, more common in HIV+ before severely immunocompromised

39

early Opportunistic Infections

TB
Candida/thrush
VZV/shingles
Recurrent Bacterial/Pneumonia
Histoplasmosis
Kaposi's sarcoma

40

late opportunistic infections

-pneumocystis pneumonia
-chronic diarrhea cryptosporidia

41

CD4

-toxoplasma (seizures)
-CMV (visual loss)
-MAC (actypial mycobac)

42

AIDS Defining conditions

-recurrent bacterial infections
-candidal infection of esophagus, trachea, bronchi
-disseminated coccidiomycosis, histoplasmosis
-extrapulmonary cryptococcosis
-chronic cryptosporidiosis or isospora
-CMV
-persistent mucocutaneous HSV
-HIV encephalopathy
-Kaposi's sarcoma
-Primary lymphoma of the brain
-Non Hodgkin's B cell lymphoma

43

women with uncontrolled HIV are more prone to more rapid

cervical cancer

44

AIDS defining conditions, cont: HIV plus

-lymphoid interstitial pneumonitis (LIP) (Pediatric)
-Cervical cancer (women)
-Disseminated Mycobacterial infection (not tb)
-extrapulmonary tb
- pneumocystis pneumonia
-progressive multifocal leucoencephalopathy
-recurrent salmonella infection
-toxoplasmosis of the brain

45

primary prevention of opportunistic infections

prevents the 1st occurrence

46

secondary prevention of opportunistic infections

-previously treated for disease
-often a reduced dose to prevent reactivation of serious disease

47

primary prevention for CD4

-penumocysits- prevent with trimethoprim/sulfa
-cheap + effective
-also prevents toxo

48

percent risk of pneumocystis / year

60%

49

primary prevention for CD4

MAC- prevent with azithromycin weekly dose

50

secondary prevention

-candida
-cryptococcal meningitis, histo, cocci
-CMV

51

ART

anti retroviral therapy

52

ART era= chronic manageable disease

-more testing, early ID, newly identified HIV+ are asymptomatic
-more sophisticated understanding of viral pathogenesis and more treatment options
-prefer ART once diagnosed, AND ready yo take pills regularly
-CD4 recovery and viral plasma RNA undetectable expected in all

53

complications of long term infection and long term therapy (difficult to separate)

-body shape abnormalities
-metabolic abnormalities (DM, hyperlipidemia, osteoporosis)

54

not all HIV associated conditions are diminishing in the era of ART

even higher CD4 counts, HIV infection is linked to
-chronic immune activation
-progressive HCV liver disease, renal disease
-Cardiovascular disease

55

even with HIV suppression through ART, HIV is linked to

-chronic immune activation
-increased cancer risk, particularly lymphomas, lung cancer and invasive cervical

56

traditional indications for antiretrovirals

"the cocktail" in combo for acute or chronic HIV, highly active ART

57

known positive HIV patient takes ART

reduces the viral concentration from the source

58

If giving tablets to HIV neg to prevent them from getting the risk, use

selectively

59

Post-exposure prevention (PEP) indications for antiretrovirals

occupational: (needlestick/sharp/blood exposure or mucosal splash)

Non-occupational: mother infant transmission + sexual exposure (high risk, known positive)

60

pre-exposure prevention (PrEP) indications for antiretrovirals

prevention for those with ongoing high risk

61

goals for anti retroviral therapy

-reduced HIV related illness and death
-improve quality of life
-restore and preserve immune function
-provide potent sustained HIV control
-prevent HIV transmission

62

each class of medications have similar

targets at diff points

63

antiretroviral drug classes

-nucleoside/nucleotides
reverse transcriptase inhibitors
(NRTIs)
-non-nucleoside reverse transcriptase inhibitors (NNRTIs)
-protease inhibitors (PIs)
-HIV entry inhibitors (fusion inhibitors + CCR5 inhibitors)
-integrase inhibitors

64

goal of ART

HIV RNA below the level of detection

65

2014 ART first regimen guidelines

2 NRTI + integrase inhibitor or with darunavir/rtv

66

most commonly used NRTI

truvada

67

most commonly used multi-class drug combos

atripia, complena, strolloid?

68

most commonly used protease inhibitors

norvir, prozigta, reyataz

69

optimal ART response

CD4 counts recovering quickly
-viral load below testing threshold which is 75

70

adverse effects of ART

-gaining weight too fast
-fatigued
-had headaches
-concerned that she was putting poison into her body each time she took ART
-discontinued ART and was lost to care for 3 years

71

CURRENT ART IS

well tolerated, much less likely Gi distress, fat wasting, fat accumulatoin and hyperlipidemias

72

protease inhibitors side effects

caused upset stomachs, diarrhea, triclyerol problmes, facial appearance changes with wasting of the temples of the cheek
-arms and legs look very muscular by you lose subcutaneous tissues

73

morphologic complications of ART

fat accumulations (lipohypertrophy)
-buffalo hump
-arm wasting
-skin very thin but fat accumulation in musculature
-wasted hollow cheeks and temples

74

benefit /risk ration

greater benefit
-reduction in mortality
-risk= short and long term toxicities

75

HIV associated body shape, metabolic and CV risk host factors

-age
-prior weight + body composition
-family history

76

HIV associated body shape, metabolic and CV risk viral factors

-severity + duration of disease (chronic inflammation)
-cannot be measured simply by CD4 count + viral load

77

HIV associated body shape, metabolic and CV risk treatment factors

individual agents associated with selected metabolic and body shape changes

78

who needs to be psychologically ready for that daily dose

newly positive patient

79

evaluation of a newly positive patient

-psychological readiness for tx
-social and economic situation

80

blood tests of a newly positive patient

blood count, renal, liver, HIV drug resistance, past and chronic infections, (RPR, Hep A/B/C, toxo)

81

preventives for a newly positive patient

bactrim, Azithro, vaccinations

82

ART for newly positive patient

if ready, willing, and able

83

HIV therapy 2015

-HIV preventives and ART need to be individualized for each patient, and supported for adherence
-current agents are potent and durable HIV control with a min of short and long term side effects, but require life long tx

84

if a patient is taking BACTRIM , count is

85

pep

post exposure prophylaxis

86

bactrim for pneumocystis prevention implies CD4 count is

low

87

off ART + low CD4 count implies

greater HIV RNA in blood, increases infectivity

88

risk

anything that is blood contaminated

89

definitions of occupational exposure

-percutaneous injury
-contact of mucous membranes or non-intact skin with blood, tissue or infectious fluids
-not infectious unless they contain visible blood

90

contact of mucous membranes or non-intact skin with blood, tissue or infectious fluids

CSF
snynovial
plueral
peritoneal
percardial
amniotic
("internal" body fluids)

91

not infectious unless they contain visible blood

("external" fluids) feces, nasal secretions, saliva, sputum, sweat, tears, urine, vomitus

92

are you at risk if you had a patient who was coughing during a tooth extraction and may have splashed your eyes with some bloody saliva

YES

93

Are you at risk if you had a patient who was coughing during a tooth extraction and may have splashed your eyes with some bloody saliva splash onto an ungloved wrist?

no

94

Are you at risk if you had a patient who was coughing during a tooth extraction and may have splashed your eyes with some bloody saliva onto yoru recently surgically repaired elbow (less than perfectly intact skin)

yes

95

definitions of occupational exposure

-any direct contact (i.e. no barrier protection) to concentrated virus in a laboratory facility
-human bite

96

human bite occupational exposure

both the person bitten and the person who inflicted the bite have potentially been exposed to bloodborne pathogens
(HIV/HBV/HCV transmission very rarely reported by this route

97

most frequent to least frequent needlestick injuries

nurses (37.9%)
residents/fellows (11.4%)
attending physicians (10.7%)
surgery attendings (9.0%)
phlebotomists (5.4%)
nonlaboratory technologists (4.7%)

98

what is associated with a 3-fold increase in the risk of needle stick injuries

long work hours + sleep deprivation among medical trainees result in fatigue

99

what increases the risk of transmission more than intact skin or mucous membrane exposures

percutaneous

100

estimated risk of transmission from percutaneous exposure to blood through needle punctures or other injuries caused by contaminated sharp objects:

HBV: 1%- 30%
HCV: 1.8-3%
HIV .3%

101

percutaneous

pertains to any medical proceudre where access to inner organs or other tissue is done via needle puncture of the skin, rahter than by using an "open" approach where inner organs or tissue are exposed (typically with the use of a scalpel)

102

percentage of HIV transmission percutaneously

0.3%

103

percentage of HIV transmission mucocutaneous

0.09%

104

percentage of HIV transmission non-intact skin exposure

?

105

mucocutaneous zone

region of the body in which mucosa transitions to skin

106

risk of HIV infection increased with exposure to larger amounts of

blood
-device visibly contaminated with patient's blood
-procedure involving direct venous or arterial puncture on the patient
-deep injury to HCW
-risk for infection increased if source patient has a high viral load

107

CDC estimates how many needle-stick injuries in US hospitals each year

61% of injuries are due to hollow bore needles

108

# cases of documented HIV seroconversion after occupational exposure (mostly nurses) predominantly before 1995

57 cases

109

no proven HIV transmission from occupational exposure reported since

1999

110

# cases of PEP failure, complex reasons

21

111

after first mucosal exposure, how many days does it take for virus to get taken by dendritic cells , to expand and replicate

5-14 days

112

HIV infection + dissemination

-virions trapped by FDCs
-follicular dendritic cells are in germinal centers of LN
-fusion of FDC and CD4 cells
-travel to regional lymph nodes
-wide spread to brain, spleen, GALT, and other lymph nodes (Day 5-14)

113

when is PEP most effected

if implemented ASAP

114

PEP probably not effective when started how many hours after exposure

>36 hrs but interval when there is NO benefit from PEP is unknown

115

100 % of macaques receiving PEP (tenofovir) within 24 hours ater iV SIV infection remained

uninfected

116

50% protection if PEP given in

48 hours

117

25% protection of PEP given in

72 hours

118

consider PEP if

>36 hours

119

optimal duration of PEP

28 days

120

if given PEP for 28 days

100 % protecition

121

if given PEP for 10 days

50% protection

122

if given PEP for 3 days

0 protection

123

based on animal studies, larger innocula decreases efficacy of

PEP

124

innoculation

the action of inoculating or of being inoculated; vaccination

125

PEP efficacy decreased by

-delaying initiation
-shortening duration or
-inappropriate choice of ARV drugs

126

CDC's retrospective case-control study of HCW showed that PEP with AZT alone decreased risk of infection by

81%

127

if source patient has a highly resistant virus, patient might need a

different med

128

before starting HIV PEP

-standard HIV ELISA on exposed person
(-HIV viral load if patient known to be HIV positive
-If thought to be high risk to be in window period)
-consider medication interactions
-

129

get baseline labs before starting HIV PEP

those include Lytes, BUN, Cr, LFTs, CBC, beta HCG, baseline HIV Ab

130

decision to treat and choice of meds made on a

case by case basis

131

patients should be given first dose of meds in the ED and a 4-5 day starter pack only to geth through their

f/u/ appt. not a prescription

132

PEP tx options

-current CDC Recs (Tenofovir + Emtricitabine (TDF/FTC) and Raltegravir 100 mg BID)

133

alternatives to raltegravir PEP trx option

ritonavir 100 mg qd with either darunavir 800mg qd or with atazaniavir 300mg qd

134

how many days is a PEP tx starter pack and how many days does it take to complete?

3-5 days; complete 28 days

135

raltegravir is replacing PI

-improved tolerability

136

Duration of PEP is how many weeks?

4

137

lab tests at 2 weeks of PEP should include

BUN, Cr, LFTs, and CBC

138

repeat HIV Ab at what weeks?

4-6 weeks, 12, wks, 24 weks

139

secondary transmission to others extremely remote but

important to modify behavior in first 6-12 weeks after exposure when most seroconversions occur

140

source patient

history
past testing
risk factors
testing
useful but not always available

141

HIV/HCV risk

hemophilia
injection drug use
hemodialysis
history of STD

142

HBV risk?

-known liver disease
-past testing
-vaccination for HBV

143

past vaccination and antibody confirmation of HVsAB for HBV is

protective

144

recommendations of hep B PEP depends on

-vaccination status of HCW
-patient's serologic status
-if results from source patient will be known in 48-72 hours, treatment can be deferred until results known

145

hep B transmission

if HBSAg not detected in blood from source patient, transmission unlikely

146

HBSAg found in blood as early

1-2 weeks post infection

147

symptomatic hepatitis occurs

4 weeks after appearance of HBSAg

148

most hep B infection

sub-clinical

149

what percentage of hep B progresses to chronic infection

5-10%

150

hepatitis B PEP primary immunization

very effective
-unvaccinated adults; 3 doses given at 0, 1, 6 mos
-primary immunization fails

151

50% of people in whom vaccine fails for Hep B (i.e. nonresponders, serum HB SAb

subsequent revaccination

152

in those who do not respond to hep B revaccination, double dose HBV vaccination can be considered

20 micrograms at 0,1, 6 mos

153

almost all persons with low antibody levels after a prior documented protective titer have

rapid increase after a booster dose of vaccine

154

Hep B evaluation:check HBSAb in exposed person if

HBV vaccination or responder status is unknown
-only check other HBV serologies if there is suspicion the exposed person could be HV infected

155

Hep B evaluation:check HBSAb in source person if

no indication for other serologies

156

hep B follow up

check HB SAb titer 102 mos after last dose of vaccine
-HBS Ab response cannot be ascertained if HBIG was given in the last 3-4 mos

157

rate of HCV transmission after accidental percutaneous exposure is

2-3%

158

% of patients with spontaneous resolution of HCV infection

15-20% of patient

159

HCV antibody usually positive within 15 weeks post exposure, median incubation how long

3 mos

160

HCV transmission and prevention

-no available HCV vaccination
-HCV antibody /immunoglobulin does not prevent infection
- high risk exposure can be monitored with antibody and RNA
- early positive result, warrants empiric tx