HIV infection Flashcards
(160 cards)
1
Q
normal CD4 count
A
500
2
Q
immunosuppressed CD4 count
A
200
3
Q
HIV transmission
A
- blood/blood products
- body fluids/ sexual transmission
4
Q
blood/blood products that transmit HIV
A
- transfusion (RBC + Clotting factors)
- IVDU (sharing needles)
- Lab/ Health care workers/ needle stick
- vertical transmission
5
Q
Body fluids/ sexual transmission of HIV
A
- MSM
- heterosexual
6
Q
where are the majority of deaths + those with HIV in children?
A
Africa
7
Q
percent of those HIV infected do not know their status
A
1/3
8
Q
who should be screened annually?
A
people at high risk
9
Q
HIV ab testing should be performed routinely in all patients age
A
13-64
10
Q
clinical manifestatios of acute HIV infections in order of most prominent to least
A
fever fatigue myalgia skin rash headache pharyngitis cervical adenopathy arthralgia night sweat diarrhea
11
Q
myalgia
A
pain in a muscle or group of muscles
12
Q
arthralgia
A
pain in a joint
13
Q
inquire new partners
A
- within last 3 mos
- past testing
- sexual risk
- exposure/assault
- needle sharing
14
Q
screening test for HIV use 4th generation use
A
immunoassays that combine HIV antigen + HIV antibody
15
Q
inquire about new partners
A
- within last 3 mos
- past testing
- sexual risk
- exposure/assault
- needle sharing
16
Q
remember the window period
A
earliest positive= 15-20 days
prior to that window, may test negative despite symptoms of acute HIV
17
Q
diagnosis of acute HIV requires detectable plasma RNA
A
-test RNA early if symptomatic
-
18
Q
4th generation diagnostic HIV tests= window
A
IgM + IgG antibody and p24 antigen
19
Q
4th generation HIV test target of detection
A
IgM + IgG antibody and p24 antigen
20
Q
4th generation window to take positive tset
A
15-20 days
21
Q
HIV viral load test target of detection
A
RNA
22
Q
HIV viral load test approximate time to positivity
A
10-15 days
23
Q
HIV II
A
rare
24
Q
how many years does it take to develop advanced disease
A
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
