HIV Primary Care: Part 1

Question 1

What tests would you order for a patient presenting with HIV?
6

Answer 1

1. LFT
2. CBC
3. rapid flu and strep
4. HIV- even though its negative
5. HIV - 1,2,3,4 (antibody)
6. PCR- viral load (confirm)

Preliminary test is the antibody
Need to confirm

Question 2

What will test positive first, the HIV RNA or the HIV antibody?

How long will each one take to test positive?

Answer 2

HIV RNA before Antibody

HIV RNA- 5 days
HIV antibody- 15 days (inclining very slowly)

Question 3

Symptomatic Disease Often Precedes or the acute illness phase often proceeds what?

And how many days after infection will this develop?

Answer 3

Symptomatic Disease Often Precedes Positive Antibody Test

15-25

Question 4

What is the eclipse phase and how many days after infection will it occur?

Answer 4

Eclipse Phase = Time between infection and detectable HIV RNA

0-10

Question 5

What is the window period and how many days after infection does it occur?

Answer 5

Window Period = Time between infection and detectable HIV antibodies

0-25

Question 6

What laboratory studies do you want to obtain for an initial HIV patient care visit?
13

Answer 6

Newly diagnose HIV-

1. CD4 count
2. CMP
3. CBC
4. LFT
5. kidney funtion test
6. Baseline - viral load (really high or low. 100,000 is the cut off)
7. PPD
8. 6 month pap smear
9. Hep C antibody test
10. Hep B antigen and antibody
11. CMV
12. Other STDs
13. IgG levels- if they ever got low enough toxo if the brian

Question 7

What categorizes a pt as an AIDS pt instead of HIV?

3

Answer 7

1. CD4 count below 200
2. Has an indicating condition
3. Has both

Question 8

The estimated number of persons living with HIV in the U.S. is 1.1 million. During the past 10 years, what has happened regarding the number of persons living with HIV in the U.S.?

Answer 8

Increased

Question 9

Who should be tested for HIV?

Answer 9

All patients aged 13-64 in all health care settings

(Unless prevalence of undiagnosed HIV

Question 10

Cutaneous Manifestations
of HIV?
6

Answer 10

1. Molluscum Contagiosum- genetic diposition and HIV apoxavirus
2. Herpes Simplex
3. Seborrheic Dermatitis
4. Herpes Zoster (Shingles)
5. Kaposi’s Sarcoma

Question 11

How is Molluscum Contagiosum acquired?

What kind of virus is it?

Answer 11

this one is genetic that you get. genetic diposition and HIV

apoxavirus

Question 12

How will herpes zoster (shingles) present in an HIV patient?

Answer 12

usually one nerve route- young kid with recurrent zoster or in multiple dermatomes want to see what is going on with his immune system

Question 13

EBV associated on the side of the tongue?

Answer 13

Oral Hairy Leukoplakia

Question 14

What are common oral infections in HIV?

Answer 14

Oral Candidiasis: Pseudomembranous
Oral Hairy Leukoplakia
HSV
Kaposi’s sarcoma

Question 15

The HIV patient’s tuberculin skin test is read 72 hours later and shows 9 mm of induration.
What do you want to do now?

Answer 15

1. chest xray!

• -neg chest xray and they are not contagious
• -pos hospitalization and isolate with 4 drug then two drug treatment

2. give B6 and LFT

Question 16

PPD > 5 mm Induration
or
Contact with Case of Active Tuberculosis
treatment?
2

Answer 16

Isoniazid: daily x 9 months
+
Pyridoxine: x 9 months

Question 17

At what CD4 threshold do you need to initiate prophylaxis for the following diseases and what would be the first choice for the prophylaxis regimen?

1. Pneumocystis pneumonia-
2. Toxoplasma encephalitis-
3. Disseminated Mycobacterium avium complex-

Answer 17

1. 200 bactrim
2. 100 bactrim
3. 50 Macrolide 1 gram a week

Question 18

A 39-year-old HIV-infected man presents to the clinic with a 2-week history of low-grade fever, headache, and a slight decline in mental status. His CD4 count is 65 cells/mm3. His only medication is TMP-SMX. Exam is normal except for oral candidiasis and a T = 37.8°C. His neck is supple and the neurologic exam is non-focal. Contrast head CT is normal. CSF shows 4 WBCs (3 lymph and 1 poly), glucose = 70.

This picture is most consistent with?

Answer 18

Cryptococcal meningitis

Question 19

Cryptococcal Meningitis and HIV/AIDS
Lumbar Puncture Findings?

What is the most important test???

Answer 19

CSF Leukocyte Count: 45 mg/dl in approximately 50%
CSF Glucose: 95%**

CSF India Ink Prep: positive in > 70%
Serum Cryptococcal Antigen: positive in > 95%

Question 20

Cryptococcal Meningitis and HIV/AIDS Preferred Induction Therapy
+
Management of Increased Intracranial Pressure
2

What about pts who have high renal dysfunction?
2

How do we monitor?

Answer 20

1. Amphotericin B
   +
   Flucytosine*
2. Lipid Formulation Amphotericin B
   +
   Flucytosine

LP- will spurt out!
Die if you dont tap it soon enough

Question 21

A 29-year-old HIV-infected man with a CD4 count of 78 cells/mm3 (on no medications) presents with 2 weeks of headache, fever, and confusion. A CT scan is performed and presumptive diagnosis of Toxoplasmosis is made.
Which of the following is TRUE regarding CNS Toxoplasmosis?

1. Most patients have a solitary lesion (CNS lymphoma is a solitary lesion)
2. With treatment, >75% improve by day 14
3. Most have a CD4 count 200-300 cells/mm3
4. Preferred therapy is Dapsone + Azithromycin

Answer 21

2. With treatment, >75% improve by day 14

Question 22

For pts with CNS Toxoplasmosis what should we look for on the CT scan?

What should we always do before an LP?

What disease will just have one solitary lesion?

Answer 22

look for asymmetry and many cysts

before LP you always do a head CT

CNS lymphoma

Question 23

Toxoplasma Encephalitis and HIV/AIDS
Treatment of Disease:
Preferred acute therapy is?
3

Answer 23

Pyrimethamine
\+
Sulfadiazine
\+
Leucovorin (rescue)-folinic acid

Question 24

A 34-year-old HIV-infected woman with a CD4 count of 18 cells/mm3 and an HIV RNA load of 226,000 copies/ml (on no medications) presents with a 10-day history of fatigue, non-productive cough, fever, and dyspnea on exertion. A diagnosis of Pneumocystis pneumonia is suspected and TMP-SMX is ordered.

What is the criteria for giving the patient corticosteroids?

1. ARDS
2. Multi-lobar involvement
3. PO2 less than 70 mm Hg
4. PO2 less than 60 mm Hg

Answer 24

3. PO2 less than 70 mm Hg

Question 25

When do we give steriods during an infection? | 2

Answer 25

PJP and pediatric menigitis give steriods. inflammation will cause more problems than the infection

Question 26

Pneumocystis Pneumonia and HIV/AIDS Treatment of Disease: Preferred treatment? Severe? Mild or Moderate?

Answer 26

Trimethoprim-Sulfamethoxazole Intravenous Trimethoprim-Sulfamethoxazole Oral

Question 27

When do we give corticosteriods with treatmetn for PCP? | 2

Answer 27

Corticosteroids if PaO2 35

Question 28

A 51-year-old HIV-infected man with a CD4 count of 14 cells/mm3 and an HIV RNA load of 186,000 copies/ml presents with odynophagia. His oral examination is shown below. What would you recommend doing at this point?

Answer 28

treat empiracally with fluconazole if it doesnt get better go with endoscopy

Question 29

A 28-year-old woman with AIDS is newly diagnosed miliary pulmonary tuberculosis. She is started on directly observed 4-drug therapy: isonizid + rifabutin+ pyrazinamide+ ethambutol. She has a CD4 count of 7, and HIV RNA greater than 500,000 copies/ml. After 2 weeks, she has marked improvement in her dyspnea and fever. Four weeks later she starts on Tenofovir-Emtricitabine-Efavirenz (Atripla) and the rifabutin dose was increased appropriately). Now 8 weeks after starting therapy for tuberculosis, she presents with a cavitary lung lesion, cervical lymphadenopathy, and fever. What would you recommend doing at this point?

Answer 29

3. Start corticosteroids and dont stop HIV meds! Its IRIS or immune reconstitution inflammatory syndrome

Question 30

What is IRIS?

Answer 30

immune system is back and in action and participating in making you sick

Question 31

What are the four indications for initiating antiretroviral therapy regardless of CD4 cell count?

Answer 31

1. clinical AIDS 2. Pregnancy 3. Chronic HBV 4. HIVAN (HIV associated neuropathy)

Question 32

A 34-year-old woman was diagnosed with HIV about 18 months ago. She is seen in the clinic for follow up. Her CD4 counts have been 670, 550, 570, 490, and 470 cells/mm3. She has no active medical, mental health, or substance abuse issues. She works full time and her social situation is stable. She has a boyfriend who is not infected with HIV. Would you recommend starting antiretroviral therapy?

Answer 32

YES, everyone with HIV gets treated BUT ALSO CD4 is declining, and her BF doesnt have it. with a lower viral load you have a less chance of spreading it

Question 33

What are benefits of treating HIV early? | 9

Answer 33

1. More effective regimens 2. More convenient regimens 3. Better tolerated therapy 4. Less long-term toxicity 5. Better immune recovery 6. Lower rates of resistance 7. More treatment options 8. Concerns for uncontrolled viremia 9. Decrease HIV transmission

Question 34

What are the benefits of treating HIV later? | 4

Answer 34

1. Lack of RCT data supporting early Rx 2. Potential drug toxicity 3. Drug and monitoring cost 4. Potential negative impact on QOL

Question 35

``` A 27-year-old man with recently diagnosed with HIV is seen in the clinic for follow up. In the past 4 months, he has had three CD4 count measurements: 410, 388, and 382 cells/mm3. A genotype performed 6 months ago showed no mutations. After extensive discussion with the patient, the plan is to start antiretroviral therapy. He definitely wants to take a once-daily regimen. What regimen(s) would you recommend? ```

Answer 35

because there is so much resistance 3 drug regimen Truvada(Tenofovir, Emtricitabine) Tivicay (Dolutegravir)

Question 36

In a three drug regimen what types of drugs do you want to give?

Answer 36

INSTI + 2 NRTIs

Question 37

A 37-year-old physician has a needlestick injury when she was putting in a central venous catheter in a patient with AIDS. The needle was a hollow-bore needle and blood was definitely on the needle at the time the injury occurred. What would you recommend (go through a step-by-step approach)?

Answer 37

1. clean off the area 2. testing for Hep BC and HIV IF POSTIVE HIgh risk exposure - the pt has high viral exposure with AIDS 3. START HIV TREATMENT NOW! 3 drug treatment standard of care (If you dont have all three drugs do not start the treatmetn with one or two) CALL redline for HIV post exposure prophylaxis (pepline)

Question 38

Which antiretroviral drug is contraindicated for postexposure prophylaxis in health care workers?

Answer 38

abacavir

Question 39

Describe the viral load before reaching AIDS? 3 How does the CD4 count correspond?

Answer 39

1. Starts off really high right after infection 2. Drops down in the itermediate stage for up to 12 years 3. Slowly increases back up again to cause AIDS inversely

Question 40

What do we have to use PIs with?

Answer 40

ritonavir | boosting drug

Question 41

If an HIV pt is infected with PJP what will we find on the CXR? HOw would we treat? 2

Answer 41

PJP- bat wing finding | bactrim plus or minus steriods

Question 42

Where do you often see wasting syndrome from HIV and how would we treat it (2)?

Answer 42

wasting syndrome- third world country not on medicines protein and antiretroviral therapy

Question 43

If we see in HIV pts with plaque liked lesions that are not raised and in a homeless pt what would we think it is?

Answer 43

norwegian scabies

Question 44

If we do an AFB stain on an HIV pts what would we be thinking is going on?

Answer 44

AFB- MAC mayyyyyybe TB

Question 45

What is dangerous about MAC? How would we treat it?

Answer 45

MAC can go anywhere, highly disseminated antiretroviral drug therapy

Question 46

Prophylaxis against Opportunistic Infections. What are they?? 6

Answer 46

1. Pneumocystis jiroveci pneumonia (PCP) 2. Toxoplasmosis gondii 3. Mycobacterium Avium Complex (MAC) 4. Cryptococcal Meningitis 5. CMV retinitis 6. Mycobacterium tuberculosis (TB)