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Clin Med - ID > Lecture 1 - HIV > Flashcards

Lecture 1 - HIV Flashcards

1
Q

How often are people getting tested for HIV?

A

@ risk pts get tested annually

The general public should get tested at least once in their life

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2
Q

PrEP

A

Pre-exposure prophylaxis for @ risk pts

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3
Q

nPEP

A

Non-occupational post-exposure prophylaxis

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4
Q

How is HIV dx?

A

4th generation immunofluorescence assay
Confirmed with multispot HIV1/HIV2 differential assay

3rd generation ELISA
Confirmed with Western Blot

PCR of viral RNA
Dx of acute retroviral infection

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5
Q

What is the HIV life cycle?

A

1) Binding –binds to CD4
2) Fusion - binds to the membrane gaining access to cell
3) Reverse transcriptase – RNA to DNA
4) Integration
Into the host DNA (in the nucelus)
5) Transcription
6) Assembly
7) Budding
8) Maturation

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6
Q

GALT

A

Gut-associated lymphoid tissue
60% of immune cells are in the gut
Major site for T cell loss and early HIV replication
Intestinal CD4 count is never restored to original levels

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7
Q

When does the primary infection of HIV occur?

A

2-4 weeks after infection

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8
Q

What does the primary infection of HIV look like?

A 
Fever 
Malaise 
N/V/D
Maculopapular rash (blanchable) 
Neurologic sxs
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9
Q

What baseline evaluations should be ordered for a newly dx HIV + pt?

A 
CD4 cell count 
HIV RNA viral load 
HLA B5701 
Renal 
LFTs 
CBC
Glucose
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10
Q

What common comorbidities are see with pts with HIV?

A 
Syphilis 
TB 
Hep A,B,C
Chlamydia, gonorrhea 
HPV 
Toxoplasma 
CMV 
Mental health: depression, substance abuse
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11
Q

How often are you following up and running labs for your HIV pts and what are you testing for?

A 
Monitor HIV and ART every 3-6 months 
Monitor medication adverse effects every 3-6 months 
CBC, CMP, HgA1C, fasting lipid 
Evaluate > annually for STIs 
TB > annually 
Cancer screening (pap and anal)
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12
Q

Which vaccinations are recommended for HIV pts and when?

A 
Any CD4: 
Hep A, B 
Influenza 
tetanus/diptheria
Pneumococcus
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13
Q

When is resistance seen with HIV treatment?

A

For pts you only take medications every now and then. If the viral load is detectable while on antiretrovirals then there is a risk for resistance. While on antiretrovirals there should be no detectable viral load.

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14
Q

What must you be sure to check for before beginning treatment for a newly dx HIV pt?

A

HBV, CD4, VL, genotype (for resistance), HLA-B5701

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15
Q

Which HIV drugs should be avoided in pregnant pts?

A

Efavirenz - during the first 8 weeks (look up in her slides where she talks about efavirenz elsewhere)

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16
Q

What drugs should be started on a pt who is newly dx with HIV?

A

Options:
Once daily dosing (single tablet)
Trumeq (dolutegravir/abacavir/lamivudine)
HLAb5701 and HBV Ag MUST be negative
Genovya/Stirbild (Elvitegravir/Cobicistat/Tenofovir (TAF/TAD)/emtricitabine)
Elvitegravir is a “boosted” drug and MUST be taken with food
Once daily dosing (2-3 tablets)
Dolutegravir + tenofovir (TAF/TDF)/emtricitabine
Tivicay = dolutegravir
TAF/emtricitabine = descovy
TDF/emtricitabine = truvada
Twice daily dosing
Raltegravir (isentress) twice daily
+
Trvada or Descoy once daily

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17
Q

What is the main difference between TAF and TDF?

A

I believe TAF is more new and is less harsh on the kidneys and bones compared to TDF

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18
Q

A newly dx HIV pt also has HBV, which medication MUST they go on?

A

Tenofovir

And the must be warned not to d/c the drug

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19
Q

Newly dx HIV pts being prescribed a combo drug with abacavir in it must have what testing done?

A

They must be HLAb5701 negative and must be HBV Ag negative

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20
Q

Which HIV drugs work against HBV in addition to HIV?

A

Tenofovir/emtricitabine (the one the MUST be used with HBV +)
D/c of tenofovir can cause HBV rebound
Lamivudine
However if tenofovir can not be safely used for some reason then entecavir should be used (look up in her slides where entecavir has been mentioned before)

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21
Q

HIV drugs have a lot of drug-drug interactions, name a few.

A

Metformin, OCP, anticonvulsants, antidepressants, statins, antacids, benzos

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22
Q

Renal damage and osteoporosis is a SE seen with which HIV drug?

A

Tenofovir DF

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23
Q

What are some overall side effects of HIV drugs?

A

DM, CVD
Hypercholesterolemia (this is why we check lipids)
Fat redistribution
Lactic acidosis, liver toxicity, hypersensitivity

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24
Q

PEP

A

Post-exposure drugs
Recommendations:
Raletgravir (isentress) 400mg twice daily + tenofovir DF/emtracitabine (truvada) once daily

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25
PrEP
Pre-exposure prophylaxis Recommendations: Tenofovir DF 300mg/emtricitabine 200mg (truvada) once daily (PO) —90 day supply F/u every 3 months Renal functions at 3 months and then every 6 months
26
Who gets offered PrEP? (CDC guidelines)
``` “Substantial risk of HIV infection” Men who have sex with men or heterosexual individuals if: HIV+ partner Recent bacterial STI High number of sex partners (subjective much?) History of no condom use Commercial sex work Injection drug users if: HIV+ injecting partner Sharing injection equipment ```
27
What complications are correlated with CD4 cell count <500?
``` Acute retroviral syndrome Candidal infections Persistent generalized lymphadenopathy Guillain-Barre syndrome Myopathy Aseptic meningitis ```
28
Which oropharyngeal infections are often seen as complications with HIV?
HSV: small painful ulcers on erythematous base CMV: large, shallow ulcers Aphthous stomatitis
29
Kaposi’s Sarcoma
Associated with herpes virus (8) | Seen as a complication of HIV with declining CD4 count
30
VZV
Recurrent dermatomal outbreaks and disseminated disease can occur A complications seen with declining CD4 count (although reactivation can even occur at high CD4 counts)
31
HSV
Genital lesions may coalesce, form large ulcers. Ulcers may become secondarily infected with bacteria. Infection can be complicated by radiculomyeltitis, proctitis Frequent recurrences can occur irrespective of a high CD4 count
32
What complications are correlated with CD4 count <200?
``` PJP Histoplasmosis Coccidiomycosis TB Wasting Dementia Cardiomyopathy Non-hodgkin’s lymphoma ```
33
Which pulmonary infections are commonly seen with CD4 count <200?
Strep pneumoniae, H. Flu, S. Aureus, Gram negative pneumonia PJP Fungal PNAs TB
34
PCP
Aka PJP (pneumocystis jiroveci pneumonia) Clinical presentation: Insidious onset of fever, sweats, fatigue, non-productive cough Dyspnea is initially exertional, but progresses with impairment of gas exchange Workup CXR Diffuse interstitial infiltrates (80%) Lactate dehydrogenase (LDH), sputum, blood gases Bronchoscopy is diagnostic
35
What is the most common non-tuberculosis pulmonary mycobacterial infection?
M. kansasii
36
IRIS
Immune reconstitution inflammatory syndrome | Seen in HIV pts with CD4 count <100
37
CMV Retinitis
Medical Emergency Sxs include progressive visual loss, blurring, and “floaters” Fundoscopic exam reveals coalescing white exudates with surrounding hemorrhage and edema Without treatment will progress to retinal detachment and visual loss Owl’s eye inclusions on histopathology dx Seen in HIV pts with CD4 <50
38
PML
Progressive multifocal leukoencephalopathy (PML) - JC virus (polyomavirus) CNS infection Rapidly progressive focal neurological deficits, most commonly hemiparesis, visual field defects, cognitive impairment Dx: CSF JC Virus PCR, MRI
39
Toxoplasmosis
Toxoplasma gondii protozoal parastie HA, confusion, behavioral/mood changes Ring enhancing lesion or lesions on CT or MRI Dx: CSF PCR
40
CMV
Polyradiucloapthy: acsending weakness and loss of reflexes, as well as, meningoencephalitis Can progress to flaccid paralysis Dx: CSF CMV PCR, CT
41
Cryptococal Meningitis
Cryptococus neoformans or gotti - encapsulated fungus HA, AMS, seizure Dx: CSF analysis, India Ink Stain
42
CMV
Can affect the entire GI system: esophagitis, gastritis, colitits Odnophagia, diarrhea, proctitis, fever, abdominal pain Dx: endoscopy or colonoscopy with biopsy and ME
43
Which intestinal parasitic infections are commonly seen in HIV pts as a complication of low CD4 count?
Microsporidium Isospora Giardia Entamoeba histolytic
44
MAC
Mycobacterirum avium complex Pts present with fever, sweats, weight loss, hepatosplenomegaly, adenopathy, and anemia Focal disease with isolated adenitis can also occur Dx: blood cultures, bone marrow biopsy, lymph node biopsy
45
How can PCP be avoided in HIV pts?
Being prophylaxis at CD4 count <200 Bactrim DS (trimethoprim-sulfamethoxazole) Also protects against toxoplasma
46
How can MAC be avoided in HIV pts?
Begin prophylaxis at CD4 count <50 | Prophylaxis with azithromycin 1200mg weekly
47
How can TB be avoided in HIV pts?
Prophylaxis with isoniazid for all pts with a positive PPD or close contacts of a pt with TB
48
IRIS
Severe decline in clinical status after ART initiation despite improved immune function due to inflammatory response against infectious agent Generally CD4 <50 and rapid decline in viral load; onset usually with 6 weeks of ART initiation, but sometimes several months later. Related to MAC, MTB, CMV, cyptococcus, PCP, HSV, VZV, HBV, HCV, JC virus (PML) and others
49
How does HIV progression and treatment differ between young pts vs older pts?
Older pts progress much faster and antiretroviral therapy is less effective
50
What did MACs show?
Mens AIDS Cohort Study A 55yo HIV infected person has similar frailty as a 65 yo HIV negative person Proposed mechanism: Mitochondrial dysfunction and increased number of free radicals and cytokines activate inflammatory pathways, ultimately leading to frailty
51
What are the risk factors for kidney disease in HIV pts?
Age, race, family hx (non-modifiable) | HIV, ART, HepC, DM, HTN (modifiable)
52
What is the risk of DM in an HIV pt?
DM in HIV positive men with ART >4x more likely than that of an HIV negative man
53
Insulin resistance is becoming a common complication seen in HIV pts d/t a metabolic syndrome that may also lead to the development of what disorders?
Type 2 DM Atherosclerosis HTN
54
Lipodystrophy is a complication seen with some HIV medications, what lifestyle modifications can be made to change this?
Reduce saturated fat/cholesterol intake Increase physical activity Stop smoking
55
Tenofovir DF is associated with what SE?
Decrease in bone mineralization | Renal disease
56
Tenofovir AF or abacavir have less bone SE if given with what?
Bisphosphonate
57
Which cancers are more commonly associated with HIV?
``` Kaposi’s Lymphoma HPV related (Cervical Penile and rectal) ```
58
What are the guidelines for cervical cancer screening in HIV infected women?
Screen twice a year when first dx | If normal, screen yearly if no change in sexual partner, use of safe sexual practices, no hx of sexual abuse, and no sxs
59
Why do HIV drug regimens change as the pt ages?
Advanced age results in decrease P450 function and decrease in renal tubular secretion and glomerular filtration Decrease in body weight/total body water can lead to higher serum levels of the drug and thus toxicities
60
NRTIs have which SE?
Lipodystrophy | Lipoatrophy
61
NNRTIs have which SE?
Lipid changes
62
Protease inhibitors have which SE?
Lipid changes Heart disease Lipodystrophy
63
If an HIV pt is on PIs or boosters (ritonavir or cobistat), which other drugs can they NOT take?
Statins (simvastatin, lovastatin, pitavastatin)
64
If an HIV pt is on PIs or NNRTIs, which drugs should they NOT take?
``` St Johns wort PDE5 inhibitors (viagra) levels increase with PIs and decrease with NNRTIs ```
65
How do PIs alter other drugs pts might be on?
CCBs (dihydropyridine) levels rise Fluticasone levels rise PDE5 inhibitor levels rise Benzos should be avoided
66
At what CD4 count to we start prophylaxing HIV pts, and for what?
``` CD4 <200 PCP Bactrim DS Dapsone Atovaquone ``` CD4 <50 MAC Azithromycin Clarithromycin

Clin Med - ID (9 decks)

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