Week 11 Infectious Diseases Flashcards
(37 cards)
HIV transmission
Contact with body fluids which could contain HIV
- Body fluids: Blood, bloody fluids, genital secretions, and breast milk, CSF, synovial fluid, pleural fluid, peritoneal, pericardial, amniotic fluid
- Not detected in: urine, feces, sputum, nasal secretions, sweat, tears, vomit w/o blood - IF TINGED W/BLOOD, then yes can be transmitted
HIV risk Factors
- Contact with body fluids that could contain HIV
- Risk Activity – risk of acquiring HIV
o I.e.: needle sharing - Prevalence – regional
Afrian MSM high and MSM
HIV Screening guidelines + Algorithm
- CDC 2006: routine, voluntary HIV screening in all13- 64-year-olds as normal part of medical care without the prior requirement for signed consent or counseling.
- USPSTF 2013: screen all 15-65 years old
- Perceived risk: screen at least annually
HIV Progression
Antiviral markers → 0-14d detection, 14d-28d symptoms
Acute Retriviral syndrome conditions and SEs
Which days in HIV progression at risk for these?
Day 10-20 (HIV DETECTABLE)
* Fever lymphadenopathy, sore throat, rash, myalgia/arthralgia, headache
* “Mono”
* “Flu”
* Can be asymptomatic
Mononucleosis
* EBV–Ebstein Barr Virus
* CMV–Cytomegalovirus
* HIV
* Toxoplasmosis
Approach to HIV (+) patient:
What to ask? What do you need in HPI/Hx
Figure out how sick the patient is
* History, examination, lab tests
* Opportunistic infection prophylaxis
* Antiretroviral therapy
* Healthcare maintenance – immunizations, med hx, allergies, screenings, etc.
History
* Symptoms (extra-pulm TB; karposi’s sarcoma)
* Risk behaviors: range of when infection occurred, other infections one may be at risk of (TB? STDs?)
* Tobacco, alcohol, illicit drug use hx; sexual history
* Social support and psychiatric history – any identifying barriers
* Medications, including alternative meds
* Disclosure – from whom you might have gotten this from? Get partners tested
HIV Lab testing (general)
TB test considerations?
- Comprehensive metabolic panel: renal, liver function
- CBC with diff
- Urinalysis (U/A)
- Serologies of infections:
- Which can reactivate: Cytomegalovirus (CMV), Toxoplasmosis IgG
- Which can need immunization: Varicella (VZV) IgG, Hepatitis A IgG, Hepatitis B surface antibody, surface antigen
- Which can complicate treatment: Hepatitis C Ab (and also Hepatitis B surface antibody, surface antigen)
A word on TB screening – test based on immune response
* Interferon gamma release assay (blood test)
* Tuberculin skin test (TST, or PPD)
– Lower cutoff for positive in HIV+ patients
– TST > 5 mm is positive in HIV+ patients
– If negative and patient’s CD4 count is < 200, repeat TST or IGRA after immune reconstitution
HIV specific lab testing
Labs AFTER initial HIV diagnosis
- CD4 cell count: best predictor of risk of opportunistic infection or cancer
- HIV RNA: “viral load”
- HIV Genotyping
HIV disease test
* CD4 count
* HIV VL with genotype (RTI, PI, Integrase Inhibitor)
* HLA-B*5701Typing (if considering abacavir)
* Safety labs:
* CBC, CMP, U/A (Cr Cl), Lipids, HgA1C or fasting glucose, G6PD, pregnancy test
Coinfections
* Hep A Ab, Hep B (Surf Ab, Surg Ag, Core Ab), Hep C Ab
* TB (IGRA)
* Toxo, CMV, VZV – IgG
* STD screening
* RPR/FTA
* GC/CT
* Trichomonas
Other: assess readiness to start HAART
HIV specific monitoring labs and frequency
CD4 count
Every 3-6 months
* For first 2 yrs of ART
* If viremia develops on ART
* CD4 is ≤ 300
Every 12 months
* After 2yrs on ART with suppressed VL
* CD4 300-500
Optional Monitoring
* If CD4 count about 500 with suppressed VL
HIV Viral Load
* With ART initiation or modification
* 4-8 weeks after ART initiation or modification
* Every 3-6 months until pt has been suppressed on ART over 2yrs
* Every 6 months for pts stable on ART over 2yrs.
Q6 months
* CMP
* CBC/CBCd
Q12 months
* HCV Ab
* Based on risk behaviors
* Lipids (if normal at measurement)
* Hgb A1C/fasting glucose (if normal at last measurement)
* UA w/microalbumin
* RPR (at minimum, more frequent based on risk behaviors)
List of diseases during course of HIV infection
Recommended regimens for HIV+ tx
When to start?
ART recommended for all HIV+ individuals regardless of CD4 cell count
Commonly used medications for HIV (out of > 25 options)
NRTIs
* Tenofovir (TDF or TAF) + Emtricitabine (FTC)
* Abacavir (ABC) + Lamivudine (3TC)
NNRTIs
* Rilpivirine (RPV) (if VL <100K, CD4>200)
* Efavirenz (EFV)
Boosted PI
* Darunavir/r (DRV/r)
* Atazanavir/r (ATV/r)
Integrase inhibitor
* Raltegravir (RAL)
* Elvitegravir (EVG)/cobicistat
* Dolutegravir (DTG)
* Bictegravir (BIC)
START ASAP - BUT assess readiness to take treatment
Get HIV genotype to help determine which HIV drugs pt is susceptible to
When to screen for CVD prevention (lipid management) for HIV+ pts
Statin contraindications
Screening: fasting lipids
* At HIV diagnosis
* Start of ART
* Change of ART
* Q6-12mos
Lipid Management
* Beware of drug interactions between statins and PIs or cobistat
Immunization schedule for HIV+ infected adults
Why?
Routine vaccines:
* MMR
* Polio
* Chickenox (Varicella)
* Flu (influenza)
* Tdap
* COVID-19 (if pt opts for vaccine)
Hepatitis A
* 2 doses, 6-18 months apart
Hepatitis B
* HeplisavB – 2 doses; ONE month apart
TwinRix (Hep A&B combo)
* 3 doses, 0, 1 month, 6 months after dose 1
Human Papilloma Virus (HPV)
* Adults up to age 45
* 3 doses; 0, 1-2 months, 6 months.
Meningococcal B (MenB)
* Typically given prior to college
* May need if no functioning spleen
Meningococcal ACWY (MenACWY)
* 2 doses are given 8 weeks apart, then booster every 5 years.
Pneumococcal (PPSV23, PCV15, PCV20)
* PCV20 alone, or PCV15 followed 8 weeks later by PPSV23.
* If only received PPSV23, may receive PCV20 or PCV 15 ≥1year after their last PPSV23 dose.
* Zoster (Shingles) ≥ 19 y/o: 2 doses; given 2-6 months apart
Increased risk for vaccine-preventable infections
Increased cancer risks
CVD risk
HIV workup and health maintenance summary
Screenings
Breast, Prostate, Colon, Lung
DEXA: postmenopausal women AND men ≥ 50 y/o
PrEP
What is it? How is it taken?
Labs to monitor? Frequency?
- One pill once daily for HIV-negative patients, taken to prevent transmission of HIV
Before PrEP – basic labs needed
* Renal panel: CrCl > 50
* LFTs
* HIV neg (test for this)
* No s/s acute HIV
* HBV sAg neg, opportunity to vaccinate (check sAb)
* Urine pregnancy testing
PrEP
* Tenofovir diisproxil fumarate / emtricitabine (TDF/FTC)
* Tenofovir alafenamide/emtricitabine
* Brand name: Truvada
* Dose: 1 tab per mouth daily
Monitoring
* (First 3 months: renal panel + LFTs)
* HIV test, risk assessment and counseling q 2-3
* months
* STI screen q 3-6 months (q3 for MSM at risk for recurrent bacterial STI)
* Renal panel q 6 months
* Provide condoms and education
* Pregnancy testing q3 months
Undetectable = unt-ransmittable → combatting stigma
NPEP
Non-occupational postexposure prophylaxis
* All primary care providers should feel comfortable prescribing NPEP!!
* Provide nPEP regimen to an individual (HIV-) after sexual contact in which there is concern/risk for HIV acquisition.
* Unprotected anal? Unprotected vaginal? Drug use?
* Medication regimen MUST be started within 72hrs of the possible contact.
* Preferred Regimen:
* Tenofovir disoproxil fumarate (TDF) 300mg with emtricitabine (FTC) 200mg [Truvada] once daily PLUS dolutegravir (DTG) 50mg [Tivicay] once daily by mouth for 28days
* Follow-up: 28days; consider transition to PrEP pending sexual preferences/behaviors
* Occupational regimen – same F/U
Post-exposure to HIV chart and which test to use
U = ________
HOW LONG THO
UNDETECTABLE
Need to be undetectable for at least 6 months
* HIV+ individual can achieve being undetectable by being on HAART/HIV med regimen
* Studies have shown those HIV+ who are undetectable (virally suppressed) have significantly lower number of virus particles in the body, such that they are unable to transmit during sexual practice.
* So few virus particle, such that lab testing unable to detect.
* Studies only been done for sexual contact, not for IV drug use or breastfeeding, etc.
Prior to starting PrEP, what to ask?
- Get a detailed sexual history from the patient prior to starting PrEP.
- Partners?
- Last sexual contact?
- Type of sex they engage in?
- Condom use?
- Risk for HIV acquisition?
- Obtain all appropriate lab work and sexual health testing (as noted in lecture slides) prior to starting PrEP.
- Patient must be HIV (-) before starting PrEP
- Ensure appropriate follow-up Q 3 months for routine sexual health labs/testing/adherence.
- Kidneys functioning on Truvada
- STDs can be asymptomatic – shedding it to other ppl
Hepatitis B
What is it and transmission
- Hepatotoxic, acute, and chronic disease
- Epi: Est worldwide 240 million people are chronically infected with hepatitis B
- > 686 000 deaths/y from complications of hepatitis B (cirrhosis, HCC)
- Virus: hepadnavirus, cccDNA
- Transmission: contact with the blood or other body fluids of an infected person (HIGHEST RISK OF TRANSMISSION BETWEEN MOM & BABY)
Hep B Pathogenesis
- HBV hijacks hepatocyte machinery to reproduce cccDNA
- Difficult to extract
- Immune response (body’s own response) causes hepatotoxicity, instead of virus
- Constant battle between viral replication and host immune response
- Some skip cirrhosis phase and → chronic (Progression to chronic HBV varies by age at acquisition)
Phases of Chronic Hep B infection
Hep B Treatment Goals
- Prevent transmission
- Prevent complications of chronic liver disease
- Prevent reactivation (cancer chemotherapy, immunosuppression, bone marrow transplantation)
HBV Screening: WHO
- PWID - persons who inject drugs
- MSM
- Persons needing immunosuppressive therapy, chemo, organ transplantation
- Elevated AST/ALT of unknown origin
- Hemodialysis
- Pregnant women
- Needlestick exposure
- HIV+
