ICM > 2: HIV > Flashcards

2: HIV Flashcards

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1
Q

describe worldwide HIV epidemic in terms of numbers and access to treatment

A
  • total number w/ HIV/AIDS increased worldwide

- less than 1/3 of people who need antiretroviral drugs have access to them

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2
Q

what method of contracting HIV has the highest transmission rate? the rest of the ways to contract HIV have what type of transmission rates?

A

transfusion of contaminated blood - 90%

rest of the methods are all

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3
Q

CDC testing guidelines

A
  • “opt out testing”
  • don’t need specific informed consent
  • persons at high risk should be screen at least annually
  • prevention counseling not required, but strongly recommended for high risk persons
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4
Q

why are E Europe and Central Asia numbers still rising?

A

heroin/IV drug use

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5
Q

historical indications for HIV testing (long list)

A
  • sexually active gay men
  • persons w/ multiple partners
  • current or past injection-drug users
  • recipients of blood products b/w 1978 and 1985
  • persons w/ current or past STIs
  • commercial sex workers and their contacts
  • persons sexually assaulted
  • persons w/ occupational exposures
  • pregnant women/women of childbearing age
  • children born to HIV-infected moms
  • sexual partners of those at risk of infection
  • persons who consider themselves at risk/request testing
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6
Q

first good protease inhibitor

A

Indenovir

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7
Q

clinical indications for testing (long list)

A
  • TB
  • syphilis
  • recurrent shingles
  • unexplained chronic constitutional sx
  • unexplained generalized adenopathy
  • unexplained chronic diarrhea or wastin g
  • unexplained encephalopathy
  • unexplained thrombocytopenia
  • thrush or chronic/recurrent vaginal candidiasis
  • HIV-associated opportunistic diseases
  • suspected primary HIV syndrome
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8
Q

significance of the release of HAART (the protease inhibitors) in 1996

A

60-80% reduction in deaths from AIDS in US

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9
Q

four H’s are risk groups:

A

heroin addicts
homosexuals
hemophiliac
Haitians

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10
Q

common signs/sx of primary HIV infection:

  • those presenting in 50-90% of patients (6)
  • those presenting in 25-50% of patients (3)
  • those presenting in
A

50-90%

  • fever
  • fatigue
  • rash
  • myalgia/arthralgia
  • pharyngitis
  • night sweats

25-50%

  • N/V/D
  • low wbc/plts
  • weight loss
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11
Q

how long is the eclipse period of HIV infection?

A

10-12d (from time of initial infection to viral detection)

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12
Q

when does one start making Ab’s to HIV?

A

after about 3w (period of seroconversion - from initial infection to first creation of Ab’s)

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13
Q

testing for HIV: how are viruses detected (what component do they test for)?

A

HIV RNA in plasma

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14
Q

other options in the primary HIV ddx

A
  • EBV mono
  • CMV
  • HSV
  • flu
  • rubella
  • viral hepatitis
  • toxoplasmosis
  • syphilis
  • disseminated GC
  • rickettsial disease
  • lyme disease
  • streptococcal infection
  • early TSS
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15
Q

clinical clues for primary HIV infection (7)

A
  • mucocutaneous ulcerations
  • rash
  • abrupt onset: “10 sx/signs in 24h”
  • GI sx
  • antedecent high risk exposure
  • prolonged sx

-cough/URI: diagnosis less likely

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16
Q

what test is used to detect HIV Abs?

A

ELISA (highly sensitive)

  • if result is (-), HIV AB reported as (-)
  • if result is (+), ELISA repeated
    • if repeat (+), Western blot (more specific) for confirmation
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17
Q

what happens when western blot results are indeterminate?

A

means 1 of 3 characteristic bands present - recommend supplemental testing

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18
Q

what can an indeterminate western blot indicate?

A

presence of recent HIV-1 infection or HIV-2 infection, which is endemic in West Africa

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19
Q

can you use a low CD4+ count to diagnose HIV?

A

no - not diagnostic and cannot be used instead of HIV Ab testing

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20
Q

are there any rapid tests for HIV?

A

yes - blood and oral swabs can give results in 20 min

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21
Q

what should you determine in a newly diagnosed HIV history? (8)

A
  • HIV risk behaviors (sexual and drug use)
  • knowledge of HIV infection
  • emotional response to diagnosis
  • family and social situation
  • employment and insurance status
  • travel history
  • exposure to TB, syphilis, other STIs, and viral hep (A,B,C)
  • status of immunizations
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22
Q

labs to run on a newly diagnosed HIV patient (12)

A
  • CBC and differential counts
  • BUN/creatinine, liver fxn tests, fasting glucose/lipid profile
  • CD4 count and HIV viral load
  • HIV genotype test
  • syphilis testing (RPR or VDRL)
  • anti-HAV, HBsAg, HBcAb (HBsAB if prior immunization), anti-HCV
  • toxoplasmosis (IgG) serology
  • PPD
  • chlamydia and GC assays in persons at risk
  • consider anal pap smear in persons at risk
  • G6PD quantitative testing (if needing pneumocystic prophylaxis)
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23
Q

what is the main surrogate marker for monitoring HIV disease progression?

A

CD4 count

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24
Q

normal range of CD4

A

350-1100/mm3

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25
what is the average decline in CD4 count per year without treatment?
75-100/mm3 - but variability b/w patient and in a given patient over time
26
what are factors that can transiently affect the value of CD4?
- intercurrent illnesses | - inter- and intra-lab variability
27
what are the clinical uses of CD4 count?
- to determine need for antiretroviral therapy - to determine need for antimicrobial prophylaxis - to assess prognosis
28
prognostic indication of high early viral load
sx are worse for patients - knocks down the CD4s faster and indicates clinically that the meds will have a rough time
29
how do you measure viral RNA loads in plasma?
PCR or branched DNA techniques
30
what is the lower limit of detection of ultrasensitive PCR assay
31
what does a high level of viral RNA in plasma correlate to?
CD4 cell count decline and clinical disease progression
32
what is the normal variability of HIV viral load?
0.3 log (3- to 5-fold)
33
what are the clinical uses of monitoring HIV viral load?
- monitor antiretroviral therapy | - to assess prognosis
34
patient presentation with CD4 > 500/mm3
- most asymptomatic - bacterial infections (pneumococcus, staph) - pulmonary TB - shingles - other dermatologic conditions
35
patient presentation with CD4 200-500/mm3
- many asymptomatic - generalized adenopathy - thrush - Kaposi's sarcoma
36
patient presentation with CD4
- PCP - toxoplasmosis - cryptococcus
37
patient presentation with CD4
- CMV and Mycobacterium avium complex infections - increased risk of lymphoma - highest mortality
38
indications of when to start HIV treatment (5)
- AIDS-defining condition | - CD4 count
39
targets of HIV drugs
- RT inhibitors - integrase inhibitors - protease inhibitors - fusion/entry inhibitors
40
HIV meds: NRTIs
- abacavir - didanosine - emtricitabine - lamivudine - stavudine - tenofovir - zidovudine
41
HIV meds: PIs
- atazanavir - darunavir - fosamprenavir - indinavir - lopinavir - nelfinavir - ritonavir - saquinavir - timpranavir
42
HIV meds: NNRTIs
- delavirdine - efavirenz - etravirine - nevirapine
43
HIV meds: integrase inhibitor
raltegravir
44
HIV meds: fusion inhibitor
enfuvirtide
45
HIV meds: CCR5 antagonist
maravioc
46
how many meds are administered at once? why? which ones?
usually 3 drugs at a time - virus can't make resistance to 3 at a time -often two NRTIs with an integrase inhibitor
47
what other non-infectious disease state should be watched for in HIV treatment?
inflammatory disease
48
preferred initial treatment: NNRTI based
EFV/TDF/FTC - don't use EFV in first trimester of pregnancy or in women trying to conceive or not using effective/consistent BC - 3TC can be used in place of FTC and vice versa
49
preferred initial treatment: PI based
ATV/r + TDF/FTC DRV/r (QD) + TDF/FTC -3TC can replace FTC
50
preferred initial treatment: II based
RAL + TDF/FTC | -3TC can replace FTC
51
preferred initial treatment: pregnant women
LPV/r (BID) + ZDV/3TC | -3TC can replace FTC
52
drug resistance testing before initiation of ART
- transmitted resistance in 6-16% of HIV patients - w/ no therapy, resistance mutations may decline over time and become undetectable by current assays, but may persist and cause treatment failure when ART is started - ID resistance mutations to optimize tx outcomes - genotype recommended for all at entry to care - recommended for all pregnant women
53
drug resistance testing in patients with virologic failure
-perform while patient is taking ART, or
54
list the complications of HIV treatment (5)
- lipodystrophy syndrome - lactic acidemia/acidosis - premature osteopenia and osteoporosis - avascular necrosis of hips - peripheral neuropathy
55
describe lipodystrophy syndrome
-body morphology changes and metabolic complications - this is why II > PI in terms of Rx: prevents buffalo humps, skinny arms, and temporal fat
56
describe the lactic acidemia/acidosis that can be caused by HIV tx
peripheral neuropathy, pancreatitis, myopathy, steatosis with liver failure
57
describe vaccinating people with HIV
- avoid live vaccines - benefits increased if given early in disease - pneomococcal: boost after 5y - Hep A and B: if Ab(-) - flu: yearly, avoid intranasal prep - HPV: to males and females age 9-26 - H. influenzae: if asplenic - varicella: if no immunity to varicella + CD4 >200 - tetanus: as w/ general pop (Tdap once) -MMR and zoster: typically avoided
58
what occupations have the most HIV exposures?
- nurses - ancillary staff - surgeon - dental workers - EMS
59
what is the risk of seroconversion with needle stick exposure for each of the following: HBV, HCV, HIV
HBV: 30% HCV: 3% HIV: 0.3%
60
``` rates of perinatal HIV transmission for each of the following viral loads at time of delivery: >100,000 40,000-100,000 3000-40,000 400-3000 ```
>100,000: 32% 40,000-100,000: 21% 3000-40,000: 11% 400-3000: 6%
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