HIV

Question 1

What can HIV be spread by?

Answer 1

• Sexual transmission
• Injection drug misuse
• Blood products
• Vertical transmission
• Organ transplant

Question 2

What is the most common cause for the spread of HIV?

Answer 2

Most commonly due to sex between men

Question 3

Can you test unconscious patients for HIV?

Answer 3

Unconscious patients can be testing if you think it is in their interest

Question 4

How do you test someone for HIV?

Answer 4

Point of care testing is done (POC):

• Blood sample from finger
• Results in 60 seconds
  
  • Negative, positive or invalid

Standard test will then confirm results

Question 5

What is the immunology of HIV?

Answer 5

Infects and destroys cells of immune system:

• Especially T helper cells that are CD4+ (have a CD4 receptor on their surface)
  
  • CD4 receptors are not exclusive to lymphocytes, also found on macrophages and monocytes, cells in the brain, skin

Question 6

What cells have CD4 receptors?

Answer 6

T helper cells

Macrophages

Monocytes

Cells in the brain

Cells in the skin

Question 7

Describe the natural history of a HIV infection?

Answer 7

Over course of infection:

• CD4 count declines and HIV viral load increases
  
  • Increasing risk of developing infections and tumours
  • Severity of illness is greater the lower the CD4 count (normal CD4>500)
  • Most AIDs diagnosis occur at CD4 count < 200

Symptoms increase as CD4 decreasing, as does opportunistic infections

Question 8

What is a normal CD4 level?

Answer 8

>500

Question 9

At what CD4 level do most AIDS diagnosis occur?

Answer 9

<200

Question 10

Describe the classification of HIV?

Answer 10

Stage 1 - asymptomatic

Stage 2 - <10% BW lost and/or performance scale 2 (symptomatic, normal activity

Stage 3 - >10% BW lost and/or performance scale 3 (bedridden <50% of day dyring last month)

Stage 4 - HIV wasting syndrome and/or performance scale 4 (bedridden, <50% of day during last month

Question 11

What opportunistic infections are common in HIV?

Answer 11

Thrush

PJP

TB

Cryptosporidiosis

Kaposis

Cryptococcal meningitis

CMV, MAC

Question 12

When does HIV become AIDS?

Answer 12

• If no symptoms then HIV
• Certain infections and tumours that develop due to weakness in immune system are classified as AIDS illnesses

Question 13

What are some clinical indicator diseases of HIV?

Answer 13

TB

Pneumocystits

Cerebral toxoplasmosis

Primary cerebral lymphoma

Cryptococcal meningitis

Kaposi’s sarcoma

Persistent cryptosporiosis

Cervical cancer

Cytomegalovirus retinitis

Question 14

How does mortality in HIV change with CD4 count?

Answer 14

One year mortality increases as CD4 count decreases

Question 15

Describe the general path of acute infection of HIV to death?

Answer 15

Question 17

What is the seroconversion illness?

Answer 17

Seroconversion illness is when HIV antibodies first develop:

• Abrupt onset 2-4 weeks post exposure
• Self limiting 1-2 weeks
• Symptoms generally non-specific and differential diagnosis includes a range of common conditions, symptoms includes
  
  • Flu-like illness
  • Fever
  • Malaise and lethargy
  • Pharyngitis
  • Lymphadenopathy
  • Toxic exanthema

Question 18

What is the presentation of the seroconversion illness of HIV?

Answer 18

• Abrupt onset 2-4 weeks post exposure
• Self limiting 1-2 weeks
• Symptoms generally non-specific and differential diagnosis includes a range of common conditions, symptoms includes
  
  • Flu-like illness
  • Fever
  • Malaise and lethargy
  • Pharyngitis
  • Lymphadenopathy
  • Toxic exanthema

Question 19

What is the most common late stage (AIDS) infection?

Answer 19

Most common late stage (AIDS) infection is pneumocystitis jiroveci pneumonia:

• Opportunistic infection
• CD cell count usually <200
• Classical history of dry cough and increasing breathlessness over several weeks
• Investigations
  
  • Chest x-ray
  • Induced sputum or broncoscopy for PCR
• Treatment
  
  • Cotrimoxazole
  • Pentamine
  • Prophylaxis until CD>200

Question 20

What is the classical history of pneumocystitis juroveci pneumonia?

Answer 20

• Classical history of dry cough and increasing breathlessness over several weeks

Question 21

What investigations are done for pneumocystitis jiroveci pneumonia?

Answer 21

• Chest x-ray
• Induced sputum or bronchoscopy for PCR

Question 22

What is the treatment for pneumocystitis jiroveci pneumonia?

Answer 22

• Cotrimoxazole
• Pentamine
• Prophylaxis until CD>200

Question 23

What is the treatment of HIV?

Answer 23

Antiretroviral therapy is used:

• Different classes of drugs acting on different stages in HIV lifecycle
• Combination antiretroviral therapy (cART) means at least 3 drugs from at least 2 groups
• Adherence needs to be over 90%
• cART can lead to normal life but side effects can be significant

Question 24

What does combination antiretroviral therapy (cART) refer to?

Answer 24

• Combination antiretroviral therapy (cART) means at least 3 drugs from at least 2 groups

Question 25

What does the adherence to HIV treatment need to be for it to work?

Answer 25

* Adherence needs to be over 90%

Question 26

What are the different classes of antiretroviral therapy?

Answer 26

Entry inhibitors Reverse transcription inhibitors Integrase inhibitors Protease inhibitors

Question 27

Where does each class of antiretroviral therapy act in the HIV lifecycle?

Answer 27

Question 28

What is the HIV lifecycle?

Answer 28

1) Binding and entry 2) Reverse transciption 3) Integration 4) Transcription 5) Assembly 6) Release and protease

Question 29

When should HIV treatment be started?

Answer 29

* Start all patients at diagnosis regardless of CD4 and viral load * If CFD4 \< 350 cells/mm³ patients at risk of developing symptoms without treatment * Any pregnant woman start before third trimester * Three drug combination with treatment adjustment if viral load not suppressed after 4-6 weeks

Question 30

What is usually the reason when HIV treatment fails?

Answer 30

When treatment fails is usually due to poor adherence leading to viral mutation and resistance

Question 31

What are side effects of each antiviral drug for HIV?

Answer 31

* Nucleoside reverse transcriptase inhibitors * Marrow toxicity, neuropathy, lipodystrophy * Non-nucleoside reverse transcriptase inhibitors * Skin rashes, hypersensitivity, drug interactions, neuropsychiatric effects * Protease inhibitors * Drug interactions, diarrhoea, lipodystrophy and hyperlipidaemia * Integrase inhibitors * Rashes, disturbed sleep

Question 32

What are side effects for nucleoside reverse transcirption inhibitors?

Answer 32

* Marrow toxicity, neuropathy, lipodystrophy

Question 33

What are side-effects for non-nucleoside reverse transcription inhibitors?

Answer 33

* Skin rashes, hypersensitivity, drug interactions, neuropsychiatric effects

Question 34

What are side effects for protease inhibitors?

Answer 34

* Drug interactions, diarrhoea, lipodystrophy and hyperlipidaemia

Question 35

What are side effects for integrase inhibitors?

Answer 35

* Rashes, disturbed sleep

Question 36

What is lipodystrophy?

Answer 36

Abnormal distribution of fat

Question 37

What are some challenges of HIV care?

Answer 37

* Osteoporosis * Cognitive impairment * Malignancy * Cerebrovascular disease * Renal disease * Ischaemic heart disease * Diabetes mellitus

Question 38

What is HIV prevention done by?

Answer 38

* Behaviour change and condoms * Circumcision * Treatment as prevention * Pre-exposure prophylaxis (PrEP) * Post-exposure prophylaxis for sexual exposure (PEPSE)