HIV

Question 1

HIV Epidemiology

1. What is the most common mode of transmission in the world? in the US?
2. How are neonates exposed to HIV?

Answer 1

1. world: heterosexual contact; US: male-male sexual contact
2. contact w/ mother’s infected blood through the vagina
   3.

Question 2

HIV Transmission

1. What enhances sexually transmitted HIV?
2. Other modes of transmission (4)

Answer 2

1. advanced disease, other STDs, and receptive anal intercourse
2. Mother to child
3. IV drug abuse
4. Blood (almost 0 due to screening)
5. Nosocomial

Question 3

Diagnosis of HIV

1. What is the primary screening test?
2. What is the confirming test?
3. How long does it take to develop antibodies?
4. What other viral detection methods are not used?

Answer 3

1. HIV-1 Antibody by EIA
2. Western blot; detects Ab against specific HIV envelope and core proteins
3. 1-3 months
4. culture (impractical), PCR (for quantification)

Question 4

Signs and Symptoms of Acute Retroviral Syndrome

Answer 4

Fever, lymphadenopathy, pharyngitis, rash, myalgia or arthralgia, diarrhea, headache, nausea and vomiting, hepatosplenomegaly, weight loss, thrush, neuro symptoms;
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Question 5

Acute Retroviral Syndrome

1. What symptom distinguishes HIV from mononucleosis?
2. What other symptom may be present?

Answer 5

1. mucocutaneous ulceration involving mouth, esophagus, or genitals
2. erythematous maculopapular rash with lesions on the face and trunk and sometimes extremities (including palms and soles)

Question 6

Acute Retrovial Syndrome: Neurological Symptoms (6)

Answer 6

1. Meningoencephalitis or aseptic meningitis (uncommon)
2. peripheral neuropathy or radiculopathy
3. Facial palsy
4. Guillain-Barre syndrome
5. Brachial neuritis
6. Cognitive impairment or psychosis

Question 7

Acute HIV Infection: Lab Testing

1. What 2 things are looked for in screening?
2. What is used to confirm?

Answer 7

1. HIV RNA and HIV Ab (may be indeterminate or negative)

2. serology

Question 8

Acute HIV Infection: Treatment

1. Benefits
2. Risks

Answer 8

1. Decrease the severity of acute disease, alter the viral set-point, reduce rate of mutation, preserve immune function, reduce risk of viral transmission
2. drug-related toxicity, earlier emergence of drug resistance, limitation of future treatment options, potential need for indefinite treatment, adverse effects on quality of life

Question 9

AIDS definition

Answer 9

Presence of HIV + one of the following: invasive candida, Pneumocystis carinii pneumonia, Kaposi’s sarcoma, Mycobaterium (TB, MAC), Wasting syndrome, or CD4<14% lymphocytes

Question 10

Natural History of HIV progression

1. What % has it in 5 years?
2. 10 years?
3. 11 years?
4. What 2 factors increase the incidence of developing AIDS?

Answer 10

1. 13%
2. 50%
3. 54%
4. low T cells; increased viral load

Question 11

Preventable complications of AIDS: PCP Prophylaxis

1. What are indications for prophylaxis?
2. What is the preferred regimen?

Answer 11

1. History of PCP, CD4 < 200 or < 14%; HIV associated thrush

2. Atovaquone

Question 12

Preventable complications of AIDS: MAC Prophylaxis

1. Indication for prophylaxis
2. Regimen
3. When can prophylaxis be discontinued?

Answer 12

1. CD4100

Question 13

Preventable complications of AIDS: Toxoplasmosis Prophylaxis

1. Indication
2. Regimen

Answer 13

1. CD4 < 100

2. Bactrim DS

Question 14

Goals of Antiretroviral Therapy (8)

Answer 14

1. improve quality of life
2. reduce HIV-related mortality and morbidity
3. restore and/or preserve immune function
4. maximal and durable suppression of viral load
5. preservation of future treatment options
6. rational sequencing of therapy
7. maximizing adherence
8. use of resistance testing in selected clinical settings

Question 15

Before Initiating ART, what 6 things need to happen?

Answer 15

1. confirm HIV results
2. complete H and P
3. CBC, chemistry profile
4. CD4 cell count, plasma RNA measurement
5. Resistance Testing (genotype)
6. Assess “readiness” for treatment and adherence (accept dx and must take drugs every day)

Question 16

Additional Tests to do before initiation ART (9)

Answer 16

1. RPR or VDRL
2. PPD
3. Chest X-ray
4. Hep A, B, C serology
5. Toxoplasma IgG
6. Fasting glucose and lipids
7. Gynecologic exam w/ pap smear
8. testing for chlamydia and gonorrhea
9. Opthalmology exam (CD4 < 100/ul)

Question 17

What are some things to consider in initiating ART in asymptomatic HIV? (5)

Answer 17

1. willingness of pt to begin and the likelihood of adherence
2. Degree of immunodeficiency
3. Plasma HIV RNA
4. Risk of disease progression
5. Potential benefits and risks of therapy

Question 18

What is the treatment recommendation for each pt?

1. Symptomatic AIDS, pregnant, neuropathy?
2. Asymptomatic HIV w/ CD4< 350
3. Asymptomatic HIV w/ CD4> 500

Answer 18

1. treat w/ any CD4 T cell and plasma HIV RNA count
2. Treat w/ any value of plasma HIV RNA
3. 50% say treat

Question 19

1. Benefits of Deferrred ART Therapy
2. Risks of Deferred Therapy
3. What therapy is never recommended?

Answer 19

1. avoid negative effects on quality of life, avoid drug-related toxicity, preserve future drug options, delay development of drug resistance, decrease total time on meds
2. possibility of irreversible immune system depletion, increased possibility of progression to AIDS, possible increased risk of HIV transmission
3. Monotherapy

Question 20

Adherence to ART

1. What does it determine?
2. What is associated with virologic failure?
3. What is required for optimal suppression?
4. What is common?

Answer 20

1. degree and duration of viral suppression
2. poor adherence
3. 90-95% adherence
4. suboptimal adherence is common

Question 21

What factors predict inadequate adherence? (8)

Answer 21

1. regimen complexity and pill burden
2. poor doctor-pt relationship
3. active drug use or alcoholism
4. unstable housing
5. mental illness (especially depression)
6. lack of pt education
7. medication adverse effects
8. fear of medication adverse effects

Question 22

What factors predict good adherence (7)?

Answer 22

1. emotional and practical supports
2. convenience of regimen
3. understanding the importance of adherence
4. belief in efficacy of medications
5. feeling comfortable taking medications in front of others
6. Keeping clinic appointments
7. severity of symptoms or illness

Question 23

ART Adverse Effects (7)

Answer 23

1. Lactic acidosis/ hepatic steatosis
2. hepatotoxicity
3. hyperglycemia
4. fat maldistribution (not specific to any 1 drug)
5. hyperlipidemia
6. increased bleeding in hemophiliacs
7. osteonecrosis, osteopenia, osteoporosis
8. rash

Question 24

ART SE: Fat Maldistribution

1. AKA
2. define
3. mechanism
4. Treatment
5. may be associated with?

Answer 24

1. Lipodystrophy
2. no uniform definition
3. not understood
4. switching to other agents may slow progression
5. dyslipidemia, insulin resistance, lactic acidosis

Question 25

ART SE: Hyperlipidemia 1. Define 2. mechanism 3. associated with which drugs? 4. consequences 5. treatment

Answer 25

1. elevations in total cholesterol, LDL, and TGs 2. unknown 3. all PIs (except ATV), d4T, EFV 4. uncertain; concern for CV/pancreatitis 5. consider ARV switch; lipid-lowering agents

Question 26

Common Diseases in AIDS Patients

Answer 26

1. Seborrhea/eczema 2. Molluscum contagiosum 3. Eosinohpilic folliculitis 4. Scabies 5. HSV 6. Varicella (should screen for HIV if pt younger than 5) 7. Hairy leukoplakia 8. Invasive thrush 9. PCP 10. CMV Retinitis (causes blindness and hemorrhage in eyes) 11. Bacillary Angiomatosis (bacterial nodules on skin) 12. Mycobacterium avium complex (GI, lung, systemic) 13 Toxoplasmosis (becomes active w/ low CD4 count) 14. AIDS wasting syndrome (>10% body weight) 15. Kaposi's Sarcoma (viral induced, purple lesion, treatable w/ chemo) 16. Cryptosporidium (persistent disease in HIV)