HIV - HPDP

Created by karenyan1203 

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Two drugs for increasing appetite and weight gain

Progestational agent Megestrol Acetate
Antiemetic agent Dronabinal

S/E of Megestrol Acetate

1. N/V
2. Thromboembolic
3. Edema and rash

S/E of Dronabinol

1. Euphoria
2. Dizziness
3. Parnoia
4 Somnolence
5. N/V

Two Regimen for increasing lean body mass

Growth hormone
Anabolic steroids

Nausea and Esophageal candidiasis Treatment

Oral Antifungal agent

What is the most common opportunistic infection associated w/t AIDS?

Pneumocystis pneumonia

What is the sign you see on Chest radiography if patient has Pneumocytis pneumonia?

Diffuse or perihilar infiltrates are most characteristics (2/3)
Apical infiltrates (1/3)

Definitive dx for Pneumocytis pneumonia?

1. Wright-Geimsa stain or direct fluorescence antibody (DFA) test of induced sputum
2. Bronchoalveolar lavage

What is the definitive dx for Cytomegalovirus pneumonia?

Biopsy

Sx of Chornic Sinusitis

Sinus Congestion and d/c
Headache
Fever

Tx for non-smoker with Chronic Sinusitis

Amoxicillin (500mg PO TID)

Tx for smoker w/t Chornic Sinusitis

Amoxicillin-postassium clavulanate (500mg PO TID)

What is the most common space-occupying lesion in HIV-infected patients?

Toxoplasmosis

What are the sx of Toxoplasmosis?

1. Headache
2. Focal neurologic deficits
3. Seizures
4. Altered mental status

What is the pattern of Toxoplasmosis in MRI?

Usually multiple lesions

What is the the 2nd most common space-occupying lesions in HIV-infected patients?

Primary non-Hodgkin Lymphoma

Lesion difference between Toxoplasmosis and non-Hodgkin Lymphoma?

non-Hodgkin Lymphoma is solitary

Sx w/t AIDS dementia complex

Difficulty with cognitive tasks and exhibit diminished motor speed

Sx of Cryptococcal meningitis

1. Headache
2. Fever
3. normal mental status

Dx test for Cryptococcal meningitis

Positive Latex agglutination test (Positive serum CRAG)

Sx o fHIV mylopathy

Leg weakness and incontinence
Spastic paraparesis and sensory ataxia

Sx of Peripheral neuropathy in HIV-infected pt

numbness, tingling, and pain in the lower extremities

CMV sx in HIV-infected pt

1. Lower extremity weakness
2. neutrophilic pelocytosis on spinal fluid analysis w/t a negative bacterial culture

Structure of HIV virus and its components

1. 2 RNA strands
2. Reverse transcriptase
3. Integrase
4. Protease

What receptors on CD4 cell for the HIV virus to fuse?

CXCR4
CCR5

What is the Mechanism of HIV infection?

1. Fusion to membrane through docking with chemokine recpetors on CD4 cell
2. Unloading of virus contents into cell cytoplasm after fusion
3. RNA reverse transcriptase to code RNA --> DNA
4. Integrase - bring the DNA strand into the nucleus and incorporate into the host's DNA for transcription
5. Protease helps to prepare the viral proteins and RNA that have been produced
6. The viral proteins and viral RNA are packaged and are pushed to the cells surface where they bud through the cell membrane and are dispersed to attack to other CD4 cells

What happens if a person have a CCR5 deletion?

~50% less likely to become infected due to decreased amount of receptor sites to which HIV can bind

Sequence of HIV infection

1. Fusion
2. Entry
3. Reverse transcription (RNA into DNA)
4. Integration
5. Transcription of (DNA to RNA)
6. Translation (RNA into proteins)
7. Assembly (of virus copies)
8. Budding

Time line of HIV infection between 0-12 wks

"window period" where pt may be infected w/t virus but may not test "positive" for the anti-envelope antibodies

Time line of HIV infection between 2-4 wks

Possible Acute HIV Infection Syndrome

Time line of HIV infection 6 months - 1 yr

"viral set point": virus level in plasma of untreated individual which is predictive of rate of disease progression

Time line of HIV infection 10 years

Average time of progression (without ARV tx) from initial HIV infection to AIDS dx

Time line of HIV infection in 2 years

Average time of progression (without ARV tx) from CD4 coutn of 200 T cells to first opportunistic infection leading to AIDS diagnosis

What is the screening test for HIV?

1. ELISA
2. Western Blot

What is ELISA?

Enzyme Linked Immunosorbant Assay - test for antibodies (this can miss if someone is in "window" period the body does not produce enough antibodies for the detection

What is Western Blot assay for?

To confirm the the HIV infection if the ELISA is positive

What is NAAT?

Nucleic Acid Amplification Testing - results available 7 days after screening sample, checks for viral particles in blood associated with infection approximately 7-10 days PRIOR TO SAMPLE COLLECTION

How do you monitor CD4 count?

By testing T Lymphocyte Helper/Suppressor counts to provide for CD3, CD4 and CD8 counts

How do you monitor the viral load?

HIV RNA through PCR - polymerase chain reaction

What is the preferred regimen for naive wild-type HIV?

1. 2NRTI + 1 NNRTI --> Atripla
2. 2NRTI + 1 PI
3. 2NRTI + 1 Integrase Inhibitors

What is Atripla?

Tenofovir + Emtricitibine + Efavirenz -- once daily dosing in combination therapy in one pill

What are some of the criteria of therapy failure?

1. If the viral load >1000 copies/mm3
2. Virologic control should be established 12-24 wks after initiation of ART or a change in tehrapy combination
3. Need to establish whether patients is resistant or non-adherence to medication

What would you do if pt failed the thearpy?

1. Run phenotype or genotype to assess for mutations and select appropriate meds
2. Identify 3 drugs from two different classess to which the virus is NOT resistant
3. May need expert assistance in interpretation of geno/phenotype results - difficult to interpret

When to start HARRT?

1. CD4 < 500 cells/mm3
2. Viral load >100,000 copies/ml
3. Pregnancy
4. Hx of AIDS defining illness
5. HIV associated nephropathy
6. Co-infection with HBV when tx is indicated

What is the opportunistic infections if CD4 <200 cells/mm3

PCP (Pneumocystis pneumonia)

What is the prophylaxis for PCP?

1. Bactrim
2. Dapsone
3. Atovaquone
4. Aerosolized pentamidine

What is the opportunistic infection if CD4 < 100

MAC (M avium)
Toxoplasmosis

What is the prophylaxis for MAC?

Clarithromycin or Azithromycin

What is the prophylaxis for Toxoplasmosis

Trimethoprim-sulfamethoxazole (Bactrim) or
Pyrimethamine+Dapsone+Leucovorin --> from CMDT
Pyrimethamine + Sulfadiazine + Clindamycin

What is the opportunistic infection if CD4 <50/75?

CMV (Cytomegalovirus)

What is the prophylaxis against CMV infection?

PO Ganciclovir
or Valganciclovir, Foscarnet

What is IRIS?

Immune Reconstitution Inflammatory Syndrome
As the immune system "turning back on", CD4 level climbs up from <200 to >200 cells/mm3
Patient appears to be more symptomatic than before
DO NOT stop HARRT

What can help to suppress inflammatory reactions and reduce sx if pt is experiencing IRIS?

Corticosteroid

How often to measure CD4 counts w/t HIV-infected pt?

3-6 months
CD8 counts included and a CBC

How often to measure viral load w/t HIV-infected pt?

Every 3-6 months and 1 month following a change of therapy

What is the prophylaxis for Cryptococcal meningitis?

Amphotericin
Fluconazole

What is the prophylaxis for Candidiasis (esophageal or recurrent vaginal?

Fluconazole

What is the prophylaxis for HSV (herpes simplex virus)

Acyclovir, Valacyclovir, Famcyclovir, Foscarnet

What is the prophylaxis for KS (Kaposis sarcoma)

Intralesional vinblastine, or systemic chemotherapy

What is the most affected subpopulations for HIV infection?

White MSM

Cell types affected by HIV

CD4
Macrophages
B lymphocytes

What is the definitive AIDS dx (with or without lab evidence of HIV infection)

1. Candidiasis of the esophagus, trachea, bronchi, or lungs
2. Cryptococcosis, extrapulmonary
3. Cryptosporidiosis with diarrhea persisting > 1 month
4. Cytomegalovirus disease of an organ other than liver, spleen, or lymph nodes
5. Herpes simplex virus infection causing a mucocutaneous ulcer persists longer than 1 month; or bronchitis, pneumonitis, or esophagitis of any duration
6. Kaposi sarcoma in a pt < 60 y/o
7. Lymphoma of the brain (primary) in a pt < 60 y/o
8. Mycobacterium avium complex or Mycobacterium kansasii disease, disseminated (at a site other than or in addition to lungs, skin, or cervical or hilar lymph nodes)
9. Pneumocystis jiroveci pneumonia
10. Progressive multifocal leukoencephalopathy
11. Toxoplasmosis of the brain

Risk factors HIV infection?

1. Sexual contact w/ an infected person
2. Parenteral exposure to infected blood (1:300)
3. Perinatal exposure

Risk factors for Anal intercourse

Insertive 1:30-100
Receptive 1:1,000

Risk factors for Vaginal intercourse

Insertive 1:10,000
Receptive 1:1,000

Risk factors for fellatio w/t ejaculation

1:1000

When to suspect HIV?

1. Pregnancy
2. Syphillis - increase recurrence & neurosyphilis
3. PID - increased severity & complication
4. Cervical dysplasia - increased incidence, recurrence & severity
5. TB
6. Occupational exposure
7. AIDS opportunistic infections

SX suggestive of HIV

1. Fever, weight loss, diarrhea
2. Lymphadenopathy
3. Oral thrush, hairy leukoplaia, periodontitis
4. Vaginal candidiasis, HSV, HPV
5. Onchomycosis, seborrheic dermatitis
6. Staphylococcal folliculitis, molluscum contagiosum

Lab suspect HIV

1. Anemia, neutropenia, thrombocytopenia
2. Hypoalbuminemia
3. Hypergammaglobulinemia (elevated TP)
4. Cervical koilocytosis, atypia or dysplasia
5. Anergy (DTH tests neg) - no immune response

The Disease Progression of HIV virus

1. Acute HIV infection
2. Latent
3. Constitutional symptoms
4. Opportunistic infection
5. IRIS
6. Death

What is Acute HIV infection?

It happens 2-4 wks after initial infection with flu-like sx, easily confused w/t other illnesses, HIV test will come back negative but viral load is high

What can cause false positive in ELISA test?

Lupus
Lyme disease
Syphilis

What are some positive predictors of adherence?

1. Pt's belief to HARRT
2. Clinician's experience
3. Social support
4. Pt's adherence to office visit

What are some negative predictors of adherence?

1. Active drug use
2. Active alcohol abuse (>14 drinks/wk)
3. Active psychiatric disease
4. Cumulative impact of HIV
5. Socio-economic status

What are the factors that is not predictive of adherence?

1. Race
2. Gender
3. Disease stage
4. Hx of substance abuse

What does Tipranavir (PI) and darunavir (PI) have?

Sulfa-moiety and patients with sulfa allergies will react to them

If pt test positive for HLAB*5701 as a result, which med would the pt more likely to experience a hypersensitivity reaciton

Abacavir (NRTI)

What is the s/e of Didanosine (NRTI)

5-10% of pt experience pancreatitis

Which med most likely to cause anemia?

Zidovudine (NRTI)

What are the 5 steps for PEP?

1. Treat the injured site
2. Report and document
3. Evaluate the exposure
4. Evaluate the exposure source
5. Disease specific PEP management

How to prevent PPE?

1. Wash hands frequently
2. Standard precautions
3. Wear PPE (Goggles, gloves and masks)
4. Use sharps with cautions
5. HBV vaccination series

What are some of the fluids with risk after exposure?

Blood, semen, vaginal secretions, CSF, synovial flluid, pelural fluid, peritoneal fluid, pericardial fluid, amniotic fluid

What are some of the fluids without risk after exposure?

Urine, saliva, nonpurulent sputum, stool, emesis, nasal discharge, tears, sweat

What tests do you run if you are evaluating the source patient?

HBsAq, HCV antibody and HIV antibody

What is the disease specific PEP management for HBV?

If the patient is not vaccinated, HBIG x 1 + HBV series

What is the disease specific PEP management for HIV?

PEP should begin immediately within 24-36 hours and last for 28 days
Contact UCSF PEP hotline for PEP guidance

What is the follow up time frame for the PEP management?

Day 0
1 month - 6 wks
3 months
6 months - should be seropositive by 6 months if it is positive

What is plasma viremia titer for?

Test the amount of virus in blood

What is normal CD4 cell level?

800-1200

When does the constitutional symptoms start?

Around 8 yrs after HIV infection

What is HIV myelopathy?

This is a late HIV finding
Sx: impaired spinal cord function, leg weakness and incontinence, sensory ataxia, spastic paraparesis

What is PML?

Progressive Multifocal Leukoencephalopathy - white matter viral infection
Sx: aphasia, hemiparesis, cortical blindness

Which virus/bacteria causes HIV-retinitis?

CMV

Sx of CMV retinitis

Pervascular hemorrhage
White fluffy exudates

What are some of the HIV-related oral lesions?

1. Candiditis or hairy leukoplakia
2. Aphthous ulcers
3. Angular cheilitis
4. Gingivitis/periodontitis

What are some bacteria that can cause HIV-Enterocolitis?

Campylobacter, Salmonella, Shigella

What are some virus that can cause HIV-Enterocolitis?

CMV, Adenovirus

What are some protozoans that can cause HIV-Enterocolitis?

Giardia, Sporidia, E. histolytica

What is the risk ratio for needle stick with infected blood?

1:300

What is the risk ratio for illicit drug use?

1:150

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