Two drugs for increasing appetite and weight gain
Progestational agent Megestrol Acetate
Antiemetic agent Dronabinal
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 are the sx of Toxoplasmosis?
2. Focal neurologic deficits
4. Altered mental status
What is the the 2nd most common space-occupying lesions in HIV-infected patients?
Primary non-Hodgkin Lymphoma
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
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
3. Reverse transcription (RNA into DNA)
5. Transcription of (DNA to RNA)
6. Translation (RNA into proteins)
7. Assembly (of virus copies)
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 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 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 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
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
4. Hx of AIDS defining illness
5. HIV associated nephropathy
6. Co-infection with HBV when tx is indicated
What is the prophylaxis for Toxoplasmosis
Trimethoprim-sulfamethoxazole (Bactrim) or
Pyrimethamine+Dapsone+Leucovorin --> from CMDT
Pyrimethamine + Sulfadiazine + Clindamycin
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?
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 HSV (herpes simplex virus)
Acyclovir, Valacyclovir, Famcyclovir, Foscarnet
What is the prophylaxis for KS (Kaposis sarcoma)
Intralesional vinblastine, or systemic chemotherapy
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
When to suspect HIV?
2. Syphillis - increase recurrence & neurosyphilis
3. PID - increased severity & complication
4. Cervical dysplasia - increased incidence, recurrence & severity
6. Occupational exposure
7. AIDS opportunistic infections
SX suggestive of HIV
1. Fever, weight loss, diarrhea
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
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
3. Constitutional symptoms
4. Opportunistic infection
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 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?
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
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?
1 month - 6 wks
6 months - should be seropositive by 6 months if it is positive
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
What are some of the HIV-related oral lesions?
1. Candiditis or hairy leukoplakia
2. Aphthous ulcers
3. Angular cheilitis