HIV clinical aspects II – Flashcards

Unlock all answers in this set

Unlock answers
question
define HAART
answer
highly active anti-retroviral therapy - applies to most current anti retroviral therapy, includes protease inhibitors etc
question
what is the first 1-6 wks of HIV infection characterized by?
answer
viral load increase followed by dramatic CD4+ decrease
question
what is the next 6-8 wks of HIV infection characterized by? what happens in this time?
answer
gradual leveling of CD4 cells = clinical latency, this is the time where 25% of HIV infected individuals are unaware and spreading disease
question
what is the first 5 years of HIV infection characterized by?
answer
some symptoms manifest themselves: diarrhea/vomiting
question
what happens around year 7-8 in HIV infected individuals?
answer
opportunistic infections and malignancies begin to arise
question
what happens around year 8-9 in untreated HIV infected individuals?
answer
death
question
what % of pts do not follow the expected curve of HIV infection?
answer
2-3%
question
what are rapid progressors?
answer
pts who go through the "natural curve" of HIV within a year
question
who are non-progressors?
answer
HIV+ pts with low viremia, relatively normal CD4+ counts
question
has HAART use been effective?
answer
yes since 1995, the number of AIDs cases/deaths has dropped and the CDC estimates that from 1994-2003, ~ 3 million lives have been saved by HAART
question
what is the avg life expectancy for HIV+ pts? is there a disparity across race?
answer
HIV+ life expectancy is from 10.5 - 22.5 years, which is higher for whites relative to blacks and hispanics
question
what is maraviroc (MVC)? what are some concerns associated with its use?
answer
maraviroc is a CCR5 inhibitor, but there are some concerns about blocking receptors on CD4+ cells - harmful effects downstream such as west nile infiltration are possible
question
what does raltegravir (RAL) do?
answer
raltegravir is an integrases inhibitor, which blocks integration of the HIV genome
question
what are atazanavir (ATV) and darunavir (DRV)?
answer
protease inhibitors that block cleavage of viral proteins - these really changed the course of HIV/AIDs
question
should anyone with an AIDs defining illness be treated with ARV? does their CD4+ factor into this decision?
answer
pts with an AIDs defining illness should be treated with ARV regardless of CD4+ count
question
what is the appropriate level of CD4+ for ARV to be started in asymptomatic HIV+ pts?
answer
350-500 cells/ul
question
what is the recommendation for asymptomatic HIV+ pts w/a CD4+ count >500?
answer
ARV tx is optional
question
what is the recommendation for pregnant asymptomatic HIV+ pts at any CD4+ level?
answer
pregnant asymptomatic HIV+ pts should be treated with ARV at any CD4+ level to prevent transmission to the child
question
what is the ARV tx recommendation for asymptomatic HIV+ pts w/any CD4+ count as well as HIV-associated nephropathy (HIVAN) or Hep B coninfection
answer
ARV tx is recommended regardless of CD4+ value
question
what is the controversy with ARV therapy for asymptomatic HIV+ pts at a CD4+ counter >500?
answer
50% of panel favors starting ART & 50% of panel views ART as optional due to toxicity/resistant issues
question
what are potential complications that can be avoided by starting early ARV therapy for asymptomatic pts with CD4+ counts >500?
answer
HIV-associated neuropathy, cardiovascular disease, malignancies (both AIDs/non-AIDs defining), neurocognitive disease, liver disease progression, blunted immunological response due to earlier ARV initiation, persistent T cell activation/inflammation
question
what are benefits of starting ARV therapy earlier?
answer
prevention of HIV sexual transmission, prevention of blood-borne transmission, prevention of mother to child HIV transmission
question
what are potential limitations of early ARV therapy?
answer
ARV-related toxicities, non-adherence to ARV (leading to drug resistance), cost of medications (1000-1500/month)
question
what are some recommendations for ARV therapy initiation?
answer
ensure the pt is willing to commit to lifelong tx and that you as the dr are not forcing it on them
question
what are the goals of ARV therapy?
answer
*restoration and/or preservation of immunologic function - increase CD4+ count*, maximal & durable suppression of viral load, improved quality of life, reduction in HIV-related morbiditiy, improved quality of life, and reduction in HIV-related morbidity/mortality, prevention of vertical MTC transmission, prevention of transmission to sexual partners
question
what are the 3 main categories of ARV regimens?
answer
1 NNRTI + 2 NRTIs, 1 protease inhibitor + 2 NRTIs, (both the first two options are preferred), and 1 integrase inhibitor + 2 NRTIs
question
what are important considerations for ARV administration? what are two specific considerations for nevirapine and abacavir?
answer
comorbidities, (liver, psych, CV, TB, pregnancy), dosing convenience (pill burden/dosing frequency), potenial side effects/interactions, pregnancy potential, drug resistance testing results, gender/CD4 count (if considering nevirapine), and HLA B 5701 test results (genetic marker for specific allele - likely to have a hypersensitivity response to abacavir)
question
what characterizes preferred ART regimens?
answer
randomized controlled trials show optimal efficacy and durability as well was favorable tolerability/toxicity profiles. drugs in this category include: the NNRTI based choice efavirenz/tenofovir/emtricitabine in one tablet - atripla, the protease inhibitor choices: atazanavir or darunavir with ritonavir/emtricitabine/tenovir, the integrase inhibitor choice: raltegravir w/emtricitabine/tenovir, and the choice for pregnant pts: lopinavir w/zidovudine/lamivudine
question
what characterizes alternative ART regimens?
answer
these are effective but have potential disadvantages, but still can be preferred tx in individual pts.
question
what characterizes acceptable ART regimens?
answer
these have less virologic efficacy (or lack of data) or greater toxicities.
question
what side effect is seen with ZDV?
answer
anemia
question
what side effect is seen with abacavir?
answer
hypersensistivity w/HLA B 5701
question
what side effect is seen with protease inhibitors?
answer
GI intolerance
question
what side effect is seen with NRTIs?
answer
rashes
question
what side effect is seen with mult ARVs?
answer
hepatotoxicity esp if HCV+
question
what side effect is seen with ddC, ddl, d4T?
answer
neuropathy and pancreatitis
question
what side effect is seen with all NRTIs?
answer
lactic acidosis/steatorrhea
question
what are multiple long term side effects with protease inhibitors and NRTIs?
answer
lipidystrophy (increase/decrease in body fat), hyperlipemia (increased cholesterol, glucose intolerance/diabetes, *coronary disease/MI
question
how long do most pts maintain virologic suppression with ARVs? what should be done to maintain this as long as possible?
answer
3-7 years. simplification of regimen and assessment of adherence should be done frequently
question
why do HIV+ pts fail virologically? what defines this?
answer
skipped doses, mutations. virologic failure is defined as: HIV RNA >400 copies/mL after 24 weeks, >50 copies/mL after 48 weeks or >400 copies/mL after viral suppression
question
why do HIV+ pts fail immunologically?
answer
poor CD4+ count rebound, generally unknown etiology
question
do HIV+ pts fail clinically?
answer
this is rare, but can happen
question
what was PACTG 076? who was involved? what was the result?
answer
a phase III randomized placebo-controlled trial of zidovudine (ZDV) for the prevention of maternal-fetal HIV transmission done in 1994. it involved tx for the mother as well as the baby for 6 wks afer birth. efficacy was observed across all subgroups and ZDV became the standard of care and at this point infected neonates should no longer be a problem.
question
is ARV therapy recommended in all HIV + pregnant women? when is it started? what is the goal
answer
yes. ARV is typically started in the 2nd trimester unless they are already being treated. the goal of tx is to reduce the maternal HIV load to undetectable (or at least <1000 copies)
question
what ARV is contraindicated in pregnancy?
answer
efavirenz (sustiva - category D)
question
what is the ARV standard of care for pregnant women?
answer
3-drug regimen containing AZT (zidovudine), and lopinavir/ritonavir
question
what do all infants born to HIV+ recieve in terms of therapy?
answer
AZT for 6 wks post-delivery
question
after delivery, can HIV+ mothers stop ARV if their CD4+ count is >500?
answer
yes
question
when is vaginal vs V-section birth recommended for HIV+ mothers?
answer
vaginal is ok if viral load is <1000 copies, if not elective C-sections can be performed at 38 wks (this is high risk for other reasons). vaginal birth has a slightly reduced risk of transmission.
question
should women with HIV in the US breastfeed? globally?
answer
no. globally, the risk is less w/breastfeeding due to contaminated water
question
is pregnancy contraindicated with HIV+ women?
answer
no, but avoidance of transmission to the partner needs to be addressed
question
has HAART helped to decrease the rate of AIDs-related opportunisitic infections?
answer
yes
question
where are opportunistic infections still seen?
answer
in previously undiagnosed late stage AIDs pts, diagnosed by untreated pts, pts who stop their ARV rx, pts whose ARV medications may be failing, and shortly after the initiation of ARV meds (1-6 months)
question
what opportunistic infections are seen with AIDs pts in the brain?
answer
toxoplasmosis (present with seizures/headaches/fever), cryptococcal meningitis, lymphoma, JC virus infections causing progressive multifocal leukoencephalopathy (PML) which consists of de-mylenation leading to excessive loss of white matter (even w/antiviral therapy, pts do not thrive)
question
what opportunistic infections are seen with AIDs pts in the eyes? how is this diagnosed?
answer
CMV retinitis, toxoplasmosis. CMV retinitis appears as hemorrhage and retinal exudates in a fundoscopic exam and leads to blindness
question
what opportunistic infections are seen with AIDs pts in the mouth? how is this treated?
answer
oral candidiasis (however it can also be due to corticosteroid inhalers) as well as esophageal candidiasis
question
what is the most common AIDs opportunistic infection?
answer
pneumocystis pneumonia (p jiroveci)
question
what else besides retinitis can CMV (an opportunistic pathogen) cause in AIDs pts?
answer
colitis
question
what is an AIDs defining illness affecting the skin and is associated with HHV-8? can it be treated? how is it transmitted?
answer
kaposi's sarcoma, which appears as non-tender, purplish, indurated skin lesions. they are common in the mouth and may disseminated to the viscera. it can usually be treated pretty successfully. it can be sexually transmitted.
question
can herpes zoster activate with AIDs pts as an opportunistic pathogen?
answer
yes
question
what is a common clinical manifestation of HPV in AIDs pts? is it considered an opportunistic pathogen?
answer
anal, genital and oral warts, usually asymptomatic - but hard to get rid of. it is considered an opportunistic pathogen
question
what are examples of disseminated opportunistic infections?
answer
mycobacterium avium complex, histoplasmosis, coccidiomycosis
question
when do opportunistic pathogens usually start becoming a problem with HIV+ pts? can antiviral/antibacterial/antifungal tx usually help?
answer
around when CD4+ drops below 200. antiviral/antibacterial/antifungal usually will help
question
what are non-infectious body fluids for HIV?
answer
urine, feces, vomitus, saliva, sweat, tears
question
what are infectious body fluids for HIV?
answer
blood, CSF, pleural, synovial, pericardial, amniotic, vaginal secerations, semen, breast milk
question
how common is HIV infection along healthcare workers? who is most at risk?
answer
very rare, but nurses and physicians are at the highest risk
question
what is the risk of HIV transmission via needle stick, non-intact skin, and mucus membrane?
answer
needle stick: 0.3% or 1/300
non-intact skin: <0.1% or 1/1000
mucous membrane: 0.09% or 1/1000
question
what is needed to assess HIV infection risk in healthcare personell?
answer
the type of exposure, (percutaneous, mucous membrane, non-intact skin, bites), the body substance, (blood, bloody fluid, potentially infectious fluid or tissue), and the source pt, (HIV antibody, HCV antibody, HBV surface antigen should be tested for)
question
how is post HIV exposure prophylaxis carried out?
answer
PEP must be given within 72 hrs, at least 2 drugs should be given, tx should be for at least 28 days if source is HIV infected, and the possibility of a drug resistant virus should be considered
question
what are the basic PEP recommendations?
answer
zidovudine + lamivudine (combivir) or tenofovir + emtricitabine (truvada - normal go to)
question
what are the alternate PEP recommendations?
answer
lamivudine or emtricitabine + stavudine or lamivudine or emtricitabine + didanosine
question
what is recommended in the case of very high risk possible HIV exposure?
answer
basica NRTI regimen plus lopinavir/ritonavir, atazanavir/ritonavir, fosamprenavir/ritonavir, nelfinavir, or efavirenz
question
if the source pt is HIV+, how is testing performed?
answer
the exposed person is tested at baseline, then @ 1,3,6 months via ELISA. f/u is extended to 12 mo if the exposed becomes infected with HCV (it might take longer to serocovert to HIV in this case)
question
what is considered a substantial risk for HIV exposure?
answer
if the vagina, rectum, eye, mouth (or other mucous membrane), non intact skin or percutanous contact is met with blood, semen, vaginal secretion, rectal secretion, breast milk, or any blood contaminated body fluid from an HIV+ individual
question
can/should PEP be given after 72 hrs?
answer
PEP has not been shown to help with exposure after 72 hours
Get an explanation on any task
Get unstuck with the help of our AI assistant in seconds
New