Hiv/aids

Front 1

screen for HIV

Back 1

everyone between the ages of 13-64 according to the CDC

get tested at least once/year if @ high risk for infection (anal sex)

Front 2

acute infection of HIV

Back 2

1st stage
in first 2-4 weeks (rarely dx in this stage)
flu-like symptoms
high VL
CD4 is dropping
nonspecific symtpoms (fever, lymphadenopathy, pharyngitis, rash, myalgia/arthralgia,diarrhea, HD,N/V)

Front 3

latent phase of HIV infection

Back 3

longest phase of patient's life
no AIDS defining illnesses
can last 8-10 years
CD8 cells maintain normal levels
VL usually drops from high level in acute infection
CD4 cells continue to drop (50 cells/year)
HIV ab becomes detectable after acute infection (can take 3-6 months) NOT TRANSMISSION!
candidiasis (oropharyngeal/vulvovaginal), cervial dysplasia, fever/diarrhea for over 1 month,hairy leukoplakia, shingles, idopathic thrombocytopenic purpura, literisosis(can occur when on steriods/alcholics, pregos,HIV),PID

Front 4

systemic immune defiency

Back 4

AIDS
AIDS defining illness
CMV,MAC,PCP,toxoplasmosis
VL increase again (like in acute infection)
CD8 % CD4 are down

Front 5

CD4 < 200

Back 5

at risk for PCP

Front 6

CD4 < 10x

Back 6

toxoplasmosis

Front 7

CD4 < 50

Back 7

CMV
MAC

Front 8

toxoplasmosis

Back 8

Dx ring enhancing lesions on CT-scan/MRI & CD4<100
tx HAART + keppra (levitracam)

Front 9

PCP

Back 9

atypical pnuemonia
fungus
chest x-ray will show bilateral cystic lesions in shape of butterfly
dry cough (not productive)
look fine until exert themselves because they have no lung reserve
hypoxemia (low O2 saturation)

Front 10

severe PCP

Back 10

add steriods
why already immunsuppressed with HIV?
prevent respiratory failure due to inflammation and fluid in the lungs

Front 11

toxoplasmosis

Back 11

prone to alcholics, immunosuppressed, steriods, pregos, in kitty litter
can progress to parasitic abscess
cause focal encephalitis

Front 12

toxoplasmosis prophylaxis w/sulfa allergy

Back 12

dapsone + pyrimethamine + leucovorin/atovaquone

Front 13

toxoplasmosis tx

Back 13

sulfadizine + leucovorin + pyrimethamine

subsitute clindamycin for sulfadizine if have sulfa allergy

Front 14

CMV

Back 14

affects eyes/GI tract/brain
leading cause of blindness in HIV
-irreversible
-see floaters
encephalitits
herpesvirus (double-stranded virus)
HIV can reactivate latent infection
no prophylaxis due to bone marrow toxicity
best preventive measure is to keep CD4 > 50

Front 15

MAC

Back 15

cause granuloma like TB
is not transmitted person-person like TB
prophylaxis when CD4 < 50
tx w/macrolide (usually azitrhomycin because clarithromycin is not well tolerated)

Front 16

HIV is

Back 16

lentiviruse
CXCR4 & CCR5 tropism
intergrates as DNA provirus
double stranded RNA
fuses w/CD4 cell membrane not nucleus
3 gene sequences: Gag, Pol, Env

Front 17

Gag

Back 17

nucleocapsid
develops matrix

Front 18

Pol

Back 18

makes polymerase
all enzyme activity

Front 19

env

Back 19

codes for envelope

Front 20

entry inhibitor

Back 20

maraviroc

Front 21

prevent reverse transcription

Back 21

NRTI & NNRTIs

Front 22

prevent intergrases

Back 22

rategravir

Front 23

env

Back 23

codes for gp120

Front 24

HIV labs

Back 24

get every 3 months
VL, LFTs, CD4
HIV-ELISA done once

Front 25

ABC

Back 25

screen for fatal hypersensitivity rxn with HLA-B5701

Front 26

CD4 = 300-400

Back 26

TB, malignancy, HSV, candiasis (oropharngeal/volvovaginal)

Front 27

CD4 = 200-300

Back 27

PCP

Front 28

CD4 = 200-100

Back 28

toxoplasmosis

Front 29

CD4 = 100-50

Back 29

CMV
MAC

Front 30

exrta pulmonary disease

Back 30

rare
associated with pentanimine prophylaxis

Front 31

PCP

Back 31

hypoxemia
elevation of lactate dehydrogenase if very commone (>500 mg/dL)

Front 32

start PCP prophylaxis

Back 32

CD4 < 200 or has decreased by 14%
recurrent bacterial pnuemonia
oral thrush (candiasis)
hx of AIDS defining illness

Front 33

prophylaxis tx of PCP

Back 33

Bactrim double strength PO QD/QMWF or regular strength QD

sulfa allergy: dapsone + pyrimethamine + leucovorin
aerolized pentamidine/atovaguone
end when CD4 > 200 for > 3 months

Front 34

treat PCP

Back 34

Dx with DFA + bronchoscopy

Tx with bactrim 15 mg/kg/day Q8 hours + corticosteriod (prednisone) if o2 sat < 75 mmHg with 72 hours

sulfa allergy: primaquine + clindamycin/atovoaquone suspencion/IV pentanamide

tx for 21 days then secondary prophylaxis (stop when CD4 > 200 for at least 6 months)

Front 35

toxoplasmosis clinical presentation

Back 35

focal encephalitis
HD
confusion
motor weakness
fever
progress to seizures, stupor, and coma if untreated
MRI/CT-scan with show contrast lesions w/edema

Front 36

toxoplasmosis prophylaxis

Back 36

start when CD4 < 100
same as PCP

tx with pyrimethamine + sulfadizine + leucovorin

sulfa allergy subsitutue sulfadizine for clindamycin
can + corticosteriods
tx for at least 6 weeks then secondary prophylaxis (end when CD4 > 200 for > 6months)

Front 37

CMV

Back 37

double stranded DNA viruse
herpes viruse
due to reactivation of latent infection
affects retina/GI/CNS
no primary prophylaxis
after tx regular eye exams are nessary as CMV retinitis can replaspe at CD4 counts > 1200!

Front 38

provalgancyclovir

Back 38

tx CMV but is not used because $$ and has not been proven to increase survival
better bioavailbility than gancyclovir
if used for prophylaxis will cause resistance

Front 39

MAC

Back 39

transmitted by inhalation, indigestion or inoculation via respiratory/GI tract
CD4 < 50
Tx w/azithromycin, azithromycin + ribautin or clarithromycin however addition of ribautin is not routinely recommended (cost, DIs, AEs)

end prophylaxis when CD4 > 100 for 3 months

Front 40

MAC

Back 40

Dx with blood culture/biopsy
should test for sensitivity to macrolides

tx w/ 2 agents!
1)macrolide (azithromycin/clarithromycin)
<1 gm of clarithromycin
2)ethambutol
3)rifabutin (optional)
withhold ART for 2 wks if not tx yet
follow by lifelong secondary prophylaxis unless CD4> 100 for > 6 months

Front 41

PCP dx

Back 41

+ DFA in bronchi

Front 42

CMV dx

Back 42

retinal hemorrage

Front 43

MAC dx

Back 43

+ blood culture
+ biopsy

Front 44

HIV

Back 44

double stranded RNA viruses
3 gene sequences including Gag, Pol, & Env capped w/LTR sequences

Front 45

Gag

Back 45

encodes for polyproteins including the matrix, capsid, & nucleocapsid)

Front 46

Pol

Back 46

ecodes for life cycle enzymes including intergrate, protease, reverse transcriptase

Front 47

Env

Back 47

encodes for external surface & transmembrane proteins and membrane glycoproteins (gp120)

Front 48

LTR

Back 48

codes for accessory or regularotry genes

Front 49

Dx HIV

Back 49

ELISA
western blot
rapid tests
PCR
genotyping
phenotyping

Front 50

ELISA

Back 50

highly sensitive
not specific
false + w/pregos, age < 18 months, syphillis, other viral infections, automiinue disease, malignancy, leprosy, malria, alcoholic hepatitis
False - during the window period (abs have not developed yet - can be 3-6 months)

Front 51

HIV genotyping

Back 51

measures the presence of specific genes of resistance for specific antiretrovirals

preferred for ART -naive patients

Front 52

HIV phenotypings

Back 52

measures the difference in viral inhibition between wild type and patient virus for a specific antiretroviral
it measures the IC50 relative to the reference strain of HIV

Front 53

Limitations of HIV genotyping & phenotyping

Back 53

low VL
mismatching amplification/sequencing primers
prepartion problems
andambious viruses

Front 54

HIV drug resisitance testing

Back 54

recommended for acute infection and prior tx in chronic infection
also for virologic failure during tx or < 4wks after D/C of therapy

not recommended for VL <1000

Front 55

HLAB*5701

Back 55

see if patients have lethal hypersensitivity rxn to ABC/abaclaviar

Front 56

HIV tropism

Back 56

used prior to intiiation of co-receptor blocker
only use if CCR5 +
HIV progresses is associated with cahnging co-receptors phenotypicaly from CCR5 to CXCR4

Front 57

initiate HAART

Back 57

hx AIDS defining illness
pregos
CD4<350
HIV-associated neuropathy
co-infected w/HBV

Front 58

HIV complications when CD4>350

Back 58

karposi sarcoma
TB
NHL
peripheral neuropathy
malignancies

Front 59

recommended NRTI backbone

Back 59

tenofovir + emtricitibine

caution in renal insufficency
don't use w/nevirapine due to early virologic failure

Front 60

recommended NNRTI

Back 60

efaverienz

don't use in pyschiatric disorders or 1st trimester of pregos

Front 61

recommended PIs

Back 61

Atazanivr + ritonavir
-don't use with >20mg PPI
Darunavir + ritonavir
-don't use w/sulfa allergy
Lopinavir + ritonavir
-use in pregos
Fosamprenavir + ritonavir

Front 62

HAART

Back 62

NNRTI + NRTI + NRTI

OR

PI + NRTI + NRTI

Front 63

virulogic failure

Back 63

VL > 400 after 24 weks
VL > 50 after 48 weeks
detectable VL after immunological suppresion

need to add at least 2 preferably 3 newly active agents to regimen

Front 64

immunologic failure

Back 64

lack of CD4 response despite virologic suppression

Front 65

risk of AIDS increases with

Back 65

increase in age
increase in VL
decrease in CD4

Front 66

fixed dose combination NRTIs

Back 66

zidovudine (AZT) + lamivudine (3TC) = combivir

abacavir (ABC) + Lamiviudine (3TC) = ePZICOME

tenofovir (TDF) + emtricitbabine (FTC) = travuda

Front 67

fixed dose NRTI + NRIT + NNRTI

Back 67

Atripla

tenofavir (TDF) + emtricitbabine (FTC) + efavirenz (EFV)

Front 68

resisitance testing

Back 68

recommended in pregnant women

not recommended when meds have been D/C for over 4 weeks or HIV RNA is < 500 copies/mL

Front 69

recommended ART for pregos
(lowest incidence of birth defects even though all ART thankfully has low incidence)

Back 69

PI - lopinavir + ritonavir

NNRTI - Nevirapine

NRTI backbone - Zidovudine + Lamivudine

Front 70

HIVAN (HIV-associated nephtropathy

Back 70

most frequent cause of chronic renal failure in HIV
more common in blacks
not related to CD4 depletion

ABC needs to be dosed based on CrCl

Front 71

Tx for HIV & HBV

Back 71

TDF (tenofavir) + FTC (emtricibane)

OR

TDF (tenofavir ) + 3TC (lamivudine)

do not use if only tx HBV! use PEG-INF

Front 72

HIV-associated nepthropathy

Back 72

do not give TDF + FTC

not for patients w/renal insufficeny

Front 73

ZDV

Back 73

NRTI
can worsen anemia or nuetropenia

Front 74

alternative nucloeside backbone

Back 74

ABC + 3TC (lamivudine)
do not use in + HLAB*5701
do not use VL > 100,000
use in caution w/CVD

Front 75

efaverienz

Back 75

preffered NNRTI
do not use in pregos 1st trimester, pregos potential, or in pyschiatric disease

Front 76

Nevarapine (NVP)

Back 76

alternative NNRTI to Efaverienz

do not use with FTC/3TC + TDF due to early virologic failure
use in pregnancy
do use in hepatic impairment
do not use in women with initial CD4 > 250 or in men with initial CD4 > 400

Front 77

ATV

Back 77

atazanavir
PI
QD
do not use > 20 mg PPIs

Front 78

DRV

Back 78

darunavir
do not use w/sulfa allergy
PI
QD

Front 79

FPV

Back 79

fosmeprenavir
PI
BID

Front 80

LPV

Back 80

lopinavir + ritonavir (in 1 TAB) - Kaletra
QD/BID
use in pregos

Front 81

NNRTIs

Back 81

have less GI side effects, fat maldistribution, & metabolic AEs
more potent and less pill burden (have to add ritonavir to PIs)
have higher incidence of skin rash, resisitance, DIs, CNS sides effects (Efaverienz)

Front 82

PIs

Back 82

high a higher genetic barrier

have higher pill burden, GI AEs, metabolic complications and DIs than NNRTIs

Front 83

TDF/FTC

Back 83

preferred nucleoside backbone
associated with nephrototoxicity and decline in BMD
do not use in renal insufficiency and w/neveripine due to virological failure

Front 84

ABC/3TC

Back 84

alternative nucleoside backbone
increase MI in patients with CV risk factors
do not use in + HLB*5708

Front 85

travuda

Back 85

TDF + FTC
should not be used in CrCl < 30 mL/min

Front 86

Epzicom

Back 86

fixed dose ABC/3TC

only pay 1 copay
reduces pill burden

Front 87

PIs for tx-naive patients

Back 87

atazanvir
darunavir
fosamprenavir
lopinavir
boost PIs with 100-200 mg of ritonavir (increases t1/2 by inhibiting the CYP34A) downside can cause ritonavir-induced hyperlipidemia

Front 88

ATV

Back 88

atazinovir can cause hyperbilrubinermia, prolong PR interval & nephrolithiasis

do not use in patients with > 20 mg PPI

Front 89

DRV

Back 89

darunvir can cause skin rash due to sulfonamide moeity, steven-johnson syndrome, erythema, and hepatotoxicity

Front 90

FPV

Back 90

fosmprevair can cause skin rash and hyperlipidemia

Front 91

LPV

Back 91

lopinavir can cause hyperlipidemia, especially increased TGs, GI intolerance, asthenia, elevated LFTs, and hyperglycemia
do for DMs or high cholesterol!!!
use in pregos

Front 92

ART for pregos + HIV

Back 92

zidovudine + lamuvdine (nucleoside backbone)

Nevirapine (NNRTIs)

lopinavir/r (PIs)

Front 93

Darunavir

Back 93

600 mg BID for tx-experienced
400 mg BID for tx-naive

can cause rash and liver toxicity

Front 94

Maraviroc

Back 94

(CCR5 inhibtor)
+ tropism
150 mg / 300 mg
not for tx-naive patients

Front 95

Maraviroc dosing

Back 95

150 mg BID with CYP34A inhibitors(PIs,-azoles,clarthromycin)
300 mg BID
600 mg BID w/CYP34A inducers(efavirenz,rifampin,carbamazepine,phenobarbital,pheytoin)

Front 96

Raltegravir

Back 96

intergrase inhibitor
400 mg BID
metabolized by UGT1A1 glucoronidation
for tx experienced
no CYP450 DIs

Front 97

resisitance to ART

Back 97

mutations at K103N, Y181C, & G190A

Front 98

tx for tx-experienced patients

Back 98

entavirine + darunavir + raltegravir

Front 99

hyperlipdemia associated with

Back 99

PIs and d4T (stavudine) NRTI

also avoid PIs in DMs due to insulin resistance

Front 100

stauduvine

Back 100

d4T
has been associated with lipatrophy/lipystrophy

Front 101

start PCP prophylaxis

Back 101

CD4 < 200
prior PCP
hx of AIDS defining illness
oral thrush
fever of unknown origin for 2 weeks

Front 102

PCP prophylaxis

Back 102

bactrim
dapsone + prymethamine + leucovorine
atovoquone 1500 mg QD w/meals
aerolized pentamidine 300 mg/month

Front 103

PCP tx

Back 103

+ corticosteriods to tx if hypoxic (PaO2 < 70 mmHg) prednisone
40 mg BID on days 1-5
40 mg QD on day 6-10
20 mg QD on day 11-21

bactrim 15 mg/kg/day Q 8 hours for 21 days
or
atovaquone for mild cases
dapsone + TMP
clindamycin + primaquine
trimetrexate + leucovorin

Front 104

NRTIS

Back 104

AZT (ziovudine
ddt (didansoine
d4t (stavudine
3TC (lamivudine
ABC (abclavir
FTC (emtricabine

Front 105

NNRTIs

Back 105

nevirapine (NVP)
DELAVIRDINE (DLV)
efavirenz (EFV)

Front 106

nucleotide RTIs

Back 106

fenofovir (TDF)