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41 Cards in this Set

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What terminology is useful in categorizing HIV infection?
1. HIV infection is classifed by numbers 1, 2, 3 depending on CD4 acount.

1: greater than 500
2: between 200 and 499
3: less than 200

2. the letters A, B or C depends on the occurrence of specific conditions.

A = asymptomatic, or persistent generalized lymphadenopathy
B = bacillary angiomatosis, oral thrush, cervical dysplasia/carcinoma, oral hairy leukoplakia, herpes zoster (recurrent or multi-dermatomal) and ITP.
C = PCP, cryptococcal meningitis, toxoplasmosis, CMV retinitis, AIDS dementia complex, TB recurrent bacterial pneumonias, Kaposi's sarcoma, CNS lymphoma, and other non-Hodgkin's lymphomas.
What are "B" conditions?
1. bacillary angiomatosis
2. oral thrush
3. cervical dysplasia/carcinoma
4. oral hairy leukoplakia
5. herpes zoster (recurrent or multi-dermatomal)
6. ITP
What are "C" conditions?
1. PCP
2. cryptococcal meningitis
3. toxoplasmosis
4. CMV retinitis
5. AIDS dementia complex
6. TB recurrent bacterial
7. pneumonias
8. Kaposi's sarcoma
9. CNS lymphoma
10. other non-Hodgkin's lymphomas
How do you begin your oral presentation of any HIV-infected patient?
By giving the classification, last CD4 count and viral load.
Why are CD4 counts and HIV viral load important?
CD4 count indicates the severity of immune suppression and is used to determine:
1. disease classification
2. when to start or change antiretroviral therapy
3. when certain opportunisitc infections are likely
4 when to start opportunisitc infection prophylaxis

Quantitative HIV viral load gives prognostic information beyond that provided by the CD4 count. The higher the viral load, the more rapidly the patient is becoming immune-suppressed. Viral load is used to assess efficacy of antiretroviral therapy within weeks of any change.
What is the occurrence of AIDS-indicating conditions in the natural history of HIV infection according to mean CD4 cell count?
1. CD4 of 275, Kaposi's sarcoma
2. CD4 of 200, NHL
3. CD4 of 120, PCP
4. CD4 of 110, Toxoplasma
5. CD4 of 100, Cryptococcal meningitis
6. CD4 of 50, MAC
7. CD4 of 40, CMV disease
What is the risk of acquiring HIV infection from a needle stick injury?
The risk of infection is low, estimated in a CDC study to be 0.5% for percutaneous exposure (3/860). Based on other data, the risk is probably somewhat less (~0.2%) than that reported by the CDC. The risk for HIV transmission is greater if:

1. blood is seen on the needle
2. needle stick is a deep wound from a hollow bore needle
3. gloves were not worn
4. source patient has advanced HIV
What test do I use to screen for HIV infection?
Do an ELISA test. This detects HIV antibodies with sensitivity and specificity of greater than 99%.
What is the positive predictive value of the ELISA? Meaning the likelihood that a patient with a positive test actually has HIV infection.
The positive predictive value of the ELISA ranges from 20% in very low risk populations to greater than 95% in patients with strong risk factors.
Because ELISA is not 100% specific, what test do you use to confirm any positive ELISA?
You do a Western blot.
What does the Western blot for HIV look for?
This test detects serum antibodies directed against specific HIV-1 proteins of various molecular weights and is defined as positive when two or more of the following antibody bands are present: p24, gp41 or gp120/160.

Indeterminate Western blots are not uncommon: without p24, gp41 or gp 120/160 bands, the patient does not have an HIV infection and does not need further evaluation.
What is the window period?
This is the period of time between acquiring infection and development of antibodies. Antibody-based tests results remain negative in this window period.
What proportion of patients undergo seroconversion within 4 weeks of infection?
90%
What 3 tests can detect HIV infection before the appearance of antibody?
viral p24 antigen and viral load testing with nucleic acid polymerase chain reaction or branch chain DNA assays.
What key questions should I ask of patients with HIV infection at clinic visits with high CD4 counts (greater than 300)?
1. Medication side effects
2. Skin changes such as seborrheic dermatitis and generalized pruritis
3. General health (fatigue, weight change, anorexia, depression, TB)
What are the medication side effects of HAART?
pancreatitis: ddI, d4T, ddC
neuropathy: ddI, ddC, d4T
myositis: AZT
kidney stones: indinavir
diarrhea: nelfinavir, ritonavir
hepatitis: all protease inhibitors, nevirapine
In patients with low CD4 (less than 300), what generally causes headache, seizure, weakness, general fever, weight loss and night sweats?
1. MAC
2. AIDS wasting syndrome
3. toxoplasmosis
4. cryptococcus
In patients with low CD4 (less than 300), what generally causes dysphagia?
candidal esophagitis (CMV/HSV esophagitis less commonly)
In patients with low CD4 (less than 300), what generally causes diarrhea?
1. C. difficile
2. Cryptosporidium
3. MAC
In patients with low CD4 (less than 300), what generally causes abdominal pain?
1. MAC
2. lymphoma
3. acalculous cholecystitis
In patients with low CD4 (less than 300), what generally causes cough and dypsnea?
pneumonia, especially PCP
In patients with low CD4 (less than 300), what generally causes vision changes?
CMV
What are the important parts of physical exam to include in all visits?
Perform skin and oral exams at each visit in all patients.
How do you test for peripheral neuropathy in patients on ddI/ddC/D4T?
This can be done easily by breaking a cotton-tipped applicator and using the sharp broken end and the soft cotton end to distinguish sharp from light touch sensation.
Examination of the anal and perineal area should be done annually in patients with a history of receptive anal intercourse. Why?
These patients are at an increased risk for anal cancer due to HPV infection.
What are the 3 forms of candidiasis you should look for on an oral exam?
1. pseudomembranous candidiasis causes well-recognized thick white plaques on the tongue and palate.
2. atrophic candidiasis causes a painful red shiny tongue or hard palate
3. angular cheilitis causes cracking and fissuring at the corners of the mouth.

Look for hairy leukoplakia, aphthous ulcers, Kaposi's sarcoma and gingivitis as well.
When should I obtain HIV RNA viral load and CD4 counts?
1. before starting antiretroviral therapy
2. 4 weeks after starting a new antiretroviral regimen
3. every 3 to 4 months during antiretroviral therapy to assess whether modifications are needed.

Check CD4 counts every 6 months when CD4 is greater than 500 and every 3 months when CD4 is less than 500.
What antiretroviral drug should I use?
Combination therapy is the rule.

The most potent combination is two nucleoside reverse transcriptase inhibitors (AZT, ddI, ddC, d4T, 3TC, tenofovir, or abacavir) with a protease inhibitor.
When should I start antiretroviral therapy?

Patients who present with acute HIV infection should be enrolled in trials looking at the efficacy of aggressive antiretroviral therapy shortly after infection occurs. Some providers treat actue infection regardless of CD4 and viral load with triple drug combination include protease inhibitors, although we do not know long-term outcomes with this approach.

In patients with CD4 counts greater than 500 and an undetectable viral load, monitoring without antiretroviral therapy is appropriate.

A high viral load greater than ________ is reason to start antiretroviral therapy regardless of CD4 count.

When the CD4 count is less than _______, antiretroviral therapy can be considered and should be encouraged if the viral load is high (greater than _______ ).

Watching closely without antiretroviral therapy is a very reasonable approach in patients with CD4 counts above ______ , but with low or nondetectable viral loads.

Antiretroviral therapy should be started only when patients can commit to making all follow up visits and taking medications without missing doses so as to decrease the risk of developing viral resistance.
When should I start antiretroviral therapy?

Patients who present with acute HIV infection should be enrolled in trials looking at the efficacy of aggressive antiretroviral therapy shortly after infection occurs. Some providers treat actue infection regardless of CD4 and viral load with triple drug combination include protease inhibitors, although we do not know long-term outcomes with this approach.

In patients with CD4 counts greater than 500 and an undetectable viral load, monitoring without antiretroviral therapy is appropriate.

A high viral load greater than 55,000 is reason to start antiretroviral therapy regardless of CD4 count.

When the CD4 count is less than 500, antiretroviral therapy can be considered and should be encouraged if the viral load is high (greater than 55,000).

Watching closely without antiretroviral therapy is a very reasonable approach in patients with CD4 counts above 350, but with low or nondetectable viral loads.

Antiretroviral therapy should be started only when patients can commit to making all follow up visits and taking medications without missing doses so as to decrease the risk of developing viral resistance.
What are the side effects of antiretroviral agents?

Zidovudine (AZT) can cause headaches, nausea and vomiting when first started.

______ and __________ occur with longer-term use and are more common in patients who have lower CD4 counts.

Patients on the drug for more than six months can develop ________ .
Zidovudine (AZT) can cause headaches, nausea and vomiting when first started.

ANEMIA and NEUTROPENIA occur with longer-term use and are more common in patients who have lower CD4 counts.

Patients on the drug for more than six months can develop MYOPATHY.
What are the side effects of antiretroviral agents?

All the drugs that begin with "D" (ddI, ddC, D4T) can cause peripheral neuropathy and ___________.

In addition, ddC can also produce ________ ulceration.
All the drugs that begin with "D" (ddI, ddC, D4T) can cause peripheral neuropathy and PANCREATITIS

In addition, ddC can also produce MUCOSAL ulceration.
What are the side effects of antiretroviral agents?

_______ can cause a life-threatening allergic reaction.
ABACAVIR can cause a life-threatening allergic reaction.
What are the side effects of antiretroviral agents?

The non-nucleoside drug ___________ is responsible for rash in 15% of patients and can rarely cause liver failure.

The non-nucleoside drug _________ can cause insomnia, nightmares, and problems concentrating.
The non-nucleoside drug NEVIRAPINE is responsible for rash in 15% of patients and can rarely cause liver failure.

The non-nucleoside drug EFAVIRENZ can cause insomnia, nightmares, and problems concentrating.
What are the side effects of antiretroviral agents?

All the protease inhibitors (indinavir, ritonavir, nelfinavir, amprenavir, lopinavir, and saquinavir) can result in __________ elevations.

_________ is known for its propensity to produce kidney stones. Patients on this drug should be counseled to stay well hydrated.

All protease inhibitors can raise _______ and lower _______ as well as cause _________ intolerance, so lipids and glucoses should be monitored regularly.
What are the side effects of antiretroviral agents?

All the protease inhibitors (indinavir, ritonavir, nelfinavir, amprenavir, lopinavir, and saquinavir) can result in TRANSAMINASE elevations.

INDINAVIR is known for its propensity to produce kidney stones. Patients on this drug should be counseled to stay well hydrated.

All protease inhibitors can raise TRIGLYCERIDES and lower HDL LEVELS as well as cause GLUCOSE intolerance, so lipids and glucoses should be monitored regularly.
What is lipodystrophy?

Patients on protease inhibitors or d4T (stavudine) can develop changes in body fat distribution referred to as lipodystrophy.

Typical features are temporal wasting and sunken checks, thin arms and thin legs with a protuberant abdomen ("protease paunch"). Veins on the arms and legs become prominent and there is an increased incidence of paronychia (soft tissue inflammation around fingernail).

Metabolic abnormalities include increase _____ and _____ and low _______ .
What is lipodystrophy?

Patients on protease inhibitors or d4T (stavudine) can develop changes in body fat distribution referred to as lipodystrophy.

Typical features are temporal wasting and sunken checks, thin arms and thin legs with a protuberant abdomen ("protease paunch"). Veins on the arms and legs become prominent and there is an increased incidence of paronychia (soft tissue inflammation around fingernail).

Metabolic abnormalities include increase GLUCOSE and TRIGLYCERIDES and low HDL LEVELS.
When should I start prophylaxis against Pneumocystis carinii pneumonia (PCP)?

Patients who have any of the following conditions should receive PCP prophylaxis:

1. CD4 count under 200
2. Previous PCP
3. Oral candidiasis


__________ is by far the most effective agent. It is also prophylactic against ______ and may prevent bacterial sinusitis and bacterial pneumonias.
When should I start prophylaxis against Pneumocystis carinii pneumonia (PCP)?

Patients who have any of the following conditions should receive PCP prophylaxis:

1. CD4 count under 200
2. Previous PCP
3. Oral candidiasis


TRIMETHOPRIM-SULFAMETHOXAZOLE is by far the most effective agent. It is also prophylactic against TOXOPLASMOSIS and may prevent bacterial sinusitis and bacterial pneumonias.
When should I start prophylaxis against Pneumocystis carinii pneumonia (PCP)?

For patients who cannot tolerate TMP/SMX, ______ is a reasonable option.
For patients who cannot tolerate TMP/SMX, DAPSONE is a reasonable option.
When should I start prophylaxis against Pneumocystis carinii pneumonia (PCP)?

Atovaquone and aerosolized _________ are third-line options, but are less effective than TMP/SMX or dapsone.

Because aerosolized __________ is not a systemic therapy, patients may develop Pneumocystis at sites other than their lungs.
When should I start prophylaxis against Pneumocystis carinii pneumonia (PCP)?

Atovaquone and aerosolized PENTAMIDINE are third-line options, but are less effective than TMP/SMX or dapsone.

Because aerosolized PENTAMIDINE is not a systemic therapy, patients may develop Pneumocystis at sites other than their lungs.
How should I start prophylaxis against Pneumocystis carinii pneumonia (PCP)?

Pneumocystis prophylaxis can be stopped in patients on highly active antiretroviral therapy (HAART) with CD4 counts that have risen above ______ and nondetectable viral loads for at least _______ months.
When should I start prophylaxis against Pneumocystis carinii pneumonia (PCP)?

Pneumocystis prophylaxis can be stopped in patients on highly active antiretroviral therapy (HAART) with CD4 counts that have risen above 200 and nondetectable viral loads for at least SIX months.
When should patients receive Mycobacterium avium (MAC) prophylaxis?

Current recommendations start MAC prophylaxis when CD4 count is under ____ .

Favored regimens are __________ or __________ .

MAC prophylaxis can be stopped in patients on HAART who have CD4 counts above 100 and non-detectable viral loads for at least _____ months.
When should patients receive Mycobacterium avium (MAC) prophylaxis?

Current recommendations start MAC prophylaxis when CD4 count is under 50.

Favored regiments are AZITHROMYCIN 1200 mg weekly or CLARITHROMYCIN 500 mg bid.

MAC prophylaxis can be stopped in patients on HAART who have CD4 counts above 100 and non-detectable viral loads for at least SIX months.
What do I do if I get a needle-stick from an HIV-infected patient?

First of all, try to prevent this by wearing gloves whenever you draw blood, manipulate IV lines, or examine a mucosal surface.

Wear eye protection for any procedure (endoscopy, bronchoscopy, surgery).

NEVER recap needles: this is the most common cause of needle stick injury.

Use of _____ after needle-stick injury appears to decrease the risk of transmission.

Current practice is to give _____ plus _____ for lower risk exposures, and to add a third drug, usually a ________ for high-risk exposures.

If the source patient has known AZT resistance, substitute D4T, abacavir, or ddI for the AZT in the prophylactic regimen.
What do I do if I get a needle-stick from an HIV-infected patient?

First of all, try to prevent this by wearing gloves whenever you draw blood, manipulate IV lines, or examine a mucosal surface.

Wear eye protection for any procedure (endoscopy, bronchoscopy, surgery).

NEVER recap needles: this is the most common cause of needle stick injury.

Use of AZT after needle-stick injury appears to decrease the risk of transmission.

Current practice is to give AZT (zidovudine) plus 3TC (lamivudine) for lower risk exposures, and to add a third drug, usually a PROTEASE INHIBITOR for high-risk exposures.

If the source patient has known AZT resistance, substitute D4T, abacavir, or ddI for the AZT in the prophylactic regimen.