HIV human immunodeficiency viruses

Diagnosis

Infection

Screening

Risks

  • MSM
  • Heterosexual, multiple partners
  • IVDU
  • Treated for hemophilia, blood transfusion 1978-85
  • Newly diagnosed TB, hep B, hep C
  • pregnant women
  • infant exposed to HIV

Frequency

  • Annual screening
  • In active MSM: 3-6 months
  • Pregnant women: 3rd trimester
  • Partner with HIV: every 6-12 months

Symptoms

  • Acute: fever, fatigue, myalgia, arthralgia, lymphadenopathy, pharyngitis, rash
  • Chronic: wax/waning lymphadenopathy
  • Opportunistic: PCP, esophageal candidiasis, cryptococcal meningitis, toxoplasma
  • Cancers: B lymphoma, Hodgkin, CNS lymphoma

Diagnosis

Initial Test

HIV Ag/Ab

  • 4th gen HIV 1/2 antigen/antibody combination test
  • decreased window period of 10 days
  • If negative and suspect HIV, use RNA PCR and retest in 4-12 wks

RNA PCR

  • High false positive in chronic infection
  • Good for acute infection if initial test negative because initial viral load is very high in HIV

Others

  • CD4, viral load, HIV genotype
  • Cancers: Anal cancer screening
  • Health: A1C, lipid, UA
  • Infections: Tb, RPR, CG, Gonorrhea, hepatitis, Pap
  • Others: pregnancy, testosterone

Routine

  • women: pap smear 2x 1st year of care, then annually if negative

Management

Principle

  • Goal: undetectable as long as possible, CD4 as high as possible
  • Pt may have blips of transietn viral load
  • drug interaction increases with age
    • Statin/topical steroids with protease inhibitors
    • metformin with dolutegravir

Interval Testing

  • CD4 percentage: good measurement of long term response because measured directly
  • CD4 cell count: derived from CBC. Vary widely
  • viral load measured 2-8 weeks after therapy initiation to assure response and adherance
  • 3 - 6 months interval testing of CD4 and viral load. 6 - 12 months if under control for 2 years

Prophylaxis

  • CD 4 > 200 for 3 months => discontinue primary prophylaxis

Immunizations

  • Pneumococcal: PCV13, when CD4 > 200 => PV23 8 wks after 13, 5 yrs later, and at 65
  • Hep A, B
  • HPV: - 26 yo
  • VSV: CD4 > 200
  • Tdap
  • Meningococcus: 2 doses 2 months apart, then q5y

Prregnant women

  • ART and then zidovudine during labor/delivery
  • neonates receive zidovudine for 4-6 wks
  • avoid breast feeding
  • vaginal delivery safe if prenatal viral load < 1000 copies/mL