Understanding HIV/AIDS and You: A Comprehensive Guide for P.A. Practitioners

1. HIV/AIDS and YOU (‘You’ being the P.A. practitioner) (I’m not implying that you have HIV) (But if you’re concerned, get tested) Ryan Scanlan, PA-C

2. History of HIV

3. History of HIV: a socio-cultural perspective

4. Infections by race/gender

5. Infection rates by age Under 13 = 217 13 to 19 = 2,234 20 to 24 = 7,565 25 to 29 = 6,823 30 to 34 = 5,954 35 to 39 = 5,523 40 to 44 = 5,720 45 to 49 = 5,296 50 to 54 = 3,671 55 to 59 = 2,154 60 to 64 = 1,119 TOTAL: 48, 298

6. Feel my fluidity • Blood and blood products • Semen • Pre-cum • Breast milks • Vaginal secretions

7. Sexual transmission • MSM • Heterosexual copulation • Circumcision, STIs • Significance of viral load • PEP • HAART • PrEP

8. The role of the t-Cell

10. infection • Seroconversion begins 7-21 days • Immune system launches enormous response • By Day 4 of seroconverting – 30% of CD4 infected or depleted • Within 2 weeks – viral load is over 1 million • Acute retroviral syndrome

11. Acute retroviral syndrome • 10-90% experience symptoms • 2-4 weeks post-exposure • Fever • Rash • Fatigue • Myalgias • Pharyngitis

12. Acute retroviral syndrome • Lymphadenopathy: • Axillary, Cervical, Occiptal nodes

13. Set point • Ineffectual Adaptive response – B cells • Mobilization of CD8 • Semi fixed viral load and CD4 • Seroconversion complete 4 – 10 weeks post-exposure • Viral Reservoirs

14. Provirus and Reservoirs • Brain • Lymphoid tissue • Genital tract • Bone marrow

15. Latent infection

16. Microbial translocation

17. Sequela of Chronic Inflammation • Constant immune activation • CD4 depletion • Derangement of function • “T-cell Exhaustion” • Greater susceptibility to infection even with CD4 count >200 cells/mL

18. Tests • ELISA – antibody detection only • OraQuick – 2nd gen – 25-35 days • UniGold – 2nd gen – 25-35 days • Western Blot – confirmation – 40 – 60 days • 4th generation – Ag/Ab test – 10-15 days • Viral load – HIV RNA

19. Initiating haart • Pregnancy • AIDS-defining conditions (OIs) • CD4 < 350, though recommended <500 • Rapidly declining CD4 (>100/year) • High viral load (>100,000 copies) • HIV-Associated nephropathy • Hep B co-infection

20. ARV therapy • Nucleoside Reverse Transcriptase Inhibitors • Non-Nucleoside Reverse Transcriptase Inhibitors • Protease Inhibitors • Integrase Inhibitors • Fusion Inhibitors • CCR5 Inhibitors

21. Antiretrovirals • NRTIs - combinations: Truvada Epzicom – good for renal impairment • NNRTI Efavirenz Atripla – Efavirenz + Truvada Complera – Rilpivirine + Truvada

22. Antiretrovirals • Protease Inhibitors – ALL are boosted with Norvir Prezista Reyataz • Integrase Inhibitors Isentress Tivicay Stribild – Integrase Inhibitor + Truvada

23. Starting a regimen • HIV genotype – Viral Load > 500 • If diagnosed after 2010, add Integrase Genotype • Regimens based on individual patient • All initial regimens have 2 NRTIs as a backbone, with one of the other classes buttressing • NNRTI – low barrier to resistance • PI / II – high barrier to resistance • Combination tablets

24. IRIS: Immune reconstitution inflammatory syndrome • Collection of inflammatory disorders associated with paradoxical worsening of preexisting infectious processes after initiation of HAART • Observed most commonly for mycobacterial infections (TB and DMAC) • Also: PCP, toxoplamosis, hep B and C, CMV, VZV, cryptococcal infection, histoplasmosis, PML • Diverse manifestations • “Unmask” disease at new site not known to be infected

26. Herpes Zoster • Impaired/depressed CD4 • Multidermatomal • Antiviral therapy

27. Diarrhea Cha Cha Cha • Frequency reduced since advent of HAART • Chronic diarrhea leads to diagnosis of HIV • Etiology may be bacterial, and the particular infectious agents are related to the level of immunocompromise • Cryptosporidium • Clostridium difficile! • Over half have no identifiable pathogen • HIV infection of the GI tract • Small bowel versus large bowel involvement

28. Diarrhea cha cha cha DIAGNOSIS: Stool culture C. Difficile toxin assay Ova and parasites Blood cultures Treatment: Flouroquinolones Metronidazole Antimotility drugs – Lotomil, Imodium

29. wasting • Increased demand • Diarrhea • Dyslipidemia

30. HIV-related Dyslipidemia • Unknown etiology – ART vs. HIV • Increases in LDL and triglycerides • Lipodystrophy • Cardiovascular risks • Treatment – Statins, to lower serum cholesterol

31. HIV-associated anemia • Heralds decreasing CD4 • Anemia of chronic disease • Decreased RBC production from chronic inflammation and defective erythropoiesis • Nutritional deficiencies and wasting • Iron, B12 Vitamin, Folate

32. Hiv Nephropathy, or, when peeing blood just doesn’t seem right • High Incidence in African Americans with HIV • 96-100% of HIV-associated nephropathy found in the African American population • Leads to ESRD • Poor prognosis – ESRD within 5-10 years of diagnosis

33. HIV Nephropathy • HIV directly infects the glomerular and renal tubular epithelial cells in HIV-associated nephropathy

34. HIV Nephropathy • Proteinuria – 1g – 30g/24 hours • Hypoalbuminemia => edema • Hyperlipidemia – decrease in HDL, increase in LDL and triglycerides • Hematuria • Hypertension

35. Hiv Nephropathy TREATMENT: 1.) HAART 2.) ACE Inhibitors – Fosinopril 10mg / day 3.) Glucocorticoids – Fail safe measure

36. Gurl, this virus is Workin’ my last nerve: HivneuropATHY • Impacts 1/3 of HIV+ patients • Distal symmetric peripheral neuropathy • Manifests as bilateral tingling and numbness • Diagnosis of HIV-related polyneuropathy is primary clinical, based on the physical exam

37. HIV Neuropathy • Treatment includes: • HAART • Anticonvulsants - Gabapentin • Antidepressants – Tricyclic antidepressants (amitriptyline) • Topical agents – lidocaine, capsaicin • Narcotics – tramadol, oxycodone, morphine, fentanyl

38. candida, aged 5 years and pairs nicely with Merlot

39. Thrush • Oral/pharyngeal candidiasis • Often asymptomatic, but can exhibit symptoms • CD4<200 = esophageal • Dx – clinical, but can use KOH mount • Tx – clotrimazol troche - 4-5 lozenges x 2 weeks • complications

40. pneumonias • Bacterial pneumonia most common • S. pneumoniae, H. influenzae, S. aureus, P. aeruginosa • Bacteremia more common in HIV infected patients • PCP second most common • Recurrences frequent – can lead to bronchiectasis

42. Pneumonias • Dx – Chest X-Ray • Findings: Bacterial – focal, segmental or lobar consolidations

43. Pneumonias • Findings: PCP – bilateral, interstitial reticular or granular opacities; upper lobe predominance

44. Pneumonias (still…) Normal CT PCP pneumo CT

45. Pneumonias • Induced sputum with Gram Stain • Bronchoscopy with Broncho-alveolar lavage (gold standard for dx of PCP pneumonia) • Treatment – CAP – flouroquinolone OR a third gen cephalosporin PLUS a macrolide • PCP - Bactrim

46. Mycobacterium avium complex (MAC) • Includes M. avium and M. intracellulare • Ubiquitous in environment • Pulmonary disease in non-AIDS pts with underlying lung dz and disseminated dz in AIDS • Involves reticuloendothelial system, GI tract • Fever, sweats, wt loss, diarrhea, malaise, anorexia • Anemia

47. MAC • Occurs at very low CD4 count (< 50) • Diagnosis usually by blood culture Lymph node biopsy

48. Prophylaxis/Treatment of MAC • Start prophylaxis when CD4 < 50 • Many would obtain baseline AFB blood cx • Can stop when CD4 > 100 x 3 mos • Azithromycin 1200 mg/wk or clarithromycin 500 mg po bid • Treatment: • Clarithromycin 500mg BID+ ethambutol 15mg/kg+/- rifabutin 300mg OD ( adjust if on a PI) • Azithromycin + ethambutol +/- rifabutin • Indefinite tx if CD4 remains low

49. Kaposi’s sarcoma • Most common malignancy in AIDS pts – association with cytotoxic T cells • Strong association with Human Herpes Virus-8 • Disproportionately affects gay men – sex, saliva • Patho: Suppression of onco-regulators • Proliferation of abnormal vascular structures – vascular tumor