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HIV Recognition in the ED

Explore the changing landscape of HIV infection, its presentations in the ED, and the importance of history-taking with a focus on adults and children living with HIV. Understand the global epidemiology and the acute HIV infection opportunities for diagnosis in various healthcare settings. 8

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HIV Recognition in the ED

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  1. HIV Recognition in the ED Martha I. Buitrago, MD Infectious Diseases Idaho State University

  2. HIV in the ED • Changing Epidemiology • HIV Infection • Presentations in the ED • History Taking

  3. Adults and children estimated to be living with HIV as of end 2003 Eastern Europe & Central Asia 1.3 million [860 000 – 1.9 million] Western Europe 580 000 [460 000 – 730 000] North America 1.0 million [520 000 – 1.6 million] East Asia 900 000 [450 000 – 1.5 million] North Africa & Middle East 480 000 [200 000 – 1.4 million] Caribbean 430 000 [270 000 – 760 000] South & South-East Asia 6.5 million [4.1 – 9.6 million] Sub-Saharan Africa 25.0 million [23.1 – 27.9 million] Latin America 1.6 million [1.2 – 2.1 million] Oceania 32 000 [21 000 – 46 000] Total: 37.8 (34.6 – 42.3) million

  4. Children(<15 years)estimated to be living with HIV as of end 2003 Eastern Europe & Central Asia 8 100 [6 600 – 12 000] Western Europe 6 200 [4 900 – 7 900] North America 11 000 [5 600 – 17 000] East Asia 7 700 [2 700 – 22 000] North Africa & Middle East 21 000 [6 300 – 72 000] Caribbean 22 000 [11 000 – 48 000] South & South-East Asia 160 000 [91 000 – 300 000] Sub-Saharan Africa 1.9 million [1.7 – 2.2 million] Latin America 25 000 [20 000 – 41 000] Oceania 600 [< 2 000] Total: 2.1 (1.9 – 2.5) million

  5. Estimated number of adults and childrennewly infected with HIV during 2003 Eastern Europe & Central Asia 360 000 [160 000 – 900 000] Western Europe 20 000 [13 000 – 37 000] North America 44 000 [16 000 – 120 000] East Asia 200 000 [62 000 – 590 000] North Africa & Middle East 75 000 [21 000 – 310 000] Caribbean 52 000 [26 000 – 140 000] South & South-East Asia 850 000 [430 000 – 2.0 million] Sub-Saharan Africa 3.0 million [2.6 – 3.7 million] Latin America 200 000 [140 000 – 340 000] Oceania 5 000 [2 100 – 13 000] Total: 4.8 (4.2 – 6.3) million

  6. Estimated number of children (<15 years)newly infected with HIV during 2003 Eastern Europe & Central Asia 1 500 [1 000 – 2 900] Western Europe < 100 [< 200] North America < 100 [< 200] East Asia 3 300 [1 200 – 9 200] North Africa & Middle East 8 400 [2 500 – 28 000] Caribbean 6 000 [3 000 – 13 000] South & South-East Asia 47 000 [29 000 – 87 000] Sub-Saharan Africa 550 000 [500 000 – 650 000] Latin America 6 400 [5 100 – 10 000] Oceania < 300 [< 1 000] Total: 630 000 (570 000 – 740 000)

  7. Estimated adult and child deaths from AIDS during 2003 Eastern Europe & Central Asia 49 000 [32 000 – 71 000] Western Europe 6 000 [<8 000] North America 16 000 [8 300 – 25 000] East Asia 44 000 [22 000 – 75 000] North Africa & Middle East 24 000 [9 900 – 62 000] Caribbean 35 000 [23 000 – 59 000] South & South-East Asia 460 000 [290 000 – 700 000] Sub-Saharan Africa 2.2 million [2.0 – 2.5 million] Latin America 84 000 [65 000 – 110 000] Oceania 700 [<1 300] Total: 2.9 (2.6 – 3.3) million

  8. About 14 000 new HIV infections a day in 2003 • More than 95% are in low and middle income countries • Almost 2000 are in children under 15 years of age • About 12 000 are in persons aged 15 to 49 years, of whom: • almost 50% are women • about 50% are 15–24 year olds

  9. Global estimates for adults and childrenend 2003 • People living with HIV • New HIV infections in 2003 • Deaths due to AIDS in 2003 37.8 million [34.6 – 42.3 million] 4.8 million [4.2 – 6.3 million] 2.9 million [2.6 – 3.3 million]

  10. 13.2 Million Children have been Orphaned Since the start of the Epidemic

  11. Epidemiology • Changing demographics: 19982000 Women 21% 27% White 38% 36% Non-White 41% 47% MSM 45% 42% IVDU 20% 25% Heterosexuals 19% 26%

  12. Idaho Cumulative HIV/AIDS 2003 -Cumulative statistics from April 1986 when HIV became a reportable disease in Idaho -HIV (+): Total # of HIV (+) individuals excluding Idaho AIDS cases

  13. HIV in Idaho – Prevalence HIV / AIDS • District 1 95 • District 2 46 • District 3 101 • District 4 333 • District 5 76 • District 6 64 • District 7 46 • Total 761 (As of June 2004)

  14. Idaho Cumulative HIV/AIDS 2003

  15. Idaho Cumulative HIV/AIDS 2003

  16. HIV Presentations • Primary HIV Infection • Asymptomatic Screening • Chronic HIV Infection • Late-Stage AIDS Mayo Clin Proc 2002;77:1097-1102

  17. HIV Presentation

  18. Case # 1 • Mr. John Corporate is a pleasant 30 y.o male, captain of the baseball team. He comes to the ER with complaints of fatigue, sore throat, painful nodes on his neck, and generalized body rash. • All symptoms started 2 months after his last business trip.

  19. Case # 1 • What other questions would you ask? • What is your differential diagnosis? • What tests would you order?

  20. Acute HIV Infection: opportunities for diagnosis • Physicians’ offices • Emergency rooms • Community health centers • Dermatology clinics • Sexually transmitted disease centers • HIV clinics Mayo Clin Proc 2002;77:1097-1102

  21. Acute HIV Infection • Transient symptomatic illness in 40-90% • nonspecific illness to severe manifestations • occasionally can result in hospitalization • No specific constellation of signs or symptoms can differentiate acute HIV from other illnesses • Kahn JO, Walker BD. Acute human immunodeficiency virus type 1 infection. N Engl J Med 1998;339:33-39 • Schacker, T, et al. Clinical and epidemiologic features of primary HIV infection. Ann Intern Med. 1996;125:257-264

  22. HIV Infection

  23. Fever Lymphadenopathy Pharyngitis Rash Myalgia/arthralgia Diarrhea Headache Nausea/Vomiting Hepatosplenomegaly Weight loss Thrush Neurologic symptoms 96% 74% 70% 70% 54% 32% 32% 27% 14% 13% 12% 12% Acute Retroviral Syndrome  CDC. Guidelines for using antiretroviral agents…MMWR 2002;51(RR-7)

  24. Acute HIV Infection • Symptoms present days to weeks after initial exposure • Most common presentation: • fever, fatigue, headache, and rash • Nonspecific symptoms overlap with common viral illnesses • High index of suspicion is CRITICAL

  25. Acute Retroviral Syndrome • Rash (40-80%) • erythematous maculopapular with lesion on face and trunk (rarely extremities) • mucocutaneous ulceration involving the mouth, esophagus, or genitals • Rash would help differentiate from infectious mononucleosis

  26. Acute Retroviral Syndrome • Neurologic symptoms (24%) • meningoencephalitis or aseptic meningitis • peripheral neuropathy or radiculopathy • facial palsy • Guillain-Barré syndrome • brachial neuritis • cognitive impairment • psychosis

  27. Influenza Epstein-Barr virus mononucleosis Severe (streptococcal) pharyngitis Secondary syphilis Primary CMV infection Toxoplasmosis Drug reaction Viral hepatitis Primary HSV infection Rubella Brucellosis Malaria West Nile Virus Acute HIV DDX

  28. Acute HIV: Diagnosis • Question all patients about HIV risk behaviors including sexual activity and injection drug use. • Perform a thorough physical examination with particular attention to the signs of primary HIV infection such as rash, mucocutaneous ulcers, and lymphadenopathy. • Perform a baseline HIV antibody test. • This serves two important purposes: • it establishes whether chronic HIV infection is present • the consent process initiates a discussion with the patient about the implications of HIV testing • Obtain an HIV viral load test, if the suspicion of acute HIV is high (the HIV antibody is likely to be negative in acute HIV infection)

  29. HIV Antibody Tests • Serum antibody (EIA) • Saliva and urine antibody tests (EIA) • Rapid tests • SUDS (microfiltration EIA) • Laboratory-based • OraQuick • Point of care • Western blot assay • Confirmatory test

  30. Potential Benefits of Treatment during PHI • Suppress initial burst of viremia • ? alter viral set-point • Decrease viral evolution • Preserve CD4 lymphocytes (both absolute number and HIV-specific) • Potentially decrease risk of transmission • Possibly allow for future cessation of therapy

  31. Potential Risks of Treatment during PHI • Drug toxicity • Costs of possible lifelong therapy • Starting therapy in patients who may never have needed it • Early development of resistance • Little evidence to date of clinical benefit

  32. Acute HIV - Treatment • Goal: long-term viral suppression • Evidence: • Animal models (Macaques/SIV) • Small case reports • Berlin patient, New York pair, Caracas couple

  33. Acute Infection No Therapy • Control of SIV viremia w/ 3 wks on Rx & 3 wks off Rx • Long term trial of 3 wks on & 3 wks off in SIV+ macaques SIV RNA (log10), Median STI-HAART HAART Weeks Lori et al. Science 2000

  34. 90,000 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 The Berlin Patient = No treatment HIV RNA, copies/mL Hepatitis A121–137 Epididymitis 15–22 176....... Permanently discontinued <500 0 -10 30 70 110 150 190 230 270 310 350 390 727 Time, days Lisziewicz et al. New Engl JMed. 1999.

  35. The symptoms — especially in mild cases — are nonspecific and resolve spontaneously without treatment. Clinicians may be uncomfortable raising the question of sexual exposure or intravenous drug-use, especially with patients whom they only see infrequently such as young, previously healthy individuals. Primary care physicians may not be aware of high-risk behavior even in patients they know well. Patients may not perceive themselves to be at risk. Acute HIV: Missed Opportunity

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