Human Immunodeficiency Virus Infections and Acquired Immunodeficiency Syndrome
Marisa Tungsiripat
Alan J. Taege
RAPID BOARD REVIEW—KEY POINTS TO REMEMBER:
Acute HIV Infection
The symptoms of acute HIV infection are self-limited and most likely correlate with viremia.
Fever (mean, 38.9°C), rash, lymphadenopathy, and nonexudative pharyngitis are each present in >70% of individuals.
Chronic HIV Infection
Frequently, the initial diagnosis of HIV infection is made when the patient develops an AIDS indicator condition.
The evaluation of fever of unknown origin or unexplained weight loss should always include an HIV test, even in elderly patients without identified risk factors.
The Centers for Disease Control and Prevention advocates HIV testing for all individuals ages 13 to 64 years, at least once, with additional annual tests for those with risk behaviors.
Diagnosis
A positive enzyme-linked immunosorbent assay (ELISA or EIA) is only a presumptive evidence of infection with HIV and must be followed and confirmed by a Western blot.
False-positive EIAs occur in chronic renal failure, malignancies, severe liver disease, vaccination, or autoreactive antibodies (i.e., ANA).
Indeterminate assays can also occur in early seroconversion. A repeat assay should be performed within 2 to 4 weeks.
Therapy
Routine health maintenance care appropriate for the individual’s age must not be overlooked, including breast, colon, and prostate cancer screening as per current guidelines.
If CD4 count <200 cells/mm3, Pneumocystis carinii (now Pneumocystis jirovecii) pneumonia (PCP) prophylaxis should be initiated. The first-line agent is trimethoprim-sulfamethoxazole (TMP-SMX), one double-strength tablet daily.
If CD4 count <100 cells/mm3, patients with positive Toxoplasma gondii IgG serologies require prophylaxis to prevent reactivation. Daily TMP-SMX is the drug of choice.
If CD4 count <50 cells/mm3, Mycobacterium avium complex prophylaxis is recommended with azithromycin 1,200 mg/week.
ANTIRETROVIRAL THERAPY
All patients with symptomatic HIV disease or a CD4 count ≤200 should be offered highly active antiretroviral therapy (HAART). The U.S. Department of Health and Human Services (DHHS) recommends the treatment should be given when CD4 ≤500 cells/mm3.
First-line regimens include two nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) and either a nonnucleoside reverse transcriptase inhibitors (NNRTI) or a protease inhibitor PI. DHHS recommends one NNRTIcontaining regimen (efavirenz) + tenofovir/emtricitabine, two PI-containing regimens (darunavir + ritonavir or atazanavir + ritonavir) + tenofovir/emtricitabine or an integrase (raltegravir) + tenofovir/emtricitabine.
Follow the viral load every 4 to 8 weeks, immediately after starting the regimen. The viral load should be undetectable after 16 to 24 weeks of therapy.
Pregnancy
Cesarean section at 38 weeks is recommended if the viral load >1,000 copies/cc in late pregnancy.
All HIV-infected women with the viral load >1,000 copies/cc should receive intravenous zidovudine during labor (or as a continuous infusion, beginning with a loading dose prior to the planned cesarean section); the infant should receive zidovudine (for 6 weeks after birth) and nevirapine.
Postexposure Prophylaxis
A percutaneous exposure through a needlestick injury or intravenous drug use results in transmission 0.4% or 0.67% of the time, respectively.
Basic regimens contain two NRTIs. The most common are zidovudine/lamivudine or tenofovir/emtricitabine.
Addition of a protease inhibitor is recommended when an expanded regimen is selected. The regimen should be initiated as soon as possible, ideally within 1 hour of the exposure, and continued for 28 days.Related posts:
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