Initial Approach to the HIV-Infected Patient

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Initial Approach to the HIV-Infected Patient
Ronald Wilcox Delta AETC
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Objectives

• Summarize the key elements of the intake history
  and physical exam of a new HIV positive patient
• Review laboratory and other studies pertinent to
  the care of a new HIV positive patient
• Discuss early treatment decisions that may be
  required

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HIV Infection- A Chronic Disease
Inpatient Management
Serologic OI HAART
Testing Prophylaxis

Outpatient Management
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Testing for HIV Infection

• Implications of testing
• Who should be tested
• How to test

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Implications of HIV Testing
Pre-test Counseling
Testing
Post-test Counseling
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How to Test for HIV Infection

• ELISA screen for chronic infection
• Western Blot confirm chronic infection
• Indirect Immunofluorescence Assay
• Viral Nucleic Acid Detection - RNA PCR
  screen for acute infection - cDNA PCR
  screen for perinatal infection - bDNA
• p24 antigen confirmation of acute infection
• Rapid HIV Screens

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Initial Approach to the HIV-Infected Patient

• Data Collection
• Patient Education
• Early Treatment Decisions

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Data Collection

• History
• Physical Exam
• Laboratory and other clinical studies

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Intake History

• Details of HIV testing
• When? Why? Previous negative test?
• HIV specific symptoms
• Fever, night sweats, weight loss, lymphadenopathy
• Symptoms indicative of HIV-associated illness
• History of tuberculosis exposure
• History of STDs
• Gynecologic history in females

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Intake History

• ALL medications include alternative, herbal ,
  and OTC medications as well as contraception
• Immunization history
• HIV transmission category and risk factors
• MSM vs IVDU vs known heterosexual exposure vs
  blood transfusion
• Social habits
• Travel history
• ROS directed towards symptoms indicative of
  HIV-associated illnesses

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Question

• Which of the following supplements is
  CONTRA-INDICATED with anti-retroviral therapy?
• 1. Gingko baloba
• 2. Creatine
• 3. Vitamin C
• 4. St. Johns Wort

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LA StatisticsExposure Category for People Newly
Diagnosed with HIV/AIDS in 2007 (06/30/08)
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Question

• Which of the following is NOT a cutaneous
  manifestation of HIV disease?
• 1. Psoriasis
• 2. Sebhorreic dermatitis
• 3. Chelosis
• 4. Bacillary angiomatosis
• 5. Eosinophilic folliculitis

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Cutaneous Manifestations of HIV Infection

• Rash of acute retroviral syndrome
• Histoplasmosis
• Scabies
• Multi-dermatomal herpes zoster
• Sebhorreic dermatitis
• Cryptococcal lesions

• Kaposi sarcoma
• Bacillary angiomatosis
• Herpes simplex
• Cheilosis/Chelitis
• Eosinophilic folliculitis
• Human papilloma virus
• Molluscum contagiosum

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Cutaneous Manifestations
Histoplasma
Cryptococcus
ARS
Scabies
Kaposi Sarcoma
Bacillary Angiomatosis
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Oropharyngeal Manifestations of HIV Infection

• Necrotizing Ulcerative Periodontitis
• Kaposi Sarcoma
• Mucosal Ulcerations
• Candida
• Histoplasmosis
• Syphilis
• Herpes simplex
• Cytomegalovirus
• Aphthous

• Non-Hodgkin Lymphoma
• Oral Squamous Cell Carcinoma
• Human Papilloma Virus
• Bacillary Angiomatosis
• Oral Hairy Leukoplakia
• Candidiasis

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Oropharyngeal Manifestations
Necrotizing Ulcerative Periodontitis
Kaposi Sarcoma
Non-Hodgkin Lymphoma
Mucosal Ulceration
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Ophthalmologic Manifestations of HIV Infection

• Progressive Outer Retinal Necrosis
• Cytomegaloviral retinitis
• Toxoplasmic chorioretinitis

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Ophthalmologic Manifestations
Toxoplasma Chorioretinitis
Progressive Outer Retinal Necrosis
Cytomegaloviral Retinitis
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Genitourinary Complications Related to HIV
Infection

• Sexually transmitted infections
• Herpes Simplex
• Human Papilloma Virus
• Syphilis
• Gonorrhea
• Chlamydia
• Trichomonas
• Vaginal aphthous ulcerations
• Cervical and Rectal Cancer

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Genitourinary Complications Related to HIV
Infection
Anogenital Warts
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Question

• An HIV positive patient with a CD4 count of 5 on
  no medications except TMP/SMX (Bactrim) presents
  to the Emergency Room after a seizure.
• What is the most likely cause of the seizure?
• 1. Toxoplasmosis
• 2. Staphylococcus aureus abscess
• 3. Non-Hodgkin Lymphoma
• 4. Progressive Multifocal Leukoencephalopathy
• 5. HIV Encephalopathy

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Neurologic Manifestations of HIV Infection

• Peripheral neuropathy
• HIV-Associated Dementia
• HIV encephalopathy
• HSV encephalitis
• Aseptic meningitis
• Vacuolar myelopathy
• TB meningitis
• Progressive Multifocal Leukoencephalopathy
• HIV Cephalgias

• Brain Mass Lesions
• MAGIC
• Metastases
• Abscesses (toxoplasma, fungal, mycobacterial,
  bacterial)
• Glioma
• Infections (PML, CMV)
• Cancer (NHL) or Cysts

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Significant Symptom Review

• Fever, weight loss, fatigue
• Disseminated MAC
• Fever, weight loss, fatigue, rash
• Disseminated histoplasmosis

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Significant Symptom Review

• Headache slowly progressive with fever
• Cryptococcal meningitis
• Tuberculous meningitis
• Seizure
• Cerebral toxoplasmosis
• Primary CNS Lymphoma

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Significant symptom review

• Shortness of breath gradual non-porductive
  cough or clear to white sputum
• Pneumocystis jirovecii (PcP)
• Productive cough, weight loss, hemoptysis
• Tuberculosis

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Laboratory Studies- ALL Patients

• CD4 cell count
• HIV viral load
• CBC with differential
• Chemistry panel
• VDRL or RPR and other STD testing
• Hepatitis A, B, and C serology

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CD4 Cell Count

• Stage disease
• Determine the risk of HIV-associated
  complications
• Determine the need for opportunistic infection
  prophylaxis
• Guide decision making regarding antiviral therapy

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CD4 cell count can vary substantially and is
affected by

• Concomitant use of corticosteroids
• Intercurrent illness
• Co-infection with HTLV-I
• Variation of other components of the WBC count
• Splenectomy

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HIV Viral Load

• Assess prognosis
• Determine the need for antiviral therapy
• Guide choice of antiviral regimen
• Assess response to therapy

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HIV Viral Load

• RNA PCR
• bDNA
• HIV Viral Load can be affected by
• Intercurrent illness
• Recent vaccination

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Question

• All of the following are increased in the
  HIV-infected patient EXCEPT
• 1. Thrombocytopenic thrombotic purpura (TTP)
• 2. Idiopathic thrombocytopenic purpura (ITP)
• 3. Anemia of chronic disease
• 4. Iron-deficiency anemia
• 5. Lymphopenia
• 6. Neutropenia

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Laboratory Studies- ALL Patients

• Anti-toxoplasma IgG
• Urinalysis
• TB skin test (or chest x-ray)
• Pap smear in women
• HIV Resistance Testing in Patients not currently
  controlled on medications and ALL treatment-naïve
  patients

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HIV Resistance in Naïve Pts

• Test to order genotype
• 15-40 of those newly diagnosed have baseline
  resistance
• Only do if never on meds before or currently on
  meds and viral load gt 1500.

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Question

• Urinalysis is done in the HIV-infected patient to
  screen for HIV-associated nephropathy (HAN).
  Which is the best indicator for the possible
  presence of HAN?
• 1. Proteinuria
• 2. Crystalluria
• 3. Hematuria
• 4. Pyuria (WBC in the urine)
• 5. Low specific gravity

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Question

• Urinalysis is done in the HIV-infected patient to
  screen for HIV-associated nephropathy (HAN).
  Which is the best indicator for the possible
  presence of HAN?
• 1. Proteinuria Focal Segmental
  Glomerulosclerosis
• 2. Crystalluria
• 3. Hematuria IgA Nephropathy
• 4. Pyuria (WBC in the urine)
• 5. Low specific gravity

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Laboratory Studies- CONSIDER

• Repeat HIV serology
• Anti-varicella IgG
• G-6-PD level
• Anal PAP smears
• HTLV 1,2 Antibodies

• Fasting lipid profile
• Morning testosterone level
• Chest radiograph
• HLA-B5701

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Patient Education

• Natural history of HIV infection
• Health maintenance issues
• Nutrition counseling
• Transmission of HIV and risk assessment
• Partner notification
• Social support evaluation
• Mental health assessment

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Early Treatment Decisions

• Immunizations
• Highly Active Antiretroviral Therapy
• Opportunistic infection prophylaxis

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Immunizations

• Optimally give when immune response most likely
• Early before immune deterioration
• After immune recovery on HAART

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Question

• Which of the following immunizations would be
  contra-indicated in a patient with AIDS?
• 1. Td
• 2. Pneumovax
• 3. Influenza
• 4. Hepatitis A
• 5. MMR

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Immunizations-Avoid Live Vaccines

• BCG
• MMR
• Varicella-zoster
• Oral polio
• Oral typhoid
• Yellow fever

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Routine Immunizations for HIV-Infected Patients

• Pneumococcal
• Influenza
• Hepatitis B begin after CD4 count gt 200 and
  viral load suppressed
• Hepatitis A
• Tetanus-Diphtheria

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Summation

• Approach to newly diagnosed HIV patient is
  similar to all patients but must specifically
  look at
• Signs or symptoms of opportunistic infections
• Unusual lab work-up including CD4 counts and
  viral loads and genotypes
• Avoidance of live viral vaccines
• Determine need for OI prophylaxis while waiting
  for evaluation by HIV expert

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Question

• As compared to how I felt before the presentation
  on evaluating newly diagnosed HIV-infected
  people, I now feel
• 1. Much more comfortable
• 2. A little more comfortable
• 3. About the same
• 4. A little more leery
• 5. I will not see patients with HIV in the future