HIV resident survival guide

HIV Resident Survival Guide Microchapters
Overview
Classification
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kanwal Khamuani, B.B.B.S.

Synonyms and keywords:

Overview

Human Immunodeficiency Virus, the agent causing Acquired Immunodeficiency Syndrome, is one of the leading infectious burdens globally and the fifth leading cause of disability in people of all ages. Belonging to the family of Retroviridae, it particularly infects the immune system cells such as CD4+ T cells, dendritic cells and macrophages. It has 2 serotypes with HIV-1 being most virulent and pathogenic. It is transmitted via sexual fluids(vaginal and semen), blood by percutaneous inoculation, Placenta(vertical transmission from mother to fetus) and breast milk. Due to competency of Antiretroviral therapy, it is now considered as a chronic illness seen most commonly in mono-sexual men. Initially, the symptoms are nonspecific until it develops into the last stage AIDS where the patient present with opportunistic infections due to suppressed immunity. It is diagnosed by PCR, ELISA, western blot and Rapid antigen testing. ART and vaccines have shown promising results in treatment and prevention respectively. As prevention is the foundation, CDC recommends screening mono-sexual men, pregnant women, drug abusers ad sexually active heterosexuals. Despite better treatment, it remains a serious disease that requires more effort by health care providers in terms of surveillance and education.

Classification

WHO and CDC classify the HIV infected individuals on the basis of CD count:

• STAGE A- Asymptomatic (CD count > 500/μl)
• STAGE B- Mild symptoms to symptoms of AIDS-related complex (CD count between 400/μl and 200/μl)
• STAGE C- AIDS defining illness (CD count <200/μl)

DISEASE PRESENTATION IN WEEKS

ACUTE PHASE SYMPTOMS ❑ Fever ❑ Lymph node enlargement ❑ Fatigue ❑ Malaise ❑ Single raised lesion ❑ Gastrointestinal symptoms ❑ Acute neuropathy ❑ Weight loss

DISEASE PRESENTATION IN MONTHS AND YEARS

Patients develop opportunistic infections and neoplasms when CD count becomes <200/μl.

FREQUENT OPPORTUNISTIC ORGANISMS ❑ Toxoplasma gondii ❑ Cryptosporidium parvum ❑ Pneumocystitis jiroveci ❑ Mycobacteria tuberculosis ❑ Atypical mycobacteria ❑ Salmonella ❑ Pneumonia ❑ Herpes Simplex virus ❑ Cytomegalovirus

FREQUENT NEOPLASMS ❑ Kaposi sarcoma by HHV-8 ❑ Non-Hodgkin EBV lymphoma ❑ HPV carcinoma

ASSOCIATED CONDITIONS ❑ Seborrhic eczema ❑ Skin atrophy ❑ Hairy leukoplakia at lateral tongue ❑ Hepatitis C

Diagnosis

Patient with high suspicion of having HIV in a highly prevalent region should have following diagnostic approach.

Abbreviations: RDTs: Rapid diagnostic tests; EIAs: enzyme immunoassays; CLIAs: chemiluminescence immunoanalysers;ELAs: electrochemiluminescence immunoanalysers;HIV: Human immunodeficiency virus

Initial approach ❑ inquire about symptoms ❑ fever ❑ joint pain ❑ sore throat ❑ skin rash ❑ swollen lymph nodes ❑ oral thrush ❑ diarrhea and weight loss ❑ fatigue ❑ Inquire about high risk behaviors and psychological factors ❑ Inquire about underlying diseases ❑ perform baseline investigations ❑ CBC ❑ Liver function test ❑ Renal function test ❑ Fasting glucose ❑ Lipid profile

If high suspicion of HIV ❑ Perform first line assays ❑ First line assays include fourth generation serological assays such as RDTs, EIAs, CLIAs, ECLs that detect HIV antibodies and P24 antigen ❑ Offer multiplex testing i-e test for syphilis, hepatitis B and C with the same sample

IF REACTIVE

IF NON REACTIVE

Confirm with second line assay from any other serological fourth generation assays

Report HIV negative

if positive

if negative

Report HIV positive and retest prior to starting ART

Repeat both first line and second line assay testing

if same results

if both negative

Report HIV negative OR retest if high risk features present

Perform third line assay

If positive-ask patient to return for testing in 14 days

if negative-report HIV negative

Treatment

The most effective treatment regimen is HAART that includes combination of 2 NRTIs and 1 drug from different class.

Abbreviations: HIV: Human immunodeficiency virus; NRTIs: nucleoside reverse transcriptase inhibitor; NNRTIs: non nucleoside reverse transcriptase inhibitor;TDF: tenofovir disoproxil fumarate;TAF: tenofovir alafenamide;CCR5: C-C motif chemokine receptor 5

HIV DRUG CLASSES

DRUG CLASS	EXAMPLES
NRTIS	Abacavir, emtricitabine, zidovudine, lamivudine, TDF, TAF
NNRTIs	Efavirenz, etravirine, neviripine, rilpivirine
INTEGRASE STARND INHIBITOR	Daltegravir, raltegravir,elvitegravir,bictegravir
PROTEASE INHIBITOR	Atazabavir, darunavir, ritonavir, tipranavir
FUSION INHIBITOR	Enfuviritide
CCR5 antagonist	Maraviroc
POST ATTACHMENT INHIBITOR	Ibalizumab
PHARMOCOKINETIC ENHANCER	Cobicistat

RECOMMENDED INITIAL REGIMENS

If Integrase inhibitor is an option

If integrase inhibitor is not an option

Dolutegravir/Abacavir/Lamivudine

Dolutegravir/TAF/Emtricitabine

Elvitegravir/Cobicistat/TAF/Emtricitabine

Raltegravir/TAF/Emtricitabine

Darunavir/TAF OR TDF/Emtricitabine

Efavirenz/TDF/Emtricitabine

Rilpivirine/TAF OR TDF/Emtricitabine

Do's

• HLAB*5701 testings should be performed before starting Abacavir.
• Monitor CBC with differentials when prescribing zidovudine.
• Monitor GFR when starting TAF or TDF.

Don'ts

• Do not give Tenofovir in renal impairment or bone disease.
• Do not give nevirapine in hepatic impairment.