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HIV and AIDS

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HIV is an infectious disease caused by a retrovirus. It infects and replicates in human lymphocytes and
macrophages, eroding the integrity of the human immune system over a number of years. Infection
culminates in immune deficiency and a susceptibility to a series of opportunistic and other infections as
well as the development of certain malignancies.

Epidemiology
According to the World Health Organization (WHO) there were approximately 38 million people living
with HIV at the end of 2019. HIV continues to be a worldwide health problem, having claimed almost 33
million lives so far. An estimated 38% of new transmissions are from people with HIV who do not know
their HIV status. The number of new patients starting treatment is below expected due to the COVID-19
pandemic which resulted in a reduction in HIV-testing and treatment initiation. By the end of 2020,
testing and treatment rates showed steady but variable recovery.

HIV Transmission
The major modes of acquiring HIV infection are:

Sexual transmission, including via heterosexual and homosexual contact

Parenteral transmission, predominantly among injection drug users (IDU)

Perinatal transmission

HIV Stages
According to the CDC, when people with HIV don’t get treatment, they typically progress through three
stages:

Stage 1: acute HIV infection

Stage 2: chronic HIV infection 

Stage 3: acquired immunodeficiency syndrome (AIDS) 

Acute HIV infection

Early HIV infection is a period of rapid viral replication with very high viral RNA levels. By around six
months of infection, plasma viremia reaches a steady-state level. Symptoms of acute HIV infection is
characterized by:

Fever 

Lymphadenopathy 

Sore throat (patients with HIV may have a chronic or recurring sore throat and develop thrush, an
opportunistic infection caused by candida albicans)

Rash

Myalgia/arthralgia 

Headache

May be asymptomatic 

Chronic HIV infection

This stage is also called asymptomatic HIV infection or clinical latency. HIV is still active but reproduces
at very low levels. The infected individual remains well with no evidence of the disease, and may only
have generalized lymphadenopathy on the exam. HIV is transmissible in this phase. The period is
variable among individuals, but the median time is ten years, if left untreated 50% will have AIDS.

CD4 count decreases 50/mm per year and is related to viral burden. In this stage it is below 500 but
more than 200 cells/microL.

Certain clinical syndromes are also seen during this stage of chronic infection, although these
complications worsen with severe immunosuppression, they can occur at CD4 cell counts >200
cells/microL: 

Recurrent or persistent oropharyngeal or vulvovaginal candidiasis

Oral hairy leukoplakia

Seborrheic dermatitis is a common early finding of HIV infection

Bacterial folliculitis, particularly due to Staphylococcus aureus 

The manifestations of herpes simplex virus, varicella-zoster virus, and human papillomavirus virus
infections are often more severe (e.g., with recurrences or more rapid progression) in the setting of
HIV infection

Acquired immunodeficiency syndrome (AIDS)

AIDS is the outcome of chronic HIV infection and consequent depletion of CD4 cells. It is defined as a
CD4 cell count <200 cells/microL or the presence of any AIDS-defining condition regardless of the CD4
cell count. AIDS-defining conditions are opportunistic illnesses that occur more frequently or more
severely because of immunosuppression and include opportunistic infections and malignancies. Patients
with AIDS have a high viral load and are very infectious. Advanced HIV infection occurs when the CD4
cell count is <50 cells/microL.

AIDS-defining conditions:

P. jirovecii pneumonia – most common 

Esophageal candidiasis

Wasting

Kaposi’s Sarcoma

Tuberculosis

Mycobacterium avium

CMV

HIV associated dementia

Recurrent pneumonia

Assessment
HIV screening and testing in primary care

Screen all patients 15 to 65 years of age at least once; younger adolescents and older adults at
increased risk should also be screened

Insufficient evidence to establish optimal intervals for screening

Reasonable to re-screen at-risk patients at a 1-year interval

Engage in high-risk behaviors

Live in or receive medical care in high prevalence settings, (e.g., correctional facilities,
homeless shelters, TB clinics, STI clinics, and clinics that serve men who have sex with men).

Screen all pregnant patients, including those who present in labor or at delivery whose HIV status
is unknown

Screen all patients being considered for pre-and post-exposure prophylaxis according to
established guidelines

Test when acute HIV infection is suspected in people with recent exposure history (i.e., within the
previous two months) and symptoms of recent viral infection, including fever, chills, night sweats,
fatigue, myalgia, lymphadenopathy, headache, sore throat, and diarrhea. 

Test when chronic HIV infection is suspected, based on clinical presentation and risk or exposure
history. Symptoms of chronic untreated HIV include fever, lymphadenopathy, malaise or fatigue,
weight loss, and symptoms from undiagnosed opportunistic infections. 

Investigations
Screening

For routine screening of HIV: 

The latest recommendation is to start with fourth generation enzyme-linked immunosorbent assay
(ELISA) that detects IgM and IgG antibodies and p24 antigen. 

Approximate window period is 15 to 20 days

Third generation ELISA detects IgG and IgM antibodies only, the window period is 20–30
days

Very high sensitivity and specificity

False negatives may occur during the window period immediately after infection 

When the result of fourth generation ELISA is positive, confirmatory tests should be followed using
HIV-1/HIV-2 differentiation immunoassay. This helps to know which type of HIV infection; type 1,
type 2 or both. But when the result of both HIV-1 and HIV-2 are negative or indeterminate, RNA
viral load should be done. 

For Discrete Exposure to HIV:

When the patient is exposed to HIV and the risk of transmission is high, it is recommended to perform
the most sensitive diagnostic tests available, such as an HIV viral load test (RT-PCR-based viral load
test). Combined antigen/antibody immunoassay test (fourth generation ELISA) should be followed. 

Baseline investigations

CD4, HIV RNA, and resistance test

Pregnancy test

CBC with differential

LFTs

Electrolytes

Serum creatinine (and calculated GFR)

Urinalysis for proteinuria

Lipid profile and blood sugar (both HIV and antiretrovirals increase the risk of CAD; medications
can affect lipids and blood sugar)

Hepatitis A, B, and C serology, Varicella Ab

STDs (gonorrhea, chlamydia, syphilis) 

Toxoplasma serology (IgG)

Pap smear at diagnosis, at six months, then yearly

Tuberculin skin test and chest x-ray

Subsequent investigations

CD4, HIV RNA every 3-4 months

Yearly PPD, lipid profile, fasting glucose, UA, and STD screening if at risk

Other important tests

Serum HIV DNA polymerase chain reaction (PCR)

Used to make a diagnosis of HIV, especially during the window period

CD4 count

Indicates immune status and assists in the staging process

CD4 count of >500 cells/ mL: patients are usually asymptomatic

CD4 count of <350 cells/mL: implies substantial immune suppression

CD4 count <200 cells/ml: defines AIDS and places the patient at high risk of most
opportunistic infections

CD4 count <50 cells/ml: advanced HIV infection

HIV prevention

At-risk individuals

Risk-reduction counseling regarding safe sex and condom use

Screening and treatment of STIs

Daily oral antiretroviral therapy (ART), known as preexposure prophylaxis (PrEP)

World Health Organization guidelines strongly recommend offering PrEP containing tenofovir

The US Centers for Disease Control and Prevention recommend PrEP with tenofovir and
emtricitabine

Prevention of HIV infection transmission from HIV mothers

To prevent HIV transmission from mother to child by suppression of the viral load by:

Early identification (screening HIV at first prenatal visit) and treatment of maternal HIV infection

Maternal adherence to ART 

Avoidance of breastfeeding if there is an alternative option 

Adherent to ART while breastfeeding if the breastfeeding is not avoidable 

Presumptive treatment for children born to mothers with HIV infection, or mothers at high risk for
HIV infection

Prevention of HIV infection: preexposure prophylaxis 

Clinicians should offer preexposure prophylaxis (PrEP) with effective antiretroviral therapy to
patients who are at high risk of HIV acquisition

Daily PrEP reduces the risk of getting HIV from sex by more than 90%

Combine with condoms to reduce risk AND to prevent other STIs

Among people who inject drugs, it reduces the risk by > 70%

Patient to be considered for PrEP 

Men who have sex with men, are sexually active, and have one of the following characteristics: 

Serodiscordant sex partner (i.e., in a sexual relationship with a partner living with HIV)

Inconsistent use of condoms

STI with syphilis, gonorrhea, or chlamydia within the past six months

Heterosexually active women and men who have one of the following characteristics: 

Serodiscordant sex partner (i.e., in a sexual relationship with a partner living with HIV)

Inconsistent use of condoms with a partner whose HIV status is unknown and who is at high
risk (e.g., a person who injects drugs or a man who has sex with men and women)

STI with syphilis or gonorrhea within the past six months

People who inject drugs and have one of the following characteristics: 

Shared use of drug injection equipment

Risk of sexual acquisition of HIV

Non-occupational post exposure prophylaxis (nPEP) 

HIV testing (rapid if possible) of patient, +/- source (can discontinue nPEP if source found to be HIV
negative)

Should be started within 72 hours of exposure

28-day course of 3-drug antiretroviral regimen

Preferred: Tenofovir disoproxil fumarate (300 mg) once daily with emtricitabine (200 mg) [Truvada]
q day plus raltegravir (400 mg) BID or dolutegravir 50 mg daily

Post exposure prophylaxis (PEP) In healthcare providers via needle stick

The risk to health care personnel (HCP) of contracting HIV from exposure to body fluids from an
HIV-infected patient is very low, about 3 per 1000 with no prophylaxis. 

The first response to a percutaneous exposure should be to wash the area thoroughly with soap
and water. For punctures and small lacerations, cleaning the area with an alcohol-based hand
hygiene agent is reasonable. Exposed mucous membranes should be irrigated copiously with water
or saline.

HCP should report exposures promptly to obtain HIV screening for both the HCP and the source
patient and to discuss the need for post-exposure prophylaxis (PEP).

Baseline investigations:

Antibody Testing Only (ELISA, EIA): Baseline, six weeks, 3, and 6 months 
or

p24 Antigen-Antibody 4th Generation: Baseline, six weeks, four months 

Indications for prophylaxis:

Offer PEP to HCP with a percutaneous mucous membrane or non intact skin exposure to
blood or bloody body fluids of a patient with a known HIV infection. 

If the HIV status of the source patient is unknown, we offer PEP while awaiting HIV testing,
particularly if the source patient is at high risk for HIV infection (e.g., drug users, men who
have sex with men) or has symptoms suggesting HIV infection. 

If the source patient cannot be identified (i.e., HIV testing not possible), we offer PEP if the
exposure occurred in a high-risk setting (e.g., a needle stick from a sharps container in an HIV
clinic or a needle exchange program). 

Timing of prophylaxis:

PEP should be started as soon as possible. The goal is to start within one to two hours (or
earlier) after exposure, with appropriate drugs that are available. It is likely that a delay in
starting PEP can reduce efficacy.

Preferred anti-retroviral for PEP:

For most patients, we suggest a three-drug regimen using Tenofovir disoproxil fumarate-
emtricitabine (300/200 mg once daily) + raltegravir (50 mg once daily) or Tenofovir disoproxil
fumarate -emtricitabine (300/200 mg once daily) plus raltegravir (400 mg twice daily).

Duration of therapy:

The recommended duration of PEP in HCP is four weeks.

Management
Giving results: HIV positive 

Must give results confidentially in person

Partner notification (screen for domestic violence)

Linkage to care: confirm contact information and insurance status 

Brief HIV education 

Communicable disease reporting: all new diagnoses must be reported to local/state health
authorities

Goals of treatment

Reduce HIV-associated morbidity and prolong duration and quality of survival

Restoration of immune function (CD4 count)

Prevention of HIV transmission: ART leads to a 96% reduction in risk of transmission among sexual
partners and vertical transmission

To keep the viral load to an undetectable level, which usually takes six months

Start with a combination of 3 antiviral drugs from 2 or more drug classes

Treatment is recommended for all patients with HIV, but some groups need it urgently

Pregnancy

History of AIDS-defining illness

Acute opportunistic infections

HIV-associated nephropathy

HIV/Hepatitis B or C virus coinfection

Patients at risk of transmitting HIV to sexual partners – Lower CD4 counts (<200 cells/mm3)

Acute/early infection

Pregnancy and ART therapy

Lowering viral load in pregnancy decreases the risk of vertical transmission

Treat regardless of CD4, the goal is to make the viral load undetectable

Avoid teratogenic drugs

All should be given ZDV as a continuous infusion during labor + their current ART therapy

C-section if viral load >1000 at 38 weeks gestation

Mothers infected with HIV should not breastfeed their infants; best way to prevent transmission of
HIV to an infant through breast milk is to not breastfeed

According to the CDC and the American Academy of Pediatrics HIV-infected mothers should
completely avoid breastfeeding their infants, regardless of ART and maternal viral load

Nucleoside/nucleotide Reverse Transcriptase lactic acidosis, hyperlipidemia, lipodystrophy, 

Inhibitors (NRTIs) 

NonNucleoside Reverse Transcriptase Inhibitors liver toxicity, lipid abnormalities, rash,

(NNRTIs) psychiatric symptoms 

Expand All Protease Inhibitors (PIs) glucose and lipid abnormalities, gastrointestinal
SE 
› Sections

 Section 1: Family Medicine

Table 18.7 – Side Effects of antiretroviral therapy
 Section 2: Internal Medicine

 Chapter 1: Epilepsy
Hepatitis A  All susceptible patients with HIV; single preparation (Twinrix) available if
 Chapter 2: Approach administering with hepatitis B vaccine 
to Dyspnea
Hepatitis B  All susceptible patients with HIV Not required if: hepatitis B surface antibody and
 Chapter 3: CNS
core antibodies are both positive
infections
or
 Chapter 4: Bruising
Hepatitis B surface antibody is positive after a previous complete vaccine series
and Bleeding
Disorders Herpes zoster  Recombinant zoster vaccine (Shingrix) is recommended for patients ≥ 50 years
 Chapter 5: Arthritis
Human Standard schedule; if not fully immunized, a catch-up immunization is indicated
 Chapter 6: Asthma papillomavirus  through 26 years of age; shared decision-making for 27 to 45 years of age
 Chapter 7: Lower
Influenza Standard schedule; live attenuated influenza vaccine contraindicated 
Respiratory Tract
(inactivated
Infections
only) 
 Chapter 8: Chronic
Obstructive Meningococcal  All patients with HIV 
Pulmonary Disease
Pneumococcal  All patients with HIV;
(COPD)
Adults who have never received a pneumococcal vaccine should receive a single
 Chapter 9: Chest Pain
dose of PCV 13 (regardless of CD4 count). Patients with a CD4 count of ≥ 200 cells
 Chapter 10: Heart per μL should then receive one dose of (PPSV23) at least eight weeks later (can
Failure offer to patients with a CD4 count < 200 cells per μL; however, PPSV23 should
 Chapter 11: Cardiac preferably be deferred until after the CD4 count increases to > 200 cells per μL
Arrhythmias with antiretroviral therapy). Administer a single revaccination dose of PPSV23 at
least five years after the previous PPSV23 dose. Administer a final dose of PPSV23
 Chapter 12: Thyroid
after 65 years of age (and should be administered at least five years after any doses
and Parathyroid
that were given before age 65). 
Disorders

 Chapter 13: Pituitary Tetanus toxoid, Standard schedule                                       

and Adrenal Disorders reduced
 Chapter 14: Urinary diphtheria
Tract Infections (UTIs) toxoid,
acellular
 Chapter 15: Gastric
pertussis
Disease
(Tdap) 
 Chapter 16: Stroke
and Transient
Ischemic Attacks (TIA) Table 18. 8 – Immunizations for adults with HIV
 Chapter 17: Note: Adults with a CD4 count < 200 cells per μL should not receive live vaccines
Osteoporosis

 Chapter 18: Sexually

Prophylactic antimicrobial agents
Transmitted Infections
› Sexually P. jiroveci prophylaxis: trimethoprim/sulfamethoxazole (TMP-SMX) if CD4 <200 cells/mm3, prior P.
Transmitted jiroveci, thrush, or unexplained fever for >2 weeks
Infections
Mycobacterium tuberculosis: Treat for latent TB if positive PPD or positive IGRA without prior
› Chlamydia
prophylaxis or treatment, with negative CXR, recent TB contact, or history of inadequately treated
Infection
TB that healed.
› Gonorrhea
Toxoplasma gondii prophylaxis: 33% per year risk of infection in untreated patients with CD4 <100
Infection
cells/mm3; prophylaxis: TMP-SMX 1 DS tab daily.
› Syphilis
M. avium complex prophylaxis: 20–40% risk with CD4 <50 and no ART. Azithromycin 1,200 mg PO
› HIV and AIDS
weekly is preferred prophylaxis.
› References
Patient monitoring
 Chapter 19: Hepatic
Disorders
HIV RNA (viral load) 2 to 8 weeks after starting therapy and repeated every 3 to 6 months until
 Chapter 20: Infectious
suppressed 
Diseases
Monitor HIV RNA, CD4, and CBC every 3 to 4 months for first 2 years of ART or if the CD4 count is
 Chapter 21: Fever of
<300 cells/mm3 
Unknown Origin
(FUO) Space CD4 monitoring to 12 months if suppressed viral load and CD4 >300 cells/mm3

 Chapter 22: Monitor HIV RNA and CBC every 6 months 

Neurology
Annual HIV RNA and CD4 count once viral load undetectable and stable
 Chapter 23:
Nephrology Once viral load has been suppressed consistently for >2 years and CD4 cell counts are consistently

Hematuria, Acute >500/μL, monitoring CD4 cell counts is optional unless virologic failure occurs (or there are

Renal Injury and intercurrent immunosuppressive treatments or conditions

Chronic Kidney Confirm HIV-1 RNA level is >50 copies/mL within 4 weeks of medication management decisions
Disease
Annual fasting lipids and fasting glucose; basic metabolic panel, AST/ALT, total/direct bilirubin
 Chapter 24:
every 6 to 12 months
Pulmonary
Annual cervical cytology annually (regardless of age) until three negative screens and then every 3
 Section 3: Pediatric years

 Section 4: Obstetric and Pregnancy test in women of childbearing age 

Gynecology Urinalysis every 6 to 12 months or as clinically indicated 

 Section 5: Psychiatry Hepatitis C as clinically indicated

 Section 6: Geriatric &

Palliative Care

 Section 7: Dermatology Was this helpful?

 Section 8: Surgery
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 Section 9: Opthalmology

 Section 10: ENT

 Section 11: Orthopedics PREVIOUSLY UP NEXT

 
Syphilis References
 Section 12: Urgent Care

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