HIV/AIDS

Definition
HIV is a retrovirus infecting the CD4 (T-Helper) cell. CD4 cells drop from a normal level of 600 to 1000
per ul at a rate of 50 to 100 per year in a person who is untreated. Depletion of the CD4 cell count takes
between 5 and 10 years before clinical manifestations generally occur. It is not HIV itself that leads to
symptoms and death. Rather, the depletion of the CD4 count leads to opportunistic infections that lead to
illness.

Etiology
HIV is transmitted through:
• Injection drug use with contaminated needles
• Sex, particularly men who have sex with men
• Transfusion (extremely rare since 1985)
• Perinatal
• Needle stick or blood-contaminated sharp instrument injury

Presentation

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Diagnostic Tests

Viral Load Testing (PCR-RNA level)

Viral load testing is useful to:
• Measure response to therapy (decreasing levels are good)
• Detect treatment failure (rising levels are bad)
• Diagnose HIV in babies
The goal of therapy is to drive down the viral load. Undetectable levels (below 50/ul) indicate that the
CD4 will most likely rise. When the viral load is driven to undetectable levels and the CD4 rises,
opportunistic infections rarely occur.
Life expectancy for a person with HIV whose viral load is undetectable by PCR-RNA is equal in duration
to an HIV-negative person.

Viral Resistance Testing (Genotyping)

Viral resistance testing should be performed prior to initiating antiretroviral medications. This decreases
the likelihood of starting medication to which the patient's virus is resistant. Resistance testing is also
done if there is evidence of treatment failure. In the event of treatment failure (if the viral load decreased
first then raised again), resistance testing guides the choice of medications to select 3 drugs from 2
different classes to which the patient's virus is susceptible.

Treatment

Initial Antiretroviral Medication

The best initial drug regimen is a combination of emtricitabine/tenofovir/efavirenz

Alternate Drug Regimens

If cannot be used because of resistance, alternate regimens are based on a combination of 3 drugs from at
least 2 different classes. The first choices are either atazanavir, darunavir, or raltegravir combined with
emtricitabine/tenofovir. Ritonavir in small dose is used to "boost" darunavir or atazanavir levels

These medications are used for those with drug resistance to multiple classes of first-line agents.
Entry inhibitors:
• Enfuvirtide
• Maraviroc (blocks the CCR5 receptor)
Integrase inhibitor:
• Raltegravir

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Crystal-induced nephropathy is a well-known side effect of indinavir therapy.

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Complication of therapy

- Immune reconstitution inflammatory syndrome (IRIS)

- Lipodystrophy

- Dyslipidemia

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Opportunistic Infections

Prophylaxis

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Mycobacterium Avium-Intracellulare (MAI)
HIV and < 50 CD4 cells.

Localized MAC may present with fever, leukocytosis, and focal lymphadenitis (cervical, intra-
abdominal, mediastinal). Blood cultures are usually negative and diagnosis is confirmed with culture from
lymph node aspirate.

Disseminated MAC usually presents with fever, night sweats, abdominal pain, diarrhea, and weight
loss (wasting syndrome).

Laboratory findings
Anemia, Pancytopenia (if bone marrow is involved)
Elevated alkaline phosphatase, LDH and GGTP with a normal bilirubin (if hepatic involvement).

Imaging:
CT scans can be normal or reveal lymphadenopathy or hepatosplenomegaly.

Diagnostic testing:
Blood culture is the least sensitive.
Bone marrow is more sensitive.
Liver biopsy is the most sensitive.

Treatment:
Clarithromycin (preferred over azithromycin) and ethambutol.
Prophylaxis with azithromycin or clarithromycin. Rifabutin is used as an alternative to macrolides
Rifabutin is added for patients with high mycobacterial loads (> 2 log colony-forming units/mL of blood)
or ineffective ART.
Patients already taking ART can continue the retroviral medications.
Patients not taking ART usually start after 2 weeks of MAC treatment to decrease the chance of immune
reconstitution inflammatory syndrome

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Pneumonia
Pneumococcal pneumonia

Pneumocystis pneumonia

· IV TMP/SMX
· If there is a rash or drop of WBCs, use IV pentamidine or the combination of clindamycin and
primaquine.
·If there are hyperkalemia and ↑ BUN → stop TMP/SMX and hydrate with saline
·Atovaquone can be used for mild pneumocystis.
·Dapsone is not intravenous and is used for prophylaxis, not treatment.

Extrapulmonary disease

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TB reactivation

Latent TB

Don’t use rifampin in combination with protease inhibitor, use rifabutin instead.

NHL
AIDS-related lymphomas are common in patients with advanced HIV, a low CD4 count (<100/pL), high
HIV viral load, and a prior diagnosis of AIDS. Patients with non-Hodgkin lymphoma (NHL) tend to
present with B symptoms. extranodal disease, and involvement of unusual locations. Diffuse large-cell
NHL and Burkitt lymphoma are the most common AIDS-related lymphomas.

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CNS

HIV dementia

Toxoplasmosis

Pyrimethamine causes bone marrow suppression and leucovorin should be used in conjunction to
decrease the risk of hematologic complications.

In HIV patient with CD4 < 100 cells/ul with ring enhancing lesion
The next best step → treat with pyrimethamine and sulfadiazine for 2 weeks
Repeat the CT scan after treatment
If smaller → Continue treatment (toxoplasmosis)
If unchanged or larger → Perform brain biopsy

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Primary lymphoma

Progressive Multifocal Leukoencephalopathy (PML)

There is no specific therapy available for PML. Treat with HAART. When the
CD4 count rises, PML will resolve.

Nocardiosis

Diagnosis
The best initial → Gram stain shows positive, branching, partially acid fast.
The most accurate → brain biopsy
Treatment TMP – SMX. Alternatives: 3rd cephalosporins, imipenem, amikacin.

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Cryptococcal meningoencephalitis

Disseminated infection

Cutaneous cryptococcus

Diagnosis

Treatment

D.D

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Skin
Kaposi sarcoma

Intralesional injections of vincristine or interferon are very successful.

If these fail, use chemotherapy with liposomal doxorubicin.

Bacillary angiomatosis

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Diarrhea in HIV

Non-opportunistic infections Salmonella, Campylobacter, Entamoeba, Chlamydia, Shigella,

and Giardia Iamblia
Opportunistic infections CMV, Cryplosporidium, lsopora belli, Blaslocyslis, MAC,
Herpes simplex virus, Adenovirus, and HIV itself
Non-infectious causes Kaposi sarcoma or lymphoma of the Gl tract

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Dysphagia (esophagitis)

Managmenet

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HIV screening

Screening for STDs

Newly diagnosed HIV

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Post exposure prophylaxis

Management

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Vaccination

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HIV during pregnancy

Current guidelines recommend that all HIV positive women take antiretroviral prophylaxis, regardless of
HIV RNA level or CD4 count.
Delaying HAART until after the 2nd trimester may not adequately suppress HIV RNA and can significantly
increase the risk of fetal transmission.

HIV during breastfeeding

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