HIV

Nota:

• Self-limiting, lasts 1-2 weeks and occurs in 30-60% HIV pts

1. Sore throat, fever, malaise, arthralgia, mouth ulcer, maculopapular rash

1. weight loss, fatigue, lymphadenopathy, night sweats, diarrhoea
2. Recurrent candidiasis
3. recurrent / extensive genital warts
4. shingles
5. oral hairy leucoplakia
6. Worsening eczema / psoriasis

Nota:

• Mean time to progession - 7-10 years, CD4+ less than 200

1. Respiratory
   1. TB

      Nota:

      • Early and late HIV present differently - early - normal presentation. advanced - malaise, fever, fatigue weight loss, CXR may be normal or pleural effusion, shadowing. tuberculin may bne negative and smear negative
      1. Presents atypically; PUO, minimal respiratory features, extra-pulmonary / disseminated disease
      2. CXR - cavitating lesions but atypical in HIV
      3. HIV / TB co infection - have a deleterious affect on each other
   2. pneumocystis pneumonia (PCP)

      Nota:

      • Pneumocystis jirovecii
      1. Gradual onset breathlessness, fever, dry cough
      2. exertional desaturation, bilateral crackles
   3. Cryptococcal

      Nota:

      • Lung, meningeal or wound infection. pigeon droppings (neoformans)
   4. Cryptosporidiosis

      Nota:

      • Infects intestine - diarrhoea - potentially fatal in AIDs
   5. Lymphocytic interstitial pneumonia

      Nota:

      • Dry cough, breathlessness
2. Malignancy
   1. Kaposis sarcoma

      Nota:

      • HHV 8 virus. commonly presents with lesions on tip of the nose - dermatological condition
   2. Cervical carcinoma
   3. Lymphoma
      1. Systemic NHL

         Nota:

         • 30% of malignancy death in HIV - associated with EBV
         1. Extranodal disease - meninges and bone marrow
3. CNS

   Nota:

   • usually at CD4 less than 100
   1. Encephalitis

      Nota:

      • Diffuse brain disorder
      1. CMV
      2. HSV
      3. HIV encephalopathy (AIDS-dementia complex)
   2. Focal / meningeal
      1. Tuberculous
      2. Cryptococcal
      3. CNS lymphoma

         Nota:

         • Single enhancing brain lesion - strongly associated with EBV. primary NHL
         • Associated with EBV - diagnosis by detection in CSF
         1. Focal neurological deficits
      4. Progressive multifocal leucoencephalopathy

         Nota:

         • focal areas of demylelination
   3. Toxoplasmosis

      Nota:

      • Multiple ring enhanced brain lesions
4. others
   1. Mucocutaneous herpes simplex
   2. Peripheral neuropathy
   3. HIV associated wasting
   4. CMV retinitis

      Nota:

      • CD4 less than 100
5. GI disorders
   1. Oral: herpes simplex, candida, apthous, hairy leucoplakia
   2. Diarrhoea; bacterial; salmonella, campylobacter, mycobacterium avium complex, protozoa; cryptosporidiosis, microsporidia, CMV
   3. Oesphageal; candidiasis, CMV oesophagitis, herpes simplex
6. Dermatological
   1. Psoriasis, achnes, seborrhoeic dermatitis
   2. itchy folliculitis
   3. Dermatophtosis
   4. crusted scabies
   5. VZV / HSV
   6. Molluscum contagiosum
   7. Recalcitrant warts

Nota:

• 5-10% HIV patients - little / no detectable virus in blood

1. cervical smears

   Nota:

   • Yearly smears as progression to malignancy to rapid
2. CD4 count

   Nota:

   • Indicates immune status. measure every 3 months
   1. less than 200 cells /mm - AIDs
3. Plasma viral load

   Nota:

   • measure every 3 months
4. Screen for other STIs

Nota:

• used in resource poor settings, window period - 3-6 months (need to wait for seroconversion?)

Nota:

• Window period 6 wks - 3 mnths (can be 15 days)

Nota:

• Generally started at CD4 counts less than 350 or opportunistic infection - balance risks and benefits

1. Risks
   1. drug toxicity
      1. Immediate - hypersensitivity reaction, acute hepatitis, pancreatitis, lactic acidosis
      2. Long term; increased MI risk, lipatrophy, lipodystrophy, nausea, diarrhoea
   2. Drug resistance

      Nota:

      • Need compliance of 95% to prevent resistance
2. Benefits
   1. Preservation of immune funtcion
   2. Decrease risk of transmission
   3. Prolonged disease free survival
   4. Reduced mortality from liver disease and malignancy
3. Types
   1. Nucleoside / tide reverse transcriptase inhibitors (NRTIs)
   2. Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
   3. Protease inhibitor
4. 2 NRTIs and 1 NNRTI / PI