chronic hiv infection clinical manifestations opportunistic infections o.i. prophylaxis

Chronic HIV Infection

Clinical Manifestations

Opportunistic Infections

O.I. Prophylaxis

1

10

100

1,000

10,000

100,000

1,000,000

10,000,000

Pla

sma

HIV

RN

A

Plasma RNA Copies

CD4 Cells

4-8 Weeks Up to 12 Years 2-3 Years

CD

4 Cell C

ount

1,000

500

Intermediate Stage AIDS

Primary Infection

Sero-conversion

CD4 Count, Viral Load and Clinical Course

Common Clinical Manifestations of Chronic HIV Infection

• Constitutional Symptoms– fever– weight loss/wasting– fatigue

• Organ/System Specific– virtually all organ systems can be affected

• Consider HIV testing for unexplained syndromes

Wasting

By Salvatore Marra, from AIDS imaging http://members.xoom.it/Aidsimaging

http://hivinsite.ucsf.edu

Oral Manifestations of HIV/AIDS

CNS Lesions

http://www.medinfo.ufl.edu/year2/ophthal/images/35.jpg

Prophylaxis against Opportunistic Infections

• Pneumocystis carinii pneumonia (PCP)

• Toxoplasmosis gondii

• Mycobacterium Avium Complex (MAC)

• Cryptococcal Meningitis

• CMV retinitis

• Mycobacterium tuberculosis (TB)

PCP - Primary Prophylaxis

• Initiate at CD4<200 or prior AIDS-defining illness

• Best: TMP-SMX– 1 DS qd, 1 SS qd, 1 DS qod or tiw– 1 DS qd also confers protection vs T. gondii and

common bacterial infections– consider desensitization if allergic reaction– up to 70% of patients can tolerate reinstitution of

therapy

Toxoplasmic Encephalitis Primary Prophylaxis

• Avoid contact with cat feces, raw or undercooked meat, esp. if IgG (-)

• Initiate primary prophylaxis at CD4<100

• Options include:– TMP-SMX– dapsone plus pyrimethamine/leucovorin– atovaquone plus pyrimethamine/leucovorin– pyrimethamine-sulfadiazine/leucovorin

MAC Primary Prophylaxis

• initiate at CD4<50; R/O dMAC first if symptomatic• options:

– clarithromycin 500mg po bid

– azithromycin 500mg po qd or 1200mg po qwk

– rifabutin 300mg po qd

• survival benefit shown for clarithromycin• multiple interactions between rifabutin and

antiretrovirals

http://www.medinfo.ufl.edu/year2/ophthal/images/35.jpg

Cytomegalovirus Primary Prophylaxis

• Counseling and regular ophthalmological exams for patients with CD4<50

• CMV(-) blood for patients who are CMV(-) at baseline

Candidal Infections

• fluconazole can reduce risk of vaginal, oropharyngeal and esophageal infection

• however, generally not recommended:– potential for resistance, cost, possibility of drug

interactions

– low mortality associated with these infections

– acute treatment generally effective

Candidal Infections for which prophylaxis may be warranted:

• recurrent esophageal candidiasis: fluconazole 100-200mg qd

• recurrent Candida vaginitis: weekly intravaginal clotrimazole tablets or lactobacillus gel capsules reduces frequency by approximately 50%1

1. Abstract 677, 7th Conference on Retroviruses and Opportunistic Infections, 2000.

Tuberculosis Prophylaxis: Treatment of Latent TB Infection

DHS/OI/PP

Isoniazid300 mg qd x 9 months

or 900 mg 2x/week x 9 months

PPD > 5 mm Indurationor

Recent Contact with Infectious TB Patient

*Rifampin600 mg qd x 2 months

plus

Pyrazinamide20 mg/kg/d x 2 months

*Use Rifabutin 300 mg qd if patient on PI

From: CDC. MMWR 1999;48:No. RR-10.

Consultation Services for Clinicians Caring for Patients with HIV/AIDS

• Northwest AETC– (206) 994-8773 pager, (206) 731-1058 VM

• University of Washington MEDCON– (800) 326-5300

• National HIV Telephone Consultation Service (Warmline)– (800) 933-3413

• National Clinicians’ Post-Exposure Prophylaxis Hotline (PEPline)– (888) HIV-4911

Extra slides

Primary Prophylaxis vs Cryptococcal Meningitis?

• Fluconazole provides limited protection

• resistance can develop

• Not routinely recommended

chronic hiv infection clinical manifestations opportunistic infections o.i. prophylaxis

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