Chronic HIV Infection

1. Chronic HIV Infection Clinical Manifestations Opportunistic Infections O.I. Prophylaxis

2. CD4 Count, Viral Load and Clinical Course Primary Infection Sero-conversion Intermediate Stage AIDS CD4 Cell Count Plasma RNA Copies 1,000 CD4 Cells 500 4-8 Weeks Up to 12 Years 2-3 Years

3. 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

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

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

6. http://hivinsite.ucsf.edu

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

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

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

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

11. Oral Manifestations of HIV/AIDS

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

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

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

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

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

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

18. CNS Lesions

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

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

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

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

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

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

25. Prophylaxis against Opportunistic Infections • Pneumocystis carinii pneumonia (PCP) • Toxoplasmosis gondii • Mycobacterium Avium Complex (MAC) • Cryptococcal Meningitis • CMV retinitis • Mycobacterium tuberculosis (TB)

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

27. 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

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

29. 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

30. 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

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

32. Cytomegalovirus Primary Prophylaxis • Counseling and regular ophthalmological exams for patients with CD4<50 • CMV(-) blood for patients who are CMV(-) at baseline

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

34. 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

35. 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.

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

37. Tuberculosis Prophylaxis: Treatment of Latent TB Infection PPD > 5 mm IndurationorRecent Contact with Infectious TB Patient *Rifampin600 mg qd x 2 monthsplusPyrazinamide20 mg/kg/d x 2 months Isoniazid300 mg qd x 9 months or 900 mg 2x/week x 9 months *Use Rifabutin 300 mg qd if patient on PI From: CDC. MMWR 1999;48:No. RR-10. DHS/OI/PP

38. 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

39. Extra slides

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

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

42. Primary Prophylaxis vs Cryptococcal Meningitis? • Fluconazole provides limited protection • resistance can develop • Not routinely recommended