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LEARNING OBJECTIVES

  1. Recommend options for pre- and postexposure prophylaxis.

  2. Recognize the symptoms of acute HIV infection.

  3. Recognize potential barriers to medication adherence and suggest potential resolutions to these barriers.

  4. Recommend a first-line treatment for women living with HIV.

  5. Describe the management of pregnant women living with HIV.

INTRODUCTION

According to the Centers for Disease Control (CDC), there were approximately 40,000 new diagnoses of Human Immunodeficiency Virus (HIV) in the United States in 2016.1 Women comprised approximately 20% of these new HIV diagnoses with heterosexual contact accounting for 87% and injection drug use (IDU) accounting for 12% of those new diagnoses. Among women who received an HIV diagnosis, 61% were African American, 19% were Caucasian, 16% were Hispanic/Latina, and 5% were other race.1 An inverse relationship is seen between HIV prevalence and markers of socioeconomic status including education, annual household income, poverty level, employment, and homelessness status. For example, in areas of lower income, the HIV prevalence is higher.2 Of the estimated 255,900 women living with HIV (WLH) at the end of 2014, 12% were unaware of their diagnosis. Among the WLH, 88% had been diagnosed, 64% were in medical care, 50% were retained in HIV care, and 48% were virologically undetectable.1

Patient Case (Part 1)

P.J. is a 32-year-old woman who presents to your clinic for preconception counseling. She was diagnosed with HIV 2 years ago and started on efavirenz/emtricitabine/tenofovir DF. Since then she has been adherent with all follow-up appointments and her HIV RNA has been undetectable for over 1 year. She has no current complaints about her ART and is excited to become pregnant as soon as possible.

PMH: HIV-1 infection (diagnosed 2 years ago)

Family History: non-contributory

Social History: denies smoking, drinking, or illicit drugs

Medications: efavirenz/emtricitabine/tenofovir DF 600/200/300 mg

Allergies: NKDA

Vital Signs: Height 5′8″; weight 155 lb; BP 122/82 mm Hg; pulse 66 beats per minute

Physical Examination: Within normal limits

Laboratory Tests: HIV RNA undetectable, CD4 T-lymphocyte count 650 cells/mm3, pregnancy test negative, STI screening negative, baseline HIV-1 genotype: wildtype

Clinical Presentation and Pathophysiology

HIV is a single stranded, positive sense RNA retrovirus. There are two related, yet distinct, types of HIV: HIV-1 and HIV-2.3 HIV-2 is more prominent in West Africa. The most common type in the Western world is HIV-1. The virus integrates its DNA into the host chromosome to establish a persistent infection, particularly in CD4 T-lymphocyte cells. Continuous antiretroviral therapy (ART) is required as the virus will re-emerge if treatment is discontinued due to this viral integration. Treatment of HIV-1 differs from HIV-2; this chapter will focus on the treatment of HIV-1 infection.

HIV infection has three stages: acute, chronic, and acquired immunodeficiency syndrome (AIDS). The diagnosis of acute HIV infection is important as this is when HIV RNA (ie, viral load) levels are high and ...

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