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Chapter 35. HIV Infection and AIDS

Elizabeth Hand; Kathryn Dzintars

Incidence of HIV Infection & AIDS: 56,000 individuals in U.S. infected annually: 21% with HIV unaware of HIV + status; 31% progress to AIDS w/in 12mo of HIV diagnosis; strongly consider testing in those with risk factors: male-to-male sexual contact, IV drug use, heterosexual contact (http://www.cdc.gov/hiv/topics/surveillance/resources/reports/; JAMA 2008;300:520)

Table 35-1 Common Presenting Signs & Symptoms of Acute HIV Infection

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Table 35-1 Common Presenting Signs & Symptoms of Acute HIV Infection

Occurred in ≥50% of Patients

Occurred in ≤50% of Patients

Fever, fatigue, rash, HA, lymphadenopathy, pharyngitis, myalgia or arthralgias, night sweats, N/V, or diarrhea

Aseptic meningitis, oral ulcers, genital ulcers, thrombocytopenia, leukopenia, elevated hepatic enzyme levels

Signs & symptoms of acute HIV infection present w/in days to weeks of viral exposure & typically last <14d (N Engl J Med 1998;339:33)
Consider acute HIV infection in persons presenting with STD; differential diagnosis if unexplained, severe febrile illness
Newly diagnosed with HIV (N Engl J Med 2005;353:1702): care primarily based on sx; counsel patient regarding disease process/progression to AIDS; limit risk of secondary transmission; ensure proper support established; perform baseline lab testing prior to HIV management

Table 35-2 Recommended Baseline Tests at Entry into Care

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Table 35-2 Recommended Baseline Tests at Entry into Care

HIV antibody testing

CD4 T-cell count

Plasma HIV RNA (viral load)

Complete blood count

Chemistry panel

Transaminase levels

BUN & creatinine

Urinalysis

RPR, VDRL, or treponema EIA

Tuberculin skin test or interferon-γ release assay

Toxoplasma IgG

Hepatitis A, B, & C serology

Pap smear

Fasting blood glucose & serum lipids if risk factors for CVD

Genotype resistance testing if viral load >1000 copies/mL

HLA-B*5701 if considering abacavir as part of initial regimen (N Engl J Med 2008;358:568)

Tropism testing if considering maraviroc as part of initial regimen

Pathophysiology

Day 0: exposure to HIV at the mucosal surface → Day 0–2: virus collected by dendritic cells, carried to lymph nodes → Day 4–11: HIV replication in CD4 cells, then released into the blood → Day 11 onward: viral spread to various organs (Ann Intern Med 1996;125:257)

Treatment & Follow-Up

Preferred initial regimens in treatment-naïve patients(as of March 27, 2012):
- Efavirenz/tenofovir/emtricitabine
- Raltegravir + tenofovir/emtricitabine
- Ritonavir-boosted atazanavir + tenofovir/emtricitabine
- Ritonavir-boosted darunavir + tenofovir/emtricitabine
Alternative regimens(as of March 27, 2012)
- Efavirenz + abacavir/lamivudine
- Rilpivirine/tenofovir/emtricitabine
- Rilpivirine + abacavir/lamivudine
- Raltegravir + abacavir/lamivudine
- Ritonavir-boosted atazanavir + abacavir or zidovudine + lamivudine
- Ritonavir-boosted darunavir + abacavir/lamivudine
- Ritonavir-boosted fosamprenavir + [abacavir or zidovudine + lamivudine] or tenofovir/emtricitabine
- Lopinavir/ritonavir + (abacavir or zidovudine + lamivudine) or tenofovir/emtricitabine