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

Plasma RNA Copies CD4 Cells 4-8 WeeksUp to 12 Years2-3 Years CD4 Cell Count 1, Intermediate StageAIDS 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

By Salvatore Marra, from AIDS imaging

Oral Manifestations of HIV/AIDS

By Salvatore Marra, from AIDS imaging

CNS Lesions

By Salvatore Marra, from AIDS imaging

By Salvatore Marra, from AIDS imaging

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

By Salvatore Marra, from AIDS imaging

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

By Salvatore Marra, from AIDS imaging

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

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

By Salvatore Marra, from AIDS imaging

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 mg 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.

By Salvatore Marra, from AIDS imaging

Tuberculosis Prophylaxis: Treatment of Latent TB Infection DHS/OI/PP Isoniazid 300 mg qd x 9 months or 900 mg 2x/week x 9 months PPD > 5 mm Induration or Recent Contact with Infectious TB Patient *Rifampin 600 mg qd x 2 months plus Pyrazinamide 20 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) pager, (206) VM University of Washington MEDCON –(800) National HIV Telephone Consultation Service (Warmline) –(800) National Clinicians’ Post-Exposure Prophylaxis Hotline (PEPline) –(888) HIV-4911

Extra slides

By Salvatore Marra, from AIDS imaging

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