HIV Recognition in the ED Martha I. Buitrago, MD Infectious Diseases Idaho State University

HIV in the ED Changing Epidemiology HIV Infection Presentations in the ED History Taking

00003-E-3 – July 2004 Adults and children estimated to be living with HIV as of end 2003 Total: 37.8 (34.6 – 42.3) million Western Europe [ – ] North Africa & Middle East [ – 1.4 million] Sub-Saharan Africa 25.0 million [23.1 – 27.9 million] Eastern Europe & Central Asia 1.3 million [ – 1.9 million] South & South-East Asia 6.5 million [4.1 – 9.6 million] Oceania [ – ] North America 1.0 million [ – 1.6 million] Caribbean [ – ] Latin America 1.6 million [1.2 – 2.1 million] East Asia [ – 1.5 million]

00003-E-4 – July 2004 Children (<15 years) estimated to be living with HIV as of end 2003 Western Europe [4 900 – 7 900] North Africa & Middle East [6 300 – ] Sub-Saharan Africa 1.9 million [1.7 – 2.2 million] Eastern Europe & Central Asia [6 600 – ] East Asia [2 700 – ] South & South-East Asia [ – ] Oceania600 [< 2 000] North America [5 600 – ] Caribbean [ – ] Latin America [ – ] Total: 2.1 (1.9 – 2.5) million

00003-E-5 – July 2004 Estimated number of adults and children newly infected with HIV during 2003 Total: 4.8 (4.2 – 6.3) million Western Europe [ – ] North Africa & Middle East [ – ] Sub-Saharan Africa 3.0 million [2.6 – 3.7 million] Eastern Europe & Central Asia [ – ] East Asia [ – ] South & South-East Asia [ – 2.0 million] Oceania [2 100 – ] North America [ – ] Caribbean [ – ] Latin America [ – ]

00003-E-6 – July 2004 Estimated number of children (<15 years) newly infected with HIV during 2003 Western Europe < 100 [< 200] North Africa & Middle East [2 500 – ] Sub-Saharan Africa [ – ] Eastern Europe & Central Asia [1 000 – 2 900] East Asia [1 200 – 9 200] South & South-East Asia [ – ] Oceania < 300 [< 1 000] North America < 100 [< 200] Caribbean [3 000 – ] Latin America [5 100 – ] Total: ( – )

00003-E-7 – July 2004 Estimated adult and child deaths from AIDS during 2003 Total: 2.9 (2.6 – 3.3) million Western Europe [<8 000] North Africa & Middle East [9 900 – ] Sub-Saharan Africa 2.2 million [2.0 – 2.5 million] Eastern Europe & Central Asia [ – ] East Asia [ – ] South & South-East Asia [ – ] Oceania700 [<1 300] North America [8 300 – ] Caribbean [ – ] Latin America [ – ]

00003-E-8 – July 2004 About new HIV infections a day in 2003 l More than 95% are in low and middle income countries l Almost 2000 are in children under 15 years of age l About are in persons aged 15 to 49 years, of whom: — almost 50% are women — about 50% are 15–24 year olds

00003-E-9 – July 2004 Global estimates for adults and children end 2003 l People living with HIV l New HIV infections in 2003 l Deaths due to AIDS in million [34.6 – 42.3 million ] 4.8 million [4.2 – 6.3 million] 2.9 million [2.6 – 3.3 million]

13.2 Million Children have been Orphaned Since the start of the Epidemic

Epidemiology  Changing demographics: Women21% 27%  White38% 36%  Non-White41% 47%  MSM45% 42%  IVDU20% 25%  Heterosexuals19% 26% 

Idaho Cumulative HIV/AIDS Cumulative statistics from April 1986 when HIV became a reportable disease in Idaho -HIV (+): Total # of HIV (+) individuals excluding Idaho AIDS cases

HIV in Idaho – Prevalence  District 195  District 2 46  District  District  District 5 76  District 6 64  District 7 46 Total 761 HIV / AIDS (As of June 2004)

Idaho Cumulative HIV/AIDS 2003 Exposure categories (Adults) Idaho HIV(+) (N=565) Idaho AIDS (N= 552) Men who have sex with men (MSM) 257 (45%)308 (56%) Injecting drug use (IDU) 95 (17%) 61 (11%) MSM & IDU44 (8%) Hemophilia/coagulation disorders 5 (1%)18 (3%) Heterosexual contact 73 (13%) 69 (13%) Receipt of blood component or tissue12 (2%) Other/risk not reported or identified 79 (14%)40 (7%)

Idaho Cumulative HIV/AIDS 2003 Exposure categories Pediatric Idaho HIV(+) (N=8) Idaho AIDS (N=3) Hemophilia/coagulation disorder0 (0%) Mother with/at risk for HIV infection 7 (88%)1(33%) Receipt of blood, components, or tissue 0 (0%)2 (67%) Other/risk not reported or identified 1 (13%)0 (0%)

HIV Presentations Primary HIV Infection Asymptomatic Screening Chronic HIV Infection Late-Stage AIDS  Mayo Clin Proc 2002;77:

HIV Presentation

Case # 1 Mr. John Corporate is a pleasant 30 y.o male, captain of the baseball team. He comes to the ER with complaints of fatigue, sore throat, painful nodes on his neck, and generalized body rash. All symptoms started 2 months after his last business trip.

Case # 1 What other questions would you ask? What is your differential diagnosis? What tests would you order?

Acute HIV Infection: opportunities for diagnosis Physicians’ offices Emergency rooms Community health centers Dermatology clinics Sexually transmitted disease centers HIV clinics  Mayo Clin Proc 2002;77:

Acute HIV Infection Transient symptomatic illness in 40-90% –nonspecific illness to severe manifestations –occasionally can result in hospitalization No specific constellation of signs or symptoms can differentiate acute HIV from other illnesses  Kahn JO, Walker BD. Acute human immunodeficiency virus type 1 infection. N Engl J Med 1998;339:33-39  Schacker, T, et al. Clinical and epidemiologic features of primary HIV infection. Ann Intern Med. 1996;125:

HIV Infection

Acute Retroviral Syndrome Fever Lymphadenopathy Pharyngitis Rash Myalgia/arthralgia Diarrhea Headache Nausea/Vomiting Hepatosplenomegaly Weight loss Thrush Neurologic symptoms  96%  74%  70%  54%  32%  27%  14%  13%  12%  CDC. Guidelines for using antiretroviral agents… MMWR 2002;51(RR-7)

Acute HIV Infection Symptoms present days to weeks after initial exposure Most common presentation: –fever, fatigue, headache, and rash Nonspecific symptoms overlap with common viral illnesses High index of suspicion is CRITICAL

Acute Retroviral Syndrome Rash (40-80%) –erythematous maculopapular with lesion on face and trunk (rarely extremities) –mucocutaneous ulceration involving the mouth, esophagus, or genitals Rash would help differentiate from infectious mononucleosis

Acute Retroviral Syndrome Neurologic symptoms (24%) –meningoencephalitis or aseptic meningitis –peripheral neuropathy or radiculopathy –facial palsy –Guillain-Barré syndrome –brachial neuritis –cognitive impairment –psychosis

Acute HIV DDX Influenza Epstein-Barr virus mononucleosis Severe (streptococcal) pharyngitis Secondary syphilis Primary CMV infection Toxoplasmosis Drug reaction Viral hepatitis Primary HSV infection Rubella Brucellosis Malaria West Nile Virus

Acute HIV: Diagnosis  Question all patients about HIV risk behaviors including sexual activity and injection drug use.  Perform a thorough physical examination with particular attention to the signs of primary HIV infection such as rash, mucocutaneous ulcers, and lymphadenopathy.  Perform a baseline HIV antibody test. –This serves two important purposes: it establishes whether chronic HIV infection is present the consent process initiates a discussion with the patient about the implications of HIV testing  Obtain an HIV viral load test, if the suspicion of acute HIV is high (the HIV antibody is likely to be negative in acute HIV infection)

HIV Antibody Tests Serum antibody (EIA) Saliva and urine antibody tests (EIA) Rapid tests –SUDS (microfiltration EIA) Laboratory-based –OraQuick Point of care Western blot assay –Confirmatory test

Potential Benefits of Treatment during PHI Suppress initial burst of viremia ? alter viral set-point Decrease viral evolution Preserve CD4 lymphocytes (both absolute number and HIV-specific) Potentially decrease risk of transmission Possibly allow for future cessation of therapy

Potential Risks of Treatment during PHI Drug toxicity Costs of possible lifelong therapy Starting therapy in patients who may never have needed it Early development of resistance Little evidence to date of clinical benefit

Acute HIV - Treatment Goal: long-term viral suppression Evidence: –Animal models (Macaques/SIV) –Small case reports Berlin patient, New York pair, Caracas couple

Weeks SIV RNA (log10), Median No Therapy STI-HAART HAART Lori et al. Science 2000 Acute Infection Control of SIV viremia w/ 3 wks on Rx & 3 wks off Rx Long term trial of 3 wks on & 3 wks off in SIV+ macaques

Lisziewicz et al. New Engl J Med <500 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 90,000 HIV RNA, copies/mL Permanently discontinued Epididymitis 15–22 Hepatitis A 121–137 = No treatment Time, days The Berlin Patient

Acute HIV: Missed Opportunity The symptoms — especially in mild cases — are nonspecific and resolve spontaneously without treatment. Clinicians may be uncomfortable raising the question of sexual exposure or intravenous drug-use, especially with patients whom they only see infrequently such as young, previously healthy individuals. Primary care physicians may not be aware of high-risk behavior even in patients they know well. Patients may not perceive themselves to be at risk.

Case # 2 MC is an 18 year old college student, who presents with increased shortness of breath for 3 weeks, fever, and non-productive cough. On exam, he has an oxygen saturation of 85% after exercise, and clear lungs.

Case #2 What other questions would you ask? What is your differential diagnosis? How would you treat?

Sexual History Taking Ensure privacy Be non-judgmental and respectful Avoid making assumptions about people Make eye contact, have relaxed body language Provide patients with a context for the questions that are to follow

Asking Questions First question is the most difficult; start with general, non-threatening Use open-ended questions Ask ‘how’, ‘what’, ‘where’ Avoid asking ‘why’ Ask about knowledge and use of barrier methods

Sample Questions Are you sexually active? How many sexual partners have you had in the past year? Do you have sex with men, women, or both? How are you protecting yourself from pregnancy?

Getting Started and the 5 “P”s Teens: –Some of my patients your age have started having sex. Have you? –What are you doing to protect yourself from AIDS or other STD’s? Adults: –I ask these questions to all my patients regardless of age or marital status….

The 5 “P”s 1.Partners 2.Sexual Practices 3.Past STDs 4.Pregnancy History 5.Protection from STDs

Importance of HIV Diagnosis Early Intervention services –Improved quality of life –Avoid complications –Healthcare maintenance Prevent transmission –Primary HIV infection Higher viral loads No antibody –Chronic infection Asymptomatic High risk behaviors

Chronic HIV Presentation Clinically latent Subtle clues Complicates other diseases Index of suspicion is CRITICAL

Mucosal Clues Oral Lesions –Thrush, hairy leukoplakia, gingivitis Genital –Recurrent candidiasis, cervical or anal dysplasia, STDs Gastrointestinal –Esophageal candidiasis, diarrhea, anorectal infections, cholangiopathy Mayo Clin Proc 2002;77:

Hairy Leukoplakia

Oral Candidiasis ErythematousPseudomembranous

Dermatologic Clues Infectious dermatitides –Bacterial, fungal, viral Neoplastic –Kaposi’s, basal-cell, squamous cell Inflammatory –Psoriasis, seborrheic dermatitis Mayo Clin Proc 2002;77:

Seborrheic Dermatitis Kaposi’s Sarcoma

Laboratory Clues Cytopenias –Anemia, ITP, leukopenia Hypergammaglobulinemia False positive results –RPR, ANA Elevated PTT Decreased cholesterol Renal insufficiency and protenuria Mayo Clin Proc 2002;77:

Late-Stage Presentation Usually clinically obvious Should not be missed Opportunistic infections predominate Wasting common

Missed Opportunities Women who do not receive prenatal care Pregnant women who seek prenatal care erratically Non-legal residents Injection drug users Homeless Women who receive prenatal care but are not offered HIV testing E Aaron, CRNP. Presented at Clinical Pathway, August 2002.

Summary HIV/AIDS is an Idaho disease! Recognizing the presentation of HIV disease is important for ALL clinicians Identifying HIV-infected individuals is important for: –The person living with HIV –The spouse / partner –Unborn children –Society Referral specialty services ARE available