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AIDS
- HIV + CD4<200
- or AIDS-defining Opportunistic Infection (OI)
- or malignancy
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What is the most reliable marker of risk for OI?
CD4 ct
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Best predictor of LT progression of AIDS?
- Viral Load (Plasma HIV-RNA)
- Shows risk of Dz progression
- Responses to Tx
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Diagnostic Tests
- ELISA: for HIV-1 Ab/Ag (+) 1-12wks post acute infxn; >99% Se; 1' screening test
- Western Blot: (+) if >= 2 bands from HIV genome; >99% Sp; conf after (+)ELISA
- Rapid Prelim Test: 4 Ab tests; saliva, plasma, blood or serum 99% Se & 96-99% Sp
- CD4 is not a dx test, bc can be HIV(+) w nml CD4 or HIV(-) w low CD4
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Start ARV Tx when CD4<?
CD4 < 500
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OI
Indication(I) and Prophylaxis(Pr)?
Tx?
- Tb: (I) (+) PPD (<=5mm)/IGRA or high risk; (P) INH + vit B6 X 9mo; (Tx) RIPE(S)
- Pneumocystis jiroveci (PCP): (I) CD4< 200 or <14% or Thrush present; (P) 1stL=TMP-SMX, 2ndL=(Dapsone/Dapsone+Pyrimethamine), or Atovaquone, or Pentamidine; (Tx) if PaO2 >70 TMP-SMX, if <70 Prednisone before Abx
- Toxoplasmosis: (I) CD4< 100 (but is already covered by PCP Prx @ 200) and (+) Toxo IgG; (P) 1stL=TMP-SMX 2ndL= (Dapsone or Atovaquone)+Pyrimethamine; (Tx) {1stL=(TMP-SMX or Pyrimethamine)+Sulfadiazine 2ndL=Pyrimethamine+Clindamycin}+ Leucovorin (incr Folate) + Corticosteroids (for neurologic Sx) + consider Anti-convulsants.
- MAC: (I) CD4<50; (P) Azithromycin or Clarithromycin; (Tx) Azithromycin or Clarithromycin + Ethambutol +/- Rifabutin
- Stop 1' Proph if CD4 >initiation threshold >3-6mo on ARVs
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CMV
- In the eye: CMV most commonly presents as a viral necrotizing retinitis with a characteristic ophthalmoscopic appearance (see image).
- Untreated CMV retinitis inexorably progresses to visual loss and blindness.
- Retinitis: typically starts in the midperiphery and can progress in a "brush fire" pattern.
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Adverse Effects of HIV Medications
- Zidovudine: Anemia
- Stavudine and Didanosine: peripheral neuropathy and pancreatitis
- Abacavir (HLA B5701): HSRxn, Steven-Johnson rxn
- Protease inhib: Hyperlipidemia, Hyperglycemia
- Indinavir: Nephrolithiasis
- Tenofovir: Renal Insufficiency
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