View source for HIV - AIDS (main)

==Background==
*In HIV+ patient presenting to ED, absolute lymphocyte count (ALC) can be used as surrogate for CD4 count <ref> Napoli AM, Fischer CM, Pines JM, Soe-lin H, Goyal M, Milzman D. Absolute
lymphocyte count in the emergency department predicts a low CD4 count in admitted HIV-positive patients. Acad Emerg Med. 2011 Apr;18(4):385-9. doi:10.1111/j.1553-2712.2011.01031.x. Erratum in: Acad Emerg Med. 2011 May;18(5):565.</ref>
**A CD4 count of <200 is very likely if the ED ALC is <950 and less likely if the ALC is >1700
**ALC is useful to confirm, but not exclude a low CD4
*Approximately 1.2 million people in the US are living with HIV <ref name="HIV">CDC. Monitoring Selected National HIV Prevention and Care Objectives by Using HIV Surveillance Data. HIV Surveillance Report. 2015; 20(2):1-70.</ref>
**13% of people with HIV in US aren't aware <ref name="HIV"></ref>
**Most affected: homosexual & bisexual men, particularly African American <ref name="HIV"></ref>

{{HIV CD4 Chart}}

==Clinical Features==
[[File:PMC3218701 hiv-2-089f1.png|thumb|View of posterior pharynx showing [[pseudomembranous oropharyngeal candidiasis]] in a patient with HIV, with a distribution concerning for esophageal candidiasis (later found on scope).]]
[[File:Kaposis sarcoma 01.jpg|thumb|[[Kaposi sarcoma]]. Characteristic purple lesions on the nose in an HIV-positive female.]]
[[File:Kaposis Sarcoma Lesions.jpg|thumb|[[Kaposi's sarcoma]] skin lesion]]
[[File:Patch stage Kaposi's sarcoma.jpg|thumb|Patch stage [[Kaposi's sarcoma]]. Red to brownish irregularly shaped macules and plaques.]]
[[File:Kaposi’s sarcoma intraoral AIDS 072 lores.jpg|thumb|An HIV-positive person presenting with a [[Kaposi's sarcoma]] lesion with an overlying candidiasis infection in their mouth.]]
[[File:Fundus photograph-CMV retinitis EDA07.jpg|thumb|Fundus photograph of [[CMV retinitis]]]]
===Acute Infection===
*Misdiagnosed frequently as "mononucleosis" or "flu"
*Largest viral load, widespread dissemination of virus, and most infectious stage<ref>Serrano KD, Westergaard RP. Diagnosis and management of acute HIV in the emergency department. EM Reports, 2012:33;16.</ref>
*Symptoms develop 2-4wks after exposure; last for <14d
**[[Fever]] (>90%)
**Fatigue (70-90%)
**[[Pharyngitis]] (>70%)
**Rash (40-80%) - [[Pruritic papular eruption of HIV]]
**[[Headache]] (30-70%)
**[[Lymphadenopathy]] (40-70%)

===Seroconversion===
*HIV Ab detectable 3-8wk after infection (sometimes sooner)
*If negative Ab test but high suspicion, can HIV viral load.

===Asymptomatic===
*Lasts for ~8yr
*Patients may have conditions that are more common in patients with HIV but no indicator conditions
**[[Thrush]]
**Persistent [[Candidiasis|candidia vaginitis]]
**Peripheral neuropathy
**Cervical dysplasia
**Recurrent [[Herpes Zoster]]
**[[ITP]]
**Unexplained weight loss

===AIDS===
*Defined as HIV + (indicator condition or CD4 < 200)
*Indicator conditions:
**Pulmonary [[TB]]
**Disseminated [[TB]]
**Invasive cervical cancer
**[[Esophageal candidiasis]]
**[[Cryptococcosis]]
**[[Cryptosporidiosis]]
**[[CMV  Retinitis]]
**[[HSV]]
**[[Kaposi sarcoma]]
**[[Pruritic papular eruption of HIV]]
**[[Primary CNS lymphoma|Lymphoma]]
**[[Mycobacterium avium|MAC]]
**[[PCP pneumonia]] 
**[[Progressive multifocal leukoencephalopathy]]
**Brain [[Toxoplasmosis]]
**HIV [[Encephalitis]]
**HIV wasting syndrome
**Disseminated [[histoplasmosis]]
**Isosporiasis
**Recurrent [[Salmonella]] septicemia 
**Recurrent Bacterial [[Pneumonia]]

==Differential Diagnosis==
{{HIV associated conditions}}

==Evaluation==
[[File:PMC4536784 ccrpm-suppl.1-2015-019f3.png|thumb|CT of [[Pneumocystis jirovecii pneumonia]], showing small nodular lesions surrounded by diffuse GGO.]]
*Typical lab testing for HIV:
**Screening test: ELISA
**Confirmatory test: Western blot
*Maintain low threshold for additional testing in setting of suspicion of opportunistic infections
*CDC (2006) recommends routine HIV screening in health care settings using an opt-out approach <ref>Branson B, Handsfield H, Lampe M. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. MMWR. 2006; 55: 1-17.</ref>
**Opt-out screening: performing the test after notifying the patient it will be performed & giving them the option to decline

==Management==
===HAART===
'''Highly Active Anti-Retroviral Therapy'''
*Reduces progression to AIDS and transmission risk
*CDC Guidelines =  all HIV+ individuals should be started on HAART, regardless of CD4 count or viral load<ref>Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. https://aidsinfo.nih.gov/guidelines Accessed 03/04/16</ref>
*Typical first line regimens include a reverse transcriptase inhibitor (NRTI) and an integrase inhibitor
**tenofovir/emtricitabine (Truvada) '''PLUS''' raltegravir (Isentress)
**tenofovir/emtricitabine (Truvada) '''PLUS''' dolutegravir (Tivicay)

==Disposition==
===Suggested Admission===
*New presentation of fever of unknown origin
*Hypoxemia worse than baseline or PaO2 <60
*Suspected PCP
*Suspected TB
*New CNS symptoms
*Intractable diarrhea
*Suicidal
*Suspected [[CMV retinitis]]
*Ophthalmicus zoster
*Cachexia or weakness
*Unable to care for self/receive care
*Unable to assure follow up

===Suggested Discharge===
*Normal or baseline vitals
*Stable medical condition
*Able to tolerate PO
*Adequate follow-up
*Able to comply with discharge instructions

==See Also==
*[[HIV post-exposure prophylaxis]]
*[[Immune reconstitution inflammatory syndrome]]

==External Links==
*http://www.cdc.gov/hiv/

==References==
<references/>

[[Category:ID]]