A recording of this presentation is available HERE.
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Many thanks to Dr. Reece Fenning for an excellent presentation this week on Acute HIV in the Hospital. A recording of his presentation is available above.
My notes:
- 75% of the HIV+ population in Sonoma County is >40 years old
- HIV disproportionately affect African American and Latinx people, who make up 65% of the new diagnoses each year
- Whereas in California 73% of people living with HIV are engaged in care and 64% are virally suppressed, in Sonoma County, 86% are engaged in care, and 82% are virally suppressed
- Patients with HIV have 1.5x the hospitalization rate as their HIV- counterparts
The CDC recommends that ALL US adults receive a one time HIV screening. People who should be tested more frequently (annually) include: 1) people with partners who are known HIV+ or have a known exposure, 2) pregnant patients, 3) patients who use IV drugs, and 4) people who exchange money (or other goods) for sex.
Luckily, our HIV testing sensitivity has improved in the last decade, and the so-called "window period" is now much shorter than the past -- it is only around 10 days (but up to 3 weeks) between viral acquisition and possibility of a false negative test.
When seeing patients with HIV in the hospital and/or outpatient, you should check their CD4 count AND their viral load. Also, screen for common co-morbid infections: TB (the most common worldwide), acute viral hepatitis (A, B, C), and other STI testing (RPR, GC/CT), and lipids.
HIV is staged based on CD4 count and/or CD4 percentage:
- Stage 1: CD4 count >500
- Stage 2: CD4 count 200-500
- Stage 3: CD4 count <200 and/or CD4 percent <14%
Newly diagnosed HIV should be treated immediately (rapid tx induction), except in rare cases of specific comorbidities. These exceptions include Cryptococcus meningitis and active TB. Both require initiation of treatment of these conditions prior to treating the HIV disease. (see chart below):
- Biktarvy (bictegravir/emtricitabine/TAF) is a single pill containing all three meds
- Alternate options includes a couple of different dolutegavir-containing regimens
- Trivicay + Descovy (2 pills)
- Trovicay + Truvada (2 pills)
- Triumeq (only one pill, but requires HLA testing, so not great for rapid treatment)
What about empiric prophylaxis Opportunistic Infections (OIs)?
You should be worried about OIs if CD4<200 and/or CD4 percentage<14%. The most common OIs for which to consider ppx are PCP pnuemonia (aka PJP) if CD4<200-- ppx is TMP-SMX daily, and MAC (if CD4<50) -- ppx is azithromycin once weekly.
How should we think about OIs in the acute setting? There are a couple of different ways to think about OIs:
Time with HIV
- newly acquired (<6 months)
- previously on treatment but now stopped
- on treatment, but its not working
Presenting symptoms:
- AMS --> think CNS infection (Crypto
- respiratory symptoms --> think PCP, MAC
- dermatologic symptoms --> think HSV, VZV, MRSA, KS
Random acute HIV symptoms and pearls:
- Acute HIV: The large majority of patients will have viral/flu-like symptoms with acute HIV that will self-resolve. Most are not sick enough to present to the ER during this acute illness.
- Immune reconstitution inflammatory syndrome (IRIS) usually appears 2-4 weeks after starting tx, it is a diagnosis of exclusion. Greatest risk with high viral load and very low CD4 (<50). Treatment is NSAID (outpatient) or steroids (inpatient)
- HIV wasting syndrome: acute weight loss (>10% of body weight), often with acute diarrhea. Looks like cancer. May need an EGD and/or colonoscopy for biopsy to diagnose. See testing algorithm below.
- Odynophagia: pain with eating may be a sign of oral thrush and/or esophageal candidiasis
- Dermatologic infections in HIV are very confusing and also often require a biopsy (see images)
(L>R clockwise: Kaposi's Sarcoma, HSV, MRSA Shingles) - Respiratory illness in HIV disease should be evaluated like non-HIV with CXR, blood work, but also add beta-D-glucan (for fungal infections). You likely will need tissue (bronchoscopy or induced sputum) to get a diagnosis.
- Neurologic symptoms in someone with HIV require a head CT, followed by CSF studies. Also don't forget a fundoscopic exam (CMV retinitis)
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