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HIV/AIDS and Needlestick Injuries

HIV/AIDS and Needlestick Injuries. Dr. M. Greidanus, CCFP(EM) January 22, 2009. Disclaimers.

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HIV/AIDS and Needlestick Injuries

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  1. HIV/AIDS and Needlestick Injuries Dr. M. Greidanus, CCFP(EM) January 22, 2009

  2. Disclaimers • I blatantly plagiarized my image slides off a talk I found in the internet by Michael Klompas from Brigham and Women’s Hospital, Boston Mass. This is because I have no idea of how to do graphics on powerpoint and his graphics were good and make my talk a little more interesting

  3. Outline • Cases – just to get you thinking • Prevalence and Testing techniques • Natural history of HIV • AIDS defining illnesses • Who to Screen for HIV in the ED • Approach to the HIV positive patient in the ED • Systems approach • Needlestick injuries • Summary

  4. Case 1 – 49 yo M with SOB Triage note states pt is here with an asthma exacerbation. SOB for a few weeks. HR – 108, RR 24, Sats 84%RA Patient is on a neb when you walk in the room. HPI – Progressive slow onset SOB past 1.5 months. Recent diagnosis of asthma a three weeks ago, nebs improve symptoms slightly. Recent 30 lb wt loss in past year. Remote history of IVDU 10-15 years ago.

  5. Case 2 – 39 yo Lawyer – requesting an HIV test • States that 4 months ago she was exposed to someone else’s bloody instruments at her dentist’s office. • Has had 2 previous HIV negative tests. • Was febrile on the weekend, concerned it was the converting illness. Here requesting another HIV test. • What do you tell her?

  6. Prevalence and Incidence • More then 1 million HIV positive in USA1 • 40 000 people being diagnosed each year1 • New HIV Rates with Screening at acute care centers2 • At John Hopkin’s Hospital ED, Balitmore – 3.2% • Massachusetts (4 hospitals) – 2.7% • People with access to HAART (highly active anti-retroviral therapy) are living longer. 1 • ED presentations now are related to CV disease, medication effects and malignancies vs opportunistic infections which was more common prior to HAART1

  7. Characteristics Rapid Test Positive Patients

  8. Rapid testing and Confirmatory Testing • Rapid Testing – EIA (enzyme linked immunoassays) • Need to call the lab • Will get the result within one hour • Confirmatory Testing - Western Blot Test • If negative or indeterminate repeat test after 4 weeks

  9. Natural History of HIV Infection Viral Load Clinical Latent Period Viral Transmission Number of CD4 cells / Viral Load Advanced AIDS Primary Infection Early HIV Infection AIDS CD4 Count 2 4 6 0 2 6 8 10 4 weeks

  10. Natural History of HIV Infection Viral Load Number of CD4 cells / Viral Load CD4 Count 2 4 6 0 2 6 8 10 4 years weeks

  11. Development of AIDS is like an impending train wreck Viral Load = Speed of the train CD4 count = Distance to the cliff HIV infection J. Coffin, XI International Conf. on AIDS, Vancouver, 1996

  12. Probability of developing AIDS within 3 years Probability of progression to AIDS (%) (N=1,637) Viral Load (copies/mL) Ann Intern Med 1997;126:946

  13. Natural History of HIV – Viral Transmission • Viral Transmission – sexual intercourse, exposure to contaminated blood or perinatal transmission • Of a review of 32497 cases, only 0.2% had no clearly defined risk factor • Risk Factors for transmission include viral load, lack of circumcision, sexual risk, presence of ulcerative STI, nitrate inhalent use and host and genetic factors • Viral load • The higher the viral load the higher the risk of transmission • No transmission seen in those with a viral load of <1500copies/mL

  14. Natural History of HIV – Viral Transmission • Receptive anal intercourse — 2 percent • Receptive vaginal intercourse — 0.1 percent • Insertive anal or vaginal intercourse — 0.06 percent • Receptive oral sex with a male partner — 0.04 percent • Other sexual exposure — 0.004 percent • Needle or syringe sharing — 0.3 percent • Bite or assault — 0.004 percent As an example, the prevalence of HIV infection in men aged 18 to 39 in the NHANES study was 0.37 percent [4]. Thus, the risk of transmission following a single episode of receptive vaginal intercourse would be approximated by multiplying 0.0037 times 0.001 for an estimate of 0.000037 (ie, 1 in ~37,000).

  15. Natural History of HIV – Seroconversion syndrome • Primary HIV infection/Seroconversion syndrome follows exposure by 2-10 weeks • 95% or more convert within 6 months • Median time from exposure to positive serology – 63 d. • Can include fever, adenopathy, fatigue, pharyngitis, diarrhea, wt loss and rash • Symptoms can persist for 1-3 weeks • After 6 months of infections, plasma viremia reaches a steady state. • Viral load is the most important predictor of progressive disease in early stages of HIV.

  16. Natural History of HIV – Clinical Latent Period • Clinical latent period • Generally no findings except for possible lymphadenopathy • Persistent generalized lymphadenopathy (PGL) referred to as enlarged lymph nodes involving at least two non-contiguous sites other than inguinal nodes • Lymphoid tissue serves as the major reservoir for HIV. Lymphoid tissue traps free virus and infected CD4 T cells

  17. Natural History of HIV - Early symptomatic HIV infection AIDS indicators – can also occur with other disease processes, but are typically more frequent or more severe with an HIV infection - Thrush - Vaginal candidiasis that is persistent, frequent, or difficult to manage - Oral hairy leukoplakia - Herpes zoster involving two episodes or more than one dermatome - Peripheral neuropathy - Bacillary angiomatosis - Cervical dysplasia - Cervical carcinoma in situ - Constitutional symptoms such as fever (38.5°C) or diarrhea for more than one month - Idiopathic thrombocytopenic purpura - Pelvic inflammatory disease, especially if complicated by a tubo-ovarian abscess

  18. Candida

  19. Herpes Zoster

  20. Natural History of HIV – AIDS • 10% of pts will develop an AIDS defining diagnosis with a CD4 count above 200/mm3 • Most common AIDS diagnosis (prior to HAART) • P. carinii pneumonia - 42.6% • Esophageal candidiasis – 15% • Wasting – 10.7% • Kaposi’s Sarcoma – 10.7% • Disseminated M. Avium infection -4.8% • Tuberculosis – 4.5%

  21. Natural History of HIV – Advanced HIV • CD4 Count <50/mm3 • Median Survival 12-18 months in the absence of ARVs • Long term Non-progressors • Elite Controllers • HIV seropositive individuals who have no evidence of viremia by ultrasensitive assays and maintain high CD4 Counts • 1/300 patients

  22. Natural History of HIV • HAART (highly active antiretroviral therapy) typically started when CD4 count <350 cells/mL • Combination of 2 nucleoside-analog reverse transcriptase inhibitors and either a non-nucleoside reverse transcriptase inhibitor or a protease inhibitor • Also based on other clinical factors • Presence of AIDS defining illnesses • Comorbid conditions that might be exacerbated by initiation of HAART • Pregnant HIV positive • Patients with HIV nephropathy

  23. How HIV Works 3. Integration into host cell’s nucleus HIV 4. Reproduction of viral components 1. Attachment to host cell • Assembly of new HIV viruses • Reverse transcriptase makes DNA from the virus’s RNA 6. Release

  24. How NRTI’S Work HIV Nucleoside reverse transcriptase inhibitors (NRTI’s) latch onto the new strand of DNA that reverse transcriptase is trying to build

  25. How NNRTI’S Work HIV Non-nucleoside reverse transcriptase inhibitors (NNRTI’s) hook onto reverse transcriptase and stop it from working

  26. How PI’s Work HIV Protease inhibitors (PI’s) prevent final assembly and completion of new HIV viruses within the cell

  27. AIDS Defining Illnesses • CD4 Count <200/mm3 • Candidiasis, esophageal or pulmonary • Cervical cancer (invasive)* • Coccidioidomycosis, Cryptococcosis, Cryptosporidiosis* • Cytomegalovirus disease • Encephalopathy (HIV-related) • Herpes simplex (an infection lasting longer than 1 month or in an area other than the skin such as esophagus or lungs) • Histoplasmosis extrapulmonary* • Isosporiasis (with diarrhea >1 month)* • Kaposi's sarcoma (KS)* • Lymphoma characterized by swollen lymph nodes (lymphadenopathy) in <60yo >60* • Mycobacterium avium complex • Pneumocystis carinii pneumonia (PCP) • Pneumonia (recurrent bacterial)* • Progressive multifocal leukoencephalopathy (PML) • Salmonella septicemia (recurrent)* • Toxoplasmosis of the brain • Tuberculosis (pulmonary or disseminated)* • HIV Wasting syndrome *Need to have a postiive HIV test in conjuction with the illness listed

  28. Pneumocystis carinii (PCP)

  29. Tuberculosis Apical infiltrates

  30. Kaposi’s Sarcoma

  31. Toxoplasmosis

  32. Lymphoma

  33. Who to test in the ED • Traditional thought was that HIV testing was not appropriate for the ED • Poor followup, confidentiality, consent issues, education issues • Rapid Screening tests changing that • Review – indicated appropriate in a higher risk population where the baseline risk is >1%3

  34. Initial Management of the HIV positive patient • History • Time of diagnosis • Last CD4 Count, Viral Load • Duration of ARV treatment • Prophylaxis use and duration • Most are on this until they have have a CD4 count >200 for at least 3 months • Type of ARV

  35. ARV General Side Effects • All ARVs can cause hepatotoxicity, from asymptomatic to fulminant hepatic failure • Lactic acidosis – presents with fatigue, vomiting, myalgias and elevated lactate. • Treat with fluids, +/- mech. vent. and/or dialysis • Each drug has its own specific SE • Enfuvirtide – subcutaneous injection, SE painful skin nodules and inc. risk of bacterial pneumonia • Raltegravir – GI SE, nausea, diarrhea and increased flatulence.

  36. Immune Reconstitution Inflammatory Syndrome • If it manifests, it does so in the first 8 weeks • Most common is M. Avium complex • Lymphadenitis • Pneumonitis • Hepatosplenomegaly • Hypercalcemia • Other opportunistic infections – show increased symptomatolgy associated with that pathogen • Aggrevation of autoimmune illnesses • Therapy is generally supportive, anti-inflammatory with steroids, treat opportunistic pathogen if there is and effective treatment agent.

  37. Cardiovascular Disease • ACS • All protease inhibitors cause hyperlipidemia, hyperglycemia and truncal obesity • Increased time receiving HAART associated with 26% increased relative risk of MI/year • Take home: Consider HIV positive patients on prolonged ARV therapy at risk for ACS often at yournger ages • Cardiomyopathy • CHF will have similar presentation

  38. Pulmonary • Strep. Pnuemonia most common pneumonia • HIV is an idependant RF for COPD • 0.5% will have pulmonary hypertension • Not related to CD4 count • Not related to specific HAART therapy

  39. Renal • HIV nephropathy – related to both viral/immunologic and treatment related toxicity • ARF is a strong predictor of mortality – kidney disease has emerged as the leading cause of death in HAART era • Protease inhibitors associated with urolithiasis • Treatment is the same as for non-HIV population

  40. Central Nervous System • Any new neuro symptom in advanced HIV/AIDS including a new headache requires CT and LP… Always CT before LP • CNS • AIDS dementia • Stroke (incidence has increased 2nd to meds) • Lymphoma • Opportunistic infections – Toxoplasma gondii • Progressive multifocal leukoencephalopathy

  41. Peripheral Nervous System • Distal sensory neuropathies – both HIV and HAART related (NRTs) • Typically hypersensitivities to distal extremities +/- absent ankle reflexes • Discontinue meds and treat with gabapentin and NSAIDS • Acute demyelinating polyneuropathy • Presents like Guillain-Barre (ascending muscle weakness and sensory changes) • Treated with plasmaphoresis • Chronic relapsing demyelinating polyneuropathy

  42. GI and Liver • Diarrhea • C. Diff is the most likely bacterial pathogen • Assess and treat as you would non-HIV patients • If advanced AIDS need to think about cryptosporidium and microrsporidia – need special stool studies • Co-infection with Hep B/C causes most serious hepatic complications • 2-3x more likely to develop chronic liver dz • Shorter time to progression of AIDS • If HAART meds stopped, severe exacerbations of Hep B can occur • Meds can cause an increase in all transaminases and unconjugated bili with no clinical liver disease • Certain meds associated with pancreatitis and lactic acidosis

  43. Hematologic and Oncologic • Anemia of chronic disease is very common • Hemolytic anemia can be severe associated with certain meds • Neutropenia, thrombocytopenia secondary to disease progression • Increased venous thromboembolic events (2-10x the risk) • Coumadin has significant interactions with Protease inhibitors meds • Increased risk of TTP regardless of HAART • Increased malignancies – Hodgkin’s, anal cancer, lung cancer • Any person with anal condylomata needs to be referred for anal cancer screening

  44. Endocrine • Protease inhibitors increase risk of hyperlipidemia and truncal obesity • Increased risk of insulin resistance and DM • Immune reconstitution syndrome can cause exacerbation of Graves and thyrotoxicosis

  45. Psychiatric • Depression 40% • Demoralization – different from depression in that it doesn’t have anhedonia • Need referral for counselling • AIDS mania • Present in manic state with no history of previous disorders • Associated with cognitive impairment (AIDS dementia) • R/O meningoencephalitis, need CT, LP • NNRTs can cause a psychosis, nightmares and increased irritability • need to terminate med only for psychosis, the other symptoms will resolve

  46. MSK/Rheumatologic Disease • Septic arthritis, osteomyelitis, diskitis • Staph pyomyositis (if CD4 < 50) • Fever, pain swelling, normal WBCs • Thigh most common site • Sarcoid • Secondary to immune reconstitution syndrome • Mean time is 9 months • Osteoporosis and osteonecrosis of the hip • Secondary to HIV and HAART side effects • Rhabdomyolysis • Secondary to interaction of Pis and cholesterol meds

  47. Dermatologic • High rate of S. Aureus folliculitis • Usually CD4<250 • Immune reconsitution syndrome • Drug reactions • Hypersensitivity reaction (macular/urticarial) • Steven Johnson syndrome

  48. Post exposure prophylaxis • No cases HIV conversion with exposure to a suture needle • Seven cases to date of HIV transmission to a patient, six of those from a single dentist • CDC recommendations • 0.3% risk with percutaneous exposure • 0.09 % with mucous membrane exposure • Test the source person and if positive do a viral load. IF unable to test then need to do a risk factor analysis • Decided on a case to case basis • 4 week regimen of two drugs initiated as soon as possible • Regimens in the ED • If unsure then call the MOH

  49. Summary • Know where your patient is in the natural course of their illness this will direct what diseases you are looking for • Know the meds they are on and look up the side effect profiles • Higher index of suspician of CAD • S. Pneumonia is still the most common cause of pneumonia • ARF is bad in the HIV patient • CNS/PNS symptoms need work up and close follow up • Most diseases ie: stroke, renal colic, dvt, rhabdo are treated the same as in the non-HIV patient

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