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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 Adults and children estimated to be living with HIV as of end 2003 Western Europe North America 1.0 million [520 000 – 1.6 million] Caribbean 430 000 [270 000 – 760 000] 580 000 [1.2 – 2.1 million] 1.3 million [860 000 – 1.9 million] East Asia 900 000 North Africa & Middle South [450 000 – 1.5 million] East & South-East Asia 480 000 Latin America 1.6 million [460 000 – 730 000] Eastern Europe & Central Asia [200 000 – 1.4 million] Sub-Saharan Africa 25.0 million [23.1 – 27.9 million] 6.5 million [4.1 – 9.6 million] Oceania 32 000 [21 000 – 46 000] Total: 37.8 (34.6 – 42.3) million 00003-E-3 – July 2004 Children (<15 years) estimated to be living with HIV as of end 2003 Eastern Europe Western Europe & Central Asia North America 6 200 11 000 [5 600 – 17 000] Caribbean 22 000 [4 900 – 7 900] [6 600 – 12 000] North Africa & Middle East [11 000 – 48 000] Latin America 25 000 8 100 21 000 [6 300 – 72 000] East Asia 7 700 South [2 700 – 22 000] & South-East Asia 160 000 Sub-Saharan Africa[91 000 – 300 000] 1.9 million Oceania [1.7 – 2.2 million] [20 000 – 41 000] Total: 2.1 (1.9 – 2.5) million 00003-E-4 – July 2004 600 [< 2 000] Estimated number of adults and children newly infected with HIV during 2003 Eastern Europe Western Europe & Central Asia North America 20 000 44 000 [16 000 – 120 000] Caribbean 52 000 [13 000 – 37 000] [160 000 – 900 000] North Africa & Middle East [26 000 – 140 000] Latin America 200 000 360 000 75 000 [21 000 – 310 000] 200 000 South & South-East Asia Sub-Saharan Africa 3.0 million East Asia [62 000 – 590 000] 850 000 [430 000 – 2.0 million] [2.6 – 3.7 million] [140 000 – 340 000] Total: 4.8 (4.2 – 6.3) million 00003-E-5 – July 2004 Oceania 5 000 [2 100 – 13 000] Estimated number of children (<15 years) newly infected with HIV during 2003 Eastern Europe Western Europe & Central Asia North America < 100 < 100 [< 200] Caribbean 6 000 [< 200] Latin America [5 100 – 10 000] [1 000 – 2 900] North Africa & Middle East [3 000 – 13 000] 6 400 1 500 8 400 [2 500 – 28 000] 550 000 3 300 [1 200 – 9 200] South & South-East Asia Sub-Saharan Africa [500 000 – 650 000] East Asia 47 000 [29 000 – 87 000] Oceania < 300 [< 1 000] Total: 630 000 (570 000 – 740 000) 00003-E-6 – July 2004 Estimated adult and child deaths from AIDS during 2003 North America 16 000 [8 300 – 25 000] Caribbean 35 000 [23 000 – 59 000] Latin America 84 000 [65 000 – 110 000] Eastern Europe Western Europe & Central Asia 6 000 [<8 000] 49 000 [32 000 – 71 000] North Africa & Middle East 24 000 [9 900 – 62 000] Sub-Saharan Africa 2.2 million [2.0 – 2.5 million] East Asia 44 000 [22 000 – 75 000] South & South-East Asia 460 000 [290 000 – 700 000] Oceania 700 [<1 300] Total: 2.9 (2.6 – 3.3) million 00003-E-7 – July 2004 About 14 000 new HIV infections a day in 2003 More than 95% are in low and middle income countries Almost 2000 are in children under 15 years of age About 12 000 are in persons aged 15 to 49 years, of whom: — almost 50% are women — about 50% are 15–24 year olds 00003-E-8 – July 2004 Global estimates for adults and children end 2003 People living with HIV New HIV infections in 2003 4.8 million [4.2 – 6.3 million] Deaths due to AIDS in 2003 2.9 million [2.6 – 3.3 million] 00003-E-9 – July 2004 37.8 million [34.6 – 42.3 million] 13.2 Million Children have been Orphaned Since the start of the Epidemic Epidemiology Changing demographics: 1998 2000 Women 21% 27% White 38% 36% Non-White 41% 47% MSM 45% 42% IVDU 20% 25% Heterosexuals 19% 26% Idaho Cumulative HIV/AIDS 2003 -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 HIV / AIDS District 1 District 2 District 3 District 4 District 5 District 6 District 7 • Total (As of June 2004) 95 46 101 333 76 64 46 761 Idaho Cumulative HIV/AIDS 2003 Exposure categories (Adults) Idaho HIV(+) (N=565) Idaho AIDS (N= 552) 257 (45%) 308 (56%) Injecting drug use (IDU) 95 (17%) 61 (11%) MSM & IDU 44 (8%) 44 (8%) 5 (1%) 18 (3%) Heterosexual contact 73 (13%) 69 (13%) Receipt of blood component or tissue 12 (2%) 12 (2%) Other/risk not reported or identified 79 (14%) 40 (7%) Men who have sex with men (MSM) Hemophilia/coagulation disorders Idaho Cumulative HIV/AIDS 2003 Exposure categories Pediatric Idaho HIV(+) (N=8) Idaho AIDS (N=3) Hemophilia/coagulation disorder 0 (0%) 0 (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;77:1097-1102 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;77:1097-1102 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;125:257-264 HIV Infection Acute Retroviral Syndrome • Fever • Lymphadenopathy • Pharyngitis • Rash • Myalgia/arthralgia • Diarrhea • Headache • Nausea/Vomiting • Hepatosplenomegaly • Weight loss • Thrush • Neurologic symptoms 96% 74% 70% 70% 54% 32% 32% 27% 14% 13% 12% 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 Acute Infection • Long term trial of 3 wks on & 3 wks off in SIV+ macaques 6 SIV RNA (log10), Median • Control of SIV viremia w/ 3 wks on Rx & 3 wks off Rx No Therapy 5 4 STI-HAART 3 HAART 2 -3 -2 +2 +5 +8 +11 Weeks Lori et al. Science 2000 +14 +17 +20 The Berlin Patient HIV RNA, copies/mL 90,000 80,000 = No treatment 70,000 60,000 50,000 40,000 176.......Permanently discontinued 30,000 20,000 10,000 <500 0 -10 30 70 110 150 190 230 270 310 350 390 727 Time, days Lisziewicz et al. New Engl J Med. 1999. 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. 2. 3. 4. 5. Partners Sexual Practices Past STDs Pregnancy History 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;77:1097-1102 Hairy Leukoplakia Oral Candidiasis • Erythematous • Pseudomembranous Dermatologic Clues • Infectious dermatitides – Bacterial, fungal, viral • Neoplastic – Kaposi’s, basal-cell, squamous cell • Inflammatory – Psoriasis, seborrheic dermatitis Mayo Clin Proc 2002;77:1097-1102 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;77:1097-1102 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