Download HIV Recognition in the ED

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