Immunizations Preventing patients with HIV from contracting vaccine- preventable illnesses is an important part of primary care. 31 Patients with low CD4 cell counts may not have optimal vaccine response. Nonemergent vaccination can be deferred until ART-induced immune system restoration. Patients with HIV infection who have CD4 cell counts <200 cells per mm 3 should not receive live vaccines (e.g., oral polio, live attenuated influenza, or varicella vaccine). 29 Table 3 outlines the currently recommended vaccines. 31
● Given the many excellent options for initial therapy, selection of a regimen for a particular patient should be guided by such factors as virologic efficacy, toxicity, pill burden, dosing frequency, drug-drug interaction potential, resistance test results, comorbid conditions, access, and cost. ● Patients without prior ART who wish to begin long-acting intramuscular cabotegravir (CAB) and rilpivirine (RPV) should first achieve viral suppression on another regimen before switching to oral, and then injectable, CAB and RPV.
Table 3: Recommended Vaccines for Patients With HIV 3 ● H. influenza type B: asplenic patients or those with a history of recurrent haemophilus infection ● Hepatitis A: Susceptible MSM and those with an indication for hepatitis A vaccine ● Hepatitis B vaccine: Patients without evidence of past or present hepatitis B infection ● Human papillomavirus (HPV): administer to all persons 13-26 years not previously vaccinated ● Influenza: Annually. Inactivated recommended ● Pneumococcal: Necessary for all patients with CD4 cell count >200/mm3 ● Polio: Inactivated only if indicated ● Tetanus toxoid: Same as people without HIV ● MMT: Administer to all nonimmune patients with CD4 cell count ≥200/ mm 3 ● Varicella zoster: Consider for varicella zoster seronegative patients with CD4 cell count ≥200/mm3 ● Meningococcal conjugate: Patients with HIV ≥2 months old
Acquired Immunodeficiency Syndrome (AIDS) AIDS refers to the most advanced stage of HIV infection. The natural, untreated course of HIV typically progress through 3 stages: 32 ● Stage 1: Acute infection ○ High viral load/greatest risk for transmission. ○ Flu-like symptoms frequent. ● Stage 2: Chronic infection ○ Asymptomatic period. ○ Active infection/virus reproduces at variable levels. Opportunistic infections were the first clinical manifestations that alerted clinicians to the occurrence of AIDS. 33 These infections typically affect patients with markedly decreased CD4 cell counts. 34 pneumocystis pneumonia (PCP), toxoplasma encephalitis (TE), cytomegalovirus (CMV) retinitis, cryptococcal meningitis, pulmonary and extrapulmonary tuberculosis, disseminated Mycobacterium avium complex (MAC) disease, and pneumococcal pneumonia, as well as certain cancers such as Kaposi sarcoma and central nervous system Co-infections Opportunistic infections lymphoma, are the most commonly diagnosed manifestation of AIDS. 33 These opportunistic infections, and many more, occur on average 7 to 10 years after infection. Until effective ART was developed, patients generally survived only 1 to 3 years after the initial manifestation of AIDS. 33 Opportunistic infections continue to have an impact on morbidity and mortality in persons with HIV in the US due to the 40% of these persons without durably
○ At the end of this stage, viral load increases and CD4 cell count decreases. ● Stage 3: AIDS ○ Most advanced stage of infection. ○ Cell-mediated immune system is markedly damaged placing these persons at high risk of opportunistic infections and cancers. ○ Diagnosis of AIDS is made based on presence of opportunistic infection or CD4 cell count <200/mm 3 . ○ High viral load/low CD4 cell count. ○ Without treatment, persons survive about 3 years. suppressed HIV infection and resulting progressive disease. 33 Durable viral suppression eliminates most but not all opportunistic infections. Tuberculosis, pneumococcal disease, and dermatomal Herpes zoster are examples of infectious diseases that occur at a higher incidence in persons with HIV regardless of CD4 cell count. 33 When most opportunistic infections occur, most notably tuberculosis and syphilis, the associated inflammatory response can transiently increase plasma viral load and decrease CD4 cell counts. 33 Tuberculosis Mycobacterium tuberculosis (TB) and HIV potentiate each other accelerating the deterioration of the immune system resulting in premature death if untreated. 35 In high-burden settings, HIV coinfection is the most important risk factor for developing active TB, which increases the susceptibility to primary infection or reinfection and also the risk of TB reactivation for patients with latent TB.35 Not only does HIV affect the progression of TB, but TB
Book Code: CT24CME
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