CMN 577 Unit 1 Exam: Hepatitis and HIV
What kind of medications improve HCV?
Direct acting Antivirals (DAAs): NS3/4A+ NS5B+ NS5A) protease inhibitors: sofosbuvir/velpatasvir/voxilaprevir (these 3 approved for all genotypes 1 through 6). Not a first line therapy. This is for the 5% who do not cure from first line. The above 3 are combined in a once daily tablet. Patient must not have cirrhosis to take DAAs. These medications show virologic cure in >96% of patients.
All HIV test results are required to be directly communicated by the provider, a nurse, counselor, or other skilled staff member. True or False?
False: Negative results can be mailed, sent electronically, etcetera. Positive results require PERSONAL contact from professional staff.
How is Hepatitis A spread? (HAV)
Fecal- oral route: contaminated food and water. Through ingestion of fecal matter from an infected person, or in food or water. In gay men this can be done through anal-oral contact or contact with fingers or objects that have been in or near the anus.
Treatment of HIV patients with cryptococcosis, Candidiasis, and endemic fungal diseases:
Fluconazole.
If viral load is >1000 copies/ml near delivery, advise the pregnant HIV+ female to do what?
Have a Cesarean delivery at 38 weeks. HIV+ mom should be offered a 6 week postnatal infant prophylaxis ART within 12 hours of birth. Breastfeeding in HIV+ moms is NOT RECOMMENDED.
Hep A vaccines include:
Havrix, Vaqta, and TwinRix. Twinrix is a combined Hep A and Hep B vaccine and is NOT indicated for POST EXPOSURE PROPHYLAXIS.
Herpes simplex in HIV:
Immunocompromised state of HIV positive patients places them at higher risk for herpes. Treat with acyclovir or valacyclovir.
Treatment of HAV:
In patients < 40: Immune globulin, must be given within 2 weeks of exposure. HAV A vaccine is treatment in 12 month to 40 year age group. Immune globulin (IG) is treatment for under 12 months, over age 75 years, allergies to HAV vaccine, or immunocompromised.
What is the incubation period of Hepatitis A (HAV)?
Incubation period is 28 days on average, but may be 15 to 50 days. Symptoms usually last 2 months, but some cases last up to 6 months. Once HAV positive, antibodies will always be made, rendering lifelong protection against recurrence.
What is Hepatitis?
Inflammation of the liver. Can be self-limiting or can progress to fibrosis, cirrhosis, liver cancer, death. Hepatitis viruses (A,B,C,D and E) are the most common cause, but toxic substances (alcohol) and autoimmune diseases can also cause Hepatitis. World hepatitis Day is July 28th.
Limitations of ART:
Lifelong treatment. Follow up is necessary. Adherence is KEY to success. Side effects.
National Hepatitis Testing Day:
May 19th.
Who are the high risk groups for HIV?
Men who have sex with men (MSM), healthcare workers, first responders, infants born to HIV infected moms, blood transfusions, being bitten, having sex with, or open mouthed kissing with an HIV positive person, eating pre-chewed food by an HIV positive person.
Transgender women:
People who were born with male genitalia at birth but identify as women.
Neurological symptoms of HIV:
Psychosis, Guillian Barre, meningitis, facial palsy, peripheral neuropathy , brachial neuritis, cognitive impairment.
Transgender:
an umbrella term describing people whose gender identity or expression differs from that associated with their birth sex
What must be done before initiating PEP or PREP?
***Baseline labs indicating negative HIV status and pregnancy must be done before initiating PREP or PEP therapy.
What may be the first sign of perinatal HIV infection in a pediatric patient?
**PJP: pneumocystis jirovecil pneumonia. High risk for infants. Prophylaxis is indicated at 4 to 6 weeks. If HIV+ mom insists on breastfeeding, then prophylaxis is needed.
What is the incubation period of HBV?
60 to 150 days with an average of 90 days incubation (according to keynotes). (45 to 160 days according to CDC) Symptoms may last weeks to 6 months. 95% recover, those who do not develop chronic HBV that leads to cirrhosis/ hepatocellular carcinoma. Treat: vaccinations, interferon.
Approximately how many people world wide die of HBV annually?
786,000.
What percent of new HIV diagnoses in the US from 2009 through 2014 were transgender women (men who identify as women)?
84% were transgender women. Half lived in the south.
As of August 2019, how many people with HIV are living in the United States?
> 1.2 million, and 1 out of 8 of these people are unaware they have the disease.
As of August 2019, how many combination medications are available to treat HIV?
>6. HIV staging must take place for the correct treatment option to be chosen: CD4 cell count. Viral load: HIV/RNA levels. HIV genotype. Anticipated patient adherence/compliance. Comorbidities. Drug interactions. Cost.
About 50% of people with Hepatitis B in the U.S. are of what ethnic background?
Asian: 50% of Hep B patients in U.S. are Asian.
Hepatitis B is spread through what?
Body fluids; semen, saliva or blood, from an infected person (NOT breastfeeding). The Hep B virus is 50 to 100 times more infectious than HIV. Transmitted through sexual activity, sharing of needles, mothers to babies at birth, transfusions of infected blood. At risk include: infants born to infected moms, IV drug users, men on men, facilities of ill or childcare, travelers, public health workers.
Sharing needles to inject drugs puts a person at risk for which? A. Hep A, Hep B, Hep C. B. Hep A, Hep C, liver failure. C. Hep B, Hep C, HIV. D. Hep A, HIV, AIDs.
C. Hep B, Hep C, HIV.
Occupational exposure of HIV:
CDC states PEP be initiated withing 2 hours of incident or sooner if possible. If employee refuses PEP, repeat HIV testing at 4 and 12 weeks. If results are negative at 12 weeks, it is reasonable that the exposure did NOT transmit HIV to the employee. No more testing is needed after 6 months.
A patient diagnosed with a clotting factor disorder should get vaccinated for which type of hepatitis?
Clotting factor disorder = Hepatitis A.
What other prevention strategies are encouraged with PEP or PREP?
Condom use. Getting HIV testing with partners. Choosing less risky sexual behaviors ( PREP says "such as oral sex").
Hepatitis C is spread through...? (HCV)
Contact with the blood of an infected person, primarily through sharing needles, syringes, or other injection drug equipment. Tattoos and body piercings in informal settings. Although uncommon, Hepatitis C can also be spread through sexual contact. No vaccine for HCV.
Up to what percent of patients over the age of 5 years will have symptoms related to HBV?
50%. symptoms are rare under age 5 and in the immunocompromised. Symptoms include fatigue, Nausea, vomiting, decreased appetite, fever, abdominal pain, clay colored stools, dark urine, jaundice, joint pain.
Of people with HIV, what percent also have Hep B, and Hep C?
10% also have Hep B. 25% also have Hep C. (Multiple sex partners and high risk behaviors.)
Repeat HIV testing of EXPOSED infants how often?
12 to 21 days, 1 to 2 months, 4 to 6 months. Children >2 years may have annual screenings. Perinatal exposure or HIV+ infants are reported to the health department.
What percent of transgender women in the US currently have HIV?
14% (as of 4/2019).
Incubation period of HEV (Hep E virus):
15 to 60 days with an average of 40 days from exposure. Patient is considered infectious for 7 days to 7 days AFTER ONSET of jaundice. Antibodies prevent recurrence of HEV. No vaccine for HEV, use proper sanitation measures and thoroughly cook foods.
What percent of transgender men were newly diagnosed with HIV from 2009 through 2014
15% were transgender men. Half lived in the south.
What is the earliest age an infant born to a HCV positive mom can be tested for antibodies?
18 months as there may be maternal antibodies present prior to that age.
What is the incubation period for HCV?
2 to 24 weeks after exposure with an average of 4 to 12 weeks. 15 to 50% spontaneously resolve. Symptoms may last up to 6 months. 50 to 85% of HCV patients become chronic and HCV infection leads to cirrhosis, hepatocellular cancer and death. HCV oral treatment exits, is expensive and must be taken strictly consistently. Treatment is 24 weeks- with adherence a cure is likely.
Currently (as of April 2019), what transgender women's group has the highest percentage of HIV?
44% of Black transgender women have the highest percentage of HIV.
Prevention of HAV includes what?
Hand hygiene, proper diaper disposal, cleanliness of bathrooms and countertops. HEP A 2 part vaccine for all patients 12 months and older.
How does being vaccinated for HBV (HEP B) prevent patients from acquiring HDV (Hep D)?
One can only contract HDV when already infected with HBV. Preventing HBV through vaccination also prevents HDV.
What ethnic LGBT group had the highest increase in HIV from 2009 through 2014?
African American: Transgender MEN 58%. Transgender Women 51%.
How is HIV NOT transmitted?
Air, water, toilet seats, tears, saliva, sweat, casual closed mouth kisses, mosquitos fleas or ticks, sharing dishes or shaking hands. These are NOT ways in which HIV is transmitted.
How often should an HIV positive MSM male patient be screened for syphilis?
All MSM patients should be screened for syphilis every 6 months by VDRL or RPR. Treatment of choice is PCN or Rocephin.
What meets criteria for confirmatory diagnosis of pediatric HIV?
Any 2 positive NAT tests.
What should be checked in all Hepatitis patients?
ETOH screening. Send referral for further workup for all hepatitis patients.
How often should there be follow up for PREP (Truvada)?
Every 3 months for HIV testing, medication adherence counseling, behavioral risk reduction support. At 3 months, then every 6 months assess renal function. Every 6 months test for bacterial STDs
Combined HIV-1/HIV-2 antibody and p24 antigen Immunoassay (4th generation test):
FIRST LINE for HIV testing. Sent out, not done in office.
Sheepskin condoms are highly effective against transmission of HIV. True or False?
False: Latex and female nitrile condoms are highly effective against transmission of HIV. Water based or silicon lubricants are best. Avoid oil based, cause increased risk of condom rupture.
Any patient diagnosed with HIV/Aids needs what in terms of hepatitis assessment?
HIV/AIDS patients need to be vaccinated for Hepatitis B and blood tested for Hep B and Hep C.
10% of new hep A cases and 20% of new Hep B cases occur in which population?
Gay and Bisexual men.
How has the incidence of Hepatitis A (HAV) changed since the introduction of vaccine in 1995?
HAV has decreased by 95%.
What is the leading cause of liver cancer?
HBV (Hepatitis B) and HCV (Hepatitis C)
Hepatitis D virus (HDV) only occurs in those who are infected with which other Hep strain?
HBV. Hep D occurs only in those who are infected with Hep B. HDV (or Delta hepatitis) is an incomplete virus and requires HBV to replicate. Dual infection results in more serious disease with worse prognosis.
75% to 85% of people who are infected with this develop chronic infection, and 1% to 5% will die from cirrhosis or liver cancer.
HCV: Hepatitis C.
What labs are drawn BEFORE initiating treatment?
HIV 1, HIV 2, serum glucose, creatinine, lipids, UA. PPD or CXR to rule out TB. Check for other STDs.
TB is higher among HIV positive patients. How often should HIV patients be tested for TB and what does a positive test look like?
HIV positive patients should have an annual PPD. A positive PPD test is >5mm induration on an HIV patient. A positive result reflexes to a chest X-ray. ANY sputum on chest x-ray indicates need for acid-fast sputum stain. Positive PPS but negative active disease is treated 9 to 12 months.
Pediatrics in HIV refers to those patients under age 13. How are these patients at risk for HIV?
Hemophilia, transfusions, being a foreign adoptee, perinatal transmission ( up to 90% of cases).
Which 2 Hepatitis strains are typically caused by ingestion of contaminated food and water?
Hep A and Hep E.
Which 3 strains occur as a result of parenteral contact with infected body fluids?
Hep B, C and D.
Which Hepatitis vaccine(s) should patients with diabetes, and/or patients on dialysis be vaccinated with?
Hep B: Hemodialysis, diabetes, international travelers, and people at risk of sexual exposure to Hepatitis should be vaccinated against HBV.
HEV is mostly transmitted how?
Hep E is mostly transmitted through consumption of contaminated water or food. *It is a common cause of Hepatitis outbreak in developing parts of the world. There are vaccines but are not widely available.
Any patient recently diagnosed with a sexually transmitted disease should be vaccinated for which?
Hepatitis B.
The CDC recommends gay and bisexual men get tested for _________.
Hepatitis B.
A patient born outside the United States should be tested for which hepatitis?
Hepatitis B. Many parts of the world have high rates of hep B including the Amazon, Asia, Africa and the Pacific Islands.
Which hepatitis has no vaccine and who are the core group infected?
Hepatitis C (HCV) has no vaccination. Baby boomers, born between 1945 and 1965 are highly affected because of their drug use in the 60's (IV drug use even once increase chances). A one time HCV antibody test is covered as a preventative service under the Affordable Care Act.
Baby Boomers: born 1945 to 1965 need which Hepatitis testing?
Hepatitis C.
Blood transfusion and organ transplant patients before July of 1992 need tested for which hepatitis?
Hepatitis C.
Patients who received a clotting factor concentrate before 1987 need blood tested for which?
Hepatitis C.
There is no vaccine for which type of viral hepatitis?
Hepatitis C. And this strain has the most new cases each year at 41,000.
Prevalent in developing countries. A large population in the United States are positive: those who have endured natural disasters, refugee camps, or overcrowding.
Hepatitis E. (HEV)
What ethnic LGBT group had the second highest increase in HIV from 2019 through 2014?
Hispanic/Latino: Transgender Men: 15% Transgender Women: 29%
What are the signs and symptoms of HIV?
Newly infected HIV patients are asymptomatic. Mononucleosis like illness in up to 90% of exposed patients. Fever & fatigue present 2 to 3 weeks after exposure, preceding seroconversion (from negative to positive) by 10 to 21 days. This time frame the person is HIGHLY CONTAGIOUS. Acute retroviral syndrome: fever of 102, fatigue, erythematous, maculopapular rash on face, body, palms and soles, headache, generalized LAD and malaise, hepatosplenomegaly, night sweats, weight loss, mouth and genital ulcers, etc.
What condition is associated with HIV positive patients with prolonged low CD4 cell counts?
Non-Hodgkin's Lymphomas (NHLs) are B type and aggressive. They are found in non nodal sites such as the central nervous system. Refer for urgent evaluation and staging for chemotherapy.
Antiretroviral therapy (ART):
Pharmacological therapy used to battle a class of retroviruses that tend to mutate quickly. Prolongs life span. Reduces risk of transmission to others. **Patients should be offered ART REGARDLESS of their CD4 counts.
What is PEP?
Post-exposure prophylaxis. A combination of 2 or 3 antiretroviral drugs. Must begin within 72 hours of exposure. Take for 4 weeks. Not 100% effective. ONLY for emergencies. Side effects: abdominal pain, fatigue
What is PREP?
Pre-exposure prophylaxis. A daily pill that must be taken consistently every day. Decreases chances of HIV up to 92% if taken consistently. 2 meds: tenofovir (TDF) and emtricitabine (FTC)= TRUVADA. Used in gay or bisexual men & heterosexual couples where 1 partner is HIV positive.
What are the symptoms of viral Hepatitis?
Symptoms range from none to fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, grey stools, joint pain, jaundice.
Which HIV test is approved for home testing?
The OraQuick: a swab test, approved in 2013 for home testing. Takes 20 minutes using oral secretions. 99% specific and sensitive, but there can be user error. This test is MOST effective 3 months after exposure.
Which 2 trials were responsible for enabling any HIV positive patient with ART treatment regardless of CD4 cell count?
The START and TEMPRANO trials.
Which HIV blood tests can be done in office?
The Uni-Gold REcombigen, takes 10 minutes for results. UniGold- only tests for HIV1. This test is highly sensitive and specific but requires a confirmation test called the Biorad Multi-spot. This is a send out test anyway.
Men who have sexual encounters with other men need what?
Vaccinations for Hep A and Hep B. Blood tested for Hep B.
An I.V. drug user needs what Hepatitis protection?
Vaccinations for Hep A and Hep B. Blood testing for Hep B and Hep C.
HIV children should receive all inactivated vaccines. If the CD4 count is >750, they may receive what?
Varicella AND the MMR. Separate, not combined.
Treatment of HIV patients with Pneumocystitis jirovecil pneumonia:
Treat with BACTRIM. Atovaquone or aerosolized pentamidine.
Treatment of HIV patients with mycobacterium avium complex infection:
Treat with CLARITHROMYCIN (Biaxin) OR Azithromycin (Zithromax).
Treatment of HIV patients with CMV:
Treat with ganciclovir in patients with CD4 cell counts of <50 cells/mcl. Watch for neutropenia. 99% of MSM are positive for CMN IgG.
Toxoplasmosis in HIV:
Treated with Bactrim. Positive IgG toxoplasma serology and CD4 counts <100cells/mcl.
Testing is not recommended for Hepatitis A for gay men. True or False?
True.
In all 3 forms of viral hepatitis a person could develop serious liver conditions, liver failure, liver cancer, and even death. True or False?
True: Hep B and Hep C can be acute or chronic and have lasting damage and possibly death. Hep A is acute. The Hep A infection usually lasts no more than 6 months. The patient may feel sick during this time, but they recover completely with no lasting liver damage. It is rare but Hep A can cause liver failure and death.
Infants with HIV have a high mortality rate prior to 24 months. True or False?
True: a child who converts later in life has a longer life expectancy.
Circumcision decreases the risk of contracting HIV from a positive female, lowers rates of STIs and lowers risk for penile cancer, but does NOT reduce risk for HIV transmission in MSM (men who have sex with men). True or False?
True: lower risk sexual behaviors such as oral sex and being sure the HIV positive male is the recipient rather than the receiver help reduce transmission, as well as ART therapy, PrEP or PEP therapy.
Written consent must be obtained prior to HIV testing. True or False?
True: the consent should contain the definition of HIV, the meaning of the possible results, easily understandable, and explained to the patient if they do not fully understand.
Confirmed HIV results must be referred to the health department. True or False?
True: the health department will likely contact your patient for additional information. The health department can also contact sex partners for screening without revealing the identity of the infecting patient.
Screening for HIV:
USPTF and CDC recommend screening all patients at least once for HIV. High risk patients should be screened annually. CDC: recommends screening at age 13. USPTF: age 15. AAFP : age 18 and up through 65.
What percent of children under age 6 are HAV asymptomatic?
Up to 70% are asymptomatic. Also, < 70% of older children, adolescents and adults will have jaundice.
The LGBT group with the third highest increase in HIV from 2019 through 2014?
Whites: Transgender Men: 16% Transgender Women: 11%
Gender identity:
a person's internal understanding of their own gender. Not necessarily the gender they were physically born with.
Transgender Men:
people who were born with female genitalia at birth but identify as men.
PEP for Pregnant women (since treatment can cause neural tube defects):
raltigravir, tenofovir and emtricitabine.
