HIV Recognition in the ED Martha I. Buitrago, MD Infectious Diseases Idaho State University

HIV Recognition in the ED

Martha I. Buitrago, MDInfectious Diseases

Idaho State University

HIV in the ED

• Changing Epidemiology

• HIV Infection

• Presentations in the ED

• History Taking

00003-E-3 – July 2004

Adults and children estimated to be Adults and children estimated to be living living

with HIV as of end 2003with HIV as of end 2003

Total: 37.8 (34.6 – 42.3) million

Western Europe580 000580 000

[460 000 – 730 000][460 000 – 730 000]

North Africa & Middle East

480 000480 000[200 000 – 1.4 million][200 000 – 1.4 million]

Sub-Saharan Africa25.0 million25.0 million

[23.1 – 27.9 million][23.1 – 27.9 million]

Eastern Europe & Central Asia1.3 million 1.3 million [860 000 – [860 000 – 1.9 million]1.9 million]

South & South-East Asia

6.5 million6.5 million[4.1 – 9.6 million][4.1 – 9.6 million]

Oceania32 00032 000

[21 000 – 46 000][21 000 – 46 000]

North America1.0 million1.0 million

[520 000 – 1.6 million][520 000 – 1.6 million]

Caribbean430 000430 000

[270 000 – 760 000][270 000 – 760 000]

Latin America1.6 million1.6 million

[1.2 – 2.1 million][1.2 – 2.1 million]

East Asia900 000900 000

[450 000 – 1.5 million][450 000 – 1.5 million]

00003-E-4 – July 2004

ChildrenChildren (<15 years)(<15 years) estimated to be living estimated to be living with HIV as of end 2003with HIV as of end 2003

Western Europe6 2006 200

[4 900 – 7 900][4 900 – 7 900]

North Africa & Middle East

21 00021 000[6 300 – 72 000][6 300 – 72 000]

Sub-Saharan Africa1.9 million1.9 million

[1.7 – 2.2 million][1.7 – 2.2 million]

Eastern Europe & Central Asia8 1008 100[6 600 – 12 000][6 600 – 12 000]

East Asia7 7007 700[2 700 – 22 000][2 700 – 22 000]South

& South-East Asia160 000160 000[91 000 – 300 000][91 000 – 300 000]

Oceania600600

[< 2 000][< 2 000]

North America11 00011 000

[5 600 – 17 000][5 600 – 17 000]

Caribbean22 00022 000

[11 000 – 48 000][11 000 – 48 000]

Latin America25 00025 000

[20 000 – 41 000][20 000 – 41 000]

Total: 2.1 (1.9 – 2.5) million

00003-E-5 – July 2004

Estimated number of adults and Estimated number of adults and childrenchildren

newly infected with HIV during 2003newly infected with HIV during 2003

Total: 4.8 (4.2 – 6.3) million

Western Europe20 00020 000

[13 000 – 37 000][13 000 – 37 000]

North Africa & Middle East

75 00075 000[21 000 – 310 000][21 000 – 310 000]Sub-Saharan Africa

3.0 million3.0 million[2.6 – 3.7 million][2.6 – 3.7 million]

Eastern Europe & Central Asia360 000360 000[160 000 – 900 000][160 000 – 900 000]East Asia

200 000200 000[62 000 – 590 000][62 000 – 590 000]South

& South-East Asia850 000850 000[430 000 – 2.0 million][430 000 – 2.0 million]

Oceania5 0005 000

[2 100 – 13 000][2 100 – 13 000]

North America44 00044 000

[16 000 – 120 000][16 000 – 120 000]

Caribbean52 00052 000

[26 000 – 140 000][26 000 – 140 000]

Latin America200 000200 000

[140 000 – 340 000][140 000 – 340 000]

00003-E-6 – July 2004

Estimated number of children (<15 years) newly infected with HIV during 2003

Western Europe< 100< 100[< 200][< 200]

North Africa & Middle East

8 4008 400[2 500 – 28 000][2 500 – 28 000]Sub-Saharan Africa

550 000550 000[500 000 – 650 000][500 000 – 650 000]

Eastern Europe & Central Asia1 5001 500[1 000 – 2 900][1 000 – 2 900] East Asia

3 3003 300[1 200 – 9 200][1 200 – 9 200]South

& South-East Asia47 00047 000[29 000 – 87 000][29 000 – 87 000]

Oceania< 300< 300[< 1 000][< 1 000]

North America< 100< 100[< 200][< 200]

Caribbean6 0006 000

[3 000 – 13 000][3 000 – 13 000]

Latin America6 4006 400

[5 100 – 10 000][5 100 – 10 000]

Total: 630 000 (570 000 – 740 000)

00003-E-7 – July 2004

Estimated adult and child deaths Estimated adult and child deaths from AIDS during 2003from AIDS during 2003

Total: 2.9 (2.6 – 3.3) million

Western Europe6 0006 000[<8 000][<8 000]

North Africa & Middle East

24 00024 000[9 900 – 62 000][9 900 – 62 000]

Sub-Saharan Africa2.2 million2.2 million

[2.0 – 2.5 million][2.0 – 2.5 million]

Eastern Europe & Central Asia49 00049 000[32 000 – 71 000][32 000 – 71 000] East Asia

44 00044 000[22 000 – 75 000][22 000 – 75 000]South

& South-East Asia460 000460 000[290 000 – 700 000][290 000 – 700 000]

Oceania700700

[<1 300][<1 300]

North America 16 00016 000

[8 300 – 25 000][8 300 – 25 000]

Caribbean35 00035 000

[23 000 – 59 000][23 000 – 59 000]

Latin America84 00084 000

[65 000 – 110 000][65 000 – 110 000]

00003-E-8 – 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-9 – July 2004

Global estimates for adults and childrenGlobal estimates for adults and childrenend 2003end 2003

People living with HIV

New HIV infections in 2003

Deaths due to AIDS in 2003

37.8 million [34.6 – 42.3 million]

4.8 million [4.2 – 6.3 million]

2.9 million [2.6 – 3.3 million]

13.2 Million Children have been Orphaned Since the start of the Epidemic

EpidemiologyChanging demographics:

1998 2000Women 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

District 1 95 District 2 46 District 3 101 District 4 333 District 5 76 District 6 64 District 7 46• Total 761

HIV / AIDS

(As of June 2004)

Idaho Cumulative HIV/AIDS 2003

Exposure categories

(Adults)

Idaho HIV(+)

(N=565)

Idaho AIDS

(N= 552)

Men who have sex with men (MSM) 257 (45%) 308 (56%)

Injecting drug use (IDU) 95 (17%) 61 (11%)

MSM & IDU 44 (8%) 44 (8%)

Hemophilia/coagulation disorders 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%)

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 AIDSMayo 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

Weeks

2

3

4

5

6

-3 -2 +2 +5 +8 +11 +14 +17 +20

SIV

RN

A (

log1

0),

Media

n

No Therapy

STI-HAART

HAART

Lori et al. Science 2000

Acute Infection

• Control of SIV viremia w/ 3 wks on Rx & 3 wks off Rx

• Long term trial of 3 wks on & 3 wks off in SIV+ macaques

Lisziewicz et al. New Engl J Med. 1999.

<500

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

HIV

RN

A,

cop

ies/

mL

0

176.......Permanently discontinuedEpidid

ymiti

s

15–2

2

Hepat

itis A

121–

137

= No treatment

Time, days-10 30 70 110 150 190 230 270 310 350 390 727

The Berlin Patient

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. Partners

2. Sexual Practices

3. Past STDs

4. Pregnancy History

5. 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