HIV/AIDS-Test and Treat Atul Kakar, Samiran Nundy
INDEX
Page numbers followed by f refer to figure, fc refer to flowchart and t refer to table.
A
Abacavir 29, 30, 43, 66, 91, 152, 167, 195, 197
caution 31
induced rash 31
side effects 30
Abnormal pap test 4
Absolute lymphocyte count 63
Absolute neutrophil count 167
Acetazolamide 134
Acid-fast bacilli 96
Acneiform lesions 125
Acute bronchitis 140
Acute human immunodeficiency virus 4
Acute primary infection 173
Adalimumab 135
Adefovir 188190
Adenosine deaminase 106
Adherence monitoring 65
Adrenal function 156
evaluating 156
Adrenal gland 154, 155
Adrenal hemorrhage 154
Adrenal insufficiency 154
Adrenal steroidogenesis 155
Adrenocorticotropic hormone 155
Advanced stage of disease 76
Aerosolized-pentamidine prophylaxis 138
Agranulocytosis 164, 167
Alafenamide 195
Alanine aminotransferase 50
Alanine transminase 54
Alcian blue stains 127
Alcoholic hepatitis 13
Alemtuzumab 135
Alendronate 184
Alpha mating types, virulence of Cryptococcus 123
American Association for the Study of Liver Diseases 195
Amphotericin-B 165
Amplified mycobacterium tuberculosis direct test 102
Amprenavir 34, 151
Anal carcinoma 9
Anemia 163
chronic disease 165
human immunodeficiency virus disease 164, 165
impact of 164
treatment of 166
Angular cheilitis 174
Antenatal blood testing 77
Antenatal care 12
Antenatal drug supplementation 78
Antenatal HIV testing 74
guidelines 74
rapid or point-of-care tests 75
Antibodies to HIV 12
Antibody-based tests 13
screening assays 13
supplemental tests 14
Antifungal
susceptibility 128
therapy 134
Antigen detection assays 106
Anti-granulocyte-macrophage 124
Anti-retro viral 42, 194
agents dosing
adjustment of 150
schedules of 27, 45
fixed drug combination 42
second-line regimens 43
therapy 49, 61, 112, 114
babies of HIV-positive mothers 83, 84fc
baseline laboratory tests 50
benefits of early start 49
classification of 27
combination 8, 27, 50, 86
early initiation of 49
eligibility for 49
guidelines for initiation of 51t
history taking before initiation of 50
how to monitor 61
laboratory monitoring of 65
laboratory tests prior to initiation of 28f
monitoring for associated allergic reactions 66
mortality, impact of 118
presence of other opportunistic infections 51
start in adults and adolescents 52
tuberculosis patients 113
treatment 54
aim of second-line 58
clinical scenario 58
drug combination 59
failure definitions 57
first line failure: follow-up and monitoring 56
first-line treatment protocol 54
fixed dose combination drug 55
mortality on 57
outcomes during the first six months of therapy 56
preferred regimen 58
pregnant and breastfeeding women 56
presence of opportunistic infections 56
second-line treatment 58
various medications available in India 43
Antituberculosis drug-related, side effects 116
Antituberculosis therapy 96, 176
regimens 116, 117
Anti-tumor necrosis factor-alpha therapy 224
Arterionephrosclerosis 149
Aspartate aminotransferase 50
Aspartate transminase 54
Assisted reproduction 88, 90
Atazanavir 35, 43, 45, 58, 151
induced hyperbilirubinemia 35f
side effects 35
Atovaquone 141
Atypical mycobacteria 154
infections 176
Atypical mycobacterium 165
Auramine 97
Autoimmune diseases 13
Autoimmune thyroid disease 157
Autologous stem cell transplantation 171
Avascular necrosis 228
Azidothymidine 29
Azoles 129
Azotemia 142
B
Bacillary angiomatosis 177
Bacterial infections 57
Bacterial pneumonia 118
Bactrim 165
Barrier contraceptives 84
Bartonella henselae 177
Baseline CSF culture 131
Basidiomycete yeast 121
Bereavement care 223
Betadine 208
Bisphosphonates 184
Bleomycin 170
Blood loss 165
Blood splashes 46
Body mass index 183
Bone, diagnosis of 182
Bone, health in HIV/AIDS 181
Bone marrow aplasia 164
Bone marrow culture sterile 227
Bone marrow failure 164
Bone marrow infection 165
Bone mineral density 181
risk factors 182
treatment 184
WHO classification of T score 183
Bones, effect of HIV on 181
Breastfeeding 84
Brentuximab vedotin 170
Bronchoalveolar lavage 140
Bronchogenic carcinoma 9
Bronchospasm, presence of 227
Burkitt lymphoma 164, 168
Burkitt's large B-cell lymphoma 8
Burkitt's lymphoma 169
C
Caffeic acid medium 128
Calcitonin 184
Calcofluor white stain 127
Candida albicans 177
Candidiasis 177
Cavitatry lesion 116
CD3-positive cells 68
CD4 cell count 8, 50
CD4 count
format of report of 68t
measuring 63
surrogate markers for 67
CD4 decline 22
CD4 depletion 162
CD4, estimation flow cytometry-based 69f
CD4, imbalance of 162
CD4 monitoring when on treatment, latest recommendations for 62
CD4 percentage, measuring 63
CD4 protein 163
CD4 recovery 56
CD4 surface membrane protein 162
CD4 thymic lymphocytes 162
CD4/CD8 ratio 49, 68
CD4+ lymphocyte 166, 171
CD4+ lymphopenia 163, 167
CD4+ T cell count 28
CD4+ T cells, progressive depletion of 61
Cellulitis 125
Centers for Disease Control and Prevention 22, 173
Central nervous system 6
infections 125
lymphoma 167
Centroblastic lymphoma 168
Cerebral edema: acute, management of 134
Cerebral toxoplasmosis 6
Cerebrospinal fluid 105, 128, 133
Cervical cancer 4
Cervical neoplasia, women for diagnosis of 77
Cervicovaginal secretions 76
Cesarean section 73
Chemokine coreceptor antagonists 152
Child Health Programme 77
Chloramphenicol 128
Chronic diarrhea 4
Chronic intestinal cryptosporidiosis 199
Chronic kidney disease 147, 151
Chronic liver and renal disease 124
Chronic meningitis 125
Classic Hodgkin's lymphoma 164, 168
Classical tests, alternate to 17
Clindamycin 141
Cobicistat 44
Colorectal carcinoma 9
Communication skills 222
Condom less anal intercourse 212
Contraception 83
Corticosteroids 124, 228
Cortisol levels 156
Cotrimoxazole 78
Cotrimoxazole prophylaxis 118
on mortality impact of 118
Creatine phosphokinase elevation of 29
Creatinine clearance monitoring 206
Cryptococcal antigen 133
Cryptococcal infection 123, 135
Cryptococcal isolates 129
Cryptococcal meningitis 52, 121, 124, 228
clinical manifestations 125
diagnosis 121
host factors 123
in AIDS 125
laboratory diagnosis 126
pathogen 121
pathogenesis 124
percentage positivity of diagnostic tests in 126t
prevention 135
prognosis and outcome 135
radiology 131
treatment of 133, 134fc
Cryptococcomas of
brain 125
chronic dementia 125
spinal cord granuloma 125
Cryptococcus 121, 124, 154, 225
infections risk factors associated with 124t
Cryptococcus neoformans 122, 157
Cryptosporidium 52
Culture filtrate protein 10 109
Cup insemination 88
Cushing's syndrome 156
Cutaneous
malignancies 9
tuberculosis 179
warts 179
Cyclophosphamide 169
CYP3A inducers 196
CYP3A4 40
Cytochrome P450 196
Cytomegalovirus 117, 140, 154, 165, 225
infections 175
Cytopenia in human immunodeficiency virus infection 166
Cytosine analog 30
D
Dacarbazine 170
Daclatasvir 196, 199
Dapsone 165
Darunavir 36, 45, 66, 151
caution 36
side effects 36
Dasabuvir 197, 199
Deep fungal infections 177
cryptococcosis 177
histoplasmosis 177
penicilliosis 177
Delavirdine 31, 66, 152
Demodex folliculorum 177
Denosumab 184
Deoxyribonucleic acid microarrays 109
Dermatophyte infections 177
DEXA
machine 183f
report 184
Dexamethasone 134
Didanosine 29, 38, 160
Dideoxyinosine 42
Dideoxynucleosides 38
Diffuse large B-cell lymphoma 164, 168
Diffusion lung capacity for carbon monoxide 139
Direct fluorescent staining for mycobacteria 97f
Direct microscopy CSF analysis 126
Directly acting antivirals 194
Directly observed therapy (DOT) 114
Disseminated cutaneous tuberculosis 174
Disseminated intravascular coagulation 164
Dolutegravir 37, 212
caution 37
side effects 37
Doxorubicin 169, 170
Drug susceptibility testing 96
Dry cough subfebrile 138
Dual energy X-ray absorptiometry (DEXA) scan 182
Dual nucleoside reverse transcriptase inhibitors 91
Duovir N kit (Cipla) 59
Dyspnea 138
E
Early infant diagnosis 82
Early secreted antigenic target 6 109
ECG changes at presentation in STEMI 122t
Edema 148
Efavirenz 30, 31, 33, 43, 44, 55, 66, 152, 215
based ART 118
caution 33
intolerance to 57
side effects 33
Effective fungicidal activity, measurement of 128
Elbasvir 196, 199
Elvitegravir 37, 45, 152
side effects 37
Empiric therapy 114
Emtricitabine 29, 43, 44, 91, 151, 182, 195, 197, 203, 205, 212
caution 30
side effects 30
End of care for HIV/AIDS patients and their family 222f
End of life care 222
Endocrinal manifestations of HIV infection 154, 155f
Endotracheal aspirates 140
End-stage renal disease, incidence of 148
Enfuvirtide 152
Enfuvirtide (T-20) 37
side effects 38
Enlarging intracranial tuberculomas 116
Entecavir 189, 190
Entry inhibitors 37
ENV gene product groups 75
Enzyme immunoassays 130
Enzyme-linked immunosorbent assay 12, 23
Epstein-Barr virus 8, 167
infections 175
Erythematous flat 173
Erythropoietin 166
Ethambutol 114, 117
Ethionamide 176
Etoposide 169
Etravirine 31, 33, 66
caution 33
side effects 34
European Association for the Study of the Liver 195
Extracerebral toxoplasmosis 6
Extranodal marginal zone B-cell lymphoma 164, 168
Extrapulmonary disease 138
case of 118
Extrapulmonary TB 95
F
Fat accumulation 39
Fat cells, apoptosis of 38
Fenofibrate 40
Fetal scalp electrode insertion 76
Fixed drug combinations 43
anti-retro viral 42
for pre-exposure and post-exposure prophylaxis 45
Fluconazole 8, 177, 178
doses of 134
maintenance therapy 130
use of 133
Fluorescent microscopy 97
Fluorimetric microparticle technology 14
Fluvastatin 40
Focal segmental glomerulosclerosis 152
Folic acid deficiency 165
Follicle-stimulating hormone 158
Folliculitis 175
Fosamprenavir 34, 45, 66, 151
FRAX tool 183
Fresh blood on penetrating instrument 209
Fumarate 189
Fungal infections 174
G
Ganciclovir 165
Gemfibrozil 40
Genetic polymorphism 148
GeneXpert system with cartridge 104f
Giant molluscum 176f
Giemsa stain 7
Glomerular disorders 147
Glomerular filtration rate 148
Glomerulonephritis 148
Glucocorticoid resistance 156
Glucose homeostasis 159
Glucose-6-phosphate 141
Gomori methenamine silver fungal stain 127
Gonadal dysfunction, drugs causing 159
Gonadotropin secretion 159
Granulocyte colony stimulating factors 167
Granulocyte-macrophage colony-stimulating factors 167
Grazoprevir 196, 199
Gynecomastia: combination of ritonavir and lopinavir 35f
H
Hematopoietic stem cell transplantation 170
Hemodialysis 150, 190
Hemoglobin consisting of 65
Hepatitis B virus 61, 225
acute infection 188
chronic infection 188
clinical syndromes 187
coinfections with 186
drug dosages 189
infection 186, 187
interpretation of 187, 188t
pathogenesis 186
vaccination 189
viremia 187
Hepatitis C virus 61
coinfections with 186
NS5A inhibitor 196
Hepatomegaly 77
Hepatotoxicity 40, 117
Herpes simplex virus 174, 225
Herpes zoster 174, 179
Herpes zoster infection 174
Hiccups 222
Higher viral load and lower CD4 cell count 193f
Highly active anti-retro viral therapy 8, 27, 163, 184, 224
Histoplasma 165
Histoplasmosis 140
Hodgkin's disease 9
Hodgkin's lymphoma 165, 168, 169
therapy 170
Hormonal contraceptives 83
Host defenses 124
Host factors 123, 148
Human herpes virus 8 225
Human immunodeficiency virus (HIV) 3f, 10, 27, 61, 73, 95, 112, 121, 147, 154, 162, 186, 203, 219
and hepatitis B virus (HIV-HBV), coinfection 186
and hepatitis C virus, coinfection 191
disease burden 191
effect on immune system 195f
effects of kinetics 192
liver transplantation in coinfected patients 199
meta analysis data 194f
risk factors for 191f
treatment of 193, 195
and kidney 147fc
and tuberculosis therapy, optimal timing of 119
antibody-based tests 12
associated collapsing glomerulopathy
clinical manifestations 148
diagnosis 148
natural history 149
pathogenesis 147
pathology 148
treatment 148
associated nephropathy 147, 152
culture 15
detection of 10
patterns of disease progression 12
window 10
DNA 15
enzyme-linked immunosorbent assay 11
host response to 11f
infected patient on antituberculous, medications monitoring 115
infected patients on ART 117
infected patients, principles of fertility of management of 87
infection
acute, detection of 16
affect fertility 87
hematological manifestations of 162, 164t
laboratory diagnosis 12
management of 49
medication, common side effects of 40f
on the course and outcome of pregnancy, effect of 75
P24 antigen detection 15
patients desiring pregnant 86
positive patients, safer options for 88
positive pregnant woman 76
positive women 73
related malignancies 8
reservoir 170
resistance testing 28
RNA polymerase chain reaction 15
serodiscordant couples 74
stages of 10
acute infection stage 11
chronic asymptomatic phase 11
skin involvement 173
TB coinfected patients 95
testing legal aspects of 17
confidentiality 17
mandatory testing 17
pre-test counseling 17
social aspects of 17
type 2 infection 22
vertical transmission, clinical trials on prevention of 79
viral load monitoring, recommendations for 63
viral load tests 64
Abbott RealTime HIV-1 64
Cobas AmpliPrep/Cobas TaqMan HIV-1 test 64
Cobas HIV-1 quantitative NAT 64
Cobas TaqMan HIV-1 test 64
Human immunodeficiency virus (HIV)/AIDS
and gonadal dysfunction in women 159
causes of pain in 220
infection laboratory diagnosis of 10
suspect 4
Human immunodeficiency virus 1 (HIV-1)
RNA quantification 64
Human immunodeficiency virus 2 (HIV-2)
coreceptor tropism 24
detection 20
diagnosis 20, 21
endemic country 22
immunoblot test 23
infection 22
diagnosis 23
monitor 23
rapid test 23
suspect 23
therapy 23
Human immunodeficiency-infected individuals 133
Human papillomavirus 167, 175
Hyperbilirubinemia 34
Hypercortisolemia 156
Hyperkalemia 142
Hypertriglyceridemia 65
Hypogonadism 154
in males 158
investigation of 159
primary 158
secondary 158
Hypothalamic-pituitary-adrenal 155
Hypothalamic-pituitary-gonadal axis 158
I
Immature fetal immune system 76
Immune cytopenia 164
Immune hemolytic anemia 164
Immune reconstitution inflammatory syndrome 57, 116, 134, 158, 179, 224
clinical features 226
diagnosis 225
differential diagnosis 226fc
management of 228f
nontuberculous mycobacteria 227
occurrence of 226
pathogenesis 224
prevention 228
risk factors 225
treatment 227
with tuberculosis 226
Immune reconstitution syndrome 125
Immune-mediated
pancytopenia 164
thrombocytopenia 164
Immunization, follow-up 82
Immunoblastic lymphoma 168
Immunocompetent hosts 124
Immunofluorescence assay 13, 14
Immunoglobulin G 6, 78
Immunological dysfunction (B cell disease) 13
Immunological failure 63, 65
Immunosuppressive therapy 124, 167
In vitro fertilization 88
India ink mount 127f
Indian National Association for the Study of the Liver 195
Indinavir 34, 151, 165, 167, 215
causes nephrolithiasis 34
Ineffective erythropoiesis 163
Infection in relation with CD4 cell count 6f
Infections and malignancies 5
Infectious Diseases Society of America 133
Infective dermatoses 174
bacterial infections 175
fungal infections 177
parasitic infections 177
viral infections 174
Inflammatory diseases 178
Injecting drug users 4
Insulin resistance and diabetes 154
Integrase inhibitors 36, 41, 152
CCR5 antagonist 24
maraviroc 24
raltegravir 24
Integrase strand transfer inhibitor 195
Interferon gamma release assays 108
Intracranial pressure elevated 134
Intramuscular depot medroxyprogesterone acetate 83
Intranatal period 75
Intrapartum anti-retro viral therapy 80
mode of delivery 80
role of cesarean section 80
Intrapartum management 80
Intrapartum period 76
Intrauterine contraceptive devices 84
Intrauterine device, insertion of 82
Intrauterine growth rate, development of 75
Intrauterine insemination 88
Iron deficiency 165
Isoniazid 114, 176
Itraconazole 8, 155, 177
Ivermectinis 177
K
K65R mutation 30
Kaposi's sarcoma 8, 140, 154, 163, 165, 178
Keloid 175f
Ketoconazole 155
Kidney transplantation 150
Kissing 210
L
Lactate dehydrogenase
elevation of 29
levels 139
Lactic acidosis 43
Lamivudine 29, 30, 43, 42, 44, 55, 58, 91, 150, 160, 182, 189, 190, 195, 197
caution 30
refractory 190
side effects 30
Latex agglutination test, strip for Cryptococcus 129
Ledipasvir 196, 199
Leprosy 13
Lesion in brain, MRI space occupying 7f
Light-emitting diode fluorescent microscopy 98
Line immunoassay 13
Lipid abnormalities 40
Lipoatrophy 38
Lipodystrophy 43, 160
grades 39f
Liposomal amphotericin B 8
Long-term nonprogressors, subset of 12
Loop-mediated isothermal amplification 105
Lopinavir 43, 45, 151
Lopinavir/ritonavir: combination 34, 46
side effect 34
Low CD4 counts 139
Lowenstein-Jensen media 99
Luteinizing hormone normal levels of 158
Lymph node
biopsy 227
palpation 173
Lymphoma 154
Lymphomas in human immunodeficiency virus, risk factors for 169
Lymphoproliferative diseases in HIV infections, spectrum of 167
Lymphoproliferative disorders 106, 124
M
M184 mutation 30
Malaise 214
Male sterilization 82
Malignancies infiltrating bone marrow 165
Mannitol 134
Maraviroc 38, 152
side effects 38
Maternal blood 76
Maternal chorioamnionitis 76
Maternal high viral load 85
Maternal immunization 77
Maternal low CD4 counts 85
Maternal malnutrition 76
Mean corpuscular volume 29
Measles 78
Medical termination of pregnancy 74, 85
Medication-related endocrinopathies 154
Megestrol acetate 155
Melanomas 9
Metabolic issues and complications 38
Metabolic problems 43
Meyer's mucicarmine stain 127
Microangiopathy hemolytic anemia 164
Microsponidosis 52
Mitochondrial toxicity of, anti-retro viral therapy 38f
Mixed feeding 85
Molecular assays 13
Molecular DNA 16
Molecular methods 130
Molluscum contagiosum 7, 125, 175
Monoclonal antibody 124
Monoclonal antibody, against RANKL 184
Mother-to-child
route 86
transmission of HIV 73
management of 73
prevention of 203
Mouth-to-mouth resuscitation 210
MTBDRplus test strips 103f
Mucosal exposure 46
Mucous membrane exposure 209
Multidrug anti-retro viral therapy 73
Multidrug-resistant systemic fungal infections 199
Multifocal leukoencephalopathy 51
Multiple pregnancies 13
Multiple transfusions 13
Mumps 78
Myalgia 214
Mycobacterial antigen, detection of 112
Mycobacterial cell wall 107
Mycobacterial tuberculosis
colonies on Lowenstein-Jensen medium 99f
Mycobacterium avium complex 51, 56, 62, 225
Mycobacterium avium-intracellulare 176
Mycobacterium tuberculosis 98, 165, 176, 225
MYH9 gene encoding myosin 148
Myobacteria tuberculosis 154
N
National Accreditation Board for Testing and Calibration Laboratories 63
National AIDS Control Organization 10, 44, 62
guidelines 54, 77
National HIV Testing Policy 17
National Strategies and Algorithm for HIV Testing, guidelines 18
Needle in contact with blood vessel 209
Nelfinavir 34, 151
Nephrotic range proteinuria 148
Neutropenia 164
Neutropenia lower, risk for developing 166
Nevirapine 31, 32, 43, 44, 66, 67, 151
caution 32
containing ART 118
dosing of 67
induced rash 32f
intolerance to 57
side effects 32
Non-AIDS-defining cancers 8
Noncommercial culture-based methods 101
Non-Hodgkin's lymphoma 165
Noninfective dermatoses 178
Non-nucleoside reverse transcriptase inhibitor 31, 32t, 66, 91, 151, 195
Nonoccupational injury 216
Nonsteroidal anti-inflammatory drugs 227
Nontuberculous mycobacteria species 100f
Nucleic acid amplification technologies 101
Nucleic acid sequence-based amplification 16
Nucleoside naive 190
Nucleoside reverse transcriptase inhibitors 24, 28, 29t, 31, 42, 178, 195
Nucleoside analogs 150
Nutritional anemia 164
O
Occupational exposure 216
Ombitasvir 197, 199
Onprotease inhibitors 160
Onychomycosis 177
Opportunistic infections 49, 62, 76
treatment of 78
Oral hairy leukoplakia 174
Oral hormonal contraceptives 83
Oral mucosa 208
Oral sex 210
Oral, vaginal contact 210
Organ, donation safety 18
Organ in opportunistic infections 5f
Osteopenia 183
Osteoporosis 183
Osteoporotic HIV infected individuals 184
Oxygenation 139
P
P24 antigen 74
P24 antigen detection 13, 16
P24 HIV antigen 12
Palliative care, components of 219
Palliative care in HIV 219
multidisciplinary approach 221
Pancreatitis 43, 65
Papilledema 125
Papular pruritic, eruptions cases of 178
Paritaprevir 197, 199
Parvovirus b19 165
Patterns of disease progression
elite controllers 12
long-term nonprogressors 12
rapid progressors 12
typical progressors 12
Pediatric HIV infection, diagnosis of 16
Pelvic inflammatory disease 4
Penicilliosis 5, 7
treatment of 8
Penicillium marneffei, dimorphic fungus 7
Pentamidine 142, 160
Perihilar infiltrates 143
Periodic acid Schiff stain 127
Peripheral neuropathy 43, 117
Peripheral T-cell lymphoma 164, 168
Peritoneal dialysis 150
Persistent pyrexia 116
Phospholipase production 123
Plasmablastic lymphoma 8, 168
Pneumocystis 139, 154, 225
Pneumocystis carinii 164
Pneumocystis carinii pneumonia 78, 173
Pneumocystis carinii pneumonitis 137
clinical features of pulmonary disease 138
diagnosis 139
differential diagnosis 140
incidence 138
microbiology 137
pathogenesis 137
presumptive diagnosis 140
risk factors 138
secondary prophylaxis 142
treatment of 141
Pneumocystis jirovecii 42, 143, 157
in human immunodeficiency virus 137
pneumonia 52, 62
Podocytes proliferation of 148
Polymerase chain reaction (PCR) 15, 64, 130, 170
Polymorphonuclear leukocytes 87
Polysaccharide capsule, measuring 121
Poor pregnancy outcome 75
Positive acid-fast bacilli 115
Postexposure prophylaxis 207
based on human and animal trials 211
course of development 207
efficacy of 211
follow-up after occupational exposure 215
formulation of 207
higher-risk exposures 209
HIV prevention counseling 214
lower-risk exposures 210
management and evaluation of exposure 208
nonoccupational exposure 209, 213
occupational exposure 208
occupational regimen 212
preferred alternative nonoccupational 213
problem statement 207
recommended nonoccupational 212
risk modification among users of 212
timing and duration of 210
Postnatal periods 75
Postpartum
care and follow-up 83
management 82
Pravastatin 40
Preconception counseling 87
Prednisolone 143, 169, 228
Pre-exposure prophylaxis 88, 203, 215
initiation of 203
regimens for 205
therapy
adverse effects and management 205
clinical follow-up and monitoring 205
evaluation of 204
goals of 204
indications 204
stopping of 205
Pregnancy with HIV infection, management of 77
antenatal management 77
criteria for ART initiation 79
monitoring during pregnancy 78
prevention of mother-to-child transmission of HIV 78
principles of 80
Pregnant women 215
first-line regimen 79t
with HIV infection 76
Prenatal counseling 73
Preterm birth 75
Preterm delivery increased risk of 75
Preterm rupture of the membranes 81
Primaquine 141
Primary effusion lymphoma 8, 168
Primary isolation media 128
Progressive multifocal leukoencephalopathy 52, 56, 199
Prolonged contact of the fetus 76
Prolonged rupture of membranes 76
Prostate carcinoma 9
Protease inhibitors 24, 34, 44, 91, 195
classification of 34t
darunavir 24
saquinavir 24
Pseudomonal infection 176
Pulmonary Koch's 57
Pulmonary tuberculosis
diagnostic algorithm for adult 110fc
screening for 95
testing and screening for 95
testing for 95, 96
Pyrazinamide 114, 176
Pyrimethamine 7
Q
Qualities of a good death 223
Quality of life during the dying process 223
Quantiferon TB gold 109
Qvir kit (Cipla) 59
R
Radioimmunoprecipitation assay 13
Raised intracranial pressure 228
Raltegravir 36, 152, 212
caution 36
side effect 36
Rapid HIV tests 13
Rapid progressors 12
Rapid screening tests 12
Real-time PCR technology 64
Receptive penile 210
Recombinant immunoblot assay 75
Relapsed infections 134
Renal and hepatic dysfunction 142
Renal function test 66, 204, 206
Renal replacement therapy: HIV infection 150
Retroviral ribonucleic acid 42
Reverse transcriptase inhibitors 165
Reverse transcriptase PCR 16
Rhabdomyolysis 40
Rheumatoid arthritis 106, 183
Rheumatologic disorder 124
Rhodamine 97
Ribavirin 199
Ribonucleic acid 10, 22
Rifabutin 117
Rifampicin 105, 114, 176
based TB therapy 119
increases cortisol metabolism 155
Rilpivirine 31, 33, 44, 152
caution 33
Risodronate 184
Ritonavir 34, 43, 45, 151, 156, 199
side effects 34
Rituximab 169
Rosuvastatin 40
Rubella 78
S
Sabouraud Dextrose Agar, primary isolation media 128
Salmonellosis 118
Saquinavir 34, 151
Sarcoidosis 124
Sarcoptes scabiei 177
Sclerotic glomeruli, large number of 149
Seborrheic dermatitis, inflammatory disease 178
Secondary hypothyroidism 158
Semen preparation, principles of 89
Serial testing strategy 18
Seroconversion during pregnancy 76
Serological tests 108
Serology 129
Serum alkaline phosphatase 50, 54
Severe osteoporosis 183
Sex hormone-binding globulin 159
Sexual activity, timing of 88
Sexually transmitted disease 4, 12, 50, 76, 86
Sexually transmitted infections 204, 209
Sick euthyroid 157
Signs of
advanced HIV infection 77
concomitant STDs 77
drug reaction 179
problems in pregnancy 87
progression of disease 68
Simeprevir 197, 199
Skin malignancies 178
Skin manifestations in HIV 173
Sofosbuvir 196, 199
Solid organ transplant 124
Species identification 128
Sperm preparation stages of 89f
Spider angiomata 77
Spinal cord granuloma 125
Splashes of
blood 209
infectious material 208
Splenomegaly 77
Staib's Birdseed Agar 128
primary isolation media 128
Staphylococcus aureus infection 175
Stavudine 29, 38, 4244, 55, 160
Stavudine-Didanosine: combination 215
Stevens-Johnson syndrome 33f, 142
Stigmata of advanced liver disease 77
Storage phase 90
Sulfadiazine 7
Sulfamethoxazole 78
Suppurative bacterial infections 157
Synacthen test 155, 156
Syndromes
acquired immunodeficiency (AIDS) 3, 10, 11, 22, 42, 49, 61, 95, 134, 141, 147, 154, 167, 173, 203
defining cancers 8
infected females 8
related lymphomas 8
acute flu-like 12
acute retroviral 215
androgen deficiency 159
clinical 187
Cushing's 156, 157
Fanconi-like 31
hemophagocytic 165
hepatopulmonary syndrome 199
HIV wasting 174, 221
hypersensitivity 66
immune reconstitution inflammatory 57, 133, 116, 125, 134, 142, 158, 179, 224226, 228
organ dysfunction 162
sick euthyroid 157
Stevens-Johnson 32, 33, 55, 59, 67, 142
Synthetic estrogen receptor modulators 184
Syphilis tests for 77
Systemic lupus erythematosus 106
T
Tachycardia 138
Tachypnea 138
Taxonomy 121
Teevir (Mylan) 59
Telbivudine 189, 190
Tellura (Mylan) 59
Tenofovir 38, 43, 44, 46, 91, 150, 182, 189, 190, 195, 203, 211, 212, 213
Tenofovir disoproxil fumarate (TDF) 30, 31
caution 31
side effects 31
Tenolam E (Hetero) 59
Testicular carcinoma 9
Testosterone versus total testosterone 159
Thrombocytopenia 164
Thrombotic thrombocytopenic purpura 164
Thymidine analog 29
development of 42
Thyroid dysfunction 154, 158
Thyroid gland 157
Thyroiditis 157
Thyroid-stimulating hormone 157
Tinea capitis 177
Tinea corporis 177
Tinea cruris 177
Tipranavir 35, 45, 66, 151, 196
side effects 35
Tissue biopsy 140
Toxic epidermal necrolysis 179f
Toxoplasma 154
Toxoplasma antibody titer 28
Toxoplasma gondii 5, 125
Toxoplasmosis 5, 118, 140
diagnosis 6
treatment 7
Transaminases, elevation of 29
Transforming growth factor-β 163
Transgenders 4
Transient viremia 64
Transmission of HIV to the fetus 76
Trimethoprim 78
Trimethoprim-sulfamethoxazole (TMP/SMX), high-dose 164
Trioday (Cipla) 59
Triomune (Cipla) 59
Trustiva (Hetero) 59
Tubercular pericarditis, management of 228
Tuberculin skin test 108
Tuberculoma expansion 227
Tuberculosis
cases of 95
diagnosis of multidrug-resistant 96
diagnostic technology 96
duration of therapy 117
in HIV 112
diagnosis 112
infected patient approach to treatment 113
treatment of 112
incidence, effect on 113
infection tests for detecting latent 108
prognosis 118
screening for 50
testing for drug-resistant 96
therapy choice of 114
treatment efficacy of 115
Tubular disorders 149
Tumor necrosis factor-α 163, 182
U
Unmet needs: tuberculosis diagnostics 109
Urease production 123
Urine routine microscopy 50
US Centers for Disease Control and Prevention 80
US Food and Drug Administration 27
V
Vaginal sex 210
Vertical transmission of HIV 75, 85, 87t
Vinblastine 170
Vincristine 169
Viraday (Cipla) 59
Viral failure 65
Viral replication cycle, steps of 28f
Viral ribonucleic acid 166
Viral treatment failure 64
Virchow-Robin spaces 131
Virulence factors 123
Visceral leishmaniasis 157
Visual abnormalities 117
Visual analogue scale 58
Visual scale: grade HIV-related facial lipoatrophy 39f
Vitamin-D deficiency 181
Volatile organic compounds 107
Vulvovaginal candidiasis 177
W
Weight loss 4
Western blot 15f, 75
assay 13, 14
criteria 14t
Window period 13, 16
World Health Organization (WHO)
based classification of HIV-associated lymphomas 168t
pain ladder 221f
Worsening
infection 228
lymphadenopathy 227
meningitis 227
pulmonary infiltrates 116
X
XDR-TB 96
Xpert MTB/RIF 104
benefits of 105
Z
Zalcitabine 29, 38
Zidolam-N (Hetero) 59
Zidovudine 29, 43, 55, 65, 58, 80, 84, 91, 150, 160, 167, 207
caution 29
intolerance to 57
prophylaxis for infants 73
side effects 29
therapy 178
Ziehl-Neelsen staining 97f
Zoledronic acid infusion 184
×
Chapter Notes

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1Basics2

IntroductionCHAPTER 1

Roopal Verma,
Atul Kakar
The human immunodeficiency virus (HIV) is a retrovirus infection which causes the acquired immunodeficiency syndrome (AIDS) (Fig. 1.1). It attacks the body's immune system; particularly destroying the CD4 T lymphocytes. This damage to immunity results in opportunistic infections and malignancies.
The first case of HIV was diagnosed in India in 1986 in a female sex worker (FSW) in Chennai. At that time, more than 20,000 cases had already been reported worldwide. Such a delayed detection of the first case in India was probably due to a lack of laboratory facilities and scientific knowledge about this disease in this country. The HIV prevalence in India among adults is now about 0.26% (2015 data); of whom 0.30% are males and 0.22% are females. Among the states, Manipur has the highest occurrence, followed by Mizoram, Nagaland, Andhra Pradesh and Telangana, Karnataka, Gujarat, and Goa. The total burden of people living with HIV (PLHIV) is approximately 21.17 lacs (in 2015); of which 6.54% are children and 40.5% are women. India is still facing an epidemic of HIV.
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Fig. 1.1: Human immunodeficiency virus.
4
In 2015, the HIV prevalence in India was an estimated 0.26%. However, of the 2.1 million patients with HIV in India, only 43% are on antiretroviral therapy (ART). The Government of India's new goal is to stop HIV spreading by testing and treating all patients by 2030.
The HIV/AIDS can affect all sectors of the population, both rich and poor, children and the old, males and females, homosexuals and heterosexuals but its prevalence is greater in certain individuals who belong to the high-risk groups. These include FSWs, men who have sex with men (MSM), transgenders (TGs)/Hijras and injecting drug users (IDUs). The people who transfer infection from the high-risk to the low-risk group are known as the bridging population, which includes migrants and long distance truckers. In India, this infection follows, the so-called type 4 pattern where first the virus enters into the high-risk groups, then involves the bridging population and finally infects the general public.
 
WHEN TO SUSPECT HIV/AIDS?
The following are the clinical scenarios for suspecting HIV infection:
  • All persons who are being evaluated or being treated for sexually transmitted diseases (STDs)
  • Voluntary testing after high-risk sexual activity
  • Recurrent infections in a person
  • Unexplained weight loss
  • Chronic diarrhea
  • More than three vaginal infections in 1 year (not related to the use of antibiotics)
  • Recurrent pelvic inflammatory disease (PID)
  • Abnormal Pap test or cervical cancer
  • Confusion and difficulty concentrating
  • Persisting dry cough
  • Explained fever
  • Recurrent oral ulcers
  • Night sweats
  • Unexplained lymph node swelling
  • Repeated outbreaks of herpes simplex
  • Thrush
  • An opportunistic infection (with bacteria, viruses, fungi, or protozoa).
 
ACUTE HUMAN IMMUNODEFICIENCY VIRUS
The HIV infection represents a spectrum of disease that can begin like a flu-like illness after viral exposure. This may be absent in some people and can 5be easily missed in many cases as the symptoms are very nonspecific. The symptoms of early HIV include headaches, fever, tiredness, swollen lymph nodes, sore throat, muscle and joint pains, mouth ulcers, genital ulcers, night sweats and diarrhea. Early HIV symptoms generally arise after 1–2 months of infection, although they can arrive as early as 2 weeks after exposure. Later Chapters in the book deal with how to test for HIV in the acute setting.
 
OPPORTUNISTIC INFECTIONS AND MALIGNANCIES
The HIV/AIDS patients are prone to many opportunistic infection and malignancies (Fig. 1.2). Many of these infections will be discussed in detail later; the opportunistic infections are related to CD4 cell counts of patient (Fig. 1.3). However, some of the clinical conditions are discussed in this chapter. These include—Toxoplasmosis and Penicilliosis.
 
Toxoplasmosis
This is caused by the intracellular protozoan Toxoplasma gondii. It usually manifests when cell-mediated immunity falls with the level of the CD4 cell count being less than 100/mm3. Its mode of spread is through the consumption of undercooked meat and water contaminated with oocysts. Transplacental transfer has been reported in HIV-infected mothers resulting in congenital toxoplasmosis. The severity of the infection depends upon the trimester of pregnancy in which the mother has acquired the infection, being most severe if this has been in the first trimester.
zoom view
Fig. 1.2: Organ involvement in opportunistic infections.
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zoom view
Fig. 1.3: Timing of opportunistic infection in relation with CD4 cell count.
Cerebral Toxoplasmosis: This is the most common and most fatal presentation of Toxoplasma infection. Usually the patient presents with altered mental status, headaches, fever, fits, unilateral limb weakness, difficulty in speech and vision, ataxia, cranial nerve palsies, and features of an increased intracranial pressure.
Extracerebral Toxoplasmosis: The eyes and lungs are the most affected sites, and may present without central nervous system (CNS) features. Very rarely, the infection may involve the liver, heart, bone marrow, gastrointestinal tract, musculoskeletal system, spinal cord, and testis.
 
Diagnosis
Serologic studies can be used for detection. A rising immunoglobulin G (IgG) level in a patient whose baseline titer is known indicates reactivation of the infection. A rise in the immunoglobulin G (IgM) titer may indicate acute infection. However, serology cannot be used as the sole modality for diagnosis. Contrast-enhanced computed tomography (CECT) or magnetic resonance imaging (MRI) brain scans show an asymmetrical target sign, which represent ring-enhancing lesions, which are usually multiple, and characteristically in the basal ganglia, brainstem, pituitary, and junction of the white and gray matter.
The differential diagnosis of cerebral toxoplasmosis includes tuberculoma, abscesses (fungal or bacterial), primary brain lymphoma, primary brain tumors, brain metastases, infarcts, arteriovenous (AV) malformations and demyelinating disease (Fig. 1.4).7
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Fig. 1.4: MRI suggestive of space occupying lesion in brain.
 
Treatment
Primary prophylaxis should start with TMP-SMX double strength daily in Toxoplasma IgG-positive individuals with CD4 cell counts less than 100. The acute infection should be treated with pyrimethamine (200 mg PO once daily followed by weight-based therapy with pyrimethamine and sulfadiazine) and leucovorin. After completion of acute treatment, all patients should be initiated onto maintenance therapy.
 
Penicilliosis
This is due to a dimorphic fungus Penicillium marneffei which causes systemic infections in patients with HIV/AIDS who have CD4 cell counts less than 100 cells/mm3. Southeast Asia is the endemic area for this fungus. In India, a new endemic zone has been recognized in Manipur.
The patient acquires the infection by inhalation of microconidia or from reactivation of a silent focus. Its clinical features are usually nonspecific (fever, anemia and weight loss). The patient usually presents with generalized skin lesions in the form of papules with central umbilication as seen in molluscum contagiosum, starting from the face and gradually spreading to involve the limbs and trunk. It may present with symptoms related to other organs such as the CNS, lymph nodes, liver, lung, intestine, and bone marrow. The definitive diagnosis is made by isolation or demonstration of the fungus in clinical specimens. An early diagnosis can be made by microscopic examination with Giemsa stain of a skin scraping, bone marrow or lymph node aspirate, which shows intracellular and extracellular yeast-like organisms with clear central septation.8
To prevent the first episode of acute infection prophylaxis should be given in the form of itraconazole 200 mg once daily to the patient whose CD4 cell counts are less than 100/mm3. Alternatively, fluconazole may be used (400 mg PO once weekly). Acute infection in severely ill patients should be managed with intravenous (IV) liposomal amphotericin B (3–5 mg/kg/day for 2 weeks) followed by itraconazole (200 mg PO BID for 10 weeks). Milder infections can be treated with itraconazole alone (200 mg PO BID for 8 weeks). The patient should then be continued on maintenance therapy with itraconazole (200 mg PO daily). Alternatively, an acute infection can be managed with voriconazole. ART should be started along with treatment of penicilliosis to improve the outcome.
 
HIV-RELATED MALIGNANCIES
Patients suffering from HIV are prone to develop malignancies. There are types which are—AIDS-defining cancers (ADCs) and non-AIDS-defining cancers (NADCs). With the introduction of highly active antiretroviral therapy (HAART), the cases of ADCs have reduced significantly.
AIDS-defining cancers: They are Kaposi's sarcoma (KS), primary CNS lymphoma, non-Hodgkin's lymphoma (NHL), and cervical cancer. ADCs reflect the point at which HIV infection has progressed to AIDS. KS is a low-grade soft tissue tumor of vascular origin, and it is associated with human herpesvirus 8 (HHV-8) infection. Manifestations of KS range from asymptomatic skin lesions to symptom producing visceral (lung and intestine) or oral lesions. NHL is a malignancy of the lymphoid tissue. In HIV/AIDS patients, the important risk factors for the development of NHL are a low CD4 count, high viral load, increasing age, and male gender. The World Health Organization (WHO) has divided AIDS-related lymphomas (ARLs) into three groups:
  1. Those also found in immunocompetent patients like Burkitt's or diffuse large B-cell lymphoma.
  2. Those found more specifically in HIV-infected patients like primary effusion lymphoma, and plasmablastic lymphoma.
  3. Those also occurring in other immunodeficiency states such as post-transplant lymphoproliferative disorders.
Certain viruses also play important roles in NHL such as Epstein-Barr virus (EBV) and HHV-8. The incidence of invasive cervical carcinoma is increased in HIV/AIDS-infected females mainly due to infection by the human papillomavirus (HPV).
Non-AIDS-defining cancers: The incidence of NADCs has increased greater than three fold in the last 10 years. This increase is due to the longer survivals in the combination ART (cART) era and due to the direct effect of HIV itself. 9All of these malignancies may found in HIV patients but their occurrence does not imply progression to AIDS. These NADCs are bronchogenic carcinoma, colorectal carcinoma, anal carcinoma, prostate carcinoma, testicular carcinoma, melanomas, Hodgkin's disease and cutaneous malignancies.
SUGGESTED READING
  1. Buchacz K, Baker RK, Palella FJ, Jr., et al. AIDS-defining opportunistic illnesses in US patients, 1994-2007: a cohort study. AIDS. 2010;24(10):1549–59.
  1. http://naco.gov.in/about-us/policies-guidelines. Opportunistic Infections and Their Management National AIDS Control Organisation. Lasted accessed on 02.01.2018.
  1. https://aidsinfo.nih.gov/guidelines. Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents. Last accessed on 27.12.2017
  1. Jones JL, Kruszon-Moran D, Sanders-Lewis K, et al. Toxoplasma gondii infection in the United States, 1994-2004, decline from the prior decade. Am J Trop Med Hyg. 2007;77(3):405–10.
  1. Patel PK, Erlandsen JE, Kirkpatrick WR, et al. The changing epidemiology of oropharyngeal candidiasis in patients with HIV/AIDS in the era of antiretroviral therapy. AIDS Res Treat. doi: 10.1155/2012/262471.
  1. Rottingen JA, Cameron DW, Garnett GP. A systematic review of the epidemiologic interactions between classic sexually transmitted diseases and HIV: how much really is known? Sex Transm Dis. 2001;28(10):579–97.
  1. Wheat LJ, Connolly-Stringfield PA, Baker RL, et al. Disseminated histoplasmosis in the acquired immune deficiency syndrome: clinical findings, diagnosis and treatment, and review of the literature. Medicine (Baltimore). 1990;69(6):361–74.
  1. World Health Organization. Global Tuberculosis Report. Geneva: World Health Organization;  2015. Available at http://apps.who.int/iris/bitstream/10665/191102/1/9789241565059_eng.pdf.