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Questions and Answers
What is the name of the virus that causes AIDS?
What is the name of the virus that causes AIDS?
Human Immunodeficiency Virus (HIV)
The British HIV Association (BHIVA) guidelines focus on the management of opportunistic infections in people living with HIV.
The British HIV Association (BHIVA) guidelines focus on the management of opportunistic infections in people living with HIV.
True
Which of the following factors are considered risk factors for pulmonary opportunistic infections in people living with HIV? (Select all that apply)
Which of the following factors are considered risk factors for pulmonary opportunistic infections in people living with HIV? (Select all that apply)
According to the BHIVA guidelines, what is the recommended first-line treatment of choice for PCP of any severity?
According to the BHIVA guidelines, what is the recommended first-line treatment of choice for PCP of any severity?
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What is the recommendation for the duration of treatment for PCP in people living with HIV?
What is the recommendation for the duration of treatment for PCP in people living with HIV?
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When is it recommended to start ART in individuals diagnosed with PCP?
When is it recommended to start ART in individuals diagnosed with PCP?
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What is the primary prophylaxis regimen recommended to prevent a first episode of PCP in adults living with HIV and a CD4 cell count of less than 200 cells/mm³?
What is the primary prophylaxis regimen recommended to prevent a first episode of PCP in adults living with HIV and a CD4 cell count of less than 200 cells/mm³?
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What are the two alternative regimens recommended for primary prophylaxis to prevent a first episode of PCP if individuals cannot tolerate trimethoprim-sulfamethoxazole?
What are the two alternative regimens recommended for primary prophylaxis to prevent a first episode of PCP if individuals cannot tolerate trimethoprim-sulfamethoxazole?
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In individuals who have responded to ART with an increase in CD4 count to greater than 200 cells/mm³ for a period of 3 months, when can primary prophylaxis for PCP be stopped?
In individuals who have responded to ART with an increase in CD4 count to greater than 200 cells/mm³ for a period of 3 months, when can primary prophylaxis for PCP be stopped?
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Secondary prophylaxis with trimethoprim-sulfamethoxazole should be stopped when an individual's CD4 count increases to greater than 100 cells/mm³ in whom plasma HIV levels remain undetectable for 3-6 months.
Secondary prophylaxis with trimethoprim-sulfamethoxazole should be stopped when an individual's CD4 count increases to greater than 100 cells/mm³ in whom plasma HIV levels remain undetectable for 3-6 months.
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What is the guideline recommendation for starting ART in individuals who are not already on ART after an episode of bacterial pneumonia?
What is the guideline recommendation for starting ART in individuals who are not already on ART after an episode of bacterial pneumonia?
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People living with HIV should be offered the pneumococcal vaccine according to national guidelines.
People living with HIV should be offered the pneumococcal vaccine according to national guidelines.
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People living with HIV who have a recent history of bacterial pneumonia should be offered a smoking cessation intervention.
People living with HIV who have a recent history of bacterial pneumonia should be offered a smoking cessation intervention.
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What is the recommended primary therapy for invasive or chronic pulmonary aspergillosis in people living with HIV?
What is the recommended primary therapy for invasive or chronic pulmonary aspergillosis in people living with HIV?
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Routine prophylaxis for pulmonary aspergillosis is recommended in people living with HIV.
Routine prophylaxis for pulmonary aspergillosis is recommended in people living with HIV.
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What is the recommended treatment for CMV pneumonitis?
What is the recommended treatment for CMV pneumonitis?
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Valganciclovir can be used for both primary and secondary prophylaxis of CMV in individuals with HIV.
Valganciclovir can be used for both primary and secondary prophylaxis of CMV in individuals with HIV.
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What is one notable way CMV has been impacted by the widespread use of ART?
What is one notable way CMV has been impacted by the widespread use of ART?
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Pneumocystis jirovecii is a host-specific opportunistic pathogen that can be found in both humans and mammals.
Pneumocystis jirovecii is a host-specific opportunistic pathogen that can be found in both humans and mammals.
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Primary infection with P. jirovecii in early life is always symptomatic and associated with mild upper respiratory tract symptoms.
Primary infection with P. jirovecii in early life is always symptomatic and associated with mild upper respiratory tract symptoms.
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Before the widespread use of PCP prophylaxis and ART, PCP occurred in up to 80% of people living with HIV.
Before the widespread use of PCP prophylaxis and ART, PCP occurred in up to 80% of people living with HIV.
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The clinical presentation of PCP is typically marked by a sudden onset of severe symptoms, characterized by rapid deterioration in respiratory function and high fever.
The clinical presentation of PCP is typically marked by a sudden onset of severe symptoms, characterized by rapid deterioration in respiratory function and high fever.
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Individuals with PCP may experience paradoxical deterioration in clinical status during the first few days of treatment.
Individuals with PCP may experience paradoxical deterioration in clinical status during the first few days of treatment.
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Which of the following are considered prognostic factors associated with a poor outcome in people living with HIV presenting with PCP? (Select all that apply)
Which of the following are considered prognostic factors associated with a poor outcome in people living with HIV presenting with PCP? (Select all that apply)
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The use of adjunctive corticosteroids has been conclusively demonstrated to provide no benefit in reducing mortality and the need for assisted ventilation in PCP.
The use of adjunctive corticosteroids has been conclusively demonstrated to provide no benefit in reducing mortality and the need for assisted ventilation in PCP.
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The clinical management of bacterial pneumonia in people living with HIV should follow the same guidelines as for those without HIV.
The clinical management of bacterial pneumonia in people living with HIV should follow the same guidelines as for those without HIV.
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A single dose of pneumococcal polysaccharide vaccine (PPV) is recommended for individuals over the age of 65 years who are living with HIV.
A single dose of pneumococcal polysaccharide vaccine (PPV) is recommended for individuals over the age of 65 years who are living with HIV.
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Smoking cessation is not considered a crucial aspect of pneumonia prevention, and therefore is not recommended for people living with HIV.
Smoking cessation is not considered a crucial aspect of pneumonia prevention, and therefore is not recommended for people living with HIV.
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The recommended primary therapy for invasive or chronic pulmonary aspergillosis in people living with HIV is the same as for those without HIV.
The recommended primary therapy for invasive or chronic pulmonary aspergillosis in people living with HIV is the same as for those without HIV.
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Extensive pulmonary cryptococcosis generally presents with a more insidious onset of symptoms than other forms of cryptococcal infection in people living with HIV.
Extensive pulmonary cryptococcosis generally presents with a more insidious onset of symptoms than other forms of cryptococcal infection in people living with HIV.
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Detection of Cryptococcus neoformans in induced sputum or BAL fluid is sufficient to confirm a diagnosis of pulmonary cryptococcosis in people living with HIV, without the need for further investigations, such as cultures or biopsies.
Detection of Cryptococcus neoformans in induced sputum or BAL fluid is sufficient to confirm a diagnosis of pulmonary cryptococcosis in people living with HIV, without the need for further investigations, such as cultures or biopsies.
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The treatment of pulmonary cryptococcosis in people living with HIV should always follow the same regimen as for CNS cryptococcal infection.
The treatment of pulmonary cryptococcosis in people living with HIV should always follow the same regimen as for CNS cryptococcal infection.
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The treatment of PCP in people living with HIV should always be done empirically.
The treatment of PCP in people living with HIV should always be done empirically.
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It is always necessary to initiate treatment with adjunctive corticosteroids for people with PCP and low oxygen saturation levels (< 92%) or a falling oxygen saturation level by greater than 3% on exercise.
It is always necessary to initiate treatment with adjunctive corticosteroids for people with PCP and low oxygen saturation levels (< 92%) or a falling oxygen saturation level by greater than 3% on exercise.
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Treatment for PCP in people living with HIV should only be considered if there is a lack of clinical improvement or worsening of oxygenation between days 4 and 8 after starting anti-Pneumocystis treatment.
Treatment for PCP in people living with HIV should only be considered if there is a lack of clinical improvement or worsening of oxygenation between days 4 and 8 after starting anti-Pneumocystis treatment.
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Treatment failure in PCP can be attributed solely to lack of clinical improvement or worsening of chest radiographic appearances, excluding other factors such as drug toxicity or the development of other infections.
Treatment failure in PCP can be attributed solely to lack of clinical improvement or worsening of chest radiographic appearances, excluding other factors such as drug toxicity or the development of other infections.
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In patients with PCP who are not responding to, or are intolerant of, first-line therapy, Caspofungin has been shown as a viable alternative treatment option.
In patients with PCP who are not responding to, or are intolerant of, first-line therapy, Caspofungin has been shown as a viable alternative treatment option.
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IRIS (Immune Reconstitution Inflammatory Syndrome) is a common occurrence following an episode of PCP in people living with HIV.
IRIS (Immune Reconstitution Inflammatory Syndrome) is a common occurrence following an episode of PCP in people living with HIV.
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In patients who have a recent history of PCP, treatment should always be deferred until immune reconstitution occurs in response to commencing ART.
In patients who have a recent history of PCP, treatment should always be deferred until immune reconstitution occurs in response to commencing ART.
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Study Notes
British HIV Association Guidelines on Pulmonary Opportunistic Infections (2024)
- Introduction: The incidence of classic pulmonary opportunistic infections is decreasing due to improved HIV testing and treatment, but other lung conditions like COPD are increasing in people with HIV. HIV alters the lung environment, impacting the microbiome, and increasing the severity of common respiratory infections. Bacterial, fungal and viral infections are considered, focusing on those with high incidence or severity.
Methods
- Literature Review: A systematic literature review using databases like Medline, Embase, and Cochrane Library was conducted to answer specific questions. The search strategy, including PICO (population, intervention, comparison, outcome) questions, is detailed in Appendix 1.
Summary of Recommendations
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PCP (Pneumocystis jirovecii pneumonia): PCP should be considered in individuals with new onset or worsening respiratory symptoms and an abnormal chest X-ray. Diagnosis is by detection of Pneumocystis in induced sputum, bronchoalveolar lavage (BAL), or pulmonary fluid. If sputum induction is negative, bronchoscopy and BAL are recommended. Early PCP may be identified by high-resolution CT in people with normal chest X-rays. PCR detection of P. jirovecii in respiratory secretions does not automatically justify PCP treatment.
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Bacterial Pneumonia: Pneumonia is a possible indicator for HIV infection. Diagnosis and management should follow national guidelines, emphasizing empirical antibiotic choices based on symptoms, risk factors, and potential resistance. Community-acquired bacterial pneumonia should be treated similarly to those without HIV.
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Influenza: Testing for influenza and COVID-19 should be conducted in people with influenza-like symptoms. Treatment with neuraminidase inhibitors (NIs) should be initiated within 48 hours of symptom onset, particularly for people with severe immunocompromise. Individuals with persistent symptoms or shedding of the virus should have their treatment regimen adjusted.
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Cryptococcal Disease: Pulmonary cryptococcosis should be diagnosed by culture or microscopic examination of fluids (e.g., bronchoalveolar lavage [BAL]). Serum cryptococcal antigen testing is advised and, if positive, lumbar puncture is recommended to assess for meningitis. Treatment strategies are usually similar to those for CNS infection, except in focal cases where fluconazole is a potential initial treatment.
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Aspergillosis: The diagnosis requires a combination of clinical presentation, radiographic features and microbiological data, including special fungal stains, serum galactomannan, and BAL tests. Primary therapy is voriconazole.
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CMV (Cytomegalovirus): Biopsy specimens demonstrating CMV infection, in conjunction with compatible clinical presentation, are suggestive of CMV pneumonia. Treatment is not routinely justified unless there are concomitant infections or insufficient response to other treatments. Ganciclovir is typically the first-line therapy.
Risk Factors
- Low CD4 Counts: Significantly linked to opportunistic infections, as well as injecting drug use.
- Viral Load: A marker for viral replication and often impacts infection risks.
- Treatment Adherence: Non-adherence to ART and prophylaxis regimens increases the risk of contracting opportunistic infections.
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Description
This quiz explores the British HIV Association's guidelines on pulmonary opportunistic infections. It covers the impact of HIV on lung health, the incidence of various infections, and summarizes key recommendations for diagnosis and management. Emphasis is placed on the changing landscape of respiratory conditions among individuals living with HIV.
