Autoimmune Disorders and HIV/AIDS - Cheat Sheet
Your 30-minute exam cramming companion for Immune System & Immunologic Disorders. All high-yield NLE facts, diagnostic criteria, drug management, and Philippine legal context condensed for rapid recall.
Systemic Lupus Erythematosus (SLE)
Important facts
- SLE predominantly affects women of childbearing age (female-to-male ratio ~9:1).
- Marked photosensitivity — UV/sun exposure is THE major flare trigger.
- ANA positive in ~95% of patients (sensitive but NOT specific); anti-dsDNA and anti-Smith highly specific.
- Complement levels (C3, C4) DECREASE during active disease — useful for monitoring.
- Flare triggers: sun/UV, infection, stress, fatigue, pregnancy, certain drugs (NSAIDs, sulfonamides), abrupt steroid withdrawal.
- Nonerosive arthritis (unlike rheumatoid arthritis which is erosive).
- Raynaud phenomenon common (episodic finger color changes with cold/stress).
- Hematologic: anemia, leukopenia, thrombocytopenia.
- CNS involvement: seizures, psychosis, cognitive changes.
- Cardiac: pericarditis, pleuritis, endocarditis risk.
Key definitions
SLE
Example
Young women with butterfly rash, arthritis, and positive ANA/anti-dsDNA.
Chronic multisystem autoimmune disease driven by immune-complex (Type III) deposition causing chronic inflammation and tissue damage.
Butterfly (Malar) Rash
Example
Acute flare often triggered by sun exposure; diagnostic for SLE when present with other criteria.
Hallmark SLE manifestation — erythematous rash across cheeks and nose bridge SPARING nasolabial folds.
Lupus Nephritis
Example
CD4 <200 and rising creatinine = urgent referral to nephrology.
Immune-complex glomerulonephritis causing proteinuria, hematuria, and progressive renal failure — leading cause of SLE morbidity/mortality.
Diagrams to know
- Butterfly rash distribution (malar area sparing nasolabial folds).
- Immune-complex deposition in kidney glomeruli.
- SLE multisystem involvement schematic.
SLE Pharmacology & Nursing Management
Important facts
- NSAIDs for mild arthralgia; monitor renal function and GI bleeding.
- Belimumab (biologic B-cell inhibitor) for active SLE.
- NEVER use live vaccines in SLE patients on immunosuppressants.
- Adherence to hydroxychloroquine prevents flares and progression.
- Pregnancy planning essential — SLE + pregnancy = increased flare risk; counsel on contraception and timing.
- Teach strict SUN PROTECTION: SPF 30+, protective clothing, hats, avoid peak sun hours (10am–4pm).
- Monitor for early lupus nephritis: urinalysis (proteinuria, casts, hematuria), 24-hr urine protein, serum creatinine.
- Educate on infection warning signs (fever, productive cough, dysuria) — steroids mask symptoms.
- Encourage regular clinic visits for CD4/ANA/complement/renal monitoring.
- Psychological support — SLE is chronic, unpredictable, affects young, active women.
Key definitions
Hydroxychloroquine
Example
Start 200–400 mg daily; baseline and annual eye exams mandatory (retinal toxicity risk).
Antimalarial drug — mainstay for skin/joint SLE; reduces flare frequency and severity.
Corticosteroids (Prednisone)
Example
Never stop abruptly (adrenal crisis); taper slowly. Teach infection signs.
Used for moderate-to-severe flares; suppresses inflammation but risk of infection, hyperglycemia, osteoporosis.
Immunosuppressants
Example
Monitor CBC for bone marrow suppression; increased infection risk.
Azathioprine, mycophenolate, cyclophosphamide — used for severe organ involvement (nephritis, CNS).
Diagrams to know
- SLE medication algorithm (mild → moderate → severe).
- Hydroxychloroquine monitoring timeline (baseline eye exam → annual).
Scleroderma (Systemic Sclerosis)
Important facts
- Hallmark: thick, taut, shiny, hardened skin — often starting in fingers/hands, progressing to face (mask-like).
- GI involvement: esophageal dysmotility → dysphagia, severe GERD.
- Pulmonary: interstitial lung disease and pulmonary hypertension — LEADING CAUSE OF DEATH.
- Renal: scleroderma renal crisis (acute severe hypertension + acute kidney injury) — treat urgently with ACE inhibitors.
- Raynaud is often the EARLIEST clinical sign (precedes skin changes by months/years).
- Limited (CREST) vs. diffuse (diffuse cutaneous) — limited has better prognosis but still at risk.
- No cure; management is supportive and symptom-based.
- Avoid vasoconstrictors (caffeine, nicotine); keep warm.
- Monitor BP and renal function closely (renal crisis is medical emergency).
- Skin care: emollients; gentle ROM exercises to maintain hand function.
Key definitions
Scleroderma
Example
Progressive skin thickening, Raynaud phenomenon, dysphagia, interstitial lung disease.
Autoimmune fibrotic disease with excessive collagen deposition in skin and organs, plus vascular injury.
CREST Syndrome
Example
Better prognosis than diffuse form; pulmonary hypertension still a major risk.
Limited form of scleroderma: Calcinosis, Raynaud, Esophageal dysmotility, Sclerodactyly, Telangiectasia.
Raynaud Phenomenon
Example
Often precedes scleroderma diagnosis by years; teach warmth, avoid cold, smoking cessation.
Episodic triphasic color changes (white → blue → red) in fingers with cold exposure or emotional stress.
Diagrams to know
- Raynaud phenomenon color progression (white → blue → red).
- CREST mnemonic visual.
- Scleroderma multiorgan involvement diagram.
Scleroderma Nursing Management
Important facts
- Warmth is CRITICAL — teach gloves, avoid cold water, warm environment.
- Smoking cessation: nicotine worsens Raynaud and vascular injury.
- GERD management: small frequent meals, avoid spicy/hot foods, elevate HOB, PPI/antacids.
- Dental care: microstomia (limited mouth opening) makes hygiene difficult — electric toothbrush, floss.
- Hand exercises: gentle ROM q.i.d. to preserve grip and function.
- Skin care: fragrance-free emollients (lanolin-based); avoid harsh soaps.
- Monitor BP and creatinine closely — renal crisis requires URGENT hospitalization.
- Pulmonary function tests (PFTs) — screen for ILD and PH.
- Emotional support: progressive, disfiguring disease; psychological referral.
- NO cure — realistic goal-setting with patient/family.
Key definitions
ACE Inhibitors (for Renal Crisis)
Example
Lisinopril, enalapril — start low, monitor creatinine; avoid NSAIDs.
First-line for scleroderma renal crisis (acute HTN + renal failure); halt progression.
Proton Pump Inhibitors (PPI)
Example
Teach: small frequent meals, remain upright 2–3 hrs after eating, head of bed elevated.
For GERD secondary to esophageal dysmotility; omeprazole, pantoprazole.
Sjögren's Syndrome
Common values
Value
<5 mm wetting in 5 minutes
Symbol
Schirmer
Quantity
Schirmer Test Positive
Important facts
- Classic TRIAD: Dry eyes (keratoconjunctivitis sicca), Dry mouth (xerostomia), Arthritis.
- Often COEXISTS with SLE or rheumatoid arthritis.
- Anti-Ro (SSA) and anti-La (SSB) antibodies — diagnostic.
- Schirmer test: <5 mm wetting = positive (tear deficiency).
- High caries risk — dental decay rapid and severe.
- Avoid dry, smoky, windy environments — use humidifiers.
- Dental visits q 3–6 months; fluoride rinses; sugarless candy/gum.
- Artificial tears (preservative-free), saliva substitutes; sip water frequently.
- No cure; lifelong symptom management.
- Screen for lymphoma — Sjögren's patients have increased risk.
Key definitions
Sjögren's Syndrome
Example
Anti-Ro (SSA) and anti-La (SSB) positive; Schirmer test for tear production.
Autoimmune infiltration/destruction of exocrine (moisture-producing) glands; presents as dry eyes, dry mouth, ± arthritis.
Keratoconjunctivitis Sicca
Example
Artificial tears hourly; avoid dry environments; regular ophthalmology screening.
Dry eyes secondary to lacrimal gland destruction; leads to corneal damage if untreated.
Xerostomia
Example
Sugar-free gum, frequent sips of water, saliva substitutes, meticulous dental hygiene.
Dry mouth secondary to salivary gland dysfunction; high risk for dental caries.
Diagrams to know
- Sjögren's triad visual.
HIV Pathophysiology & Stages
Common values
Value
500–1,600 cells/mm³
Symbol
CD4
Quantity
Normal CD4 Count
Value
<200 cells/mm³
Symbol
CD4
Quantity
AIDS Definition (CD4)
Value
<50 copies/mL (undetectable)
Symbol
VL
Quantity
Goal Viral Load
Important facts
- HIV → reverse transcriptase → integrase → protease → viral particles.
- Stages: acute infection (flu-like seroconversion) → clinical latency (asymptomatic, years) → AIDS.
- CD4 count inversely correlates with opportunistic infection risk.
- Viral load HIGH during acute infection and late AIDS; LOW during latency.
- ART suppresses but does NOT CURE HIV — lifelong therapy required.
- Window period: infected but antibody-negative for ~3 months (up to 6 months rare).
- 4th-generation antigen/antibody tests detect p24 antigen earlier (~2 weeks).
- Nucleic acid (RNA) tests even earlier (~1–2 weeks).
- Sexual transmission most efficient from high viral-load partners.
- Occupational exposure risk: needlestick ~0.3%, mucous membrane ~0.09%.
Key definitions
HIV (Human Immunodeficiency Virus)
Example
Uses reverse transcriptase to convert RNA → DNA; integrates into host genome; replicates and depletes CD4 cells.
Retrovirus that infects and destroys CD4+ T helper lymphocytes, progressively collapsing cell-mediated immunity.
CD4 Count
Example
CD4 <200 → high risk for PCP, TB, candidiasis, toxoplasmosis, CMV.
Marker of immune function; normal ~500–1,600 cells/mm³; defines AIDS when <200 cells/mm³.
Viral Load
Example
Goal: UNDETECTABLE (<50 copies/mL) on ART; U=U (Undetectable = Untransmittable).
Amount of HIV RNA in blood (copies/mL); indicates infectivity and disease activity.
AIDS (Acquired Immunodeficiency Syndrome)
Example
PCP, TB, cryptococcal meningitis, toxoplasmosis, CMV, Kaposi sarcoma, NHL, cervical cancer.
Final stage of HIV; defined by CD4 <200 cells/mm³ OR presence of AIDS-defining opportunistic infection/malignancy.
Diagrams to know
- HIV replication cycle (reverse transcriptase → integration → translation → budding).
- CD4 count decline timeline vs. opportunistic infections.
Reactions or equations
CD4 count <200 cells/mm³ = AIDS-defining
Note
CD4 <200 triggers PCP prophylaxis (co-trimoxazole), MAC prophylaxis (azithromycin), CMV monitoring.
Conditions
Regardless of opportunistic infection status; or any AIDS-defining infection regardless of CD4 count.
HIV Opportunistic Infections & AIDS-Defining Conditions
Common values
Value
<200 cells/mm³
Symbol
CD4
Quantity
CD4 threshold for PCP prophylaxis
Value
<50 cells/mm³
Symbol
CD4
Quantity
CD4 threshold for MAC prophylaxis
Value
<50 cells/mm³
Symbol
CD4
Quantity
CD4 threshold for CMV monitoring
Important facts
- CD4 <200: PCP, candidiasis (oral/esophageal), TB.
- CD4 <100: cryptococcal meningitis, toxoplasmosis (CNS), CMV.
- CD4 <50: MAC (Mycobacterium avium complex), CMV retinitis.
- PCP prophylaxis: co-trimoxazole (TMP-SMX, preferred) when CD4 <200.
- TB in HIV: may be ATYPICAL (extrapulmonary, disseminated); early diagnosis critical.
- Candidiasis: oral thrush (pseudomembranous white plaques) → esophageal (dysphagia).
- Toxoplasmosis: mass lesion(s) in brain on CT/MRI; ring-enhancing; treat with sulfadiazine + pyrimethamine.
- CMV: retinitis (floaters, vision loss), colitis (diarrhea), encephalitis.
- MAC: disseminated infection; fever, weight loss, abdominal pain; clarithromycin + ethambutol.
- Kaposi sarcoma: purple/brown patches/plaques (skin, oral, visceral); associated with HHV-8.
Key definitions
Pneumocystis jirovecii Pneumonia (PCP)
Example
Prophylaxis: co-trimoxazole (TMP-SMX) when CD4 <200. Chest X-ray shows bilateral interstitial infiltrates.
Classic AIDS-defining pneumonia (CD4 <200); presents with dyspnea, dry cough, fever, hypoxemia.
Tuberculosis (TB)
Example
CD4 <50 → MAC prophylaxis (azithromycin); CD4 <200 → TB prophylaxis (isoniazid) if TB exposure risk.
Leading opportunistic infection and cause of death in HIV in Philippines; may be atypical (extrapulmonary, disseminated).
Cryptococcal Meningitis
Example
CSF cryptococcal antigen; fluconazole IV then oral maintenance; high mortality.
CNS fungal infection (CD4 <100); presents with fever, headache, altered mental status, nuchal rigidity.
Diagrams to know
- CD4 count stages and associated opportunistic infections.
- PCP vs TB vs cryptococcal meningitis differential diagnosis.
HIV Diagnostics & Testing
Important facts
- Screening: 4th-generation antigen/antibody test or rapid HIV test.
- Confirmation: supplemental antibody differentiation test OR HIV RNA (nucleic acid) test.
- Window period: must counsel on retesting if negative within 3 months of suspected exposure.
- Rapid tests: result in <20 min; lower sensitivity/specificity; must be confirmed.
- Baseline testing: ANA (to rule out SLE-like symptoms), CBC, LFTs, renal function, TB screening, STI screening.
- Viral load: monitored at diagnosis, after ART initiation (should decrease), and regularly on therapy.
- CD4 count: baseline, then q 3–6 months on stable ART; guides prophylaxis (CD4 <200 → PCP ppx, <100 → crypto ppx, <50 → MAC ppx).
- Resistance testing: if virologic failure (detectable viral load despite adherence).
- Genotypic resistance: determines which drugs virus is resistant to; guides ART switch.
- Post-exposure prophylaxis (PEP) evaluation: risk assessment, baseline testing, start ART within 72 hours.
Key definitions
Antigen/Antibody Immunoassay (4th Generation)
Example
Positive result requires confirmatory test (supplemental antibody test or RNA test).
Screening test detects HIV antibodies + p24 antigen; reduces window period to ~18–45 days.
HIV RNA (Nucleic Acid Test)
Example
Used for confirmation and for monitoring viral load (treatment goal <50 copies/mL).
Gold-standard confirmatory test; detects viral RNA directly; window period ~10–33 days.
Window Period
Example
Antibody test: ~3 months; 4th-gen: ~2–4 weeks; RNA: ~1–2 weeks. RETEST if negative within 3 months of exposure.
Interval between HIV infection and detectable test result; infected person is infectious but tests NEGATIVE.
CD4 Count Test
Example
Repeated at diagnosis, q 3–6 months on ART, or if viral load detectable.
Monitors immune status; normal ~500–1,600 cells/mm³; guides prophylaxis decisions.
Diagrams to know
- HIV diagnostic algorithm (screening → confirmation → monitoring).
- Window period timeline for different test types.
Antiretroviral Therapy (ART) — Principles & Drug Classes
Important facts
- COMBINATION of 3+ drugs MANDATORY — never single-drug therapy (resistance develops rapidly).
- ART DOES NOT CURE HIV — it suppresses replication; lifelong therapy required.
- Goal: UNDETECTABLE viral load (<50 copies/mL) within 3–6 months of starting ART.
- U=U: Undetectable = Untransmittable — person with sustained undetectable VL cannot transmit HIV sexually (DOH standard).
- Preferred first-line regimen: 2 NRTIs + InSTI (e.g., tenofovir/emtricitabine + dolutegravir).
- Adherence CRITICAL: missed doses allow viral replication and drug resistance.
- Resistance develops when viral replication exceeds immune suppression; resistance mutations accumulate.
- Virologic failure: viral load remains >50 or rebounds after becoming undetectable; assess adherence, then consider resistance testing.
- Immunologic failure: CD4 remains <200 or increases <50 cells/year despite suppressed VL; usually reflects late diagnosis (baseline CD4 very low).
- Clinical failure: new AIDS-defining illness despite VL suppression (immune reconstitution still incomplete).
Key definitions
Combination ART (HAART)
Example
Standard: 2 NRTIs + 1 NNRTI/PI/InSTI. Newer: integrase inhibitor-based regimens preferred.
Minimum 3 drugs from ≥2 classes targeting different steps in HIV replication; suppresses viral replication and prevents resistance.
NRTIs (Nucleoside Reverse Transcriptase Inhibitors)
Example
Zidovudine (AZT) side effect: bone marrow suppression (anemia, leukopenia). Abacavir: hypersensitivity rash if HLA-B*5701 positive.
Drugs that inhibit reverse transcriptase; block HIV RNA → DNA conversion. Examples: tenofovir, lamivudine, zidovudine, abacavir.
NNRTIs (Non-Nucleoside RTIs)
Example
Efavirenz: CNS side effects (dizziness, nightmares). Nevirapine: hepatotoxicity, Stevens-Johnson syndrome risk.
Non-competitive reverse transcriptase inhibitors. Examples: efavirenz, nevirapine.
Integrase Inhibitors (InSTI)
Example
Dolutegravir: minimal side effects, high barrier to resistance, fewer drug interactions. Raltegravir: need BID dosing.
Block integrase enzyme (HIV DNA integration); now preferred first-line. Examples: dolutegravir, raltegravir.
Protease Inhibitors (PI)
Example
Ritonavir: boosting agent (low doses increase PI levels via CYP3A4 inhibition). GI upset, lipodystrophy common.
Block protease enzyme (viral protein maturation). Examples: lopinavir/ritonavir, atazanavir.
Entry/Fusion Inhibitors
Example
Used only in highly resistant HIV; enfuvirtide: subcutaneous injection; maraviroc: CCR5 antagonist (requires tropism testing).
Block HIV entry into CD4+ cells. Examples: enfuvirtide, maraviroc.
Diagrams to know
- HIV replication cycle with drug targets (RT, integration, protease, entry).
- ART drug classes and mechanisms.
Reactions or equations
Combination ART = 3 drugs minimum from 2+ classes
Note
Adherence >95% required to prevent resistance. Missed doses = virus can replicate and mutate.
Conditions
Common: 2 NRTIs + 1 NNRTI or PI or InSTI. Never use single or dual monotherapy.
ART Drug Side Effects & Interactions
Important facts
- Zidovudine (AZT): bone marrow suppression (anemia, leukopenia), GI upset, lipodystrophy.
- Tenofovir (TDF): nephrotoxicity (monitor creatinine, urine glucose); bone loss (monitor DEXA if osteoporosis risk).
- Lamivudine (3TC): minimal toxicity; good tolerability.
- Abacavir (ABC): hypersensitivity reaction (fever, rash, GI symptoms, respiratory symptoms); HLA-B*5701 screening prevents; DO NOT RECHALLENGE.
- Efavirenz (EFV): CNS effects (dizziness, vivid dreams, paranoia, impaired concentration); take at bedtime; teratogenic (avoid in pregnancy).
- Nevirapine (NVP): hepatotoxicity, Stevens-Johnson syndrome (SJS) risk; higher risk in high baseline CD4; baseline LFTs required; rash (10–15%).
- Dolutegravir (DTG): minimal side effects; integrase inhibitor preferred first-line; safe in pregnancy (newer data).
- Raltegravir (RAL): minimal side effects; BID dosing (less convenient); must be taken with food.
- Lopinavir/ritonavir (LPV/r): GI upset, diarrhea, nausea, lipodystrophy, increased cholesterol/triglycerides.
- Atazanavir (ATV): indirect hyperbilirubinemia (yellowing of skin/sclera without toxicity); unconjugated hyperbilirubinemia; lipid sparing (may be advantage).
Key definitions
Lipodystrophy
Example
Teach exercise, healthy diet, screen for dyslipidemia and diabetes; consider switching drugs if severe.
Abnormal fat redistribution: loss in face/limbs + central accumulation (buffalo hump); metabolic side effect of PIs and some NRTIs.
Drug Interactions
Example
PIs + statins = high statin levels (rhabdomyolysis risk); avoid or use lowest statin dose. Check drug interactions before adding any new drug.
Many ART drugs inhibit/induce CYP450 enzymes; affect metabolism of other drugs (PIs inhibit CYP3A4, NNRTIs induce CYP3A4).
Diagrams to know
- ART side-effect profile by drug class.
ART Adherence & Nursing Management
Important facts
- Adherence >95% needed to prevent resistance; even one missed dose can impact.
- Teach pill organization: pill boxes, phone reminders, link to daily activities (meals, bedtime).
- Manage side effects: GI upset (take with/without food per drug), dizziness (bedtime dosing for EFV), rash monitoring.
- Address barriers: cost (patient assistance programs), stigma (confidentiality), depression (mental health referral), pill burden (once-daily regimens preferred).
- Viral load monitoring: baseline, 2–4 weeks (partial response expected), then monthly until undetectable, then q 3 months if stable.
- CD4 monitoring: baseline, then q 3 months until >200 for 3+ months (can space out monitoring).
- Baseline resistance testing before starting ART (genotypic resistance testing).
- IRIS risk: highest when CD4 very low at baseline (<50) and rises rapidly in first weeks/months. Manage with symptomatic treatment; continue ART.
- Virologic failure: detectable VL despite ≥3 months ART; assess adherence first, then send resistance test, switch regimen.
- Clinic appointments essential: baseline, 2–4 weeks, 8–12 weeks, then q 3 months; labs (CD4, VL, LFTs) at each visit initially.
Key definitions
Adherence Counseling
Example
Teach: understand why adherence matters, set medication reminders, manage side effects, address barriers to adherence (cost, stigma, depression).
Patient education on taking ART exactly as prescribed; missed doses breed resistance; core nursing intervention.
Immune Reconstitution Inflammatory Syndrome (IRIS)
Example
TB-IRIS: worsening TB lesions/lymph nodes despite TB treatment; MAC-IRIS: fever, night sweats, adenitis. Managed with steroids, not by stopping ART.
Paradoxical worsening of infections or appearance of new infections when CD4 rises rapidly after starting ART; immune system becomes strong enough to react.
Diagrams to know
- Viral load response timeline to ART (weeks 1–2, 4–6, 12 weeks).
HIV Prevention — PEP & PrEP
Common values
Value
Within 72 hours of exposure (ideally within 2 hours)
Symbol
PEP
Quantity
PEP Window
Value
28 days
Symbol
PEP
Quantity
PEP Duration
Important facts
- PEP must start within 72 hours of exposure (ideally within 2 hours); better efficacy with earlier start.
- PEP standard: 3-drug regimen (2 NRTIs + 1 InSTI/PI), 28 days total.
- PEP for occupational exposure: assess risk (depth of injury, hollow needle vs. solid, source patient's status); baseline testing and baseline for source if possible.
- PEP for sexual exposure: condomless receptive anal intercourse highest risk (~1.38%), condomless receptive vaginal (~0.08%), condomless insertive (~0.06%).
- PEP retest schedule: baseline, 6 weeks, 3 months, 6 months (window period).
- PrEP indication: HIV-negative and high risk (MSM, healthcare workers, sex workers, serodiscordant couples, IVDU).
- PrEP regimen: daily TDF + emtricitabine; or event-driven (on-demand) for limited activity.
- PrEP adherence: 4–7 doses/week for high efficacy (>90%); <2 doses/week offers minimal protection.
- PrEP baseline testing: HIV test (must be negative), CD4, LFTs, renal function, HBsAg (if HBV+, needs different agent).
- PrEP follow-up: retest q 3 months for HIV; annual LFTs, renal function.
Key definitions
Post-Exposure Prophylaxis (PEP)
Example
Occupational PEP: 3-drug ART (TDF + 3TC + DTG or PI). Must retest at 6 weeks, 3 months, 6 months.
Emergency ART after potential HIV exposure (occupational needlestick, sexual assault, unprotected sex with unknown/positive partner); started within 72 hours, continued 28 days.
Pre-Exposure Prophylaxis (PrEP)
Example
DOH offers PrEP to MSM, healthcare workers, sex workers, partners of HIV-positive people; must be HIV-negative before starting.
Preventive ART for HIV-negative high-risk individuals; typically TDF + emtricitabine (Truvada); taken daily or event-driven.
Diagrams to know
- PEP timeline (exposure → 72-hour window → start ART → 28-day course → retest).
- PrEP daily vs. event-driven regimens.
Prevention of Mother-to-Child Transmission (PMTCT)
Common values
Value
<2%
Symbol
PMTCT
Quantity
Transmission risk with optimal PMTCT
Value
15–45%
Symbol
PMTCT
Quantity
Transmission risk without intervention
Important facts
- Maternal ART during pregnancy: goal undetectable VL at delivery (reduces transmission to <2%).
- Safe delivery practices: minimize fetal blood exposure, avoid fetal monitoring scalp electrodes if possible.
- Infant ART prophylaxis: typically zidovudine (AZT) for 4–6 weeks or combination ART if high risk (maternal VL >1,000).
- Delivery method: vaginal delivery acceptable if mother has undetectable VL; cesarean section considered if VL >1,000.
- Infant feeding: AVOID breastfeeding if safe formula feeding available (Filipino context: formula access variable).
- Infant testing: within 48 hours, 48 hours to 2 weeks, 1–2 months, 2–3 months, 4–6 months (virologic testing via RNA, not antibody — maternal antibodies cross-react).
- Infant prophylaxis: AZT alone or combination (AZT + 3TC + nevirapine) depending on risk.
- Partner notification and testing: male partners of pregnant HIV+ women should test and start ART if positive.
- Contraception counseling: allow birth spacing, avoid pregnancy if uncontrolled VL.
Key definitions
PMTCT
Example
With optimal PMTCT, transmission risk <2%; without intervention, 15–45%.
Combination of interventions to prevent HIV transmission from mother to infant: maternal ART, obstetric care, infant prophylaxis, feeding counseling.
Diagrams to know
- PMTCT cascade (pregnant + → maternal ART → safe delivery → infant prophylaxis → infant testing).
HIV Transmission & Standard Precautions
Common values
Value
~0.3%
Symbol
Risk
Quantity
Occupational needlestick transmission risk
Value
~0.09%
Symbol
Risk
Quantity
Mucous membrane exposure transmission risk
Important facts
- HIV transmission routes: SEXUAL (most common globally and in Philippines), BLOOD (needle sharing, transfusion, needlestick), PERINATAL (pregnancy, delivery, breastfeeding).
- Fluids that transmit HIV: blood, semen, vaginal/rectal secretions, breast milk.
- Fluids that DO NOT transmit HIV: saliva, urine, feces, sweat, tears (unless visibly bloody).
- NOT transmitted by: casual contact (hugging, handshakes), sharing utensils, sneezing/coughing, insect bites, toilet seats.
- Hand hygiene FIRST: wash hands with soap and water before and after EVERY patient contact — single most important measure.
- Glove indication: contact with blood, body fluids, mucous membranes, or nonintact skin.
- Gown, mask, eye protection: when splashing of blood/body fluids is likely (deliveries, surgery, trauma).
- Sharps safety: NEVER recap needles; use safety-engineered devices; dispose in puncture-proof sharps container immediately after use.
- Needlestick injury: wash immediately with soap and water, assess source if possible, report immediately, initiate PEP evaluation within 2 hours ideally.
- Spill management: contain spill with absorbent material, spray with disinfectant (bleach 1:10 or EPA-approved), let sit 10 minutes, wipe clean, repeat.
Key definitions
Standard (Universal) Precautions
Example
Hand hygiene, gloves, gowns, masks, safe sharps handling — same precautions for all patients.
Infection-control practices treating ALL blood and body fluids from EVERY patient as potentially infectious, regardless of known HIV status.
Diagrams to know
- Hand hygiene steps (WHO 5-moment framework).
- Needlestick injury protocol (immediate actions → reporting → PEP evaluation).
HIV — Philippine Legal & Public Health Context
Important facts
- RA 11166 protects HIV status CONFIDENTIALITY — unauthorized disclosure is penalized (criminal and civil liability).
- Non-discrimination: illegal in employment, education, healthcare, housing, travel based on HIV status.
- Voluntary HIV counseling and testing (VCT) is the cornerstone; consent required before testing.
- Age of consent for VCT lowered to 15 years (parental involvement for <15 with conditions).
- Establishes Philippine National AIDS Council (PNAC) — coordinates national response.
- DOH leads prevention, treatment, and support programs; free ART and OI prophylaxis via government facilities.
- Prevention: comprehensive sex education, condom availability, harm reduction (needle exchange), PEP and PrEP programs.
- Treatment: initiate ART at diagnosis; goal is undetectable VL for all (treat-all strategy).
- Support: psychological counseling, nutritional support, opportunistic infection management, employment protection.
- Nurse role: maintain confidentiality, provide non-judgmental counseling, ensure informed consent, support disclosure and partner testing, report violations of RA 11166.
Key definitions
RA 11166 (Philippine HIV and AIDS Policy Act of 2018)
Example
Nurse must maintain strict confidentiality; unauthorized disclosure is criminal. Must provide non-judgmental care and support partner notification/testing.
Philippine law protecting rights of people living with HIV; mandates confidentiality, non-discrimination, access to counseling/testing, treatment, and support.
Diagrams to know
- RA 11166 pillars (confidentiality, non-discrimination, VCT access, treatment access, support).
Transplant Immunosuppression & Rejection
Common values
Value
Minutes to hours post-transplant
Symbol
Timing
Quantity
Hyperacute rejection onset
Value
Days to months post-transplant
Symbol
Timing
Quantity
Acute rejection onset
Value
Months to years post-transplant
Symbol
Timing
Quantity
Chronic rejection onset
Important facts
- Immunosuppression goal: balance enough suppression to prevent rejection against infection risk (central nursing tension).
- Hyperacute rejection: minutes–hours post-transplant; pre-formed antibodies; irreversible; prevented by ABO/crossmatch compatibility.
- Acute rejection: days–weeks post-transplant; lymphocytic infiltration; usually reversible with pulse steroids/increased immunosuppression.
- Chronic rejection: months–years; progressive fibrosis and dysfunction; partially reversible with increased immunosuppression.
- Cyclosporine toxicities: nephrotoxicity (dose-dependent), HTN, tremor, hirsutism, gum hyperplasia; narrow therapeutic window.
- Tacrolimus toxicities: nephrotoxicity, HTN, tremor (more than cyclosporine), diabetes (hyperglycemia), neurotoxicity; potent.
- Drug-level monitoring: CRITICAL for calcineurin inhibitors; trough levels drawn pre-dose (12 hours post-dose); therapeutic range varies by drug/transplant type.
- Grapefruit juice: increases calcineurin-inhibitor levels (avoid completely); many drug interactions (check each drug before adding).
- Live vaccines: CONTRAINDICATED in transplant patients on immunosuppression; use inactivated vaccines instead.
- Infection is major risk: fever may be masked by steroids; educate on signs/symptoms and when to seek help; prophylaxis for PCP (if CD4 <200) and TB if exposed.
Key definitions
Rejection (Type IV Hypersensitivity)
Example
Hyperacute (minutes–hours): pre-formed antibodies; acute (days–months): lymphocytic infiltration, often reversible; chronic (months–years): progressive fibrosis.
Cell-mediated immune response against transplanted allograft; classified as hyperacute, acute, or chronic based on timing and reversibility.
Calcineurin Inhibitors
Example
Monitor through levels (trough = pre-dose level); toxicities: nephrotoxicity (monitor creatinine), HTN (monitor BP), tremor (tacrolimus), gum hyperplasia/hirsutism (cyclosporine).
Cyclosporine and tacrolimus; inhibit T-cell activation and IL-2 production; narrow therapeutic window requiring drug-level monitoring.
Antiproliferatives
Example
Mycophenolate: GI upset, teratogenic. Azathioprine: bone marrow suppression (CBC monitoring), pancreatitis risk.
Mycophenolate and azathioprine; inhibit lymphocyte proliferation; monitor for bone marrow suppression.
Diagrams to know
- Rejection timeline (hyperacute → acute → chronic).
- Calcineurin inhibitor monitoring (drug level, BP, renal function, glucose).
Transplant Nursing Management
Important facts
- Lifelong adherence to immunosuppression: missed doses allow rejection; counsel importance and side-effect management.
- Graft function monitoring: baseline labs (creatinine, BUN, LFTs), then q 3 months initially, adjust frequency based on stability.
- Infection prevention: hand hygiene, avoid sick contacts, prophylaxis (PCP if CD4 <200, TB if exposed), vaccinations (inactivated only).
- Medication adherence support: pill organizers, reminders, side-effect education (lipodystrophy, hyperglycemia, HTN management).
- Diet: no restrictions typically, but avoid grapefruit and grapefruit juice (raises calcineurin-inhibitor levels dangerously).
- Drug interactions: many ART, antibiotics, antifungals, anticonvulsants interact with calcineurin inhibitors — check ALL before adding drugs.
- Fever and infection signs: masked by steroids; educate to report fever, productive cough, dysuria, wound redness, etc., immediately.
- Malignancy risk: increased skin cancer (sun protection), lymphomas, cervical cancer in women; screen annually.
- Psychological support: adjustment to chronic disease, medication burden, lifestyle changes; referral as needed.
- Sexual and reproductive health: contraception counseling (some drugs teratogenic); pregnancy risks (rejection flares, drug teratogenicity) — planned pregnancy with nephrologist/OB.
Must remember
SLE HALLMARK = butterfly (malar) rash + marked photosensitivity; Type III (immune-complex) disease; anti-dsDNA/anti-Smith highly specific; ANA ~95% sensitive but not specific; lupus nephritis is leading cause of death → monitor urinalysis, proteinuria, creatinine.
SLE FLARE TRIGGERS = sun/UV, infection, stress, fatigue, pregnancy, certain drugs → teach strict sun protection (SPF 30+, protective clothing, avoid 10am–4pm); monitor for infection signs; counsel on contraception and family planning.
HYDROXYCHLOROQUINE for SLE requires BASELINE and PERIODIC eye exams (retinal toxicity) — non-negotiable; never stop abruptly; corticosteroids for moderate–severe flares but taper slowly (adrenal crisis risk).
SCLERODERMA = fibrosis + Raynaud phenomenon (often earliest sign) + esophageal dysmotility (GERD) + pulmonary disease (ILD, PH = leading cause of death); CREST mnemonic for limited form; ACE inhibitors for renal crisis (medical emergency).
HIV DESTROYS CD4+ T CELLS: normal ~500–1,600 cells/mm³; CD4 <200 = AIDS (opportunistic infection risk); PCP (classic, CD4 <200), TB (leading OI in Philippines), cryptococcal meningitis (CD4 <100) → prophylaxis when CD4 thresholds reached.
WINDOW PERIOD = infected but antibody-negative (typically up to ~3 months, rare up to 6 months); 4th-gen antigen/antibody test reduces to ~2–4 weeks; RNA test ~1–2 weeks → RETEST if negative within 3 months of exposure; PEP evaluation within 72 hours (ideally <2 hours).
ART = COMBINATION of ≥3 drugs from ≥2 classes (HAART); DOES NOT CURE but suppresses virus; goal = UNDETECTABLE VL (<50 copies/mL); U=U (Undetectable = Untransmittable) — DOH standard; ADHERENCE >95% critical → missed doses = resistance; never single-drug therapy.
STANDARD (UNIVERSAL) PRECAUTIONS = treat ALL blood/body fluids as potentially infectious for EVERY patient; hand hygiene FIRST (before/after every contact); NEVER recap needles; dispose sharps in puncture-proof container immediately; needlestick → wash, report, PEP evaluation within 72 hours.
RA 11166 (Philippine HIV and AIDS Policy Act 2018) = HIV status CONFIDENTIAL (unauthorized disclosure = criminal penalty), NON-DISCRIMINATION, voluntary counseling/testing (consent age 15), free ART/OI prophylaxis via DOH → nurse maintains confidentiality, provides non-judgmental care, supports disclosure/partner testing.
TRANSPLANT IMMUNOSUPPRESSION = calcineurin inhibitors (cyclosporine, tacrolimus) require DRUG-LEVEL MONITORING + renal function/BP monitoring; infection major risk; AVOID live vaccines + grapefruit juice; lifelong adherence prevents rejection; acute rejection (reversible) vs. chronic rejection (progressive).
Last minute tips
ALWAYS associate SLE with BUTTERFLY RASH + PHOTOSENSITIVITY + ANA/ANTI-dsDNA; if an NLE question mentions young woman with malar rash and sun-triggered flares, think SLE first. Lupus nephritis (proteinuria, hematuria, rising creatinine) = urgent referral.
Why
These are the most recognizable and testable SLE features; they appear in almost every NLE case scenario on autoimmune disorders.
For HIV: REMEMBER CD4 THRESHOLDS = <200 (PCP prophylaxis, AIDS definition), <100 (cryptococcal meningitis, toxoplasmosis), <50 (MAC, CMV). If an NLE question gives CD4 count, immediately check if prophylaxis indication met.
Why
CD4-guided prophylaxis prevents opportunistic infections and is a core nursing intervention; NLE loves testing this decision-making at different CD4 levels.
ADHERENCE IS KING: If an NLE case describes missed doses or virologic failure, the answer almost always involves assessing adherence first, then resistance testing if adherence adequate. Never jump to switching ART without checking adherence.
Why
Adherence >95% is non-negotiable for ART success; poor adherence is the #1 cause of virologic failure and resistance in resource-limited settings (Philippines context). NLE prioritizes this as a nursing competency.
POST-EXPOSURE PROPHYLAXIS (PEP) = WITHIN 72 HOURS of exposure; if an NLE question gives a timeline beyond 72 hours, PEP may not be indicated (reassess the question). Stress to patients: occupational + sexual exposures both qualify; retest at 6 weeks, 3 months, 6 months.
Why
The 72-hour window is strict and commonly tested; missing this deadline is a major exam trap. NLE also tests partner notification and testing protocols.
STANDARD PRECAUTIONS ARE UNIVERSAL: Don't get lulled into thinking HIV patients need 'special' precautions. Same hand hygiene, same glove use, same sharps safety for EVERY patient. The point is: apply these rigorously for everyone, HIV status unknown or known.
Why
NLE assesses whether graduates understand that infection prevention is standardized, not diagnosis-specific. Avoid the trap of over-precautions or under-precautions based on diagnosis.
Comparison tables
SLE vs Scleroderma vs Sjögren's — Key Distinguishing Features
| Feature | SLE | Scleroderma | Sjögren's |
|---|---|---|---|
| Primary target | Multisystem (immune complexes) | Skin/organs (fibrosis) | Exocrine glands |
| Hallmark manifestation | Butterfly rash + photosensitivity | Tight shiny skin + Raynaud | Dry eyes + dry mouth |
| Antibodies | ANA, anti-dsDNA, anti-Smith | Anticentromere, anti-Scl-70 | Anti-Ro (SSA), anti-La (SSB) |
| Skin involvement | Malar rash, discoid lesions | Fibrotic thickening, hardened | Minimal |
| GI involvement | Variable | Esophageal dysmotility → GERD | Minimal |
| Pulmonary involvement | Pleuritis, pericarditis | ILD, pulmonary HTN (leading cause of death) | Uncommon |
| Renal involvement | Lupus nephritis (leading cause of death) | Scleroderma renal crisis | Rare |
| Raynaud phenomenon | Common | Hallmark, often first sign | Uncommon |
| Drug of choice | Hydroxychloroquine (+ NSAIDs, steroids) | Supportive (ACE inhibitors for renal crisis) | Artificial tears/saliva + dental care |
| Female predominance | 9:1 | ~4:1 | 9:1 |
HIV CD4 Count Stages, Risk Thresholds, & Prophylaxis/Monitoring
| CD4 Range | Clinical Stage | Opportunistic Infection Risk | Prophylaxis Indicated | Additional Monitoring |
|---|---|---|---|---|
| >200 cells/mm³ | Normal/Early infection | Minimal OI risk | None (except general measures) | Baseline labs, annual screening |
| 100–200 cells/mm³ | Advanced | PCP, TB, oral candidiasis | PCP prophylaxis (TMP-SMX) | CD4 q 3 months, VL monthly |
| <100 cells/mm³ | AIDS | Cryptococcal meningitis, toxoplasmosis, CMV | MAC prophylaxis (azithromycin), CMV monitoring | CD4 q 1–3 months, VL monthly, ophthalmology for CMV |
| <50 cells/mm³ | Severe AIDS | MAC, CMV retinitis/colitis, disseminated fungal | MAC + CMV prophylaxis/monitoring, TB prophylaxis if exposed | Frequent lab/clinical monitoring, ophthalmology q 1–2 months |
ART Drug Classes — Mechanisms, Examples, & Key Toxicities
| Drug Class | Mechanism | Examples | Key Toxicity/Caution | Monitoring |
|---|---|---|---|---|
| NRTIs | Inhibit reverse transcriptase (competitive) | TDF, 3TC, AZT, ABC | AZT: bone marrow suppression; ABC: hypersensitivity (HLA-B*5701 screen); TDF: renal, bone loss | CBC (AZT), creatinine (TDF), HLA-B*5701 (ABC) |
| NNRTIs | Inhibit reverse transcriptase (non-competitive) | EFV, NVP | EFV: CNS effects, teratogenic; NVP: hepatotoxicity, SJS, rash | LFTs (baseline, NVP), psychiatric assessment (EFV), rash monitoring |
| Integrase Inhibitors (InSTI) | Inhibit integrase (HIV DNA integration) | DTG, RAL | DTG: minimal; RAL: minimal; requires food (RAL) | VL monitoring; kidney/liver function |
| Protease Inhibitors (PI) | Inhibit protease (viral maturation) | LPV/r, ATV | GI upset, diarrhea, lipodystrophy, hyperglycemia/lipidemia, hyperbilirubinemia (ATV) | Lipids, glucose, LFTs; ritonavir drug interactions |
| Entry/Fusion Inhibitors | Block HIV entry into CD4+ cells | Enfuvirtide, Maraviroc | Enfuvirtide: injection site reactions; Maraviroc: hepatotoxicity | LFTs, CCR5 tropism (maraviroc) |
Types of Rejection in Organ Transplantation
| Rejection Type | Timeline | Mechanism | Reversibility | Prevention/Management |
|---|---|---|---|---|
| Hyperacute | Minutes–hours | Pre-formed antibodies (ABO/HLA) binding to graft endothelium | Irreversible | Prevent: ABO/HLA typing, crossmatch; occurs despite prevention rarely |
| Acute | Days–weeks/months | T-cell infiltration and antibody formation | Usually reversible | Pulse methylprednisolone, increase calcineurin inhibitor, add/switch immunosuppressant |
| Chronic | Months–years | T-cell and antibody-mediated fibrosis/vasculopathy | Partially reversible | Increase immunosuppression, optimize drug levels, manage HTN/dyslipidemia |
HIV Testing — Window Periods by Test Type
| Test Type | What It Detects | Window Period | Sensitivity/Specificity | Screening vs. Confirmatory |
|---|---|---|---|---|
| Antibody (2nd/3rd gen) | Anti-HIV antibodies | ~18–45 days (up to 3 months) | High (>99%) but requires confirmation | Screening |
| Antigen/Antibody (4th gen) | HIV antibodies + p24 antigen | ~18–45 days (shorter than 2nd gen) | Very high (99%+) | Screening/Confirmatory |
| Rapid HIV Test | Antibodies (sometimes antigen) | ~18–45 days | Variable (85–99% sensitivity); must confirm | Screening only |
| HIV RNA (Nucleic Acid) | HIV RNA directly | ~10–33 days (shortest) | Very high; gold standard | Confirmatory or baseline |
Diagrams
Autoimmune Disorders Overview — Pathophysiology & Clinical Presentation
Mind map showing three major autoimmune disorders, their mechanisms, key clinical manifestations, and diagnostic markers. Highlights the central theme of loss of self-tolerance and immune dysregulation.
HIV Pathophysiology — From Infection to AIDS
Flowchart depicting the HIV infection cascade from initial infection through integration, CD4 depletion, and progression to AIDS. Shows decision points for ART initiation and management outcomes leading to viral suppression.
HIV Testing Window Period & Seroconversion Timeline
State diagram showing the progression from HIV exposure through the window period to seroconversion. Illustrates when different test types become positive and emphasizes the need for retesting in the window period.
CD4 Count-Guided Prophylaxis & Management Algorithm
Flowchart showing CD4-guided clinical decision-making for opportunistic infection prophylaxis and ART management. Integrates CD4 thresholds, OI prevention strategies, and viral load monitoring into a cohesive management algorithm.
SLE Diagnosis & Monitoring — ANA-Anti-dsDNA Interpretation
Diagnostic flowchart for SLE incorporating ANA screening and specific antibody interpretation. Shows how anti-dsDNA/anti-Smith confirmation, complement monitoring, and urinalysis guide diagnosis and ongoing disease assessment.
Organ Transplant Rejection Timeline & Prevention Strategy
Timeline showing the temporal progression of rejection types in organ transplantation, from hyperacute to chronic, with corresponding mechanisms, reversibility, and management strategies. Emphasizes the balance between immunosuppression and infection risk.