31. HIV Flashcards
this is the virus responsible for causing AIDS
HIV (human immunodeficiency virus)
if someone has a CD4 < 200, or >200 with an AIDS-indicator condition; the most advanced stage of a HIV infection
AIDS (acquired immunodeficiency syndrome) -> more proper to say “advanced HIV infection”
infection caused by organisms that are not normally pathogenic in an immunocompetent patient, therefore only happens in immunosuppressed people
opportunistic infection
this is a helper T-cell and is the primary target for an HIV infection
CD4
this is a measure of the amount of HIV viral RNA measured in the blood; reported as copies/mL
viral load
how many copies/mL of viral load is considered “undetectable”
< 20 copies/mL
explain the 95-95-95 commitment Canada has enrolled in to end the HIV epidemic
95% of the people living with HIV are diagnosed
95% of those diagnosed are on treatment
95% of those on treatment have a suppressed viral load
what are some social factors that may be related to HIV transmission
- substance abuse (especially injecting)
- trauma
- mental health issues
how is HIV transmitted?
infectious body fluids
what is the main body fluid that HIV can be transmitted through
Blood
what are some other body fluids that HIV may be transmitted through
- semen/vaginal fluids
- CSF, synovial, amniotic
true or false: HIV can be transmitted through urine, sweat, and tears
false - only if they contain visible blood
true or false: HIV is commonly seen in North America
false
what is the main population type that HIV is seen in
gay, bisexual and other men who have sex with men
what populations is HIV on the rise in
females and people who inject drugs
what are some indications for HIV testing (with informed consent)
- an individual requests a test
- pregnancy
- sexually active and never been tested
- protected sex or use of shared drug equipment with a partner who is HIV positive or unknown status
- signs or symptoms of acute HIV infection
- illness associated with a compromised immune system
- someone with TB
- someone who has been sexually assaulted
what is the gold standard HIV test
blood test that tests for HIV antibodies and p24 antigen
this refers to the time that someone can get a false negative on a HIV test
window period
what is the window period of the gold standard HIV test
10 days - 4 weeks
what should be done if someone who has a high suspicion that they may have contracted HIV gets a negative result on gold standard HIV test within the window period
they should be retested outside the window period
true or false: POCT for HIV can be used to diagnose HIV
false - only used for screening; therefore if POCT is reactive, then needs to be confirmed with standard test as well because POCT only tests for antibodies
what is the window period of POCT for HIV
1-3 months
true or false: when someone becomes infected with HIV, their viral load and CD4 count increases immediately
false - viral load increases and CD4 decreases
true or false: when someone with HIV is started on ART (anti-retroviral therapy) their viral load starts to decrease and their CD4 count starts to increase
true
what is the “viral setpoint”
the lowest amount of viral load present due the persons immune system kicking in to try and fight the infection
true or false: long-term controlled HIV infection may still be associated with morbidity, such as accelerated aging process seen with early onset CV disease, neurologic, renal and bone disease
true
what are some ways a new HIV infection may present?
usually looks like any other viral infection, which usually lasts for a week or two and then goes away on its own
- fever
- lymphadenopathy
- pharyngitis
- rash
- mucocutaneous ulcers
- myalgia
- arthralgia
- diarrhea
- headache
- N/V
if at a later stage in the disease, a patient may be asymptomatic or present with an opportunistic infection
what are the goals of therapy for a patient newly diagnosed with an HIV infection
- slow disease progression and complications
- prevent OI’s
- prolong duration and quality of life
- minimize adverse effects of therapy
- prevent the emergence of ARV-resistant strains of HIV
- prevent HIV transmission
viral load <20 copies/mL = virological suppression
get CD4 count as high as possible = preserve immunological function
A patient of yours is on ART and they currently cannot afford their medication. they are looking to get 2 weeks of medication filled for now and take a pill every second day so it will last them a month. what should you tell them?
it is better to stop the medication altogether rather than take it sparingly, as taking it now and then can lead to ARV-resistant strains that cannot be treated!!!
what are some non-pharm options to consider for HIV management
- counselling on safer sex and drug use
- the importance of good nutrition and preventative health
- vaccines to prevent other infections for people living with HIV
true or false: there are vaccines available to prevent HIV infection
false
true or false: there is a vaccine that can treat HIV infection
false
what vaccines should be avoided in advanced immunosuppression (when CD4 is less than 200) - give some examples
live attenuated vaccines
- MMR (measles/mumps/rubella)
- Varicella (chicken pox)
- live influenza
true or false: the live influenza vaccine can be given to an HIV patient if their CD4 count is >200
false - not given EVER
- we use inactivated influenza vaccine
what should a baseline assessment at HIV diagnosis include
- med hx + physical exam
- lab tests (VL, CD4, assess for other co-infections and OI’s such as STI,s Hep A, B, C, toxoplasmosis, TB; CBC, LFT, Scr, fasting glucose, lipids, HLAB*5701 gene
- readiness to start therapy (drug coverage, adherence, psychosocial readiness e.g. if have a severe mental health condition such as depression, may have to delay ARV initiation and get depression under control first)
if a patient newly diagnosed with HIV is getting ready to start treatment, but also has an opportunistic infection, what should occur first?
treatment of the OI is a priority, but then HIV treatment should be started as soon as possible (simultaneously if possible)
note: rare cases where delay may be warranted is cryptococcal or TB meningitis due to concerns re: immune reconstitution inflammatory response (IRIS)
what are the benefits of starting treatment as early as possible
- reduces disease progression
- prevents HIV transmission to others
true or false: if someone has an undetectable VL, HIV can still be transmitted to their sexual partner
false
true or false: if someone has an undetectable VL, HIV can still be transmitted to someone who they are sharing injectable drug equipment with
true - possibility
list the nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs)
- Abacavir (ABC)
- Emtricitabine (FTC)
- Lamivudine (3TC)
- tenofovir alafenamide hemifumurate (TAF)
- tenofovir disoproxil fumigate (TDF)
what side effects may be seen with all NRTIs
nausea and hepatic effects
what is the main toxicity concern with Abacavir
if have the HLA*B5701 gene -> hypersensitivity syndrome
what is the main toxicity concern with Emtricitabine
hyperpigmentation (rare)
what is the main toxicity concern with TAF
increased lipids and weight gain
what is the main toxicity concern with TDF
renal impairment and decreased BMD
true or false: all NRTIs must be taken with food
false - no food effect
true or false: all NRTIs are dosed once daily
true
which NRTIs have a better virologic response if the VL is > 100,000
Emtricitabine (FTC) & TDF
list the integrase strand transfer inhibitors (INSTIs)
“tegravirs”
- Bictegravir (BIC)
- Dolutegravir (DTG)
- Elvitegravir (w/ cobicistat) (EVG/c)
- Raltegravir (RAL)
- Cabotegravir (CAB)
which INSTIs have a higher genetic barrier to resistance
Bictegravir and Dolutegravir
which INSTIs should not be used in people with pre-existing psychiatric conditions due to possible depression and suicidal ideation
Dolutegravir and Elvitegravir
which INSTI is not used for intital therapy and can be switched when in VL supression
Cabotegravir
which INSTI has alot of resistance therefore there are no new starts with this agent
Raltegravir
true or false: Bicategravir is dosed once daily
true
true or false: Bicategravir needs to be taken with food
false
true or false: Dolutegravir is dosed once daily
true - but BID if INSTI resistance
true or false: Dolutegravir needs to be taken with food
false
true or false: Elvitegravir (w/ cobicistat) is dosed once daily
true
true or false: Elvitegravir (w/ cobicistat) needs to be taken with food
true
true or false: Raltegravir is dosed once daily
false - BID
true or false: Cabotegravir is dosed once daily
false - monthly or bi-monthly IM injection (coadministered with Ripilvirine)
true or false: all INSTIs are well tolerated and adverse effects are uncommon
true
list the non-nucleoside reverse transcriptase inhibitors
“VIR”
- doravirine (DOR)
- efavirenz (EFV)
- rilpilvirine (RPV)
which NNRTIs potency persists regardless of baseline viral load
Doravirine and Efavirenz
which NNRTI has higher rates of failure in pts with HIV RNA >100,000 copies/mL
Rilpilvirine
which NNRTI has activity against some NNRTI resistant virus strains and may be used as part of salvage regimens
Doravirine
which NNRTI is taken once daily with or without food
Doravirine
which NNRTI is taken once daily, ideally at night, without food
Efavirenz
which NNRTI is taken once daily with a 500kcal meal
PO Rilpivirine
what are the major toxicity concerns with Doravirine
nausea, dizziness, and abnormal dreams
what are the major toxicity concerns with Efavirenz
psychiatric effects (depression, insomnia and vivid dreams) and Qtc prolongation
true or false: Rilpilvirine has the same side effects of Efavirenz [psychiatric effects (depression, insomnia and vivid dreams) and Qtc prolongation] except the psychiatric effects are fewer
true
which NNRTI comes in both a PO and IM formulation
Rilpilvirine
IM is in combination with Cabotegravir
list the protease inhibitors (PIs)
- Darunavir boosted with Ritonavir (DRV/r)
- Darunavir boosted with cobicistat (DRV/c)
other: Atazanavir (AZT)
if resistance testing is not available, which PI should be used
Darunavir boosted with Ritonavir (DRV/r)
what are the major toxicity concerns for PIs
- metabolic: increased lipids and insulin resistance
- MI/stroke, hepatitis and skin rxn
- GI s/e
Darunavir may cross-react with this type of antibiotic allergy
sulfa
true or false: all PIs are taken once daily with food
true
true or false: PIs are first-line agents
false - not used much anymore unless resistance is present or if the patient is pregnant
this booster may cause GI upset, metallic taste, diarrhea, liver enzyme elevations, hyperlipidemia, PR interval prolongation and inhibits and induces many CYP enzymes
Ritonavir -> dirty dirty drug
this booster has no antiviral activity and inhibits CYP3A4 only in order to boost ARVs
Cobicistat
what is the typical combination of ARTs
combination of 3 drugs from two different classes
- a combination of INSTI + 2 NRTIs is preferred for most patients
what are the crietria that need to be considered when deciding whether or not to put a patient on a 2 drug ART option (such as Dovato = Dolutegravir/Lamivudine)
- VL < 500,00
- no hep B infection
- confirmed genotype sensitivity
what are the 3 most common first line agents
- BIC/TAF/FTC
- DTG + (TAF or TDF) + (FTC or 3TC)
- DTG/3TC (if meet specific criteria)
what is the monitoring for viral load
goal = undetectable (<20 copies/mL)
- at baseline
- 2-8 weeks after starting ART
- recheck q 4-8 weeks until detectable
- q 3-6 months once undetectable
what is the monitoring for CD4
goal = high as possible (> 200)
- at baseline
- q 3-6 months
what is the monitoring for lytes, Scr, glucose, AST, ALT, CBC
- at baseline
- 2-8 weeks after starting ART
- q 6 months after that
what is the monitoring for lipid profile
- at baseline
- q 6-12 months after that
what is the monitoring for urinalysis and serum PO4
- at baseline
- q 6 months if on TDF (can cause renal impairment)
what medication can bind to INSTIs and decrease their serum concentration
minerals (e.g. Al, Mg, Fe, Ca)
* space INSTIs from minerals*
what medication can interact with Dolutegravir and Bictegravir
Metformin (increased metformin levels - only an issue when starting metformin)
what medication can interact with PIs and other ritonavir and cobicistat-boosted regimens
Corticosteroids (increased levels in steroids = adrenal suppression)
* include inhaled and intranasal steroids *
- beclomethasone may be used
what medication can interact with TDF
NSAIDs - both can cause AKI/renal impairment + combining can cause decrease elimination of TDF and risk of cumulative renal toxicity
which acid suppression medication is contraindicated with rilpivirine
PPIs
true or false: antacids and H2RAs are contraindicated with Rilpilvarine
false - need to be spaced*
true or false: it is common for patients to die from HIV or AIDS
false - patients do not die from HIV or AIDs, they die from complications (e.g. OI’s, malignancies, ARV toxicities seen with older agents)
when should OI prophylaxis be initiated?
when CD4 count is < 200
true or false: OI prophylaxis works for all opportunistic infections
false - some
true or false: people with CD4 count < 200 can get sick from non-opportunistic pathogens too (e.g. COVID, flu, strep-pneumonia)
true
what OI is treated if a patients CD4 count is < 200
PJP (P. Jiroveci pneumonia)
what are the preferred agents for treating PJP (CD4 < 200)
Cotrimoxazole i DS tab daily or 3x/week
Cotrimazole i SS tab daily
what OI is treated is a patients CD4 count is < 100
PJP (P. Jiroveci pneumonia)
T. gondii
what are the preferred agents for treating PJP (P. Jiroveci pneumonia) and T. gondii (CD4 < 100)
Cotrimoxazole i SS tab daily
what OI is treated if a patients CD4 count is < 80
PJP (P. Jiroveci pneumonia)
T. gondii
Disseminated M. avium complex (MAC)
what are the preferred agents for treating PJP (P. Jiroveci pneumonia), T. gondii & MAC
azithromycin 1200 mg once weekly or 600 mg twice weekly
Clarithromycin 500 mg BID potent 3A4 inhibitor thus drug interactions
what are the 3 ways ARVs can be used for HIV prevention
- prenatal transmission
- pre-exposure prophylaxis (PrEP)
- post-exposure prophylaxis (PEP)
true or false: PrEP contains two situations -> occupational and non-occupational
false - PEP
true or false: treatment is different for occupational and non-occupational PEP
false - treatment is the same
when is the opt-put HIV testing done during pregnancy
at diagnosis and repeat in 3rd trimester
what should be done if the pregnant patients VL is > 1000 close to the time of delivery
schedule a C-section at 38 weeks gestation
what medication should be given at the time of labour if the pregnant patients VL is > 1000
continue ARV and give IV zidovudine
what should be avoided during the delivery process with a HIV positive mother
A. artificial premature rupture of membranes
B. fetal scalp electrode
C. vacuum or forceps delivery if VL > 50
D. all of the above
D
what type of infant prophylaxis should be given if the mother was on ARV and VL < 50
4 weeks of ZDV administered within 6-12 hours after birth
what type of infant prophylaxis should be given if the mothers VL was > 50
presumptive triple therapy administered from birth up to 6 weeks
true or false: breastfeeding is recommended for mothers who are HIV positive when their VL is < 50
false - BF is not recommended at all
who is PrEP indicated for
- MSM at high risk (multiple sex partners, hx of STI)
- hetersexual men and women at high risk (multiple sex partners, hx of STI)
- people who inject drugs
- HIV serodiscordant couples when pregnancy is desired
what are the 3 options for PrEP
- oral TDF/emtricitabine
- oral TAF/emtricitabine
- Cabotegravir (administered at month 0, 1 and then q 2 months)
this PrEP agent may be used off label for on demand use
TDF/emtricitabine
explain how PrEP should be taken
if have sex within 24 hours of the first dose:
take 2 tablets 2 hours before sex
take 1 tablet 24 hours after sex
take 1 tablet 48 hours after sex
if have sex beyond 24 hours after the first dose:
take 2 tablets 2 hours before sex
take 1 tablet 24 hours after sex (if have sex again within another 24 hours, take 1 tablet 24 hours after this time, and so on)
take 1 tablet 48 hours after the last time you had sex
take 1 tablet 72 hours after the last time you had sex
why is it important for people who are taking PrEP are HIV negative
because PrEP is only two antiretrovirals, and if the patient is HIV positive then they need to be on THREE ARVs. if they stay on only two ARVs this can create resistance and their HIV will be much harder to treat
when someone is started on PrEP, when should we follow up
before dispensing check renal function!
at 30 days:
assess tolerability (e.g. renal fucntion, BMD) and adherence
at 3 months:
repeat testing for HIV (Rx’s must not be continued beyond 3 months without confirming continued HIV-negative status)
-also test for Hep B and C, other STIs, pregnancy
when does PEP need to be started after an exposure?
within 72 hours (the sooner they start the better)
