Antiretroviral Therapy for Special Populations

Question 1

HIV-TB Co-infection: Rifampin effects on ART

Answer 1

• significantly ↓ ALL PIs – cannot use together • ↓ RAL and DTG concentrations (need to ↑ RAL to 800 mg bid, DTG to 50 mg bid) • ↓ NNRTI concentrations: EFV 600 (or 800) mg daily

Question 2

Acute or Recent HIV: Need for treatment and recommended regimen if genotype results . . .

Answer 2

• ART reduces symptoms and signs. • If ART is started prior to genotype results, use a PI-based or dolutegravir-based, rather than an NNRTI-based, regimen.

Question 3

Treating Acute Cryptococcal Meningitis and acute HIV

Answer 3

Delay ART • Conclusion: Early ART led to ↑ mortality

Question 4

HIV-TB Co-infection: timing of starting ART based on CD4 count:

Answer 4

• For CD4 <50, start ART within 2 weeks of TB rx
• For CD4 >50 with severe clinical disease, start ART within 2-4 weeks of TB rx
• For CD4 >50 without severe clinical disease, start ART within 8-12 weeks of TB rx

Question 5

HIV-TB Co-infection: For MDR or XDR TB

Answer 5

start ART within 2-4 weeks of TB rx.

Question 6

Rifamycin preferred for HIV-TB Co-infection:

Answer 6

• Rifabutin

Question 7

Management for IRIS in HIV - TB Co-infection:

Answer 7

• For IRIS, continue both ART and TB meds while managing the syndrome

Question 8

ART with activity against HBV:

Answer 8

• lamivudine (3TC), emtricitabine (FTC), tenofovir (TDF or TAF)

Question 9

Number of active agents to treat HIV-HBV Co-infection

Answer 9

• 2 active agents for HBV • 3 active agents for HIV

Question 10

Does ART increase risk of birth defects

Answer 10

NOT

Question 11

Rec near delivery, if HIV RNA >1000 (or unknown):

Answer 11

• intravenous zidovudine, and
• recommend C-section at 38 weeks

Question 12

NRTI in Pregnancy: • Preferred: • Alternative:

Answer 12

Preferred: • abacavir (ABC)/lamivudine (3TC) • tenofovir (TDF)/emtricitabine (FTC) (or lamivudine)

Alternative: • zidovudine (AZT)/lamivudine

Question 13

NNRTI in Pregnancy: • Alternative:

Answer 13

NNRTI in Pregnancy: Alternative: • efavirenz (screen for depression) • rilpivirine (not with baseline VL >100K or CD4 <200)

Question 14

PI in Pregnancy: • Preferred: • Alternative:

Answer 14

PI in Pregnancy: Preferred: • atazanavir/ritonavir • darunavir/ritonavir (use bid) Alternative: • lopinavir/ritonavir (use bid)

Question 15

Integrase inhib in Pregnancy: • Preferred: • Alternative:

Answer 15

Integrase inhib in Pregnancy:

Preferred: • raltegravir

Alternative: • dolutegravir (neural tube defects described if taken during conception,

but not later in pregnancy)

Question 16

Postexposure prophylaxis (PEP): occupational and non-occupational exposure:

Answer 16

• start ASAP (within 72 hours)

T D F (R)

• tenofovir (TDF)/emtricitabine (FTC) + dolutegravir (DTG) (not in women in early pregnancy or sexually active and not on birth control) or raltegravir (RAL)

Question 17

CDC Guidance for PrEP:

Answer 17

• document HIV Ab negative and r/o acute infection, CrCl >60, screen for STIs

and HBV infection

• Prescribe tenofovir (TDF)/emtricitabine (FTC) 1 po daily X 90 days
• HIV testing every 3 months
• evaluate the need to continue PrEP

Question 18

Acute OI and ART

Answer 18

• Acute OI – ART within 2 weeks of diagnosis reduces mortality; • caution with CNS opportunistic infections.