Exam 3 Add. 2: HIV

Question 1

What are the goals of ART?

Answer 1

• Maximal & durable viral suppression
• Restoration & preservation of immune function (esp. CD4 counts)
• Improved QoL
• Reduce HIV-related opportunistic infections
• Reduced morbidity and mortality

Question 2

What is the first line regimen of ART for most people with HIV?

Answer 2

INSTI + 2 NRTIs
OR
DTG/3TC

Question 3

What are some possible AEs of INSTIs?

Answer 3

GI distress
CNS disturbances
Rash
False SCr elevation
Weight gain (more in Black/female patients)

Question 4

Which INSTI has interactions with metformin?

Answer 4

Dolutegravir

Question 5

Which INSTI has a low barrier to resistance (develops resistance quickly)?

Answer 5

Raltegravir

Question 6

What ART combo is contraindicated at HIV viral load > 500k, HBV confection, or without resistance testing?

Answer 6

DTG/3TC

Question 7

Which NRTI requires HLA-B*5701 testing?

Answer 7

Abacavir

Question 8

Omeprazole and pantoprazole decrease the concentration of this NNRTI:

Answer 8

Rilpivirine

Question 9

What ART drugs shouldn’t be used in pregnant women?

Answer 9

Bictegravir (INSTI)
Doravarine (NNRTI)
Cobicistat (Booster)

Question 10

Patient HV is diagnosed with HIV. When should ART be initiated?

Answer 10

Same day! Don’t need CD4 cell count

Question 11

What are some AEs of NNRTIs (except doravarine)?

Answer 11

Liver toxicity
Rash
Hyperglycemia
Hyperlipidemia
*neuropsychiatric effects (efavirenz and rilpivirine)

Question 12

What NNRTI is CYP3A4 inhibitors? What NNRTI is a CYP3A4 substrate?

Answer 12

Efavirenz = inhibitor
Rilpivirine = substrate

Question 13

What is special about TAF over TDF (NRTI)?

Answer 13

TAF has less of an impact on renal tubular dysfunction

Question 14

Entry inhibitors (enfuvurtide, maraviroc, ibalizumab) are not first line despite being extremely efficacious. Why?

Answer 14

Lots of AEs, mostly reserved for patients with lots of resistance

Question 15

Why would a patient develop clinical resistance to ART drugs?

Answer 15

HIV mutates very quickly and these stronger mutations are passed on easily.
(Less likely to be able to use single pill regimens)

Question 16

When do we use boosted PIs?

Answer 16

Starting ART before resistance data
Poor adherence
Genetics cause increased resistance
Currently using multiple daily doses

Question 17

What are some AEs of using boosted PIs?

Answer 17

Drug-drug interactions
GI intolerance
Hyperlipidemia
CV risk
Metabolic syndromes

Question 18

Which INSTI must be taken with FOOD?

Answer 18

Elvitegravir (part of Genvoya/Stribild)

Question 19

In order to use Genvoya/Stribild, CrCL must be ____ mL/min at baseline and not fall below ___ mL/min

Answer 19

70 mL/min baseline
Cannot go below 50 mL/min

Question 20

What is a challenge of using Cobicistat or ritonavir?

Answer 20

They are extremely potent, pure CYP3A4 inhibitors

Cannot be used with:
- anticoagulants
- anticonvulsants
- rifampin
- ergotamines
- St. John’s wort
- Lovastatin, Simvastatin**
- Sildenafil
- Midazolam

Question 21

What are the black box warnings for emtricitabine and tenofovir (FTC/TNF or TAC)?

Answer 21

DO NOT USE WITH:

Lactic acidosis/severe hepatomegaly
Hepatitis B infection

Question 22

Who should be started on PrEP medications?

Answer 22

Men who have sex with men
Nonmonogamous heterosexual people who have had STIs ~6 months or infrequently use condoms
People who share injectable drug equipment

Question 23

What must be documented before initiating PrEP?

Answer 23

Negative HIV test
No signs/symptoms of HIV
Normal renal function
HBV vaccine up to date

Question 24

What drug is prescribed for PReP?

Answer 24

FTC/TDF or TAF (CI with HBV infection) 200/300 mg po QD
TDF not recommended if CrCL is <60 mL/min

*cannot prescribe more than 90 day supply, patient must be reassessed!

Question 25

Efficacy of PReP drug is HIGHLY reliant on what?

Answer 25

Adherence