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446- ID and transplant > HIV > Flashcards

HIV Flashcards

1
Q

HIV - ___ is a major cause of AIDs, HIV- -_ is also recognized to cause AIDs but is much less prevalent

A

1, 2

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2
Q

what is the HIV/AIDs target for 2020

A

90-90-90
90 dx, 90 dx and tx, 90 suppressed

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3
Q

which of the following is false
1. 1 in 8 are not aware of their HIV status
2. key populations that are disproportionally affected include people with experience in the prison system
3. 75% of people with HIV were accessing antiretroviral tx
4. antiretrovirals are a low cost drug program4

A

4

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4
Q

3 way of HIV transmission

A

sexual, parenteral, perinatal

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5
Q

the risk of transmitting HIV increases with higher

A

higher HIV viral load

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6
Q

____ can increase the risk of HIV transmission

A

STIs

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7
Q

U = U means

A

undetectable = untransmissible

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8
Q

the highest risk of HIV transmission is

A

anal receptive intercourse and needle sharing

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9
Q

HIV + and =>40 copies/mL =

A

high risk

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10
Q

HIV + and <40copies/mL but may have STIs =

A

low but nonzero risk

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11
Q

HIV + and <40 copies/ mL but no known STIs and of the general population =

A

negligible or no risk

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12
Q

rank the following from highest to lowest risk of HIV transmission: anal insertive, anal receptive, needle sharing, oral sex (giving), vaginal (receptive), sharing sex toys, blood on compromised skin

A

anal receptive, needle sharing, anal incentive, vaginal receptive, oral sex (giving), sharing sex toys, blood

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13
Q

risk of perinatal transmission of HIV is ____ in absence of tx

A

~25%

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14
Q

risk of HIV transmission perinatally increases with

A

higher HIV viral load, duration of ruptured membranes, mode of delivery, breastfeeding

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15
Q

list 3 strategies for preventing HIV transmission

A

Safer sex practices (ex- condoms)
Identifying and tx STIs
Needle exchange programs, sterilized equipment, opiate agonist tx
Pre-exposure prophylaxis (PrEP)
Post-exposure prophylaxis (PEP)
Tx individuals living with HIV (includes preg pts - perinatal)

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16
Q

what is acute retroviral syndrome

A

the first stage of infection with the human immunodeficiency virus (HIV)

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17
Q

most common sx of acute retroviral syndrome

A

sim to flu- fever, maculopapular rash, lymphadenopathy, myalgia or arthralgia, pharyngitis, oral ulcers, weight loss

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18
Q

5 definitions of AIDs

A

CD4 <200 cells/uL (not a part of case definition in Canada)
opportunistic infections
HIV associated encephalopathy
HIV associate wasting
HIV related neoplasms

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19
Q

HIV initially replicates in

A

MPs, CD4+ lymphocytes, possibly dendritic cells in tissue and blood

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20
Q

infected cells bring HIV particles to

A

lymphoid tissue

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21
Q

HIV infects ____, then, dendritic and other APCs promote ______________

A

activated T cells
additional rounds of HIV infection and replication

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22
Q

HIV infection firmly establishes in ____ where replication continues at a high rate

A

lymphoid organs

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23
Q

HIV testing should be offered when

A

screening for other STBBIs

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24
Q

early dx and tx with cART =

A

decreased transmission
reduced morbidity and mortality due to HIV infection

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25
Q

individuals at high risk of HIV should be rescreened ___________

A

annually

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26
Q

pregnant individuals should be offered HIV testing at ____________ (initial testing when?)

A

first prenatal visit

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27
Q

pregnant individuals who test negative but continue to be at risk of getting HIV could benefit from

A

regular retesting and testing at point of delivery

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28
Q

what should we do if a pregnant patient arrives at delivery without a history of a prenatal HIV test?

A

offer rapid HIV testing

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29
Q

what is gold standard for HIV testing

A

public health lab venous blood sample- 2 step process
1. Antibody/ antigen screening (4th gen test)
2. confirmatory testing of reactive results

results not reported until step 2 is completed for + test results = true positives

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30
Q

how long does it take for lab HIV testing results to return

A

~ 1 week

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31
Q

what is the only HC approved POCT

A

INSTI HIV1/HIV 2 antibody test

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32
Q

the INSTI test results uses ________ sample and results are available in _____. it is considered eq to a _____ gen standard test

A

fingerstick blood sample
1 minute
3rd gen

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33
Q

the INSTI test is considered an HIV _________ and a reactive test result requires _____________

A

screening test
standard test to confirm HIV diagnosis

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34
Q

T or F: false negatives are common with INSTI test and hence a standard test must always be used for confirmation

A

F- false - rare and only a reactive test result requires standard test confirmation

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35
Q

a negative HIV result can be considered a true negative unless the person is in the

A

window period of infectivity

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36
Q

The period from infection to the primary seroconversion illness is usually

A

1-4 weeks

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37
Q

the HIV self test is considered a __________ and requires _________

A

screening test
standard test to confirm diagnosis if + result

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38
Q

what are 2 challenges with HIV self testing

A

delivery of pre and post test counselling + linkages to care
support or counselling

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39
Q

___________ is the first province to announce free HIV self test kits

A

saskatchewan

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40
Q

dried blood spot testing can detect ____________ to HIV and _______

A

antibodies to HV
HIV RNA

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41
Q

what lab tests are used to monitor HIV infection?

A

viral load
CD4+ count

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42
Q

viral load monitors

A

amount of virus in blood (HIV RNA) in copies/ mL

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43
Q

viral load monitoring is indicated for

A

diagnosing acute HIV infections
surrogate marker for tx response
assess risk of HIV transmission

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44
Q

the goal of HIV RNA is to be

A

below the limit of detection at <20-50copies/ mL

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45
Q

viral load is measured at ___, ______ after starting tx, and repeat in _____. very stable patients with suppressed viral load may repeat in _____

A

baseline
1-2mths after starting tx
repeat in 3-4mths
q6mths if stable

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46
Q

CD4+ T cell count is a major indicator of _______ and a strong predictor of _______ and _______

A

immunocompetence
disease progression and survival

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47
Q

CD4+ T cell count is ordered at _______ and _______ initially. In stable patients with suppressed viral loads, ___CD4 monitoring (or less) is reasonable

A

baseline
q3-6mths initially
yearly

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48
Q

what are the 5 classes of antiretrovirals

A

NRTIs
NNRTIs
PIs
entry inhibitors (fusion inhibitors, attachment inhibitors, CCR5 antagonists)
INSTIs

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49
Q

abacavir, emtricitabine, lamivudine, and tenofovir are

A

NRTIs

50
Q

rilpivaririne and doravirine are

A

NNRTIs

51
Q

-avir are

A

protease inhibitors

52
Q

-gravir are

A

integrase inhibitors

53
Q

maraviroc is a

A

CCR5 antagonist

54
Q

Biktarvy is a combo of

A

BIC + TAF + FTC

55
Q

_________ and ________ are the first long acting antiretrovirals

A

cabotegravir and rilpivirine

56
Q

an oral lead in of ___ days is recommended for cabogravir

A

28 days

57
Q

rilpivirine is to be
1. taken without food
2. taken with food
3. doesn’t matter as long as it is consistent

A

2

58
Q

what are the first 2 long acting antiretrovirals

A

cabotegravir and rilpivirine

59
Q

how are cabogravir and rilpivirine used

A

oral lead in of 28 days
intragluteal injections of 3mL C and R on both sides for each injection 0, 1 mth then q2mths
may also do monthly injections of 2mL dose

60
Q

if cabotegravir/ rilpivirine injections are missed by 1 week or more, ________ is needed

A

oral bridging

61
Q

ART is recommended for _______ to reduce risk of disease progression and _________

A

all patients
prevention of transmission

62
Q

ART is recommended to be started
1. after the window period
2. ASAP after dx
3. immediately after exposure while waiting for labs
4. after HIV RNA >20 copies/ mL

A

2

63
Q

the recommended initial HIV regimen for most people is

A

integrase inhibitor based + 1 or 2 NRTIs

64
Q

pts who are HLA-B5701 -ve without chronic HBV should be on _______________ for hIV tx

A

dolutegravir + abacavir + lamivudine

65
Q

what are 3 populations that shouldn’t be on dolutegravir + lamivudine

A

VL >500k, HBV coinfection, genotypic resistance testing not available

66
Q

list 3 factors to consider when choosing initial HIV regimen

A

Baseline HIV RNA (viral load?), ARV resistance (if any)
Food requirements
Coinfection with HepB
Pretxt CKD, osteoporosis, cardiac diseases, etc
Note- pts with HIV from long time ago may have more resistance due to lack of good multifaceted tx (only monotx used)
Pregnancy (or individuals of child bearing potential)
AEs and drug drug intx

67
Q

genotypic antiretroviral drug resistance testing (GART) is used at _________ and after _________ to look for _____________

A

baseline and virologic failure
resistance mutations associated with antiretroviral resistance

68
Q

4 AEs of tenofovir disproxil fumerate

A

renal impairment
decreased BMD
HA, GI intolerance

69
Q

how should renal impairment be monitored fir TDF

A

SCr and urinalysis at baseline, then SCr q3-6mths, baseline ACR and PCR ratio

70
Q

tenofovir alafenamide (TAF) has a ________ risk of renal impairment and effects on BMD due to lower systemic exposure to tenofovir compared to TDF

A

lower

71
Q

which has higher weight gain? TAF or TDF

A

TAF

72
Q

which of the following should not be taken with food
1. TDF
2. TAF
3. ABC
4. EFV

A

4

73
Q

abacavir AEs

A

hypersensitivity reaction

74
Q

when is the median onset of ABC hypersens rxn

A

9-11 days

75
Q

ABC hypersens rxn is associated with

A

HLA-B*5701 = only start in HLA-B5701 negative pts

76
Q

efavirenz AEs

A

neuropsychiatric common (vivid dreams, insomnia, dizzy, depression)
rash

77
Q

which of the following MUST be taken with food
1. EFV
2. DOR
3. RPV
4. TAF

A

3- ~400kcal

78
Q

rilpivirine AEs

A

depression, rash

79
Q

all PIs must be taken (with/ without) food

A

with

80
Q

PI AEs

A

GI SEs (D/N)
hyperlipidemia (less with atazanavir/ darunavir)
insulin resistance and diabetes (less with atazanavir/ darunavir)
lipodystrophy (less with atazanavir/ darunavir)
elevated LFTs

81
Q

INSTI SEs

A

generally well tolerated (some HA, N/V/D, insomnia)
may lead to greater weight gain (more with DTG and BIG)
DTG and BIC modestly increase SCr

82
Q

why do DTG and BIC increase SCr

A

inhibit active tubular secretion of creatinine through OCT2

83
Q

which class is associated with greater weight gain
1. NRTIs
2. NNRTIs
3. PIs
4. INSTIs

A

4

84
Q

which 2 INSTIs increase SCr

A

DTG and BIG

85
Q

most clinically relevant drug interactions involving ARVs occur due to alterations in ________ or ___________

A

CYP450 (esp 3A4) and drug transporters (P-gp)

86
Q

_____ related physiological changes, CYP, and drug transporters can affect drug interactions, PK, and PD properties of meds

A

age

87
Q

rate the 5 classes from highest to lowest potential for interactions: INSTIs, NRTIs, NNRTIs, PIs, CCR5s

A

PIs and cobicicstat
NNRTIs
CCR5 antagonists
INSTIs
NNRTIs

88
Q

INSTIs _____ when administered with antacids or cations, hence should be separated by ____ or ________

A

chelate
2hrs or take with food

89
Q

protease inhibitors and cobicistat interact with (3)

A

antidepressants, oral hypoglycemics, warfarin

90
Q

what are ritonavir boosted PI regimens

A

using low dose ritonavir in combo with another PI

91
Q

what are 2 antiretrovirals ritonavir is generally combined with

A

atazanavir
darunavir

92
Q

what is virologic failure

A

inability to achieve and maintain viral replication (to <200 copies/ mL)

93
Q

low amounts of viremia appears to occur more frequently with

A

newer, more sensitive real time PCR assays

94
Q

3 general causes of virologic failure

A

patient/ adherence related
HIV related
antiretroviral regmen related

95
Q

what level of adherence is needed to achieve virologic suppression?

A

80% with newer agents
90-95% with older drugs due to poor PK qualities

96
Q

HIV care is moving beyond helping individuals living with HIV to

A

maintain an undetectable viral load- focusing on reducing the epidemic and LT management

97
Q

what are some potential contributors to higher rates of comorbidities in people living with HIV

A

Certain RF assoc w/ ↑ risk of comorb more common in HIV + pts, irrev damage done by HIV viremia, chronic inflam, coinfections, AEs of meds (esp older antiretrovirals)

98
Q

comorbidities of aging associated with HIV meds

A

more sus to developing CVD, bone fractures, DM, renal failure, higher rates of cancer, neuro impairment, liver disease

99
Q

which of the following facts about PreP is false
1. does not prevent STIs other than HIV
2. is TDF + FTC
3. is not recommended if CrCL <60mL/min
4. takes 20 days to establish protective levels in the vagina
5. is only effective 100% adherent

A

5

100
Q

PreP is ___ + ____

A

TDF + FTC

101
Q

PreP is not recommended if

A

CrCL <60 or unknown/ + HIV status

102
Q

how long does it take for PreP to reach protective levels in the rectum and vagina?

A

rectum = 7 days
vag - 20 days

103
Q

what is the HIV care continuum look like for an HIV + person

A

treatment as prevention

104
Q

MSM, trans women, and gender diverse people who have condomless anal sex within the last 6mths + any of (4) are el8igible for PreP

A

infectious syphilis or bacterial STI in past 12mths
nPEP more than once
ongoing sexual relationship with HIV+ partner with substantial risk of transmissible HIV
HIRI-MSM risk score =>11

105
Q

heterosexual persons are eligible for PreP if

A

they are HIV - and have a partner who is HIV + and engage in condomless vaginal/ anal sex where HIV + partner has substantial risk of transmissible HIV (ex- VL >40 copies/ mL) or HIV status unknown but from a higher risk pop (ex- MSM, PWID)

106
Q

people who inject drugs may be eligible for PreP if

A

they share injection drug use paraphernalia

107
Q

how does PreP work?

A

prevents HIV from establishing infection

108
Q

4 additional general criteria for assessing eligibility for PreP

A

individual is HIV negative + at high risk of acquiring HIV infection
no s/sx of acute HIV in last month
no documented CI to FTC/TDF
other lab tests like HBV, HCV, STI, CBC, SCr, urinalysis

109
Q

what other lab tests may be done at baseline before starting PreP

A

CBC, SCr, urinalysis

110
Q

PreP must be prescribed by a ________________ and initial prescription can only be _________. refills for no more than _____ to encourage followup q_mths

A

designated prescribed
30 days
90 days
q3mths

111
Q

once you are stabilized on PreP, you need to get bloodwork q____mths

A

3

112
Q

what is PEP?

A

combo antiretroviral therapy (cART) given to someone who may have been exposed to HIV
2 or 3 drug regimen to prevent getting HIV infection

113
Q

cART should be given _____ within ___hrs

A

ASAP
72hrs

114
Q

where should you refer someone who may have been exposed to HIV in the last 72hrs

A

ER

115
Q

should you still take PEP if >3 days since exposure

A

unlikely to have much benefit

116
Q

what is preferred regimen for PEP

A

truvada

117
Q

Perinatal transmission
Overall risk of ____% in absence of intervention, ____% occurs just before/ during delivery
_______ highest risk for in utero transmission

A

25%
80%
primary HIV

118
Q

there is ~0% risk of transmission if VL <_____ at conception + through pregnancy

A

<50 copies/ mL

119
Q

before delivery, _____ should be used during pregnancy to suppress viral load

A

ARVs

120
Q

what ARV regimens are rec in pregnancy

A

Preferred dual NRTI backbone: abacavir/ lamivudine OR tenofovir DF + emtricitabine or lamivudine OR tenofovir alafenamide/ emtricitabine
3rd drug: INSTI- dolutegravir or PI- darunavir/ ritonavir

121
Q

what should be done for HIV + mom in L&D

A

IV zidovudine + oral ARVs for mother
C section if VL >1000 copies/ mL close to delivery

122
Q

after the baby is delivered to an HIV + mom, they should
1. do breastfeeding as benefit > risk of 0.5% risk of getting HIV
2. do formula feeding only to decrease risk
3. start oral zivudine for 4-6wks within 6 hours
4. 2+3

A

4

446- ID and transplant (18 decks)

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