HIV Flashcards
HIV - ___ is a major cause of AIDs, HIV- -_ is also recognized to cause AIDs but is much less prevalent
1, 2
what is the HIV/AIDs target for 2020
90-90-90
90 dx, 90 dx and tx, 90 suppressed
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
4
3 way of HIV transmission
sexual, parenteral, perinatal
the risk of transmitting HIV increases with higher
higher HIV viral load
____ can increase the risk of HIV transmission
STIs
U = U means
undetectable = untransmissible
the highest risk of HIV transmission is
anal receptive intercourse and needle sharing
HIV + and =>40 copies/mL =
high risk
HIV + and <40copies/mL but may have STIs =
low but nonzero risk
HIV + and <40 copies/ mL but no known STIs and of the general population =
negligible or no risk
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
anal receptive, needle sharing, anal incentive, vaginal receptive, oral sex (giving), sharing sex toys, blood
risk of perinatal transmission of HIV is ____ in absence of tx
~25%
risk of HIV transmission perinatally increases with
higher HIV viral load, duration of ruptured membranes, mode of delivery, breastfeeding
list 3 strategies for preventing HIV transmission
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)
what is acute retroviral syndrome
the first stage of infection with the human immunodeficiency virus (HIV)
most common sx of acute retroviral syndrome
sim to flu- fever, maculopapular rash, lymphadenopathy, myalgia or arthralgia, pharyngitis, oral ulcers, weight loss
5 definitions of AIDs
CD4 <200 cells/uL (not a part of case definition in Canada)
opportunistic infections
HIV associated encephalopathy
HIV associate wasting
HIV related neoplasms
HIV initially replicates in
MPs, CD4+ lymphocytes, possibly dendritic cells in tissue and blood
infected cells bring HIV particles to
lymphoid tissue
HIV infects ____, then, dendritic and other APCs promote ______________
activated T cells
additional rounds of HIV infection and replication
HIV infection firmly establishes in ____ where replication continues at a high rate
lymphoid organs
HIV testing should be offered when
screening for other STBBIs
early dx and tx with cART =
decreased transmission
reduced morbidity and mortality due to HIV infection
individuals at high risk of HIV should be rescreened ___________
annually
pregnant individuals should be offered HIV testing at ____________ (initial testing when?)
first prenatal visit
pregnant individuals who test negative but continue to be at risk of getting HIV could benefit from
regular retesting and testing at point of delivery
what should we do if a pregnant patient arrives at delivery without a history of a prenatal HIV test?
offer rapid HIV testing
what is gold standard for HIV testing
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
how long does it take for lab HIV testing results to return
~ 1 week
what is the only HC approved POCT
INSTI HIV1/HIV 2 antibody test
the INSTI test results uses ________ sample and results are available in _____. it is considered eq to a _____ gen standard test
fingerstick blood sample
1 minute
3rd gen
the INSTI test is considered an HIV _________ and a reactive test result requires _____________
screening test
standard test to confirm HIV diagnosis
T or F: false negatives are common with INSTI test and hence a standard test must always be used for confirmation
F- false - rare and only a reactive test result requires standard test confirmation
a negative HIV result can be considered a true negative unless the person is in the
window period of infectivity
The period from infection to the primary seroconversion illness is usually
1-4 weeks
the HIV self test is considered a __________ and requires _________
screening test
standard test to confirm diagnosis if + result
what are 2 challenges with HIV self testing
delivery of pre and post test counselling + linkages to care
support or counselling
___________ is the first province to announce free HIV self test kits
saskatchewan
dried blood spot testing can detect ____________ to HIV and _______
antibodies to HV
HIV RNA
what lab tests are used to monitor HIV infection?
viral load
CD4+ count
viral load monitors
amount of virus in blood (HIV RNA) in copies/ mL
viral load monitoring is indicated for
diagnosing acute HIV infections
surrogate marker for tx response
assess risk of HIV transmission
the goal of HIV RNA is to be
below the limit of detection at <20-50copies/ mL
viral load is measured at ___, ______ after starting tx, and repeat in _____. very stable patients with suppressed viral load may repeat in _____
baseline
1-2mths after starting tx
repeat in 3-4mths
q6mths if stable
CD4+ T cell count is a major indicator of _______ and a strong predictor of _______ and _______
immunocompetence
disease progression and survival
CD4+ T cell count is ordered at _______ and _______ initially. In stable patients with suppressed viral loads, ___CD4 monitoring (or less) is reasonable
baseline
q3-6mths initially
yearly
what are the 5 classes of antiretrovirals
NRTIs
NNRTIs
PIs
entry inhibitors (fusion inhibitors, attachment inhibitors, CCR5 antagonists)
INSTIs
abacavir, emtricitabine, lamivudine, and tenofovir are
NRTIs
rilpivaririne and doravirine are
NNRTIs
-avir are
protease inhibitors
-gravir are
integrase inhibitors
maraviroc is a
CCR5 antagonist
Biktarvy is a combo of
BIC + TAF + FTC
_________ and ________ are the first long acting antiretrovirals
cabotegravir and rilpivirine
an oral lead in of ___ days is recommended for cabogravir
28 days
rilpivirine is to be
1. taken without food
2. taken with food
3. doesn’t matter as long as it is consistent
2
what are the first 2 long acting antiretrovirals
cabotegravir and rilpivirine
how are cabogravir and rilpivirine used
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
if cabotegravir/ rilpivirine injections are missed by 1 week or more, ________ is needed
oral bridging
ART is recommended for _______ to reduce risk of disease progression and _________
all patients
prevention of transmission
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
2
the recommended initial HIV regimen for most people is
integrase inhibitor based + 1 or 2 NRTIs
pts who are HLA-B5701 -ve without chronic HBV should be on _______________ for hIV tx
dolutegravir + abacavir + lamivudine
what are 3 populations that shouldn’t be on dolutegravir + lamivudine
VL >500k, HBV coinfection, genotypic resistance testing not available
list 3 factors to consider when choosing initial HIV regimen
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
genotypic antiretroviral drug resistance testing (GART) is used at _________ and after _________ to look for _____________
baseline and virologic failure
resistance mutations associated with antiretroviral resistance
4 AEs of tenofovir disproxil fumerate
renal impairment
decreased BMD
HA, GI intolerance
how should renal impairment be monitored fir TDF
SCr and urinalysis at baseline, then SCr q3-6mths, baseline ACR and PCR ratio
tenofovir alafenamide (TAF) has a ________ risk of renal impairment and effects on BMD due to lower systemic exposure to tenofovir compared to TDF
lower
which has higher weight gain? TAF or TDF
TAF
which of the following should not be taken with food
1. TDF
2. TAF
3. ABC
4. EFV
4
abacavir AEs
hypersensitivity reaction
when is the median onset of ABC hypersens rxn
9-11 days
ABC hypersens rxn is associated with
HLA-B*5701 = only start in HLA-B5701 negative pts
efavirenz AEs
neuropsychiatric common (vivid dreams, insomnia, dizzy, depression)
rash
which of the following MUST be taken with food
1. EFV
2. DOR
3. RPV
4. TAF
3- ~400kcal
rilpivirine AEs
depression, rash
all PIs must be taken (with/ without) food
with
PI AEs
GI SEs (D/N)
hyperlipidemia (less with atazanavir/ darunavir)
insulin resistance and diabetes (less with atazanavir/ darunavir)
lipodystrophy (less with atazanavir/ darunavir)
elevated LFTs
INSTI SEs
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
why do DTG and BIC increase SCr
inhibit active tubular secretion of creatinine through OCT2
which class is associated with greater weight gain
1. NRTIs
2. NNRTIs
3. PIs
4. INSTIs
4
which 2 INSTIs increase SCr
DTG and BIG
most clinically relevant drug interactions involving ARVs occur due to alterations in ________ or ___________
CYP450 (esp 3A4) and drug transporters (P-gp)
_____ related physiological changes, CYP, and drug transporters can affect drug interactions, PK, and PD properties of meds
age
rate the 5 classes from highest to lowest potential for interactions: INSTIs, NRTIs, NNRTIs, PIs, CCR5s
PIs and cobicicstat
NNRTIs
CCR5 antagonists
INSTIs
NNRTIs
INSTIs _____ when administered with antacids or cations, hence should be separated by ____ or ________
chelate
2hrs or take with food
protease inhibitors and cobicistat interact with (3)
antidepressants, oral hypoglycemics, warfarin
what are ritonavir boosted PI regimens
using low dose ritonavir in combo with another PI
what are 2 antiretrovirals ritonavir is generally combined with
atazanavir
darunavir
what is virologic failure
inability to achieve and maintain viral replication (to <200 copies/ mL)
low amounts of viremia appears to occur more frequently with
newer, more sensitive real time PCR assays
3 general causes of virologic failure
patient/ adherence related
HIV related
antiretroviral regmen related
what level of adherence is needed to achieve virologic suppression?
80% with newer agents
90-95% with older drugs due to poor PK qualities
HIV care is moving beyond helping individuals living with HIV to
maintain an undetectable viral load- focusing on reducing the epidemic and LT management
what are some potential contributors to higher rates of comorbidities in people living with HIV
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)
comorbidities of aging associated with HIV meds
more sus to developing CVD, bone fractures, DM, renal failure, higher rates of cancer, neuro impairment, liver disease
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
5
PreP is ___ + ____
TDF + FTC
PreP is not recommended if
CrCL <60 or unknown/ + HIV status
how long does it take for PreP to reach protective levels in the rectum and vagina?
rectum = 7 days
vag - 20 days
what is the HIV care continuum look like for an HIV + person
treatment as prevention
MSM, trans women, and gender diverse people who have condomless anal sex within the last 6mths + any of (4) are el8igible for PreP
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
heterosexual persons are eligible for PreP if
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)
people who inject drugs may be eligible for PreP if
they share injection drug use paraphernalia
how does PreP work?
prevents HIV from establishing infection
4 additional general criteria for assessing eligibility for PreP
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
what other lab tests may be done at baseline before starting PreP
CBC, SCr, urinalysis
PreP must be prescribed by a ________________ and initial prescription can only be _________. refills for no more than _____ to encourage followup q_mths
designated prescribed
30 days
90 days
q3mths
once you are stabilized on PreP, you need to get bloodwork q____mths
3
what is PEP?
combo antiretroviral therapy (cART) given to someone who may have been exposed to HIV
2 or 3 drug regimen to prevent getting HIV infection
cART should be given _____ within ___hrs
ASAP
72hrs
where should you refer someone who may have been exposed to HIV in the last 72hrs
ER
should you still take PEP if >3 days since exposure
unlikely to have much benefit
what is preferred regimen for PEP
truvada
Perinatal transmission
Overall risk of ____% in absence of intervention, ____% occurs just before/ during delivery
_______ highest risk for in utero transmission
25%
80%
primary HIV
there is ~0% risk of transmission if VL <_____ at conception + through pregnancy
<50 copies/ mL
before delivery, _____ should be used during pregnancy to suppress viral load
ARVs
what ARV regimens are rec in pregnancy
Preferred dual NRTI backbone: abacavir/ lamivudine OR tenofovir DF + emtricitabine or lamivudine OR tenofovir alafenamide/ emtricitabine
3rd drug: INSTI- dolutegravir or PI- darunavir/ ritonavir
what should be done for HIV + mom in L&D
IV zidovudine + oral ARVs for mother
C section if VL >1000 copies/ mL close to delivery
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
4
