HIV

Question 1

7 stages of HIV replication

Answer 1

1) Binding/attachment
2) Fusion
3) Reverse transcription
4) Integration
5) Replication
6) Assembly
7) Budding and maturation

Question 2

Preferred 1st line HIV therapy

Answer 2

Biktarvy
Triumeq
Dovato

Question 3

Examples of nucleoside/tide reverse transcriptase inhibitors (NRTIs)

Answer 3

Abacavir
Emtricitabine
Lamivudine
TDF
TAF
Zidovudine

(Z-LATTE)

Question 4

Key points for NRTIs
5 points

Answer 4

Target reverse transcription phase
Zidovudine = twice daily (all others once daily)
All except abacavir require renal dosing
IV zidovudine is given during labor and delivery in HIV moms to protect baby
Box warning for lactic acidiosis and hepatomegaly

Question 5

Main SE for TAF and TDF

Answer 5

Worse with TDF: renal injury, decreased BMD
Worse with TAF: lipid abnormalities

Question 6

Key points for abacavir
3 points

Answer 6

Requires screening for HLA-B*5701
Pts must carry a medical card including emergency symptoms of HSR
Can increase risk of MI

Question 7

Which NRTIs can also be used in hepB (and can cause hepB exacerbation when stopped)?

Answer 7

Emtricitabine
Lamivudine
TAF/TDF

Question 8

Examples of integrase strand transfer inhibitors (INSTIs)?

Answer 8

Bictegravir
Cabotegravir
Dolutegravir
Elvitegravir
Raltegravir

(-tegravir)

Question 9

Key points for INSTIs
7 points

Answer 9

Target integration stage
Stribild should not be started if CrCl <70, stopped if <50
Biktarvy/Genvoya should not be started if CrCl <30
Must be separated from cations (2h bef, 6h aft)
Raltegravir - can cause rhabdo
Dolutegravir - HSR, hepatotoxicity, rhabdo
B&D - falsely increase SCr

Question 10

Examples of non-nucleoside reverse transcriptase inhibitors (NNRTIs)

Answer 10

Efavirenz
Rilpivirine

(-vir-)

Question 11

Key points for NNRTIs
4 points

Answer 11

Target reverse transcriptase stage
Take efavirenz on empty stomach at bedtime (decrease CNS SE)
Take rilpivirine with meal and water; do not use with PPIs, separate from H2RAs and antacids
CYP3A4 substrates

Question 12

Examples of protease inhibitors

Answer 12

Atazanavir
Darunavir
(-navir)

Question 13

What should protease inhibitors be taken with?

Answer 13

Food and a booster (ritonavir or cobicistat)

Question 14

Key points for protease inhibitors

Answer 14

Targets budding/maturation stage
Take with food + booster
Strong CYP 3A4 inhibitors/substrates - many DDIs
Atazanavir needs an acidic gut - can only use PPIs if boosted and separated by 12 hours
Darunavir cross reacts with sulfa allergy
Usually only taken with 2 NRTIs

Question 15

SE for protease inhibitors

Answer 15

Hyperglycemia, insulin resistance, increased body fat
Dyslipidemia (increased CVD risk)
Hepatic dysfunction
HSR
Common: GI upset

Question 16

Key points for ritonavir/cobistat

Answer 16

Take with food
Not interchangable
Liquid ritonavir contains 43% alcohol - disulf rxns
Cobistat can be coformulated easily
Inhibit CYP3A4 and 2D6, P-gp, OAT

Question 17

What test must be performed before starting maraviroc?

Answer 17

Tropism assay (will only be effective if HIV strain can only bind to CCR5 co-receptor)

Question 18

What are agents of choice for PrEP?

Answer 18

Truvada (CrCl >60)
Descovy (CrCl >30)
IM cabotegravir

Question 19

Agents of choice for PEP?

Answer 19

Truvada + dolutegravir or raltegravir

Question 20

Duration for PEP

Answer 20

Start within 72 hours of exposure
Continue for 28 days