HIV

Question 1

What markers do we look at in HIV?

Answer 1

CD4 cells (T-lymphocyte) - normal range 500-1500, decline indicates HIV progression. Symptoms: <500 - oral candida, herpes zoster, anemia, weight loss; 200 - certain cancers, TB, pneumocystis; 50 - disseminated CMV and MAI.

Question 2

What are the treatment goals?

Answer 2

Achieve and maintain an undetectable viral load, increase CD4 count to normal range, ensure patient adherence to medication.

Question 3

Why is adherence important?

Answer 3

Adherence ensures medication effectiveness, prevents resistance, and reduces complications. Missing doses can lead to increased viral load, requiring more medications, and experiencing more adverse drug reactions and interactions.

Question 4

What are the barriers to adherence?

Answer 4

Acceptance, knowledge/understanding, adverse drug reactions, drug interactions, language barriers, medication factors (e.g., pill size, reminder of illness), disclosure concerns, and stigma.

Question 5

How can language barriers be overcome?

Answer 5

Language barriers can be overcome by using interpreters, although this may prolong consultation times. It’s crucial to ensure interpreters are knowledgeable about HIV and provide accurate translations. Patients may also be concerned about confidentiality when using interpreters from small communities.

Question 6

What are some examples of medication factors?

Answer 6

Medication factors include polypharmacy, pill size, and the reminder of being infected, which can be distressing for patients.

Question 7

What are some solutions to improve adherence?

Answer 7

Solutions include adherence clinics, blister packs with symbols or multilingual instructions, online forums, mentoring programs, clinic hosts, social gatherings, language services, psychological support, and informative websites like AIDSmap, adherence clinics.

Question 8

How do drug interactions impact HIV treatment?

Answer 8

Drug interactions, particularly with ritonavir and other antiviral drugs, are common and can affect the efficacy and safety of HIV medications. It’s essential to check for interactions with prescribed, over-the-counter, herbal, and recreational drugs.

Question 9

What is the significance of PrEP and PEP?

Answer 9

PrEP (pre-exposure prophylaxis) reduces the risk of HIV transmission for high-risk individuals, while PEP (post-exposure prophylaxis) provides treatment after potential exposure to HIV. Both are essential strategies for HIV prevention and control.

Question 10

What are some future developments in HIV treatment?

Answer 10

Future developments include newer drugs with fewer side effects, dual therapy, long-acting injections, and initiatives like the U=U campaign (Undetectable = Untransmittable) to reduce stigma and transmission.

Question 11

What is PeP?

Answer 11

• Available in al A&Es in the UK and most sexual health clinics
• Must be started within 72hrs
• 28 day course must be completed
• SARC/police may need to be involved in some cases  SA referral centres, we have more female staff and psychologist
• Also available via occupational health
• Dentist needle stick injury, nurse who took blood test from patient, other scenarios such as one night stands and etc.

Question 12

What is PrEP

Answer 12

A clinic in Boston in America so a 90% reduction in infections in people being prescribed PrEP
Greg Owen infected by HIV in 2015, he looked at how it could be prevented and he came across PrEP, he asked why he didn’t get it, he was driven by this and didn’t want other people infected he set up a website people in the UK who don’t have HIV can obtain PrEP from abroad and have it daily so they don’t get HIV
Risk of HIV due to lifestyle, if they are prescribed Prep this reduces significantly chances of HIV

Question 13

PrEP vs PePPost exposure

Answer 13

when someone is first infected the virus like to stay in the blood for 72 hrs before travelling to other parts of the body, getting the virus before it gets to the other parts of the body, however with pre exposure the drug is already in the system so when the virus comes in it gets killed

Question 14

What are common drugs that interact with HIV drugs?

Answer 14

Ritonavir, efavirenz, cobicistat are biggest culprits, also always check for prescribed, OTC, herbal and also recreational drugs (an increasing problem)

Question 15

How can a drug interaction benefit a patient?

Answer 15

saquinavir and ritonavir - Saquinavir with ritonavir boosts levels of saquinavir  this meant instead a daily dose 3600mg of saquinavir we can give 1600mg with 100mg of ritonavir OD
Pros and cons - can use interaction to benefit but need to know the impact it will have on non-HIV drugs

Question 16

Which non-HIV drug interactions with ritonavir? List 3.

Answer 16

• Simvastatin – leads to a marked increase in concentrations can increase the risk of serious reaction like myopathy and rhabdomyolysis
• Fluticasone (given with Seretide and component of some nasal sprays) – increase AUC by around 350 fold and Cmax by 25 fold. This can result in a significant decrease (86%) in plasma cortisol AUC. Systemic corticosteroids effect, including Cushing’s syndrome and adrenal suppression have been reported
• Sildenafil – levels sustainably increased with dose not to exceed 25mg in 48hrs
• Cocaine – level can be increased resulting in toxicity
• Omeprazole/lansoprazole – decreases atazanavir AUC by 75% makes it useless
• Garlic capsules – decreases saquinavir exposure by around 50%
• St Johns wort – significant decrease in HIV drug plasma concentrations are expected due to induction of VUP3A enzymes
• Ginkgo – may decrease levels of Efavirenz

Question 17

How is a HIV treatment regime put together?

Answer 17

We start with a NARTI backbone which made up of 2 drugs and then a third agent which can be a protease inhibitor, non nucleotide reverse transcriptase inhibitor or an integrase inhibitor, usually patient preference

Question 18

Give some examples of NARTI backbone

Answer 18

Tenofovir, emtricitabine, abacavir and lamivudine are NARTI backbone drugs.

Question 19

List 4 barriers to adherence

Answer 19

• Acceptance
• Knowledge/understanding
• ADRS
• Drug interactions
• Language barriers
• Medication factors
• Disclosure
• Stigma