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MBBS 4: Family Medicine > HIV > Flashcards

HIV Flashcards

1
Q

First line ART regimens and their contraindications?

A
  1. AZT/3TC+EFV
    - ANAEMIA, hx psychosis
  2. TDF/3TC/EFV
    - uncontrolled BP, diabetes, renal failure
  3. ABC/3TC+LPV/r
    - hypersensitivity)
  4. TDF/3TC/DGT (standard ≥ 30kgs adults)
    - uncontrolled BP, diabetes, renal failure, epilepsy, hepatitis B &C
  5. AZT/3TC+ DTG
    - anemia, epilepsy, hepatitis
  6. ABC/3TC+ DTG
    - hypersensitivity, epilepsy, hepatitis
  7. ABC/3TC+ RAL
    - hepatitis, hypersensitivity
  8. ABC/3TC+ EFV
    - Hypersensitivity, history of psychosis
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2
Q

Second line ART regimens and their contraindiations?

A
  1. TDF/3TC+ATV/r
    - uncontrolled BP, diabetes, renal failure, patient on RIF, preexisting jaundice/suspected hepatitis
  2. AZT/3TC+ATZ/r
    - anemia, patient on RIF, preexisting jaundice/suspected hepatitis
  3. TDF/3TC+LPV/r
    - uncontrolled BP, diabetes, renal failure
  4. AZT/3TC+LPV/r
    - anemia
  5. TDF/3TC/DGT (standard ≥ 30kgs adults)
    - uncontrolled BP, diabetes, renal failure, epilepsy, hepatitis B &C
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3
Q

Third line regimens and their contraindications?

A

DRV+r+DTG
- epilepsy

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4
Q

Side effects of EFV?

A
  1. Mild skin rush, nightmares, psychosis
  2. Breast enlargement in children and men
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5
Q

Side effects of ATZ/r and what you can substitute with it instead?

A
  • can cause jaundice
  • No combination RIF+ ATV/r
  • Pre-existing jaundice/suspected hepatitis: no ATV/r instead LPV/r
  • jaundice=cosmetic concern
  • Do LFT, if only indirect raised stop drug, if no LFT available stop ATV/r
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6
Q

Side effects of ABC?

A

Fever, body pains, vomiting, cough/breathing problems and sore throat ; life-threatening SE of ABC
- Stop and never restart ABC

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7
Q

DTG and antiepileptic drugs and what to do in case you have to use both together?

A
  • Never combine DTG with standard antiepileptic’s drugs
    e.g. carbamazepine, phenobarbital, phenytoin
  • Consider regimen without DTG
  • Give antiepileptic’s with double dose of DTG
  • Check VL 6-monthly to confirm suppression
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8
Q

Benefits of DTG in pregnant women?

A
  1. Faster and durable in VL suppression
  2. Lower risk of maternal OIs and death
  3. Risk of HIV transmission to sex partners and to child
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9
Q

Side effects of DTG in pregnant women?

A

Potential risk of tube neural defect is now considered very low

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10
Q

Side effects of DTG?

A

DTG and RAL are well tolerated
1. Mild headache
2. insomnia
3. nausea
4. diarrhea usually subsides
5. DTG and RAL worsen liver damage, but rarely cause hepatotoxicity
- Check transaminases before and after initiation of DGT in patients with known hepatitis B/C
6. DTG is associated by with a risk of obesity in some patients

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11
Q

Who uses 13A and what can you use instead?

A

13A cannot be used in < 20 kg children due the high dose of TDF:
1. 15P : 20-24.9 Kg
2. 15A: 25-29.9 Kg
- Monitor weight and routinely move to 13 a once they reached 30 Kgs
- Confirm VL suppression in the last 6 months before making this transition

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12
Q

Combining ARVs and TB treatment?

A
  1. DTG and RAL regiments (13,14,15 and 16) are good combination with TB 1st line treatment, but:
    - Daily dose of DTG and RAL needs to be doubled while on RIF
    - Take double the regular RAL-dose regimen in the morning and in the evening
    - Doubling of DTG and RAL also applies to children
  2. Continue double dose 7 days after last dose of RIF
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13
Q

Describe urine LAM/serum CrAg screening?

A
  1. Serum CrAg +: LP, treat for active meningitis if CSF testing ( CrAg, Indian ink, Gxpart) result is positive
  2. LP negative: pre-emptive antifungal therapy
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14
Q

Management of urine LAM/serum CrAg positive?

A
  1. Admit patient
  2. Option 1: Induction phase: liposomal amphotericin-B + Fluocytosine for 7/7
  3. Option 2: Fluconazole +fluocytosin for 14 days
  4. Option 3: liposomal amphotericin-B + fluconazole for 14 days
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15
Q

Option 1 in the Induction phase in treatment for positive urine LAM/ serum CrAg?

A
  1. Adult: liposomal amphotericin : 3-4mg/kg IV over 6hours, 24 hourly ( but 6m/kg in case of treatment failure or serious disease)
    child: 6mg/Kg IV over 6hrs, 24 hourly
  2. Flucytosine tabs: 100mg/kg/day divided into 4 , 6 hourly
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16
Q

Option 2 in the Induction phase in treatment for positive urine LAM/ serum CrAg?

A
  1. This option requires FBC monitoring: at baseline, and 2-3 times in the second week of treatment
  2. Adults: fluconazole tabs: 1200mg 24-hourly, child: 12mg/kg (max 800mg) 24-hourly
  3. Flucytosin tabs: 100mg/kg/day divided into 4 doses (6-hourly)
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17
Q

Option 3 in the Induction phase in treatment for positive urine LAM/ serum CrAg?

A

requires FBC, creatinine, and K+ monitoring; baseline, 2-3 times second week of Rx
1. Liposomal amphotericin B: 3-4 mg/kg iv over 6 hours 24-hourly or 6 mg/kg for Rx failure or serious diseases
2. Fluconazole tabs: adults: 1200 mg 24-hourly; child: 12 mg/kg (max 800 mg) 24-hourly.

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18
Q

Consolidation and maintenance phases in treatment for positive urine LAM/ serum CrAg?

A
  1. Fluconazole tab for 8 weeks:
    - Adults: 800 mg 24 hourly
    - Children: 12 mg/kg (800 mg) 24-hourly
  2. Maintenance phase for life
    - Adults: 200 mg 24-hourly
    - 6 mg/kg 24-hourly
19
Q

Key things to remember when treating cryptococcal?

A
  1. Early diagnosis and management= life-saving
  2. Liposomal amphotericin B has lower toxicity than the regular amphotericin B; there can be given at higher dosage
  3. Before giving liposomal amphotericin B: pre-hydrate, supplement electrolytes
20
Q

Indications for TB preventive therapy?

A
  1. Hiv infected children and adults regardless of TST status
  2. Children under 5 living with patients on TB Rx (sputum positive/negative/LAM positive): 6 months IPT
21
Q

Do you need to take TBT again if you have taken it before?

A

Those who completed 6-Months of IPT in the past do not need another course of TPT

22
Q

When not to take TPT?

A

No TPT if any sign of TB
- full investigation of TB and start full TB drugs if positive

23
Q

Who needs to take TBT?

A
  1. New patients: ARV+TPT+CPT
  2. Already on ART: start TPT regardless the time of ART
  3. Give TPT regardless of previous TB treatment
24
Q

Side effects of TBT?

A
  • Most side-effects minor and disappear within 3 months
  • Major rare SE: hypersensitivity, neuropathy, and severe hepatitis
  • well tolerated by most patients
25
Q

Describe 2 alternative TPT options?

A
  1. 6H
  2. 3HP
26
Q

6H alternative TB preventative therapy?

A
  • 6-MONTHS COURSE of daily dose of isoniazid
  • Immediately available
  • suitable for children
  • not suitable for pregnant women
  • can be combined with all ART regimens
27
Q

3HP alternative TB treatment?

A
  • 3-MONTH COURSE of weekly doses of isoniazid-rifapentine
  • easy to complete due to short duration, not suitable for children under 20 and pregnant women
  • cannot be combined with PI-containing regimens
  • Women on hormonal contraception need to use condoms while on 3HP. - Rifampicin reduces contraceptive effectiveness.
28
Q

Indications to stop TPT?

A
  1. Nausea, vomiting and loss of appetite
  2. Pellagra-type skin rash: in sun-exposed areas or any other skin
  3. Yellows eyes
  4. Dizziness, confusion, convulsion
  5. Severe numbness, burning pains, muscular weakness of legs and/or arms
29
Q

Contraindications for IPT and 3HP?

A
  1. Suspected or confirmed active TB
  2. Prior adverse event or hypersensitivity to INH
  3. Active hepatitis, liver damage, heavy alcohol use
  4. Severe peripheral neuropathy
  5. Pregnant women or women planning to become pregnant during treatment
30
Q

Contraindications for 3HP?

A
  1. PRIOR adverse events or hypersensitivity to 3HP
  2. Children under 20 kg: almost all will now be on LPV/r based regiments, which cannot combined with 3 HP
  3. Unable to swallow a tablet without CRUSHING/CHEWING
  4. PI-based ART regimens
31
Q

Timing for viral load?

A
  1. Next VL collected 11 months or more after the first
  2. Don’t delay a scheduled, targeted or routine VL because of poor adherence
  3. Ascertain good adherence in the last 3 months before taking the follow-up sample after high VL:
  4. Delay collection of follow-up sample after after IAC only if poor adherence is confirmed and if the patient is still clinically stable
32
Q

How to Ascertain good adherence in the last 3 months before taking the follow-up sample after high VL?

A
  1. Review pill count and doses missed carefully and discuss openely TO know true circumstances
  2. Trust the patients if they insist that adherence is good
  3. Do not rely on pill count alone
33
Q

Describe how to do viral load monitoring?

A
  1. The VL monitoring aims to detect ART failure while avoiding unnecessary tests ( cost-effectiveness)
  2. Collect the first scheduled VL after 6 months on Rx
    - Normally, we expect undetectable VL
    - If VL detectable, investigate
  3. After that, patients who are adherent and clinically well have a low risk of ART failure
    - Therefore, routine VL monitoring is scheduled approximately every 12 months from the last test
34
Q

What does it mean if viral load is detectable after 6 months on treatment?

A
  1. Patient was infected with drug-resistant HIV
  2. Patient developed drug resistance from previous ARV use (infants who received nevirapine prophylaxis)
  3. High VL can also be sign of poor adherence
35
Q

Describe what to do at a viral load testing appointment?

A
  1. Collect missed VL tests at the next routine visit
  2. Do additional targeted VL when suspecting drug resistance
  3. Explain the standard monitoring schedule to every patient. Ask patient to help remember when VL is due.
  4. Actively communicate any detectable VL results (above detection limit, even if < 1000) to patient as soon as the resut is received at the site
    - Call for early appointment
36
Q

What samples can you do viral load testing?

A
  1. dried blood sampling
  2. plasma
37
Q

Difference between dried blood sample and plasma in VL testing?

A

DBS (DRIED BLOOD SAMPLE) and VL produced different results in the low range below 839 copies/ml:
1. DBS results are not quantifiable below 839 copies/mls
2. Plasma results are usually quantified above 40 copies/ml
3. Both DBS and plasma results of <LDL mean that no virus has ben detected, i,.e. the VL is undetectable or fully suppressed.
4. Plasma is the gold-standard for VL testing. If possible, collect plasma samples.

38
Q

Suppressed VL in DBS?

A

<LDL

39
Q

VL Low level viraemia in DBS?

A

<400
<550
<839
Any value 400-999

40
Q

VL High level viraemia in DBS?

A

1000+

41
Q

Suppressed VL in plasma?

A

<LDL
<20
<40
<150
Any between 20-199

42
Q

Low level viraemia VL in plasma?

A

Any value 200-999

43
Q

High level viraemia VL in plasma?

A

1000+

MBBS 4: Family Medicine (27 decks)

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