HIV Flashcards
(176 cards)
1
Q
How is HIV transmitted?
A
- direct contact between infected body fluid (blood, semen, vaginal/rectal secretions, and breast milk)
- direct contact with mucous membranes or open wounds (IV drug use)
- mother-to-child/ vertical transmission through pregnancy, childbirth, or breastfeeding
2
Q
How often is HIV testing recommended for all patients 13-64 y/o?
A
once unless other RF
3
Q
What patients should have HIV screening annually?
A
- history of other STIs, hepatitis, or TB
- those engaging in high-risk activities (sex with multiple partners/unknown sexual history, MSM, anal/vaginal sex with someone who has HIV, sharing needles/syringes for IV drugs)
4
Q
What are the symptoms of acute HIV infection?
A
- non-specific flu-like symptoms few days to several weeks (fever, myalgia, headache, lymphadenopathy, pharyngitis, rash)
- asymptomatic
- no antibody response for weeks -months
5
Q
When is AIDs diagnosed?
A
CD4 count <200 cells/mm3
OR
Aids defining condition:
1. opportunistic infection
2. cancers (Kaposi’s sarcoma)
3. HIV wasting syndrome
6
Q
What medications can be utilized to treat HIV wasting syndrome?
A
- dronabinol (Marinol, Syndros)
- megestrol (a progestin)
7
Q
How is HIV diagnosed?
A
- initial screening for antibodies or antigens
- confirmatory test
- nucleic acid test detecting HIV RNA viral load (if confirmatory test is negative/ indeterminant)
8
Q
How long does it take for HIV antibodies to be detected?
A
4-12 weeks after infection; up to 6 months
9
Q
What OTC HIV test detects the presence of antibodies and provides immediate results?
A
OraQuick In-Home HIV Test
10
Q
What are counseling points for OraQuick In-Home HIV Test?
A
- swab upper and lower gums with the test stick then insert into a test tube containing liquid
- result can be read in 20 minutes
- 1 line (control) is a negative result; 2 lines is a positive result
- testing <3 months after exposure can lead to false negative due to a lag in antibody production
- positive result must follow up for a confirmatory test
11
Q
What type to virus is HIV?
A
RNA retrovirus that uses host cell processes to replicate
12
Q
What are the 8 stages of HIV replication?
A
- blinding and attachment
- fusion
- reverse transcriptase
- nuclear import
- integration
- transcription/translation
- assembly
- budding and maturation
13
Q
Why is it important that patients with HIV are adherent to ART (antiretroviral therapy)?
A
prevent resistance and prolong life
14
Q
What is tested as an indicator of immune function and will determine the need to prevent OIs?
A
CD4 count
15
Q
What is tested as an indicator of ART response?
A
HIV viral load
16
Q
What should happen to CD4 count and HIV viral load as a result of starting ART?
A
- increased CD4
- decreased HIV viral load
17
Q
What should be monitored for the efficacy of ART?
A
- CD4 count
- HIV viral load
18
Q
What are warnings with NRTIs?
A
- lactic acidosis
- hepatomegaly with steatosis (fatty liver)
19
Q
What are SEs with NRTIs?
A
- nausea
- diarrhea
20
Q
What are the treatment goals of ART?
A
- achieve and maintain an undetectable viral load
- restore and maintain immune function
- reduce HIV-related morbidity (OIs)
- reduce mortality
- prevent transmission
21
Q
What are the preferred once-daily, single-tablet regimens for initial ART?
A
- Biktarvy (bictegravir/emtricitabine/tenofovir alafenamide)
- Triumeq (dolutegravir/abacavir/lamivudine)
- Dovato (dolutegravir/ lamivudine)
22
Q
What are the preferred once-daily, two-tablet regimens for initial ART?
A
- Tivicay + Truvada (dolutegravir + emtricitabine/tenofovir disoproxil fumarate)
- Tivicay + Descovy (dolutegravir + emtricitabine/ tenofovir alafenamide)
23
Q
What drug classes are preferred to include in ART?
A
2 NRTIs + 1 INSTI
24
Q
What are the 2 most common NRTI regimens?
A
- emtricitabine/ tenofovir alafenamide (Descovy)
- emtricitabine/tenofovir disoproxil fumarate (Truvada)
25
Which 2 NRTIs are both cytosine analogs that would result in antagonism of each other and should not be used together?
lamivudine and emtricitabine
26
Which medication should not be used for initial treatment if HIV viral load >500,000 or Hep C co-infection (or unknown status)?
Dovato (dolutegravir/lamivudine)
27
What medication requires HLA-B* 5701 allele testing and what does it mean?
1. Triumeq (dolutegravir/abacavir/lamivudine)
2. A positive result indicates a higher risk of for severe hypersensitivity reaction in any abacavir-containing product and is CI
28
What HIV medication has more flexible dosing for CrCl<30?
Biktarvy; the individual components (bictegravir/emtricitabine/tenofovir alafenamide) can be given separately to allow for renal dosage adjustment
29
How should most HIV medications be dispensed?
dispensed in the manufacturer's bottle; most medications will come in a 1 month's supply in the original container
30
Why are alternative ART regimens using single products/combination products less ideal?
1. increased resistance (except PIs)
2. decreased patient tolerability
3. higher potential for drug interactions
31
What drugs make up an alternative ART regimen?
1 base (PI (boosted) / NNRTI/INSTI) + 2 NRTIs
32
How should pregnant patients be treated for HIV?
1. continue if already taking ART
2. most HIV meds are considered safe in pregnancy
33
What are preferred regimens in ART-naive pregnant patients?
INSTI (dolutegravir preferred) OR boosted PI (darunavir preferred)
PLUS 2 NRTIs
34
What medication can be given around the time of delivery to prevent verticle transmission of HIV?
IV zidovudine to mother and newborn
35
What is immune reconstitution inflammatory syndrome (IRIS)?
unexpected (paradoxical) worsening of a known or unidentified underlying condition after ART is started or starting a more effective ART; the immune system is now capable of mounting an immune response
36
What conditions may typically worsen due to IRIS?
1. OIs
2. Hep B and C
3. HSV/VZV (shingles)
4. autoimmune conditions
5. some cancers
37
When does IRIS typically occur?
when a low CD4 count begins to recover
38
How is IRIS managed?
continue ART as symptoms are usually self-limiting; treat the unmasked condition
39
How can the NRTIs be remembered?
Z LATTE
40
What drugs are in the NRTI class?
Zidovudine
Lamivudine
Abacavir
Tenofovir disoproxil fumarate
Tenofovir alafenamide
Emtricitabine
41
What is the MOA of NRTIs?
competitively inhibit the reverse transcriptase enzyme, preventing the conversion of HIV RNA to HIV DNA
42
What NRTI does NOT need renal dosage adjustment?
Abacavir
43
Why are 2 NRTIs included in a typical ART regimen?
low barrier to resistance (high rates of resistance)
44
What NRTIs are available as once-daily regimens?
1. both forms of Tenofovir
2. abacavir
3. lamivudine
45
What NRTIs are available as twice-daily regimens?
1. Zidovudine
2. abacavir
3. lamivudine
46
What are warnings with all NRTIs
1. lactic acidosis
2. hepatomegaly with steatosis (fatty liver)
47
What are BOXED warnings with Zidovudine?
1. lactic acidosis
2. hepatomegaly with steatosis (fatty liver)
48
What are the boxed warnings for HBV and HIV co-infections?
1. severe acute HBV exacerbation can occur if NRTI is D/C
2. Do NOT use Epivir-HBV for the treatment of HIV (contains lower dose of lamivudine than what is needed to treat HIV)
49
What is a boxed warning for abacavir
risk for hypersensitivity reaction
50
What type of screening should be done before starting abacavir?
HLA-B*5701 allele; CI if positive
51
What are warnings with tenofovir TDF>TAF?
1. renal impairment including acute renal failure and Fanconi syndrome (renal tubular injury and electrolyte abnormalities)
2. decreased bone mineral density; consider calcium/ vitamin D and DEXA scan if at risk
52
What should be done if a patient on abacavir experiences HSR?
1. D/C and never rechallenge
2. must carry a medication card indicating the HSR (N/V/D, fatigue, fever, rash, dyspepsia, cough) is an emergency
53
Abacavir
Ziagen
54
What is a unique SE with emtricitabine?
hyperpigmentation of the palms of hands or soles of feet
55
What SE is exclusive to zidovudine and requires monitoring?
1. hematologic toxicity
2. neutropenia and anemia
3. macrocytosis (high MCV) is a sign of adherence
56
What SE is exclusive to TAF and requires monitoring?
lipid abnormalities; monitor lipids if switching from TDF to TAF
57
Emtricitabine
Emtriva
58
Lamivudine
Epivir
59
tenofovir disoproxil fumarate TDF
Viread
60
tenofovir alafenamide TAF
Vemlidy (SINGLE ENTITY ONLY USED FOR HBV; combination only for HIV)
61
Zidovudine
Retrovir
62
How can integrase strand transfer inhibitors (INSTIs) be remembered?
B CRED; ends in -gravir
63
What is the MOA of INSTIs?
inhibit the integrase enzyme; prevents HIV DNA from inserting into the host cell DNA
64
What are SEs with all INSTIs (-tegravir)?
1. weight gain
2. insomnia
3. risk of depression and suicidal ideation in those with pre-existing psychiatric conditions (rare)
65
Which INSTIs have a higher barrier to resistance?
bictegravir
dolutegravir
66
What are unique SEs with doultegravir?
1. increase SCr (by inhibiting tubular secretion) no change in eGFR
2. increase CPK, myopathy, and rhabdomyolysis
3. HSR syndrome (rash, fever, symptoms of allergic reaction)
4. hepatotoxicity especially if co-infection with hep B or hep C
67
What are unique SEs with bictegravir?
increase SCr (by inhibiting tubular secretion) no change in eGFR
68
What are unique SEs with raltegravir?
1. increase CPK, myopathy, and rhabdomyolysis
2. HSR syndrome (rash, fever, symptoms of allergic reaction)
69
What are CIs to starting/ continuing Stribild?
CrCl<70: do not start
CrCl<50: discontinue
70
What is a CI to starting Biktarvy or Genvoya?
CrCl<30
71
What are unique SEs with IM cabotegravir?
injection site reactions
72
What are DIs with INSTIs?
polyvalent cations can chelate and decrease absorption; take INSTIs 2 hours before or 6 hours after products containing Al, Ca, Mg, Fe (dolutrgravir and bictegravir can be taken with Ca and Fe if also taken with food)
73
What are indications for PO cabotegravir?
1. optional lead in treatment to assess tolerability prior to cabotegravir/rilpivrine injection
2. bridge therapy in patients that will miss a scheduled cabotegravir/rilpivrine injection for >7 days
74
What are the indications for cabotegravir extended-release injection?
pre-exposure prophylaxis
75
cabotegravir PO
Vocabria
76
cabotegravir extended-release injection
Apretude
77
dolutegravir
Tivicay
78
Raltegravir
Isentress
Isentress HD
79
What is the MOA of non-nucleoside reverse transcriptase inhibitors (NNRTIs)?
non-competitively inhibits the reverse transcriptase enzyme, preventing conversion of HIV RNA to HIV DNA
80
How can NNRTIs be remebered?
REDEN; -vir-
81
What are extremely important counseling points for rilpivirine effectiveness?
1. take with a meal and water (do not substitute with a protein drink)
2. requires an acidic environment for absorption; avoid PPIs and separate administration of antacids and H2RAs
82
What is an extremely important counseling point for efavirenz?
take on an empty stomach at night to decrease and sleep through CNS SEs; food increases the bioavailability and risk of CNS effects
83
What are SEs with all NNRTIs?
1. hepatotoxicity
2. severe rash, including SJS/TENS
84
What are unique SEs with efavirenz?
1. psychiatric symptoms (depression, suicidal thoughts)
2. CNS effects (impaired concentration, abnormal dreams, confusion); generally resolves in 2-4 weeks in most patients
3. increased total cholesterol and TGs
85
What are unique SEs with rilpivirine?
1. depression
2. increased SCr with no effect on GFR
3. do not use if initial viral load >100,000 copies/mL and/or CD4 count <200 cells/mm3 (high failure rate)
4. injection site reactions (IM Cabenuva)
86
What should be noted about nevirapine SEs?
highest risk of hepatotoxicity and severe rash (SJS/TENS) out of all NNRTIs
87
What are drug interactions with NNRTIs?
all NNRTIs are major CYP3A4 substrates
88
Which NNRTIs should not be used with strong CYP3A4 inducers (phenytoin, rifampin, rifapentine, carbamazepine, oxcarbazepine, phenobarbital, St.Johns Wart)?
1. rilpivirine
2. doravirine
89
Which NNRTIs are moderate CYP3A4 inducers and have many interactions?
1. efavirenz
2. etravirine
90
Rilpivirine
Edurant
91
Doravirine
Pifeltro
92
Etravirine
Intelence
93
How should rilpivirine be taken with H2RAs?
take H2RAs 12 hours before or 4 hours after rilpivirine
94
How should rilpivirine be taken with antacids?
take antacids 2 hours before or 4 hours after rilpivirine
95
How can protease inhibitors be remembered?
"-navir"
96
What is the MOA of protease inhibitors?
inhibit the HIV protease long viral protein chains from being broken down into the smaller chains needed to produce mature (infectious) virus during the budding and maturation stage
97
What medications must be used with a PI to act as a "booster"?
1. ritonavir
2. cobicistat
98
Which PI is only used at low doses for pharmacokinetic boosting?
Ritonavir
99
What are the warnings with all PIs?
1. metabolic abnormalities: HLD/insulin resistance, dyslipidemia, increased body fat and lipodystrophy
2. increase CVD risk
3. hepatic dysfunction: increased LFTs, hepatitis, and/or exacerbation of pre-existing hepatic disease
4. HSR: rash including SJS/TEN, angioedema, bronchospasm, anaphylaxis
100
What are common SEs with PIs?
1. diarrhea
2. nausea
101
Which PI product contains 42% alcohol in its oral formulation and can cause a disulfiram reactions with metranidazole?
Lopinavir/Ritonavir (Kaletra)
102
What PIs should be used with caution in those with a sulfa allergy?
1. darunavir
2. fosamprenavir
3. tipranavir
103
What are unique SEs with atazanavir?
1. hyperbilirubinemia (jaundice or scleral icterus, remember with "bananavir")
2. requires acidic gut for absorption
104
What PIs should be taken with food to decrease GI upset?
1. darunavir
2. atazanavir
105
What medications should be separated from atazanavir since it requires an acidic gut for absorption?
1. antacids
2. H2RAs
3. avoid PPIs (unboosted atazanavir)
106
When can PPIs be used with boosted atazanavir?
take boosted atazanavir 12 hours after the PPI (dose should not exceed omeprazole 20mg or equivalent)
107
What CYP inducers will decrease concentrations of all PIs?
strong CYP3A4 inducers
108
What does not need to be considered when dosing PIs?
renal function
109
Atazanavir
Reyataz
110
Darunavir
Prezista
111
Tipranavir
Aptivus
112
Ritonavir
Norvir
113
Cobicistat
Tybost
114
Maraviroc
Selzentry
115
Fostemsavir
Rukobia
116
Ibalizumab-uiyk
Trogarzo
117
Enfuvirtide
Fuzeon
118
Lencapavir
Sunlenca
119
Bictegravir/emtricitabine/ tenofovir alafenamide
Biktarvy
120
Cabotegravir/rilpivirine
Cabenuva
121
Dolutegravir/abacavir/lamivudine
Triumeq
122
Dolutegravir/lamivudine
Dovato
123
Dolutegravir/rilpivirine
Juluca
124
Elvitegravir/cobicistat/emtricitabine/
tenofovir disoproxil fumarate
Stribild
125
Elvitegravir/cobicistat/emtricitabine/
tenofovir alafenamide
Genvoya
126
Doravirine/lamivudine/tenofovir disoproxil fumarate
Delstrigio
127
Efavirenz/lamivudine/tenofovir disoproxil fumarate
Symfi
128
Rilpivirine/emtricitabine/tenofovir disoproxil fumarate
Complera
129
Rilpivirine/emtricitabine/tenofovir alafenamide
Odefsey
130
Darunavir/cobicistat/emtricitabine/ tenofovir alafenamide
Symtuza
131
Abacavir/lamivudine
Epzicom
132
Emtricitabine/tenofovir alafenamide
Descovy
133
Emtricitabine/tenofovir disoproxil fumarate
Truvada
134
Lamivudine/zidovudine
Combivir
135
lamivudine/tenofovir disoproxil fumarate
Cimduo
136
Atazanavir/cobicistat
Evotaz
137
Darunavir/cabicistat
Prezcobix
138
What is dosing for ritonavir?
100-200mg PO (oral powder or tablet) QD/BID with food + boosted drug
139
What is dosing for cobicistat?
150mg PO QD with food + boosted drug
140
How does ritonavir and cobicistat boost PIs?
inhibitors of CYP3A4, inhibit ART metabolism which increases ART/therapeutic level
141
Why is ritonavir not utilized as a PI?
not well tolerated at higher doses; booster doses are lower with reduced metabolic side effects
142
Can cobicistat and ritonavir be interchanged?
NO
143
What drugs are contraindicated/ avoided with boosted PIs?
1. alpha-1blockers (tamsulosin, silodosin, alfuzosin)
2. amiodarone, dronedarone
3. anticoagulants/antiplatelets (apixaban, rivaroxaban, ticagrelor)
4. azole antifungals
5. hepatitis C protease inhibitors (grazoprevir, galeprevir)
6. Lovastatin/simvastatin
7. PDE-5 inhibitors used for pulmonary hypertension (sildenafil, tadalafil)
8. Strong CYP3A4 inducers (carbamazepine, phenytoin, rifampin, st.john's wort
9. inhaled, systemic, and intranasal steroids (except beclomethasone)
144
What is the MOA of maraviroc?
a CCR5 antagonist; blocks HIV from binding (and subsequently entering the CD4 cell in virus strains that use the CCR5 coreceptor
145
What baseline testing is required for maraviroc use?
must have tropism assay results before starting (determines if HIV strain infecting the patient can only bind to the CCR5 co-receptor
146
Why is testing required before using maraviroc for HIV treatment?
if the HIV strain can bind to CXCR 4 or mixed co-receptors maraviroc will not work HIV can still get into the cell
147
What are warnings/ SEs with maraviroc?
1. hepatotoxicity (boxed warning)
2. HSR including SJS/TENS
3. orthostatic hypotension on those with renal impairment
148
What patients should maraviroc not be used in?
1. severe renal impairment (CrCl<30_
2. potent CYP3A4 inducers/inhibitors
149
What is the MOA of fostemavir?
converted to temsavir which binds to the gp120 subunit of HIV envelope proteins, inhibiting the interaction between the virus and the CD4 host cell; attachment inhibitor
150
What are warnings and SEs with fostemavir?
1. do not use with strong CYP3A4 inducers
2. must maintain effective HBV treatment in patients coinfected with HBV
3. can increase SCr (higher risk for underlying renal disease)
4. indicated in combination with other ARTs in heavily treatment-experienced patients who are failing current therapy
151
What is the MOA of Ibalizumab-uiyk?
monoclonal antibody that binds to a select domain of CD4 cell receptors, blocking the entry of the virus into the cell; fusion inhibitor
152
What are warnings/SEs for ibalizumab-uiyk?
1. infusion-related reactions (observe for 1 hour after the first infusion)
2. diarrhea
3. dizziness
4. nausea
5. rash
6. indicated in combination with other ARTs in heavily treatment-experienced patients who are failing current therapy
153
How is ibalizumab-uiyk administered?
IV injection administered by a health care professional
154
What is the MOA of Lencapavir?
inhibits multiple stages of the HIV cycle including capsid transport into the nucleus, virus assembly and capsid formation, resulting in a malformed capsid; capsid inhibitor
155
What are warnings/SEs wit lencapavir?
1. CI with strong CYP3A4 inducers
2. local injection site reactions: erythema, induration, nodule, pain swelling
3. indicated in combination with other ARTs in heavily treatment-experienced patients who are failing current therapy
156
How is lencapavir administered?
oral loading dose followed by SQ injection into the abdomen every 6 months
157
What is the MOA of Enfuvirtide?
prevents HIV from fusing to the CD4 cell membrane, preventing virus entry into the cells; fusion inhibitor
158
What are warnings/SEs with enfuvirtide?
1. risk of bacterial pneumonia, hypersensitivity reactions
2. local injection site reactions (occur in nearly all patients): erythema, nodule, pain, swelling, cysts,
3. ecchymosis (bleeding under the skin)
4. nausea
5. diarrhea
6. fatigue
7. reserved for use as salvage therapy in patients with extensive HIV resistance
159
How is enfuvirtide administered?
powder for injection (self-administered SQ into the abdomen, front of the thigh, or back of the arm
160
What medications are first line for HIV treatment?
1. Biktarvy
2. Triumeq
3. Dovato
161
What is the indication for Cabenuva and Juluca?
only indicated to replace a stable ART regimen in patients with virologic suppression and no history of treatment failure or known resistance
162
How is Cabenuva administered?
IM once monthly by a healthcare professional (may be preceded by lead-in treatment with oral cabotegravir to assess tolerability
163
When should tenofovir disoproxil fumarate products not be started in patients with impaired renal function?
CrCl <50 (CrCl <70 for Stribild)
164
When should tenofovir alafenamide products not be started in patients with impaired renal function?
CrCl <30
165
Which ART medications must be taken with food?
Stribild & Genvoya (taken with food due to cobicistat component)
166
What is pre-exposure prophylaxis (PrEP)?
prescribing ART to prevent HIV infection in patients who engage in high risk activities
167
What oral regimens are used for PrEP?
Truvada and Descovy taken daily with no more than a 90 day supply dispensed at a time
168
What injectable regimen can be used for PrEP?
Apretude; long-acting cabotegravir administered by a healthcare provider monthly for 2 doses, then once every 2 months
169
What tests must be done before starting PrEP?
1. confirm pt is HIV negative
2. ask about recent symptoms
3. confirm CrCl≥60 (if using Truvada; cut off higher for PrEP) and CrCl≥30 (if using Descovy)
4. Screen for Hep B and STIs
170
What tests must be done while PrEP is continued/follow-up testing?
1. test for HIV at each visit and confirm negative test before refilling PrEP treatment
2. follow-up every 3 months for oral treatments; follow up 1 month after the first injection then every 2 months (Apretude)
3. STI screening, renal function, and adverse drug reactions are recommended to be monitored at every follow-up visit
171
When is post-exposure prophylaxis (PEP) used/recommended?
for emergency situations when a non-infected person is exposed to body fluids that are known to be or could be infected with HIV
172
What are the types of PEP?
1. nonoccupational (nPEP); after sex without a condom, injection drug use, or other type of occupational exposure
2. occupational (oPEP); typically used for healthcare personnel who are exposed to body fluids that could be infectious (needle stick injury)
173
When should PEP treatment be started and how long is treatment?
ASAP within 72 hours of the exposure and is continued for 28 days
174
For those taking PEP how often should they be tested for HIV after the exposure?
4-6 weeks, 3 months, and 6 months after the exposure
175
Which INSTI-containing regimens are once-daily?
1. Biktarvy
2. Stribild
3. Genvoya
4. Isentress HD
5. Tivicay
6. Triumeq
7. Dovato
176
Which INSTI-containing regimens are twice-daily?
1. Insentress
2. Tivicay (twice daily only for treatment-experienced patients, those with INSTI resistance, or taking UGT1A1/CYP3A4 inducers)
