HIV Flashcards
1
Q
What year was the first antiretroviral approved?
A
1986
2
Q
What is the life expectancy of someone living with HIV?
A
since the advent of HAART people living with HIV have an expected lifespan similar to those who are HIV negative
3
Q
What populations do not have the same lifespan expectations with HIV? (3 groups)
A
- individuals who are not white
- individuals with history of injection drug use
- individuals who began ART at low CD4 counts
4
Q
What do the 95-95-95 targets outlined by UNAIDS mean?
A
95% of all people living with HIV know their status
95% of people diagnosed are on antiretroviral treatment
95% of all people receiving antiretrovirals are suppressed
5
Q
Injection Drug Use used to be the most common risk factor for acquiring HIV, but what risk factor is emerging and taking over as the most common risk factor?
A
Heterosexual Sex
6
Q
When do pregnant women get screened for HIV?
A
1st trimester
Repeat screening during 3rd trimester may be indicated as well
7
Q
What information is required for a patient to give consent for HIV testing?
A
- clinical and prevention benefits of testing
- right to refuse
- HIV is reportable to the MHO
- follow up services will be offered
- if positive, identify others who have been exposed
- person testing positive must inform sexual and drug using partners
8
Q
What are the 4 options for HIV Testing (in SK)
A
- standard screen (blood draw)
- point of care (finger prick)
- dried blood spot
- self testing (not widely available anymore)
9
Q
Standard Screen HIV Test
A
- uses the 4th generation Ab and Ag screen
- nearly 100% sensitive and specific for chronic HIV
- cannot differentiate between HIV-1 and HIV-2
- takes few days to 2 weeks for results (~3 days)
10
Q
Point of Care HIV Test
(General, Interpretation of Negative and Positive Result)
A
- rapid antibody screen for HIV 1 and 2
- results in minutes
- Negative = no HIV
- Positive = confirmatory testing required
11
Q
Dried Blood Spot HIV Test
A
- blood collected using a finger prick and placed on a sheet of paper that is sent away
- advantages: better confidentiality, multiplex testing
- no immediate results
12
Q
What does HIV stand for?
A
Human Immunodeficiency Virus
13
Q
What does HIV target in the body?
A
CD4 T lymphocytes
14
Q
What is the role of CD4 T Lymphocytes?
A
help coordinate an immune response by stimulating other immune cells such as macrophages, B cells and CD8 T lymphocytes
15
Q
What does AIDS stand for?
A
Acquired Immunodeficiency Syndrome
16
Q
What is AIDS? How is it defined?
A
- end stage or advanced stage of HIV infection
- defined as CD4 count less than 200 or presence of 1 or more AIDS-defining illnesses or Opportunistic infections
17
Q
Why is HIV a lifelong infection?
A
Because HIV inserts itself into host chromosomes
18
Q
What type of virus is HIV?
A
retrovirus
19
Q
What are the two types of HIV?
A
HIV-1 and HIV-2
20
Q
What type of HIV is most common?
A
HIV-1
21
Q
How is HIV spread?
A
contact with HIV-infected fluids (blood, semen, vaginal fluid, rectal fluid, breastmilk)
22
Q
What must HIV infected fluids come in contact with for transmission to occur?
A
mucous membranes (located in rectum, vagina, penis and mouth) or damaged tissue or be directly injected into the bloodstream
23
Q
What are the 3 modes of transmission of HIV?
A
- sexual transmission
- blood contact
- vertical transmission
24
Q
Sexual Transmission of HIV
A
unprotected sexual contact with HIV
insertive and receptive sex (anal, vaginal)
25
Blood Contact Transmission of HIV
Sharing needles or other drug equipment
Sharing tattoo and piercing equipment, razors
Blood transfusion in Canada prior to 1985
occupational exposure such as needle stick injuries
26
Vertical Transmission of HIV
to fetus/infant in utero at delivery or through breast milk
27
When is vertical transmission of HIV highest risk?
- seroconversion occurs during pregnancy due to higher viral load
- pregnant person is HIV+ but not diagnosed or not on ART
28
What does U=U mean?
Undetectable = Untransmittable
29
What are symptoms of HIV?
- flu like symptoms within 2-4 weeks after infection (fever, sore throat, enlarged lymph nodes, night sweats, chills, fatigue, muscle aches, rash)
But many have no symptoms at all!
30
What is the CD4 count? (General terms)
marker of immune system health
31
What is a normal CD4 count?
800-1200
32
What does CD4 count indicate in terms of HIV? (4)
- urgency to start ARVs
- if opportunistic infection prophylaxis is necessary
- disease progression
- if improving indicates therapeutic response and adherence to therapy
33
What CD4 % correlates to an absolute count of ~200
14%
34
Which CD4 count lab value does not fluctuate very often?
percentage
35
What is HIV viral load?
amount of virus present in the blood measured in copies/mL
36
What viral load is considered suppressed?
less than 50 copies
37
How long does it approximately take an individual to become suppressed when starting ART?
1-2 months
38
What are benefits of ARV therapy? (4)
- allows restoration and preservation of immunologic function
- reduces HIV related morbidity and mortality
- increases duration and quality of life
- prevents transmission
39
Broadly - what do antiretrovirals do to restore immune function?
block viral replication within the CD4 cell
40
What are the 4 classes of antiretrovirals?
NRTIs (nucleoside reverse transcriptase inhibitors)
NNRTIs (non-nuceloside reverse transcriptase inhibitors)
INSTIs (integrase strand transfer inhibitors)
PIs (protease inhibitors)
41
How many antiretrovirals are required for HIV treatment?
more than 1
3 active agents from 2 different classes
OR
dual therapy regimens
BUT NEVER MONOTHERAPY
42
MOA of NRTIs
act as host nucelotide decoys and cause termination of the elongating HIV DNA chain
43
Tenofovir Disoproxil Fumarate (TDF) - Class
NRTI
44
Tenofovir Alafenamide (TAF) - Class
NRTI
45
Abacavir - Class
NRTI
46
Emtricitabine - Class
NRTI
47
Lamivudine - Class
NRTI
48
Those with HIV are 2x more likley of having a ________ event even if on ART and suppressed
cardiovascular
49
Which NRTI is a pro-drug?
TAF
50
Which NRTI concentrates intracellularly?
TAF
51
Does TAF or TDF have more side effects?
TDF
52
Which NRTI do we have to check HLA-B*5701 prior to initiating? Why?
Abacavir due to risk of hypersensitivity reactions
53
Doravarine - Class
NNRTI
54
Efavirenz Class
NNRTI
55
Rilpivirine Class
NNRTI
56
MOA of NNRTIs
bind directly to the HIV reverse transcriptase enzyme and inhibit the function of it
57
Nevirapine Class
NNRTI
58
Which NNRTI if used in adults has a lead in period until auto-induction is complete?
Nevirapine
59
Which NNRTI is still used in peds because it comes in a liquid formulation?
Nevirapine
60
INSTIs MOA
blocks HIV integration into the host DNA
61
Bictegravir - Class
INSTI
62
Dolutegravir Class
INSTI
63
Cabotegravir Class
INSTI
64
Elvitegravir Class
INSTI
65
Raltegravir Class
INSTI
66
Does dolutegravir or bictegravir have more side effects?
Dolutegravir
67
What INSTI has a slight risk of neural tube defects?
Dolutegravir
68
Darunavir Class
Protease Inhibitor
69
MOA of protease inhibitors
disrupts the normal maturation process which prevents infection of new cells
70
What is darunavir always given with?
a PK booster - ritonavir or cobicistat
71
Ritonavir Class
Used as PK booster
(but it is a protease inhibitor - just no longer used as that anymore)
72
Cobicistat Class
PK booster
73
Do the PK boosters count towards one of the antiretroviral requirement of needing more than 1 agent to achieve suppression?
No
74
What is the injectable ART?
Cabenuva - contains Cabotegravir and Rilpivirine
(INSTI + NNRTI)
75
Where is Cabenuva injected and how often?
gluteal IM injection every month or every 2 months (into each buttock)
76
PK of Cabenuva
has a very long PK tail (in body for up to 12 months) which has implications for resistance if patient were to discontinue
77
Checklist for suitability of Cabenuva injection (10)
- no known or suspected mutations to agents
- no evidence of chronic hepatitis B infection
- CrCl >30mL/min
- no signs of liver failure
- not currently pregnant or planning to become pregnant
- virally suppressed before first injection
- ability to commit to regular injections
- reliable contact information
- travel considerations in place (bridging with po if outside of 7 day target tx date)
- no drug interactions exist
78
What are the significant drug interactions with Cabenuva (4)?
aniconvulsants (CBZ, oxCBZ, PHB, PHT)
antimycobacterials (RFB, RIF)
Dexamethasone (>1 dose)
SJW
79
What does rapid start of ART mean?
ART given within days up to 2 weeks from when the pt is diagnosed
80
What are the benefits of rapid initiation of ART? (5)
- earlier linkage to care
- higher rates of retention in care
- higher rates of suppression and shorter time to suppression
- health benefits to the patients
- reduces onward transmission
81
What are 2 medications that are used for rapid start? Why?
Biktarvy or Truvada + Tivicay (Dolutegravir)
because these regimens have low likelihood of resistance if the patient happened to have transmitted disease
| Biktarvy =Bictegravir, Emtricitabine, TAF
Truvada = Emtricitabine & TDF
82
How long does it take to get genotype results back for HIV?
approx. 6 weeks
83
When do we test HIV viral load after initiating ART?
Otherwise?
4-6 weeks after initiating ARV or switching
otherwise q3-6 months
84
How often do we test CD4 count?
every 3-6 months
can lengthen to 12 months if consistent, adherent and suppressed
85
When does monitoring CD4 become optional?
If CD4 is >500 after 2 years with suppressed viral load
86
Which 2 ARVs cause QT prolongation?
Rilpivirine, Efavirenz
87
What adverse effect is abacavir associated with?
MI
88
Which ARVs can cause bone density loss?
TDF > other NRTIs
but all ARV regimens have some decrease
89
What adverse effect is boosted Darunavir associated with?
CV events
90
What ARVs can cause dyslipidemia?
TAF, Abacavir, Efavirenz, boosted PIs, Elvitegravir
91
Which antiretroviral has a lipid suppressive effect?
TDF
92
Which ARVs are associated with hypersensitivity reactions?
Abacavir, Nevirapine
93
Which ARV's are associated with hepatoxicity?
efavirenz, nevirapine, darunavir, dolutegravir
94
Which ARVs can cause psychiatric effects?
efavirenz, rilpivirine, dolutegravir, doravirine
95
What can TDF cause in term of renal adverse effects?
increased ScR, proteinurea, hypophosphatemia, phosphate wasting, glycosuria
96
What class of ARVs is associated with weight gain?
INSTIs
97
What is the major factor in ensuring virologic success and is a major determinant of survival?
adherence
98
What are some factors associated with poor adherence?
active alcohol or drug use, competing priorities, depression, lack of social support, low literacy, advanced HIV infection, young age
99
What is HIV drug resistance caused by?
changes in genetic structure of HIV that affect the ability of drugs to block the replication of the virus
100
What are the two types of resistance? Which is more common?
transmitted and acquired
acquired is most common
101
Define transmitted resistance
when a person acquires a strain of HIV that is already resistant to certain antiretroviral drugs
102
Define acquired resistance
when a drug-resistant strain of HIV emerges while a person is taking antiretroviral therapy
103
What does a high genetic barrier to resistance allow?
allows a medication to bind itself tightly to the virus and keeps working even if the virus has changed
104
What does virologic failure mean?
inability to achieve or maintain suppression of viral replication to <200 copies/mL
105
What opportunistic infections occur at CD4 <200 ?
penumocystitis pneumonia, oropharyngeal candidiasis
106
What opportunistic infections occur at CD4 <100?
crytpococcal pneumonia and meningitis, toxoplasmosis, esophageal candidiasis
107
What opportunistic infections occur at CD4 <50?
disseminated MAC, CMV retinitis
108
At what CD4 level can tuberculosis occur in at HIV?
Risk at any CD4 level
109
What is the most common opportunistic infection in HIV patients?
oropharyngeal candidiasis
110
Treatment for oropharyngeal candidiasis
oral fluconazole 100mg/day x 7-14 days
111
Esophageal candidiasis treatment
oral fluconazole 100-400mg/day x 14-21 days
112
What fungi causes pneumocystis pneumonia (PCP)?
pneumocystitis jirovecii
113
How does PCP usually present?
as a subacute onset syndrome of dry cough, fever, exertional dyspnea, chest discomfort and even respiratory failure
114
Who is PCP prophylaxis recommended for?
suggested for those with a CD4 count <200 cells/mm3 or <14%
115
What is the recommended agent for PCP prophylaxis?
Septra (1 DS tab daily)
116
What is the recommended agent for PCP treatment?
Septra DS 2 tabs q8h for 21 days
117
What are some clues that a patient might have MAC?
severe anemia, elevated alkaline phosphatase
118
What is recommended for MAC Prophylaxis?
Azithromycin 1250mg once weekly
119
What is MAC Treatment?
Two or more antimycobacterial drugs:
- clarithromycin (or azithromycin)
- ethambutol
- rifabutin
120
What is IRIS?
Immune reconstitution inflammatory syndrome
an exaggerated inflammatory reaction to a disease-causing microorganism that can occur when the immune system starts to recover following initiation of ARV's
121
What is unmasking IRIS?
refers to a flare up of a previously undiagnosed infection soon after ARV's are started
122
What is paradoxical IRIS?
worsening of a previously diagnosed infection after ARV's are started
123
Common Drug Interactions with ARV's
- TB meds rifampin
- acid reducers, PPI's, H2RAs, antacids
- anticoagulants, antiplatelets
- statins
- steroids (all routes)
- anticonvulsants
- antidepressants, anxiolytics, antipyschotics
- alpha adrenergic antagonists for BPH
124
What is a quick rule of thumb for drug interactions with ARV's?
check for DI with any regimen that has PK booster (ritonavir or cobicistat) as they have a lot of drug interactions
125
What is pre-exposure prophylaxis?
an HIV prevention strategy to reduce the risk of acquiring HIV
126
Who is at risk of HIV?
- MSM and transgender women engaging in condomless sex within the last 6 months who have any of the following:
syphilis or rectal STI, recurrent use of nPEP, ongoing relationship with HIV+ partner with risk of transmissible HIV, high incidence risk score
- heterosexual exposure
- people who inject drugs (PWID) exposure
127
What is the most common agent used for PrEP?
Truvada - TDF, emtracitabine
128
When should PEP be started?
must be started within 72 hours of exposure
129
How long is PEP treatment?
28 days
130
Who is HIV dual therapy not indicated for? (3)
initial viral load >500,000
active HBV
awaiting genotype results
131
What does incomplete virologic response mean?
two consecutive HIV RNA levels >200 copies/mL after 24 weeks on an ARV regimen in a patient who hasn't had documented virologic suppression on that regimen
132
What ARV medication interacts with metformin? Describe the interaction.
Dolutegravir interferes with the renal elimination of metformin approximately doubling the serum concentrations of it. (increases risk of lactic acidosis)
133
What ARV medication interacts with NSAIDs? Describe the interaction.
TDF can cause acute kidney injury. Risk is elevated when given with nephrotoxic drugs such as NSAIDs.
134
What ARV medication class interacts with Ca/Mg/Fe/Al? Describe the interaction and how to manage.
INSTIs. Minerals can bind to INSTIs and decrease absorption due to chelation. Space by 2 hours from any of these mineral containing products (multivitamins, antacids, etc.)
135
How fast do CD4 counts rise?
approx. 50-100/year when on effective treatment
136
If someone with HIV is co-infected with HBV what medications should they be on?
TDF or TAF
AND
Lamuvidine or Emtracitabine
137
If someone with HIV is co-infected with Tuberculosis what medications should they be on?
At least 2 NRTIs: usually TDF + emtracitabine
PLUS
Dolutegravir or Efavirenz
138
If a patient with HIV is pregnant which PK booster is CI? Why?
Cobicistat because plasma levels decrease during pregnancy so there is a risk of viral rebound
139
At what CD4 count are live vaccines contraindicated?
<200
140
What lab tests need to be done more frequently if patient is on TDF?
urinalysis, urine ACR and serum phosphate
141
What INSTIs can increase sCr within first few months of initiating? By how much? Is it indicative of true renal function?
Dolutegravir and Bictegravir can increase sCr approx. 10-15 umol/L
Does not reflect true renal function as change is due to the inhibition of sCr secretion
142
Which ARV should be taken with at least 400 calories?
Rilpivirine
143
What quantifies a significant CD4 change (both absolute and percentage)
30% change in absolute CD4
CD4% change by 3 points
144
Protease inhibitors are CYP 3A4 _____ and CYP 3A4 ______?
inhibitors and substrates
145
Efavirenz, Etravirine and Nevirapine are CYP 3A4 _____ and CYP 3A4 ______?
inducers and substrates
