HIV Flashcards
Who should be tested for HIV?
“everyone”
- People with risk factors: IVDU, MSM, sex workers, people with multiple partners, areas of high endemicity, rape victims, suggestive sx
- Mandated in blood donors, organ recipients/donors, military applicants, active duty, and sometimes newborns, pregnant women, inmates
What are office tests for HIV?
Gold standard: 4th generation HIV Ab/Ag test that can detect P24 (which appears more quickly in immune response)
Uses modified ELISA technology that tests for HIV1 and 2 and antibodies and P24 antigen
Usually serum test and needs no confirmation
Urine test: calypte for HIV 1 Ab only
What are at-home tests for HIV?
Oraquick, Insti HIV1/2 Serum, saliva Results in 20 minutes ELISA technology to detect Abs only Few are 4th gen, so you will need confirmation with serology
AIDS Law Project Act 148/Act 59
HIV test offered in “opt out” format so that pt is advised that an HIV test will be performed unless they specifically decline it
Written informed consent is not required for test, provider documents the patient’s consent/refusal
Negative results don’t need to be given in person
Why is testing for HIV a big deal?
15% of people in US are HIV+ and unaware
Undiagnosed patients account for majority of transmission
Who is affected the most by HIV?
67% are gay and bisexual men
-Diagnoses have increased in AA (4%) and in
Hispanic/Latino (14%)
9% are people who inject drugs (PWID), but rate has been declining
When does acute HIV infection occur?
Usually 2-4 weeks after infection
And, about 50-90% of pts have some sx of acute seroconversion syndrome
What are the manifestations of acute HIV infection?
Typically manifest in 3-10 weeks after primary infection
Common: fever, adenopathy, pharyngitis, rash, myalgias, diarrhea, headache, N/V, hepatosplenomegaly, weight loss, neuro sx
Rare: thrush, herpes zoster, opportunistic infections (most commonly PCP)
How do you diagnose acute HIV infection?
- ELISA (serum) test: but there is a window (2-4 weeks post/infection) where P antigen has not reached detectable levels yet…if you are suspicious, do the 4th gen serum test AND…
- HIV RNA PCR (“viral load”): actually measures the virus and can detect it w/in a couple days of infection
What is the HIV progression?
Primary infection
2-4 week incubation
Weeks 3-10: acute viral syndrome with wide dissemination of virus
10 weeks-up to 9 years: clinical latency where you may not see any sx
Constitutional sx
Opportunistic disease/s
Death
What are conditions associated with CD4 <500?
Candidiasis (oral thrush, vaginal candidiasis) Pneumococcal pneumonia Pulmonary tuberculosis Herpes zoster Kaposi sarcoma Cryptosporidiosis Oral hairy leukoplakia HIV-associated ITP
What are conditions associated with CD4 <200
clinically-defined AIDS
Pneumocystis jirovecii pneumonia (PCP)
Toxoplasmosis
Cryptococcal meningitis
Miliary or disseminated tuberculosis
What are conditions associated with CD4 <50?
Disseminated CMV
Disseminated Mycobacterium avium complex
Progressive multifocal leukoencephalopathy
HIV-associated wasting disease
Neuropathies, HIV associated encephalopathy
HIV-associated cancers (most common)
When is prophylaxis recommended for HIV patient?
When CD4<200 (AIDS), put patient on double-strength Bactrim QD
Can stop prophylaxis when CD4 count has been >200 for >6 months
When CD4<50, continue Bactrim QD
What are AIDS defining illnesses?
Candidiasis - Bronchi, trachea, lungs, Esophageal Coccidiomycosis, disseminated Cryptococcosis Cryptosporidiosis (>1mo) CMV disease - Disseminated, Retinitis HSV - Chronic ulcers >1mo, Bronchitis, pneumonitis, esophagitis Histoplasmosis, disseminated Isosporiasis, chronic (>1mo) MAI or M kansasii, disseminated Non-tuberculous mycobacteria, extrapulm Pneumocystis jirovecii pneumonia Recurrent pneumonia Salmonella septicemia (recurrent) Toxoplasmosis Tuberculosis of any site HIV Encephalopathy Cervical cancer, invasive Kaposi sarcoma Lymphoma - Burkitt’s, Immunoblastic, Primary CNS Lymphoid interstitial pneumonia or pulm. lymphoid hyperplasia complex Progressive multifocal leukoencephalopathy HIV wasting syndrome
What is the initial workup of an HIV+ patient?
HIV genotype/resistance testing CD4 count and viral load CBC with Diff CMP Fasting lipid profile Hepatitis A, B, and C serologies RPR, rectal, pharyngeal, urine or cervical GC/Chlamydia PCR Tuberculosis screening
What immunizations are recommended in HIV+?
Yearly influenza vaccine Pneumococcal vaccine Hepatitis A and B vaccination series TDaP Yearly PPD (or IGRA, eg Quantiferon Gold) Meningitis Shingrix (shingles) Gardasil
What labs are recommended for routine management of HIV+?
CBC, Panel 20, CD4, viral load, RPR: every 3 months (q6 months if stable and undetectable) STI screening (and HCV) Standard cancer screening recs: Annual Pap smear (rectal and cervical) Mammograms Colonoscopy at age 50 DEXA scan at age 50
Who should be treated for HIV?
EVERYONE should be treated immediately, regardless of CD4 count in order to decrease morbidity/mortality
What are the treatment options for HIV?
NRTIs Integrase Inhibitors NNRTIs Protease Inhibitors CCR5 Inhibitors Fusion Inhibitors
What are the most common NRTIs (Nucleoside Reverse Transcriptase Inhibitors) used to treat HIV?
Abacavir (Ziagen) Emtricitabine (Emtriva) Lamivudine (Epivir) Tenofovir (Viread) Zidovudine (Retrovir) Tenofovir alafenamide
What are the integrase inhibitors?
Raltegravir (Isentress)
Elvitegravir
Dolutegravir (Tivicay)
Bictegravir (Bictarvy)
These should be paired with NRTI
What are the most common NNRTIs?
Efavirenz (Sustiva)
Rilpivirine (Edurant)
Doravirine (Pifeltro)
What are the most common protease inhibitors?
Atazanavir (Reyataz)
Darunavir (Prezista)
Darunavir/cobicistat (Prezcobix)
Atazanavir/cobicistat (Evotaz)
Note: ritonavir and cobicistat have no action on their own, but are given in combination with other meds to boost action
What are fusion inhibitors?
NOT first line treatment
Enfuviritide (Fuzeon)
What are CCR5 Antagonists
NOT first line treatment
Maraviroc (Selzentry)
If pt’s virus is CCR5 (receptor) positive, can qualify to use this
What is the deal with Ritonavir (Norvir)?
It is technically a protease inhibitor, but it does not count as an active agent
Instead, it boosts other proteas inhibitors by increasing their serum levels w/o increasing toxicity
It is a CYP3A4 inhibitor
What is the deal with Cobicistat (Tybost)?
It is chemically similar to ritonavir
Boosts other medications, but with no inherent antiviral properties of its own
What are the first-line ARV regimens in naive patients?
Drug regimens usually consist of 2 NRTIs + integrase inhibitor
Dolutegravir/Abacavir/Lamivudine*
Dolutegravir + (TAF or Tenofovir)/Emtricitabine*
Elvitegravir/Cobicistat/Tenofovir/Emtricitabine
Elvitegravir/Cobicistat/TAF/Emtricitabine
Raltegravir + (TAF or Tenofovir)/Emtricitabine
**Dolutegravir (Tivicay) can increase neural tube defects, so currently shouldn’t be used in pts planning to become pregnant
What are the rules for prescribing ART?
People generally need THREE active agents
Almost everyone is started with 2 NRTIs as the backbone
Plus, either:
Integrase inhibitor OR
NNRTI OR
Boosted protease inhibitor (PI)
What are some considerations regarding prescribing Abacavir (which is a component of Triumeq and Epzicom)?
Must get genetic marker testing because of a potentially fatal reaction to Abacavir
What are some SE considerations with Reyataz?
Causes jaundice and realllly high bilirubin, but the hyperbilirubinemia is not clinically significant
But this is why it is not first line treatment
How do statins and ART interact?
Protease inhibitors increase statin levels
NNRTIs decrease statin levels
How does Warfarin and ART interact?
ARVs (NNRTIs and PIs) may increase OR decrease the INR (monitor)
How do PPIs & H2 blockers interact with ART?
PPIs/H2 blockers and subsequent acid suppression significantly DECREASES the absorption of Atazanavir or Rilpivirine, which seriously decreases the concentration of those ARTs
How do Trazodone and ART interact?
All protease inhibitors (e.g., ritonavir) increase trazodone AUC by up to 240%
How do Alprazolam and Diazepam and ART interact?
All protease inhibitors increase the AUC of benzos by up to 250%
Use instead: lorazepam, oxazepam, temazepam
