HIV Flashcards
Which 2 agents should you be cautious with starting for viral loads>100000 copies/ml?
Abacavir and rilpivirine
What are the creatinine clearance limits for tenofovir?
CrCl <70 for TDF, <30 for TAF
If starting treatment, and cannot use TDF, TAF or ABC, what is recommended?
Darunavir/ritonavir and Raltegravir
In which 2 populations and 3 clinical scenarios should therapeutic drug monitoring be considered?
Children, pregnancy
malabsorption, drug interactions, suspected non adherence
If stopping treatment NRTI with NNRTI, what should it be switched to?
Darunavir/ritonavir for 4 weeks
If previous NRTI resistance, what agent should be switched to?
Protease inhibitor
What is a virological blip, low-level viraemia, incomplete virological response and virological failure?
1) blip- VL 50-200 followed by undetectable result
2) low-level viraemia- multiple blips
3) incomplete virological response VL>200 but never undetectable
4) failure- VL>200 after being undetectable
Virological failure- what should the switch be for:
1) on 1st line ART and wild type?
2) on 1st line PI +2 NRTI with limited major PI mutation?
3) Extensive drug resistance?
1) switch to PI based combination
2) switch to active PI and 1-2 agents with novel mechanism
3) 2 or more fully active agents with at least 1 PI and 1 novel agent (INI, MVC or enfurvitide) with Etravirine an option
HIV/TB co-infection, when should ART start if:
1) CD4 <50
2) CD4>50?
1) within 2 weeks
2) delay 8-12 weeks
What is the 1st line ART for HIV/TB coinfection?
Tenofovir DF, emtricitabine and efavirenz
HIV/TB- when should rifabutin be used instead of rifampicin?
If using ritonavir, cobicistat or nevirapine
HIV/TB- what are the issues with rifampicin and:
1) efavirenz
2) raltegravir
3) dolutegravir?
1) use same dose regardless of weight
2) cautious due to reduced levels
3) can use but 50mg BD, frequent viral load monitoring
Which are the AIDS defining cancers?
Kaposi’s sarcoma
Non hodgkin’s lymphoma (Burkitt’s, primary effusion lymphoma, DLBCL etc)
Cervical cancer
What should be considered with chemotherapy and HIV?
1) drug interactions ,especially cytochrome P450 with ritonavir/cobicistat
2) prophylaxis if previous Hep B
3) prophylaxis if previous HSV
In cardiovascular disease, which is the preferred PI?
Atazanavir/ritonavir
In cardiovascular disease, what is 1st line ART?
tenofovir DF, lamivudine or emtricitabine and dolutegravir or raltegravir or rilpivirine (<100000)
In cardiovascular disease, which agents should be avoided?
abacavir, maraviroc, lopinavir/ritonavir and fosamepravir
What are the 4 issues with rilpivirine?
Can’t give initially if VL>100,000, need to take with food, prolongs QT interval, interacts with PPI
In which 3 scenarios regarding bone health would you avoid TDF?
1) >40 yrs with osteoporosis
2) history of fragility fracture
3) FRAX score >20%
In which 4 scenarios would you expedite treatment for primary HIV infection?
1) Neurological involvement
2) CD4< 350
3) AIDS defining illness
4) diagnosed within 12 weeks of previous negative HIV test
In suspected TB meningitis in HIV patients, what is the WHO preferred test on CSF for diagnosis?
Xpert MTB/Rif
In patients with TB pleuritis and HIV why should respiratory samples be obtained in the absence of lung parenchymal involvement?
Because sputum culture diagnosis approaches 55%
What urinary test has a high sensitivity for TB and is best at what CD4 counts?
LF- liparabinomannan, CD4<100
Why are corticosteroids not advised in HIV patients with TB pericarditis despite shorterning resolution of effusions/thickening?
Increased risk of Kaposi’s Sarcoma and CMV disease, no effect on mortality or respiratory function.
What is the regime for HIV patients with isoniazid only resistance?
RZE and levofloxacin for 6 months
in RR/MDR TB how many effective agents are recommended?
at least 4 during intensive phase, moving to orals where possible
In RR or MDR TB, in which circumstance can isoniazid be used?
If InhA resistance, not KatG
What is the definition of DILI for asymptomatic and symptomatic patients
> 5x ULN ALT asymptomatic, or >3x ULN ALT for symptomatic patients
in Pre-existing liver disease, which standard TB meds are most likely to cause hepatotoxicity?
pyrazinamide>isoniazid>rifampicin
in pre-existing liver disease, if ALT is 2-3 times higher than the baseline, what standard regimen should be employed?
stop pyrazinamide, give RH for 9 months with E for 8 weeks (or stop once known sensitive)
In pregnant women starting ART for HIV, when should viral loads be checked
2-4 weeks after starting, at least once per trimester, at 36 weeks and delivery
When should women seek advice about dolutegravir around pregnancy?
Around conceiving and risks of neural tube defects. Also to take folic acid 5mg daily during 1st trimester.
When should pregnant women start ART?
If VL<30,000 during 2nd trimester
if VL 30-1000,000 start of 2nd trimester
if VL>100,000 during 1st trimester and/or CD4<200
What are recommended 3rd ART agents in pregnancy?
efavirenz or atazanavir/ritonavir
rilpivirine, raltegravir and darunavir/ritonavir are alternatives
Under what circumstance is zidovudine monotherapy acceptable in pregnancy?
Patient refuses cART, has VL<10000 and agrees to Caesarean section
If VL is >100,000 during pregnancy at 28 weeks what should be done?
Use a 3-4 drug regimen including raltegravir 400mg bd or dolutegravir 50mg daily
What ART regimen should be given to untreated HIV +ve pregnant women presenting at term?
stat nevirapine, plus zidovudine/lamivudine/raltegravir and IV zidovudine throughout labour +/- double dose tenofovir to load pre-term infant if unable to take oral
when should pre-labour C section be considered or recommended in HIV?
At 36 weeks: VL 50-399, consider
VL 400 or more, recommend
In which 3 situations would you give intrapartum IV infusion of zidovudine?
1) VL>1000 in labour or SROM or having pre-labour C section
2) Untreated women in labour whose viral load is unknown
3) VL 50-1000
Infant PEP should be given within 4 hours of birth, but what regimes are advised for very low risk, low risk, high risk?
zidovudine monotherapy for 2 weeks (very low risk), 4 weeks (low risk), zidovudine, lamivudine and nevirapine for high risk
What are the recommendations for infant feeding in HIV mothers?
Formula feed recommended, and cabergoline to suppress lactation.
However breastfeeding mothers (controlled on cART) can do so with monthly monitoring, and HIV RNA in infant tested up to 2 months after breastfeeding
When should infants be tested for HIV RNA and antibody testing?
non breastfed: 48 hours after delivery and at discharge, 6 weeks and 12 weeks (at least 4 and 8 weeks post PEP), Antibody at 22-24 months, f/u till at least 18 months.
Breastfed: 2 weeks, monthly for duration of breastfeeding, 4 weeks and 8 weeks post breastfeeding. Antibody test minimum 8 weeks post breastfeeding if this is the latter or 22-24 months
