HIV Flashcards
What investigations do you order to stage HIV?
- CD4 count
- Opportunistic Infection Screen
- Viral Load (RNA)
- Genotype (Resistance)
- Tropism Testing (CCR5)
What does tropism testing identify in patients with HIV?
HIV requires both the CD4 receptor and a coreceptor in order to enter CD4+ T-cells. A tropism test identifies which co-receptor (CCR5 or CXCR4) the patient’s HIV strain uses. There are specific treatments that target against CCR5 (CCR5 antoagonist - macaviroc) which can be used in the treatment of HIV.
What serological should you order in HIV patients upon initial diagnosis?
CMV IgG
Toxoplasmosis IgG
Hepatitis B/C Serology
What is the recommend anti-retroviral regimen for HIV?
2 Nucleoside Reverse Transcriptase Inhibitors (NRTIs)
PLUS
1 INSTI (integrase stand transfer inhibitor)
OR
1 NNRTI (non-nucleoside reverse transcriptase inhibitor)
OR
1 PI (protease inhibitor)
What is the initial recommended regimen for HIV in most patients?
- Bictegravir + tenofovir alfenamide + emtricitabine
OR - Dolutegravir + one of:
- tenofovir alafenamide + emtricitabine
- tenofovir disoproxil fumarate + emtricitabine
- tenofovir disoproxil fumarate + lamivudine
OR - Dolutegravir + lamivudine w/caveats
What are examples of nucleoside reverse transcriptase inhibitors (5)?
- tenofovir
- emtricitabine
- lamivudine
- zidovudine
- abacavir
What are examples INSTI (integrase strand transfer inhibitors)?
- Bictegravir
- Dolutegravir
- Elvitegravir
- Rastegravir
At what CD4 count is PCP prophylaxis recommended in HIV patients?
CD4 < 200
What is the preferred PCP prophylaxis in patients with HIV?
TMP/SMX 1 DS Tab PO Daily
Which other medications (besides Septra) can be used for PCP prophylaxis?
- Dapsone (OK if Sulfa allergy BUT NOT if previous SJS/TEN from Septra)
- Atovaquone 1500 mg PO daily
- INH pentamidine monthly
How long do you continue PCP prophylaxis for in patient you begin treating for HIV?
Continue prophylaxis until CD4 count stabilized > 200 for at least 3 months
When is MAC prophylaxis recommended in HIV patients?
When CD4 < 50 AND the patient is either not starting ART therapy or not on fully suppressive therapy. DO NOT need to give prophylaxis if the patient is starting regular ART therapy.
What is the prophylactic therapy for MAC in HIV patients?
Azithromycin 1200 mg PO weekly
Can also use clarithromycin
Which infection do HIV patients require prophylaxis for once CD4 count drops < 100?
Toxoplasmosis if the patient is toxoplasmosis IgG positive.
What is the recommended regimen for toxoplasmosis prophylaxis in HIV patients?
TMP/SMX 1 DS Tab PO Daily
What would you use for prophylaxis of PCP in pregnancy, if needed?
You would treat with Septra, but supplement with folic acid during the first trimester to prevent neural tube defects.
What are the treatment options for infection with PCP in HIV patients?
(1) TMP-SMX 15-20 mg/kg IV x 21d
Alternatives for moderate-severe disease:
(A) Primaquine + clindamycin IV
(B) Pentamidine IV
Alternatives for mild to moderate disease:
(A) Dapsone + TMP
(B) Primaquine + clindamycin PO
(C) Atovaquone 750 mg PO BID
What qualifies as severe PCP infection, warranting treatment with steroids?
If PaO2 < 70% OR A-a gradient > or = 35 mmHg:
Treat with tapering steroid regimen for 21 days:
Prednisone 40 mg PO BID x 5d, then
20 mg PO BID x 5d, then
20 mg PO daily x 11d
What is the preferred treatment for MAC infection in the setting of HIV?
Clarithromycin + ethambutol OR
Azithromycin + ethambutol
12 months of treatment
What are the preferred treatments (2) for toxoplasmosis infection in patients with HIV?
(1) Sulfadiaxine + pyrimethamine
(2) Pyrimethamine + clindamycin
What CD4 count cutoff puts you at risk for PML in HIV?
< 100
What CD4 count puts you at risk for CNS lymphoma in patients with HIV?
< 50
What CD4 count cutoff puts you at risk for CMV infection in patients with HIV?
< 50
At what HIV viral load would you recommend a mother undergo a scheduled C/S rather than spontaneous vaginal delivery?
VL > 1000
What is the preferred treatment for HIV in pregnancy?
Dolutegravir
