HIV-AIDS - 12 questions Flashcards
Route of transmission
-exposure of mucous membrane or damaged tissue to infected body fluids
- blood stream exposure to infected body fluids
- mother-to-child
OraQuick - rapid at home testing
Seroconversion window is 3 months
one line is a negative test
2 lines is a positive
Nucleoside reverse transcriptase
drugs, MOA, and class adverse effects
result in elongation termination of growing proviral DNA chain
AE: mitochondrial toxicity and lactic acidosis
*Emtricitabine
*Lamivudine
*Tenofovir DF
*Tenofovir alafenamide
Abacavir
Zidovudine
*Seen in first line regimens
NRTIs - Abacavir AE
Hypersensitivity reaction
- Must get HLAB57 genetic testing before starting to avoid the hypersensitivity reaction
NRTIs - Tenofovir disoproxil fumarate AE
Osteomalacia and renal insufficiency
NRTIs - Zidovudine
Bone marrow suppression
Non-nucleoside reverse transcriptase inhibitors
MOA, Drugs, and class adverse effects
all have -vir- in middle
bind to allosteric site of reverse transcriptase enzyme reducing its function
Class AE
- rash
Efavirenz
Nevirapine
Etravirine
Rilpivirine
Doravirine
NNRTIs - Efavirenz
counseling and AE
Take on empty stomach at bedtime
AE - CNS (suicidality, abnormal dreams)
NNRTIs - Nevirapine
Counseling
Titrate dose over 14 days to avoid rash - Administer 200mg daily for 14 days then increase to 200mg BID or 400mg daily (stevens-johnsons syndrome)
NNRTIs - Etravirine
Counseling
Take with food
NNRTIs- Rilpivirine
counseling
Take with meal (not protein shake)
must be at least 390 calories
Protease inhibitors and boosting
MOA, Class AE, and drugs
all end in -navir
inhibit viral protease preventing the assembly, maturation, and release of new virions
Class AE
- GI intolerance, insulin resistance, and lipodystrophy
Atazanavir/ cobicistat
Darunavir/ cobicistat
Fosamprenavir
Lopinavir/ritonavir
Nelfinavir
Ritonavir
Tipranavir
Boosting: adding ritonavir or cobicistat at low doses (do not have any antiviral effect at this dose) are potent inhibitors of CYP3A4 - adding increases absorption, lengthened elimination half-life
PIs- Atazanavir
Counseling and AE
Take with food
Indirect hyperbilirubinemia
PIs - Ritonavir
AE
Even with antiviral dose and low dose for bosting can cause nausea, vomitting, and diarrhea
Integrase Strand Transfer inhibitors
MOA, Class AE, and drug names
- all end in -tegravir
Inhibit HIV integrase, prevents HIV DNA from integrating into the host cell
Class AE
weight gain
*Dolutegravir
*Bictegravir
Elvitegravir
Raltegravir
Cabotegravir
- are first line options in combo therapy with other classes
INSTIs - Raltegravir
drug specific side effect
CK elevation
INSTIs - Cabotegravir
administration
30mg tablets; 200mg/ml injectable solution
30mg daily lead in for > or equal to 28 days
INSTIs- Elvitegravir
Counseling
TAKE with food
INSTIs - Dolutegravir
Dosing specifics
50mg daily - for INSTI-naive patients
50mg BID - for INSTI-experienced
BID dosing regimen is also required when co-administered with UGT1A/CYP3A4 inducers (rifampin, Fosamprenavir/ritonavir, tipranavir/ritonavir)
Attachment inhibitor - Fostemsavir
MOA, AE
Bind to gp120 on the surface of HIV, blocking attachement to CD4 T-cells
Last line therapy for those who have failed multiple other therapies
AE
- Nausea
- QTc prolongation
-elevated transaminases
Post-Attachment inhibitor - Ibalizumab-uiyk
Bind to domain D2 on the CD4 cell and inhibits the post attachment steps required for HIV to enter host cell
IV administration
Chemokine coreceoptor 5 antagonist - Maraviroc
MOA, Precautions and interactions
binds to CCR5 on the CD4 cell and inhibits the binding of gp120 thus preventing entry of the HIV into host cell
**Before treatment can be considered MUST do a tropism assay (ONLY ACTIVE AGAINST CCR5-TROPIC strains of HIV) - EXAM Q
- Tropism assay for CXCR4 or CCR5 - would use this drug in patients who’s results come back exclusively CCR5
Capsid inhibitor - Lenacapavir
MOA, administration, what is it approved for
Bind to the interface between capsid protein (p24) subunits and interfere with uptake of proviral DNA, assembly and release, and capsid core formation
Only approved in patients with multidrug resistant infection who are failing their antiretroviral regimen
927mg SUBQ every 6 months (plus lead-in of 600mg PO daily for 2 days)
Single tablet regimen - first line options
Biktarvy - Bictegravir + emtricitabine + tenofovir alafenamide daily
Dovato - Dolutegravir + lamivudine
Other combination tablets - first line options
Truvada - Emtricitabine 200mg + Tenofovir Df 300mg daily
Descovy - Emtricitabine 200mg + Tenofovir Alafenamide 25mg daily
Cimduo and Temixys - Lamivudine + Tenofovir DF (both 300mg daily
Website housing the federally approved HIV/AIDs medical practice guidelines
HIV.gov
HIV-drug interactions.org
Goals of therapy
Maximally and durably supress plasma HIV RNA to below the lower level of detection of the assay
restore and preserve immunologic function
reduce HIV associated morbidity and prolong the duration and quality of survival
prevent transmission
When to start therapy and what to start
Recommended for all HIV-infected persons regardless of CD4 count
monotherapy is a big NO NO
want to start
Two NRTIs in combo with a third active ARV from of three drug classes
1. INSTI (-tegravir)
2. NNRTIs (-vir-)
3. PI boosted (-navir)
INSTI based initial regimens
- Biktarvy - once daily
- Dolutegravir + Truvada (tenofovir DF + Emtricitabine) OR Descovy (Tenofovir alafenamide + emtricitabine) OR Cimduo/Temixys (Lamivudine + Tenofovir DF)
- Dovato: Dolutegravir + Lamivudine
- Except for individuals with HIV RNA >500,000 - Dolutegravir/abacavir/lamivudine
ONLY IF HLAB*57 NEGATIVE
PI-based regimen initial treatment options
- Darunavir/cobicistat/emtricitabine/tenofovir alafenamide (symtuza)
- Doravirine/cobicistat PLUS abacavir/lamivudine
- IF HLAB*57 NEGATIVE
NNRTI-based regimen initial treatment options
- Doravirine/tenofovir DF/Lamivudine (delstrigo)
OR
Doravirine/tenofovir alafenamide/emtricitabine - Rilpivirine/Tenofovir alafenamide/emtricitabine (odefsey)
-IF HIV RNA <100,000 and CD4 >200
Drug interactions and what to do
ACID reducers -EXAM Q
Separate antacids from PO INSTIs by 6 hours, but NEVER give raltegravir with Al or MG
Atazanavir and PO rilpivirine are reduced by acid reducers; rilpivirine is contraindicated with PPIs
Drug interactions and what to do
Benzodiazepines - EXAM Q
With protease inhibitors and cobicistat, preferred benzodiazepines are lorazepam, oxazepam, and temazepam (LOT)
Drug interactions and what to do
Cortiocosteroids - EXAM Q
with protease inhibitors and cobicistat, beclomethasone is preferred
Drug interactions and what to do
Statin - EXAM Q
With protease inhibitors and cobicistat, low doses of atorvastatin, rosuvastatin, pitavastatin, or pravastatin are preferred.With NNRTIs, dose may need increased.
Drug interactions and what to do
Biguanide - EXAM Q
Dolutegravir increases metformin, so a dose decrease of metformin may be necessary.
Drug interactions and what to do
PDE5 inhibitors - EXAM Q
With protease inhibitors and cobicistat, use very low doses q48-72 hours.
Drug interactions and what to do
Polyvalent cation supplements - EXAM Q**
With integrase inhibitors, space apart by 6 hours. Coadministration of Ca/Fe with dolutegravir or bictegravir OK if also taken with food.
Genetic resistance
NNRTIs and boosted-PIs
boosted-PIs need 3 or 4 mutations to have resistance - high genetic barrier to resistance
NNRTIs - have a lower genetic barrier to resistance - only need 1 mutation to cause resistance
Resistance testing
1.ALWAYS at entry to care
- Virologic failure or suboptimal viral response
- genotype is recommended when failing 1st and 2nd regimen
- Specimen should contain >500 copies/ml for best likelihood of yielding a successful standard resistance test - EXAM Q
Undetectable equals untransmittable
Maintaining plasma HIV RNA <200 copies/ml with ART prevents sexual transmission of HIV to sexual partners
Another form of prevention should be used for at least 6 months and until HIV RNA <200 (condoms PrEP, abstinence)
Pre-exposure prophylaxis (PrEP)
Who should start it, contraindications, lab testing needed before starting, what are options
- those with sexual partner HIV positive
- those having unprotected sex with unknown HIV status partner
- A recent bacterial sexually transmitted infection
- injection drug use with sharing needles
- anyone who requests
Contraindications:
Weight <77kg
HIV infection
suspected exposure in last 72 hours
Lab testing before starting:
If considering oral get CrCl, Hep B, Cholesterol and triglycerides
Oral regimens
1. Emtricitabine/Tenofovir DF for all risk groups
- NO if CrCl <60
- Emtricitabine/Tenofovir alarenamide PO daily for men and transgender women who have sex with men
- NO if CrCl <30
Injectable
- Cabotegravir 600mg IM - second dose 1 month after first then q2 months thereafter
Post-exposure prophylaxis (PEP)
who is recommended for it, what are the regimens
recommended after an accidental exposure to HIV has occured : Healthcare setting, sexual assult, accidental condom break
Emtricitabine/tenofovir DF for 28 days + raltegravir PO BID for 28 days OR Dolutegravir 50mg PO daily for 28 days)
Must initiate withing 72 hours or little benefit will be optained
monitor
- rapid testing at baseline, at 4-6 weeks, and at 3 months
Stages of HIV
stage 1: CD4 > or equal to 500 and CD4 % > or equal to 26
Stage 2: CD4 200-499 and CD4% 14-25
Stage 3 (AIDs): CD4 <200 and CD4% <14
