HIV/AIDs Flashcards
What laboratory assays would you diagnose HIV/AIDs?
Step 1: HIV antigen/antibody combination immunoassay - detects antibodies for HIV-1 and HIV-2 infection and p24 HIV antigen
Step 2: HIV 1 and 2 differentiation immunoassay
- Detects antibodies to HIV-1 or 2 and differentiates between the 2 strains
If HIV 1 and 2 differentiation indeterminate,
can pursue HIV-1 nucleic acid testing
What were the results of the START study?
Studied initiation of ART asymptomatic HIV infection, immediate ART vs deferred ART (CDR < 350)
Primary outcome:
- Death from AIDs or any AIDs defining event, hodgkin’s lymphoma (72% reduction p < 0.001 in immediate ART)
- Serious non-AIDs related event: CVD, ESRD, liver disease, non-AIDs defining cancers (SCC), death from CA (39% reduction in immediate ART)
What is the HPTN-052 study?
Looked at antiretroviral therapy to prevent HIV transmission within HIV infected serodiscordant couples, immediate ART vs delayed ART (CD4 < 250)
- Primary outcome: HIV transmission (overall 39 transmission events, most transmission occurred in delayed arm (27), p < 0.001)
- Primary clinical endpoints: WHO stage 4 events, pulmonary TB, severe bacterial infection and/or death
When can Dovato (DTG + lamivudine) be used?
Except for HIV RNA >500K c/mL, HBV co-infection, before resistance testing (specifically reverse transcriptase aka lamivudine resistance)
What time period is recommended to avoid DTG in pregnancy?
First 6 weeks and for women that wish to conceive
What first line agents impact MATE-1 and inhibits tubular secretion of creatinine?
Cobicistat, DTG, bictegravir
Expect SCr to increase 10-20% within 1-2 weeks and plateus
How should metformin (pathway of elimination) be adjusted due to OCT2 and MATE-1 inhibition? What HIV meds would cause this interaction?
DTG and BTG
Titrate metformin slowly
What cardiac medication is CI with OCT2 and MATE-1 inhibitors?
Dofetilide is contraindicated with DTG and BTG
What statins should be separated or dose adjusted with HIV medications? What HIV medication would cause this?
EVG/c
Avoid simvastatin and lovastatin; limit atorvastatin to 20 mg
What symptoms are expected with abacavir associated hypersensitivity?
Multi organ system sundrome with symptoms from >at least 2:
- Fever, rash, GI (N/V/D or abdominal pain), malaise/fatigue, cough, dyspneia
What co-morbid condition should be avoided with abacavir?
High cardiac risk (MI, stroke)
When should HIV VL and CD4 be follow up after initiating ART?
HIV VL 2-8 weeks (expect 10 fold decrease at 4 weeks)
CD4 3-6 months (expect 50 cell/mm3 increase in 3 mo)
Describe the design and outcomes of the iPrEx trial?
HIV seronegative men with risk of HIV acquisition was split between Truvada vs Placebo
- Outcome: 44% reduction in HIV acquisition in Truvada group, 92% reduction in HIV acquisition if patients had detectable TDF (great adherence)
How often should follow up testing occur after PrEP is initiated?
3 months (HIV test, adherence counseling, side effects, STI symptom assessment)
When should steroids be started in PJP pneumonia?
PaO2 < 70 mmHg, arterial-alveolar O2 gradient > 35 mmHg
What is defined mild-moderate vs moderate-severe PJP? What is the treatment regimen of each?
Mild-Moderate: pO2 > 70 mmHg or AA O2 gradient < 35 mmHg (TMP/SMX 2DS tabs PO TID x 21 days)
Moderate-Severe: pO2 < 70 mmHg or AA O2 gradient > 35 mmHg (TMP/SMX weight based IV x 21 days)
How long would you continue primary or secondary prophylaxis for the following opportunistic infections?
- PJP
- Toxoplasmosis
- MAC
- PJP: Continue until CD4 > 200 cell/mm3 for >3 months
- Toxoplasmosis encephalitis:
- > Primary prophylaxis is indicated for positive toxoplasma IgG and CD4 < 100. Continue until CD4 > 200 for >3 months in response in ART
- MAC
- > Only initiate primary prophylaxis for patients not on suppressive ART. Also discontinue once patients are on fully suppressive ART regimen
How would you treat oropharyngneal candidiasis?
Preferred: Fluconazole 100 mg PO daily (duration: 7-14 days)
Alternative: Clotrimazole troches, miconazole mucoadhesive buccal tablets, nystatin oral suspension
What is the preferred/alternative treatments and treatment duration for Toxoplasmosis Encephalitis?
Preferred: Sulfadiazine + pyrimethamine + leucovorin
Alternative: Clindamycin + pyrimehtamine + leucovorin, Atovaquone + pyrimethamine + leucovorin
Duration: At least 6 weeks and chronic maintenance until asymptomatic and CD4 > 200 cells/mm3 for >6 months in response to ART
What is the preferred treatment regimens for Cryptococcal meningitis?
Induction phase: Liposomal Ampho B + flucytosine (at least 2 weeks)
Consolidation phase: Fluconazole 400 mg PO daily (at least 8 weeks)
Maintenance phase: Fluconazole 200 mg PO QD (at least 1 year)
Duration: Asymptomatic and CD4 > 100 for at least 3 months on ART
How do you treat disseminated MAC? What is treatment duration and considerations for discontinue treatment therapy?
Preferred: Clarithromycin or Azithromycin PO + ethambutol
Duration: At least 1 year
* Asymptomatic with a CD4 > 100 cells/mm3 for >6 months on ART
When do you add additional drugs for disseminated MAC? What additional drugs can you add?
When CD4 < 50, high mycobacterial load (> 2 log CFU/mL of blood) or absence of effective ART
Alternatives: rifabutin, amikacin/streptomycin or levoflxoacin/moxifloxacin
When should ART be delayed in opportunistic infections?
- OIs that affect the CNS such as cryptococcal and tuberculosis meningitis, immediate ART may increase risk of serious IRIS
- MAC
*Delay for 2-3 weeks after OI treatment
When should ART be started immediately in HIV associated OIs?
PJP: should be started within 2 weeks after PCP diagnosis which has led to mortality benefit
Non-meningeal tuberculosis: start ART within 2 weeks if cell count < 50 cells/mm3 (improves long term survival) and by 8 weeks for all others
Which patient groups should efavirenz be avoided?
- Psychiatric history (ex: depression) or psychoactive medication
