HIV/AIDs

Question 1

What laboratory assays would you diagnose HIV/AIDs?

Answer 1

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

Question 2

What were the results of the START study?

Answer 2

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)

Question 3

What is the HPTN-052 study?

Answer 3

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

Question 4

When can Dovato (DTG + lamivudine) be used?

Answer 4

Except for HIV RNA >500K c/mL, HBV co-infection, before resistance testing (specifically reverse transcriptase aka lamivudine resistance)

Question 5

What time period is recommended to avoid DTG in pregnancy?

Answer 5

First 6 weeks and for women that wish to conceive

Question 6

What first line agents impact MATE-1 and inhibits tubular secretion of creatinine?

Answer 6

Cobicistat, DTG, bictegravir

Expect SCr to increase 10-20% within 1-2 weeks and plateus

Question 7

How should metformin (pathway of elimination) be adjusted due to OCT2 and MATE-1 inhibition? What HIV meds would cause this interaction?

Answer 7

DTG and BTG

Titrate metformin slowly

Question 8

What cardiac medication is CI with OCT2 and MATE-1 inhibitors?

Answer 8

Dofetilide is contraindicated with DTG and BTG

Question 9

What statins should be separated or dose adjusted with HIV medications? What HIV medication would cause this?

Answer 9

EVG/c

Avoid simvastatin and lovastatin; limit atorvastatin to 20 mg

Question 10

What symptoms are expected with abacavir associated hypersensitivity?

Answer 10

Multi organ system sundrome with symptoms from >at least 2:

- Fever, rash, GI (N/V/D or abdominal pain), malaise/fatigue, cough, dyspneia

Question 11

What co-morbid condition should be avoided with abacavir?

Answer 11

High cardiac risk (MI, stroke)

Question 12

When should HIV VL and CD4 be follow up after initiating ART?

Answer 12

HIV VL 2-8 weeks (expect 10 fold decrease at 4 weeks)

CD4 3-6 months (expect 50 cell/mm3 increase in 3 mo)

Question 13

Describe the design and outcomes of the iPrEx trial?

Answer 13

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)

Question 14

How often should follow up testing occur after PrEP is initiated?

Answer 14

3 months (HIV test, adherence counseling, side effects, STI symptom assessment)

Question 15

When should steroids be started in PJP pneumonia?

Answer 15

PaO2 < 70 mmHg, arterial-alveolar O2 gradient > 35 mmHg

Question 16

What is defined mild-moderate vs moderate-severe PJP? What is the treatment regimen of each?

Answer 16

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)

Question 17

How long would you continue primary or secondary prophylaxis for the following opportunistic infections?

• PJP
• Toxoplasmosis
• MAC

Answer 17

• 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

Question 18

How would you treat oropharyngneal candidiasis?

Answer 18

Preferred: Fluconazole 100 mg PO daily (duration: 7-14 days)
Alternative: Clotrimazole troches, miconazole mucoadhesive buccal tablets, nystatin oral suspension

Question 19

What is the preferred/alternative treatments and treatment duration for Toxoplasmosis Encephalitis?

Answer 19

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

Question 20

What is the preferred treatment regimens for Cryptococcal meningitis?

Answer 20

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

Question 21

How do you treat disseminated MAC? What is treatment duration and considerations for discontinue treatment therapy?

Answer 21

Preferred: Clarithromycin or Azithromycin PO + ethambutol

Duration: At least 1 year
* Asymptomatic with a CD4 > 100 cells/mm3 for >6 months on ART

Question 22

When do you add additional drugs for disseminated MAC? What additional drugs can you add?

Answer 22

When CD4 < 50, high mycobacterial load (> 2 log CFU/mL of blood) or absence of effective ART

Alternatives: rifabutin, amikacin/streptomycin or levoflxoacin/moxifloxacin

Question 23

When should ART be delayed in opportunistic infections?

Answer 23

• 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

Question 24

When should ART be started immediately in HIV associated OIs?

Answer 24

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

Question 25

Which patient groups should efavirenz be avoided?

Answer 25

• Psychiatric history (ex: depression) or psychoactive medication