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HIV and AIDS Flashcards

1
Q

Define HIV

A

Enzyme-linked immunosorbent assay (ELISA) and Western blot positive

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2
Q

Define AIDS

A
  • CD4+ cell count that is, or every has been, less the 200 cells/mm3
  • HIV seropositive and a diagnosis of an AIDS-defining illness (ADI)
    • Tuberculosis
    • Kaposi sarcoma
    • Non-Hodkin lymphoma
    • P. jiroveci
    • Toxoplasmosis
    • Crptococcal meningitis
    • Mycobacterium avium
    • Cytomegalovirus
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3
Q

Perinatal/Vertical transmission of HIV

A
  • about 25% risk
  • oral zidovudine at 13-14 weeks gestation (mom)
  • zidovudine intravenous loa and infusion during labor and delivery (mom)
  • oral zidovudine for first 6-8 weeks of life (neonate)
  • usually zidovudine is prescribed as a component of three-drug antiretroviral regimen, reducing risk to less than 1%
  • elective cesarian section: viral load greater than 1000 copies/ml
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4
Q

Conversion Syndrome

A

1) Occurs within days to weeks after initial infection
2) High viral load
3) Fever, rash, fatigue, malaise, lymphadenopathy

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5
Q

Screening for HIV

A

1) anual screening for all Americans 13-64 years of age
2) OraQuick Advantage HIV-1 and HIV-2
- 20 minute rapid test
- approved for over-the-counter status
3) HIV ELISA
- enzyme linked immunosorbent assay
- high sensitivity
4) Western blot
- high specificity
- cost

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6
Q

Antiretrovirals

A

1) Nucleoside reverse transcriptase inhibitors (NRTIs)
2) Nucleotide reverse transcriptase inhibitors
3) Nonnucleoside reverse transcriptase inhibitors (NNRTIs)
4) Protease inhibitors (PIs)
5) Fusion inhibitors
6) Coreceptor antagonists
7) Integrase inhibitors

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7
Q

Treatment principles for HIV

A

1) Monotherapy is never appropriate (except in certain extenuating cases involving pregnancy)
2) Standard of care consists of three concurrent antiretrovirals
3) Resistance testing is indicated in treatment-naive patients initiating therapy and in treatment failure.
Treatment failure: Inability to achieve undetectable viral load (less than 48 copies/mL) at 24 weeks o presence of a viremia in a patient who had previously achieved an undetectable viral load.
4) Primary goal is undetectable viral load, Secondary goal is an increase CD4+ cell count.
5) Therapy is lifelong, and it requires strict adherence
6) For drug toxicity, it is acceptable to exchange a substitute frug from the same class as the offending agent without altering the entire antiretroviral regimen.
7) Salvage therapy: Use of unconventional antiretroviral combinations in an effort to achieve an undetectable viral load (usually in treament-experience patients)
8) Current treatment may reduce infectivity, but is never curative

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8
Q

General principles of resistance testing in HIV

A

1) Costly and time-consuming
2) Sometimes difficult to interpret
3) Requires a viral load of at least 1000 copies/mL to be performed
4) Patients should continue on failing antiretroviral regimens while testing is performed

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9
Q

Genotype resistance testing in HIV

A

1) Analysis of viral genetic mutations known to be associated with resistance to particular antiretrovirals
2) Preferred testing modality early in the course of the disease (naive patients)
3) Less costly and quicker turnaround compared with phenotypic assays
4) Provides resistance or susceptible data and associated mutation present
5) May become particularly difficult to interpret when several mutations are present.

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10
Q

Phenotype resistance testing in HIV

A

1) Measure of direct susceptibility, which requires viral culture
2) Preferred testing modality in treatment-experienced patients
3) More costly and time-consuming than genotyping
4) May account for “mixtures” of mutations that are synergistic or antagonistic

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11
Q

Guidelines for initiating HIV therapy

A

1) initiate therapy in all patietns with an ADI or a CD4+ count less than 500 cells/mm3
2) Initiate therapy (regardless of CD4+) in patients who are pregnant, have HIV nephropathy, or have hepatitis B confection (when hepatitis B treatment is indicated)
3) Treatment is recommended for patients with a CD4+ count between 350 and 500 cells/mm3
4) In patients with a CD4+ count >500 cells/mm3, the panel was split 50:50 to treat or make treatment optional
5) Patients and/or providers may choose to defer or initiate therapy on a case-by-case basis

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12
Q

Preferred antiretroviral combinations for initiating therapy

A

1) Two NRTIs plus one NNRTI: Tenofovir plus emtricitabine plus efavirenz
2) Two NRTIs plus one PI
- Tenofovir plus emtricitabine plus ritonavir-boosted atazanavir
- Tenofovir plus emtricitabine plus darunavir
3) Two NRTIs plus one integrate inhibitor
- Tenofovir plus emtricitabine plus raltegravir

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13
Q

Other considerations in initiating therapy in HIV

A

1) Monotherapy should be avoided (although in unusual circumstances, zidovudine may be employed
2) Dual and triple NRTI regimens should be avoided
3) Efavirenz should not be employed during pregnancy in the first trimester or in women of childbearing potential who are not on adequate contraception
4) Nevirapine should not be initiated in treatment naive women with CD4+ greater than 250 cells/mm3 or in men the CD4+ cell counts greater than 400 cell/mm3
5) Zidovudine and stavudine should not be combined secondary to the risk of drug-drug antagonism

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14
Q

Vaccinations in HIV

A
  • No live vaccines
    • varicella unless CD4+ cell count >200
    • zoster unless CD4+ cell coung >200
    • intranasal influenza
  • Inactivated vaccines may be administered
  • Specially indicated:
    • Hepatitis A (MSM)
    • Hepatitis B
    • Pneumococcal (every 5 years)
    • Tdap (once during adulthood and then tetanus and diptheria (Td) every 10 years)
    • Influenza (inactivated form yearly)
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15
Q

Tuberculosis (TB) Screening in HIV

A

1) Mantoux test (purifited protein derivative (PPD) of tuberculin
2) Yearly screening
3) Read in 48-72 hours
4) Positive test (greater than 5mm) - follow up with chest radiograph
5) Blood-based assays: QuantiFERON-TB may be used instead of PPD

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16
Q

NRTI - Zidovudine

A
  • anemia

- not to be combined with stavudine

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17
Q

NRTI- Didanosine EC

A
  • do not crush or chew
  • peripheral neuropathy
  • pancreatitis
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18
Q

NRTI - Lamivudine

A
  • relatively benign adverse effect profile

- activity against hepatitis B

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19
Q

NRTI - Emtricitabine

A
  • lamivudine analogue with a long half-life, once-daily dosing
  • activity against hepatitis B
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20
Q

NRTI - Abacavir

A
  • hypersensitivity reactions (rash, shortness of breath

- HLA_B*5701 screening (positive test precludes drug use

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21
Q

NRTI - Tenofovir

A
  • often classified with the NRTIs
  • nephrotoxicity
  • activity against hepatitis B
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22
Q

NNRTI - Nevirapine

A
  • low resistance ceiling
  • dosing tiration reduces incidence of rash
  • risk of hepatitis (based on sex an CD4* cell count)
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23
Q

NNRTI - Efavirenz

A
  • bedtime dosing to avoid “central nervous sytem (CNS) disengagement” and dizziness
  • nightmares and vivid dreams
  • avoid in patients with substance abuse or psychiatric diseases such as depression
  • avoid in pregnancy and in women of childbearing potential
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24
Q

NNRTI - Etravirine

A

“Second-generation” NNRTI with higher resistance ceiling and twice-daily dosing

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25
Q

NNRTI - Rilpivarine

A

“Second-generations” NNRTI with slightly higher resistance and once-daily dosing

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26
Q

PI - Saquinavir

A
  • gastrointestinal (GI) toxicity

- should be boosted with ritonavir

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27
Q

PI - Ritanovir

A
  • GI toxicity
  • potent CYP P450 inhibitor
  • Never employed at its therapeutic doses because of its adverse effect profile but often used as a low-dose booster of other PIs (reduced daily dose or frequency of substrate PI)
  • as a “booster”, not counted as an antiretroviral component of a given regimen
  • many drug-drug interactions
  • newly formulated tablets do not require refrigeration
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28
Q

PI - Indinavir

A
  • less commonly employed

- maintain hydration status - Nephrolithiasis risk

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29
Q

PI - Nelfanivir

A
  • high incidence of diarrhea, which is amenable to OTC products
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30
Q

PI - Fosamprenavir

A
  • GI toxicity
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31
Q

PI - Lopinavir/itonavir

A
  • a fixed-dse combination of lopinavir and a boosing dose of ritonavir
  • GI toxicity
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32
Q

PI - Atazanavir

A
  • the PI least likely to alter serum lipid levels
  • may cause a “nontoxic” increase in serum bilirubin and associated jaundice
  • requires acidity for absorption; avoid PPIs; space 12 hours apart from H2 receptor blockers and antacids
  • ritonavir boosting is required when the drug is coadministered with tenofovir
33
Q

PI - Tipranavir

A
  • must be ritonavir boosted in all cases

- may possess a unique resistance profile compared with other PIs

34
Q

PI - Darunavir

A
  • must be ritonavir boosted in all cases (requires lower daily dose of ritonavir than tipranavir)
  • may possess a unique resistance profile compared with other PIs
35
Q

Fusion Inhibitor - Enfuvirtide

A
  • reserved for salvage therapy
  • subcutaneous administration
  • costly
36
Q

Coreceptor Antagonism - Maraviroc

A
  • CCR5 blocker
  • costly
  • requires tropism assay
  • several philosophical concerns
37
Q

Integrase Inhibitors - Raltegravir

A
  • few adverse effects (may increase creatine phosphokinase levels
  • few drug-drug interactions
38
Q

Combination products

A

?

39
Q

Common drug-drug interactions

A

?

40
Q

HIV treatments failure

A

1) When viral load does not become undetectable within 24 weeks of therapy or when a previously undetectable viral load becomes detectable (greater than 48 copies/ml)
2) Role of resistance test
3) Considerations
a) adherence
b) serious coinfections (pneumonia)
c) recent immunizations

41
Q

AIDS - Opportunistic infection prophylaxis

A

1) Primary - prevention of initial infections
2) Secondary - Prevention of reinfection
3) Discontinuation - Acceptable if patient is above CD4* count threshold for at least 3 months with a sustained undetectable viral load (primary vs secondary

42
Q

AIDS - common opportunistic infections

P. jiroveci pneumonia (PCP)

A
  • Symptoms: cough, fever, hypoxia

- Primary: (CD4* count 200 cells/mm3 for at least 3 months

43
Q

AIDS - common opportunistic infections

Toxoplasmosis (Toxoplasma gondii)

A
  • Symptoms: headache, confusion
  • Primary (CD4* cell count <100 cell/mm3) - Sulfatrim DS once daily
  • Secondary: sulfadiazine plus pyrimethamine (reduced treatment doses) plus leucovorin
  • Treatment - sulfadiazine plus pyrimethamine plus leucovorin
  • Prophylaxis alternatives:
    • Dapsone plus pyrimethamine plus leucovorin
    • ATovaquone with or without pyrimethamine plus leucovorin
  • Discontinuation: CD4* cell count 200 cells/mm3 for at least 3 months (6 months in cases of secondary prophylaxis after a full treatment course
44
Q

AIDS - common opportunistic infections

M. avium complex

A
  • Symptoms - cough, fever, lymphadenopathy, disseminated infection (positive blood cultures)
  • Primary (CD4+ cell count 100 cells/mm3 for at least 3 months (6 months in cases of secondary prophylaxis after a full treatment course)
45
Q

AIDS - common opportunist infections

Candidiasis

A
  • Thrush - fluconazole (oral)

- Esophageal: fluconazole (intravenous or high dose)

46
Q

AIDS - common opportunistic infections

Herpes simplex virus-1 and -2

A
  • acyclovir o similar analog

- treatment (high dose) versus suppressive therapy (ongoing low dose)

47
Q

HIV/AIDS
Postexposure Prophylaxis
Percutaneous

A

risk 0.32%
Key questions:
- When did the exposure occur
- What was the device being used for (e.g., im injection, venipuncture)
- What (if anything) is known about the status of the source patient

Treatment:

1) three-drug regiment (two NRTIs plus one PI x 30 days
2) baseline and followup testing
3) safer sex
4) risk reduction of 0.79%

48
Q

HIV/AIDS
Postexposure Prophylaxis
Mucus membrane

A

risk 0.1%
Treatment
1) two drug regimen (two NRTIs) for 30 days
2) baseline and followup testing

49
Q

HIV/AIDS
Postexposure Prophylaxis
Intact skin

A

risk less than 0.1%

treatment not recommended in most circumstances

50
Q

HIV/AIDS

Nonoccupations PIP

A

Conroversial

Treatment not recommended in most circumstances

51
Q 
HIV/AIDS
Preexposure prophylaxis (PrEP
A

Controversial public health intervention to reduce transmission among high-risk individuals

  • ELISA and creatinine clearance at baseline
  • Screen for STIs/hepatitis B
  • Truvada 1 orally daily x 90 days
  • At 30 days and then yearly - renal function tests
  • at 90 days: HIV ELISA
  • at 6 months: Screen for STIs/hepatitis B
  • Ongoing: risk reduction, condoms, counseling
52
Q

HIV/AIDS

Primary care

A

1) Screen all HIV-seropositive patients for other STIs
2) HIV screening is a standar component of prenatal testin
3) Baseline hepatitis A, B, and C serologies

53
Q

HIV/AIDS
Postexposure Prophylaxis
Percutaneous

A

risk 0.32%
Key questions:
- When did the exposure occur
- What was the device being used for (e.g., im injection, venipuncture)
- What (if anything) is known about the status of the source patient

Treatment:

1) three-drug regiment (two NRTIs plus one PI x 30 days
2) baseline and followup testing
3) safer sex
4) risk reduction of 0.79%

54
Q

HIV/AIDS
Postexposure Prophylaxis
Mucus membrane

A

risk 0.1%
Treatment
1) two drug regimen (two NRTIs) for 30 days
2) baseline and followup testing

55
Q

HIV/AIDS
Postexposure Prophylaxis
Intact skin

A

risk less than 0.1%

treatment not recommended in most circumstances

56
Q

HIV/AIDS

Nonoccupations PIP

A

Conroversial

Treatment not recommended in most circumstances

57
Q 
HIV/AIDS
Preexposure prophylaxis (PrEP
A

Controversial public health intervention to reduce transmission among high-risk individuals

  • ELISA and creatinine clearance at baseline
  • Screen for STIs/hepatitis B
  • Truvada 1 orally daily x 90 days
  • At 30 days and then yearly - renal function tests
  • at 90 days: HIV ELISA
  • at 6 months: Screen for STIs/hepatitis B
  • Ongoing: risk reduction, condoms, counseling
58
Q

HIV/AIDS

Primary care

A

1) Screen all HIV-seropositive patients for other STIs
2) HIV screening is a standar component of prenatal testin
3) Baseline hepatitis A, B, and C serologies

59
Q

HIV/AIDS
Managing adverse effects and comorbidities
Nausea and vomitting

A
  • may respond to PPI, H2 blockers, antacids, prokinetic
  • prn antiemetics such a prochlorperazine, promethazine or ondansetron may be considered in patients with severe complaints
  • avoid PPIs with atazanavir
  • space H2 blockers and antacids when they are combined with atazanavir
60
Q

HIV/AIDS
Managing adverse effects and comorbidities
Diarrhea

A
  • consider loperamide

- nelfinavir-induced diarrhea is common and responds well to OTC products

61
Q

HIV/AIDS
Managing adverse effects and comorbidities
Depression

A
  • SSRIs are often the preferred agents

- duloxetine and other SRNIs may be beneficial in patients with peripheral neuropathies

62
Q

HIV/AIDS
Managing adverse effects and comorbidities
Hyperlipidemia

A
  • treat as you would in an HIV-seronegative patient
  • diet and exercise for at least 6 months before considering hyperlipidemia therapy
  • certain antiretrovirals may be more commonly associated with lipid disturbances, whereas only atazanavir has been associated with reductions in serum lipids
  • preferred LDL-C lowering agents include preavastatin, atorvastatin and rosuvastatin. other statins should be avoided because of their propensity to interact with various PIs
  • other lipid altering agents, including fish oil, niacin, and vibrates may be used inpatients with HIV infection, but drug interaction resources should always be consulted
  • use the lowest dose of an anithyperlipidemic agent and titrate upward
63
Q

HIV/AIDS
Managing adverse effects and comorbidities
Anxiety

A

avoid triazolam and midazolam

64
Q

HIV/AIDS
Managing adverse effects and comorbidities
Tuberculosis

A
  • avoid rifampin, substitute with rifabutin

- several drug-druginteractions; consult references and/or exper

65
Q

HIV/AIDS
Managing adverse effects and comorbidities
Erectile dysfunction

A
  • common condition among men with HIV infectinos secondary to hypogonadism and/or depression
  • use erectile dysfunction medication cautiously, especially when coprescribed with ritanovir (dose reductions will be necessary)
    • Sildenafil: 25mg every 48 hours
    • Vardenafil: 2.5mg every 72 hours
    • Tadalafil: 10mg every 72 hours
66
Q

HIV/AIDS

Common recreational drugs of abuse

A

1) Methamphetamine
2) Methyenedioxymethamphetamine (MDMA)
3) gamma-hydroxybutyric acid (GHB)
4) Amyl and butyl nitrates and nitrites “poppers”

67
Q

HIV in Pregnancy

A
  • IF mono therapy AZT (zidovudine)

- want mon on 3 drugs

68
Q

AVOID in pregnancy

A
  • didanosine - higher risk of lactic acidosis
  • stavdine - higher risk of lactic acidosis
  • tenofovir - bone issues
  • efavirenz ***** absolute contraindication - teratogentic
69
Q

transmission of hepatitis

A

A is for “ate” - fecal oral
B is for blood and bodily fluids
C is for “cut” - needles, dirty tattoo instruments

70
Q

Atripla

A

3 antiretrovirals

- efavirenz
- TF
- FTC - not dosed in morning - gives a buzz - can cause vivid dreams/nightmares
 - not drug users
 - not schizophrenics - efavirenz - therefore not pregnant women
71
Q

Triple therapy drugs

A
  • Atripla
  • Complera
  • Stribild
72
Q

boosting

A

Ratonivir - 200mg bid for CYP inhibitor to boost PI’s to decrease to once daily from
Ritanovir- go toxicity
new booster - cobicistat (Strbild) - not antiretroviral so doesn’t contribute to resistance and not gi toxicity

73
Q

Tonopovir

A

mild renal toxicity

74
Q

ebacovir

A

the A in ebacovir is for anaphylaxis
test for HLA-B*5701
always test before starting

75
Q

atazanovir

A
  • increases bilirubing up to 5x normal
  • may decrease serum lipis (only PI that doesn’t increase
  • A in atazanovir means acid - cant take with PPIs
76
Q

A in AZT

A

Anemia

77
Q

Vaccines in HIV patients

A
  • can’t get live vaccines
    • varicellar
    • zoster
    • MMR
    • Flumist
  • can get dead vaccines as often as you want
    • may not develop immunity if CD4 count is low
78
Q

Prophylasis for AIDs Defining Illnesses

A

PCP, Toxo MAC
CD4 count less than 200 bactrim for PCP
CD4 count less than 100 bacterium for toss
CD4 count less and 50 azithromycin 1200mg once a week
Prophylaxis can be discontinued if CD4 count is above the threshold for 3-6 months and the viral load is undetectable

HIV and AIDS (1 decks)

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