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SPRING16 757 PC Adults > HIV Care > Flashcards

HIV Care Flashcards

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

1
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Recommended testing to establish HIV infection

***exam

A
  • CDC no longer recommends ELISA w/western blot
  • Use 4th generation HIV 1/2 immunoassay (detects Ag & Abs = better in acute setting)
    • If 4th gen positive
      • >> confirmatory HIV-1/HIV-2 antibody differentiation immunoassay (better in acute infection)
      • >>If indeterminate or acute HIV suspected: HIV RNA testing
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2
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Important questions/education for patients newly diagnosed w/HIV

A
  • Start with what do they know
  • How are they coping?
  • sources of support
  • offer counseling
  • how/when contracted
  • HIV is no longer a ‘death sentence’
    • Diabetes mellitus can be a useful analogy
      • Chronic, incurable disease
      • Not immediately fatal
      • Eventually requires medications in most cases
      • Can usually be controlled with careful adherence, management, and follow-up
      • As with the care of persons with diabetes, working in a team and providing continuing education is essential throughout the course of the disease
  • Patients educated about HIV and the potential for resistance have better adherence to therapy
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3
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Relationship between HIV and CD4

A

HIV Infection is characterized by a steady decline in the number of CD4 cells

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4
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

At what CD4 count do HIV infected patients develop a high risk for opportunistic infections?

***exam

A
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5
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

How did AIDS mortality changed from 1996 to 2001

A

show how haart has changed mortality. After 1996 – had PIs, which changed the game. At that time, AIDS was #1 cause of death in youngmen

Can keep from opportunist infections and death

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6
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Common responses to how they are coping w/dx of HIV

A

Common responses (in my experience):

  • “I’ve tried not to think about it, ever since I found out”
  • “I’ve watched so many friends die, and now I’m next”
  • “My friends tell me it’s not that big a deal”
  • “I’ve been researching this on the internet and I have a 10-page list of questions for you”
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7
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Why is it important to know how/when a patient contracted HIV?

A
  • Risk factor identification can guide counseling and prevention
  • Resistance
    • Increasing transmission of drug-resistant HIV strains
    • Resistance testing indicated for patients infected for ALL newly diagnosed patients, even if antiretroviral therapy is not being considered in the near future
    • Primary HIV Infection (PHI)
      • Loss of HIV-specific CD4 cells occurs immediately after PHI
      • Some evidence that early treatment of PHI may favorably influence subsequent course of disease
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8
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

CD4 Count, Viral Load, and Clinical Course

***exam

A

Early infection – may have rash, pharyngitis, lad, but pass off as sth else

Some progress quickly, but typically several years until CD4 count

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9
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Consideration if HIV+, HCV ab negative, elevated transaminases?

***exam

A
  • Up to 19% of HIV+ individuals with chronic hepatitis C have negative HCV Ab titers
  • HCV RNA PCR (viral load) testing is indicated if chronic hepatitis C suspected
  • # 1 cause of death for aids is End stage liver dz, predominantly 2/2 chronic hep c
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10
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Goals of Treatment with ART

A
  1. Reduce HIV-related morbidity
  2. Prolong the duration and quality of survival
  3. Restore and/or preserve immunologic function
  4. Maximally and durably suppress HIV viral load
  5. Prevent HIV transmission
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11
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

What is ART recommended for and why?

A
  • ALL Persons Living with HIV
  • To reduce morbidity and mortality
  • To prevention transmission of HIV
    • Perinatal
    • Heterosexual
    • MSM
    • PWID
  • * Patients starting ART should be willing and able to commit to treatment and understand the importance of adherence.
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12
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

How have ART initiation guidelines changed over the years?

A
  • Used to be much more conservative - concern regarding SEs (obs studies not sufficient evidence)
  • HPTN 052 – major study that was pivotal in looking at reduction in transmission w/HAART vs deferral showing HAART significantly reduced transmission such that the trial was stopped
  • TEMPRANO: final big RCT that showed benefit of immediate start >500
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13
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

HAART vs ART

A

used to be “highly active” after introduction of Pis which lead to drop in death rates. Now all are highly active, so we just call combo art.

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14
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

How has ART eligibility changed over time?

A

Now finally recommend all be treated!

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15
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Currently available ARTs

A
  • TAF is new – same as tenofovir but less renal toxicity
  • Complera: RPV/TDF/FTC (not for VL >100K or CD4
  • Stribild: EVG/COBI/TDF/FTC (COBI inhibits active tubular secretion of creatinine, resulting in increases in serum creatinine and a reduction in estimated creatinine clearance (CrCl) without reducing glomerular function.73 A
  • Atripla : EVF/TDF /FTC
  • Truvada: TDF/FTC
  • Ziagen: ABC/3TC
  • Atazanavir/cobicistat?
  • Darunavir/ cobisstat?
  • Genvoya EVG/COBI/FTC/TAF
  • TAF Tenofovir Adlafenamide (TAF) prodrug of TDF
  • Triumeq (DTG/ABC/3TC)
  • Evotaz (ATZ+ Cobicistat)
  • Prezcobix (DRV+ COBI)
  • TAF is being evaluated in 3 combinations:
    • elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide
    • darunavir/cobicistat/emtricitabine/tenofovir alafenamide
    • emtricitabine/tenofovir alafenamide
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16
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

HIV Replication Cycle and Sites of Drug Activity

A
  • Key is trying to attack virus where it replicates. Now say use either a PI combo w/ritonavir, or II. Have removed NNRTIs as primary tx.
  • Ritonavir is booster – boosts effectiveness w/o increasing Ses
  • Fewer interactions w/IEs as they don’t go through same pathway
  • Reverse Transcriptase
  • HIV is a retrovirus, uses RT to make RNA into proviral DNA. Humans don’t have RT.
  • Protease
  • functions to cut the long protein precursors made in the translation process into functional pieces. If not performed properly HIV is not viable.
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17
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Necessary steps, tests before starting ART

A
  • HIV Ab Confirmation, HIV VL, CD4, HIV Genotype
  • Assess understanding of disease
  • Assess Readiness to start
  • Current and PMH
  • Social History: Travel, Sexual, Substance use
  • Alcohol and Drug Use Disorder Screen
  • Mental Illness Screen
  • Housing status
  • Support systems
  • Pregnancy/ contraceptive use
  • Baseline labs: CBC, Renal Function, LFTs, Hep A, B, C status, TB status
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18
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

When is HLA-B*5701 screening recommended?

A
  • before starting ABC (abacovir), to reduce risk of hypersensitivity reaction (HSR)
  • HLA-B*5701-positive patients should not receive ABC
  • Positive status should be recorded as an ABC allergy
  • If HLA-B*5701 testing is not available, ABC may be initiated after counseling and with appropriate monitoring for HSR
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19
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

When is Coreceptor tropism assay recommended?

A
  • Should be performed when a CCR5 antagonist
  • is being considered
  • Phenotype assays have been used; genotypic test now available but has been studied less thoroughly
  • Consider in patients with virologic failure on a CCR5 antagonist (though does not rule out resistance to CCR5 antagonist)
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20
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Initial ART regimens: recommended

A

Main are integrase inhibitor based and one PI based

RAL must take once a day = used less often

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21
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

For which patients are integrase inhibitors approved?

A

all are approved for naive pts

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22
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Pros and Cons to the IE raltegravir

A
  • Pro: the longest clinical trial and post-marketing experience and has been shown to have durable potency.
  • Cons: twice daily dosing, II resistance mutations.

(don’t memorize)

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23
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Pros and Cons to the IE Elvitegravir

A
  • Pro: within a fixed-dose combination product taken as a single-tablet, once-daily regimen.
  • Cons:
  • must be given with food.
  • Cobi is a potent CYP3A4 inhibitor that may result in drug-drug interaction with other concomitant medications.
  • the fixed-dose combination product is only approved for patients with estimated creatinine clearance of ≥70 mL/min.

(don’t memorize)

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24
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Pros and Cons to the IE Dolutegravir

A
  • the most recently approved INSTI
  • Pro: It can be given once daily with or without food.
  • Pro: In randomized trials, DTG was non-inferior to RAL and was superior to both DRV/r and EFV (because of fewer drug discontinuations in those who received DTG).
  • Con: DTG has the shortest duration of follow-up and limited post-marketing experience to date.

(don’t memorize)

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25
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Recommended ART in CKD (eGFR

A
  • Consider avoiding TDF
  • If eGFR
  • EVG/c/TDF/FTC
  • ATV/c + TDF
  • DRV/c + TDF
  • Options:
  • ABC/3TC if HLA-B*5701 negative (if HIV RNA >100,000, do not use with EFV or ATV/r; if CrCl
  • DRV/r + RAL
  • LPV/r + 3TC
  • Modify TDF dose
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26
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Recommended ART in Osteoporosis

A
  • Consider avoiding TDF: associated with greater decrease in BMD, osteomalacia, urine phosphate wasting
  • Use ABC/3TC if HLA-B*5701 negative
  • (if HIV RNA >100,000 copies/mL, do not use with EFV or ATV/r)
27
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Recommended ART in Psychiatric illness

A

Consider avoiding EFV: can exacerbate psychiatric symptoms; may be associated with suicidality

28
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Recommended ART in high cardiac risk

A

Consider avoiding ABC and LPV/r: increased CV risk in some studies

29
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Recommended ART in hyperlipidemia

A
  • Adverse effects on lipids:
    • PI/r
    • ABC
    • EFV
    • EVG/c
  • Beneficial lipid effects:
    • TDF
30
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Recommended ART in pregnancy and in HCV

A

§Consult current recommendations

31
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Recommended ART in HBV

A
  • Use TDF/FTC (or TDF + 3TC) if possible: use 2 NRTIs with activity against both HIV and HBV
  • If TDF contraindicated: cotreat HBV with FTC or 3TC + entecavir or another HBV-active drug
32
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

ARV regimens not recommended:

A
  • Monotherapy with NRTI*
  • Monotherapy with boosted PI
  • Dual-NRTI therapy
  • 3-NRTI regimen (except ABC + 3TC + ZDV or possibly TDF + 3TC + ZDV)

ARV components not recommended:

  • ddI + d4T
  • ddI + TDF
  • FTC + 3TC
  • d4T + ZDV
  • DRV, SQV, or TPV as single PIs (unboosted)
  • ATV + IDV
  • EFV during first trimester of pregnancy and in women with significant potential for pregnancy*
  • NVP initiation in women with CD4 counts of >250 cells/µL or in men with CD4 counts of >400 cells/µL
  • ETR + unboosted PI
  • ETR + RTV-boosted ATV, FPV, or TPV
  • 2-NNRTI combination
  • * Exception: when no other ARV options are available and potential benefits outweigh the risks
33
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

ARV Components in Initial Therapy: INSTIs

advantages

A
  • ADVANTAGES
  • Virologic response noninferior to EFV
  • Fewer adverse events than with EFV or PIs
  • RAL, DTG have fewer drug-drug interactions than with PIs or NNRTIs (not true of EVG/COBI)
  • Single-pill combination regimens available with DRV, EVG/COBI
34
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

ARV Components in Initial Therapy: INSTIs

disadvantages

A
  • DISADVANTAGES
  • Lower genetic barrier to resistance than PIs
  • COBI has many drug-drug interactions
  • COBI may cause or worsen renal impairment
  • Myopathy, rhabdomyolysis, skin reactions reported with RAL (rare)
35
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

ARV Components in Initial Therapy: PIs

advantages

A
  • ADVANTAGES
  • Higher genetic barrier to resistance
  • PI resistance uncommon with failure of boosted PIs
36
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

ARV Components in Initial Therapy: PIs

disadvantages

A
  • DISADVANTAGES
  • Metabolic complications
  • (fat maldistribution, dyslipidemia, insulin resistance)
  • GI intolerance
  • Potential for drug interactions (CYP450), especially with RTV
  • No single-pill combination regimens
37
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

ARV Components in Initial Therapy: NNRTIs

advantages

A
  • ADVANTAGES
  • Long half-lives
  • Less metabolic toxicity (dyslipidemia, insulin resistance) than with some PIs
  • Single-pill combination regimens available with EFV and RPV
38
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

ARV Components in Initial Therapy: NNRTIs

disadvantages

A
  • DISADVANTAGES
  • Low genetic barrier to resistance – single mutation
  • Cross-resistance among most NNRTIs
  • EFV: high rate of CNS-related side effects
  • RPV: lower efficacy if HIV RNA >100,000 or CD4
  • Rash; hepatotoxicity
  • Potential drug interactions (CYP450)
  • Transmitted resistance to NNRTIs more common than resistance to PIs
39
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Adverse Effects: NRTIs

A

All NRTIs:

  • Lactic acidosis and hepatic steatosis (highest incidence with d4T, then ddI and ZDV, lower with TDF, ABC, 3TC, and FTC)
  • Lipodystrophy
  • (higher incidence with d4T)a

ABC

  • HSR*
  • Rash
  • Possible increased risk of MI
  • ddI
  • GI intolerance
  • Peripheral neuropathy
  • Possible increased risk of MI
  • Pancreatitis
  • Possible noncirrhotic portal hypertension

d4T

  • Peripheral neuropathy
  • Lipoatrophy
  • Pancreatitis

TDF (shouldn’t be an issue w/taf)

  • Renal impairment
  • Decrease in bone-mineral density
  • Headache
  • GI intolerance

ZDV

  • Headache
  • GI intolerance
  • Lipoatrophy
  • Bone-marrow suppression

* Screen for HLA-B*5701 before treatment with ABC; ABC should not be given to patients who test positive for HLA-B*5701.​

40
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Adverse Effects: INSTIs

A
  • DTG
    • Headache
    • Insomnia
    • Rash, hypersensitivity reaction
  • EVG/COBI
    • Decreased CrCl
    • Increased risk of TDF-related nephrotoxicity
    • Nausea, diarrhea
  • RAL
    • Nausea
    • Headache
    • Diarrhea
    • CPK elevation, myopathy, rhabdomyolysis
    • Rash
41
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Adverse Effects: PIs

A

•All PIs:

–Hyperlipidemia

–Lipodystrophy

–Hepatotoxicity

–GI intolerance

–Possibility of increased bleeding risk
for hemophiliacs

–Drug-drug interactions

•ATV

–Hyperbilirubinemia

–PR prolongation

–Nephrolithiasis, cholelithiasis

•DRV

–Rash

–Liver toxicity

•FPV

–GI intolerance

–Rash

–Possible increased risk of MI

•IDV

–Nephrolithiasis

–GI intolerance

–Diabetes/insulin resistance

•LPV/r

–GI intolerance

–Diabetes/insulin resistance

–Possible increased risk of MI

–PR and QT prolongation

•NFV

–Diarrhea

•SQV

–GI intolerance

–PR and QT prolongation

•TPV

–GI intolerance

–Rash

–Hyperlipidemia

–Liver toxicity

–Contraindicated if moderate-to-severe hepatic insufficiency

–Cases of intracranial hemorrhage

42
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Adverse Effects: Pharmacokinetic Boosters

A

•Ritonavir

–GI intolerance

–Hyperlipidemia, hyperglycemia

–Hepatitis

  • Cobicistat
  • GI intolerance
  • Increase in serum creatinine
43
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Adverse Effects: NNRTIs

A

•All NNRTIs:

–Rash, including Stevens-Johnson syndrome

–Hepatotoxicity (especially NVP)

–Drug-drug interactions

•EFV

–Neuropsychiatric, Suicidality, Depression

–Teratogenic in nonhuman primates + cases of neural tube defects in human infants after first-trimester exposure

–Dyslipidemia

•NVP

–Higher rate of rash

–Hepatotoxicity (may be severe and life-threatening;
risk higher in patients with higher CD4 counts at the time they start NVP, and in women)

•RPV

–Depression

44
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Concern with EFV-based initial ART

A

associated with 2-fold increase in hazard of suicidality* vs EFV-free ART

efavirenz

45
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Adverse Effects: CCR5 Antagonist

A

•MVC

–Drug-drug interactions

–Rash

–Abdominal pain

–Upper respiratory tract infections

–Cough

–Hepatotoxicity

–Musculoskeletal symptoms

–Orthostatic hypotension, especially if severe renal disease

46
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Adverse Effects: Fusion Inhibitor

A

•ENF

–Injection-site reactions

–HSR

–Increased risk of bacterial pneumonia

47
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Predictors of Poor Adherence

***exam

A
  • Active alcohol or substance abuse
  • Work outside the home for pay
  • Depressed mood
  • Lack of perceived efficacy of ART
  • Lack of advanced disease
  • Concern over side effects
  • Regimen complexity

•

48
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Factors Associated with Higher Levels of Adherence

***exam

A
  • Twice-daily or once-daily regimens
  • Belief in own ability to adhere to regimen
  • Not living alone
  • Dependent on a significant other for support
  • History of opportunistic infection or advanced HIV disease
  • Belief in efficacy of antiretroviral therapy
  • Belief that non-adherence will lead to viral resistance
  • Treatment of depression
  • Treatment of opioid dependency with OST
49
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

St John’s Wort for depression in HIV pts treated with ART

***exam

A

significant interactions with many antiretroviral agents and not as effective as other antidepressants such as SSRIs

50
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Accuracy of Clinicians’ Estimates of Adherence

A

Not Much Better Than Random

51
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Drug use and adherence to ART

A

Drug use is related to decreased adherence to medical care and HAART adherence

need tx for SAD!

52
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Efficacy of HIV treatment in setting of opioid dependence

***exam

A
  • In IDU who are not actively using, efficacy similar to other populations
  • Active drug use may interfere with adherence and ARV success
    • DAART (Directly Administered Antiretroviral therapy )
  • Substance abuse treatment may be required for ARV success
    • Methadone, Buprenorphine, Extended-release Naltrexone
  • Many other support mechanisms may be effective
53
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Relationship btwn HIV and HCV

***exam

A
  • HIV accelerates the course of hepatitis C, but variable rates of progression still seen
  • Avoiding alcohol, other insults to the liver is critical
  • Co-infection with HIV also reduces the response rate to treatment for hepatitis C – but treatment can be curative!
  • Focus on HIV first, but discuss the possibility of future treatment and a Hepatology consultation is a good idea
54
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

What is the goal of ART for viral load?

***exam

A

VR < 20

can see as early as 6-8wks with dolutegravir

55
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

ART: goal response in terms of CD4?

***exam

A

Usually increase cd4 by 100 to 200 cells / yr if caught early

If older and caught late, may not be able to raise so significantly

56
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

RHM in HIV infected patients: vaccines

***exam

A

•Vaccines

–Hepatitis A, hepatitis B (if not immune)

–Pneumococcal

–Influenza

–Tetanus

–VZV

57
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents. December 2015.

***exam (PCP)

A
58
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

RHM in HIV infected pts: paps

***exam

A

•Pap smears

–Every year

–If ASCUS or more significant abnormalityà colposcopy per latest guidelines (do not triage by HPV status)

59
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

RHM in HIV infected pts:

ca screening

***exam

A

•Breast, prostate, colorectal cancer screening

–Same as for HIV-negative patients

60
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

RHM in HIV infected pts:

CHOL screening

***exam

A

•screening (every 6 months)

–Protease inhibitors, efavirenz, some NRTIs associated with dyslipidemia

–Check baseline lipids before treatment and periodically after initiation of treatment

–Higher rates of CAD among HIV-infected patients starting to be seen (ABC)

61
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

RHM in HIV infected pts:

STI screening

***exam

A

–Annual anal/pharyngeal/urethral screening for GC, urethral chlamydia recommended for MSM

–Annual RPR

–More frequent STI screening may be appropriate for some patients

62
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

Summary of recommendations when starting ART

A
  • When starting ARTS- be PRO-ACTIVE!
  • •Must know about co-infections or co-morbid medical conditions before starting therapy.
  • •Important to discuss potential adverse effects with patient
  • •Adherence issues need to be assessed prior to start
  • •Must frequently follow laboratory parameters, CBC, chemistries including LFTs and bun/creat
63
Q

Exam: interpretation of lab results, comorbidity w/HCV, preventative care, RFs, presenting complaints, PCP & Tx, Serologies in testing for HIV, NYS AIDS institute recs (anal pap)

NYS AIDS Institute recommendations for anal pap screening

***exam

A

Baseline & annually

o For men who have sex with men

o Any patient with a history of

anogenital condylomas

o Women with abnormal cervical/vulvar histology

SPRING16 757 PC Adults (7 decks)

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