HIV & Opportunistic Infections Flashcards
HIV 4th generation test
First step to diagnosing HIV inpatient.
If positive, then will need HIV-1/2 Ab differentiation immunoassay
If negative, then no HIV.
> 99% sensitivity and specificity
HIV-1/2 Ab Immunassay
Administer if 4th generation test positive
Differentiates HIV 1 from HIV 2
If positive, diagnosis made
If negative, administer HIV-1 nucleic acid test
> 99% sensitivity and specificity
HIV-1 nucleic acid test
Administer if 4th gen HIV test +, HIV-1/2 Ab immunassay negative
Tests for HIV-1
If positive, diagnosis made
If negative, no HIV
Rapid HIV test
Can have result in 20 minutes after oral swab or fingerstick
If positive, repeat with another manufacturer test. IF that is positive, then positive . If negative, repeat with another manufacturer’s test.
If negative, no need to retest.
HIV RNA Viral suppression
Goal of ART
HIV RNA <20-75 (level of detection of assay)
HIV RNA <200 prevents HIV transmission to sexual partners
HIV RNA testing - when to test
- Baseline
- If not on therapy, every 3-6 months
- 2-4 weeks after starting or changing therapy
- Then, every 3-4 months while on treatment. Can go to q6 months if suppressed >1yr
- Clinical event or decrease in CD4 count
PrEP options
Anyone who wants it and recently tested negative for HIV
- Tenofovir disoproxil fumarate 300mg + emtricitabine 200mg (truvada)
- Tenofovir alafenamide 25mg + emtricitabine 300mg (descovy)
- Cabotegravir 600mg months 1 & 2, then q8w
On demand PrEP
for MSM, infrequently, can anticipate when. Not FDA approved.
Truvada (tenofovir disoproxil fumarate/emtricitabine):
2 doses 24hrs before sex, 1 dose 24 hrs after first dose, 1 dose 48 hours after first dose
Monitoring parameters for PrEP
Baseline:
1. HIV test
2. Renal function (for tenofovir)
3. STI
4. Lipids
Repeat HIV test q3months (or 2 months on cabotegravir)
Repeat renal fxn, STI, lipids q6-12 months
HIV in Pregnancy
ALL WOMEN SHOULD BE ON COMBINATION ART ASAP EVEN IN FIRST TRIMESTER
Regimens:
1. A dual nucleoside reverse transcriptase inhibitor (NRTI) combo: abacavair/lamivudine; tenofovir/emtricitabine; tenofovir/lamivudine
- Ritonavir-boosted protease inhibitor: darunavir/ritonavir
- Integrase strand transfer inhibitor (INSTI): dolutegravir
HIV in labor with HIV RNA >1000
Zidovudine IV should be given
Or if HIV RNA unknown
Infant born to HIV + mom, low risk transmission
Zidovudine 4mg/kg/dose q12H for 4 weeks.
Start within 6 hours of delivery
Infant born to HIV + mom, high risk of transmission
Zidovudine, lamivudine and nevirapine
OR
Zidovudine, lamivudine, and raltegravir
6 weeks
Nonoccupational post-exposure prophylaxis HIV
Begin with 72 hours of coming in contact with blood, semen, vaginal secretion, breast milk
Raltegravir twice daily OR dolutegravir daily
+
Tenofovir disoproxil fumarate/emtricitabine daily
Alt: darunavir/ritonavir + tenofovir disoproxil fumarate/emtricitabine
Treat 4 weeks
Occupational PEP HIV
Begin ASAP
Raltegravir BID
+
Tenofovir disoproxil fumarate/emtricitabine
Several alts
Continue 4 weeks
Nucleoside/nucleotide reverse transcriptase inhibitors
LATTEZ
Lamivurdine
Abacavir
Tenofovir disoproxil fumarate
Tenofovir alafenamide
Emtricitabine
Zidovudine
TAF vs TDF
TDF more favorable on lipids
TAF more favorable on bones and kidneys
NRTI renal adjustment needed
Emtricitabine
Lamivudine
Zidovudine
TDF do not use <50-70 ml/min
TAF do not use <15 ml/min
TAF has way more drug interactions, mainly with the 3A4 strong inducers
NRTI hepatic adjustment needed
Abacavir
Genetic test before abacavir
HLA B*5701 to determine if risk for hypersensitivity reaction
Nonnucleoside Reverse Transcriptase Inhibitors (v’s)
ENDER of hiv
Efavirenz
Nevirapine
Doravirine
Etravirine
Rilpivirine
ALL metabolized by CYP 3A4
NNRTI with renal adjustment & hepatic adjustment
Nevirapine
Protease inhibitors (-navirs)
LARD get this hiv outta me
Lopinavir/ritonavir
Atazanavir
Ritonavir
Darunavir
TAKE ALL WITH FOOD
All metabolized by CYP3A4
Endocrine disturbances with protease inhibitors
T2DM
Peripheral fat loss & central fat accumulation
Lipid abnormalities
Protease inhibitor renal adjustment
Atazanavir
Protease inhibitor hepatic adjustment
Atazanavir
Darunavir
Integrase Strand Transfer Inhibitors (-gravirs)
C BRED (can take with food)
Cabotegravir (PO and IM)
Bictegravir
Raltegravir
Elvitegravir
Dolutegravir
INSTIs with renal adjustment
Bictegravir
Elvitegravir
INSTIs with hepatic adjustment
Bictegravir
Dolutegravir
Elvitegravir
Entry Inhibitors
FILME at the entry
Fostemsavir
Ibalizumab (IV)
Lenacapavir (PO and SC)
Maraviroc
Enfuvirtide (SC)
Entry inhibitors renal adjustment
Maraviroc
Recommended initial ART therapy
2 NRTIs (LATTEZ) + INSTI (-gravirs)
Pneumocystitis jiroveci pneumonia (PJP) Preferred Treatment
Mod-severe: Bactrim 15-20mg/kg/day TMP dividied q6-8h x21 days - may use IV
Mild-mod: 2 bactrim DS tabs TID
Add steroid taper if severe (A-a gradient >35 or Po2 <70): pred 40mg BID x5d, then 40mg x5d, then 20mg daily for remainder of therapy
steroids decrease mortality
PJP prophylaxis
Use if CD4 < 200. May D/C if CD4 > 200 for 3 months
Bactrim SS or DS daily
Alt: Bactrim DS 3x/week
Alt: Atovaquone 1500mg daily
Alt: Pentamidine monthly inhalation
Alt: Dapsone 100mg daily or combine with pyrimethamine & leucovorin
PJP Alterantive regimens
- Clindamycin and primaquine
- Atovaquone
- Pentamidine (IV)
- Trimethoprim & Dapsone
Pyrimethamine + leucovorin purpose
Leucovorin helps prevent myelosuppression. Must be given with pyrimethamine
Toxoplasmosis preferred therapy
Pyrimethamine 50-75mg/day + Sulfadiazine 1000-1500mg q6h
Add leucovorin 10-25mg/day to reduce bone marrow suppression effect of pyrimethamine
6 weeks at least
Can be used for chronic maintenance
Toxoplasmosis alternative therapy
- Clindamycin + pyrimethamine
- Bactrim
- Atovaquone + pyrimethamine/leucovorin
- Atovaquone + sulfasalazine
- Atovaquone alone
Similarly can be used for chronic maintenance therapy, different dosing
Toxoplasmosis prophylaxis
CD4 <100. Can d/c if CD4 >200 for 3 months
- Bactrim DS daily
- Dapsone/pyrimethamine/leucovorin
- Atovaquone +/- pyrimethamine
Oropharyngeal candidiasis treatment
Fluconazole 100mg daily
Alt: Itraconazole 200mg solution daily
Alt: Posaconazole suspension 400mg daily
Alt: Miconazole buccal tabs
Alt: Clotrimazole troches
Alt: Nystatin 5ml 4-5x daily
Treat 7-14 days
Esophageal candidiasis treatment
Fluconazole 100-400mg daily PO or IV
Itraconazole 200mg PO daily
Several alts
Treat 14-21 days
Vulvovaginal candidiasis treatment
Fluconazole 150mg x1
Topical azoles
Alt: itraconazole 200mg solution daily
Treat 3-7 days
Cryptococcal meningitis induction therapy
Preferred:
**1. Liposomal amphotericin B 3-4 mg/kg/day PLUS flucytosine 25mg/kg q6h
2. Amphotericin B deoxycholate 0.7-1 mg/kg/day PLUS flucytosine 25mg/kg q6h (renal toxicity)
Several alts. Pick liposomal amp B.
Induction is 2 weeks
Cryptococcal meningitis consolidation therapy
Fluconazole 800mg daily (may decrease to 400mg if CSF negative, ART started)
At least 8 weeks
Cryptococcal meningitis maintenance therapy
Fluconazole 200mg daily x1 year.
May d/c after a minimum of a year if CD4 > 100 for 3 months
When to start ART with cryptococcal meningitis
AFter 2-10 weeks of treatment.
Risk of IRIS
Cryptococcal meningitis prophylaxis
Not indicated
MAC preferred therapy
Clarithromycin 500mg BID PLUS ethambutol 15mg/kg/day
Can use azithromycin 500-600mg in place of clarithromycin if drug interactions or intolerance
Treat for 12 months minimum
Add on therapy to MAC preferred therapy
If CD4 <50, high mycobaterial load, or no ART
- Rifabutin 300mg/day
- FQ (levo 500, moxi 400)
- Aminoglycoside (amikacin 10-15 mg/kg IV or streptomycin 1g IV/IM)
MAC prophylaxis
CD4 <50 and not on ART. If immediately started on ART, not needed.
Use a macrolide
Cytomegalovirus retinitis, sight threatening lesions
Can progress to blindness or retinal detachment
Valganciclovir 900mg BID x14-21 days, then 900mg daily.
May add on intravitreal injections of ganciclovir or foscarnet
Alt: ganciclovir IV
Alt: Foscarnet IV
Alt: Cidofovir IV
Cytomegalovirus retinitis, peripheral lesions
Valganciclovir 900mg BID x14-21 days, then 900mg daily for 3-6 months until ART induced immunity
Cytomegalovirus esophagitis, colitis, pneumonitis, neuro
Use ganciclovir, foscarnet, or valganciclovir
CMV prophylaxis
Not indicated
Positive TB skin test
Ranges from >=5 to >=15 depending on risk factors
Latent TB regimens, non HIV
- Rifapentine 900mg + isoniazid 900mg weekly for 12 weeks
- Rifampin 600mg daily x4 months
- Rifampin 600mg daily + isoniazid 300mg daily x3 months
- Isoniazid 300mg daily or 900mg twice weekly for 6-9 months
Latent TB treatment, with HIV
- Rifapentine 900mg daily + isoniazid 15mg/kg + pyridoxine 50mg daily weekly for 12 weeks
- Isoniazid 300mg + rifampin 600mg + pyridoxine 25-50mg daily x3 months
Can still do rifampin 600mg daily x4 months
If rifampin drug interactions concerning, then isoniazid 300mg daily + pyridoxine 25-50mg daily x6-9 months
First line active TB agents
Rifampin
Isoniazid
Pyrazinamide
Ethambutol
Intensive & continuation phase for TB, no HIV
Intensive: RIPE x2 months (daily or 5x weekly)
Continuation: isoniazid + rifampin x4 months (daily or 5x weekly)
If TB isolate susceptible to isoniazid, rifampin, then can exclude ethambutol
Intensive, continuation phase for TB, HIV +
Intensive: RIPE daily x2 months (may use rifabutin instead of rifampin)
Continuation: isoniazid + rifampin or rifabutin daily x4 months
When to extend continuation phase of TB treatment
nonHIV: positive sputum and xray after intensive phase
HIV: if not on ART
increase from 4 to 7 months
Purpose of pyridoxine in RIPE therapy
Prevent neuropathy caused from isoniazid
When to use rifabutin over rifampin for HIV + on ART
ART contains protease inhibitor
ART contains TAF
Dose adjustment to ART needed if contain INSTIs
Need washout period after rifampin of 2 weeks before restarting PIs, elvitegravir, or NNRTI
Rifabutin + ART
May need to increase dose to 450-600mg daily if in combo with NRTI and NNRTIs
Do not give with TAF
If PI boosted with ritonavir, decrease rifabutin dose
Avoid elvitegravir and bictegravir with rifabutin
