HIV Pt 2 Flashcards
1
Q
HIV: What is the action of HIV?
A
- A retrovirus that depends on reverse transcriptase (RNA dependent DNA polymerase) to replicate.
2
Q
HIV: Which is the most prevalent in the US, HIV 1 or 2?
A
- HIV 1
3
Q
HIV: How does this virus enter a CD4+ T helper cell?
A
Via chemokine receptors (CCR5 and CXCR4)
4
Q
HIV: What genetic deletion tends to favorably prevent or suppress HIV?
A
- CCR5 deletion
5
Q
HIV: Why would a CCR5 deletion suppress or prevent HIV?
A
- HIV relies on this receptor to enter CD4+ T helper cells. - If HIV cannot enter this cell the virus cannot replicate.
6
Q
HIV: Once HIV replicates within a CD4+ T helper cell, what is the fate of the cell?
A
- cell fusion or death
7
Q
HIV: Once HIV has replicated and destroyed the host CD4+ T helper cell, what does it do next?
A
- Adheres to the next CD4+ T helper cell and enters that cell for replication and cell destruction.
8
Q
HIV: (T/F) Replication of HIV is dependent of the cell death and fusion of the CD4+ T helper cell it has infiltrated.
A
- TRUE
9
Q
HIV: What is the pathophysiology that is occuring during the “latent stage” of the infection?
A
- Integration of HIV genome into cell genome.
10
Q
HIV: (T/F) Without ART, CD4 count continues to decline with increasing length of infection.
A
- TRUE
11
Q
HIV life cycle: How many steps are there in the HIV life cycle?
A
- Five steps
12
Q
HIV life cycle: What are each of the five steps of the HIV life cycle?
A
- Step 1: Viral entry
- Step 2: Reverse transcription
- Step 3: Integration
- Step 4: Transcription and translation
- Step 5: Assembly and budding
13
Q
HIV: Clinical signs and symptoms?
A
- Asymptomatic - Fever, night sweats, and weight loss - Presence of opportunistic infection - Kaposi’s sarcoma - Lymphoma - Oral lesions such as hairy leukoplakia
14
Q
HIV timeline: Within the first 12 weeks the CD4 count dips and rises again (though not quite back to baseline) before dropping. Why is that?
A
- During the initial drop the body recognizes A decreased amount of CD4+ T helper cells and tries to make up for it but cannot produce enough to compete against the exponentially growing HIV.
15
Q
HIV timeline: (T/F) Most patients will acquire Acute retroviral syndrome.
A
- FALSE - Most patients are asymptomatic.
16
Q
HIV timeline: At what point in the timeline is a patient most likely to develop acute retroviral syndrome?
A
- During the initial CD4+ T helper cell count dip and rise.
17
Q
HIV timeline: What is the cause of the Acute retroviral syndrome?
A
- The peak in viral load that accompanies the immediate dip in CD4+ T helper cells prior to the body’s reaction to produce more of these cells.
18
Q
HIV timeline: Clinical latency occurs around what time period?
A
6-10 years
19
Q
HIV timeline: Following clinical latency the CD4+ T helper cell count begins to drop at a faster rate as the viral load increases and surpasses the CD4+ T helper cell count. What does the graph look like from that point on? What syndrome develops as a result?
A
- Viral load exponentially increases. - CD4+ T helper cell count continues to decline drastically. - AIDS
20
Q
Acute HIV infection: S/Sx?
A
Non-specific “flu like” symptoms: - Fever - Fatigue - Pharyngitis - Lymphadenopathy - Rash
21
Q
Acute HIV infection: It is important to remember that patients experiencing acute retroviral syndrome have very high viral loads and as a result are highly ___.
A
infectious.
22
Q
Acute HIV infection: Patients experiencing acute retroviral syndrome are so contagious that it is suspected that up to ___% of new HIV transmissions in sub-Saharan Africa are believed to occur during the acute phase of infection
A
50% (thus driving the pandemic)
23
Q
HIV: While the CDC recommends opt out testing for HIV, who should be tested?
A
- Anyone between 13 and 64 - IVDU and their sex partners - Persons who exchange sex for money or drugs - Sex partners of HIV infected persons - MSM - Heterosexual partners if either have had more than one previous sex partner
24
Q
HIV lab tests: What are the two lab tests associated with screening for HIV?
A
- ELISA
- EIA
25
HIV lab test: If you have a positive ELISA result, what do you have to confirm that result with?
- A Western blot confirmation.
26
HIV lab test: If you have a positive EIA test, what do you confirm that test with?
- NAT- (HIV RNA by PCR)
27
HIV lab tests: Which of the screening tests has been available the longest? Which test is now recommended over the other?
- ELISA: historic test. - EIA: Recommended over ELISA for screening.
28
HIV lab tests: What does ELISA testing look for?
- Looks for antibody only.
29
HIV lab tests: How long does it take for enough of the HIV antibodies to develop before the ELISA test can detect the antibodies?
- 4-12 weeks for antibody to develop.
30
HIV lab tests: EIA is also known by what names?
- The combination or 4th generation test.
31
HIV lab tests: What does EIA testing detect?
- HIV antibody [and] - p 24 antigen
32
HIV lab tests: How long does it take for enough of the HIV antibodies to develop before the EIA test can detect the antibodies?
- 2-6 weeks from exposure to positivity
33
HIV lab tests: You have screened a patient for HIV using an EIA lab test and it has come back positive. What are the baseline tests you will order next?
- CD4+ T cell count
| - VL
34
HIV lab tests: While older tests were able to detect viral load only if it was greater than 1000, newer tests can detect viral load greater than what value?
> 500
35
HIV lab tests: You have collected your CD4+ T cell count and viral load (which is above 500). What testing do you do next?
- Assess the nature of the virus.
- Phenotyping and genotyping.
- Drug resistance testing.
36
HIV lab tests: When considering the overall health of a recently diagnosed HIV patient, what are some of the baseline tests you would order for the patient (non-specific to CD4+ T-cell count, VL, and drug resistance of HIV)?
- Chemical screen - CBC - LFTs - STI testing - Hepatitis testing - opportunistic infection tests (e.g. toxoplasmosis, TB) - Pap test (consider anal Pap test for men and women who participate in anal sex)
37
HIV lab tests: Which forms of hepatitis should you have a higher index of suspicion of in an HIV patient due to their bloodborne natures?
- HBV - HCV
38
HIV Tx: What is the general goal of HIV Tx?
- Increase CD4+ T-cell count.
39
HIV Tx: At what CD4+ T-cell count do you initiate therapy?
- At ANY CD4+ T-cell count.
40
HIV Tx: At what CD4+ T-cell count is typically the threshold for seeing infections like thrush?
< 350 cells/mm^3
41
HIV Tx: What is the historic name for the type of therapy used for HIV Tx?
- HAART - Highly active antiretroviral therapy
42
HIV Tx: The term HAART has gone by the wayside. What is the current name for HIV therapy?
- antiretroviral therapy (ART)
43
HIV Tx: What kind of medications make up standard medication categories of ART?
- Protease inhibitors (PIs) - Nucleoside reverse transcriptase inhibitors (NRTIs) - Non-Nucleoside reverse transcriptase inhibitors (NNRTIs) - Integrase strand transfer inhibitors (INSTIs)
44
HIV Tx: What does "PIs" stand for?
- Protease inhibitors
45
HIV Tx: What does "NRTIs" stand for?
- Nucleoside reverse transcriptase inhibitors
46
HIV Tx: What does "NNRTIs" stand for?
- Non-Nucleoside reverse transcriptase inhibitors
47
HIV Tx: What does "INSTIs" stand for?
- Integrase strand transfer inhibitors
48
HIV Tx: What are the goals of HIV therapy?
- Suppression of Viral load
- Restoration of immune function
- Prevention of HIV transmission
- Prevention of Drug resistance
- Improvement in quality of live.
49
HIV Tx: What is the quantitative goal associated with our intent to suppress viral load via pharmacotherapy?
- Suppression of viral load to < 50 copies per mL
50
HIV Tx: How do we measure immune function in HIV patients?
- CD4+ T-cell count
51
Principles of therapy: HIV treatment regimens typically have two components. What are those two components referred to as?
- the backbone and the base.
52
Principles of therapy: Describe the "backbone" of an HIV regimen.
- Typically consists of two Nucleoside reverse transcriptase inhibitors (NRTIs)
53
Principles of therapy: Describe the "base" of an HIV regimen.
Traditionally included either a... - NNRTI [or] - PI [or] - INSTI
54
Principles of therapy: In December 2019, this medication was added to guidelines for treatment as a base.
- Integrase inhibitor: Reltegravir
55
Principles of therapy: What is an appropriate website to refer patients to to serve as a comprehensive HIV patient-friendly website?
www.poz.com
56
HIV Med Chart: What do the generic names of all protease inhibitors (PI) have in common?
- They end in "-navir"
57
HIV Med Chart: What are two newer NRTIs that have become more common in treatment plans?
- Emtricitabine (FTC) - Tenofovir (TAF)
58
HIV Med Chart: Atripla is a commonly used combined medication consisting of three medications. What are these medications?
- Emtricitabine (FTC) [NRTI] - Tenofovir (TAF) [NRTI] - Efavirenz (EFV) [NNRTI]
59
HIV Med Chart: Efavirenz (EFV) is a ___ generation NNRTI medication.
- First
60
HIV Med Chart: Tenofovir (TAF) has two formulations: an old and a new. Which formulation is old?
- Tenofovir disoproxil
61
HIV Med Chart: Tenofovir (TAF) has two formulations: an old and a new. Which formulation is new?
- Tenofovir alafenamide
62
HIV Med Chart: Tenofovir (TAF) has two formulations: an old and a new. The older formulation has a higher risk of what complications?
- Renal failure - Osteoporosis
63
HIV Med Chart: (T/F) Tenofovir alafenamide has a decresased risk of causing renal failure and osteoporosis than tenofovir disoproxil.
- TRUE * Tenofovir alafenamide is the newer formula.
64
HIV Med Chart: Which formulation of tenofovir is in the medication Truvada?
- Tenofovir disoproxil (the older formulation)
65
HIV Med Chart: The PIs are the drugs that end in "-navir". What is the one PI drug you want to remember?
- Darunavir (DRV)
66
HIV Med Chart: Why is it important to remember darunavir (DRV) as a PI medication?
- It is on the treatment guidelines - You can use it with tenofovir[TAF] / emtricitabine(FTC)[NRTI] backbone
67
HIV Med Chart: Integrase Strand Transfer Inhibitors (INSTIs) end in what?
- "-egravir"
68
HIV Med Chart: What are the three main INSTIs to know?
- Raltegravir (RAL) - Eltegravir (EVG) - Dolutegravir (DTG)
69
HIV Med Chart: Which INSTI medication is the oldest and is generally regarded as the cheaper option of the INSTIs?
- Raltegravir (RAL)
70
HIV Med Chart: Combination medications have what benefit in terms of administration frequency?
- You can have once daily dosing.
71
HIV Med Chart: What are the brand names of the common combination meds?
- Atripla - Stribild - Genvoya - Complera - Odefsey
72
HIV Med Chart: Atripla is a combination medication composed of what?
- Tenofovir disoproxil (TAF) [NRTI] - Emtricitabine (FTC) [NRTI] - Efavirenz (EFV) [NNRTI]
73
HIV Med Chart: Stribild is a combination medication composed of what?
- elvitegravir (EVG) [INSTI] - cobicistat (pharmacokinetic enhancer) - emtricitabine (FTC) [NRTI] - tenofovir disoproxil (TDF) [NRTI]
74
HIV Med Chart: Genvoya is a combination medication composed of what?
- elvitegravir (EVG) [INSTI] - cobicistat (pharmacokinetic enhancer) - emtricitabine (FTC) [NRTI] - tenofovir alafenamide (TAF) [NRTI]
75
HIV Med Chart: Cobicistat is a pharmacokinetic enhancer found in combination medications. What medication(s) does it boost?
- elvitegravir (EVG) [INSTI]
76
HIV Med Chart: Complera is a combination medication composed of what?
- emtricitabine (FTC) [NRTI] - rilpivirine (RPV) [NNRTI] - tenofovir disoproxil fumarate (TDF) [NRTI]
77
HIV Med Chart: Odefsey is a combination medication composed of what?
- emtricitabine (FTC) [NRTI] - rilpivirine (RPV) [NNRTI] - tenofovir alafenamide (TAF) [NRTI]
78
Initiating Tx: Historically, decision on when to treat HIV was based off of what lab finding?
- CD4+ T-cell count
79
Initiating Tx: Based on the most recent guideline (January 2020), when should you initiate treatment?
- All HIV positive patients should be considered for initiation of treatment.
80
Initiating Tx: When choosing an initial treatment plan, there are three main categories. What are they?
1) 1 INSTIs + 2 NRTIs 2) 1 PK-boosted PI + 2 NRTIs 3) NNRTI + 2 NRTIs
81
Initiating Tx: What do all of the three main categories of initial treatment plans have in common?
Base and backbone: - 1 base medication - 2 backbone medications
82
Initiating Tx: When choosing a regimen, one of the two NRTIs should be which medications?
- lamivudine (Epivir) (3TC) [or] - emtricitabine (Emtriva) (FTC)
83
HIV Tx - Bottom line: What is the common/historic formula for initiating treatment?
1) 2 NRTIs (FTC+TAF) + 1 NNRTI (ex.EFV) 2) 2 NRTIs + 1 INSTI (ex. RAL) 3) 2 NRTIs + "boosted" PI (DRV)
84
HIV Tx - Bottom line: PIs can be boosted by which two pharmacokinetic enhancer drugs?
- cobicistat - ritonavir
85
Benefits of early therapy: Untreated HIV is associated with the development of what condition(s) (general)?
- AIDS - Non-AIDS-defining conditions
86
Benefits of early therapy: Earlier ART may prevent what HIV-related complication?
- end-organ damage
87
Benefits of early therapy: (T/F) Deferred ART reliably repairs HIV-related damage acquired earlier.
- FALSE - Deferred ART may not reliably repair HIV-related damage acquired earlier.
88
Benefits of early therapy: (T/F) End-organ damage occurs at all stages of HIV infection.
- TRUE
89
Benefits of early therapy: What renal pathologies may benefit from early therapy?
- HIV-associated nephropathy
90
Benefits of early therapy: (T/F) Early therapy may decrease the risk of neurocognitive decline.
- TRUE
91
Benefits of early therapy: (T/F) Early therapy has not shown to decrease the risk of cardiovascular disease and malignancies.
- False - Decreases risk of CV dz and malignancies (AIDS defining and non-AIDS defining)
92
Benefits of early therapy: What hepatic pathologies may benefit from early therapy?
- Liver disease progression from hepatitis B or C
93
Benefits of early therapy: What are common legitimate concerns surrounding initiating early therapy?
- ARV-related toxicities - Non-adherence to ART - Drug resistance - Cost * Truvada, without insurance, costs ~$2,000 per month
94
CD4 levels: How often do you get a CD4+ T-helper cell count?
- Check at baseline (x2) - At least every 3-6 months - Immediately before initiating ART
95
CD4 levels: How often are you checking CD4+ T-helper cell counts if you've initiated ART?
- Every 3-6 months during first 2 years of ART [OR] - if CD4+ T-cells are < 300 cells/uL
96
CD4 levels: After 2 years on ART with HIV RNA consistently suppressed, how often are you checking the patient's CD4+ T-cell levels if they have historically been in the 300 to 500 cells/uL range?
- Every 12 months
97
CD4 levels: After 2 years on ART with HIV RNA consistently suppressed, how often are you checking the patient's CD4+ T-cell levels if their previous lab results have been > 500 cells/uL?
- Optional
98
CD4 levels: What are common scenarios in which you would want to test a patient more frequently?
- If also on A medication that may lower CD4 count - Clinical decline
99
Other monitoring studies: If you want to start a patient on abacavir (ABC) [NRTI], what screening should you consider?
- HLA-B*5701 screening
100
Other monitoring studies: Patients who test positive for HLA-B*5701 are at risk of developing what if they take abacavir (ABC) [NRTI]?
- Hypersensitivity reaction
101
Other monitoring studies: (T/F) A patient is screened for HLA-B*5701 which comes back positive. A trial of abacavir (ABC) [NRTI] should at least be attempted prior to listing the medication as an allergy on the patient's chart.
- False - If they have a positive HLA-N*5701, then the patient should automatically considered to have an abacavir (ABC) [NRTI] allergy.
102
Other monitoring studies: (T/F) If HLA-B*5701 testing is not available, abacavir (ABC) may be initiated after counseling and with appropriate monitoring for a hypersensitivity reaction.
- TRUE
103
HIV life cycle & Txs: At what stage of the HIV life cycle do NRTIs and NNRTIs intervene?
- Step 2: Reverse transcriptase
104
HIV life cycle & Txs: At what stage of the HIV life cycle do PIs intervene?
- Step 5: Assembly and building
105
HIV life cycle & Txs: At what stage of the HIV life cycle do INSTIs intervene?
- Step 3: Integration
106
ART: (T/F) There is a high potential for adverse effects with ART.
- TRUE
107
ART: What are the MC adverse effects associated with ART?
- Rash - Diarrhea - Pancreatitis - Hyperlipidemia and lipodystrophy - Increased cardiac risk - CNS effect: psychological disturbances
108
ART: What are adverse effects of PIs?
- Hyperlipidemia - lipodystrophy - Hepatotoxicity - GI intolerance - Possibility of Increased bleeding risk for hemophiliacs - Drug-Drug interactions.
109
ART: Which medication is contraindicated in all HIV Tx options?
- Rifampin
110
ART: Why is rifampin contraindicated with all HIV Tx options?
- Because Rifampin can render the HIV drugs ineffective.
111
ART: Adverse effects associated with NRTIs?
- Lactic acidosis - Hepatic steatosis - lipodystrophy
112
ART: Adverse effects associated with NNRTIs?
- Rash (including Stevens-Johnson syndrome) - Hepatotoxicity (especially NVP) - Drug-drug interactions
113
ART: What is lipoatrophy?
- A term describing the loss of fat tissue. - Often associated with the face. In this instance referred to as "facial wasting"
114
ART: What is lipodystrophy?
- lipodystrophy refers to medical problem where there is an abnormal distribution of fat in the body. - this can refer both to fat loss (lipoatrophy) and abnormal accumulation of fat tissue. - the disease may be inherited genetically, (for example, familial partial lipodystrophy or FPLD), or acquired
