HIV treatment Flashcards
what are the primary goals of ART?
- maximal and durable viral suppression
- restoration and preservation of immune function (CD4 count)
- improved quality of life
- reduced HIV-related opportunistic infections (OIs)
- reduced morbidity and mortality
what is the recommended treatment for most people with HIV?
INSTI (integrase strand transfer inhibitor) + 2 NRTIs (nucleoside/nucleotide reverse transcriptase inhibitors)
what are some examples of treatments recommended for most people with HIV?
- *BIC/FTC/TAF -> bictegravir/emtricitabine/tenofovir alafenamide
- *DTG/ABC/3TC -> dolutegravir/abacavir/lamivudine
- DTG + XTC + (TAF or TDF) -> dolutegravir + lamivudine + (tenofovir alafenamine or tenofovir disoproxil fumarate)
- RAL + XTC + (TAF or TDF) -> raltegravir + lamivudine + (tenofovir alafenamine or tenofovir disoproxil fumarate)
what is an example of a INSTI + 1 NRTI treatment?
DTG/3TC -> dolutegravir/lamivudine
what are some side effects of integrase inhibitors?
- GI distress
- CNS disturbances
- Rash (less with BIC)
- False elevation in creatinine
- weight gain! (~10 pounds)
what are some DDIs with integrase inhibitors?
- CATIONS (acid reducers), Metformin
- others related to the other drugs used in the combination (like tenofovir and salicylates or nephrotoxic drugs)
what are the integrase inhibitors for first-line ART?
- Bictegravir (BIC)
- Dolutegravir (DTG)
- Raltegravir (RAL)
what are some advantages and disadvantages of Bictegravir (BIC)?
advantages
- STR (single tablet regimen) once daily with FTC/TAF
- few drug/food interaction
- high barrier to resistance
disadvantages
- least amount of data
- only available STR
- limited safety data in pregnancy
what are some advantages and disadvantages of Dolutegravir (DTG)?
advantages
- STR once daily with 3TC or 3TC/ABC
- also available as a single agent
- few drug/food interactions
- high barrier to resistance
- a preferred option for pregnant women in every trimester
disadvantages
- ABC coformulation requires HLA-B*5701 testing
- increases metformin levels
- limited safety data at conception
what are some advantages and disadvantages of Raltegravir (RAL)?
advantages
- longest experience
- few drug/food interactions
- a preferred option for pregnant women
disadvantage
- multiple pills (no STR)
- lower barrier to resistance than BIC or DTG
- limited safety data at conception
what are some INSTI STRs available for initial ART?
- BIC/FTC/TAF (INSTI + dual NRTI)
- DTG/3TC (INSTI + single NRTI)
- DTG/3TC/ABC (INSTI + dual NRTI)
- EVG/COBI/FTC/(TAF OR TDF) (Boosted INSTI + dual R+NRTI)
clinical caveats of DTG/3TC
do NOT use if HIV-1 RNA > 500,000 c/mL, HBV coinfection, or without resistance testing results
which STR treatment requires HLA-B*5701 test to be NEGATIVE?
DTG/3TC/ABC
what are some NNRTI STRs available for initial ART?
- DOR/3TC/TDF
- EFV/3TC/TDF
- EFV/FTC/TDF
- RPV/FTC/(TAF or TDF)
what are some boosted PI STRs available for initial ART?
DRC/COBI/FTC/TAF
what is important about RPV/FTC/(TAF or TDF)?
ONLY use if HIV-1 RNA < 100,000 c/mL AND CD4+ cell count > 200 cells/mm^2
which integrase inhibitors should NOT be given with antacids?
DTG/RPV -> causes decrease in RPV
-> MOSTLY due to RPV
what are the preferred regimen for ART in pregnancy and in non-pregnant women who are trying to conceive?
preferred regimens: ual NRTI backbone plus INSTI or boosted PI
alternative regimens: dual NRTI backbone plus NNRTI
NRTI backbone for treatment in pregnant women/non-preg trying to conceive
preferred:
- 3TC/ABC
- FTC/TDF
- 3TC/TDF
alternative:
- FTC/TAF
- 3TC/ZDV
what is significant about TAF?
spares kidneys
preferred INSTI treatment in preg/non-preg trying to conceive?
- DTG
- RAL BID
NO BIC due to caution in preg
alternative NNRTI for preg/trying to conceive?
- EFV
- RPV
preferred boosted PIs in preg/trying to conceive?
- ATV/RTV
- DRV/RTV BID
when do we go to boosted PIs in therapy?
if know of resistance!
