HIV Treatment

Question 1

As a general rule, HIV regimens consist of [+]

What is the BHIVA recommendation drug regimens to start for HIV tx? [4]

Answer 1

As a general rule, regimens consist of:

Two nucleoside reverse transcriptase inhibitors (NRTIs)

A third agent, typically one of:
- Ritonavir-boosted protease inhibitor (PI/r)
- Non-nucleoside reverse transcriptase inhibitor (NNRTI)
- Integrase inhibitor (INI) - RECOMENDED

OR
- Dolutegravir + Lamivudine

This is the list of BHIVA preffered drug regimens to start

In theory; any of above can be used; but BHIVA slide is the.

Question 2

Why would you not use abacavir/lamivudine/dolutegravir for first line treatment of HIV? [1]

Answer 2

If 10 year risk of CVD more than 10%

Question 3

Which

Question 4

Entry inhibitors aim to prevent HIV from entering host cells.

Name two classes and drug examples of entry inhibitors used for HIV Tx

Answer 4

CCR5 inhibitors (CCR5 is a co-receptor for CD4 allowing the entry of HIV into target cells)
- E.g. Maraviroc

Fusion inhibitors:
- block glycoprotein-41
- Enfuvirtide

NB: not really used

Question 5

Describe the MoA of NRTIs and NNRTIs [2]

Answer 5

NRTIs:
- inhibiting the action of reverse transcriptase

NNRTIs
- preventing the action of reverse transcriptase.

Question 6

Name examples for NRTIs [4] and NNRTIs [2]

Answer 6

NRTIs:
* Tenofovir disoproxil fumarate
* Abacavir
* Emtricitabine
* Lamivudine

NNRTIs:
- Efavirenz
- Nevirapine

As NRTIs are the backbone - don’t want to be LATE with starting treatment Lamivudine, Abacavir TDF Emtricitabine

Question 7

Describe the MoA of PIs [1]

Answer 7

Protease inhibitors (PIs) inhibit the action of protease preventing the cleavage of Gag-Pol polyproteins.

Question 8

PIs are given alongside which drug [1] as they boost the action of the drug

Name two examples of PIs

Answer 8

They are given alongside ritonavir - referred to as a boosted PI - which increase the action of the drug.

PIs:
* Atazanavir
* Darunavir
* Lopinavir

Question 9

Post-attachment inhibitors prevent envelope protein [] engaging with co-receptors.

Name an example [1]

Answer 9

Post-attachment inhibitors prevent envelope protein glycoprotein-120 engaging with co-receptors.

There is currently one medication in this class, the monoclonal antibody Ibalizumab. It is given as an IV infusion once every two weeks.

Answer 10

Tenofovir disoproxil fumarate is associated with renal failure and osteoporosis. Lamivudine has been shown to cause pancreatitis, whilst abacavir is avoided in patients with cardiovascular disease. Emtricitabine may cause hyperpigmentation of the palms of hands and soles of feet.

Question 11

[] tend to have a high barrier to resistance and therefore may be preferred in patients where there are concerns regarding adherence

NRTIs
NNRTIS
PIs
II
EI

Answer 11

[] tend to have a high barrier to resistance and therefore may be preferred in patients where there are concerns regarding adherence

NRTIs
NNRTIS
PIs
II
EI

Question 12

Which drugs are contained in PEP? [2]
For how long is the course? [1]

Answer 12

Once a day of:
* Tenofovir disoproxil fumerate
* Two Raltegravir

for 28 days

Question 13

State 3 side effects of protease inhibitors [3]

Answer 13

There are many adverse effects including lipodystrophy, hyperlipidaemia, insulin resistance and hepatotoxicity.

Question 14

Which drugs are used in PrEP? [1]

Answer 14

Tenofovir-df/emtricitabine

Question 15

How do you measure safety and toxicity of ARTs? [3]

Answer 15

• Renal and liver test
• Lipids and metabolic tests
• FBCs

Question 16

What is the most common cause of HIV VL rebounding? [1]

Answer 16

Intermittent adherence (but alsocould be low drug levels / bad luck)

Question 17

Which ART causes a risk of hypersensitivty? [1]

Which drug class does it belong to? [1]

Answer 17

Abacavir: hypersensitivity
- NRTI

Question 18

Which ART causes a risk of hepatotoxicity? [1]

Which drug class does it belong to? [1]

Answer 18

Nevirapine NNRTI

Question 19

Which ART can cause this reaction? [1]

Which drug class? [1]

Answer 19

Darunavir
- PI

NB: Reaction = SJS

Question 20

Efavirenz can cause which side effects? [3]

Answer 20

Neuropsychotic / CNS side effects:
- impaired concentration
- mood swings
- sleep disturbance

Question 21

Renal disease is caused by long term use of which ART? [1]

Answer 21

Tenofovir

Question 22

Which ART might cause this reaction

Abacavir
Efavirenz
Tenofovir
Darunavir
Nevirapine

Answer 22

Which ART might cause this reaction

Abacavir - get HLAB5701 screen

Efavirenz
Tenofovir
Darunavir
Nevirapine

Question 23

Which two drugs make up long-acting drugs for HIV treatment? [2]

Answer 23

II and NNRTI

Question 24

Name two side effects of Tenofovir DF long term use [2]

Answer 24

Tenofovir DF:
- Tubular toxicity (prevents re-ab of certain solutes at PCT - risk of kidney failure
- Reduction in bone mineral density

Question 25

Name a side effect of abacavir long term use [1]

Answer 25

Dyslipidaemia / atherosclerosis | Avoid in ptx with high risk CVD

Question 26

Name two side effects of boosted PIs long term use [1]

Answer 26

Dyslipidaemia / atherosclerosis and increased other drug dose

Question 27

Boosted PIs may cause which other metabolic effects? [1]

Answer 27

Insulin resistance and diabetes

Question 28

Dolutegravir is which drug class? [1]

Answer 28

Integrase inhibitor

Question 29

Which drug class is associated with Cushingoid appearances? [1]

Answer 29

AZT / old medications

Question 30

Which drug is most likely to cause vivid dreams, and somnolence Efavirenz Emtricitabine Lopinavir Abacavir Enfuvirtide (T-20) Tenofovir Atazanavir Raltegravir Ritonavir Dolutegravir Nevirapine

Answer 30

Which drug is most likely to cause vivid dreams, and somnolence **Efavirenz** Emtricitabine Lopinavir Abacavir Enfuvirtide (T-20) Tenofovir Atazanavir Raltegravir Ritonavir Dolutegravir

Question 31

Which drug is most likely to cause **diarrhoea, nausea Hyperlipidaemia** Efavirenz Emtricitabine Lopinavir Abacavir Enfuvirtide (T-20) Tenofovir Atazanavir Raltegravir Ritonavir Dolutegravir Nevirapine

Answer 31

Which drug is most likely to cause **diarrhoea, nausea Hyperlipidaemia** **Lopinavir** (PI)

Question 32

Which drug is most likely to cause **elevation in bilirubin (unconjugated)** Efavirenz Emtricitabine Lopinavir Abacavir Enfuvirtide (T-20) Tenofovir Atazanavir Raltegravir Ritonavir Dolutegravir Nevirapine

Answer 32

Which drug is most likely to cause **elevation in bilirubin (unconjugated)** **Atazanavir** (PI)

Question 33

Which drug is most likely to cause **a severe reaction at the injection site** Efavirenz Emtricitabine Lopinavir Abacavir Enfuvirtide (T-20) Tenofovir Atazanavir Raltegravir Ritonavir Dolutegravir Nevirapine

Answer 33

Which drug is most likely to cause **a severe reaction at the injection site** Efavirenz Emtricitabine Lopinavir Abacavir **Enfuvirtide (T-20)** Tenofovir Atazanavir Raltegravir Ritonavir Dolutegravir

Question 34

Which drug is most likely to cause **mood / sleep disturbance and is an II?** Efavirenz Emtricitabine Lopinavir Abacavir Enfuvirtide (T-20) Tenofovir Atazanavir Raltegravir Ritonavir Dolutegravir Nevirapine

Answer 34

Which drug is most likely to cause **mood / sleep disturbance and is an II?* **Dolutegravir**

Question 35

Which drug is most likely to cause **SJS** Efavirenz Emtricitabine Lopinavir Abacavir Enfuvirtide (T-20) Tenofovir Atazanavir Raltegravir Ritonavir Dolutegravir Nevirapine

Answer 35

Which drug is most likely to cause **SJS** **Nevirapine**

Question 36

Which drug is most likely to cause **renal dysfunction** Efavirenz Emtricitabine Lopinavir Abacavir Enfuvirtide (T-20) Tenofovir Atazanavir Raltegravir Ritonavir Dolutegravir Nevirapine

Answer 36

**Tenofovir**

Question 37

Which drug is most likely to cause **reduced bone minderal density** Efavirenz Emtricitabine Lopinavir Abacavir Enfuvirtide (T-20) Tenofovir Atazanavir Raltegravir Ritonavir Dolutegravir Nevirapine

Answer 37

**tenofovir**

Question 38

Which drug is most likely to cause **an increased risk of CVD** Efavirenz Emtricitabine Lopinavir Abacavir Enfuvirtide (T-20) Tenofovir Atazanavir Raltegravir Ritonavir Dolutegravir Nevirapine

Answer 38

Which drug is most likely to cause **an increased risk of CVD** Efavirenz Emtricitabine Lopinavir **Abacavir** Enfuvirtide (T-20) Tenofovir Atazanavir Raltegravir Ritonavir Dolutegravir Nevirapine

Question 39

Which antiretroviral is most likely to be responsible for jaundice? Abacavir Atazanavir Darunavir Efavirenz Emtricitabine/FTC Lamivudine/3TC Lopinavir Nevirapine Raltegravir Ritonavir Tenofovir | TMS

Answer 39

**Atazanavir**

Question 40

Generalised itchy rash with raised liver enzymes 2-4 weeks into treatment is most likely? [1]

Answer 40

**Nevirapine**

Question 41

Risk of weight gain seems to be higher with some ART agents: - Tenofovir **[]** is associated with more weight gain than Tenofovir **[]**, which may be protective

Answer 41

Risk of weight gain seems to be higher with some ART agents: - **Tenofovir alafenamide (TAF)** is associated with more weight gain than **Tenofovir (TDF)**, which may be protective ## Footnote TAF --> FAT

Question 42

**[Drug class]** are associated with more weight gain than other ART: Raltegravir >

Answer 42

**Integrase Inhibitors** are associated with more weight gain than other ART: Raltegravir >

Question 43

**[]** tend to exacerbate the cytopenic effects of chemotherapy. NNTRIS NRTIs IIs PIs FI

Answer 43

**NRTIs** tend to exacerbate the cytopenic effects of chemotherapy.

Question 44

**[]** are potent liver enzyme inducers and may lower the levels of other drugs NNTRIS NRTIs IIs PIs FI

Answer 44

**[]** are potent liver enzyme inducers and may lower the levels of other drugs **NNTRIS** NRTIs IIs PIs FI

Question 45

How should you manage infants born to HIV infected mothers? [1]

Answer 45

**Most infants should be given AZT monotherapy for 4 weeks**

Question 46

When should an elective caesarean section should be planned for 38 weeks? [2]

Answer 46

Women on combination therapy with detectable viraemia Women with HIV / HCV co-infection

Question 47

For ART to be successful, adherence rates must be in the range of **[]-[]**%

Answer 47

For ART to be successful, adherence rates must be in the range of **90-95%**