HIV - Treatment and Care Flashcards
What to look for in a physical examination?
Kapusi’s sarcoma - purple-y vasculor tumours
Mucosal candidiasis - also check for painful swallowing which is associated with immunosupression
Pneumocystic pneumonitis
Syphilis
Name the targets for antiretroviral drugs
Reverse transcriptase Integrase Protease Entry - Fusion - CCR5 receptor Maturation
Name the only drug that targets the host
CCR5 antagonist
Effectiveness of mono and dual therapy
Monotherapy - reduced viral load but not survival
Dual therapy - slightly better but not much. Useful to prolong survival only if patient is started on dual therapy directly, rather than adding to monotherapy.
Define highly active anti-retroviral therapy ***
a combination of 3 drugs from at least 2 drug classes to which the virus is susceptible
What is the purpose of highly active antiretroviral therapy (HAART)
Reduce viral load to undetectable
Restore immunocompetence
Reduce morbidity and mortality
Preventing drug resistance
ADHERENCE (95%) - take medicines every day
Lifestyle - night shifts? regular meals? Tolerability Pharmacokinetics Drug-drug interactions Treatment interruptions
How to manage treatment interruptions
Provide protease which is harder to get resistance to and allow some viral breakthrough as it is better than resistance
Factors to consider when choosing an anti retroviral
Tolerability Low toxicity Low pill burden Low dosing frequency Minimal drug-interactions High barrier to resistance
List the effects of HAART toxicity in each system
GI side-effects (protease inhibitors)
Skin: rash, hypersensitivity, Stevens-Johnsons (abacavir, nevirapine)
CNS side-effects: mood, psychosis (efavirenz)
Renal toxicity: proximal renal tubulopathies (tenofovir, atazanavir)
Bone: osteomalacia (tenofovir)
CVS: increased MI risk (abacavir, lopinavir, maraviroc)
Haematology: anaemia (zidovudine)
GI: transaminitis, fulminant hepatitis (nevirapine, most others)
What is the only HAART drug licensed to be used in pregnant women?
Zidovudine
Drug-drug interactions in HAART therapy
Protease inhibitors are generally potent liver enzyme inhibitors
NNRTIs are generally potent liver enzyme inducers
Some drugs require pharmacological boosting (with potent liver enzyme inhibitors)
Is partner disclosure and notification mandated by law?
No. Voluntary process.
What are the different partner notification strategies
Partner referral
Provider referral
Conditional referral
Barriers to PN and disclosure
Fear
- rejection
- isolation
- violence
Confidentiality
Stigma - leads to discrimination and/or ostracisation
What does prevention medicine encompass?
CVS risk Smoking cessation STI screening Hep A/B Flu vaccine HPV vaccine Harm reduction
Prevention of onward HIV transmission
Sexual transmission
- Condom use
- HIV treatment
- STI screening and treatment
- Sero-adaptive sexual behaviours
- Disclosure
- Post-exposure prophylaxis
- Pre-exposure prophylaxis
Sero - adaptive behaviour
If the HIV +ve partner is the inserting partner, the risk of transmission is greater rather than if he is the receiving partner
STI and HIV transmission
HIV is more likely to take root in the presence of an STI rather than without it during intercourse with an HIV+ person
Can HIV be transmitted through use of cutlery, kissing, bath towels or other casual/household contact?
No
Conception options for HIV+ male and HIV - female
Treatment as prevention
(+/- timed condomless sex)
?HIV PrEP for female partner
Conception options for HIV- male and HIV + female
Treatment as prevention
(+/- timed condomless sex)
? Self-insemination
?HIV PrEP for male partner
Prevention of mother to child transmission
HAART during pregnancy Vaginal delivery if undetected viral load Caesarean section if detected viral load 4/52 PEP for neonate Exclusive formula feeding
List members of the MDT in HIV management
Physicians Nurse specialists Pharmacist Patient co-ordinator Secretaries Virologists Clinical psychologist Social workers Sexual health
List the HIV prevention strategies that are effective on the individual level
Condom programmes
PEPSE
Behavioural change interventions (short term impact)
PrEP
List the HIV prevention strategies that are effective on the community level
Needle exchange
Testing and treatment for STIs
Circumcision
Treatment as prevention
PrEP eligibility criteria
Aged ≥ 16 and
HIV negative and
Can commit to 3/12’ly follow-up and
Willing to stop if eligibility criteria no longer apply and
Resident in Scotland
Is the patient high risk for HIV?
HIV+ partner with detectable viral load or
MSM or transwoman
UPAI ≥ 2 partners in 12/12 and likely to do so again in next 3/12 or
Confirmed bacterial rectal STI in last 12/12 or
Other high risk factor agreed with another clinician
