HIV - Tx Principles, Regimens, and Monitoring Flashcards
Who is ART indicated for?
EVERYONE with HIV, regardless of CD4 count
What is key for a pt to successfully manage an HIV infection and remain non-infectious?
ADHERENCE to ARV tx regimen
What are the goals of ARV tx?
- reduce viral load to < 20 copies/mL (undetectable)
- restore CD4+ count to > 500 cells/mm^3
- prevent HIV transmission (U=U)
How long does it take for ART to reduce viral load to undetectable?
6-12 wks after initiation
When should HIV tx be started?
ASAP
Name the NRTIs:
abacavir (ABC) emtricitabine (FTC) lamivudine (3TC) tenofovir (TDF and TAF) zidovudine (AZT, ZDV)
Name the NNRTIs
Efavirenz (EFV) Etravirine (ETR) Nevirapine (NVP) Rilpivirine (RPV) Doravirine
Name the PIs
Atazanavir (ATV)
Darunavir (DRV)
Lopinavir (LPV)
Name the pharmacokinetic boosters:
Cobicistat (/c)
Ritonavir (/r)
Name the INSTIs
Raltegravir (RAL)
Eltegravir (EVG)
Dolutegravir (DTG)
Bictegravir (BIC)
How’re HIV drugs usually combined?
3 active drugs from 2 diff classes
usually 2 NRTIs and another drug class [usually an INSTI or PI, and s.times an NNRIT]
What’s the most common fixed-dose NRTI combo?
Truvada (TDF + FTC)
When should CD4 absolute and HIV viral load be monitored?
Baseline (before tx) and after 3-4 mnths of tx
What’s the most IMPORTANT value to monitor?
viral load
Which drug requires that we check for HLA B *5701?
abacavir
The function of which organs should be monitored while on antiretrovirals?
Liver, kidneys
When does resistance develop?
When the HIV virus replicates in the presence of drug
Low adherence can lead to viral resistance against antivirals. What kind of HIV drugs are avoided in pts who have sucky adherence?
Drugs have low genetic barrier to resistance
1 cause of ARV resistance?
Poor or intermittent adherence
Which antiretroviral is preferred in renal dysfn pts?
tenofovir (TDF and TAF)
CrCl down to 60 ml/min = TAF and TDF regimens; CrCl down to 30 ml/min = TAF okay
Which antiretroviral is preferred in pts who have comorbid HBV?
tenofovir
What kind of ARV tx is preferred in pts w/ osteoporosis?
NNRTI regimens (avoid TDF, but TAF is okay > these are NRTIs)
What HIV meds should be avoided in depression/anxiety?
EFV and DTG
Which HIV meds should be avoided if pt has CV risks?
PIs, EFV (may increase lipids), ABC (may increase MI risk)
Which HIV meds should be avoided in DM pts?
PIs (raises blood glucose)
Which of the following does not help w/ improving adherence?
a. phone alarms
b. single pill regimens
c. monthly dispense
d. blister packing
c. monthly dispense
Rather, weekly/biweekly dispenses will help
What should be done if pt adherence is a concern during ARV tx?
Pick a regimen w/ higher genetic barrier to resistance
How much should pts pay for their antiretrovirals in SK?
$0
After how many weeks of ARV should another blood test be taken?
~6weeks
What are the two most important variables on a blood test in an HIV pt
- viral load
2. CD4 count
As long as HIV virus is still detectable, how often should monitoring be done?
q6-8 wks
When HIV virus is suppressed, how often should monitoring be done?
q6mths
When does it become unnecessary to check CD4 counts?
when it gets > 500 cells/mm^3
Low vs high genetic barrier drugs: what’s the difference?
Lower genetic barrier drugs - may only require single base pair change to confer resistance
Higher genetic barrier drugs - require multiple base pair changes to confer resistance
T or F: drug resistant HIV can be transmitted.
T
T or F: Women who get pregnant and who are already on ARV tx’s should halt their tx for the time being until they
F
They should continue it
How big is the drop in viral load after 6 weeks of ART?
2 log drop
What is considered a virological failure wrt HIV tx?
When pt isn’t achieving a viral load below 200 copies/mL
What is considered an immunologic failure?
failure to achieve/maintain adequate CD4 counts despite undetectable viral load
What is to be done during virological failure?
Genotypic testing, assess adherence, pick new regimen + check viral load in 4-6wks
T or F: There’s no solution available for immunologic failures other than treating illnesses that may arise as a result of it.
T
What does an HIV regimen consist of?
at least 3 active drugs from 2 diff classes > 2 NRTIs and one of PI/INSTI/NNRTI
T or F: Properly treated HIV is still considered a chronic illness.
F
It’s considered a chronic “condition”
What is PrEP, and what drugs comprise it?
It’s a treatment protocol used to prevent acquiring the HIV virus
It’s comprised of FTC/TDF (Truvada) > ONLY PrEP drug available for now
What is usually used as a post-exposure prophylaxis (PEP)?
PI or INSTI
+
TDF/FTC backbone
How long is PEP used for?
28 days (or less if source is confirmed to not have HIV)
After being exposed to HIV, how much time do you have to receive PEP before its effectiveness becomes negligible?
72h
What drug is used for infant PEP who are born to HIV+ mothers?
AZT (zidovudine)
What may happen if Truvada (PrEP tx composed of TDF and FTC) is used in an HIV+ person?
Drug resistance to Truvada (since it’s not triple tx)
T or F: PrEP is enough as a stand-alone intervention for HIV prevention
F
Other methods are important (condoms, clean injection equipment, etc.)
Renal fn requirement for PrEP?
eGFR > 60 mL/min for TDF/FTC use
T or F: It’s appropriate to stop a problematic component of an HIV regimen to reduce AEs.
F
NEVER EVER DO THIS > risks resistance
T or F: ART in HIV pts is lifelong
T
What’s the viral load target for ART in HIV pts?
< 20 copies/mL
aka < 2.00+E01 copies/mL
aka “target not detected”
T or F: Non-adherence is worse than intermittent adherence wrt ART.
F
Largest comorbidity in HIV pts, even when the virus is suppressed.
Inflammation
