ID Opportunistic and HIV

Question 1

What CD4+ T lymphocyte count is considered immunocompromised?

Answer 1

<200

Question 2

Use of systemic steroids for ____ days or longer at a prednisone dose of ____mg/d or _____mg/kg/d can cause an immunocompromised state

Answer 2

14 days or longere
Dose of 20mg/d or more
2mg/kg/d or more

Question 3

Lack of what organ can cause an immunocompromised state?

Answer 3

Spleen (asplenia)

Question 4

Use of what medications can cause an immunocompromised state

Answer 4

Immunosuppressants

Cancer chemo

Question 5

What is chemoprophylaxis?

Answer 5

Prophylaxis of opportunistic infections

Question 6

What are common opportunistic infections that require primary prophylaxis?

Answer 6

Pneumocystitis pneumonia (PCP or PJP)
Toxoplasmosis gondii encephalitis
Mycobacterium avium complex (MAC)

Question 7

Is prophylaxis recommended for candida infections in immunocompromised people?

Answer 7

Immunocompromised patients are at a higher risk but prophylaxis is not recommended

Question 8

What ANC level is considered severe neutropenia?

Answer 8

ANC < 500 cells/mm3

Question 9

What primary prophylaxis medications are good to use in the setting of sulfa allergy

Answer 9

atovaquone
dapsone
pentamidine

Question 10

What primary prophylaxis medications are good to use in the setting of G6PD deficiency?

Answer 10

atovaquone

pentamidine

Question 11

What medication is added to all pyrimethamine-containing regimens as rescue therapy to reduce the risk of pyrimethamine-induced myelosuppression?

Answer 11

Leucovorin

Question 12

When to initiate and discontinue primary prophylaxis for Pneumocystitis pneumonia (PCP or PJP) in HIV

Answer 12

Initiate when CD4 count <200 cells, oropharyngeal candidiasis, or other AIDS-defining illness
D/C when CD4 >200 cells for 3 or more months on ART

Question 13

Primary prophylaxis regimen for Pneumocystitis pneumonia (PCP or PJP) in HIV

Answer 13

Preferred: bactrim DS or SS daily
Alternative: bactrim DS 3x/wk OR dapsone +/- (pyrimethamine + leucovorin) OR atovaquone

Question 14

When to initiate and discontinue primary prophylaxis for toxoplasma gondii encephalitis

Answer 14

Initiate when CD4 count < 100

D/c when CD4 >200 for >3 months on ART

Question 15

Primary prophylaxis regimen for Toxoplasma gondii encephalitis

Answer 15

Preferred: bactrim DS daily
Alternative: bactrim DS 3x/wk OR dapsone + pyrimethamine + leucovorin OR atovaquone OR atovaquone + pyrimethamine + leucovorin

Question 16

When to initiate and discontinue primary prophylaxis for Mycobacterium avium complex (MAC) infection

Answer 16

Initiate when NOT taking ART and CD4 <50 (if on ART - not recommended)
D/c when taking fully suppressive ART

Question 17

Primary prophylaxis regimen for mycobacterium avium complex (MAC)

Answer 17

Preferred: azithromycin 1200mg weekly
Alternative: Azithromycin 600 twice weekly OR clarithromycin 500mg BID

Question 18

When treating thrush in someone with HIV is systemic or topical treatment preferred?

Answer 18

Systemic

Question 19

Preferred, alternative, and secondary prophylaxis regiment for
Candida (thrush)

Answer 19

Preferred: fluconazole
Alternative: itraconazole, posaconazole
Secondary prophylaxis: None

Question 20

Preferred, alternative, and secondary prophylaxis regiment for
Cryptococcal menintigis

Answer 20

Preferred: Amphotericin B + flucytosine
Alternative: fluconazole +/- flucytosine
Secondary prophylaxis: Fluconazole (low dose)

Question 21

Preferred, alternative, and secondary prophylaxis regiment for
Cytomegalovirus (CMV)

Answer 21

Preferred: Valganciclovir or ganciclovir
Alternative: Foscarnet, cidofovir
Secondary prophylaxis: None; maintain CD4 > 100 cells

Question 22

Preferred, alternative, and secondary prophylaxis regiment for
Mycobacterium avium complex (MAC)

Answer 22

Preferred: (Clarithromycin or azithromycin) + ethambutol
Alternative: preferred PLUS rifabutin, amikacin or streptomycin, moxifloxacin, or levofloxacin
Secondary prophylaxis: Same as treatment regimen

Question 23

Preferred, alternative, and secondary prophylaxis regiment for 
Pneumocystitis pneumonia (PCP)

Answer 23

Preferred: Bactrim +/- prednisone or methylprednisolone x 21 days
Alternative: Atovaquone OR pentamidine IV
Secondary prophylaxis: same as primary prophylaxis

Question 24

Preferred, alternative, and secondary prophylaxis regiment for
Toxoplasmosis gondii encephalitis

Answer 24

Preferred: Pyrimethamine + leucovorin + sulfadiazine
Alternative: Bactrim OR (clinda or azithormycin) +/- pyrimethamine + leucovorin OR atovaquone +/- (atovaquone + sulfadiazine)
Secondary prophylaxis: Same as treatment; reduced dose

Question 25

What cells does HIV use to replicate?

Answer 25

CD4+ T cells

Question 26

When is AIDS diagnosed?

Answer 26

When a patient's CD4 count falls below 200 cells/mm3 or the presence of an AIDS defining condition

Question 27

Who should be tested for HIV?

Answer 27

Everyone at least once Everyone ages 13-64 at high risk - annually - Sharing drug equipment needles - High-risk sexual behaviors - History of a sexually transmitted infection

Question 28

What are the 3 stages of HIV?

Answer 28

Acute infection Chronic infection AIDS

Question 29

What happens during the acute infection stage of HIV?

Answer 29

Lasts 2-4 weeks HIV multiplies rapidly S/sx are flu-like Highly infectious

Question 30

What happens during the chronic infection stage of HIV?

Answer 30

ART suppresses the viral load OR the virus is replicating causing the viral load to increase and CD4 count to decrease

Question 31

What happens during the AIDS stage of HIV?

Answer 31

Patient has AIDS-defining condition or CD4 count <200

Question 32

How is HIV diagnosed?

Answer 32

Positive HIV-1/HIV-2 antigen/Antibody immunoassay THEN positive confirmatory testing with HIV-1/HIV-2 antibody differentiation immunoassay

Question 33

What is an OTC in-home HIV test? How does it work?

Answer 33

Oraquick Detects presence of HIV Ab Positive test requires f/u testing Should be done >3 months from exposure

Question 34

What are the 7 stages of HIV replication?

Answer 34

``` 1 - binding/attachment to CD4 cell 2 - fusion 3 - reverse transcription 4 - integration 5 - transcription and transplantation 6 - assembly 7 - budding and maturation ```

Question 35

What stage of HIV replication does Maraviroc (Selzentry) and Ibalizumab-uiyk (Trogarzo) inhibit?

Answer 35

Stage 1 - binding/attachment to CD4 cell

Question 36

What stage of HIV replication does Enfuvirtide (Fuzeon) inhibit?

Answer 36

Stage 2 - fusion

Question 37

What stage of HIV replication do non-nucleoside and nucleoside reverse transcriptase inhibitors (NNRTIs and NRTIs) inhibit?

Answer 37

Stage 3 - reverse transcription

Question 38

What stage of HIV replication do integrase strand transfer inhibitors (INSTIs) inhibit?

Answer 38

Stage 4 - integration

Question 39

What stage of HIV replication do protease inhibitors inhibit?

Answer 39

Stage 7 - budding and maturation

Question 40

What is a normal CD4 count?

Answer 40

800-1200 cells/mm3

Question 41

What testing should HIV patients undergo during initial evaluation?

Answer 41

``` CD4 count HIV viral load Drug resistance genotype testing CMP Hepatitis B and C testing Pregnancy (women) Drug-specific screening ```

Question 42

How high must adherence be to HIV medications to prevent resistance?

Answer 42

>95%

Question 43

What are the recommended regiments for initial ART in most treatment-naive adults that are 1 pill once daily?

Answer 43

1 INSTI + 1 or 2 NRTIs Biktarvy (bictegravir/emtricitabine/tenofovir alafenamide) Triumeq (dolutegravir/abacavir/lamivudine) Dovato (dolutegravir/lamivudine)

Question 44

What are the recommended regimens for initial ART in most treatment-naive adults that are 2 pills?

Answer 44

[Tivicay (dolutegravir) OR Isentress (Ralegravir)] PLUS [Truvada (emtricitabine/tenofovir disoproxil) OR Descovy (Emtricitabine/Tenofovir alafenamide)]

Question 45

``` Tenofovir DF (TDF) vs tenofovir AF (TAF) Which has more renal and bone issues? ```

Answer 45

TDF | Do not use if renal impairment or high fracture risk

Question 46

Which medication requires HLA-B*5701 allele testing? | What does the allele indicate?

Answer 46

Abacavir | Allele indicates higher risk of severe hypersensitivity reaction

Question 47

When should dovato not be initiated?

Answer 47

When HIV RNA > 500,000 copies/mL | Hepatitis B co-infection

Question 48

Nucleoside(tide) reverse transcriptase inhibitor (NRTI) MOA

Answer 48

Competitively block reverse transcriptase enzyme

Question 49

What medications are NRTIs?

Answer 49

``` Tenofovir disoproxil fumarate Tenofovir alafenamide Lamivudine Emtricitabine Abacavir Zidovudine ```

Question 50

Which NRTI is given during delivery when the viral load is >1000 to protect the baby

Answer 50

Zidovudine (Retrovir)

Question 51

Which NRTIs have a higher risk of adverse effects?

Answer 51

Stavudine, didanosine, and zidovudine - older | Lactic acidosis and hepatomegaly with steatosis

Question 52

NRTI SE

Answer 52

N/D, increased LFTs

Question 53

What is PEP and PrEP?

Answer 53

PEP - post-exposure prophylaxis | PrEP - pre-exposure prophylaxis

Question 54

Integrase strand stransfer inhibitors (INSTIs) MOA

Answer 54

Block the integrase enzyme, preventing viral DNA from integrating into the host cell DNA

Question 55

What drugs are integrase strand transfer inhibitors (INSTIs)

Answer 55

Bictegravir (BIC) Elvitegravir (EVG) Dolutegravir (Tivicay) Raltegravir (RAL)

Question 56

INSTIs SE

Answer 56

HA, insomnia, diarrhea, weight gain, depression, CKP/myositis/rhabdomyolysis

Question 57

Non-nucleoside reverse transcriptase inhibitors (NNRTIs) MOA

Answer 57

Bind to the enzyme non-competitively causign a conformational change that inhibits the enzyme

Question 58

What medications should not be taken with integrase strand transfer inhibitors

Answer 58

Cations | Take INSTI 2 hours before and 6 hours after aluminum and mg containing products

Question 59

NNRTIs BBW and CI

Answer 59

BBW: hepatotoxicity, severe rash CI: Rilpivarine - do not use with PPIs; Rilpivirine and doravirine - do not use with strong CYP inducers

Question 60

Protease inhibitor medications

Answer 60

Atazanavir (reyataz) | Darunavir (Prezista)

Question 61

Protease inhibitor MOA

Answer 61

Inhibits protease enzyme which prevents protein strands from being cut into the smaller pieces needed for assembly of new virions HIV continues to replicate but produces immature virions that are not infectious

Question 62

Protease inhibitors and drug interactions

Answer 62

CYP3A4 inducers decrease concentration of PIs

Question 63

What medications are boosters?

Answer 63

Ritonavir | Cobicistat

Question 64

Boosters MOA

Answer 64

Ritonavir and cobicistat are inhibitors of CYP3A4 | Inhibit ART metabolism, increasing ART effect

Question 65

What medicationsare CCR5 atagonists

Answer 65

Maravioric

Question 66

Maravioric MOA

Answer 66

Blocks HIV from binding to the CCR5 co-receptor on the CD4+ cell, preventing HIV from entering the cell

Question 67

What test needs to be done before giving maravioric?

Answer 67

Tropism assay to reveal co-receptor | Only works with CCR5 tropic disease and is NOT useful if CXCR4 or mixed

Question 68

Maravioric BBW, CI, and SE

Answer 68

BBW: hepatotoxicity CI: Severe renal impairment (CrCl<30); potent CYP3A4 inhibitors/inducers SE: N/D, LFTs, URTIs

Question 69

What medication is a fusion inhibitor

Answer 69

Enfuvirtie (T20)

Question 70

Enfuviritide MOA

Answer 70

Prevents HIV from fusing to CD4 cell membrane, preventing entry into the cell

Question 71

Enfuviritide warnings and SE

Answer 71

Warnings: bacterial pneumonia, hypersensitivity reaction SE: local injection site reaction

Question 72

What medication is a CD4 directed post-attachment HIV-1 inhibitor

Answer 72

Ibalizumab-uiyk (Trogarzo)

Question 73

Ibalizumab-uiyk MOA

Answer 73

Monoclonal antibodies that bind to CD4+ cell to block HIV entry

Question 74

What are AIDS defining conditions?

Answer 74

Opportunistic infections Kaposi's sarcoma HIV wasting syndrome

Question 75

What is immune reconstitution inflammatory syndrome (IRIS)?

Answer 75

Paradoxical worsening of either a new or known condition that has been supressed, but becomes unmasked after ART is started

Question 76

Which HIV medication can cause neural tube defects in pregnancy?

Answer 76

Dolutegravir - small risk | Continue if this medication is effective

Question 77

Recommended HIV treatment in treatment-naive pregnant women

Answer 77

Two NRTIs (Abacavir/lamivudine OR TDF/emtricitabine) PLUS Boosted PI: (Atazanavir or darunavir+ritonavir) OR Raltegravir or dolutegravir

Question 78

PrEP - when to take medication and what medication to take

Answer 78

Before high-risk activity then daily | 1 tablet with 2 drugs (Truvada or descovy)

Question 79

PEP - when to take medication and what medication to take

Answer 79

After HIV-exposure, within 72 hours, take for 28 days | Truvada (If CrCl>60) + dolutegravir (Tivicay) OR Raltegravir (Isentress)