ID Opportunistic and HIV Flashcards
What CD4+ T lymphocyte count is considered immunocompromised?
<200
Use of systemic steroids for ____ days or longer at a prednisone dose of ____mg/d or _____mg/kg/d can cause an immunocompromised state
14 days or longere
Dose of 20mg/d or more
2mg/kg/d or more
Lack of what organ can cause an immunocompromised state?
Spleen (asplenia)
Use of what medications can cause an immunocompromised state
Immunosuppressants
Cancer chemo
What is chemoprophylaxis?
Prophylaxis of opportunistic infections
What are common opportunistic infections that require primary prophylaxis?
Pneumocystitis pneumonia (PCP or PJP)
Toxoplasmosis gondii encephalitis
Mycobacterium avium complex (MAC)
Is prophylaxis recommended for candida infections in immunocompromised people?
Immunocompromised patients are at a higher risk but prophylaxis is not recommended
What ANC level is considered severe neutropenia?
ANC < 500 cells/mm3
What primary prophylaxis medications are good to use in the setting of sulfa allergy
atovaquone
dapsone
pentamidine
What primary prophylaxis medications are good to use in the setting of G6PD deficiency?
atovaquone
pentamidine
What medication is added to all pyrimethamine-containing regimens as rescue therapy to reduce the risk of pyrimethamine-induced myelosuppression?
Leucovorin
When to initiate and discontinue primary prophylaxis for Pneumocystitis pneumonia (PCP or PJP) in HIV
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
Primary prophylaxis regimen for Pneumocystitis pneumonia (PCP or PJP) in HIV
Preferred: bactrim DS or SS daily
Alternative: bactrim DS 3x/wk OR dapsone +/- (pyrimethamine + leucovorin) OR atovaquone
When to initiate and discontinue primary prophylaxis for toxoplasma gondii encephalitis
Initiate when CD4 count < 100
D/c when CD4 >200 for >3 months on ART
Primary prophylaxis regimen for Toxoplasma gondii encephalitis
Preferred: bactrim DS daily
Alternative: bactrim DS 3x/wk OR dapsone + pyrimethamine + leucovorin OR atovaquone OR atovaquone + pyrimethamine + leucovorin
When to initiate and discontinue primary prophylaxis for Mycobacterium avium complex (MAC) infection
Initiate when NOT taking ART and CD4 <50 (if on ART - not recommended)
D/c when taking fully suppressive ART
Primary prophylaxis regimen for mycobacterium avium complex (MAC)
Preferred: azithromycin 1200mg weekly
Alternative: Azithromycin 600 twice weekly OR clarithromycin 500mg BID
When treating thrush in someone with HIV is systemic or topical treatment preferred?
Systemic
Preferred, alternative, and secondary prophylaxis regiment for
Candida (thrush)
Preferred: fluconazole
Alternative: itraconazole, posaconazole
Secondary prophylaxis: None
Preferred, alternative, and secondary prophylaxis regiment for
Cryptococcal menintigis
Preferred: Amphotericin B + flucytosine
Alternative: fluconazole +/- flucytosine
Secondary prophylaxis: Fluconazole (low dose)
Preferred, alternative, and secondary prophylaxis regiment for
Cytomegalovirus (CMV)
Preferred: Valganciclovir or ganciclovir
Alternative: Foscarnet, cidofovir
Secondary prophylaxis: None; maintain CD4 > 100 cells
Preferred, alternative, and secondary prophylaxis regiment for
Mycobacterium avium complex (MAC)
Preferred: (Clarithromycin or azithromycin) + ethambutol
Alternative: preferred PLUS rifabutin, amikacin or streptomycin, moxifloxacin, or levofloxacin
Secondary prophylaxis: Same as treatment regimen
Preferred, alternative, and secondary prophylaxis regiment for Pneumocystitis pneumonia (PCP)
Preferred: Bactrim +/- prednisone or methylprednisolone x 21 days
Alternative: Atovaquone OR pentamidine IV
Secondary prophylaxis: same as primary prophylaxis
Preferred, alternative, and secondary prophylaxis regiment for
Toxoplasmosis gondii encephalitis
Preferred: Pyrimethamine + leucovorin + sulfadiazine
Alternative: Bactrim OR (clinda or azithormycin) +/- pyrimethamine + leucovorin OR atovaquone +/- (atovaquone + sulfadiazine)
Secondary prophylaxis: Same as treatment; reduced dose
What cells does HIV use to replicate?
CD4+ T cells
When is AIDS diagnosed?
When a patient’s CD4 count falls below 200 cells/mm3 or the presence of an AIDS defining condition
Who should be tested for HIV?
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
What are the 3 stages of HIV?
Acute infection
Chronic infection
AIDS
What happens during the acute infection stage of HIV?
Lasts 2-4 weeks
HIV multiplies rapidly
S/sx are flu-like
Highly infectious
What happens during the chronic infection stage of HIV?
ART suppresses the viral load OR the virus is replicating causing the viral load to increase and CD4 count to decrease
What happens during the AIDS stage of HIV?
Patient has AIDS-defining condition or CD4 count <200
How is HIV diagnosed?
Positive HIV-1/HIV-2 antigen/Antibody immunoassay THEN positive confirmatory testing with HIV-1/HIV-2 antibody differentiation immunoassay
What is an OTC in-home HIV test? How does it work?
Oraquick
Detects presence of HIV Ab
Positive test requires f/u testing
Should be done >3 months from exposure
What are the 7 stages of HIV replication?
1 - binding/attachment to CD4 cell 2 - fusion 3 - reverse transcription 4 - integration 5 - transcription and transplantation 6 - assembly 7 - budding and maturation
What stage of HIV replication does Maraviroc (Selzentry) and Ibalizumab-uiyk (Trogarzo) inhibit?
Stage 1 - binding/attachment to CD4 cell
What stage of HIV replication does Enfuvirtide (Fuzeon) inhibit?
Stage 2 - fusion
What stage of HIV replication do non-nucleoside and nucleoside reverse transcriptase inhibitors (NNRTIs and NRTIs) inhibit?
Stage 3 - reverse transcription
What stage of HIV replication do integrase strand transfer inhibitors (INSTIs) inhibit?
Stage 4 - integration
What stage of HIV replication do protease inhibitors inhibit?
Stage 7 - budding and maturation
What is a normal CD4 count?
800-1200 cells/mm3
What testing should HIV patients undergo during initial evaluation?
CD4 count HIV viral load Drug resistance genotype testing CMP Hepatitis B and C testing Pregnancy (women) Drug-specific screening
How high must adherence be to HIV medications to prevent resistance?
> 95%
What are the recommended regiments for initial ART in most treatment-naive adults that are 1 pill once daily?
1 INSTI + 1 or 2 NRTIs
Biktarvy (bictegravir/emtricitabine/tenofovir alafenamide)
Triumeq (dolutegravir/abacavir/lamivudine)
Dovato (dolutegravir/lamivudine)
What are the recommended regimens for initial ART in most treatment-naive adults that are 2 pills?
[Tivicay (dolutegravir) OR Isentress (Ralegravir)]
PLUS
[Truvada (emtricitabine/tenofovir disoproxil) OR Descovy (Emtricitabine/Tenofovir alafenamide)]
Tenofovir DF (TDF) vs tenofovir AF (TAF) Which has more renal and bone issues?
TDF
Do not use if renal impairment or high fracture risk
Which medication requires HLA-B*5701 allele testing?
What does the allele indicate?
Abacavir
Allele indicates higher risk of severe hypersensitivity reaction
When should dovato not be initiated?
When HIV RNA > 500,000 copies/mL
Hepatitis B co-infection
Nucleoside(tide) reverse transcriptase inhibitor (NRTI) MOA
Competitively block reverse transcriptase enzyme
What medications are NRTIs?
Tenofovir disoproxil fumarate Tenofovir alafenamide Lamivudine Emtricitabine Abacavir Zidovudine
Which NRTI is given during delivery when the viral load is >1000 to protect the baby
Zidovudine (Retrovir)
Which NRTIs have a higher risk of adverse effects?
Stavudine, didanosine, and zidovudine - older
Lactic acidosis and hepatomegaly with steatosis
NRTI SE
N/D, increased LFTs
What is PEP and PrEP?
PEP - post-exposure prophylaxis
PrEP - pre-exposure prophylaxis
Integrase strand stransfer inhibitors (INSTIs) MOA
Block the integrase enzyme, preventing viral DNA from integrating into the host cell DNA
What drugs are integrase strand transfer inhibitors (INSTIs)
Bictegravir (BIC)
Elvitegravir (EVG)
Dolutegravir (Tivicay)
Raltegravir (RAL)
INSTIs SE
HA, insomnia, diarrhea, weight gain, depression, CKP/myositis/rhabdomyolysis
Non-nucleoside reverse transcriptase inhibitors (NNRTIs) MOA
Bind to the enzyme non-competitively causign a conformational change that inhibits the enzyme
What medications should not be taken with integrase strand transfer inhibitors
Cations
Take INSTI 2 hours before and 6 hours after aluminum and mg containing products
NNRTIs BBW and CI
BBW: hepatotoxicity, severe rash
CI: Rilpivarine - do not use with PPIs; Rilpivirine and doravirine - do not use with strong CYP inducers
Protease inhibitor medications
Atazanavir (reyataz)
Darunavir (Prezista)
Protease inhibitor MOA
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
Protease inhibitors and drug interactions
CYP3A4 inducers decrease concentration of PIs
What medications are boosters?
Ritonavir
Cobicistat
Boosters MOA
Ritonavir and cobicistat are inhibitors of CYP3A4
Inhibit ART metabolism, increasing ART effect
What medicationsare CCR5 atagonists
Maravioric
Maravioric MOA
Blocks HIV from binding to the CCR5 co-receptor on the CD4+ cell, preventing HIV from entering the cell
What test needs to be done before giving maravioric?
Tropism assay to reveal co-receptor
Only works with CCR5 tropic disease and is NOT useful if CXCR4 or mixed
Maravioric BBW, CI, and SE
BBW: hepatotoxicity
CI: Severe renal impairment (CrCl<30); potent CYP3A4 inhibitors/inducers
SE: N/D, LFTs, URTIs
What medication is a fusion inhibitor
Enfuvirtie (T20)
Enfuviritide MOA
Prevents HIV from fusing to CD4 cell membrane, preventing entry into the cell
Enfuviritide warnings and SE
Warnings: bacterial pneumonia, hypersensitivity reaction
SE: local injection site reaction
What medication is a CD4 directed post-attachment HIV-1 inhibitor
Ibalizumab-uiyk (Trogarzo)
Ibalizumab-uiyk MOA
Monoclonal antibodies that bind to CD4+ cell to block HIV entry
What are AIDS defining conditions?
Opportunistic infections
Kaposi’s sarcoma
HIV wasting syndrome
What is immune reconstitution inflammatory syndrome (IRIS)?
Paradoxical worsening of either a new or known condition that has been supressed, but becomes unmasked after ART is started
Which HIV medication can cause neural tube defects in pregnancy?
Dolutegravir - small risk
Continue if this medication is effective
Recommended HIV treatment in treatment-naive pregnant women
Two NRTIs (Abacavir/lamivudine OR TDF/emtricitabine)
PLUS
Boosted PI: (Atazanavir or darunavir+ritonavir)
OR
Raltegravir or dolutegravir
PrEP - when to take medication and what medication to take
Before high-risk activity then daily
1 tablet with 2 drugs (Truvada or descovy)
PEP - when to take medication and what medication to take
After HIV-exposure, within 72 hours, take for 28 days
Truvada (If CrCl>60) + dolutegravir (Tivicay) OR Raltegravir (Isentress)
