HIV Flashcards
(140 cards)
1
Q
What is HIV?
A
HIV is a single-stranded RNA retrovirus that uses the machinery in host CD4 T-helper cells (T cells) to replicate. The viral copies burst through the CD4 cell membrane, destroying the cell in the process
2
Q
What happens when HIV continues to replicate?
A
When HIV continues to replicate, the viral load increases and the CD4 count decreases
3
Q
When is AIDS diagnosed?
A
AIDS is diagnosed when the CD4 count falls below 200 cells/mm3 or the patient develops an AIDS-defining condition
4
Q
What happens when a patient has AIDS?
A
The immune system is very weak and can no longer ward off opportunistic infections and specific malignancies that are indicative of AIDS
5
Q
How is HIV treated and what is an important counseling point given to patients about the therapy?
A
Antiretroviral therapy is used to treat HIV. The ART regimens currently available allow people with HIV to live long and healthy lives if adherent to treatment
6
Q
How is HIV transmitted?
A
Infection is spread by direct contact with blood, semen, vaginal secretions, rectal secretions and breast milk. Most infections are caused by unprotected vaginal and rectal sex, and sharing injection drug equipment, including needles. Infection can spread from a woman with HIV to her child during pregnancy, childbirth of breastfeeding (mother-to-child or vertical transmission)
7
Q
What does the CDC recommend with regards to HIV screening?
A
The CDC recommends HIV routine screening at least once for all patients who are 13-64 years old. If a person is high-risk for infection, testing should be done at least annually
8
Q
What are high risk indicators for becoming infected with HIV?
A
- Sharing drug-injection equipment: needles, syringes and cookers (used to mix up or “cook drugs”)
- High-risk sexual behaviors: men who have sex with men, multiple sexual partners, sex with a person known to be infected or a history of sexually transmitted infections
- History of hepatitis or tuberculosis (TB) infection
9
Q
How does acute HIV infection present?
A
Acute HIV infections presents with non-specific flu-like symptoms that can last a few days to several weeks, including fever, myalgias, headache, lymphadenopathy, pharyngitis and rash
10
Q
What happens after an acute HIV infection presents?
A
An antibody response can take weeks or months to develop and, in most cases, is not fully able to fend off the virus. Patients become asymptomatic after this initial phase, but the virus is still replicating and capable of being transmitted. Over time, the CD4 count decreases, but it can take several years for an untreated patient to develop AIDS
11
Q
What happens ~2 weeks post-infection?
A
The viral load is high enough for HIV RNA and HIV p24 antigens to be detected with an initial HIV-1/HIV-2 antigen/antibody screening test
12
Q
What does a positive result of theHIV-1/HIV-2 antigen/antibody screening test indicate?
A
Positive results should be confirmed with an antibody differentiation immunoassay which differentiates HIV-1 from HIV-2 antibodies. Antibodies can be detected in most people about 4-12 weeks after contracting the disease, but it can take up to 6 months for some and repeat testing may be needed
13
Q
What is an example of over-the-counter HIV testing?
A
The OraQuick In-Home HIV Test detects the presence of HIV antibodies and provides immediate results. Individuals with a positive OraQuick result must follow up with a confirmatory laboratory test
14
Q
How do you use the OraQuick test?
A
The upper and lower gums are swabbed with a test stick, which is then inserted into a test tuber containing liquid. After 20 minutes, the test stick can be read. The tests should be used > 3 months from exposure due to the lag in antibody production; testing sooner can cause a false negative result
15
Q
What are different HIV replication stages?
A
1) Binding/attachment
2) fusion
3) Reverse Transcription
4) Integration
5) Replication
6) Assembly
7) Budding and Maturation
16
Q
What happens in the binding stage?
A
HIV attaches to a CD4 receptor and the CCR5 and/or CXCR4 co-receptors on the surface of the CD4 host cell
17
Q
What are the drug/drug classes that target the binding/attachment stage?
A
- CCR5 antagonist: maraviroc
- Attachment inhibitor: fostemsavir
- Post-attachment inhibitor: ibalizumab-uiyk
18
Q
What happens in the fusion phase?
A
The HIV viral envelope fuses with the CD4 cell membrane. HIV enters the host cell and releases HIV RNA, viral proteins and enzymes needed for replication
19
Q
What drug works in the fusion phase?
A
Fusion inhibitor: enfuvirtide
20
Q
What happens in the reverse transcription phase?
A
HIV RNA is converted to HIV DNA by reverse transcriptase (an HIV enzyme). HIV DNA can then enter the CD4 cell nucleus
21
Q
What drug/drug classes target the reverse transcription stage?
A
- Nucleoside reverse transcriptase inhibitors (NRTIs): e.g. emtricitabine, tenofovir)
- Non-nucleoside reverse transcriptase inhibitors (NNRTIs) (e.g. efavirenz, rilpivirine)
22
Q
What happens in the integration stage?
A
Once inside the CD4 cell nucleus, integrase (an HIV enzyme) is released and used to insert HIV DNA into the host cell DNA
23
Q
What drug/drug classes work in the integration phase?
A
Integrase strand transfer inhibitors (INSTIs): e.g. bictegravir, dolutegravir, raltegravir)
24
Q
What happens in the replication stage?
A
Host cell machinery is used to transcribe and translate HIC DNA into HIV RNA and long-chain proteins (the HIV building blocks)
25
What happens in the assembly phase?
New HIV RNA, proteins and enzymes (including protease) move to the cell surface and assemble into immature HIV
26
What happens in the budding and maturation stage?
Immature HIV pushes out of the CD4 cell and protease (an HIV enzyme) breaks up the long viral protein chains, creating mature virus that can infect other cells
27
What drug/drug classes work in the budding and maturation phase?
Protease inhibitors (PIs): e.g. atazanavir, darunavir
28
What are the routine labs tests needed for patients with HIV?
- CD4 count: the major indicator of immune function used to determine the need for OI prophylaxis
- HIV viral load: indicates how much HIV RNA is in the blood. It is the most important indicator of response to ART. A high viral load can be due to medication nonadherence or drug resistance. The treatment goal is an undetectable HIV viral load
- Drug resistance genotyping testing
- Comprehensive metabolic panel (including LFTs), CBC with differential , random or fasting lipid panel, random or fasting glucose level and urinanalysis
- Hepatitis B and C screening
- Pregnancy test (women)
- HLA-B*5701 allele (if considering abacavir) or a tropism assay (if considering using maraviroc)
29
When should ART be started?
ART should be started as soon as possible in all HIV-infected individuals.
30
What is the goal of initiating ART therapy?
The goal is to reduce disease progression by suppressing the HIV viral load, preserving the immune system and reducing HIV-associated morbidity and mortality
31
Why is treatment adherence important with ARTs?
Treatment adherence is essential to prevent drug resistance
32
What is the preferred initial ART regimens in most treatment naive adults?
One-pill, once daily (single tablet regimens), two-pills (once daily for most)
33
What are some examples of one-pill once daily (single tablet regimens)?
- Biktarvy: Bictegravir/Emtricitabine/Tenofovir alafenamide
- Triumeq: Dolutegravir/Abacavir/Lamivudine
- Dovato: Dolutegravir/Lamivudine
34
What are some examples of two-pills (once daily for most)?
- Tivicay + Truvada: Dolutegravir + Emtricitabine/Tenofovir disoproxil fumarate
- Tivicay + Descovy: Dolutegravir + Emtricitabine/Tenofovir alafenamide
- Isentress + Truvada: Raltegravir + Emtricitabine/Tenofovir disoproxil fumarate
- Isentress + Descovy: Raltegravir + Emtricitabine/Tenofovir alafenamide
35
What do the most preferred ART regimens contain?
2 NRTIs and 1 INSTI
36
What medications make up the backbone in most regimens?
Emtricitabine/tenofovir disoproxil fumarate (Truvada) or emtricitabine/tenofovir alafenamide (Descovy) make up the NRTI backbone in most regimens
*Lamivudine and emtricitabine are interchangeable but should not be used together (both are cytosine analgos and are therefore antagonistic)
37
What is an important note about Dovato (1 NRTI + 1 INSTI)?
Do not use in treatment-naive patients if HIV RNA > 500,00 copies/mL, known hepatitis B virus (HBV) co-infection or HIV genotypic testing not yet available
38
What is an important note about Triumeq?
Test for the HLA-B*5701 allele before using. A positive result indicates a higher risk for a severe hypersensitivity reaction (HSR) and any abacavir-containing product is contraindicated
39
Which fixed dose combinations have less flexibility with renal dosing?
Biktarvy, Triumeq, Dovato, Truvada, Descovy (do not use if CrCl < 30 mL/min
*Except for Biktarvy, individual components of these drugs can be given separately to allow for more flexible dosing with renal-dose adjustments
40
What are some examples of alternative ART regimens?
- PI-based (boosted with cobicistat or ritonavir): Darunavir or atazanavir
- NNRTI-based: Efavirenz or rilpivirine
- INSTI-based (co-formulated in one pill): Elvitegravir/cobiscistat/TDF or TAF
- NRTI backbone (2 drugs, 1 from each row): TDF or TAF or abacavir PLUS emtricitabine or lamuvudine
*A complete HIV ART regimen has one "base" plus two NRTIs to serve as the "backbone"
41
What are some examples of nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs)?
Abacavir(Ziagen), Emtricitabine (Emtriva), Lamivudine (Epivir), Tenofovir disoproxil fumarate or TDR (Viread), Tenofovir alafenamide (TAF, Zidovudine (Retrovir)
42
What is the MOA of NRTIs?
Competitively inhibit the reverse transcriptase enzyme, preventing the conversion of HIV RNA to HIV DNA in stage 3 (reverse transcription) of the HIV life cycle. NRTIs have a low barrier to resistance
43
How often is Tenofovir administered?
Once daily
44
How often is Abacavir and Lamivudine administered?
Once daily and twice daily regimens
45
How often is Zidovudine?
Twice daily
46
Do the NRTIs needed to be renally dose adjusted?
All NRTIs, except abacavir: decrease dose with renal impairment
47
How is TDF oral powder administered?
Mix with 2-4 oz of soft food (applesauce, yogurt) to avoid bitter taste; do not use liquid; contains lactose
48
What special time is Zidovudine administered?
Administered IV during labor and delivery in women with HIV RNA > 1000 copies/mL (to protect the baby)
49
What are some key features and safety issues of all NRTIs?
- Warning for lactic acidosis and hepatomegaly with steatosis (fat build up in the liver); boxed warning for didanosine, stavudine and zidovidine
- Common side effects: nausea, diarrhea, headache, increasd LFTs
50
What are some HBV and HIV coinfection boxed warnings?
- Severe acute HBV exacerbation can occur if emtricitabine, lamivudine or tenofovir-containing productis are discontinued
- Do not use Epivir-HBV for the treatment of HIV (contains a lower dose of lamivudine)
51
What are some key features and safety issues specific to abacavir?
- Boxed warning: risk for hypersensitivity reaction (HSR)
- Screen for HLA*5701 allele before starting; abacavir is contraindicated if positive (higher risk of HSR)
- Patient must carry a medication card indicating that HSR is an emergency
- Never-rechallenge if history of HSR
- Consider avoiding with CVD due to potential increased risk for MI
52
What is a specific key feature and safety issue specific to emtricitabine?
Hyperpigmentation of the palms of the hands or soles of the feet
53
What are some key features and safety issues specific to Tenofovir Formulations (higher risk with TDF)?
- Renal impairment, including acute renal fallure and Fanconi syndrome (renal tubular injury with hyperphosphatemia)
- Decrease dose with renal impairment and avoid other nephrotoxic drugs (e.g. NSAIDs)
- Decrease bone mineral density; consider calcium/vitamin D supplementation and DEXA scan if at risk
- Note; monitor lipids if switching from TDF to TAF for improved side effect profile (TAF associated with higher risk of lipid abnormalities)
54
What are some key features and safety issues of Zidovudine?
- Hematologic toxicity: neutropenia and anemia (increases MCV is a sign of adherence)
- Myopathy
55
What are some examples of integrase strand transfer inhibitors?
Bictegravir, Cabotegravir (Vocabria), Dolutegravir (Tivicay), Elvitegravir (only in combination drugs Genvoya and Stribild), Raltegravir (Isentress, Isentress HD)
56
What is the MOA of integrase strand transcriptase inhibitors?
Block the integrase enzyme, preventing the HIV DNA from inserting into the host cell DNA in stage 4 (integration) of the HIV life cycle
* INSTIs have higher barrier to resistance than NRTIs and NNRTIs
57
How is Biktarvy, Stribild, Genvoya, Isentress HD and Tivicay administered?
Once daily
58
How is Isentress, Tivicay administered for treatment-experienced patients, those with INSTI resistance or those taking YGT1A1 or YP3A4 inducers?
Twice daily
59
How is Cabotegravir PO administered?
Indicated only for lead-in treatment to assess tolerability prior to initiation of cabotegravir/rilpivirine (Cabenuva) injection, or as bridge therapy in patients who will miss a scheduled cabotegravir/rilpivirine injection for > 7 days
60
What are some side effects and warnings associated with Bictegravir, dolutegravir?
Increases SCr (by inhibiting tubular secretion) with no effect on GFR
61
What are some side effects and warnings associated with Raltegravir?
Increased CPK, myopathy and rhabdomyolysis
62
What are some side effects and warnings associated with Elvitegravir?
Proteinuria
63
What are some side effects and warnings associated with Dolutegravir?
- Hypersensitivity reaction (HSR) with severe rash and organ dysfunction, including hepatotoxicity
- Small risk of neural tube defects in women (though still a preferred drug for treatment during pregnancy)
- Increased CPK, myalgia
64
What are some side effects and warnings associate with all INSTIs?
Headache, insomnia, diarrhea, weight gain, rare risk of depression and suicidal ideation in patients with pre-existing psychiatric conditions (except bictegravir)
65
Describe the drug interactions with polycovalent cations?
Separate from polycovalent cations (take INSTIs 2 hours before or 6 hours after: aluminum, calcium, magnesium and iron-containing products)
- Dolutegravir and bictegravir can be taken with oral calcium or iron if also taken with food
- Dose separations with raltegravir may not be effective; avoid polycovalent cations if possible
66
What are some examples of non-nucleoside reverse transcriptase inhibitors (NNRTIs)?
Efavirenz (Sustiva), Rilpivirine (Edurant), Doravirine (Pifeltro), Etavirine (Intelence), Nevirapine (Viramune)
67
What is the MOA of NNRTIs?
Non-competitively inhibit the reverse transcriptase enzyme, preventing the conversion of HIV RNA to HIV DNA in stage 3 (reverse transcription) of the HIV life cycle
*NNRTI have a lower barrier to resisttance than INSTIs or PIs
68
How should Rilpivirine be administered?
- Take with water and a meal (do not substitute with protein drink)
- Requires acidic environment for absorption; do not use with PPIs and separate from H2RAs and antacids
69
How should Efavirenz be administered?
Food increases bioavailability and risk for CNS effects; take on an empty stomach QHS to decrease (and sleep through) CNS effects
70
What are key features and safety issues for all NNRTIs?
- Used in alternative ART regiments (not first line in most patients): 1 NNRTI plus 2 NRTIs
- Hepatotoxicity and rash/severe rash, including SJS/TEN; highest risk with nevirapine
71
What are some key features and safety issues specific to efavirenz?
- Psychiatric symptom (depression, suicidal thoughts)
- CNS effects (impaired concentration, abnormal dreams, confusion), generally resolve in 2-4 weeks
- Increases total cholesterol and triglycerides
72
What are some key drug interactions of all NNRTIs?
- All NNRTIs are major CYP3A4 substrates (and some are substrates of other CYP enzymes)
- Rilpivirine and Doravirine: do not use with strong CYP3A4 inducers (carbamazepine, oxcarbazepine, phenobarbital, phenytoin, rifampin, rifapentine, St. John's Wort)
- Efavirenze and etravirine are moderate CYP3A4 inducers (many drug interactions)
- Rilpivirine and acid-suppressants (take H2RAs at least 12 hours before or 4 hours after rilpivirine; take antacids at least 2 hours before or 4 hours after rilpivirine)
73
What are some key safety issues with Rilpivirine?
- Depression
- Increased SCR with no effect on GFR
- Do not use if viral load > 100,000 copies/mL and/or CD4 count < 200 cells/mm (higher failure rate)
74
What are some examples of protease inhibitors?
Atazanavir (Reyataz), Darunavir (Prezista), Fosamprenavir (Lexiva), Lopinavir/ritonavir (Kaletra), Saquinavir (Invirase), Tipranavir (Aptivus)
75
What is the MOA of protease inhibitors?
Inhibit the HIV protease enzyme, preventing long viral protein chains from being broken down into the smaller chains needed to produce mature (infectious) virus in stage 7 (budding and maturation) of the HIV life cycle; HIV continues to replicate, but produce immature virions that are not infectious
*PIs have a high barrier to resistance
76
How are all PIs recommended to be administered?
- Recommended to take with a booster (ritonavir or cobicistat)
- No renal dose adjustments
- Take with food to decrease GI upset except Fosamprenavir oral solution (without food) and Lopinavir/ritonavir tablets (with or without food)
77
What is the recommended administration of Atazanavir?
Needs an acidic gut for absorption
78
What is the recommended administration for Ritonavir?
Only used for pharmacokinetic boosting
79
What are some key features and safety issues of PI?
- Used in alternative ART regimens (not first line in most patients): 1 PI (boosted with ritonavir or cobicistat) plus 2 NRTIs
- Metabolic abnormalities: hyperglycemia/insulin resistance, dyslipidemia (with increased LDL and increased TGs), body fat and lipodystrophy
- Hepatic dysfunction: increased LFTs, hepatitis (highest risk with tipranavir) and/or exacerbation of preexisting hepatic disease
- Hypersensitivity reactions: rash (including SJS/TEN), bronchospasm, angioedema, anaphylaxis
- Common side effects: diarrhea, nausea
80
What are some key features and safety issues of Atazanavir?
- Hyperbilirubinemia (jaumdice or scleral icterus): reversible, does not require discontinuation
- Requires acidic gut for absorption
- Antacids: take atazanavir 2 hours before or 1 hour after
- H2RAs: avoid or take atazanavir 2 hours before or 10 hours after
- PPIs: avoid with unboosted atazanavir; take boosed atazanavir at least 12 hours after the PPI (dose should not exceed omeprazole 20 mg or equivalent)
81
What is a key safety issue of Darunavir, Fosamprenavir, Tiprananvir?
Caution with sulfa allergy
82
What is a key safety issue with Lopinavir/Ritonavir?
Oral solution contains 42% alcohol: can cause a disulfiram reaction if taken with metronidazole
83
What is a key safety issue of Tipranavir?
Incracranial hemorrhage
84
What are some key drug interactions of PIs?
- All PIs are major CYP3A4 substrates and more are strong CYP3A4 inhibitors
- Do not use the following drugs with PIs: Alfuzosin, Colchicine, Dronedarone, Lovastatin and simvastatin (Atorvastatin and rosuvastatin are preferred with PIs), CYP3A4 inducers, anticoagulants/antiplatelets (warfarin is not contraindicated but INR should be monitored closely), direct-acting antivirals for hepatitis C, some hormonal contraceptives, steroids
85
What are some examples of pharmacokinetic boosters?
Ritonavir (Norvir), Cobicistat (Tybost)
86
How is Ritonavir administered?
- 100 to 400 mg PO daily (in 1-2 divided doses) with food
- Oral solution contains 43% alcohol: can cause a disulfiram reaction if taken with metronidazole
- Powder: mix with soft food or liquid and take within 2 hours
87
How is Cobicistat administered?
150 mg PO daily with the boosted drug and with food
88
What are some key features of the pharmacokinetic boosters?
- Ritonavir and cobicistat are inhibitors of CYP3A4. They inhibit ART metabolism, which increases (boosts) the ART levels and therapeutic effect
- Ritonavir is a PI, but is used as a booster because it is a strong inhibitor and is not well tolerated at the higher doses needed for antiretroviral activity. Booster dosing is lower than treatment dosing, making metabolic side effects much less of a concern
- Ritonavir and cobicistat are not interchangeable. Do not use both together
89
What are some key booster drug interactions?
- Ritonavir and cobicistat are strong inhibitors of CYP3A4 and they also inhibit CYP2D6, P-gp transporters and some of the OAT family of transporters
- They increase the levels of many other drugs; knowing which ART combinations contain these boosters is important to identify possible interactions with other CYP substrates, inhibitors and inducers
- Drugs that are contraindicated with ritonavir and cobicistat include Alfuzosin, tamsulosin, colchicine, lovastatin and simvastatin, azole antifungals, cardiovascular drugs, PDE-5 inhibitors, many tyrosine kinase inhibitors, CYP3A4 inducers, any narrow therapeutic index drug that is highly dependent on CYP3A4 for clearance
90
What are some examples of entry and attachment inhibitors?
- CCR5 antagonist: Maraviroc (Selzentry)
- Attachment inhibitor: Fostemsavir (Rukobia)
- Post-Attachment inhibitor: Ibalizumab-uiyk (Trogarzo)
- Fusion inhibitor: Enfuvirtide (Fuzeon)
91
What is the MOA of CCR5 antagonists?
Blocks HIV from binding (and subsequently entering) the CD4 cell in virus stains that use the CCR5 co-receptor in stage 1 of the HIV life cycle (binding/attachment)
92
What are some safety issues of Maraviroc?
- Hepatotoxicity (boxed warning), hypersensitivity reactions (including SJS/TEN), CV events (including MI), orthostatic hypotension in patients with renal impairment
- Do not use if severe renal impairment (CrCl < 30 mL/min) and taking potent CYP3A4 inhibitors/inducers
93
What are the baseline tests required for Maraviroc?
- Must have tropism assay results before starting (test that determines if the HIV straining infecting the patient can only bind to the CCR5 co-receptor)
- If the HIV strain can bind to CXCr4 or mixed (CXCr4/CCR5) co-receptors, maraviroc will not work and HIV will still be able to enter the CD4 cell
94
What is the MOA of Fostemsavir?
Converted to temsavir (active form), which binds to the gp120 subunit of HIV envelope proteins, inhibiting the interaction between the virus and the CD4 host cell in stage 1 of the HIV life cycle (binding/attachment)
95
What are some safety issues of Fostemsavir?
- Do not use with strong CYP3A4 inducers
- Must maintain effective HBV treatment in patients coinfected with HBV
- Can increase SCr (higher risk if underlying renal disease)
96
What are some notes associated with Fostemsavir?
Indicated in combination with other ARTs in heavily treatment-experienced patients who are failing current therapy
97
What is the MOA of Ibalizumab?
Monoclonal antibody that binds to a select domain of CD4 cell receptors in stage 1 (binding/attachment) of the HIV life cycle, blocking entry of the virus into the cell
98
What are some safety issues associated with Ibalizumab?
Infusion-related reactions (observe for 1 hour after first infusion), diarrhea, dizziness, nausea, rash
99
What are some notes associated with Ibalizumab?
- Refrigerate unused vials and administer immediately after dilution
- Indicated in combination with other ARTs in heavily treatment-experienced patients who are failing current therapy
100
What is the MOA of Enfuvirtide?
Prevents HIV from fusing to the CD4 cell membrane in stage 2 (fusion) of the HIV life cycle, which prevents virus entry into the cell
101
What are some safety issues of Enfuvirtide?
- Risk of bacterial pneumonia, hypersensitivity reactions
- Local injection site reactions (nearly all patients): pain, erythema, nodiles and cysts, ecchymosis, nausea, diarrhea and fatigue
102
What are some notes about Enfuvirtide?
Store unused drugs/supplies at room temperature; once reconstituted, refrigerate and use within 24 hours
103
What are some examples of INSTI-based tablets?
Biktarvy, Cabenuva, Triumeq, Dovato, Juluca, Stribilid, Genvoya
104
What are some notes about the INSTI-based regimens?
- Biktarvy, Triumeq, Dovato: first line
- Cabenuva: adminstered IM once monthly by a healthcare professional (must be preceded by one month of lead-in treatment with oral cabotegravir to assess tolerability)
- Cabenuva, Dovato, Juluca: can be used to replaced a current stable ART regimen in patients with virologic suppression and no history of treatment failure or known resistance
- CrCl < 50 mL/min: do not start tenofovir disoproxil fumarate (< 70 mL/min for Stribild)
- CrCl < 30 mL/min: do not start tenofovir alafenamide products
- Stribild, Genvoya: take with food
105
What are some examples NNRTI-based single tablet regimens?
Delstrigo, Atripla, Symfi, Complera, Odefsey
106
What are some notes about NNRTI-based single tablet regimens?
- Same renal dosing criteria as above for tenofovir-containing products
- Atripla, Symfi: take on empty stomach (contains efavirenz)
- Complera, Odefsey: take with food (contains rilpivirine)
107
What is an example of a PI-based single tablet regimen?
Symtuza
108
What is a note about Symtuza?
Take with food. Do not start if CrCl < 30 mL/min (contains tenofovir alafenamide)
109
What are some examples of NRTI combination single pill regimens?
Epzicom, Trizivir, Descovy, Truvada, Combivir, Cimduo
110
What are some notes about the NRTI combination products?
- Epzicom, Trizivir: requires baseline testing for HLA-B*5701 (contains abacavir)
- Descovy, Truvada: part of the first-line regimens. Do not use if CrCl < 30 mL/min (< 60 mL/min for Truvada if using for PrEP)
- Trizivir, Combivir: twice daily
- Cimduo: do not use if < 50 mL.min
111
What are some examples of common PI combination single pill regimens?
Evotaz, Prezcobix
112
What are some notes of common PI combination single pill regimens?
Take cobicistat-containing products with food
113
When is AIDS diagnosed?
AIDS is diagnosed when the CD4 count is < 200 cells/mm or by the presence of an AIDS-defining condition
114
What are some examples of AIDS-defining conditions?
- Opportunistic infections: e.g. Mycobacterium avium complex, PJP or PCP), Cryptococcus neoformans, Histoplasmosis, severe candida albicans infections
- Severe cancers, including Kaposi's sarcoma
- HIV wasting syndrome, a debilitating condition with loss of fat tissue (lipoatrophy), muscle mass and appetite (anorexia), and diarrhea. Options to increase appetite are slim and include the cannabis-related drugs dronabinol and nabilone and megestrol, a progestin that stimulates appetite
115
What is immune reconstitution inflammatory syndrome (IRIS)?
Paradoxical (unexpected) worsening of a known underlying condition, or a previously identified condition, after ART is started or treatment is changed to a more effective regimen. As the immune system begins to recover, it becomes capable of mounting an inflammatory response, and the symptoms of the underlying condition can become unmasked
116
What are some key points about IRIS?
- It is more likely to occur as the viral load decreases and the CD4 count recovers
- Underlying conditions that can appear or worsen include common OIs, hepatitis B and C, herpes simplex virus, varicella zoster virus, autoimmune conditions and some cancers
- IRIS symptoms can range from mild to severe and are typically self-limited. ART should be continued and the unmasked condition should be treated
117
What should be done for HIV treatment during pregnancy?
All pregnant women with HIV should take ART during pregnancy for their own health and to prevent mother-to-child transmission. Most HIV medications are considered safe to use during pregnancy without an increased risk of birth defects
118
What is the recommended HIV regimen for treatment-naive pregnant women?
Treatment should consist of three drugs: two NRTIs plus wither an INSTI or a boosted PI.
- NRTI combinations: Abacavir/lamivudine, Tenofovir disoproxil fumarate/emtricitabine, tenofovir disoproxil fumarate/lamivudine
- INSTI: Raltegravir, Dolutegravir
- Boosted PI: Atazanavir/ritonavir, Darunavir + ritonavir
119
How can HIV treatment be used as prevention?
Treatment with current ART regimens is so effective that people with HIV who are adherent can achieve a viral load low enough to prevent infecting other people. When appropriate, PrEP and PEP are two other ways to reduce HIV infection risk before or after exposure
120
What is pre-exposure prophylaxis?
An HIV prevention method in which people who don't have HIV take a 2 drug combination (either Truvada or Descovy) to prevent infection from high-risk behaviors, including safe sex practices
121
What should be done before starting PrEP?
- Confirm that the person is HIV-negative with an HIV Ab test (use of a 2-drug regimen in an HIV-positive person would cause resistance to commonly used treatments)
- Ask about recent symptoms that could indicate HIV infection, due to the lag time for detectable antibody
- Confirm CrCl > 60 mL/min (if using Truvada) or > 30 mL/min (if using Descovy)
- Screen for hepatitis B and STIs
122
What should be done with PrEP initiation and follow-up?
- Provide no more than a 90 day supply of Truvada or Descovy at a time
- Follow up at least every 3 months. At each visit: test for HIV and document negative result (do not refill drug without confirming HIV-negative status); check and document pregnancy status; counsel on PrEP adherence and safe sex/high risk behaviors
- Every 6 months, check SCr (to calculate CrCl) and test for STIs
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What is post-exposure prophylaxis?
PEP can be used when a non-infected person is exposed to bodily fluids that are known to be or could be infected with HIV
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What are two types of PEP?
Nonoccupational (nPEP) and occupation (oPEP)
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When is nPEP used?
nPEP can be used after sex without a condom, after injection drug use or some other type of non-occupational bodily fluid exposure
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When is oPEP used?
oPEP is typically used for health care personnel who are exposed to bodily fluids that could be infectious, such as from a needlestick
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When is PEP used?
PEP is for emergency situations. For both types, treatment should be started as soon as possible within 72 hours (3 days) of the exposure, and continued for 28 days. The exposed individual should receive a baseline HIV Ab test and a follow up test at 4-6 weeks, 3 months and 6 months after the exposure
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What are some key counseling points of all HIV medications?
- Do not skip doses or stop taking HIV medications unless instructed to do so and get refills before running out
- The medication is not a cure for HIV. Do not share needles or other drug mixing equipment. Use safe sex practices
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What are key counseling points for all NRTIs?
- If you have hepatitis B, do not stop taking this medication without discussing with your healthcare provider as severe worsening of the hepatitis can occur
- Can cause lactic acidosis
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What are some key counseling points of abacavir?
Your blood should be tested to see if you are at higher risk for a severe reaction before using this medication
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What is a key counseling point of emcitricitabine?
This medication can cause darkened spots on the palms of hands and on the soles of feet
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What is a key counseling point of tenofovir disoproxil fumarate and tenofovir alafenamide?
- Can cause (less with alafenamide): kidney impairment, low bone density/fracture risk
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What is a key counseling point of all INSTIs?
This medication can interact with antacids, Take 2 hours before or 6 hours after this medication
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What is a key counseling point of all NNRTIs?
Can cause rash/severe rash, hepatotoxicity
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What are some key counseling points of Efavirenz?
- Take on an empty stomach at bedtime to reduce side effects
| - Can cause (at start, gets better in 2-4 weeks): depression/psychosis, confusion and abnormal dreams
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What are some key counseling points of Rilpivirine?
- Take with a full meal and water, not a protein drink
- Do not use proton pump inhibitors; take H2RAs 12 hours before or 4 hours after, and antacids 2 hours before or 4 hours after rilpivirine
- Can cause depression
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What are some key counseling points of all PIs?
- Take with food (except fosamprenavir oral solution in adults)
- Can cause high blood glucose, high triglycerides or body fat redistribution
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What is a key counseling point or Atazanavir or Darunavir?
If taking ritonavir, make sure to take both at the same time
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What is a key counseling point of Atazanavir?
- Do not take acid-suppressing medications with atazanavir
| - Can cause hyperbilirubinemia
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What is a key counseling point of Darunavir, fosamprenavir, Tipranavir?
Caution with sulfa allergy
