HIV

Question 1

Examples of immune-compromised states

Answer 1

1. Diseases (e.g. HIV) with CD4 < 200
2. Systemic steroids for 14 days + at prednisone equivalent dose of ≥ 20mg/day or 2mg/kg/day
3. Asplenia
4. Use of immunosuppressants
5. Cancer chemotherapy (ANC < 500)

Question 2

Common OIs requiring PPX

Answer 2

1. PCP/PJP
2. Toxoplasmosis gondii encephalitis
3. Mycobacterium avium complex (MAC)

Question 3

PCP: criteria for starting + preferred regimen (Prophylaxis)

Answer 3

CDC < 200 or AIDs defining illness
Bactrim SS or DS daily

Question 4

PCP: Criteria for discontinuing ppx

Answer 4

CD4 count > 200 or > 3 months on ART Same for toxo

Question 5

ALT agents when sulfa allergy is present for OI

Answer 5

Atovaquone
Dapsone
Pentamidine

Question 6

ALT in setting of G6PD deficiency in OI

Answer 6

Atovaquone
Pentamidine

Question 7

Toxoplasmosis: criteria for starting + preferred regimen (ppx)

Answer 7

IgG positive AND CD4 < 100
Bactrim DS daily

Question 8

When is leucovorin added to OI regimens?

Answer 8

Whenever Pyrimethamine-containing regimens are used to reduce risk of pyrimethamine-induced myelosuppression

Question 9

MAC: criteria for starting + preferred regimen (ppx)

Answer 9

If NOT taking ART & CD4 < 50
Azithromycin 1,200 mg weekly

Question 10

MAC: when to d/c ppx

Answer 10

Taking fully suppressive ART

Question 11

Candidiasis (thrush) preferred, + ALT treatment

Answer 11

Fluconazole
ALT = Itraconazole, Posaconazole
Oropharngeal: Topicals
Esophageal: Voriconazole

Question 12

Cryptococcal meningitis preferred + ALT treatment

Answer 12

Amp B + Flucytosine
ALT = fluconazole + flucytosine OR Amp B. + fluconazole

Question 13

Cytomegalovirus preferred + ALT treatment

Answer 13

Valganciclovir or ganciclovir
ALT = Foscarnet or cidofovir

Question 14

PCP preferred + ALT treatment (active infection)

Answer 14

Bactrim high dose +/- prednisone or methylprednisone
ALT = atovaquone or pentamidine IV

Question 15

MAC preferred + ALT treatment (active infection)

Answer 15

(Clarithromycin/azithromycin) + ethambutol
ALT = add 3rd or 4th agent using rifabutin, amikacin, or levofloxacin

Question 16

Toxoplasmosis: risk factors

Answer 16

undercooked/raw meats, raw shellfish or contact with cat feces/litter

Question 17

Toxoplasmosis preferred + ALT treatment (active infection)

Answer 17

Pyrimethamine + leucovorin + sulfadiazine
ALT = Bactrim

Question 18

HIV drugs that act on stage 1 (binding/attachment)

Answer 18

CCR5 antagonist: Maraviroc
Attachment inhibitor: Fostemsavir
Post-attachment inhibitor: Ibalizumab-uiyk

Question 19

HIV drugs that act on stage 2 (fusion)

Answer 19

Fusion inhibitor: Enfuvirtide

Question 20

HIV drugs that act on stage 3 (Reverse transcription)

Answer 20

NRTIs: emtricitabine, tenofovir
NNRTIs: efavirenz, rilpivirine

Question 21

HIV drugs that act on stage 4 (Integration)

Answer 21

INSTIs: Bictegravir, Dolutegravir, Raltegravir

Question 22

HIV drugs that act on stage 7 (Budding & maturation)

Answer 22

Protease inhibitors: Atazanavir, darunavir

Question 23

Initial evaluation + labs

Answer 23

1. CD4 count
2. Viral load
3. Drug resistance genotyping
4. CMP (including LFTs, CBC, lipids, BG, UA)
5. Hep B & C screening
6. Pregnancy test
7. HLA-B*5701 (for abacavir) or tropism assay (for maraviroc)

Question 24

When NOT to use Dovato?

Answer 24

HIV RNA > 500,000 copies/mL
Known Hep B co-infection or unknown
HIV genotyping unavailable

Question 25

Zidovudine: use

Answer 25

IV during labor to protect the baby in pts with unknown HIV RNA or HIV RNA lvl > 1,000 copies/mL

Question 26

All NRTIs: warnings

Answer 26

Lactic acidosis + hepatomegaly

Question 27

Emtricitabine: warning

Answer 27

Hyperpigmentation of palms of hand or soles of feet

Question 28

INSTIs: drug interactions

Answer 28

Polyvalent cations, must take 2 hours before or 6 hours after (Al, Ca, Fe, Mg)

Question 29

Which INSTIs "falsely" raise SCr?

Answer 29

Bictegravir Dolutegravir

Question 30

Which INSTIs cause inc in CPK & myopathy?

Answer 30

Raltegravir Dolutegravir

Question 31

Which INSTI is preferred in pregnancy?

Answer 31

Dolutegravir

Question 32

All NNRTIs warnings

Answer 32

Hepatotoxicity rash (SJS/TEN) --> highest risk with rilpivarine

Question 33

Rilpivirine (Edurant): administration

Answer 33

Take with meal & water Requires acidic environment (C/I with PPIs, separate with H2RAs and Tums)

Question 34

Efavirenz (Sustiva): administration

Answer 34

Empty stomach @ HS to dec. CNS effects

Question 35

Atazanavir: features

Answer 35

Hyperbilirubinemia Needs acidic environment

Question 36

All PIs: warnings

Answer 36

Metabolic abnormalities Hepatic dysfunction Hypersensitivity reactions (rash, angioedema, anaphylaxis)

Question 37

Which PI should you be concerned with regarding sulfa allergy?

Answer 37

Darunavir

Question 38

Which PI is preferred in pregnancy?

Answer 38

Darunavir

Question 39

PEP: when to start & end treatment

Answer 39

Start within 72 hours and continue for 28 days

Question 40

CrCl and PrEP

Answer 40

Must be ≥ 60 mL/min for Truvada or ≥30 mL/min for Descovy