HIV1 ART

Question 1

Elite controllers when to treat

Answer 1

1. ART recommended in disease progression - declining CD4, inverted CD4:CD8 (<1), any HIV complications.
2. HBV/HCV/HTLV co infection
3. Significant immunosuppressive disease/ CAD
4. Chemotherapy
5. Pregnancy & breastfeeding

Question 2

Elite controllers monitoring

Answer 2

1. 6-12 months VL
2. 6 monthly CD4 & CD4:CD8 ratio
3. 6 monthly CVD, malignancy, pregnancy, HBV or HCV co-infection

Question 3

Recommended first line agents HIV1

Answer 3

1. Bictegravir/emtricitabine/TAF
2. Dolutegravir/emtricitabine/TAF (or TDF)
3. Dolutegravir/lamivudune:
   A. No baseline resistance
   B. Baseline VL < 500,000
   C. CD4 > 200
4. Dolutegravir/lamivudine/abacavir

Question 4

TDF caveats

Answer 4

Bone & renal

Avoid in age <25 prior to peak bone mass accrual

Avoid in osteoporosis/fragility fracture/FRAX>10%

Question 5

Abacavir caveats

Answer 5

HLA B*5701 negative
QRISK < 10%

Question 6

HIV1 pregnancy/ on TB treatment first line regimen

Answer 6

Efavirenz + emtricitabine/lamivudine + abacavir/TAF/TDF

Question 7

HIV1 drug resistance baseline testing & regimen

Answer 7

1. Baseline RT/protease resistance testing
2. INSTI testing if:
   A. Any major mutation detected
   B. Diagnosis made in pregnancy
   C. Likely acquisition from someone with INSTI resistance

Regimen: TAF/TDF + LAM/emtricitabine + Dolutegravir/Bictegravir/Boosted Darunavir

Question 8

Rapid ART/High VL (>500,000) ART regimen

Answer 8

TAF/TDF + Lam/Emtricitabine + Dol/Bic/Boosted Darunavir

Question 9

HIV1 two drug regimens

Answer 9

1. Dol + Lam
2. Dol + Rilpivirine
3. Boosted PI + Lam/emtricitabine

Caveats:
* No previous virological failure
* No NNRTI/INSTI resistance
* No HBV co infection
* No risk of HBV

Question 10

HIV1 injectable regimen

Answer 10

Cabo/rilpivirine in:

1. Challenges in taking oral ART
2. <50copies/mL > 6 months
3. No known/auspected NNRTI/INSTI resistance
4. No virological failure
5. No history of INSTI monotherapy
6. Can commit to 2 monthly injections
7. BMI <30
8. NON A1/A6 subtype IF baseline resistance unknown
9. No HBV

2 monthly VL monitoring!

Question 11

Stopping ART

Answer 11

If stopping an NNRTI based regimen, all drugs should be replaced by a PI for 4 weeks and not abruptly stopped due to risk of resistance.

Other regimens, can be stopped immediately.

Question 12

Blips

Answer 12

Single VL 50-200 preceded and followed by undetectable.

Repeat in 2-6 weeks

Question 13

Low level viraemia

Answer 13

Repeated blips:

1. Resistance test
2. Use high barrier drugs

Question 14

Virological failure

Answer 14

Incomplete virological response OR virological rebound

IVR - VL >200 in 2 consecutive tests after 24 weeks without ever becoming undetectable

Virological rebound - failure to maintain VL<200 on 2 consecutive tests

Rapid retest
Resistance testing

Continue same regimen if no resistance

Question 15

CVD ART considerations

Answer 15

Avoid Abacavir
Avoid lopinavir/ritonavir

Question 16

Renal considerations ART

Answer 16

If eGFR < 60

Avoid TDF
Avoid lopinavir/ritonavir
Avoid atazanvir

Question 17

Cognitive considerations ART

Answer 17

Avoid efavirenz in cognitive impairment & in psych disorders

INSTIs with caution in psych disorders or depression

Question 18

When to start ART in AIDS

Answer 18

If CD4<200 or AIDS defining illness, start ART within 2 weeks

Question 19

Primary HIV considerations

Answer 19

1. Seen by HIV Specialist within 2 weeks
2. Start ART ASAP

Question 20

Efavirenz in 1st line HIV Tx scenarios

Answer 20

TB & pregnancy