HIV - Treatment, Monitoring, Drug interactions, Resistance, Prevention

when to start ART

immediately regardless of CD4 count

common ART regimen

2 NRTIs + INSTI or PI booster + PK enhancer

only 2 drug regimen

dolutegravir- lamivudine

Initial regiment options

biktarvy
truvada + dolutegravir
cimduo/Temixus + dolutegravir
Dovato

second line therapy - first line if previously used cabotegravir for HIV prevention

Symtuza

biktarvy contains + dose

bicetegravir 50
tenofovir alafenamide 25
emtricitabine 200

truvada contains + dose

tenofovir disproxil fumarate 25
emtricitabine 200

cimduo/temixus contains + dose

tenofovir 300
lamivudine 300

dovato contains + dose

dolutegravir 50
lamivudine 300

symtuza contains + dose

darunavir 800
cobicistat 150
emtricitabine 200
tenofovir 10

what regimens contain two pills

truvada
cimduo/Temixus

when to NOT use dovato

HIV RNA > 500,000 copies/mL
co-infected with HBV
ART intitiated before HIV and HBV testing available

laboratory monitoring

CD4 count
HIV viral load
resistance
Hep B serology
chemistry

labs for abacovir

HLA-B*5701

labs for maraviroc

tropism

PI metabolism (exception)

CYP 3A4 inhibitor (not tipranavir)

NNRTIs metabolism (exception)

CYP3A4 inducers (rilpivirine and doravirine just inducers)

separate from antacids

INSTIs

avoid giving with Al or Mg

raltegravir

reduced by acid reducers

atazanavir and rilpivirine

contraindicated with PPIs

rilpivirine

BZDs preferred with PIs + cobicistate

lorazepam
oxazepam
tempazepam

corticosteroid to use with PI + cobicistat

beclomethasone

use a low dose statin

PI + cobicistat

may need to increase dose with statins

NNRTIs

increases metformin levels

dolutegravir

use low dose of PDE5 inhibitor every 48-72 hours

PI + cobicistat

space 6 hours from polyvalent cation supplement

INSTIs

may take with Ca or Fe in taken with food

dolutegravir
bicetegravir

most common mutation

point mutation (aa substitution)

resistance obtained with initial HIV infection or super infection

transmitted

resistance due to inadequate adherence, dosing, drug concentration

acquired

how many copies in a resistance test

> 500 copies/mL

undetectable = untrans,ittable

maintain HIV RNA < 200 + ART prevents sexual transmission

when is PrEP contraindicated

HIV infection
< 77 lbs
CrCl < 60 (TDF)
CrCl < 30 (TAF)
possible HIV exposure within the past 72 hours

PrEP treatment options

emtricitabine 200 + tenofovir DF 300 for all risk patients
emtricitabine 200 + tenofovir AS 25 for MVM TWWM
cabotegravir 600 IM q2months

PEP treatment

Truvada

when to use PEP

accidential exposure to HIV