HIV Part 2 (Dr. Lam)

1. Which ART regimens are preferred to be taken with food for best absorption? (Select all that apply)

1. Genvoya® (elvitegravir/cobi/TAF/emtricitabine)

2. Triumeq® (dolutegravir/abacavir/lamivudine)

3. Juluca® (dolutegravir/rilpivirine)

4. Atripla® (efavirenz/TDF/emtricitabine)

1,3

1. Which NNRTI agent should be taken on an empty stomach and preferably at bedtime?

1. Nevirapine (Viramune®)

2. Efavirenz (Sustiva®) → EF: Empty Food 

3. Etravirine (Intelence®)

4. Rilpivirine (Edurant®)

2

1. Which ARV agents are associated with CNS and/or neuropsychiatric adverse effects? (Select all that apply)

1. Abacavir (Ziagen®)

2. Efavirenz (Sustiva®)

3. Dolutegravir (Tivicay®)

4. Rilpivirine (Edurant®)

2,3,4

1. Which ART regimen could cause weight gain? (Select all that apply)

1. Biktarvy® (BIC/FTC/TAF)

2. Triumeq® (DTG/ABC/3TC) INSTI (DTG) 

3. Complera® (RPV/FTC/TDF)

4. Atripla® (EFV/FTC/TDF)

1,2

1. (True/False): Entry inhibitors are used primarily in treatment-experienced patients who have multi-resistant HIV infection.

true

1. (True/False): A pregnant woman with HIV infection can deliver an HIV-negative baby as long as her HIV is controlled (undetectable VL) on an ART regimen.

true

1. What is the ARV medication given to a low-risk newborn baby from an HIV+ mother to prevent HIV acquisition? What is the duration of prophylaxis?

• Zidovudine, 2 weeks of oral for low risk 

• Zidovudine and lamivudine plus nevirapine or raltegravir for 2-6 weeks for high risk

1. Which single tablet regimen’s AUC can be increased when taken with food? (Select all that apply)

1. Odefsey® (rilpivirine/emtricitabine/TAF) → RPV 

2. Biktarvy® (bictegravir/emtricitabine/TAF)

3. Genvoya® (elvitegravir/cobi/emtricitabine/TAF)

4. Atripla® (efavirenz/emtricitabine/TDF)

1, 3

1. Among the entry inhibitors, how are the routes of administration different for ibalizumab (Trogarzo®) versus cabotegravir + rilpivirine (Cabenuva®) and lenacapavir (Sunlenca®)?

Ibalizumab → IV 

Cabotegravir/Rilpivirine (Cabenuva) →  IM 

Lenacapavir (Sunlena) → SQ 

1. Which NRTI agent could be administered in patients with severe renal impairment without adjusting its dose?

1. Emtricitabine (Etriva®, FTC)

2. Abacavir (Ziagen®, ABC)

3. Tenofovir disoproxil fumarate (Viread®, TDF)

4. Tenofovir alafenamide (Vemlidy®, TAF)

B

A patient is newly diagnosed with HIV-1 infection and wants to be started on a 2-drug regimen since he has been hearing they are “less toxic” to the body than the standard 3-drug regimen. His VL = 250,000 copies/mL and CD4+ count = 455 cells/mm3. Which oral 2-drug ART regimens could be considered for this patient? 

1. Cabenuva®

2. Dovato®

3. Epzicom®

4. Juluca®

2

You are working with BP, a 45-year-old woman with HIV infection. Her HIV is controlled on Biktarvy®, and she requests a long-acting injectable (LAI) ART regimen so to avoid taking a daily pill. Which LAI ART regimen would you recommend for BP?

1. Apretude®

2. Cabenuva®

3. Sunlenca®

4. Trogarzo®

B

1. What are the laboratory biomarkers that should be monitored in a neonate on zidovudine prophylaxis?

CBC 

Hemoglobin, hematocrit, platelets, and MCV 

Neonate doesn’t undergo severe anemia

1. (True/False): In the US, it is strongly recommended for an HIV+ mother to breastfeed her baby.

false

1. Which ARVs are FDA-approved for pre-exposure prophylaxis (PrEP)? (Select all that apply)

1. Descovy® (FTC/TAF)

2. Epzicom® (ABC/3TC)

3. Truvada® (FTC/TDF)

4. Apretude® (CAB)

1,3,4

1. What are the ARVs in oral PrEP medications? What are the long-acting injectable PrEP medications called (give generic and brand names)?

Oral 

• Descovy (FTC/TAF) & Truvada (FTC/TDF) 

Injectable

• Apretuda (Cabotegravir)

1. Which FDA-approved PrEP medication is considered the “universal” PrEP medication and can be given to all individuals (adolescents ≥ 35 kg and adults)?

Truvada (FTC/TDF) 

(True/False): A nurse was administering immunizations for an HIV-positive patient, and accidentally stuck herself with the same needle used in the patient. She could prevent herself from being infected after potentially being exposed to HIV by taking PrEP.

False

• Should be PEP not PrEP

• Occupational Exposure 

• If they are exposed by needle stick, stepping on broken glass, condom broke, then it is no longer PrEP

1. Based on the DISCOVER trial, Descovy® is only approved as PrEP for which patient populations? (Select all that apply)

A. Men who have sex with men

B. Transgender women

C. Transgender men

D. Cisgender women

A,B

1. What baseline tests need to be obtained from an individual before initiating oral PrEP? When should labs be followed up after the individual starts PrEP? 

1. Labs done every 3 months 

• HIV-½ Ag/Ab and HIV-1 RNA 

• BUN/SCr

• Hepatitis B serology

• Hepatitis C antibody

• Gonorrhea & Chlamydia

• Lipid panel 

• Pregnancy

1. What baseline tests need to be obtained from an individual before initiating long-acting injectable PrEP? When should labs be followed up after the individual starts PrEP?

1. 1 month after start

• HIV-½ Ag/Ab

• HIV-1 RNA

• Hepatitis B serology 

• Hepatitis C antibody

• Syphilis serology 

• Gonorrhea & chlamydia 

• Pregnancy

1. What are the preferred ARV classes and agents for post-exposure prophylaxis (PEP)? What is the duration of PEP?

• Dolutegravir (Tivicay) + Truvada or Descovy 

• Duration of PEP: 28 days 

or just BICTARVY

1. Before initiating PEP, what baseline tests need to be obtained from the individual? When should labs be followed up after the individual starts PEP?

• Follow up after 4-6 weeks 

• HIV-½ Ag/Ab immunoassay 

• Hepatitis B serology 

• Hepatitis C antibody 

• Syphilis serology, gonorrhea, chlamydia 

• Pregnancy, serum creatinine & transaminases 

1. When should PEP be initiated after suspected positive HIV exposure?

• Most effective if initiated ASAP after exposure 

• No more or later than 72 hours, but would still give patient something and test

1. A lab technician accidentally cuts his finger with a broken glass tube containing some blood. Upon further investigation, his lab manager found out that the blood belongs to an HIV-positive patient. When should PEP be initiated for the technician after his recent possible exposure to HIV?

1. PEP should be started within 72 hours after recent possible exposure to HIV.

2. PEP should be started after the technician is evaluated for acute symptoms of infection.

3. PEP should be started after the technician’s HIV-1/2 Ag/Ab and CD4+ count results become available.

4. PEP should be started after finding out what the HIV-positive patient’s VL is.

A

1. A medical resident has been working long shifts in the past week and accidentally exposed herself to blood of an HIV-positive patient. Based on the current HHS guidelines, which treatment and duration would be MOST preferred for PEP?

• Truvada (FTC/TDF) + dolutegravir x 28 days 

1. An HIV-negative woman (pronouns: she, her, hers) is in a monogamous relationship with her boyfriend who is HIV-positive. His HIV is virally suppressed on ART (VL <20 copies/mL). She asks you if she should be on PrEP. They occasionally use condoms during sex. Select the MOST appropriate answer.

1. She should receive PrEP because her boyfriend is HIV-positive.

2. She should receive PrEP because her boyfriend is HIV-positive and on ART.

3. She does not need PrEP because her boyfriend’s HIV VL is undetectable on ART.

4. She does not need PrEP because they use condoms during sex.

3

1. Which PrEP medication is safe and preferred in pregnant women?

Truvada

1. Which PrEP medication could be used as 2-1-1 or “on demand” PrEP?

truvada

•  2 tabs 2-24 hours w/food before sex, then 1 tab 24 hours, and lastly 1 tab 48 hours after the first dose

1. Compare the dosing and administration schedule of Apretude (CAB) vs. Yeztugo (LEN).

• Apretude (CAB) 

  • Prep

  • 600mg (3ml) IM 

  • 1 month follow up (2nd dose) 

• Yeztugo (LEN) 

  • Prep 

  • Day 1: LEN 600 mg oral + LEN 3mL SQ 

  • Day 2: LEN 600 mg oral 

  • 927 mg SQ Q6 months 

1. How often should patients on oral PrEP receive laboratory monitoring after their initial (baseline) assessment? 

• 3 months after initial baseline assessment then 6th and 12th month (every 3 months) 

The following patients present requesting PrEP. All have negative rapid point-of-care HIV blood test results. For whom would it be most appropriate to prescribe PrEP today before full baseline lab tests are available? 

1. A 19-year-old MSM with multiple partners and inconsistent condom use; has T2DM and history of acute kidney injury.

2. A 25-year-old cisgender woman who has recently lost her health insurance and living with friends, reports sex with multiple partners without condom use.

3. A 32-year-old cisgender man with multiple partners with consistent condom use, wants PrEP for added protection; has hypertension and hyperlipidemia; taking losartan and rosuvastatin.

4. A 40-year-old cisgender man whose male partner has HIV, but his HIV viral load was detectable; suspected HIV exposure after condom broke 24 hours ago.

2

1. (True/False): A patient on Symtuza® (DRV/c/TAF/FTC) can take low dose atorvastatin (NMT than 20 mg daily).

true

1. Explain the significant drug-drug interaction between rifampin and protease inhibitors. What is the alternative anti-mycobacterial agent that can be used instead of rifampin?

• Rifampin is a potent CYP450 inducer → C/I with all PIs also 2nd gen NNRTIs - etravirine, rilpivirine, and doravirine, cobi- and TAF based regimens, fostemsavir)

Alternative: rifabutin → less potent inducer, 150 mg PO daily or 300 mg TIW with all boosted PIs & monitor patient very closely

An HIV-positive woman is currently taking Genvoya® (EVG/c/FTC/TAF). She is recently diagnosed with mixed hyperlipidemia. Which HMG-CoA reductase inhibitors should NOT be considered for her? (Select all that apply)

1. Atorvastatin

2. Lovastatin

3. Rosuvastatin

4. Simvastatin

2,4

Which HMG-CoA reductase inhibitors are NOT contraindicated with ritonavir and cobicistat-based regimens? (Select all that apply)

1. Pravastatin

2. Simvastatin

3. Rosuvastatin

4. Pitavastatin

1,3,4

A patient comes to your pharmacy to pick up a prescription of trazodone 50 mg PO QHS PRN. Upon review of her medication history, you noticed she is currently on Symtuza® (darunavir/cobi/TAF/emtricitabine). What do you do?

1. Fill the prescription as there are no significant drug-drug interactions between trazodone and patient’s ART regimen.

2. Fill the prescription as the drug interaction between trazodone and patient’s ART regimen is minor.

3. Do not fill the prescription because trazodone is not as effective as zolpidem. She should take zolpidem for her insomnia.

4. Do not fill the prescription because there is a drug-drug interaction between Symtuza® and trazodone.

1

1. A person with HIV (PWH) is planning to take St. John’s wort to manage her depression. Her current ART regimen includes Odefsey® (rilpivirine/emtricitabine/TAF). Do you agree or disagree with her decision? Please explain. 

• Disagree → interact with rilpivirine 

A 28-year-old MSM (pronouns: he, him, his) comes to your HIV clinic service for ART initiation. He is newly diagnosed with HIV-1 infection. He reports taking One-A-Day vitamins, which contains several minerals, FeSO3, and CaCO3. He has NKDA and is HLA-B*5701 negative. His CBC and Chem 13 panel are WNL. Which ART regimen could he take with his vitamins simultaneously with food? 

1. Cabenuva® (CAB/RPV)

2. Genvoya® (EVG/c/FTC/TAF)

3. Triumeq® (DTG/ABC/3TC)

4. Biktarvy® (BIC/FTC/TAF)

3,4

1. A patient is recently diagnosed with HIV. She has NKDA and is taking a MVI and omeprazole for GERD management. Her PCP plans to prescribe Dovato® for her. Do you agree or not agree with the plan? Please explain. 

• Agree: Dovato (DTG/3TC) → take 2 hours before or 6 after supplements w/food

• PPIs (e.g., omeprazole) are CI with rilpivirine (Complera, Odefsey, Juluca)

1. A 60-year-old PWH has been stable on warfarin for his atrial fibrillation (INR goal 2-3) for many years now. He is treatment-experienced and recently switched from Biktarvy® to Symtuza® for better control of his HIV. Are there any concerns with the patient’s warfarin and the new ART regimen? 

• Symtuza (DRV/c/TAF/FTC) → Monitor INR levels closely since there will be fluctuations with all PI w/RTV or cobi

• Bictegravir, dolutegravir, and raltegravir are good alternatives to elvitegravir/c with all DOACs, warfarin, prasugrel, ticagrelor, and vorapaxar

A 47-year-old transgender male (pronouns: he, him, his) is newly diagnosed with HIV-1 infection. He has essential hypertension and hyperlipidemia. He is taking chlorthalidone and lovastatin. His physician plans to start him on Genvoya®. Which is true regarding a potential drug-drug interaction between Genvoya® and his current medications?

1. Cobicistat will significantly reduce the plasma levels of lovastatin.

2. Cobicistat will significantly enhance the plasma levels of lovastatin.

3. Cobicistat will significantly reduce the plasma levels of chlorthalidone.

4. Cobicistat will significantly enhance the plasma levels of chlorthalidone.

2

Which medications can potentially interact with the INSTI class and affect its AUC if given concomitantly in a fasting condition? (Select all that apply)

1. Milk of magnesium

2. Calcium carbonate

3. Cyanocobalamin

4. Ferrous sulfate

1,2,4

PA’s HIV-1 infection is controlled on an ART regimen of Odefsey® (rilpivirine/emtricitabine/TAF). PA is complaining of bothersome heartburn symptoms and asks you if he could take OTC Nexium® with Odefsey®. You reply to him:

1. Yes. Prilosec® should be fine with Odefsey®.

2. Yes. Prilosec® should be fine with Odefsey®, but they need to be separated by at least 12 hours.

3. No. Prilosec® is contraindicated with Odefsey®.

4. No. Prilosec® is not as effective as Nexium®. He should take Nexium® instead.

3

A 28-year-old female presents to the emergency department with wheezing and exacerbation of her asthma. She is HIV+ and currently takes Genvoya® (elvitegravir/cobicistat/emtricitabine/TAF). Which steroid could she take to manage her symptoms without any significant drug-drug interaction?

1. Beclomethasone

2. Fluticasone

3. Methylprednisolone

4. Budesonide

1

Which medication will interact with Triumeq® (dolutegravir/abacavir/lamivudine) and its maximum daily dose needs to be lowered?

1. Atorvastatin

2. Clopidogrel

3. Sildenafil

4. Metformin

4

Which INSTI agent could be coadministered with anticonvulsants, but its dose needs to be increased due to its decreased AUC from their inductive effects? (Select all that apply)

1. Bictegravir

2. Cabotegravir

3. Dolutegravir 

4. Raltegravir 

3,4

1. (True/False): There is a significant drug-drug interaction between polyvalent cations (i.e., Tums) and long-acting injectable cabotegravir.

false

Which antiplatelet medication could be administered to a patient taking Symtuza® (DRV/c/FTC/TAF)?

1. Apixaban

2. Clopidogrel

3. Prasugrel

4. Rivaroxaban

3

1. Name the 3 benzodiazepines that would NOT interact with protease inhibitors and cobicistat-based regimens.

• Lorazepam, oxazepam, and temazepam (“LOT”)

1. Name the 3 antiepileptics that should NOT be administered with protease inhibitors and cobicistat-based regimens. —> PCP

• Phenytoin, carbamazepine, phenobarbital → significantly lowers PI levels

Which ARV is a substrate of the CYP3A4 enzyme and should be monitored when given with potent CYP3A4 inducers/inhibitors? (Select all that apply) —> MR.F

1. Fostemsavir

2. Ibalizumab

3. Maraviroc

4. Rilpivirine

1,3,4

1. (True/False): Rifampin is contraindicated with all protease inhibitors, TAF- and cobicistat-based regimens.

true

1. Name the INSTI that is mainly metabolized by CYP3A4 enzyme and requires boosting.  

• Hint: with cobicistat

• Elvitegravir 

1. Substrate of CYP3A4 and UGT1A1 (similar to BIC)

2. Genvoya (EVG/cobi/TAF/FTC)

3. Stribild (EVG/cobi/TDF/FTC)

1. Explain why atorvastatin could be administered with PIs and cobicistat but at a lower dose compared to simvastatin and lovastatin.

• Atorvastatin is a minor substrate for CYP3A4, whereas simvastatin and lovastatin are potent CYP3A4 substrates (plasma levels will significantly increase)