ILE XI HIV/Meningitis Objectives

How must the HIV RNA genome enter into cDNA for the virus to replicate and target CD4 cells?

Reverse Transcribed

What helper cell is a target for HIV because it helps cytotoxic cells kill other infected cells and plays an essential role in the immune system?

CD4 T cells

What structural component of HIV allows it to be inserted into the membranes of CD4 cells?

Glycoprotein Spike

What must occur in order for HIV integrated DNA to replicate into an infected version of mRNA?

T cell activation

What clinical stage of HIV occurs in the first 4-8 weeks and is represented by an initial increase in viral load?

Acute HIV Syndrome

What clinical stage of HIV may last up to 10 years, has a lower level of viral load, but a large increase in antibodies?

Clinical Latency

What are HIV patients at risk for in the last 2-3 years following clinical latency due to an increase in viral load and decrease in CD4 count?

Opportunistic Infections

What medication class prevents vRNA from being prepared and, therefore, hinders its ability to combine with host DNA?

NRTIs

What medication class are the following drugs?

Tenofovir

Abacavir

Emtriciabine

Lamivudine

NRTIs

What medication class has the same MOA as NRTIs, but does not bind to the allosteric site?

NNRTIs

What medication class are the following drugs?

Efavirenz

Rilpivirine

Ertavirine

Doravirine

NNRTIs

What medication class prevents the new viral DNA from being formed into the active virion?

Protease inhibitors

What medication class are the following drugs?

Atazanavir

Darunavir

Protease Inhibitors

What medication class causes chain termination by forming a covalent bond between the viral and host DNA?

Integrase Inhibitors

What medication class are the following drugs?

Raltegravir

Elvitagravir

Dolutegravir

Bictegravir

Integrase Inhibitors

What two medication classes are known to have partial or complete cross-resistance to other members within the class?

NNRTIs and INSTIs

What medications are purine analogs and, therefore, should not be combined due to their drug structures?

Abacavir and TAF/TDF

What medications are cytidine analogs and should, therefore, not be combined due to their drug structure?

Lamivudine and Emtricitabine

What type of absorption profile do atazanavir and rilpivirine have in common, leading to their drug interaction with PPIs that leads to treatment failure?

pH based

What medication should be taken with the largest meal due to a decrease in AUC if the patient is fasting?

Rilpivirine

What medication class undergoes chelation with polyvalent cations and, therefore, should not be combined?

INSTIs

What medication has a max dose of 1000 mg when used in combination with dolutegravir?

Metformin

What NNRTI should be taken on an empty stomach to increase absorption?

Efavirenz

What patient counseling point should be made for any of the following medications/medication classes?

Ertavirine

Protease Inhibitors

Elvitegravir/cobicistat

Take with food

What medication is a cell membrane ergosterol inhibitor/binder that binds to fungal membrane ergosterols to form a polyene/egosterol complex that causes intercalation of the cell membrane, altered permeability and cell death?

Amphotericin B

What medication is an intracellular pyrimidine analog and thymidylate synthase inhibitor?

Flucytosine

What medication is a cell membrane 14-alpha-demethylase inhibitor that prevents demethylation of lanosteroil, leading to decreased ergosterol synthesis, inhibition of cell membrane formation, accumulation of toxic metabolites and cell death?

Fluconazole

What opportunistic infection commonly presents with cough, progressive dyspnea, fever, chest discomfort, and has an onset in days to weeks?

PJP

What opportunistic infection commonly presents with fever, abdominal pain, weight loss, diarrhea, night sweats, fatigue and has an onset of several weeks?

MAC

What opportunistic infection commonly presents with headache, fever, N/V, altered mental status, neck stiffness, photophobia, and typically presents for care 2 weeks after symptom onset?

Cryptococcal Meningitis

What symptom of cryptococcal meningitis indicates a worse prognosis?

Altered mental status

What CSF finding is unique to fungal meningitis?

Monocytes

At what CD4 count are HIV positive patients at risk for PJP Pneumonia?

Less than 200

At what CD4 count are HIV positive patients at risk for MAC or cryptococcal meningitis?

Less than 50

What two environmental exposures are risk factors for cryptococcal meningitis?

Birds, decaying wood

How long should induction therapy for cryptococcal meningitis last prior to switching to maintenance?

At least 2 weeks

What medication combination is the primary choice for induction therapy of cryptococcal meningitis?

Liposomal Amp B, Flucytosine

What may be considered for patients undergoing maintenance therapy of cryptococcal meningitis once they have the following criteria?

- 1 year of anti fungal therapy

- Asymptomatic

- CD4 ≥ 100 and virologically suppressed on ART

Discontinuation

What syndrome is a complication of ART initiation and should be monitored, especially in patients that are initiated on ART prior to 4-6 weeks after anti fungal therapy initiation?

IRIS

Within what period of time may IRIS occur following the initiation of ART?

within 3 months

What type of IRIS occurs after an opportunistic infection is diagnosed and treated successfully before ART initiation?

Paradoxical

What type of IRIS occurs when ART is initiated and clinical symptoms of an opportunistic infection develop after initiation?

Unmasking

What lab values may be elevated in patients presenting with IRIS?

CRP, Cytokines

What should be done to opportunistic infection therapy and ART upon diagnosis of IRIS?

Continue

What two types of medications may be used in the management of IRIS?

NSAIDs, steroids

When is the optimal time to initiate ART after anti fungal therapy initiation?

4-6 weeks

What influenza vaccine formulation is contraindicated in HIV-infected patients?

Live, Intranasal

What two vaccines are contraindicated in patients with CD4 < 200?

MMR, Varicella

What two vaccines have evidence of efficacy in patients with CD4 < 200?

PCV15, PCV20

What vaccine has high efficacy in patients on sufficient cART?

HPV

What type of vaccines have similar safety profiles for HIV positive patients when compared to HIV-uninfected patients?

Inactivated

What three vaccines have poorer response rates when compared to HIV-uninfected patients?

Flu, PPSV23, HBV

What IV therapy is recommended for mother to child transmission prophylaxis in women with HIV RNA < 1000 within 4 weeks of delivery or an unknown viral load?

Zidovudine

In what stage of pregnancy is the HIV exposure risk highest?

Intrapartum

At which HIV visit(s) is the ideal time to administer vaccinations?

1st or 2nd

For which opportunistic infection is primary prophylaxis indicated in patients with CD4 < 200?

PJP

For which opportunistic infection is primary prophylaxis indicated for patients with CD4 < 50?

MAC

What is the typical primary prophylaxis regimen for PJP?

TMP/SMX DS daily or TIW

What is the typical primary prophylaxis regimen for MAC?

Azithromycin 1200 mg once weekly

For what amount of time must CD4 > 200 in response to ART in order to be considered for PJP prophylaxis discontinuation?

3 months

For what amount of time must CD4 be 100-200 WITH undetectable HIV RNA on ART in order to be considered for PJP prophylaxis discontinuation?

3-6 months

When may discontinuation be considered for patients undergoing primary MAC prophylaxis?

effective ART initiation