HIV

What is the CD4 count?

indicator of immune function

When the CD4 count falls below ____ cells/mm3, the immune system cannot ward off opportunistic infections.

200

CD4 _______ with ART

A. Increases

B. Decreases

A. Increases

HIV viral load ______ with ART

A. Increases

B. Decreases

B. Decreases

All persons aged ____-___ years should be screened for HIV at least once

13-64 yo

What is the OTC HIV test?

OraQuick looking at antibodies only

OraQuick results (1 line vs 2 line)

• 1 line = negative result

• 2 lines = positive resukt

How often can you perform the OraQuick?

every 3 months

Typical HIV regimen components **

BASE + 2 NRTIS as backbone

Base: PI, NNRTI, INSTI

NRTI MOA

inhibit reverse transcription, blocking the conversion of HIV RNA to HIV DNA

NRTI drugs (6)

• Zidovudine

• Lamivudine

• Abacavir

• TDF

• TAF

• Emtricitabine

ZLATTE

NRTI BW (1)

HBV/HIV coinfection

Warning with NRTI's (2)

lactic acidosis

severe hepatomegaly

What drug has BBW of HLAB5701?

Abacavir (NRTI)

Abacavir

A. HLA-B*7801

B. HLA-B*5701

C. HLA-B*5801

B. HLA-B*5701

Contraindicated with CrCl < 50

A. TDF

B. TAF

A. TDF

Contraindicated with CrCl < 30

A. TDF

B. TAF

B. TAF

Causes more renal dysfunction and decreased bone mineral density

A. TDF

B. TAF

A. TDF

lipid abnormalities

A. TDF

B. TAF

B. TAF

What drug can cause hyperpigmentation of hands/feet?

Emtricitabine (NRTI)

T/F: if a pt takes abacavir they must carry a medication card indicating that HSR is a medical emergency

True

What drug should be given during labor?

Zidovudine (NRTI)

Zidovudine side effect (1)

Hematologic toxicity (anemic, neutropenia, and macrocytosis)

INSTI MOA

Directly block integrase to prevent HIV DNA from inserting itself into host cell DNA

INSTI drugs (5) ("gravir)

• Bictegravir

• Cabotegravir

• Raltegravir

• Elvitegravir

• Dolutegravir

BCRED

What 2 INSTI's increase Scr with little to no effects on GFR?

• Bictegravir

• Dolutegravir

What 2 INSTI's can increase CPK and cause rhabdo?

• Raltegravir

• Dolutegravir

Class side effects with INSTI's (3)

• Weight gain

• Insomnia

• Depression

INSTI main DDI

• Do not use with polyvalent cations bc they decrease INSTI absorption

• Take INSTI 2 hours before or 6 hours after

What class causes weight gain? (1)

INSTI's

"BCRED"

NNRTI drugs (5) ("vir)

• Rilpivirine

• Efavirenz

• Doravirine

• Etravirine

• Nevirapine

REDEN

What NNRTI must be taken with food & water (not a protein shake)?

Rilpivirine

What NNRTI can be taken on an empty stomach?

Efavirenz

What drug should not be used if viral load >100,000 or CD4 <200?

Rilpivirine (NNRTI) due to high failure rates

What drug can cause bad CNS and psychiatric effects?

Efavirenz (NNRTI) - it will resolved in 2-4 weeks in most pts

What drug can increase cholesterol and triglycerides?

Efavirenz (NNRTI)

T/F: Rilpivirine needs an acidic gut for absorption

True

What NNRTI drug requires an acidic enviorment and should not be taken with PPIs?

Rilpivirine (NNRTI)

What NNRTI should NOT be used with PPIs!!!

Rilpivirine bc it needs an acidic gut for absorption

What DDI are seen with NNRTI's?

Major CYP3A4 substrates

PI drugs (2)

• Atazanavir

• Darunavir

"navirs" + BOOSTER

• Ritonavir, cobicistat

What medication should be avoided with sulfa allergies?

Darunavir

What drug class causes metabolic side effects (Decreased HDL, increased LDL and TG and BG)?

PI's

What medication can cause hyperbilirubinemia, which is reversible?

Atanavir (PI)

Maraviroc class and MOA

• CCR5 antagonist

• blocks HIV from binding to CD4 cells that use the CCR5 co-receptor

Maraviroc BW (1)

Hepatotoxicity

What drug requires a baseline tropism assay before starting?

Maraviroc

What drug can cause orthostatic hypotension in pts with renal impairment?

Maraviroc

What is PrEP?

Pre-exposure ppx to prevent HIV in pts who engage in high risk activities

PrEP treatment (3 options)

• Truvada or Descovy QD

• LA IM Cabenuva monthly x 2 months, then every 2 months

What is PEP?

• Post exposure ppx for emergency situations who a non-infected person is exposed

• Ex: non-occupational (sex, IVDU) vs. occupational (healthcare provider)

When and for how long is PEP treatment?

• TX ASAP within 72 hours of exposure and continued for 28 days

Criteria for progression to AIDS

CD4 count < 200 cells/mm^3 or AIDS defining conditions such as

-OI

-Kaposi's sarcoma

-HIV wasting syndrome (Loss of fat tissue and muscle)

Appetite stimulants for HIV wasting syndrome

Dronabinol

Megestrol

Only NRTI that does not need renally dose adjusted

abacavir

Preferred 1 pill once a day txs

Biktarvy

Dovato

Preferred two pills once a day

Tivicay + truvada

Tivicay + Descovy

Biktarvy

bictegravir/emtricitabine/TAF

Dovato

dolutegravir/lamivudine

Tivicay

dolutegravir

Truvada

emtricitabine/TDF

Descovy

emtricitabine/tenofovir alafenamide

When to not use Dovato

Do not use in tx naive if HIV RNA > 500,000 copies/mL, Hep B coinfection, or HIV resistance testing not performed

Immune reconstitution inflammatory syndrome (IRIS) cause

worsening of a unknown underlying condition that reveals itself after ART is started

IRIS tx

Continue ART

Sx management

Anti-infectives if OI

Cabotegravir

Apretude

Compenent of Cabenuva

Dolutegravir

Tivicay

Component of Triumeq and Dovato

Elvitegravir

Component of Genoya and Stribild

Raltegravir

Isentress

Isentress HD

Once daily regimens that include INSTIs

Biktarvy

Stribild

Genoya

Isentress HD

Tivicay

Triumeq

Dovato

Twice daily regimens that include INSTIs

Isentress

When to not start Stribild

CrCl < 70

When to not start Biktarvy or Genoya

CrCl < 30

When to d/c stribild

CrCl < 50

Indication of Apretude

PrEP

Proper separation of H2RA or PPIs or antiacids from riplivirine

H2RAs take at least 12 hrs before or 4 hrs after

PPIs DO NOT USE

Separate antiacids take at least 2 hrs before or 4 hrs after

NNRTIs MOA

inhibit the reverse transcriptase

Doravirine

Pifeltro

Component of Delstrigo

Rilpivirine

Component of Complera, Odefsey, Cabenuva

Which NNRTI can increase Scr but not effect eGFR

Rilpivirine

When not to use Rilpivirine

Initial viral load > 100,000 copies/mL or CD4 count < 200 cells/mm^3

Which PI requires an acidic gut

Atazanavir

PI MOA

inhibit the HIV protease enzyme during the budding and maturation stage

Which PI's need to be taken with food

Darunavir and atazanavir

Side effects of all PIs

Metabolic abnormalities

Hepatic dysfunction

D/V

Hypersensitivity rxns

Risk of lopinavir/ritonavir (Kaletra) solution

Disulfiram rxn if taken with metronidazole due to high alc content of solution

List PK boosters

Ritonovir (navir)

Cobicistat (tyboost)

Ritonavir dosing and admin

100-200 mg with the boosted drug and with food

Cobicistat admin

with the boosted drug and with food

PI and PK booster drug interactions

Alpha 1A blockers

Amiodarone, dronedarone

Anticoags/antiplatelets

Azole antifungals

Hep C PI

Lovastatin and simvastatin

PDE-5 inhibitors when used for PAH

Strong CYP3A4 inducers

Steroids (except beclomethasone)

Administration of post-attachment inhibitor Ibalizumab-uiyk

IV

First line HIV regimen (2)

Biktarvy or Dovoto

Cabenuva

cabotegravir/rilpivirine

Triumeq

dolutegravir/abacavir/lamivudine

Stribild

elvitegravir/cobicistat/emtricitabine/TDF

Genvoya

elvitegravir + cobicistat + emtricitabine + tenofovir alafenamide

Delstringo

Doravirine/Lamivudine/TDF

Complera

rilpivirine/emtricitabine/TDF

Odefesy

rilpivirine + TAF + emtricitabine

Symtuza

darunavir/cobicistat/emtricitabine/TAF