Hiv / Aids

Front 1

___ is a disease that is often found alongside HIV and AIDS

Back 1

Hepatitis C

Front 2

HIV is known as a ___virus

Back 2

Retro

Front 3

HIV uses the enzyme ____ to replicate itself

Back 3

Reverse transcriptase

Front 4

AIDS - diagnosis/definition

Back 4

HIV positive plus an AIDS-defining illness:

-CD4 count < 200

-26 different diagnoses: eg. PJP, TB, Cancers (such as cervical, Kaposi's sarcoma, lymphomas), extrampulmonary coccidiomycosis

Front 5

___% of individuals will show antibodies to HIV at __ to __ weeks. It should not take more than ___ months for antibodies to develop.

Back 5

-95%

-4 to 6 weeks

-6 months

Front 6

HIV - Window period - definition

Back 6

The period which antibodies have not developed but patient may still be infectious

Front 7

HIV - Blood testing

Back 7

- HIV Ag/AB Combo Assay (11days-1month detection, 99.9% conclusive at 6 weeks)

- Secondary testing: Western blot: 99.9% at 6 - 8 weeks

-EIA Rapid test (results in 5-30minutes)

Front 8

HIV - What are CD4 cells?

Back 8

Immune cells found in the blood, lymph nodes, and other places in the body which fight infection

Front 9

HIV - Pathophysiology

Back 9

HIV enters CD4 cells to multiply or make copies of itself.

CD4 counts drops while viral load increases.

Front 10

HIV - Seroconversion reaction

Back 10

Following initial infection, patients experience a viral like illness(>90%) characterized by fever, swollen lymph glands, sore throat, rash, muscle aches, headache, fatigue.

Caused by immune system producing antibodies in response to the illness.

Characterized by sharp drop in CD4 count, this is the window period as the body hasn't made a sufficient number of HIV antibodies yet.

Front 11

HIV - What happens after seroconversion usually?

Back 11

Often followed by a long period(years) of no symptoms.

CD4 levels initially rise up a bit but slowly decreases over time with viral load gradually increasing.

Front 12

HIV - General symptoms of HIV (6)

Back 12

L. DUFFY:
- Lymph nodes @ neck, groin, axilla swollen and tender
- Diarrhea (persistent)
- Unexplained weight loss
- Fever (persistent)
- Fatigue
- Yeast infections, thrush

Front 13

HIV can be found in varying amounts in these bodily fluids

Back 13

(Most body fluids)
-Blood
-Breast milk
-Semen
-Saliva
-Vaginal fluid
-Tears

Front 14

HIV can be transmitted by __ (5)

Back 14

ONIUM:
-Occupational exposure risk
-Needles used for tattoos, acupuncture
-IV Drug use
-Unprotected sex through linings of penis, vagina, vulva, rectum (rarely via mouth)
-Mother to baby during delivery and breastfeeding

Front 15

HIV - If mom is not on ARV therapy, there is a ___% vertical transmission risk from mother to baby. If treated, drops to almost 0%.

Back 15

25%

Front 16

Which has more efficient HIV transfer? Female to male transmission or male to female?

Back 16

Males to female.

2-2.5 times more efficient.

Front 17

Younger women(up to 20 years of age) have an increased risk of HIV contraction due to ___.

Back 17

Immature genital mucosa.

Less reliable mucous production.

Front 18

You cannot contract HIV from the following situations

Back 18

-Sharing cups
-Kissing/Hugging
-Coughing
-Sneezing
-Swimming pools

Front 19

Highest risk activity for contracting HIV is ___.

Back 19

Anal intercourse - Males having sex with males(MSM)

Front 20

HIV - 6 classes of ARVs

Back 20

F'N PINE:
- Fusion inhibitors
- NRTI
- Protease inhibitor
- Integrase strand transfer inhibitor
- NNRTI
- Entry inhibitor (CCR5 inhibitor)

Front 21

HIV - When to start treatment. The ___ (earlier / later) the better.

Back 21

Earlier

Front 22

HIV treatment - Reasons to start early (4)

Back 22

- HIV viremia harmful regardless of CD4 count
- Resistance decreased
- Cost savings ( as in associated costs with treating later)
- Transmission decreased

Front 23

HIV - Goals of therapy (5)

Back 23

- HIV associated mortality (reduce it)
- Immunologic function (restore and preserve it)
- Maximal, sustained viral load suppression
- Disease progression (prevent or slow it)
- Life expectancy and QOL(increase it)
- Prevent HIV transmission(including mother to child transmission)

Front 24

HIV eradication is not possible with the current ARV treaments because of ___.

Back 24

Sanctuary sites in brain, lymph nodes, genitals.

They harbor latently infected CD4 cells(established in acute phase of infection)

Front 25

HIV treatment that is very aggressive - designed to hit HIV hard, suppress viral replication and prevent progression(and resistance) of the disease - What therapy is this? What are the component combinations?

Back 25

-HAART - highly active antiretroviral therapy.

-2 NRTI's and a PI

-2 NRTI's and a NonNRTI

Front 26

HIV - Average CD4 count in healthy individuals is ___

Back 26

1000 (range is 800-1600)

Front 27

HIV - ___ is a better indicator of the state of the immune system than CD4 count. Normal range for that is ___.

Back 27

CD4 fraction %.

Normal range is above 15%(27-60%).

Front 28

HIV therapy - With treatment, CD4 cell count is expected to rise ___ per year.

Back 28

100 - 150 cells/mm3

Front 29

HIV therapy - When should one check CD4 counts?

Back 29

- At baseline

- Then every 3-6 months (if viral load stable then q6-12months)

Front 30

HIV therapy - What is the target viral load for therapy? When should you attain it?

Back 30

- Undetectable, or <40 - 50 copies/mL

- Within 8 weeks of starting therapy(Rx Files says 6 months)

Front 31

HIV treatment - When should one initiate treatment?

Back 31

- Depends on CD4 cell count, but generally ASAP

- If < 350 cells/mm3 then should start immediately (A1 grade evidence)

- 350 - 500 cells/mm3 then A2 evidence

- >500 cells/mm3 then B3 evidence

OR if have one of following conditions HPAN:
1) Hep B virus coinfection
2) Pregnant
3) AIDS defining illness Hx (eg. TB, PJP)
4) Nephropathy that is HIV associated

Front 32

HIV treatment - Should generally start right away except for when you have ___

Back 32

Cryptococcal meningitis (associated with higher mortality if on ARV regimen)

Front 33

HIV therapy - Genotyping the virus is how one can check for resistance. When is it usually done?

Back 33

- Prior to starting therapy

- Whenever viral load > 500 without an obvious cause

Front 34

HIV therapy - Minimum viral load for genotyping is ___.

Back 34

500 copies/mL

Front 35

HIV therapy - Must be on ARV therapy for at least ___ weeks (or stopped within) to get accurate genotyping/resistance testing.

Back 35

4 weeks

Front 36

HIV - Gene that you must check prior to starting Abacavir. What is the reason for doing so?

Back 36

- HLA-B*5701

- To prevent hypersensitivity reaction (serious and life threatening): Occurs in 1st 2 weeks, Rash, Joint pain, Fever, Respiratory Sx

- DO NOT RE-CHALLENGE (death due to liver failure), Stop Abacavir immediately

Front 37

HIV therapy - Which drug do you have to check for the CCR5 receptor? What is the alternate receptor analogous to CCR5(that this drug does not work on)?

Back 37

Maraviroc.

CXCR4. If the person has both CCR5 and CXCR4 mixed receptors then maraviroc is not a good choice.

Front 38

HIV therapy - Regimen to start in ARV naiive patients - NNRTIs

Back 38

Viral load > 100,000:
ATRIPLA : Efavirenz(NonNRTI) plus Tenofovir(NRTI) and Emtricitabine(NRTI)

Viral load < 100,000 and HLA-B*5701 negative:
Efavirenz(NonNRTI) plus Abacavir(NRTI) plus Lamuvidine(NRTI)

Front 39

HIV therapy - An alternative to the NonNRTI Efavirenz(not Rilpivirine) is ___. What to look out for with that is ___(SE).

Back 39

Nevirapine.

Rash, Steven Johnsons Syndrome, Hepatitis (frequency higher with CD4 counts > 250 for females, >400 for males)

Front 40

HIV - Complera (a third NonNRTI regimen) is used when..

Back 40

Viral load > 100,000 and must be taken with a 500+ calorie meal.

Similar to Atripla except Efavirenz switched to Rilpivirine.

Front 41

HIV therapy - ___% adherence is required for effective viral load suppression

Back 41

95%

Front 42

HIV therapy - Name the NonNRTIs (3)

Back 42

NER: (they have "vir" in middle of word)
- Nevirapine
- Efavirenz
- Rilpivirine

Front 43

HIV therapy - Of the NRTIs, the only nucleotide one is ___. The rest are nucleoside.

Back 43

Tenofovir

Front 44

HIV therapy - This drug you need to test the HLA-B*5701 gene beforehand

Back 44

Abacavir

Front 45

HIV therapy - Name the NRTIs (5)

Back 45

STEALZ:
- Stavudine
- Tenofovir
- Emtricitabine
- Abacavir
- Lamivudine
- Zidovudine

Front 46

HIV therapy - ATRIPLA (2 NRTIs + NonNRTI) is comprised of:

Back 46

TEE:
- Tenofovir
- Emtricitabine
- Efavirenz

Front 47

HIV therapy - COMPLERA (2 NRTIs + NonNRTI) is comprised of:

Back 47

TER:
- Tenofovir
- Emtricitabine
- Rilpivirine

Front 48

HIV therapy - Protease Inhibitors are boosted with ___ (Drug). How and why?

Back 48

Ritonavir.

CYP inhibitor. To decrease total dose and allow for once daily dosing.

Front 49

HIV therapy - Name some common Protease Inhibitors (3)

Back 49

LAD: (All agents ending in "AVIR" are PI except abacavir, rategravir and elvitegravir)
- Lopinavir
- Atazanavir
- Darunavir

Front 50

HIV therapy - Name the components of NRTI fixed dose TRUVADA and KIVEXA.

Back 50

TRUVADA: Tenofavir, Emtricitabine (starts with a T)

KIVEXA: Abacavir, Lamivudine

Front 51

HIV therapy - Name the Integrase Inhibitors (2)

Back 51

(IRE) RE:
- Raltegravir
- Elvitegravir

Front 52

HIV therapy - Stribild is known as the ___ tablet.

It contains ___.

Back 52

QUAD

Elvitegravir, cobicistat, emtricitabine, tenofavir

Front 53

HIV therapy - Cobicistat is not a ARV but is there to ___

Back 53

Limit liver enzymes which break down elvitegravir, therefore boosting the dose.

Front 54

HIV therapy - Raltegravir is given (OD / BID).

Back 54

BID

Front 55

HIV therapy - Treatments during pregnancy

Back 55

- NRTI:
Combivir: Lamvudine and zidovudine 1 tab BID

- PI:
Atazanivir 300mg and Ritonavir 100mg OD

Front 56

HIV therapy - Why do patients feel worse after starting ARV treatment?

Back 56

- IRIS - Immune Response Inflammatory Syndrome

- Previously immune system was repressed so cannot recognize TB, MAC, PCP, herpes.

- Immune system is boosted and recognizes them and overcompensates. can be FATAL.

Front 57

HIV therapy - Vaccinations, which to get and does it work? Can only give vaccination if CD4 count is greater than ___.

Back 57

- No live vaccines as weakened immune system

- Pneumococcal vaccine, Hep A, Hep B, Flu

- CD4 count > 200.

- Vaccinations may increase viral load in next 4 weeks. Do not measure viral load after 4 weeks post vaccination.

Front 58

HIV therapy - What are the general classes of medications that can potentially cause a DI with HIV meds? (6)

Back 58

MANIAS:
- Methadone
- Antidepressants
- Nutritional supplements (eg st johns)
- Illicit drugs and alcohol
- Anticonvulsants
- Sedatives/Hypnotics

Front 59

HIV therapy - What is the main herbal that interacts with PIs?

Back 59

St. John's Wort.

Decreases PI by 50%.

Front 60

HIV therapy - What HIV treatment drug classes are CYP metabolized? (2)

Back 60

PI and NonNRTI

Front 61

HIV therapy - Which anticonvulsants should be avoided with HIV medication?

Back 61

- Carbamezepine
- Oxcarbazepine
- Phenytoin
- Phenobarbital
- Primidone
- Felbamate

All are enzyme inducers. Use 2nd line like Gabapentin or Lamotrigine.

Front 62

HIV therapy - Methadone DI?

Back 62

- Efavirenz is an inducer of CYP which will increase methadone metabolism. May need to increase methadone dose.

Front 63

HIV therapy - OCPs DI?

Back 63

- Most ARVs decrease levels of estrogen and effectiveness in body.

- Use alternative forms of birth control.

Front 64

HIV therapy - Which drug used in TB/MAC treatment greatly decreases Efavirenz efficacy?

Back 64

Rifampin

Front 65

HIV therapy - Which drugs greatly increase PI levels? What is the result? Alternatives?

Back 65

Lovastatin, Simvastatin.

Increase in LFTs, liver toxicity/death. Rhabdomyolysis.

Rosuvastatin, Pravastatin preferred.

Front 66

HIV therapy - Which BZD has a DI?

Back 66

Triazolam.

2000% increase in AUC.

Front 67

HIV therapy - What is the point which is considered virologic treatment failure?

Back 67

Unable to maintain less than 200 copies/mL

Front 68

HIV therapy - What is immunologic failure?

Back 68

Unable to increase CD4 count to over 150 cells/mm3 in 1st year

Front 69

HIV therapy - With virologic failure, what should be done?

Back 69

Change to a new regimen of at least 2 or 3 active drugs.

Front 70

HIV therapy - If pt develops a rash, should they discontinue their medication?

Back 70

- Not necessarily. Maybe if angry red rash.

- Only stop if rash is accompanied by fever, flu like symptoms, swollen throat.

Front 71

HIV therapy - What are the expected body changes with HIV?

Back 71

- Bone loss
- Increased cholesterol
- Increased blood sugars

Front 72

HIV therapy - Which drug can cause hepatic steatosis and/or life threatening lactic acidosis?

Back 72

Zidovudine.

Stop NRTIs. May need IV fluids.

Drug affects mitochondrial function so cannot process lactate.

Front 73

HIV therapy - Zidovudine - What are the signs/symptoms of lactic acidosis? (7)

Back 73

VW NASAL:
- Vomiting (persistent)
- Weight loss
- Nausea (persistent)
- Abdominal pain
- SOB
- Abnormal heart rate
- Liver tenderness increased

Front 74

HIV therapy - What is one means of measuring compliance with a lab test?

Back 74

Zidovudine(AZT) and Stavudine both increase MCV.

This is not due to folic acid or B12 deficiency but a normal response of using these meds. Don't treat.

Front 75

HIV therapy - Side effects generally improve in ___ weeks. What can be done to manage them?

Back 75

3 - 4 weeks.

Use OTCs to manage SE.

Gravol.
Use Boost/Ensure for weight loss.

The usuals for diarrhea, headache, rash.

Front 76

HIV therapy - Nevirapine dosing

Back 76

200mg OD for first few weeks then 200mg BID.

May see rash if not initiated at lower dose.

Front 77

HIV complications - Symptoms of PCP (Pneumocystis Jiroveci Pneumonia)

Back 77

W SCOFF:
- Weight Loss
- SOB
- Cough
- O2 desaturation
- Fever
- Fatigue

Front 78

HIV complications - PCP treatment and prophylaxis

Back 78

Co-trimoxazole (SMX-TMP) IV or Oral, 15mg/kg/day divided q6-8h.

Prophylaxis if CD4 < 200: 1 tab Septra regular strength every day of week until CD4 >200 for 3months. OR. double strength tablet 3 times a week (MWF).