- CD4 < 200 - AIDS defining condition

- Everyone once between 19-64 yo - High-risk for infection annually - High-Risk: sexual behaviors, injecting drugs, STIs/TB hx

- Flu-like sxs (occurs in 50-70%) - About 2 weeks post-infection high enough viral load for HIV RNA/p24 antigen to be connected (use HIV1/2 antigen/antibody screening) - Positive screening + positive confirmatory = HIV diagnosis

- At home HIV antibody test - Done 3+ months post-exposure - Earlier can give false negative - Requires positive confirmatory test for diagnosis

- Binding/attachment - Binds to CD4 receptor by CCR5 and/or CXCR4

- Works on stage 1 - CCR5 antagonist - Only works if patient only has CCR5 receptors

- Works on stage 1 - Attachment inhibitor

- Works at stage 1 - Post attachment inhibitor - Uncommonly used - IV injection - For MDR HIV

- Enfurvirtide - Fusion inhibitor - SQ injection - Works at stage 2

- Reverse transcription - RNA converted to DNA by reverse transcriptase and enters nucleus

- Nucleoside/Nucleotide Reverse Transcriptase Inhibitors - Works at stage 3 - Ex: Tenofovir, Emtricitabine - Only abacavir DOESN'T need renal adjustment - Drug Class Warning: lactic acidosis, hepatomegaly w/ steatosis - SE: nausea, diarrhea, HA, increased LFT - Some used to treat HBV too, DON'T D/C if HBV positive

- Non-nucleoside reverse transcriptase inhibitors - Works at stage 3 - Drugs contain -vir- - Ex: Efavirenz, rilpivirine - Box Warning: rash/severe rash, hepatotoxicity

- Integrase strand transfer inhibitors - Works at stage 4 - Drugs end in -gravir - Preferred tx with NRTI backbone in patient naive - Separate Al/Mg antacids from INSTIs (2 before, 6 after) - SE: HA, insomnia, diarrhea. weight GAIN

- Replication - Assembly - No drug associations

- Protease inhibitors - Works at stage 7 - Drugs end in -navir - SE: metabolic problems (sugars/chol.), lipodystrophy - Lowest risk: atazanavir and darunavir

HIV Flashcards by Rachel Crusius

AIDS

CD4 < 200

- AIDS defining condition

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AIDS-defining Condition

Opportunistic Infections:

MAC
PJP
Severe Candida albicans
Thrush
TB

Cancers:
-Kaposi’s sarcoma

Other: HIV Wasting Syndrome

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Screening/Diagnosis

Everyone once between 19-64 yo
High-risk for infection annually
High-Risk: sexual behaviors, injecting drugs, STIs/TB hx

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Acute HIV

Flu-like sxs (occurs in 50-70%)
About 2 weeks post-infection high enough viral load for HIV RNA/p24 antigen to be connected (use HIV1/2 antigen/antibody screening)
Positive screening + positive confirmatory = HIV diagnosis

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OraQuick

At home HIV antibody test
Done 3+ months post-exposure
Earlier can give false negative
Requires positive confirmatory test for diagnosis

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Stage 1

Binding/attachment

- Binds to CD4 receptor by CCR5 and/or CXCR4

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Maraviroc

Works on stage 1
CCR5 antagonist
Only works if patient only has CCR5 receptors

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Fostemsavir

Works on stage 1

- Attachment inhibitor

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Ibalizumeb-uiyk

Works at stage 1
Post attachment inhibitor
Uncommonly used
IV injection
For MDR HIV

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Stage 2

Fusion

- Virus fuses with cell membrane and release HIV RNA/enzymes/proteins

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Fuzeon

Enfurvirtide
Fusion inhibitor
SQ injection
Works at stage 2

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Stage 3

Reverse transcription

- RNA converted to DNA by reverse transcriptase and enters nucleus

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NRTIs

Nucleoside/Nucleotide Reverse Transcriptase Inhibitors
Works at stage 3
Ex: Tenofovir, Emtricitabine
Only abacavir DOESN’T need renal adjustment
Drug Class Warning: lactic acidosis, hepatomegaly w/ steatosis
SE: nausea, diarrhea, HA, increased LFT
Some used to treat HBV too, DON’T D/C if HBV positive

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NNRTIs

Non-nucleoside reverse transcriptase inhibitors
Works at stage 3
Drugs contain “-vir-“
Ex: Efavirenz, rilpivirine
Box Warning: rash/severe rash, hepatotoxicity

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Stage 4

Integration

- Integrase (HIV enzyme) released and HIV DNA incorporated into host DNA

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INSTIs

Integrase strand transfer inhibitors
Works at stage 4
Drugs end in “-gravir”
Preferred tx with NRTI backbone in patient naive
Separate Al/Mg antacids from INSTIs (2 before, 6 after)
SE: HA, insomnia, diarrhea. weight GAIN

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Stages 5/6

Replication
Assembly
No drug associations

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Stage 7

Budding/Maturation

- Protease breaks up long viral chains to make them mature, infectable HIV

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Protease inhibitors
Works at stage 7
Drugs end in “-navir”
SE: metabolic problems (sugars/chol.), lipodystrophy
Lowest risk: atazanavir and darunavir

Initial Evaluation

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CD4 count (goal: normal levels)
HIV viral load (goal: undetectable)
Hep B/C screening
Pregnancy test
HLA-B*5701 (abacavir req., CI if positive, severe allergic rxn risk)
Tropism assay (maraviroc req.)

Preferred ART Therapy

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2 NRTIs and 1 INSTI
Descovy or Truvada are common for 2 NRTI backbone
NEVER use lamivudine and emtricitabine together (redundant)
If renally insufficient, harder to use combo products (use individuals)

Dovato

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Dolutegravir/Lamivudine
Don’t use in naïve pts with RNA >500K, known HBV coinfection, or no genotyping
One pill per day
Dolutegravir: Increases SCr w/o eGFR

Triumeq

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Dolutegravir/Abacavir/Lamivudine
Abacavir requires HLA-B*5701 testing, CI if positive, severe allergic rxn risk
One pill per day
Dolutegravir: Increases SCr w/o eGFR

Biktarvy

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Bictegravir/Emtricitabine/TAF
One pill per day
Emtricitabine: risk for hyperpigmentation in hands/feet
Can be given with iron/calcium IF taken with food
Bictegravir: Increases SCr w/o effect on GFR

NRTI Backbone

-TAF OR TDF OR ABACAVIR PLUS -Emtricitabine OR Lamivudine -Then combined with INSTI, NNRTI, or PI for regimen

Z LATTE

``` NRTI pneumonic: Z - Zidovudine (only used L&D now if RNA > 1000, protect baby) L - Lamivudine A - Abacavir T - TDF T - TAF E - Emtricitabine ```

Descovy

- Emtricitabine/TAF | - Emtricitabine: risk for hyperpigmentation in hands/feet

Truvada

- Emtricitabine/TDF - Emtricitabine: risk for hyperpigmentation in hands/feet - CrCl should be > 60

Tivicay

- Dolutegravir - INSTI - Dolutegravir: Increases SCr w/o eGFR

Isentress

- Raltegravir - INSTI - Can be used in HD patients - Used multiple times a day - SE: myopathy/increased CPK/rhabdo, rash risk - Can be taken with calcium carbonate - Used in PEP

BRED

``` INSTI Pneumonic: B: Bictegravir R: Raltegravir E: Elvitagravir D: Dolutegravir ```

Tenofovir Formulations

- Viread: TDF - Vemlidy: TAF (monotherapy not available) - NRTIs - NOF Risks: nephrotoxicity, osteoporosis, Fanconi syndrome - TAF has less toxicities compared to TDF

Epivir

- Lamivudine - NRTI - Used for HBV AND HIV (different brands, use right one for indication)

Emtriva

- Emtricitabine - NRTI - Risk for hyperpigmentation in hands/feet

Ziagen

- Abacavir - NRTI - Require HLA-B*5701

Retrovir

- Zidovudine - NRTI - Anema (treat with erythropoietin) - Give IV during L&D if RNA > 1000 to protect baby

Atripla

- Efavirenz/Emtricitabine/TDF - Efavirenz can cause depression/psych issues => take at bedtime on empty stomach to reduce these SE - Emtricitabine has risk for hyperpigrmentation in hands/feet - FIRST one pill QD, so some still on it

Rilpivirine

- NNRTIs - MUST be take with full meal > 500 kcal - CI with PPIs - Don't use if viral load >100K or CD4 < 400 - H2RAs/antacids need to be separated

Reyataz

- Atazanavir - PI - CI: acid lowering medications - SE: hyperbilirubinemia ("bananavir")

Prezista

- Darunavir - PI - Caution with sulfa allergy - SJS/TEN Risk

Norvir

- Rilpivirine - ONLY used with PI - PK booster - Numerous DDI! - 43% alcohol: avoid with metronidazole, disulfiram, etc.

Tybost

- Cobicistat - PK booster - No ART activity - Can be used with other ART classes - Numerous DDI!

Wasting Syndrome Tx

- Characterized by loss muscle mass, loss of appetite, diarrhea - Cannabis related products like Syndros (dronabinal) or nabilone help improve appetite - Megace ES (megesterol) is a progestin that also stimulates appetite

IRIS

- Immune reconstitution inflammatory syndrome - Worsening of underlying condition after starting ART (unmasks condition) - Self-limited, DON'T start ART - More likely to occur as viral loads drop and CD4 rises

Preggo Tx Options

- Abacavir/Lamivudine OR TDF/Emtricitabine (or Lamivudine here) with a boosted PI OR INSTI - Boosted PI Options: Atazanavir or darunavir with ritonavir - INSTI Options: Raltegravir or dolutegravir * *NO TAF**

PrEP

- Confirm negative HIV test first - Screen recent sxs, CrCl >= 60, HepB/STI screening - Treat with Truvada or Descovy - Follow-up in 3 months to ensure HIV negative status and check kidneys/STIs

PEP

- Start ASAP (w/in 72 hours) no matter then circumstance - Baseline HIV test, follow-up in 4-6 weeks, 3 months, and 6 months - Treat with Truvada + Tivicay OR Raltegravir - Raltegravir preferred for preggo/childbearing age

HIV Flashcards

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