HIV Antiretroviral Drugs Quiz

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Questions and Answers

Which class of antiretroviral drugs is responsible for preventing the integration of HIV into the host cell's DNA?

Fusion Inhibitors

Reverse Transcriptase Inhibitors

Integrase Inhibitors (correct)

Protease Inhibitors

What type of antiretroviral class primarily targets the HIV infection process occuring during Stage 7 of the HIV lifecycle?

Reverse Transcriptase Inhibitors

Protease Inhibitors (correct)

Integrase Inhibitors

Fusion Inhibitors

Which of the following drugs is NOT part of the recommended first-line treatment options for individuals newly diagnosed with HIV?

Atazanavir (correct)

Tenofovir

Dolutegravir

Abacavir

Which of the following antiretroviral classes work by preventing the HIV virus from entering a CD4 cell?

Attachment Inhibitors (A) Signup and view all the answers

According to the information provided, which of the following antiretroviral classes directly targets an enzyme responsible for a critical step in the HIV lifecycle?

Integrase Inhibitors (B) Signup and view all the answers

What is the primary target for HIV infection?

CD4 helper T cells (D) Signup and view all the answers

What is the CDC definition of AIDS based on?

CD4 count and symptoms (B) Signup and view all the answers

Which of the following is NOT a common symptom associated with primary HIV infection?

Hepatitis (B) Signup and view all the answers

What represents the primary goal for monitoring response to ART?

Viral load below 20 copies/mL (A) Signup and view all the answers

What does the term 'undetectable' refer to in relation to HIV?

A viral load below the limit of detection of ultrasensitive assays (A) Signup and view all the answers

What is the typical CD4 count range during the chronic infection stage of HIV before ART?

200-500 cells/mm³ (D) Signup and view all the answers

Which of the following is NOT considered an opportunistic infection?

Hepatitis C virus infection (B) Signup and view all the answers

Which of these is NOT a common symptom associated with an acute seroconversion syndrome?

Pneumonia (C) Signup and view all the answers

How many people globally were estimated to be living with HIV in 2022?

39.0 million (B) Signup and view all the answers

What is the primary goal of non-pharmacologic therapy in HIV management?

Reduce the risk of transmission and complications (A) Signup and view all the answers

What is the purpose of antiretroviral therapy (ARV) in treating HIV infection?

To suppress the HIV virus to undetectable levels (D) Signup and view all the answers

Why is it important to monitor viral load in HIV patients undergoing antiretroviral therapy?

All of the above (D) Signup and view all the answers

What is the recommended approach to HIV treatment?

Combination therapy with multiple ARVs (B) Signup and view all the answers

Which of the following is NOT a factor influencing the treatment of HIV infection?

Patient's blood type (D) Signup and view all the answers

What does the abbreviation 'OI' stand for in the context of HIV?

Opportunistic Infection (D) Signup and view all the answers

What is the relationship between CD4 count and viral load in the progression of HIV?

As CD4 count decreases, viral load increases (D) Signup and view all the answers

What is the recommended treatment duration for Pneumocystis jiroveci pneumonia (PCP) in an individual with HIV?

21 days (D) Signup and view all the answers

What is the recommended dosage for trimethoprim/sulfamethoxazole in the treatment of PCP in an individual with HIV?

2 DS tabs TID x 21 days (C) Signup and view all the answers

Which of the following conditions is NOT a common adverse effect of cotrimoxazole treatment for PCP?

Hypokalemia (C) Signup and view all the answers

What is the recommended duration of secondary prophylaxis for PCP, assuming the individual's CD4 count remains below 200?

Indefinitely (C) Signup and view all the answers

What is the recommended approach to administering ARVs to a pregnant individual with HIV who is not already on ARVs?

Initiate therapy as soon as possible, regardless of viral load or CD4 count (D) Signup and view all the answers

What is the primary mechanism by which PrEP works to prevent HIV infection?

Blocking the attachment of HIV to CD4 cells (D) Signup and view all the answers

Which of the following factors is NOT considered a contributing factor to the increased risk of perinatal HIV transmission?

Maternal use of illicit drugs (C) Signup and view all the answers

What is the recommended threshold for viral load at 36 weeks of gestation that would prompt a scheduled Cesarean section at 38 weeks?

1000 copies/mL (A) Signup and view all the answers

In the context of perinatal HIV prevention, what is the purpose of the opt-out HIV testing policy for pregnant individuals?

To ensure that all pregnant individuals are tested for HIV (B) Signup and view all the answers

What is the primary reason why breastfeeding is not usually recommended for HIV+ mothers?

It significantly increases the risk of HIV transmission to the infant (B) Signup and view all the answers

Which of the following opportunistic infections is NOT typically associated with a CD4 count below 50?

Candida esophagitis (D) Signup and view all the answers

A patient with a CD4 count of 150 presents with a painful oral lesion consistent with herpes simplex virus. What is the most appropriate initial treatment?

Valacyclovir (B) Signup and view all the answers

A patient with a CD4 count of 49 presents with fever, night sweats, and weight loss. A biopsy from a lymph node reveals Mycobacterium avium complex. Which of the following is the most appropriate treatment regimen?

Azithromycin + ethambutol +/- rifabutin (B) Signup and view all the answers

Which of the following opportunistic infections requires a CD4 count below 100 AND a positive serological test for primary prevention?

Toxoplasmosis encephalitis (C) Signup and view all the answers

Primary prevention of Pneumocystis jiroveci pneumonia (PJP) is recommended for patients with a CD4 count below:

200 (C) Signup and view all the answers

A patient with a CD4 count of 40 presents with fever, headache, and stiff neck. A lumbar puncture reveals cryptococcal antigen in the cerebrospinal fluid. What is the initial phase of treatment?

Amphotericin B + Flucytosine (C) Signup and view all the answers

Which of the following statements about the treatment of CMV retinitis is CORRECT?

Treatment typically consists of a maintenance phase following induction therapy. (A) Signup and view all the answers

A patient with a CD4 count of 180 is diagnosed with Pneumocystis jiroveci pneumonia. Which of the following is the MOST appropriate treatment regimen?

Cotrimoxazole i DS tab daily (A) Signup and view all the answers

Which of the following is NOT a factor that may decrease the risk of HIV transmission?

Frequent STI screening (B) Signup and view all the answers

Which of the following situations would warrant HIV testing?

All of the above (D) Signup and view all the answers

What is the minimum frequency for risk assessment for HIV testing?

Every year (D) Signup and view all the answers

Which statement regarding HIV testing is TRUE?

HIV testing should be a component of routine medical care. (C) Signup and view all the answers

Which of the following is NOT mentioned as a factor that may decrease the risk of HIV transmission?

Vaccination against HIV (A) Signup and view all the answers

Study Notes

HIV Care and Prevention

Presenter: Dr. Debbie Kelly, PharmD, FCSHP, AAHIVP, Professor, Memorial University, Clinical Pharmacotherapy Specialist, Provincial HIV program
Date: Winter 2025

Learning Objectives

Describe the global and national epidemiology of HIV
Discuss Canada's public health goals for HIV
Outline who, how, and when to test for HIV infection
Describe the treatment goals and principles of HIV treatment, relating to antiretroviral (ARV) therapy
Explain monitoring ARV therapy for effectiveness and safety
Discuss the epidemiology of opportunistic infections (OIs) in the context of HIV
Detail recognition and diagnosis of major OIs (e.g., P. jirovecii pneumonia) in a patient with HIV infection
Cover the management approach for P. jirovecii pneumonia, including treatment and follow-up
Describe HIV prevention and control methods

Definitions and Terminology

HIV: Human Immunodeficiency Virus, responsible for AIDS
AIDS: Acquired Immunodeficiency Syndrome; CDC definition based on CD4 count ( <200) or CD4 count (>200) and AIDS-indicator conditions
ARV: Antiretroviral therapy; medications to treat HIV infection, always combination therapy
Opportunistic Infection (OI): Infection in an immunocompromised patient caused by normally non-pathogenic organisms
CD4: Helper T-cell, the primary target for HIV infection
VL: Viral load; the amount of HIV viral RNA in the blood, typically reported in copies per mL; "undetectable" is <20 copies/mL.

Summary of the Global HIV Epidemic (2022)

Total: 39.0 million people living with HIV (range: 33.1-45.7 million)
Adults (15+): 37.5 million (range: 31.8-43.6 million)
Women (15+): 20 million (range: 16.9-23.4 million)
Men (15+): 17.4 million (range: 14.7-20.4 million)
Children (<15): 1.5 million (range: 1.2-2.1 million)
People acquiring HIV: 1.3 million (range: 1.0-1.7 million)
HIV-related deaths: 630,000 (range: 480,000-880,000)

National Rate per 100,000 Population (Canada 2023)

Total Rate: 6.1
Increase of 35.2% in 2023 compared to 2022
Most common exposure in adults is male-to-male sexual contact

Canada's Progress towards Meeting the 95-95-95 Targets (2022)

89% of people living with HIV (PLHIV) were diagnosed
85% of people diagnosed with HIV were on treatment
95% of those on treatment had a suppressed viral load
1 in 10 PLHIV did not know their status

HIV Transmission

Infectious Body Fluids: Blood, semen, vaginal fluids, and "internal" body fluids (CSF, synovial, etc.) as well as fluids containing visible blood (tears, sweat, urine)

HIV Testing

HIV testing should be a part of routine medical care
Informed consent is not always necessary
HIV is a reportable disease

Indications for HIV Testing

Request for testing
Sexually active and never tested
Unprotected sex
Unclear/positive partner HIV status
Shared drug use equipment exposure
Sexual assault
Signs or symptoms of acute HIV infection
Illnesses signaling immunosuppression (e.g., tuberculosis)
Pregnancy or planning pregnancy

Risk Assessment for HIV Testing

MSM (men who have sex with men) with multiple or anonymous partners
Any individual using illicit drugs during sex

Clinical Presentation

Varies depending on disease stage at diagnosis; may be asymptomatic or present with opportunistic infections
Primary HIV infection associated with acute seroconversion syndrome
Common symptoms: fever, lymphadenopathy, pharyngitis, rash, mucocutaneous ulcers, myalgia, arthralgia, diarrhea, headache, nausea, and vomiting

The Natural History of HIV Without ART

CD4 count: Varies; typically starts high and decreases
Viral load: High initially followed a period of decreased viral load via the use of ARV and high viral load

Goals of HIV Treatment

Clinical goals: Slow disease progression; prevent OIs; prolong duration, and quality of life; minimize adverse effects; prevent resistance strains of HIV; prevent transmission
Virological goals: Maximal and durable viral suppression (VL <20 copies/mL within 8–24 weeks)
Immunological goals: Restore and/or preserve immunologic function (high CD4 count)

Non-Pharmacologic Therapy

Counselling to address safer sex practices and drug use
Importance of good nutrition and preventative health
Vaccination with precautions for those with prior immunosuppressive conditions

Baseline Assessment at Diagnosis

Medical history and physical exam
Comorbidities
Opportunistic infections
HIV viral load
CD4 count
Screening for co-infections (e.g., STIs, hepatitis) and OIs
HIV viral genotype testing
HLA-B*5701 testing

Initiating ART

ART is indicated for all patients with HIV infection
If patient has OI treatment of the OI should be the priority, but treatment of HIV should start as soon as possible, potentially concurrently
Caution with drug interactions with concurrent use of any medicine

Patient Follow-up

Check-in at one month for adherence to plan and treatment tolerability
Review concurrent medications carefully to rule out/manage drug interactions.
Monitor VL regularly to assess initial response

Laboratory Monitoring

Viral load (VL): Undetectable (<20 copies/mL)
CD4 count: As high as possible (>200 cells/mm³)
Lytes, SCr, glucose, AST, ALT, Tbili, Lipid profile: Normal levels
Serum PO4: Normal (if applicable based on additional conditions)

Opportunistic Infections

Patients do not die of HIV; they die of opportunistic infections, complications, malignancies, and ARV toxicities from older antiretroviral therapies
Effective ARV therapy produces viable and durable immune reconstitution–most effective way to prevent OIs is through suppressive ARV therapy to maintain immune function

Prediction of OI risk

Risk increases as CD4 count decreases
Initiation of OIs prophylaxis is commonly indicated for patients with CD4<200
Some non-opportunistic pathogens may still cause illness

"Common" OIs in HIV infection

Several common pathogens including yeast (e.g., thrush), bacteria (e.g., oral hairy leukoplakia), and fungus (e.g., P. jirovecii pneumonia) cause OI following a confirmed HIV diagnosis
TB is also considered an example of pathogen

Prediction of OI Risk

Risks of OIs increase with declining CD4 counts
Patients with CD4 counts < 200 typically warrant OI prophylaxis

CD4 < 200/ CD4 < 100/ CD4 < 50 Opportunistic Infections

Common OIs with accompanying preventative treatments are presented
Various OIs are detailed based on CD4 count classifications

Primary Prevention of OI

Prevention is indicated for patients with certain CD4 counts and associated diagnoses or positive serologies

Case: FR

34-year-old man with HIV presenting to ED with symptoms (cough, dyspnea, and fever) that suggest opportunistic P. Jirovecii pneumonia (PJP)
HIV is not fully controlled (VL 25000, CD4 120)
Lab findings: indicate possible Pneumocystis jirovecii pneumonia (PJP)

PJP Pneumonia

Caused by Pneumocystis jirovecii a unicellular fungus
Primarily invades the lungs and less likely to invade extrapulmonary areas
Previously known as PCP
Primarily seen in immunocompromised patients
Mortality is up to 33%

PJP Presentation

Symptoms are usually slow and insidious, including fever and cough
Chest X-ray and HRCT commonly indicate bilateral interstitial or alveolar infiltrates
Sputum induction and bronchoalveolar lavage for testing frequently supports diagnosis
PJP testing is highly sensitive for HIV in immunocompromised patients

PJP Treatment

First-line treatment includes TMP-SMX (cotrimoxazole) for 21 days.
Corticosteroids are often indicated to improve clinical outcomes if paO2 is less than 70, but only if administered within the first 72 hours
Important to address drug interactions with any concurrent therapy
Continuous use of secondary prevention measures are indicated until the CD4 count is above 200

Monitoring

Clinical improvement
Treatment toxicity (e.g., rash, fever, leukopenia, thrombocytopenia, hepatitis, hyperkalemia)
Long-term CD4 recovery must also be monitored

HIV Prevention

Use of ARVs for Prevention:
Perinatal transmission
Pre-Exposure Prophylaxis (PrEP)
Post-Exposure Prophylaxis (PEP)

Perinatal Transmission

Risk of transmission is approximately 25% without prophylaxis, reduced to <1% with appropriate ARV interventions
Timing of perinatal transmission (in utero, intrapartum, breastfeeding). Effective ARV therapy (antepartum, intrapartum, and postpartum) and elective caesarian delivery as appropriate. Formula feeding
If the pregnant person is not already on ARVs, they should initiate therapy ASAP, regardless of VL or CD4 count, and continue taking it

Prevention of Perinatal Transmission

Opt-out HIV testing policy
HIV testing during pregnancy (repeated in the second trimester)
VL testing at 36 weeks if greater than 1000, consider C-section
IV Zidovudine during labor
Avoid artificial premature rupture of membranes
Presumptive triple therapy (for babies) when mom's VL >50

Pre-Exposure Prophylaxis (PrEP)

HIV-negative individuals use ART to reduce risk of infection
Taken regularly, it significantly reduces the likelihood of becoming infected by greater than 90%
Adherence is critical for PrEP effectiveness, and testing for other STIs is crucial

Who is a Candidate for PrEP?

Men who have sex with multiple partners
Heterosexual individuals with high-risk partners (including multiple partners and/or STI history)
People who inject drugs
HIV serodiscordant couples
Note - there are exceptions for considerations regarding sex with an HIV+ partner if the HIV+ partner is on effective ARVs and maintaining an undetectable VL

What PrEP Options Exist?

Oral TDF/emtricitabine (Truvada, generics); Oral TAF/emtricitabine (Descovy); Cabotegravir IM

PrEP is More Than Just a Drug

Comprehensive monitoring is critical to adherence to PrEP and to exclude contracting other conditions (STIs, or HIV)
Prescriptions typically are extended if HIV-negative status and absence of other STIs and further concerns are confirmed (every 3 months) and monitoring

Post-Exposure Prophylaxis (PEP)

Occupational exposure (PEP)
Non-occupational exposure (nPEP)
Must start as soon as possible following exposure, ideally < 72 hours
PEP is generally a combination treatment with 3 drugs and continued for 28 days
PrEP may be a consideration for someone with frequently repeated nPEP exposures if it is deemed appropriate

When PEP is Considered

Depends on: HIV status of source patient (if known), type and nature of exposure, type of body fluid, timing of exposure
Significant Exposures Warrant PEP: HIV status of source unknown but from a population with high HIV prevalence, or from confirmed HIV (high or low viremia) and presence of an STI, or when patient status is unknown, from general population

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Description

Test your knowledge on antiretroviral drugs used in the treatment of HIV. This quiz covers drug classes, their mechanisms, and the clinical definitions related to HIV and AIDS. Understand how various treatments impact the lifecycle of HIV.