HIV Handout 2025 PDF

HIV treatment Overview  Learning Objectives ▪ Recognize regimens that are current first-line therapy for the treatment-naïve patient ▪ List key counseling points for current first-line regimens ▪ Identify a monitoring plan for a patient receiving HIV therapy ▪ Choose an appropriate regime...

HIV treatment Overview  Learning Objectives ▪ Recognize regimens that are current first-line therapy for the treatment-naïve patient ▪ List key counseling points for current first-line regimens ▪ Identify a monitoring plan for a patient receiving HIV therapy ▪ Choose an appropriate regimen for either pre- or post-exposure HIV prophylaxis  HIV History Quiz ▪ When were the first HIV cases identified? 1. 1976 2. 1981 3. 1986 4. 1991 https://hivinfo.nih.gov/understanding-hiv/infographics/fda-approval-hiv-medicines Accessed Jan 5, 2025  2022 incidence: 31,800 https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics/ Accessed Jan 5, 2025 https://www.cdc.gov/hiv/basics/statistics.html Accessed Jan 5, 2024 https://www.cdc.gov/hiv/basics/statistics.html Accessed Jan 5, 2024  HIV versus AIDS ▪ HIV – Positive for HIV virus only ▪ AIDS ▪ CD4 Count less that 200 cell/mm3 ▪ Presence of opportunistic infections (OIs)  HIV timeline https://step1.medbullets.com/immunology/105067/human-immunodeficiency-virus--acquired-immunodeficiency-syndrome#popup/image/105467 Accessed Jan 5, 2024  HIV Testing ▪ WHO ▪ 13-64 y/o - all healthcare settings ▪ Annually in high-risk groups High-risk sexual behavior, TB, Hepatitis, STIs ▪ Tests ▪ Virus isolation ▪ Antiviral antibodies ▪ Viral nucleic acid or antigens  HIV Testing ▪ Initial Screening ▪ HIV antibody / HIV p24 antigen ▪ Delay in positivity ▪ Early as 4 to 8 weeks ▪ Up to 3 to 6 months ▪ Must do confirmatory testing  HIV Testing ▪ Antibody self-tests ▪ OraQuick In-Home HIV Test ▪ Swab upper and lower gums ▪ Insert into liquid ▪ Run time: 20 minutes ▪ IgG and IgM antibodies https://oraquick.com/why-oraquick Accessed Jan 5, 2024  HIV Testing ▪ Antibody Point-of-Care ▪ DPP HIV-1/2 ▪ HIV 1/2 STAT-PAK Assay ▪ INSTI HIV-1/HIV-2 Antibody Test ▪ OraQuick ADVANCE Rapid HIV-1/2 Antibody Test ▪ Reveal G4 Rapid HIV-1 Antibody Test ▪ SURE CHECK HIV 1/2 Assay ▪ Uni-Gold Recombigen HIV-1/2 https://www.cdc.gov/hiv/testing/laboratorytests.html Accessed Jan 5, 2024  HIV Testing https://stacks.cdc.gov/view/cdc/50872 Accessed Jan 5, 2024  Review Question ▪ According to current CDC guidelines, who should be tested for HIV? 1. Only those at high-risk for infection 2. Only if an opportunistic infection occurs 3. Everyone 13 to 64 years old 4. Only sexually active individuals  HIV History Quiz ▪ Which famous actor was one of the first to knowingly die of HIV-related complications? 1. Yul Brynner 2. Ricky Nelson 3. Orson Wells 4. Rock Hudson  Goals of HIV Therapy ▪ Normal CD4+ cell count ▪ Indicator of immune function ▪ Need of prophylaxis against OIs ▪ Undetectable viral load ▪ Regimen selection ▪ Compliance and resistance ▪ Delay disease progression ▪ Prevent transmission https://clinicalinfo.hiv.gov/en/guidelines Accessed Jan 5, 2024  Initial Evaluation if HIV+ ▪ Determine HIV strain ▪ CD4+ cell count ▪ Viral load via NAT ▪ HIV resistance testing ▪ Blood chemistry, CBC/diff, Liver function, Lipid panel, Urinalysis ▪ Pregnancy test, Drug-specific testing https://clinicalinfo.hiv.gov/en/guidelines Accessed Jan 5, 2024  Initial HIV Therapy ▪ Recommended in all HIV+ Individuals ▪ Not curative ▪ 95% compliance required ▪ Regimens ▪ Therapy for most people with HIV ▪ Certain clinical situations ▪ Special groups: Pediatrics, Hepatitis, Organ dysfunction, etc. https://clinicalinfo.hiv.gov/en/guidelines Accessed Jan 5, 2024 https://www.hiv.uw.e du/go/antiretroviral- therapy/general- information/core- concept/all Accessed Jan 5, 2025  Initial HIV Therapy ▪ Recommended in all HIV+ Individuals ▪ Not curative ▪ 95% compliance required ▪ Regimens ▪ Therapy for most people with HIV ▪ Certain clinical situations ▪ Special groups: Pediatrics, Hepatitis, Organ dysfunction, etc. https://clinicalinfo.hiv.gov/en/guidelines Accessed Jan 5, 2025  Initial Tx – Most Pts Integrase Strand Nucleoside Reverse Inhibitor Transcriptase Inhibitors Bictegravir Abacavir Dolutegravir Emtricitabine Tenofovir alafenamide Tenofovir disoproxil fumerate Lamivudine https://clinicalinfo.hiv.gov/en/guidelines (Table 6) Accessed Jan 5, 2025  Initial Tx – Most Pts One-Pill, Once Daily Biktarvy® – Bictegravir/Emtricitabine/Tenofovir ALA Dovato® – Dolutegravir/Lamivudine Two-Pills, Once Daily Tivicay® – Dolutegravir PLUS Truvada® – Emtricitabine / Tenofovir DF OR Descovy® – Emtricitabine / Tenofovir ALA https://clinicalinfo.hiv.gov/en/guidelines (Table 6) Accessed Jan 5, 2025  Transition Tx Patients stable on ART regimen with undetectable viral load One-Pill, Once Daily Juluca® – Dolutegravir/Rilpivirine Dovato® – Dolutegravir/Lamivudine IM, Once Monthly Carbenuva® – Cabotegravir/Lamivudine IM https://clinicalinfo.hiv.gov/en/guidelines Accessed Jan 5, 2025  Initial Tx – Side Effects Nucleoside Reverse Transcriptase Inhibitor Box Warnings: lactic acidosis, hepatomegaly with steatosis, exacerbation of HBV upon discontinuation Nausea, diarrhea, headache Abacavir: hypersenitivity reaction (HLA-B*5701), increased risk of myocardial infarction Emtricitabine: hyperpigmentation Tenovovir: TDF > ALA: acute renal failure, Fanconi syndrome, osteomalacia ALA > TDF: increased TG, LDL, HDL https://clinicalinfo.hiv.gov/en/guidelines Accessed Jan 5, 2025  Initial Tx – Side Effects Integrase Strand Inhibitors Weight gain Rash Insomnia, depression, suicidality (esp. patients with pre-existing psychiatric history) Headache Separate from polyvalent cations https://clinicalinfo.hiv.gov/en/guidelines Accessed Jan 5, 2025  Initial Tx – Side Effects Integrase Strand Inhibitors Increased serum creatinine without affecting GFR: Bictegravir, Dolutegravir Hepatotoxicity in hepatitis patients: Dolutegravir Increased CPK, myopathy, rhabdomyolysis: Dolutegravir, Raltegravir Hypersensitivity reactions: Raltegravir Injection site pain, nodules, induration, swelling, hematoma: Cabotegravir hyperlipidemia (increased TG, LDL, HDL), nausea/diarrhea: Elvitegravir (boosted) https://clinicalinfo.hiv.gov/en/guidelines Accessed Jan 5, 2025  Initial Tx – Side Effects Immune Reconstitution Inflammatory Syndrome Flare of opportunistic infection Inflammatory reaction at site of infection Most common: Low CD4+ count / high viral load What do we do! 1) Treat the opportunistic infection 2) Continue the ART regimen 3) Steroids in selected situations https://clinicalinfo.hiv.gov/en/guidelines Accessed Jan 5, 2025  Drug Interactions Integrase strand inhibitors: Polyvalent cations, P-gp & UGT1A1 substrate Elvetegravir/Cobicistat: 3A4 substrate, 3A4/2D6 Inhibitor, 2C9 Inducer, Nonnucleoside Reverse Transcriptase Inhibitors Tenofovir: P-gp substrate Protease Inhibitors: MANY!!!! P-gp, 3A4, 2D6 substrate, inhibitor, inducer Ritonavir: 1A2, 2B6, 2C8, 2C9, 2C19 inhibitor https://clinicalinfo.hiv.gov/en/guidelines Accessed Jan 5, 2025  Key Counseling Points Do not skip doses or stop taking your HIV medication Keep in original container Contact your physician if you experience muscle ache, burning, rapid breathing, nausea, stomach pain Avoid antacids 2 hours before to 6 hours after taking the medication Many possible drug interactions – notify your provider Abacavir: watch for rash Emtricitabine: may see darkening of palms and soles TAF/TDF: consider taking vitamin D and calcium supplements https://clinicalinfo.hiv.gov/en/guidelines Accessed Jan 5, 2025  Review Question ▪ A patient is being initiated on HIV therapy. They wish to use a once daily, single tablet regimen. Which one is appropriate? 1. Truvada® 2. Carbenuva® 3. Biktarvy® 4. Descovy®  HIV History Quiz ▪ When did combination therapy or highly active antiretroviral therapy (HAART) become the standard of care? 1. 1987 2. 1992 3. 1997 4. 2002  Initial Tx – Other Pts Integrase Strand Inhibitor Nonnucleoside Reverse Elvitegravir Transcriptase Inhibitors Raltegravir Doravirine Protease Inhibitor Efavirenz Darunavir (boosted) Rilpivirine Atazanavir (boosted) Common Combinations Stribild® – Elvitegravir/Cobicistat/Emtricitabine/Tenofovir DF Genvoya® – Elvitegravir/Cobicistat/Emtricitabine/Tenofovir AF https://clinicalinfo.hiv.gov/en/guidelines (Table 6) Accessed Jan 5, 2024  Key Side Effects NNRTIs: rash and heptoxoticity Efavirenz: take at bedtime on empty stomach, depression, psychosis, confusion, abnormal dreams Rilpivirine: take with full meal, avoid PPIs, separate H2RAs and antacids, depression PIs: take with food, hyperglycemia, fat redistribution, hypertriglyceridemia Atazanavir: avoid PPIs/H2RAs/antacids, hyperbilirubinemia Darunavir: Sulfa allergy https://clinicalinfo.hiv.gov/en/guidelines Accessed Jan 5, 2026  Initial Tx – Pregnancy NRTI Combinations Plus one of the following: Epzicom® – Abacavir + Darunavir + Ritonavir Lamivudine Dolutegravir Truvada® – Emtricitabine + Tenofovir DF Descovy® – Emtricitabine + Tenofovir AF Cimduo® – Lamivudine + Tenofovir DF Lamivudine + Tenofovir AF https://clinicalinfo.hiv.gov/en/guidelines Accessed Jan 5, 2024 Post Exposure Prophylaxis (PEP) Occupational versus Non-occupational Window for treatment: Less than 72 hours Duration of treatment: 28 days HIV antibody: baseline, 4-6 weeks, 3 months, 6 months Preferred: Dolutegravir (Tivicay®) plus Emtricitabine/Tenofovir DF (Truvada®) May substitute Raltegravir (Insentress®) https://clinicalinfo.hiv.gov/en/guidelines Accessed Jan 5, 2024  Pre-Exposure Prophylaxis (PrEP) Who: High risk for exposure, active IV drug users Prior: HIV negative, CrCl > 60 mL/min, HBV -, No STIs Preferred: Emtricitabine/Tenofovir AF (Descovy®) Emtricitabine/Tenofovir DF (Truvada®) Cabotegravir (Apretude®) IM every 2 months Follow-up: Every 3 months: 90-day supply, HIV test, pregnancy test Every 6 months: Scr, CrCl, test for STIs https://clinicalinfo.hiv.gov/en/guidelines Accessed Jan 5, 2024  Review Question ▪ A co-worker inadvertently stuck themselves with a needle while giving an immunization to an HIV+ patient. Which therapy is appropriate? 1. Truvada® 2. Insentress® + Truvada® 3. Apretude® 4. Descovy®  HIV History Quiz ▪ Which famous athlete retired when diagnosed with HIV only to return to his sport later? 1. Randall Cunningham 2. Ryne Sandberg 3. Magic Johnson 4. Mario Lemieux  HIV History Quiz ▪ Which famous athlete retired when diagnosed with HIV only to return to his sport later? 1. Randall Cunningham 2. Ryne Sandberg 3. Magic Johnson* 4. Mario Lemieux  Opportunistic Infections Organism CD4 Count Agent Pneumocystis < 200 cell/mm3 TMP/SMX Toxoplasma < 100 cell/mm3 TMP/SMX MAC* < 50 cell/mm3 Azithromycin * - Mycobacterium avium complex https://clinicalinfo.hiv.gov/en/guidelines Accessed Jan 5, 2024  HIV History Quiz ▪ What was the first drug approved for the treatment of HIV? 1. Zidovudine 2. Didanosine 3. Zalcitabine 4. Stavudine