HIV Infection

They probably won’t ask you to manage an HIV patient’s antiretrovirals, but prophylaxis and medication side effects are fair game.

• Know that everyone with a diagnosis of HIV should get HAART, which is usually 2 NRTIs and an NNRT or a PI. It’s always at least 3 drugs.
• You should probably be able to identify which drugs are in which class (but you don’t need to know brand names).
  • Most  NRTIs end in “e” because they are “excellent” backbones for therapy, but there are a few popular outcasts (abacavir and tenofovir).
  • In general “VIR” is the middle of NNRTs and at the end of PIs (that’s not always true). I like to remember that PIs cause a lot of digestive problems, so they come out of your rear end (gross)

NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS   ABACAVIR AND  “–INE”’S	Abacavir                        Lamivudine   Didanosine                   Stavudine Emtricitabine               Zidovudine	RENAL ELIMINATION (except abacavir and zidovudine   ADE:  lactic acidosis, diarrhea, abd pain, n/v NO CLASS RESISTANCE
NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS   “-VIR-”	Efavirenz                        Nevirapine   Etravirine                       Rilpivirine Delavirdine	HEPATIC ELIMINATION (CYP3A4)   ADE:  Steven Johnsons CLASS RESISTANCE
NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITOR	Tenofovir	Renally filtered/actively secreted   ADE: GI, HA Good against strains resistant to other RTIs
PROTEASE INHIBITORS   “-VIR”	Atazanavir                    Nelfinavir   Darunavir                     Ritonavir Fosamprenavir            Saquinavir Indinavir                       Tipranavir Lopinavir/Ritonavir	HEPATIC ELIMINATION   ADE:  GI, lipodystrophy, lipid abnormalities, hyperglycemia, increased bleeding NOT CLASS RESISTANCE INTERACTS with:  antifungals, antimycobacterials, hormone contraceptives, -statins, anticonvulsants, methadone, Viagra
ENTRY INHIBITORS	Enfuvirtide                     Maraviroc
INTEGRASE INHIBITORS   “-GRAVIR”	Dolutegravir                 Raltegravir   Elvitegravir

Side effects:

Interacts with PPIs	Peripheral neuropathy	Sulfa	Anemia, leukopenia	Pancreatitis	Bone Marrow Suppression	Headache	Kidney Stones
Atazanavir	Lamivudine   Stavudine Didanosine	Darunavir   Tipranavir	Didanosine   Lamivudine Abacavir	Didanosine   Stavudine Lopinavir/ritonavir	Zidovudine	Lamivudine   Zidovudine	Indinavir

Prophlaxis

• If exposed, get baseline labs including HIV, HBV, and HCV testing.  HIV test will not test positive until 2-3 weeks after infection.  Treat within 72 hours of exposure.  Repeat testing at 6 weeks, 12 weeks and 6 months.
• Initiate therapy with 3 drugs ASAP and continue at least 4 weeks.
• Tenofovir 300 mg plus emtricitabine 200 mg is used for pre-exposure prophylaxis for existing sex partners.
• Occupational prophylaxis: if exposed, treat immediately and continue for 4 weeks. Usually use raltegravir PLUS tenofovir and emtricitabin.
• In pregnancy, use zidovudine.  Do not breast-feed for at least 6-12 weeks.  Do not delay treatment in pregnancy, but avoid EFV because of neural tube defects.
• Baby should be treated for 6 weeks (regimen for mother should be continued intrapartum with zidovudine infusion added)
• If mother did not receive ART during pregnancy, baby should have zidovudine for 6 weeks plus nevirapine at birth, 48 hours later, then 96 hours after 2^nd dose

Opportunistic Infections

There are 9 main infections. Not all need prophylaxis.

CD4 count in normal people is 500-1300.

• CD4 = 200 to 500
  • candidiasis:
    • Treatment: usually give nystatin or clotrimazole (mild) or fluconazole (severe) for 7 to 14 days.
• CD4=100-200
  • PJP (fungus)
    • Prophylaxis: Bactrim until CD4> 200, Dapsone in sulfa allergy
    • Treatment: Bactrim for 21 days
  • Histoplasmosis (fungus)
    • Prophylaxis: Prophylaxis until CD4 < 150 with itraconazole daily
    • Treatment: Liposomal amphotericin B for 4-6 weeks, then itraconazole for 12 months
  • PML
    • Treatment: Best treatment is ART, but cidofovir also
• CD4 = 50-100
  • Toxoplasmosis –
    • Prophylaxis: Bactrim daily
    • Treatment: pyrimethamine (add leucovorin to protect bone marrow) and sulfadiazine for 6 weeks or Bactrim for 6 weeks
  • Cryptosporidiosis
    • Treatment – ART is best in infected individuals, can use nitazoxanide in non-HIV infected
• CD4 < 50
  • Cryptococcus –
    • Prophylaxis: Usually not recommended
    • Treatment: fluconazole 200-400 mg daily. If severe, can use amphotericin B for 2 weeks, fluconazole for 10 weeks and flucytosine.  never give flucytosine alone.
  • MAC
    • Prophylaxis: azithromycin 1200 mg weekly or clarithromycin
    • Treatment: azithromycin and ethambutol
  • CMV
    • Treatment: ganciclovir only (acyclovir and valacyclovir ARE NOT OPTIONS).  Foscarnet if ANC < 500.
• If you have to guess, Bactrim is a good choice!