Transcript HIV Update and State of the Art

July 17, 2015
HIV Update and State of the Art
Christian Woods, MD
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Disclosures
• Speaker Bureau for Cubist Pharmaceuticals
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Objectives
• Brief review of advances in HIV medicine
• Brief review of the current epidemiology of HIV
• Brief review of advances in HIV prevention
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HIV Update and State of the Art
THE BASICS
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Co-Receptor
Inhibitors
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Fusion
Inhibitors
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Nucleoside
Reverse
Transcriptase
Inhibitors
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NonNucleoside
Reverse
Transcriptase
Inhibitors
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Integrase
Inhibitors
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Protease
Inhibitors
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Acute HIV
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Fever
Fatigue and Myalgia
Lymphadenopathy
Pharyngitis
(nonexudative)
Weight Loss
Headache
Nausea & Diarrhea
Rash (erythematous,
macular)
• Thrush
• Rarely Pneumocystis
• Aseptic Meningitis
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CDC HIV CLASSIFICATION SYSTEM
CD4 Criteria
• Stage 1: CD4 >500
• Stage 2: CD4 200-500
• Stage 3: CD4 <200
Symptom Criteria
• Stage A: Asymptomatic
• Stage B: B symptoms
• Stage C: AIDS Defining
Conditions
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CDC HIV CLASSIFICATION SYSTEM
CD4 Criteria
• Stage 1: CD4 >500
• Stage 2: CD4 200-500
• Stage 3: CD4 <200
Symptom Criteria
• Stage A: Asymptomatic
• Stage B: B symptoms
• Stage C: AIDS Defining
Conditions
• For example, a 21 year old man with CD4 150 and no
complications other than Thrush is stage B3
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Direct Viral Mediated End Organ Damage
• HIV Associated Nephropathy
– Focal Segmental Glomerulonephritis with Nephrotic
Range Proteinuria
– Rapid deterioration and progression to need for
Kidney Replacement Therapy
• HIV Associated Cardiomyopathy
– Manifests like other viral cardiomyopathies
– Can progress to need for ventricular assist device or
cardiac transplant
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Direct Viral Mediated End Organ Damage
• HIV Associated Dementia Complex
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Cognitive abnormalities
Can also manifest motor abnormalities
Psychiatric disturbance is not uncommon
Significant progressive functional impairment
• HIV Associated Minor Cognitive-Motor Disorder
– Minor impairments in attention, concentration,
memory, movement, coordination, memory,
personality change
– Often very slow to progress
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Direct Viral Mediated End Organ Damage
• Hematologic Injury
– Idiopathic Thrombocytopenic Purpura
– Thrombotic Thrombocytopenic Pupura
– Anemia, mild thrombocytopenia, relative leukopenia
not emergencies
• Nervous System
– Peripheral Neuropathy
– Vacuolar Myelopathy
• Musculoskeletal
– Myositis and Rhabdomyositis
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Direct Viral Mediated End Organ Damage
• Suppression of HIV with Antiretroviral therapy
can halt disease progression
• Only option in most (except ITP and TTP)
• Rapid initiation of antiretrovirals and suppression
of viral load is imperative to prevent disease
progression
• This is also true for the Opportunistic Infection
Progressive Multifocal Leukoencephalopathy
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Primary Prophylaxis in HIV
VACCINES
Opportunistic Infections
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• Pneumocystis/Toxoplasma
Pneumovax
Prevnar
Influenza
TDAP
Hepatitis A
Hepatitis B
Zostavax (CD4>200)
HPV Vaccine (age 13-26)
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CD4 <200/100
Bactrim (DS/SS, QD/TIW)
Dapsone 100 mg daily
Atovaquone 1500 mg daily
• MAC (CD4 <50)
– Azithromycin 1200 mg
Weekly/divided Twice Week
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Primary Prophylaxis in HIV
• Special Cases
– Residing in an area endemic for Histoplasmosis and
CD4<150: Itraconazole 200 mg daily
– Residing in an area endemic for Coccidioides and
CD4<250: Fluconazole 400 mg daily
– Residing in an area endemic for Penicilliosis and
CD4<100: Itraconazole 200 mg daily
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Endemic Areas for Coccidioidomycosis
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Endemic Areas for Histoplasmosis
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Endemic Areas for Penicilliosis
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TAKE HOME MESSAGES
• Mono-like illness: Consider Acute HIV
• Vaccinate: Prevnar, Pneumovax, Influenza
• Stage and Prophylax
– CD4 count < 200: Pneumocystis
– CD4 count <100: Toxoplasmosis
– CD4 count < 50: MAC
• End Organ Damage is an HIV Emergency
– HIVAN
– Dementia
– Cardiomyopathy
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A 28 year old African American man presents to
your clinic with complaints of 2 days of fever, night
sweats, and sore throat. He admits to accepting
money from men in exchange for unprotected sex
starting three months ago. Exam reveals thrush,
swollen cervical and inguinal lymph nodes, a flat
erythematous rash on his trunk. Which test is
most likely to be diagnostic right now?
A. HIV ELISA Antibody Test
B. Oraquick HIV Antibody Test
C. HIV Western Blot Test
D. HIV 4th Generation Antigen/Antibody Test
E. CD4 count
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A 28 year old African American man presents to
your clinic with complaints of 2 days of fever, night
sweats, and sore throat. He admits to accepting
money from men in exchange for unprotected sex
starting three months ago. Exam reveals thrush,
swollen cervical and inguinal lymph nodes, a flat
erythematous rash on his trunk. Which test is
most likely to be diagnostic right now?
A. HIV ELISA Antibody Test
B. Oraquick HIV Antibody Test
C. HIV Western Blot Test
D. HIV 4th Generation Antigen/Antibody Test
E. CD4 count
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Window Period
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HIV Update and State of the Art
HIV TESTING
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CDC HIV Testing Recommendations:
HIV screening is normal medical practice
• HIV screening is recommended for patients in
ALL health-care settings (opt-out screening) –
particularly pregnant women
• High Risk Persons should be screened annually
• Separate written consent should not be required
• Repeat screening should occur for pregnant
women in the 3rd trimester
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Terms
• High Risk (Expanded!!)
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IDU and their sex partners
Commercial sex workers
Partners of HIV infected persons
Men who have sex with men (MSM)
Persons who have had more than 1 sex partner since
their most recent HIV test (or their partners)
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Tests Available
• Antibody Tests (confirmatory WB required)
– Laboratory Blood Tests
– Rapid Blood Tests (multiple)
– Home Access/Express HIV-1 Test System using
fingersticks
– Home Rapid Tests (Oraquick, Orasure) using Saliva
• Western Blot (Confirmatory)
– Positive: 2 of the following – p24, gp41, gp120/160
– Indeterminate: any positive bands
– Negative: no positive Bands
• 4th Generation HIV Antibody/Antigen Tests
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4th Generation
• Architect HIV-1/2/O/M Ag/Ab Combo (Lab)
• Alere Determine HIV-1/2 Ag/Ab Combo (Rapid)
• Reflex testing
– Reflex to HIV1 and HIV 2 specific testing
– If either test is positive, then the patient has a positive
test for either HIV1 or HIV2 and no Western Blot
required
– If both negative then reflex to viral load testing
– If viral load test is positive, then patient has a positive
test and no Western Blot is required
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TAKE HOME MESSAGES
• All adults (and sexually active adolescents)
should be tested on entry into medical care
• Repeat annual testing in high risk groups (living
in DC is a high risk group – see next section!)
• Rapid Tests and Home Tests still need
confirmation
• 4th Gen Test will detect infection in the “Window
Period”
• Otherwise, use Nucleic Acid test to detect
infection in the “Window Period”
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Which of the following locations is estimated to
have a higher prevalence of HIV than the others
listed?
A. Ethiopia
B. Haiti
C. Guinea-Bissau
D. Washington, DC
E. Sierra Leone
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Which of the following locations is estimated to
have a higher prevalence of HIV than the others
listed?
A. Ethiopia (1.4 %)
B. Haiti (1.8%)
C. Guinea-Bissau (1.4%)
D. Washington, DC (2.7%)
E. Sierra Leone (1.6%)
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Which of the following locations is estimated to
have a higher prevalence of HIV than the others
listed?
Washington, DC (2.7%)
Swaziland (26%)
Mozambique (11.3%)
Botswana (23.4%)
Malawi (10%)
Lesotho (23.3%)
Uganda (7.2%)
South Africa (17.3%)
Kenya (6.2%)
Zimabwe (14.9%)
Tanzania (5.8%)
Nambia (13.4%)
Gabon (5%)
Zambia (12.5%)
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HIV Update and State of the Art
EPIDEMIOLOGY
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WHO Global summary of the AIDS epidemic 2011
Number of people
living with HIV
Total 34.0 million [31.4–35.9 million]
Adults 30.7 million [28.2–32.3 million]
Women 16.7 million [15.4–17.6 million]
Children (<15 years) 3.3 million [3.1–3.8 million]
People newly infected
with HIV in 2011
Total 2.5 million [2.2–2.8 million]
Adults 2.2 million [1.9–2.4 million]
Children (<15 years) 330 000 [280 000–390 000]
AIDS deaths in 2011
Total 1.7 million [1.5–1.9 million]
Adults 1.5 million [1.3–1.7 million]
Children (<15 years) 230 000 [200 000–270 000]
Adults and children estimated to be living with HIV  2011
Western &
Central Europe
Eastern Europe
& Central Asia
900 000
1.4 million
[830 000 – 1.0 million] [1.1 million – 1.8 million]
North America
1.4 million
East Asia
[1.1 million – 2.0 million]
830 000
Middle East & North Africa
Caribbean
230 000
[200 000 – 250 000]
Latin America
1.4 million
[1.1 million – 1.7 million]
[590 000 – 1.2 million]
300 000
[250 000 – 360 000]
South & South-East Asia
4.0 million
Sub-Saharan Africa
[3.1 million – 5.2 million]
23.5 million
[22.1 million – 24.8 million]
Oceania
53 000
[47 000 – 60 000]
Total: 34.0 million [31.4 million – 35.9 million]
Estimated adult and child deaths from AIDS  2011
Western &
Central Europe
Eastern Europe
& Central Asia
[6100 – 7500]
[63 000 – 120 000]
7000
North America
92 000
21 000
East Asia
[17 000 – 28 000]
59 000
Middle East & North Africa
Caribbean
10 000
[8200 – 12 000]
Latin America
54 000
[32 000 – 81 000]
[41 000 – 82 000]
23 000
[18 000 – 29 000]
South & South-East Asia
250 000
Sub-Saharan Africa
[190 000 – 340 000]
1.2 million
[1.1 million – 1.3 million]
Oceania
1300
[<1000 – 1800]
Total: 1.7 million [1.5 million – 1.9 million]
New HIV infections and AIDS-related deaths, 1990–2011
People
Globally new HIV infections peaked in 1997
4 500 000
4 000 000
3 500 000
3 000 000
2 500 000
2 000 000
1 500 000
1 000 000
500 000
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
New HIV infections
AIDS-related deaths
millions
People living with HIV, 1990–2011
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35
30
25
20
15
10
5
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
People living with HIV
Total number of people dying from AIDS-related causes in lowand middle-income countries, 1995–2011
3 000 000
Without antiretroviral therapy
2 500 000
With antiretroviral therapy
2 000 000
1 500 000
1 000 000
500 000
0
1995
1995 1996 1997 1998 1999 2000
2000 2001 2002 2003 2004 2005
2005 2006 2007 2008 2009 2010
2010 2011
District of Columbia
• Rate=2,704.3 people living with HIV per 100,000
population in DC at end 2011
• >2.7% of DC population HIV positive in 2011
• Caveats: DC is a city and statistics not
muted by a non-urban populations as in the
states
– However, DC still had the highest rate of any US
city
• DC DOH recommends annual HIV testing for all
residents 13-78 regardless of stated sexual
activity or risk group
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TAKE HOME POINTS
• MSM, African Americans still the hardest hit
• Safe Sex, Needle Exchange, Education
• DC has an epidemic rate comparable to countries in
Subsaharan Africa
• DC DOH recommends all residents aged 13-78 be
tested ANNUALLY for HIV
• In the US, HIV is not a death sentence – now a
survivable and manageable chronic disease
• Money and work required to make this true in
resource limited countries, like those in Subsaharan
Africa
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A 56 year old man with newly diagnosed HIV and
baseline resistance on genotype to non-nucleoside
reverse transcriptase drugs is recommended to
start antiretrovirals. After discussing different
regimens that are available to him, he settles on
Truvada & Ritonavir boosted Atazanavir. Which of
the following drugs can he continue to take?
A. Omeprazole 40 mg daily
B. Simvastatin 40 mg daily
C. Fluticasone nasal spray
D. Inhaled Salmeterol
E. Metoprolol
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A 56 year old man with newly diagnosed HIV and
baseline resistance on genotype to non-nucleoside
reverse transcriptase drugs is recommended to
start antiretrovirals. After discussing different
regimens that are available to him, he settles on
Truvada & Ritonavir boosted Atazanavir. Which of
the following drugs can he continue to take?
A. Omeprazole 40 mg daily
B. Simvastatin 40 mg daily
C. Fluticasone nasal spray
D. Inhaled Salmeterol
E. Metoprolol
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HIV Update and State of the Art
ANTIRETROVIRAL THERAPY
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Thinking about HIV
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1982 – What is it?
1985 – Incurable virus – why know?
1987 – Toxic therapy –
1993 – false hope of Duotherapy
1996 – HAART!! (angel choirs and bolts of glory)
2000 – Toxicity – delay therapy?
2004-2009 – Non-toxic therapies (Truvada,
Atazanavir, Darunavir, Raltegravir)
• 2011 – HPTN 052
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HPTN 052
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Community Viral Load
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NIH/USHHS Guidelines on HIV Treatment
• All HIV-infected patients are recommended to start
Antiretrovirals to prevent disease progression
– CD4<350 (AI)
– CD4 350-500 (AII)
– CD4 >500 (BIII)
• And to prevent transmission of disease
– Perinatal Transmission (AI)
– Heterosexual Transmission (AI)
– All other Transmission groups (AIII)
• Therapy can be deferred by provider or patient
based on clinical or social factors
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• NRTI
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Zidovudine
Lamivudine
Zalcitabine
Didanosine
Stavudine
Abacavir
Tenofovir
Emtricitabine
• NNRTI
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Delavirdine
Nevirapine
Efavirenz
Etravirine
Rilpivirine
• Fusion Inhibitor
• Protease Inhibitors
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Saquinavir
Indinavir
(Ritonavir)  boosting agent
Nelfinavir
Amprenavir  fos-Amprenavir
Lopinavir
Atazanavir
Tipranavir
Darunavir
• Co-Receptor Inhibitor
– Maraviroc
• Integrase Inhibitor
– Raltegravir
– Elvitegravir
– Dolutegravir
– Fuzeon
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Combination Pills
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Combivir (Zidovudine/Lamivudine)
Epzicom (Lamivudine/Abacavir)
Trizivir (Zidovudine/Lamivudine/Abacavir)
Truvada (Tenofovir/Emtricitabine)
Atripla (Tenofovir/Emtricitabine/Efavirenz)
Complera (Tenofovir/Emtricitabine/Rilpivirine)
Kaletra (Ritonavir/Lopinavir)
Stribild (Tenofovir/Emtricitabine/Cobicistat/
Elvitegravir)
• Triumeq (Dolutegravir/Abacavir/Lamivudine)
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Highly Active Antiretroviral Therapy
(HAART)
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1 agent insufficient to suppress viral replication
Combination therapy potent enough
2NRTI “backbone” PLUS
1 potent agent (PI, NNRTI, Integrase Inhibitor)
Resistance  Salvage regimens
Also called Potent AntiRetroviral Therapy
(PART), Combination AntiRetroviral Therapy
(CART)
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Resistance
• Highly Error Prone Reverse Transcriptase
– 1 mutation produced per genome copied
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Viral Turnover rate: 1x109 particles/day
Mutation Rate * Turnover Rate/# of basepairs
Mutation at every genome position every day
Drug resistance archived
Fitness Cost=Reversion to wildtype
Genotype testing unreliable absent selection
pressure
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Resistance
• Risk
– Drug pressure (taking drugs)
– Viral Replication (poor adherence/poor drug selection)
• Consequences: multi-drug resistance
• Lessons
– Simplest regimen=better compliance=less resistance
– Close monitoring to ensure viral suppression
– Compliance to visits and education
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Starting Regimens
• Only start with referral to an expert
• Never start without appropriate testing –
– HIV Genotype
– HBV Serologies (co-treatment)
– HLAB5701
• Always assess potential side effects and fit
regimen to patient profile – comorbidities, drug
interactions, lifestyle preferences
• Always review adherence strategies with the
patient
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Starting Regimens
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Atripla
Complera
Stribild
Epzicom/Efavirenz
Truvada OR Epzicom + Ritonavir/Atazanavir
Truvada OR Epzixom +Ritonavir/Darunavir
Truvada Raltegravir
Combivir or Truvada or Epzicom + Kaletra
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Important Side Effects
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NRTIs: peripheral neuropathy, lipoatrophy
Zidovudine – headache, asthenia, anemia
Didanosine – pancreatitis, neuropathy
Stavudine – lactic acidosis, neuropathy
Tenofovir – Fanconi Syndrome
NNRTIS: rash, TEN, Stevens Johnson
Nevirapine – liver failure
Efavirenz – drowsiness, vivid dreams,
depression
• Rilpivirine -- depression
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Important Side Effects
• Protease Inhibitors: Hyperlipidemia,
lipodystrophy, hyperglycemia, diarrhea, nausea
• Atazanavir: nephrolithiasis, prolonged QT,
benign asymptomatic hyperbilirubinemia
• Tipranavir: Intracerebral hemorrhage
• Integrase Inhibitors: myositis
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Some Interactions
• Oral contraceptives
• HMG Co-A Reductase (least with rosuvastatin
and atorvastain)
• Steroids (avoid fluticasone, beclomethasone
preferred)
• Salmeterol
• Psychiatric medications
• Anticonvulsants
• Antifungals
• Proton Pump Inhibitors (Atazanavir, Rilpivirine)
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TAKE HOME POINTS
• All patients encouraged to start therapy to
prevent opportunistic infections, malignancy, and
to decrease community viral load
• Resistance is a problem – continuous monitoring
necessary
• Do not refill HIV meds if patients are not making
their follow ups with their HIV provider
• Look out for drug interactions
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A 26 year old HIV negative man who is nonmonogamously partnered with an HIV positive
man on antiretroviral therapy asks you if there is a
drug he can take to reduce his risk of getting HIV.
What do you tell him?
A. Safe sex is the only prevention available
B. Truvada has had success but needs close
monitoring and compliance
C. The best option for him is abstinence
D. Combivir and Kaletra has had success with
close monitoring and compliance
E. This therapy has only had success in IDU
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A 26 year old man with male who is nonmonogamously partnered with an HIV positive
man on antiretroviral therapy asks you if there is a
drug he can take to reduce his risk of getting HIV.
What do you tell him?
A. Safe sex is the only prevention available
B. Truvada has had success but needs close
monitoring and compliance
C. The best option for him is abstinence
D. Combivir and Kaletra has had success with
close monitoring and compliance
E. This therapy has only had success in IDU
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HIV Update and State of the Art
PRE AND POST EXPOSURE
PROPHYLAXIS
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Occupational Exposures
• Sep 2013 - New guidelines from USDPHHS in
Infection Control & Hospital Epidemiology
• Source: body fluids from infected or high risk
patients (blood, semen, vaginal secretions, CSF,
synovial, pleural, peritoneal, pericardial,
amniotic)
• Excludes: feces, urine, saliva, emesis
• Exposures: Percutaneous injury, mucous
membrane, non-intact skin
• Risk: 0.3% percutaneous blood, 0.09% mucous
membrane
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PEP Regimens
• Timing: within 72 hours of exposure for 4 weeks
• No 2 vs. 3 drug regimens based on risk – just 3
drugs!
• Preferred: Truvada Raltegravir
• Alternatives
– Fixed dose single agent: Stribild  OR
– Combine: Raltegravir, Ritonavir/Darunavir, Etravirine,
Rilpivirine, Ritonavir/Atazanavir, Kaletra
– With: Truvada, Combivir,
– Others: only with expert ID consultation
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PEP Regimens
• Follow Up
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BASELINE: HIV test, CBC, CMP, counseling
2 weeks: CBC, CMP, counseling
6 wks: HIV Test, counseling
3 months: HIV Test
6 months: HIV Test
• If 4th Generation HIV Test is used
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BASELINE: HIV test, CBC, CMP, counseling
2 weeks: CBC, CMP, counseling
6 wks: HIV Test, counseling
4 months: HIV Test
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nPEP
• 2005 CDC initiated guidelines
• Criteria for nPEP
– <72 hours from exposure
– Source patient HIV positive or unknown
– Substantial exposure risk
• Substance: Blood, Semen, Vaginal Secretions, Rectal
Secretions, Breast Milk
• Exposure: Vagina, Rectum, Eye, Mouth, Other Mucous
Membrane, Non-Intact Skin, Percutaneous Injury/Contact
• No Risk: urine, nasal secretions, saliva, sweat, tears
– Previous Recommendations PI based
– Now most moving to PEP drugs
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PrEP
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•
•
•
Pre-Exposure Prophylaxis
Truvada approved by FDA for PrEP in 2012
Recommended by CDC in 2012
Evidence
– iPrEx (in HIV negative US MSM)
– Partners PrEP (in serodiscordant heterosexual
couples in Kenya and Uganda)
– The Bangkok Tenofovir Study (in IDU)
– No significant adverse events
– Success predicated on close monitoring, risk
reduction counseling, and compliance
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iPrEx
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Partners PrEP
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The Bangkok Tenofovir Study
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PrEP Guidelines
• Eligibility:
– Baseline HIV negative
– High Risk
• MSM
• Multiple partners
• Commercial Sex
Workers
• Not using condoms
• IDU
• Partner is HIV positive
• Discordant couple
trying to conceive
• Baseline Testing
– Renal Function
– Hepatitis B status (if
positive can treat as
part of HBV therapy)
– Pregnancy Test
– Pregnant: counsel on
lack of data
• Counseling
– Risk Reduction!
– Adherence!
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PrEP Guidelines
• Follow Up
– No more than 90 day prescription and no automatic
refills
– Every 2-3 months: HIV 4th gen test and pregnancy
test, adherence education
– At 3 months then every 6 months thereafter: Renal
Function, HBV screen, STD Screening
• Discontinuation
– Screen for pregnancy, HIV, HBV
– If positive, linkage to care for appropriate therapy
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TAKE HOME POINTS
• PEP now much more simple
– Truvada Raltegravir is recommended regimen
– The sooner you start the better
• Truvada can be used for PrEP
– High risk populations (MSM, commercial sex workers,
HIV negatives in serodiscordant couples, IVDU)
– Concomitant risk reduction counseling
– Close monitoring required for safety and success
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HIV Update and State of the Art
HIV CARE AT MWHC
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HIV Care at MWHC
• Section of Infectious Diseases
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–
–
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Glenn Wortmann, Section Chief, PD
Maria Ruiz, Assistant Chief, IRB Chair
Leon L. Lai, Ryan White Program Director, APD
Christian Woods, (Pulm Crit Care), APD
Dawn Fishbein, Viral Hepatitides
Faria Farhat
Joe Kovacs and Caryn Morse from the NIH
4 MWHC ID Fellows
2 NIH ID Fellows
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HIV Care at MWHC
• HRSA Ryan White Part
C and D Supported
– Jasmine Reid, RN,
Program Coordinator
– Chizoba Anako, NP and
Women’s Health Liaison
– Allison Daly, Case Manager and Medication Educator
– Antonio Pineda, Treatment Navigator
– Patricia Bauza, MD, Psychiatry
– Allen Zemon, PhD, Psychology
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HIV Care at MWHC
• Outpatient Services
• Inpatients with HIV
• HIV and pregnancy
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TAKE HOME POINTS
• Call us if you have any questions!
– Chris Woods, MD at 202-877-7164
• Outpatients –
– Ryan White Intake: 202-877-7412
– Appointments: 202-877-0333
• Pregnancy and HIV is an emergency!
– Contact NP Anako at 202-877-7164
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July 17, 2015
Selected References
Baeten JM et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. NEJM 2012. 367(5):
399.
Choopanya K et al. Antiretroviral prophylaxis for HIV ifnection in injecting drug users in Bangkok, Thailand (the
Bangkok Tenofovir Study): a randomised, double-blind, placebo-controlled phase 3 trial. Lancet 2013. 381:2083.
Cohen MS et al. Prevention of HIV-1 infection with early antiretroviral therapy. NEJM 2011. 365(6): 493.
Das, M et al. Decreases in community viral load are accompanied by reductions in new HIV infections in San
Francisco. PLoS One 2010. 5(6):e11068.
Grant RM et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. NEJM 2010.
363(27): 2587.
Kuhar DT et al. Updated US Public Health Service guidelines for the management of occupational exposures to
Human Immunodeficiency Virus and recommendations for post-exposure prophylaxis. Infection Control and
Hospital Epidemiology, 2013. 34(9):875.
Panel on the Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV1 infected adults and adolescents. Department of Health and Human Services. February 12, 2013.
Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment
of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease
Control and Prevention, the National institutes of Health, and the HIV Medicine Association of the Infectious
Diseases Society of America. July 8, 2013.
Smith DK et al. Update to interim guidance for preexposure prophylaxis for the prevention of HIV Infection. MMWR
2013. 62(23):463.
Strategic Information System, HAHSTA, DC Department of Health. Annual Epidemiology and Surveillance Report,
2011.
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104
July 17, 2015
Post-Test Question 1
A 68 year old male resident of DC comes to you
for care of his hypertension, hyperlipidemia, and
diet controlled diabetes. He lives with his wife,
daughter, and twin grandchildren. He says he is
monogamous, is a prior smoker, and never used
drugs. Which is not a routine part of his care?
A. Flu shot
B. HIV Test
C. Abdominal Ultrasound
D. Hemoglobin A1C
E. PSA
105
July 17, 2015
Post-Test Question 1
A 68 year old male resident of DC comes to you
for care of his hypertension, hyperlipidemia, and
diet controlled diabetes. He lives with his wife,
daughter, and twin grandchildren. He says he is
monogamous, is a prior smoker, and never used
drugs. Which is not a routine part of his care?
A. Flu shot
B. HIV Test
C. Abdominal Ultrasound
D. Hemoglobin A1C
E. PSA
106
July 17, 2015
Post-Test Question 1
A. Flu shot – recommended yearly for patients
over 65 years of age and with HIV
B. HIV Test – recommended yearly in all DC
residents
C. Abdominal Ultrasound – recommended once in
men over the age of 65 in all smokers or
previous smokers
D. Hemoglobin A1C – recommended every 6
months in patients with diabetes
E. PSA – no longer recommended screening
except in high risk men
July 17, 2015
107
Post-Test Question 2
A 32 year old HIV negative old woman who is the
partner of a 36 year old man with HIV well
controlled for 10 years on antiretroviral therapy
wishes to conceive. They cannot afford sperm
washing. How do you advise her?
A. They can use a turkey baster to decrease risk
B. The risks of pregnancy are too high
C. He is undetectable on his meds, so there is no
risk
D. She can take PrEP to reduce her risk
E. They should use an HIV positive surrogacy
program
July 17, 2015
108
Post-Test Question 2
A 32 year old HIV negative old woman who is the
partner of a 36 year old man with HIV well
controlled for 10 years on antiretroviral therapy
wishes to conceive. They cannot afford sperm
washing. How do you advise her?
A. They can use a turkey baster to decrease risk
B. The risks of pregnancy are too high
C. He is undetectable on his meds, so there is no
risk
D. She can take PrEP to reduce her risk
E. They should use an HIV positive surrogacy
program
July 17, 2015
109
Post-Test Question 2
A. They can use a turkey baster to decrease risk –
does not reduce risk from HIV infected semen
B. The risks of pregnancy are too high – untrue –
successful pregnancy in HIV is quite possible
with appropriate care and counseling
C. He is undetectable on his meds, so there is no
risk – risk is greatly reduced but data is unclear
if there is NO risk
D. She can take PrEP to reduce her risk – true,
and part of CDC PrEP guidelines
E. They should use an HIV positive surrogacy
program – this does not exist
July 17, 2015
110
Post-Test Question 3
A 48 year old woman with HIV, seasonal allergies,
asthma, hypertension, dyspepsia, and coronary
artery disease comes to your clinic for a routine
checkup. Her med list includes Truvada, Ritonavir,
Atazanavir, Inhaled Beclomethasone, Advair
(Fluticasone/ Salmeterol), Metoprolol, and Aspirin.
Which is causing an interaction?
A. Aspirin
B. Advair
C. Beclomethasone
D. Metoprolol
July 17, 2015
111
Post-Test Question 3
A 48 year old woman with HIV, seasonal allergies,
asthma, hypertension, dyspepsia, and coronary
artery disease comes to your clinic for a routine
checkup. Her med list includes Truvada, Ritonavir,
Atazanavir, Inhaled Beclomethasone, Advair
(Fluticasone/ Salmeterol), Metoprolol, and Aspirin.
Which is causing an interaction?
A. Aspirin
B. Advair
C. Beclomethasone
D. Metoprolol
July 17, 2015
112
Post-Test Question 3
A. Aspirin - there is no interaction
B. Advair – both fluticasone and salmeterol,
components of Advair, have significant
interactions with protease inhibitors
C. Beclomethasone – this is the preferred steroid
to use in inhaled and intranasal preparations
when a patient is on protease inhibitors
D. Metoprolol - there is no interaction
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July 17, 2015
Post-Test Question 4
A 26 year old man with HIV returns to care after 18
months. His viral load was undetectable on Atripla
but he says he has been off medicines for over a
year. You obtain a genotype and there is no
resistance. Which is true?
A. He may still harbor hidden resistance
B. Resistance to Atripla is rare
C. Once a resistant virus reverts to wildtype, it
becomes sensitive to drug again
D. The resistance test needs to be repeated again
before starting new medications
July 17, 2015
114
Post-Test Question 4
A 26 year old man with HIV returns to care after 18
months. His viral load was undetectable on Atripla
but he says he has been off medicines for over a
year. You obtain a genotype and there is no
resistance. Which is true?
A. He may still harbor hidden resistance
B. Resistance to Atripla is rare
C. Once a resistant virus reverts to wildtype, it
becomes sensitive to drug again
D. The resistance test needs to be repeated again
before starting new medications
July 17, 2015
115
Post-Test Question 4
A. He may still harbor hidden resistance – Resistance
is archived in memory T cells, but may not be the
dominant virus in a patient absent drug pressure –
thus genotypic testing off therapy can be unreliable
B. Resistance to Atripla is rare – The most common
mutations, M184V and K103N are induced by
atripla
C. Once a resistant virus reverts to wildtype, it
becomes sensitive to drug again – false – the
resistant mutant is archived and will re-emerge with
sufficient drug pressure
D. The resistance test needs to be repeated again
before starting new medications – false, resistance
test should be repeated after restarting HIV
medications if there is an inappropriate response
July 17, 2015
116
Post-Test Question 5
A 32 year old previously healthy man residing in
New Orleans presents to his physician with a
chancre. RPR is positive, HIV is positive, CD4
count is 18. He is treated for syphilis. Which of
the following is not indicated?
A. Bactrim DS daily
B. Azithromycin 1200 mg weekly
C. Fluconazole 200 mg daily
D. Itraconazole 200 mg daily
E. Pneumovax
117
July 17, 2015
Post-Test Question 5
A 32 year old previously healthy man residing in
New Orleans presents to his physician with a
chancre. RPR is positive, HIV is positive, CD4
count is 18. He is treated for syphilis. Which of
the following is not indicated?
A. Bactrim DS daily
B. Azithromycin 1200 mg weekly
C. Fluconazole 200 mg daily
D. Itraconazole 200 mg daily
E. Pneumovax
118
July 17, 2015
Post-Test Question 5
A. Bactrim DS daily – indicated for CD4 count
<200
B. Azithromycin 1200 mg weekly – indicated for
CD4 count <50
C. Fluconazole 200 mg daily – not indicated in a
patient without persistent candidasis or at risk
for Coccidioides imitis
D. Itraconazole 200 mg daily – indicated for a
patient with CD4 <150 residing in area endemic
for Histoplasmosis (New Orleans)
E. Pneumovax – indicated in all HIV patients
July 17, 2015
119
Post-Test Question 6
You see a 36 year old woman with well controlled
HIV on Truvada, Ritonavir, and Atazanavir. She is
asymptomatic except for icterus. Viral Load is <20
copies/ml, CD4=565, and Total Bilirubin is 2.3.
Which of the following is true?
A. Abdominal Ultrasound should be done
B. Antiretrovirals should be held
C. Antiretrovirals should continue unless the
icterus is intolerable to her
D. Cholecystectomy for acalculous cholecystitis is
the next step
July 17, 2015
120
Post-Test Question 6
You see a 36 year old woman with well controlled
HIV on Truvada, Ritonavir, and Atazanavir. She is
asymptomatic except for icterus. Viral Load is <20
copies/ml, CD4=565, and Total Bilirubin is 2.3.
Which of the following is true?
A. Abdominal Ultrasound should be done
B. Antiretrovirals should be held
C. Antiretrovirals should continue unless the
icterus is intolerable to her
D. Cholecystectomy for acalculous cholecystitis is
the next step
July 17, 2015
121
Post-Test Question 6
A. Abdominal Ultrasound should be done –
B. Antiretrovirals should be held
C. Antiretrovirals should continue unless the
icterus is intolerable to her – Atazanavir
induces a benign moderate hyperbilirubinemia
that does not require cessation of therapy or
any other intervention absent patient
dissatisfaction with cosmetic effects of icterus.
Severe hyperbilirubinemia warrants further
workup and consideration for change in therapy
D. Cholecystectomy for acalculous cholecystitis is
the next step
July 17, 2015
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