HIV for the Internist!

Dr. Spencer mixed up Noon Report today and educated the VA residents about HIV, anti-retrovirals, and special health care maintenance needed for patients with HIV.

Screening for HIV is indicated at least once for all patients between ages 13 -65 (CDC and USPTF) and after any high risk behavior or exposure. For HIV screening, we start with the 4th generation Ag/Ab Immunoassay which becomes positive much more quickly than the traditional western blot.

 

Don’t forget that Antigen/Antibody positivity takes~17 days. If high clinical suspicion for acute HIV, get a HIV viral load/PCR.

If a patient comes in with a positive home POC test you should still start the algorithm at the beginning with Ag/Ab immunoassay.

 
 
 

 
 

NRTIs:

Tenofovir: side effects include renal dysfunction, osteoporosis

Abacavir: requires HLAB5701 testing due to risk of hypersensitivity reaction

Emtricitabine: side effects include dyslipidemia

NNRTIs:

induces CYP 2A which can interact with Keppra

Efavirenz: neuropsychiatric side effects

Rilpivirine: cannot be started when VL >100K; cannot use with PPI (requires acid for absorption)

Protease Inhibitors and Boosters (ritonavir, darunavir, atazanavir)

CYP inhibition:

  • can increase statin levels and cause myopathy and rhabdomyolysis

  • inihibit steroid metabolism which can cause iatrogenic Cushing’s

  • side effects include dyslipidemia

Integrase inhibitors (raltegravir, dolutegravir)

  • New data questioning potential for neural tube defects during pregnancy

  • Interacts with divalent cations (cannot take with Mg, Ca supplements)

Entry Inhibitors:

Maraviroc: requires tropism testing

Thanks Dr. Spencer!


References:

•Deeks SG, Lewin SR, Havlir DV. The end of AIDS: HIV infection as a chronic disease. Lancet. 2013;382(9903):1525–1533. doi:10.1016/S0140-6736(13)61809-7

•Branson BM et.al Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. 2006. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm