HIV & ART General Concepts

HIV/AIDS and ART – Joseph Quintana

 

Background

  • Why is ART important?
    • Clear morbidity and mortality benefits across all CD4 counts
    • Decreases subsequent infections (both common and opportunistic)
    • Decreased HIV related comorbid conditions and viral reservoirs
    • Reduced HIV transmission
    • Long term improvement in immune cell function and activation
    • Most patients will have their care at Comprehensive care clinic (CCC), the Vanderbilt HIV clinic, and these clinicians staff Rogers ID and HIV consult service
  • New HIV Diagnosis
    • ID consult (important for initiation, follow up [CCC], social work assistance)
    • ART is indicated for all HIV+ patients, regardless of CD4; however, starting ART requires appropriate outpatient follow up
    • Lab evaluation:
    • HIV viral load, genotype and resistance testing
    • T cell subsets (CD4 Count)
    • HLA*B5701 testing before using abacavir containing regimen
    • CBC with differential, CMP, UA
    • T-Spot
    • Pregnancy testing
    • Viral hepatitis serologies
    • Toxoplasma serologies
    • Other STI screening (Syphilis, Gonorrhea/chlamydia)
  • Timing of ART initiation
    • Engage ID, address social barriers, baseline laboratory evaluation, arrange follow up
    • Factors affecting timing
      • Drug toxicity and interactions, risks for resistance, adherence
      • Barriers to medication adherence (homelessness, substance use disorder, behavioral health diagnosis)
      • Treatment of opportunistic infections may delay initiation of ART given associated risk of immune reconstitution inflammatory syndrome (IRIS)
      • Delay ART for several weeks after initiation of therapy for cryptococcal meningitis, in which IRIS can be fatal
  • ART plan for overnight admits
    • Okay to continue home ART, special consideration for:
      • Pts with hepatic or renal dysfunction, may need dose adjustment
      • If there is concern for non-adherence, can hold morning dose
      • Can be discussed with ID/outpt provider in the morning
      • Combination pills may need to be ordered as the separate components
  • Common key regimens for initiation
    • Most regimens consist of an NRTI backbone (2 agents) plus a 3rd agent
    • Many patients are started on combination pill regimens, including Integrase Inhibitor based regimens: Biktarvy®, Triumeq®, dolutegravir + Descovy®
      • Dolutegravir and bictegravir have high barriers to resistance relative to first-generation integrase inhibitors elvitegravir and raltegravir