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
- Okay to continue home ART, special consideration for:
- 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
- Dolutegravir and bictegravir have high barriers to resistance relative to first-generation integrase inhibitors elvitegravir and raltegravir