December 6, 2021: Switching Antiretroviral Therapy After Nucleotide Reverse Transcriptase Inhibitor and Nonnucleoside Reverse Transcriptase Inhibitor Mutations

Previous Questions

Responses
A. Start postexposure prophylaxis (PEP) 11% (60)
B. Check HIV viral load and start PrEP today 49% (261)
C. Check HIV viral load and delay starting PrEP 37% (197)
D. Start 3-drug antiretroviral treatment twice daily 3% (16)
  • A. Start postexposure prophylaxis (PEP)
  • B. Check HIV viral load and start PrEP today
  • C. Check HIV viral load and delay starting PrEP
  • D. Start 3-drug antiretroviral treatment twice daily

Correct answer is B. This patient has been off PrEP for several months, and he reports ongoing potential HIV exposures. He has some symptoms concerning for possible acute HIV (chills, subjective fevers, sore throat), but he has a cough and several sick contacts, which is suggestive of a respiratory infection. The rapid HIV test has a longer window period, so he would be false negative in the setting of acute HIV infection. It would be important to evaluate for acute HIV, and restarting PrEP would be reasonable given the symptoms are most consistent with an upper respiratory infection.

For more information, click the Watch Webcast button below to view the presentation, “Assessing and Monitoring Persons Interested in Starting and Continuing PrEP”, presented by Hyman Scott, MD, MPH, at the November 19, 2021, virtual course, PrEParing for PrEP: From Policy to Implementation.

Responses
A. Raltegravir 1200 mg daily 16% (90)
B. Bictegravir 50 mg daily 14% (83)
C. Lopinavir 400 mg/ritonavir 100 mg twice daily 10% (58)
D. Efavirenz 600 mg daily 60% (342)
  • A. Raltegravir 1200 mg daily
  • B. Bictegravir 50 mg daily
  • C. Lopinavir 400 mg/ritonavir 100 mg twice daily
  • D. Efavirenz 600 mg daily

Correct answer is D. Standard TB treatment includes rifampin, so multiple drug-drug interactions are possible. Raltegravir should be dosed at 800 mg twice daily; single daily dosing results in unacceptable decreases in concentration. Bictegravir and lopinavir/ritonavir should not be coadministered because of large decreases in antiretroviral concentrations. In contrast, rifampin only leads to modest reduction in efavirenz concentrations at most, so no dose adjustment is needed.

For more information, click the Watch Webinar button below to view the presentation, Update on Tuberculosis/HIV Coinfection: Across the Spectrum From Latent Infection Through Drug-Susceptible and Drug-Resistant Disease, presented by Susan Swindells, MBBS, on November 16, 2021.

Responses
A. A 40-year-old smoker with a 15-pack-year history 19% (148)
B. A 60-year-old with a 40-pack-year history and no other pulmonary issues 40% (309)
C. A 55-year-old with a 35-pack-year history and complaints of chronic cough with occasional hemoptysis 35% (273)
D. A 70-year-old with a 30-pack-year history who quit smoking 20 years prior 6% (50)
  • A. A 40-year-old smoker with a 15-pack-year history
  • B. A 60-year-old with a 40-pack-year history and no other pulmonary issues
  • C. A 55-year-old with a 35-pack-year history and complaints of chronic cough with occasional hemoptysis
  • D. A 70-year-old with a 30-pack-year history who quit smoking 20 years prior

Correct answer is B. The USPSTF screening recommendations are for people 50- to 80-years-old with a history of at least 20-pack-years, who are current smokers or have quit within the past 15 years, and currently have no signs of lung cancer.

For more information, click the Watch On-Demand Session button below to view the presentation, “Non-AIDS Cancers,” presented by Timothy J. Wilkin, MD, on October 5, 2021, for the Ryan White HIV/AIDS Program CLINICAL CONFERENCE.

Responses
A. The drug inhibits HIV replication via 2 different mechanisms making resistance less likely 57% (369)
B. The drug obtains high levels in plasma that are maintained over time 12% (81)
C. The drug has a long intracellular half-life 21% (135)
D. None of the above 10% (65)
  • A. The drug inhibits HIV replication via 2 different mechanisms making resistance less likely
  • B. The drug obtains high levels in plasma that are maintained over time
  • C. The drug has a long intracellular half-life
  • D. None of the above

Correct answer is A. Islatravir has a dual mechanism of action, inhibiting translocation and chain termination. These properties are expected make it more difficult for resistant viruses to emerge with this antiretroviral drug.

For more information, click the Watch On-Demand Session button below to view the presentation, “New and Investigational ART Drugs and Strategies,” presented by Judith S. Currier, MD, on October 3, 2021, for the Ryan White HIV/AIDS Program CLINICAL CONFERENCE.

Responses
A. Oral absorption of integrase strand transfer inhibitors is significantly reduced by polyvalent cations such as aluminum, calcium, magnesium, iron, and zinc 13% (131)
B. Potent enzyme and transporter inducers reduce cabotegravir/rilpivirine exposures when cabotegravir/rilpivirine is given orally, but not when given intramuscularly 43% (417)
C. Several antiretroviral drugs inhibit membrane transporters resulting in higher exposures of transporter substrates 25% (243)
D. Iatrogenic Cushing’s syndrome may occur when inhaled, intra-nasal, intraarticular, or ocular corticosteroids are used in people with HIV on antiretroviral regimens that contain ritonavir or cobicistat 19% (182)
  • A. Oral absorption of integrase strand transfer inhibitors is significantly reduced by polyvalent cations such as aluminum, calcium, magnesium, iron, and zinc
  • B. Potent enzyme and transporter inducers reduce cabotegravir/rilpivirine exposures when cabotegravir/rilpivirine is given orally, but not when given intramuscularly
  • C. Several antiretroviral drugs inhibit membrane transporters resulting in higher exposures of transporter substrates
  • D. Iatrogenic Cushing’s syndrome may occur when inhaled, intra-nasal, intraarticular, or ocular corticosteroids are used in people with HIV on antiretroviral regimens that contain ritonavir or cobicistat

Correct answer is B. Potent enzyme and transporter inducers reduce cabotegravir/rilpivirine exposures both when given orally and when administered intramuscularly.

For more information, click the Watch On-Demand Session button below to view the presentation, “Managing Polypharmacy and Drug-Drug Interactions,” presented by Jennifer J. Kiser, PharmD, PhD, on October 4, 2021, for the Ryan White HIV/AIDS Program CLINICAL CONFERENCE.

Responses
A. Trichomonas can cause urethritis in men who have sex with other men, likely acquired through receptive anal intercourse 16% (107)
B. N. meningitidis has a similar colony morphology appearance on culture and cannot be distinguished from N. gonorrhoeae on Gram stain 27% (178)
C. Herpes simplex virus (HSV)-2 is a more common etiology of urethritis than HSV-1 6% (39)
D. M. genitalium urethritis has been associated with chronic complications among men, including epididymitis, prostatitis, or infertility 51% (339)
  • A. Trichomonas can cause urethritis in men who have sex with other men, likely acquired through receptive anal intercourse
  • B. N. meningitidis has a similar colony morphology appearance on culture and cannot be distinguished from N. gonorrhoeae on Gram stai
  • C. Herpes simplex virus (HSV)-2 is a more common etiology of urethritis than HSV-1
  • D. M. genitalium urethritis has been associated with chronic complications among men, including epididymitis, prostatitis, or infertility

Correct answer is B. N. meningitidis has a similar colony morphology appearance on culture and cannot be distinguished from N. gonorrhoeae on Gram stain.

T. vaginalis can cause urethritis among heterosexual men. However, the prevalence varies substantially by US geographic region, age, sexual behavior, and within specific populations.

N. meningitidis has similar colony morphology appearance on culture and cannot be distinguished from N. gonorrhoeae on Gram stain. Identification of N. meningitidis as the etiologic agent with presumed gonococcal urethritis on the basis of Gram stain but negative nucleic acid amplification testing (NAAT) for gonorrhea requires a confirmation by culture. Meningococcal urethritis is treated with the same antimicrobial regimens as gonococcal urethritis.

Nongonococcal urethritis (NGU) can be caused by herpes simplex virus, Epstein-Barr virus, or adenovirus acquired by oral-penile contact. Herpes simplex virus (HSV)-1 infections are usually the most common and may be associated with meatitis or genital ulcerations.

Associations between urethritis and insertive anal and oral exposure among heterosexual men with urethritis have been reported with Leptotrichia or Sneathia species. These studies increase concern for possible undetected infectious rectal or vaginal pathogens, or alternatively, a transient reactive dysbiosis after exposure to a new microbiome or even a noninfectious reactive etiology.

Data are insufficient to implicate M. genitalium infection with chronic complications among men, including epididymitis, prostatitis, or infertility.

For more information, click the Watch Webinar button below to view the presentation, “Exploration of the Latest Update to the Sexually Transmitted Infection (STI) Treatment Guidelines,” presented by Kimberly A. Workowski, MD, on October 19, 2021.

Responses
A. Inflammation 7% (90)
B. Metabolism of antiretroviral drugs 29% (354)
C. C. difficile infection 59% (717)
D. Epithelial barrier damage 5% (60)
  • A. Inflammation
  • B. Metabolism of antiretroviral drugs
  • C. C. difficile infection
  • D. Epithelial barrier damage

Correct answer is C. Inflammation, metabolism of antiretroviral drugs, and epithelial barrier damage have been shown to increase HIV transmission. Although C. difficile infection has been associated with and has been shown in some studies to increase HIV pathogenesis, it has never been shown to increase HIV transmission.

For more information, click the Watch Webinar button below to view the webinar, “The Role of the Microbiome in Modulation of Inflammation and Impact on Disease in HIV and COVID-19,” presented by Nichole Klatt, PhD, on July 27, 2021.

Responses
A. Increased weight 28% (340)
B. Lower CD4+ count 34% (408)
C. Mood disturbance 4% (47)
D. HIV disease progression 19% (222)
E. Increased cardiovascular mortality 15%(176)
  • A. Increased weight
  • B. Lower CD4+ count
  • C. Mood disturbance
  • D. HIV disease progression
  • E. Increased cardiovascular mortality

Correct answer is A. There are studies that suggest poor sleep in people with HIV is associated with a lower CD4+ count, HIV disease progression, increased cardiovascular mortality, and mood disturbance. However, it is not evident that increased weight is associated with poor sleep in people with HIV.

To learn more about sleep disorders in people with HIV, click the Watch Webinar button below to view the webinar, “Sleep Disorders and Sleep Assessment in People with HIV,” presented by Ana C. Krieger, MD, MPH, on September 21, 2021.

Responses
A. Azithromycin 1 g orally once 11% (66)
B. Azithromycin 1 g orally once a week for 3 consecutive weeks 4% (22)
C. Ceftriaxone 500 mg intramuscularly once 5% (32)
D. Doxycycline 100 mg orally twice daily for 1 week 28% (171)
E. Doxycycline 100 mg orally twice daily for 3 weeks 52%(315)
  • A. Azithromycin 1 g orally once
  • B. Azithromycin 1 g orally once a week for 3 consecutive weeks
  • C. Ceftriaxone 500 mg intramuscularly once
  • D. Doxycycline 100 mg orally twice daily for 1 week
  • E. Doxycycline 100 mg orally twice daily for 3 weeks

Correct answer is E. This patient has Chlamydia trachomatis proctitis, which may be caused by the D-K serovars or the lymphogranuloma venereum (LGV) serovars. There is no way to know because additional testing to determine the serovar is not available. The best antibiotic to treat chlamydia proctitis is doxycycline. The treatment duration depends on symptoms when LGV testing is not available. For mild symptoms, 1 week of doxycycline is sufficient. For severe symptoms, 3 weeks is necessary. The patient has severe symptoms of proctitis, and she would need a 3-week course of therapy.

The 2021 CDC STI screening recommendations can be read on the CDC website.

Dr Khalil G. Ghanem will give an in-depth update on STIs and HIV in a presentation titled, “Diagnosing and Managing Sexually Transmitted Infections,” which will be available for on-demand viewing approximately 2 weeks following the virtual Ryan White HIV/AIDS CLINICAL CONFERENCE.

Which statement is true regarding screening or treatment of hyperlipidemia in people with HIV?

Responses
A. A CD4+ count of less than 200 cells/µL is as strong a risk factor for cardiovascular disease as hypertension 10% (141)
B. All people with HIV should be on a statin, regardless of low-density lipoprotein (LDL) cholesterol level 4% (64)
C. Lovastatin and simvastatin are preferred statins with protease inhibitors 7% (101)
D. Prolonged HIV viremia increases cardiovascular risk, requiring adjustment of risk calculator score 79% (1152)
  • A. A CD4+ count of less than 200 cells/µL is as strong a risk factor for cardiovascular disease as hypertension
  • B. All people with HIV should be on a statin, regardless of low-density lipoprotein (LDL) cholesterol level
  • C. Lovastatin and simvastatin are preferred statins with protease inhibitors
  • D. Prolonged HIV viremia increases cardiovascular risk, requiring adjustment of risk calculator score

Correct answer is D. Prolonged HIV viremia is a potential HIV-related cardiovascular disease (CVD) risk-enhancing factor and is a consideration for increasing a patient’s risk calculator score.

To learn more about the latest recommendations for preventing and managing CVD in people with HIV, as well as other important updates on primary care for people with HIV, click the Watch Webinar button below to view the webinar, “HIV 101: Fundamentals of HIV Medicine, Initiation of Antiretroviral Therapy, and Primary Care for People With HIV,” which was presented by Melanie A. Thompson, MD, on September 28, 2021.

For an in-depth update on CVD and HIV, click the Watch Webcast to view “Cardiovascular Disease in HIV: Moving From Insights to Interventions,” presented by Matthew J. Feinstein, MD, MSc, on June 25, 2021.

Approximately what proportion of people with HIV experience sleep disturbances compared with the general public?

Responses
A. About half as many 5% (57)
B. About the same 9% (101)
C. About twice as many 72% (779)
D. About 3 times as many 14% (151)
  • A. About half as many
  • B. About the same
  • C. About twice as many
  • D. About 3 times as many

Correct answer is C. Approximately 70% of people with HIV experience some type of sleep disturbance impacting their overall health. This is more than twice the rate of the general public, which is approximately 30%. Sleep problems in people with HIV are associated with lower treatment adherence, lower quality of life, impaired metabolic control, and depression.

For more information, click the Watch Webinar button below to watch the webinar, “Sleep Disorders and Sleep Assessment in People with HIV,” presented by Ana C. Krieger, MD, MPH, on September 21, 2021.

Which HIV preexposure prophylaxis (PrEP) regimen or formulation is NOT under clinical investigation?

 

Responses
A. Daily oral tenofovir alafenamide/emtricitabine (TAF/FTC) 30% (203)
B. Weekly tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) patch 36% (246)
C. Monthly oral islatravir 14% (95)
D. Injectable cabotegravir administered every 2 months 7% (48)
E. Subcutaneous lenacapavir administered every 6 months 13% (90)
  • A. Daily oral tenofovir alafenamide/emtricitabine (TAF/FTC)
  • B. Weekly tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) patch
  • C. Monthly oral islatravir
  • D. Injectable cabotegravir administered every 2 months
  • E. Subcutaneous lenacapavir administered every 6 months

Correct answer is B. There is no antiretroviral patch for HIV prevention currently in clinical trials, but several are in pre-clinical development. All of the other PrEP regimens and formulations listed have reached clinical trials.

For more information, click the Watch Webcast button below to watch Rapid Review of New Scientific and Clinical Data Presented at the International AIDS Society (IAS) 2021 Conference, presented by Roy M. Gulick, MD, MPH, on September 7, 2021.

Regarding screening for cognitive impairment in older patients with HIV, which of the following recommendations is shared across commonly used guidelines?

Responses
A. All patients with HIV should have a baseline cognitive screening and repeat screening annually 29% (281)
B. No cognitive screening is recommended 3% (29)
C. There is substantial controversy across guidelines in terms of regular cognitive screening 33% (321)
D. The United States Preventative Service Task Force (USPSTF) recommends cognitive screening for all patients over the age of 60 years regardless of HIV status
35% (342)
  • A. All patients with HIV should have a baseline cognitive screening and repeat screening annually
  • B. No cognitive screening is recommended
  • C. There is substantial controversy across guidelines in terms of regular cognitive screening
  • D. The United States Preventative Service Task Force (USPSTF) recommends cognitive screening for all patients over the age of 60 years regardless of HIV status

Correct answer is C. There is substantial inconsistency across major guidelines, including that of the International Antiviral Society-USA (IAS–USA), the United States Department of Health and Human Services (DHHS), the European AIDS Clinical Society, and the Infections Disease Society of America (IDSA). Recommendations from some groups include frequent screening and others suggest screening in symptomatic patients. Although the USPSTF does not offer recommendations specific to people with HIV, their general guidance on screening for cognitive impairment in the general population states that “the evidence is insufficient to balance the benefits and harms.”

For more information, click the Watch Webcast button below to watch “Neurocognition and the Aging Brain,” presented by Victor G. Valcour, MD, PHD, at June 25, 2021, virtual course, Aging and HIV: Issues, Screening, and Management in Individuals with HIV as They Age.

A 25-year-old transgender woman has just been diagnosed with anal chlamydia in your clinic. You advise her to consider preexposure prophylaxis (PrEP) with daily tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) to reduce her risk for HIV acquisition. She takes oral spironolactone 100 mg twice daily and oral estradiol 2 mg twice daily as part of her gender-affirming hormone regimen. Baseline test results are HIV antigen/antibody negative, hepatitis B surface antigen (HBsAg) negative, and an estimated glomerular filtration rate (eGFR) of 90. She is concerned about the possibility of drug-drug interactions between her hormones and PrEP. Which statement is true regarding the use of PrEP among transgender women?

Responses
A. TDF/FTC has been demonstrated in clinical trials to be as effective in preventing HIV acquisition among transgender women as in cisgender men 53% (344)
B. TDF/FTC is associated with a 10 to 15% reduction in estradiol levels among transgender women receiving gender-affirming hormones 14% (89)
C. Feminizing hormones significantly reduce levels of TDF/FTC and therefore PrEP should be avoided in this population 3% (16)
D. Stricter adherence to daily TDF/FTC in transgender women may be needed to prevent HIV infection 30% (197)
  • A. TDF/FTC has been demonstrated in clinical trials to be as effective in preventing HIV acquisition among transgender women as in cisgender men
  • B. TDF/FTC is associated with a 10 to 15% reduction in estradiol levels among transgender women receiving gender-affirming hormones
  • C. Feminizing hormones significantly reduce levels of TDF/FTC and therefore PrEP should be avoided in this population
  • D. Stricter adherence to daily TDF/FTC in transgender women may be needed to prevent HIV infection

Correct answer is D. Daily oral TDF/FTC is effective in preventing HIV in transgender women when taken as prescribed. There are no known drug-drug interactions between TDF/FTC and gender-affirming hormones, nor are there any known contraindications to concomitant use of PrEP with gender-affirming hormone therapy. There are indications that TDF levels are lower in the presence of estrogen, but the clinical significance is not known. Transgender women on hormone therapy may need to have better adherence to TDF/FTC to be sufficiently protected.

For more information, click the Watch Webinar button below to watch Management and Prevention of HIV Infection Among Transgender Adults, presented by Asa E. Radix, MD, PhD, MPH, on August 18, 2020.

Which of the following is a potential toxic effect of bacteriophage therapy?

Responses
A. Induction of septic shock by accelerated lysis of bacterial pathogens
27% (124)
B. Induction of bacteriophage-specific adaptive immune responses
21% (99)
C. Urine NAATs for gonorrhea and chlamydia, and pharyngeal NAAT for gonorrhea only 17% (77)
D. Inadvertent administration of endotoxin or other impurities in bacteriophage preparations 35% (159)
  • A. Induction of septic shock by accelerated lysis of bacterial pathogens
  • B. Induction of bacteriophage-specific adaptive immune responses
  • C. Massive disruption of the host microbiome
  • D. Inadvertent administration of endotoxin or other impurities in bacteriophage preparations

Correct answer is D. Toxic effects of bacteriophage therapy could theoretically include inadvertent administration of endotoxin or other impurities in bacteriophage preparations. However, very sensitive endotoxin assays are now available and if used during the preparation of the phage for administration, prevent this from being an issue.

To learn more about the potential clinical niches for bacteriophage therapy, click the Watch Webinar button below to watch Bacteriophage Therapy: The Enemy of My Enemy is My Friend, presented by Robert T. Schooley, MD, on August 24, 2021.

A 38-year-old man with HIV has been on antiretroviral therapy for the past 2 years and has had a viral load of less than 200 copies/mL for the last 18 months. He is in a relationship but occasionally has sexual encounters outside of his primary relationship with other men, using condoms for anal sex but not oral. He is asymptomatic of any problems suggestive of sexually transmitted infections (STIs). The appropriate recommendation for STI testing for this individual, based on the United States Department of Health and Human Services (DHHS) and Centers for Disease Control and Prevention (CDC) guidelines, would be:

 

Responses
A. No testing is needed since he has an undetectable HIV viral load and is asymptomatic 2% (18)
B. Urine nucleic acid amplification tests (NAATs) for gonorrhea and chlamydia only 2% (19)
C. Urine NAATs for gonorrhea and chlamydia, and pharyngeal NAAT for gonorrhea only 5% (33)
D. Urine NAATs for gonorrhea and chlamydia, rectal NAATs for gonorrhea and chlamydia, and pharyngeal NAAT for gonorrhea only 8% (54)
E. Urine NAATs for gonorrhea and chlamydia, rectal NAATs for gonorrhea and chlamydia, pharyngeal NAAT for gonorrhea, and syphilis serology testing 83% (592)
  • A. No testing is needed since he has an undetectable HIV viral load and is asymptomatic
  • B. Urine nucleic acid amplification tests (NAATs) for gonorrhea and chlamydia only
  • C. Urine NAATs for gonorrhea and chlamydia, and pharyngeal NAAT for gonorrhea only
  • D. Urine NAATs for gonorrhea and chlamydia, rectal NAATs for gonorrhea and chlamydia, and pharyngeal NAAT for gonorrhea only
  • E. Urine NAATs for gonorrhea and chlamydia, rectal NAATs for gonorrhea and chlamydia, pharyngeal NAAT for gonorrhea, and syphilis serology testing

Correct answer is E. The updated CDC STI treatment guidelines recommend regular (at least once annually, or 3 to 6 times if at greater risk) testing for gonorrhea, chlamydia, and syphilis for those at higher risk, including people with HIV and men who have sex with men (MSM). For gonorrhea, it is recommended that sites of contact for MSM (urine, rectal, and pharyngeal) be tested regardless of condom use. For chlamydia, it is recommended that sites of contact for MSM (urine and rectal) be tested regardless of condom use. For syphilis, it is recommended that those who are asymptomatic and at higher risk be tested at least once annually.

The 2021 CDC STI screening recommendations can be read on the CDC website.

Which of the following statements is true regarding the HIV reservoir in elite controllers?

Responses
A. Their HIV reservoir is extremely large 6% (37)
B. Integrated proviruses from elite controllers are often transcriptionally active 28% (177)
C. Most intact proviruses accumulate at non-genic and satellite DNA 45% (283)
D. Immune pressure has likely no impact on the reservoir in elite controllers 21% (138)
  • A. Their HIV reservoir is extremely large
  • B. Integrated proviruses from elite controllers are often transcriptionally active
  • C. Most intact proviruses accumulate at non-genic and satellite DNA
  • D. Immune pressure has likely no impact on the reservoir in elite controllers

Correct answer is C. Clonally-expanded intact proviral genomes in exceptional elite controllers accumulate at satellite DNA in centromeric regions and KRAB-ZNF genes on chromosome 19. Elite controllers usually carry a very small frequency of infected cells, most proviruses in elite controllers are integrated in regions of the chromatin that repress gene transcription, and the reservoir of elite controllers is under the pressure of a potent cytotoxic T lymphocyte (CTL) response.

Click the Watch Webcast button to view “Elite Controllers: A Model for a Functional Cure of HIV-1 Infection,” presented by Xu Yu, MD, at vCROI 2021 on March 8, 2021.

Most of the individuals who responded that they were going to “wait and see” when asked if they were planning to get a COVID-19 vaccine in January 2021 have now been vaccinated.

 

Responses
A. True 50% (616)
B. False 50% (607)
  • A. True
  • B. False

Correct answer is A. In January 2021, the Kiser Family Foundation COVID-19 Vaccine Monitor asked individuals if they were going to get a COVID-19 vaccine once they were eligible. In a new poll published on July 13, 2021, of the individuals that responded that they were going to “wait and see,” 54% have now reported that they are vaccinated.

Click the Watch Webinar button to view COVID-19 Vaccine Hesitancy, Crucial Conversations, and Effective Messaging for Patients and Healthcare Teams, presented by Marie T. Brown, MD, and moderated by Constance A. Benson, MD, IAS-USA Webinar, on August 3, 2021.

As highlighted in the NA-ACCORD (North American AIDS Cohort Collaboration on Research and Design) study, which of the following was associated with an increased risk for hepatocellular carcinoma (HCC) in people with HIV/HBV coinfection?

 

Responses
A. Detectable HIV viral load 17% (171)
B. Low CD4+ cell percentage 14% (146)
C. Hepatitis B virus (HBV) DNA level above 200 IU/mL 50% (505)
D. Hepatitis delta infection 12% (126)
E. Race 7% (71)
  • A. Detectable HIV viral load
  • B. Low CD4+ cell percentage
  • C. Hepatitis B virus (HBV) DNA level above 200 IU/mL
  • D. Hepatitis delta infection
  • E. Race

Correct answer is C. Even a low level of HBV viral replication was associated with an increased risk of HCC. Undetectable HBV for more than a year was associated with lower HCC rate, compared with detectable HBV or undetectable for less than a year. This highlights the importance of monitoring for HBV suppression in HIV/HBV coinfection as the data suggests sustained suppression of HBV replication may be key to reducing HCC risk, rather than simply getting HBV below a certain threshold.

Click the Read Article button to read “CROI 2021: Viral Hepatitis and Other Forms of Liver Injury Impacting People with HIV,” authored by Anne F. Luetkemeyer, MD, and David L. Wyles, MD, in IAS-USA Topics in Antiviral Medicine, Volume 29, Issue 3.

Which of the following statements is true?

 

Responses
A. Anal cancer screening has been shown to reduce the rates of anal cancer in people with HIV (PWH) 42% (269)
B. Rates of anal cancer in PWH approximate or exceed the rates of lung, colon, and cervical cancer in the general population 47% (302)
C. Among women with HIV, only those with certain risk factors should be screened for anal cancer precursors or anal high grade squamous intraepithelial lesions (HSIL) 11% (72)
  • A. Anal cancer screening has been shown to reduce the rates of anal cancer in people with HIV (PWH)
  • B. Rates of anal cancer in PWH approximate or exceed the rates of lung, colon, and cervical cancer in the general population
  • C. Among women with HIV, only those with certain risk factors should be screened for anal cancer precursors or anal high grade squamous intraepithelial lesions (HSIL)

Correct answer is B. Among men who have sex with men with HIV, the rates of anal cancer match or exceed those of colon, lung, and possibly prostate cancer. Among women with HIV, the rate of anal cancer approximates historic cervical cancer rates prior to widespread cervical cancer screening.

Click the Watch Webinar button to view Prevention of HPV-Related Anal Cancer in Persons With HIV: How Should We Screen and Will Vaccines Make a Difference?, presented by Grant Ellsworth, MD, MS, at the July 13, 2021, IAS-USA webinar.

Which of the following is a valid reason to check for SARS-CoV-2 spike antibody levels in a vaccinated patient?

Responses
A. To find out if they are protected 18% (177)
B. To find out if a booster shot is needed 16% (150)
C. For research purposes only 63% (609)
D. Because your patient wants to know 3% (26)
  • A. To find out if they are protected
  • B. To find out if a booster shot is needed
  • C. For research purposes only
  • D. Because your patient wants to know

Correct answer is C. More research is needed to determine if spike binding antibodies can be useful for determining if a patient is immune-protected or needs a booster. This is currently unknown. Both the United States Center for Disease Control and Prevention (CDC) and United States Federal Drug Administration (FDA) do not recommend that post-vaccination antibody levels be routinely checked, since we do not know how to interpret that information, how to act on it, and the commercial antibody assays are not authorized for that use.

Commercial spike antibody assays are not authorized (nor are they proven to have predictive value) by the FDA for determining if a person has immune-protection against SARS-CoV-2 and variants, and may or may not need a booster shot. The authorized COVID-19 vaccines induce functional antibody (Ab) and cellular responses. Commercial assays are qualitative or semi-quantitative measures of binding antibodies only, not measures of functional antibodies (eg, neutralizing Ab, antibody-dependent cellular cytotoxicity [ADCC]) and/or cellular immunity.

Healthcare practitioners can educate their patients who want to know their antibody levels and request post-vaccination testing about the above facts; and, where available, refer them to research studies currently investigating the duration of immunity post-vaccination and the utility of booster shots.

Click the Watch Webinar button to view “COVID-19 Vaccines and the Viral Variants: New Aspects of Vaccine Research,” presented by Mark J. Mulligan, MD, at the June 29, 2021, IAS-USA webinar.

As of July 5, 2021, which of the following individuals is eligible for monoclonal antibody treatment under the Emergency Use Authorization (EUA)?

Responses
A. A 66-year-old woman with a positive SARS-CoV-2 polymerase chain reaction (PCR) but no symptoms and a body mass index (BMI) of 30 but no comorbidities 11% (53)
B. A 66-year-old woman with a positive SARS-CoV-2 PCR, a mild cough starting 2 days prior, and no comorbidities, but lives with her husband who has diabetes 14% (69)
C. A 66-year-old man with diabetes who was exposed to his wife who has a positive SARS-CoV-2 PCR but his PCR was negative 9% (43)
D. An 86-year-old man with a positive SARS-CoV-2 PCR, is hospitalized with COVID-19 pneumonia, and has a cough, but is not requiring oxygen 35% (171)
E. An 86-year-old man with no comorbidities and a positive SARS-CoV-2 PCR with mild fatigue starting 2 days prior 31% (153)
  • A. A 66-year-old woman with a positive SARS-CoV-2 polymerase chain reaction (PCR) but no symptoms and a body mass index (BMI) of 30 but no comorbidities
  • B. A 66-year-old woman with a positive SARS-CoV-2 PCR, a mild cough starting 2 days prior, and no comorbidities, but lives with her husband who has diabetes
  • C. A 66-year-old man with diabetes who was exposed to his wife who has a positive SARS-CoV-2 PCR but his PCR was negative
  • D. An 86-year-old man with a positive SARS-CoV-2 PCR, is hospitalized with COVID-19 pneumonia, and has a cough, but is not requiring oxygen
  • E. An 86-year-old man with no comorbidities and a positive SARS-CoV-2 PCR with mild fatigue starting 2 days prior

Correct answer is E as of the posting of the question on July 5, 2021.The EUA of monoclonal antibodies is for the treatment of COVID-19 in people who are at high risk of disease progression (people who are older and have comorbidities) and not already hospitalized.

Please note, the field of COVID-19 changes rapidly and the half-life of information is short.

Click the Watch Webcast button to view “Preventing Severe COVID-19: The Role of Monoclonal Antibodies and Beyond,” presented by Davey Smith, MD, at the May 20, 2021, virtual course, Unique Issues in HIV Prevention, Treatment, and Care in the COVID-19 World

For asymptomatic individuals with HIV at average risk for colon cancer, what age group does the United States Preventive Services Task Force (USPSTF) recommend routine colon cancer screening?

Responses
A. 50-85 years 9% (62)
B. 45-85 years 13% (88)
C. 50-75 years
18% (122)
D. 45-75 years 39% (263)
E. Beginning at 50 years with no upper age limit 21% (138)
  • A. 50-85 years
  • B. 45-85 years
  • C. 50-75 years
  • D. 45-75 years
  • E. Beginning at 50 years with no upper age limit

The correct answer is D. In May 2021, the USPSTF broadened the age range that adults should be routinely offered colon cancer screening. For individuals 50 to 75 years old, the recommendation strength is “A,” and for individuals 45 to 49 years old, the recommendation strength is “B.” The USPSTF continues to recommend selective screening for individuals 76 to 85 years old, taking into consideration the patient’s overall health, prior screening history, and preferences, with a recommendation strength of “C.” The HIV Medicine Association (HIVMA)/Infectious Diseases Society of America (IDSA) HIV Primary Care Guidance recommends following the USPSTF recommendations for colon cancer screening for persons with HIV.

Which of the following drugs could cause postural hypotension in an elderly HIV-infected patient?

Responses
A. Dolutegravir 7% (74)
B. Efavirenz 9% (82)
C. Tamsulosin
70% (687)
D. Fexofenadine 5% (46)
E. Sertraline 9% (89)
  • A. Dolutegravir
  • B. Efavirenz
  • C. Tamsulosin
  • D. Fexofenadine
  • Sertraline

The correct answer is C. Tamsulosin is an alpha1 antagonist, and can cause postural hypotension. Use caution whenever prescribing alpha antagonists in the elderly, who may have greater risk for cardiovascular instability.

The course presentation covering this topic, along with other presentations that cover some of the key issues unique to management and care of older patients with HIV, will be available for viewing on demand on the IAS–USA website. Those who did not participate in the live activity can earn continuing education credits for viewing the on-demand webcasts.

To learn more about this topic and other issues unique to managing the care of older patients with HIV, watch webinars of June 25, 2021, course, Aging and HIV: Issues, Screening, and Management in Individuals with HIV as They Age.

A 33-year-old man with well-controlled HIV infection was diagnosed with gonococcal infection by his primary HIV practitioner. STI testing had been ordered by the patient’s primary HIV practitioner at a telehealth visit. However, the primary practitioner’s office is not open for in-person visits, and so the patient is referred to your sexual health center for treatment. He brings the results of gonorrhea and chlamydia nucleic acid amplification testing, which show positive oropharyngeal testing for gonorrhea and negative chlamydia oropharyngeal testing. Also negative are rectal and urine gonorrhea and chlamydia testing, as well as syphilis treponemal testing. How do you manage this patient according to the updated Centers for Disease Control and Prevention (CDC) recommendations from December 2020?

Responses
A. Ceftriaxone 250 mg, followed by a test of cure in 7 to 14 days 7% (57)
B. Ceftriaxone 250 mg, no subsequent test of cure but retesting in 3 months to assess for reinfection 8% (69)
C. Ceftriaxone 500 mg, followed by a test of cure in 7 to 14 days 54% (453)
D. Ceftriaxone 500 mg, no subsequent test of cure but retesting in 3 months to assess for reinfection 31% (255)
  • A. Ceftriaxone 250 mg, followed by a test of cure in 7 to 14 days
  • B. Ceftriaxone 250 mg, no subsequent test of cure but retesting in 3 months to assess for reinfection
  • C. Ceftriaxone 500 mg, followed by a test of cure in 7 to 14 days
  • D. Ceftriaxone 500 mg, no subsequent test of cure but retesting in 3 months to assess for reinfection

Correct answer is C. The updated CDC recommendations for treatment of uncomplicated gonococcal infection of the pharynx is ceftriaxone 500 mg, administered as a single intramuscular dose for those weighing less than 150 kg (or 300 lbs). For those weighing more, 1 gm of ceftriaxone should be administered. If chlamydia infection has not been excluded, treatment should also include doxycycline 100 mg twice daily for 7 days (unless the patient is pregnant, and then 1 gm of azithromycin should be administered for chlamydia treatment). A test of cure, using culture or nucleic acid amplification testing, is recommended at 7 to 14 days after treatment for pharyngeal infection. Test-of-cure is not thought to be necessary after treatment for uncomplicated urogenital or rectal gonorrhea when a recommended regimen is used.

Click the Watch Webcast button to view “Management and Prevention of Sexually Transmitted Infections,” presented by Meredith Clement, MD, at the April 30, 2021, virtual course, Annual Update on HIV Management: State-of-the-Art Updates on HIV, STIs, and COVID-19.

A 52-year-old man with HIV is seen in clinic for a routine visit. He received his second dose of COVID-19 vaccine (Moderna product) 4 days ago with only a mild reaction and currently is asymptomatic. He is scheduled to get a dose of pneumococcal polysaccharide vaccine (PPSV-23) at this visit. What would you recommend regarding administering the PPSV-23 vaccine for this man?

Responses
A. He must wait at least 14 days after the most recent COVID-19 vaccine dose 40% (419)
B. He must wait at least 6 weeks after the most recent COVID-19 vaccine dose 6% (66)
C. He must wait at least 12 weeks after the most recent COVID-19 vaccine dose 3% (36)
D. He can receive the PPSV-23 vaccine at this clinic visit
51% (540)
  • A. He must wait at least 14 days after the most recent COVID-19 vaccine dose
  • B. He must wait at least 6 weeks after the most recent COVID-19 vaccine dose
  • C. He must wait at least 12 weeks after the most recent COVID-19 vaccine dose
  • D. He can receive the PPSV-23 vaccine at this clinic visit

Correct answer is D. Prior to May 14, 2021, the Centers for Disease Control and Prevention (CDC) recommended that no vaccines be coadministered within 14 days (before or after) any dose of the COVID-19 vaccine. These recommendations changed on May 14, 2021, and the CDC guidance now provides the following guidance (verbatim) regarding coadministering vaccines with COVID-19 vaccines:

  • COVID-19 vaccines and other vaccines may now be administered without regard to timing.
  • COVID-19 vaccines and other vaccines on the same day, as well as coadministration within 14 days.
  • If multiple vaccines are administered at a single visit, administer each injection in a different injection site.

This guidance does not mean that a practitioner cannot elect to defer a vaccine, which may be prudent in some situations, such as coadministering a dose of non-COVID-19 vaccine with the COVID-19 vaccine on the same day if the non-COVID-19 vaccine has a potent conjugate or adjuvant (eg, recombinant zoster vaccine or CPG-HepB) that may enhance the reactogenicity to the COVID-19 vaccine (or create highly uncomfortable/problematic combined postvaccine symptoms). Also, some practitioners may elect to delay the non-COVID-19 vaccine if it can easily be delayed and there is no eminent threat from that pathogen. In general, given the current state of the COVID-19 epidemic, the COVID-19 vaccine should always have priority for administration over a non-COVID-19 vaccine.

Click the Watch Webcast button to view “Vaccine Prevention for Individuals With HIV in the Era of COVID-19,” presented by David H. Spach, MD, at the May 20, 2021, virtual course, Unique Issues in HIV Prevention, Treatment, and Care in the COVID-19 World.