HIV/ID report! ARV basics

Thank you to Scott Goldberg for presenting his first case in morning report today! We are super grateful for the strong intern attendance at ZSFG report =)
Choosing a regimen
  • goal is three active drugs from two different classes
Where should I go to get up to date info on recommended regimens? Two awesome resources
Here are HHS recommendations for first-line ART
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  • Many HIV docs are pumped about dolutegravir-based regimens due to their high tolerability, high barrier to resistance, and impressive ability to suppress the virus.
What the heck is tenofovir alafenamide?!
  • Old fashioned tenofovir is tenofovir diisoproxyl fumarate. 
  • Tenofovir is a sternralong-time mainstay of ART and PREP regimens with some serious downsides with long term use
    • renal impairment, specifically a fanconi’s syndrome
    • osteoporosis
  • TAF is a new (very expensive, conveniently timed for when tenfovir became generic) medication that, based on it’s pharmacokinetics, should be less nephrotoxic.
  • The TAF-involved regimen above is highlighted because it’s new, not because it’s preferred
  • TAF cannot be used for PReP because it is unclear whether it is present in adequate level in the anal mucosa.
Bonus pearl – LGV proctitis
  • lymphogranuloma venerum is caused by the L1, L2, and L3 serovars of chlamydia
  • It used to be rare outside the US but there have been outbreaks of LGV ano-rectal syndrome among MSM.
  • LGV ano-rectal syndrome
    • primary LGV infection is an ulcer at the site of infection with inflammation ~ 1 week after infection
    • ano-rectal syndrome presents 2-6 weeks after primary infection with a rectal mass, fevers, tenesmus, constipation, fevers, or bloody diarrhea. It can be mistaken for inflammatory bowel disease.
 
Sources:
Blank S, Schillinger JA, Harbatkin D Lymphogranuloma venereum in the industrialised world.Lancet. 2005;365(9471):1607.
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