Human

Immunodeficiency
Virus & Hepatitis C
Kenedie Krout
PGY1 Pharmacy Resident
Franciscan Health Indianapolis
 Background of HIV

HIV transmission and screening

Stages of HIV replication

Topics of Preferred antiretroviral treatment of HIV
Discussion HIV Prevention

Background of hepatitis C

Preferred treatment of hepatitis C

HIV Prevalence

~1.2 million people are infected with HIV in the United

States, and ~13% of those patients are unaware.

Each year ~38,000 people are diagnosed with HIV

HIV can progress to advanced stage of the infection

known as acquired immunodeficiency syndrome (AIDS)
 • Single stranded, RNA virus
• Uses host CD4 T-helper cells (T cells) to replicate
• Once replicated, viral copies break the CD4 cell
HIV membrane- destroying the cell

Pathophysiology • If left untreated, billions of T cells can be

destroyed each day
• Untreated: viral load increases and CD4 count
decreases
• AIDS: CD4 count below 200 cells/mm 3 or the
patient develops an AIDS-defining condition
Transmission Blood

of HIV Semen

Vaginal secretions

Rectal secretions

Ingestion of breast milk or vertical transmission

Most common mechanisms: unprotected sex

and sharing injection drug equipment
Who Should Using IV drugs &
sharing equipment
Be Screened At least once for
everyone ages 13-
for HIV? 64
High-risk sexual
behaviors
Annually for those
who are considered
high risk History of sexually
transmitted
infections

History of hepatitis
C or tuberculosis
 Stage 1: Binding/Attachment

HIV Replication • HIV attaches to a CD4 receptor and CCR5 and/or CXCR4 co receptors

Stage 2: Fusion
• HIV is enveloped and enters the cell to release HIV RNA, proteins, and
enzymes used for replication

Stage 3: Reverse Transcription (NRTI Therapy Target)

• HIV RNA is converted to HIV DNA by reverse transcriptase (HIV enzyme)

Stage 4: Integration (INSTI Therapy Target)

• Integrase (HIV enzyme) is released and used to insert the HIV DNA into the
host cell's DNA

Stage 5: Replication
• HIV DNA is transcribed and then translated into HIV RNA

Stage 6: Assembly
• The new HIV RNA, proteins, and enzymes move back to the surface of the
cell to make immature HIV

Stage 7: Budding and Maturation

• The immature HIV leaves the CD4 cell and protease (HIV enzyme) breaks up
the long chain to create mature virus that can infect other cells
Antiretroviral Therapy (ART)
NRTI INSTI
Preferred Initial ART Regimen in
Treatment-Naïve Adults: Emtricitabine Bictegravir
2 NRTIs + 1 INSTI
Tenofovir Dolutegravir
Lamivudine and Emtricitabine can be
used interchangeably but should not
be used together – both cytosine Lamivudine Raltegravir
analogs
 One Pill Once Daily
Current • Biktarvy: Bictegravir / Emtricitabine / Tenofovir
alafenamide
Available • Triumeq: Dolutegravir / Abacavir / Lamivudine

Formulations • Dovato: Dolutegravir / Lamivudine

Two Pills Once Daily

• Tivicay + Truvada: Dolutegravir + Emtricitabine / Tenofovir
disoproxil fumarate
• Tivicay + Descovy: Dolutegravir + Emtricitabine / Tenofovir
alafenamide

Clinical Pearls
• Medications containing abacavir (Triumeq) require testing
for the HLA-B*5701 allele before using- if positive, higher
risk of hypersensitivity reaction
• Do not use if CrCl < 30 mL/min
• Most HIV medications come in a 30-day supply and should
be dispensed in the manufacturer bottle
 • NRTI
- Nausea, diarrhea, headache, increased
LFTs
- Emtricitabine: hyperpigmentation of the
Side Effects -
palms of the hands or soles of the feet
Tenofovir formulations: decreased bone
& Warnings mineral density

of ART • INSTI
- Bictegravir: increased SCr
- Do not take with cations- aluminum,
calcium, magnesium, iron-containing
products
HIV Pre-Exposure Prophylaxis (PrEP)
Prevention • For those who have high-risk behaviors
but do not have HIV
• Preferred: Oral Regimen of Truvada or
Descovy prescribed no more than 90
days at a time
• Before initiation: confirm the patient is
HIV negative, screen for STIs, and check
renal function

PrEP Follow-Up Appointments:

• Test for HIV
• Screen for STIs
HIV Post-Exposure Prophylaxis (PEP)

- This is for emergency situations where a non-infected person is exposed to or possibly

exposed to HIV via bodily fluids
- Two types: nonoccupational (nPEP) and occupational (oPEP)
- nPEP: examples are sexual assault or injection drug use
- oPEP: typically for health care workers who are exposed to bodily fluids of infected
patients (ex: needlestick)
- Both treatments: started within 72 hours of exposure and continued for 28 days
- Treatment: more drugs needed due to higher risk of a true exposure
- Truvada + Dolutegravir (Tivicay) OR Raltegravir (Isentress)
Quick Facts: Opportunistic Infections
& Primary Prophylaxis

Pneumocystis Mycobacterium
Toxoplasma gondii
jirovecii pneumonia avium complex
encephalitis
(PJP or PCP) (MAC)

Azithromycin 1,200
Bactrim preferred Bactrim preferred mg weekly preferred
when CD4 < 200 when CD4 < 100 when CD4 < 50
cells/mm3 cells/mm3 cells/mm3 AND not
taking ART
 Hepatitis = inflammation of the liver

Caused by hepatitis virus, alcohol, drugs, autoimmune

disease, and other viruses
Transmission of hepatitis C occurs from contact with
Hepatitis C blood or bodily fluids of a patient who has hepatitis

Background Due to increased prevalence of hep C, one time

screening in everyone 18 and older is recommended
Pregnant women should be screened with each
pregnancy for hep B and hep C
There is no vaccine for hep C
Drug Treatment for Hepatitis C
• Preferred hep C regimens consist of 2-3 direct acting antivirals (DAAs) with
different mechanisms for 8-12 weeks
Mechanism Name Clue Drug
NS3/4A Protease Inhibitors -previr Glecaprevir
Grazoprevir
Paritaprevir
Voxilaprevir
NS5A Replication Complex -asvir Elbasvir
Inhibitors Ledipasvir
Ombitasvir
Pibrentasvir
Velpatasvir
NS5B Polymerase Inhibitors -buvir Dasabuvir
Sofosbuvir
Example of appropriate therapy: velpatasvir + Sofosbuvir (2 different
mechanisms of action)
Side Effects, All protease inhibitors need to be taken with
Monitoring, & food

Clinical Pearls Boxed warning for all direct acting antivirals:

risk of reactivating hepatitis B, test all
patients for hep B before starting DAA

Sofosbuvir-containing regimens interact

with amiodarone and cause serious
symptomatic bradycardia

Monitor for hypoglycemia with insulin or

other drugs that can cause hypoglycemia