ART Provider Treatment Planning & Patient Care 3 — Questions and Answers
Question 1: A patient on efavirenz-based ART reports vivid nightmares and difficulty concentrating three weeks after initiation. What is the most appropriate response?
- Immediately switch the regimen to avoid CNS toxicity
- Counsel that these CNS side effects are common with efavirenz and usually resolve within 2–4 weeks (Correct answer)
- Order a brain MRI to rule out CNS opportunistic infection
- Reduce the efavirenz dose by half
Correct answer: Counsel that these CNS side effects are common with efavirenz and usually resolve within 2–4 weeks
CNS side effects including vivid dreams, dizziness, and difficulty concentrating are common with efavirenz and typically resolve within the first 2–4 weeks of therapy.
Question 2: Which monitoring parameter is most critical within the first 2 weeks of ART initiation in a patient with CD4 < 50 cells/µL?
- Lipid panel
- Signs and symptoms of immune reconstitution inflammatory syndrome (IRIS) (Correct answer)
- Bone mineral density
- Serum testosterone levels
Correct answer: Signs and symptoms of immune reconstitution inflammatory syndrome (IRIS)
Patients with very low CD4 counts are at high risk for IRIS when ART is initiated, which can unmask or worsen underlying opportunistic infections.
Question 3: A patient's genotype resistance test reveals a K65R mutation. Which nucleoside reverse transcriptase inhibitor should be avoided?
- Zidovudine (AZT)
- Tenofovir disoproxil fumarate (TDF) (Correct answer)
- Lamivudine (3TC)
- Emtricitabine (FTC)
Correct answer: Tenofovir disoproxil fumarate (TDF)
The K65R mutation confers reduced susceptibility to tenofovir (TDF and TAF), making it an inappropriate choice when this mutation is present.
Question 4: A 55-year-old male patient on ART develops a buffalo hump and central fat accumulation. These findings are most consistent with which condition?
- Cushing's syndrome from corticosteroid use
- Lipodystrophy associated with antiretroviral therapy (Correct answer)
- Uncontrolled hypothyroidism
- Wasting syndrome from uncontrolled HIV
Correct answer: Lipodystrophy associated with antiretroviral therapy
Lipodystrophy, characterized by central fat accumulation and peripheral fat loss, is a recognized metabolic complication of long-term ART, particularly with older agents.
Question 5: Before prescribing abacavir (ABC), the most essential pre-treatment screening test is:
- G6PD enzyme level
- HLA-B*5701 genotyping (Correct answer)
- CYP2D6 metabolizer status
- Glucose-6-phosphate dehydrogenase deficiency testing
Correct answer: HLA-B*5701 genotyping
HLA-B*5701 screening must be performed before abacavir initiation because carriers are at high risk for a severe, potentially fatal hypersensitivity reaction.
Question 6: A patient who is virologically suppressed on ART wants to switch regimens for convenience. Which approach best guides the switching decision?
- Switch to any newer regimen without reviewing prior resistance history
- Review full resistance history and select a regimen with confirmed activity based on cumulative resistance data (Correct answer)
- Automatically switch to the newest approved regimen regardless of prior mutations
- Discontinue ART for 4 weeks before switching to clear the system
Correct answer: Review full resistance history and select a regimen with confirmed activity based on cumulative resistance data
Cumulative resistance testing history must guide regimen switches even in virologically suppressed patients, because archived mutations can re-emerge after a regimen change.
Question 7: Which patient population requires dose adjustment of certain integrase strand transfer inhibitors (INSTIs) due to drug interaction with rifampin-based TB treatment?
- Patients older than 65 years
- Patients on raltegravir or dolutegravir requiring dose doubling of dolutegravir (Correct answer)
- Patients with renal impairment on elvitegravir/cobicistat
- Patients who are HLA-B*5701 positive
Correct answer: Patients on raltegravir or dolutegravir requiring dose doubling of dolutegravir
Rifampin is a potent inducer of drug metabolism that significantly reduces dolutegravir levels, requiring twice-daily dosing of dolutegravir when used concurrently.
ART Provider Treatment Planning & Patient Care 3
A patient on efavirenz-based ART reports vivid nightmares and difficulty concentrating three weeks after initiation.
What is the most appropriate response?