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Project ECHO - UNM HIV TeleECHO Clinic ART Drug Interactions August 31, 2021 Clinical Pharmacist- Southwest CARE Center Clinical Director- UNM AETC Carly Floyd, PharmD, PhC, AAHIVP, CDCES, TTS V_08 2021 1 Conflict of Interest Disclosure Statement Speaker has nothing to disclose. This presentation was reviewed by UNMHSC and SCAETC faculty to ensure it meets Continuing Education guidelines. This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS). Under grant number U1OHA33225 (South Central AIDS Education and Training Center). It was awarded to the University of New Mexico. No percentage of this project was financed with non-governmental sources. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government. 2 Learning Objectives Recognize that antiretrovirals (ARVs) have multiple potential drug-drug interactions. Identify a resource for the evaluation of drug-drug interactions. 3 Reasons for Drug Interactions Polypharmacy Average 6-10 medications Co-morbidities Renal or hepatic dysfunction Absorption issues Over the counter medications (OTCs) and herbals Diet Food requirement https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv/over... 4 Mechanism of Interactions Pharmacokinetic (ADME) Absorption (bioavailability) Distribution Metabolism CYP450 uridine diphosphate glucuronosyltransferase (UGT) Excretion Pharmacodynamic 1. Dose Response Dose directly affects response 2. Drug Receptor Complex Ability of drug to reach target receptor https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv/over... 5 Drug Interactions with ARVs Two enzyme systems: CYP3A4 most common All protease inhibitors (PIs) & non-nucleoside/tide reverse transcriptase inhibitors (NNRTIs) metabolized by the hepatic CYP 450 system, particularly the CYP3A4 UGT1A1 enzyme Primary metabolism for integrase inhibitors (INSTIs)-bictegravir (BIC), dolutegravir (DTG), and raltegravir (RAL) Clinical Pharmacology 6 Common Class Interactions with ARVs Anticonvulsants lower levels of PIs, NNRTIs, INSTIs, & TAF Phenobarbital Phenytoin Carbamazepine, Oxcarbazepine Antimycobacterials Clarithromycin use alternative if NNRTI or boosted PI Rifampin Only safe with efavirenz, or with dose-adjusted RAL or DTG Must use TDF (not TAF) Rifabutin generally safer than rifampin Avoid bictegravir (BIC) or elvitegravir (EVG) regimens Must use TDF (not TAF) TAF = tenofovir alafenamide, TDF = tenofovir disoproxyl fumarate; www.hiv-druginteractions.org; DHHS HIV Guidelines 2021 PI=protease inhibitor; NNRTI=non-nucleoside reverse transcriptase inhibitors; INSTI=integrase strand transfer inhibitors; TAF=tenofovir alafenamide (a nucleotide reverse transcriptase inhibitor); TDF=tenofovir disoproxil fumarate; RAL=raltegravir; DTG=dolutegravir; BIC=bictegravir Anticonvulsants Significant pharmacokinetic drug interactions occur with concomitant use of anticonvulsants and antiretroviral medications. Several anticonvulsant medications significantly lower antiretroviral drug levels, potentially leading to virologic failure. This is particularly a concern with older anticonvulsants, particularly phenobarbital, phenytoin, carbamazepine, and oxcarbazepine, since these medications act as potent inducers of CYP enzymes These older anticonvulsants can lower levels of PIs, NNRTIs, INSTIs, and also the newer co-formulated medications that contain tenofovir alafenamide Antimycobacterials - The interaction of antiretroviral therapy and medications used in treatment regimens for mycobacterial infections (including active and latent Mycobacterium tuberculosis as well as the nontuberculous mycobacteria, including Mycobacterium avium complex, or MAC) is well recognized - Clarithromycin: Clarithromycin is a commonly used antimycobacterial for treatment of nontuberculous mycobacteria. An alternative to clarithromycin should be considered if using with an NNRTI or a PI boosted with ritonavir or cobicistat - Rifampin: Rifampin significantly reduces the levels of PIs, NNRTIs, and INSTIs. The only antiretroviral anchor drugs that are acceptable for use with rifampin are efavirenz, raltegravir, and dolutegravir; when using rifampin with raltegravir or dolutegravir, dose adjustments of the INSTIs are necessary, including doubling the dose of raltegravir from 400 mg twice daily to 800 mg twice daily and increasing dolutegravir from 50 mg once daily to 50 mg twice daily.- -The regimen bictegravir-tenofovir alafenamide-emtricitabine should be avoided with rifampin due to reduced plasma concentrations of bictegravir. - Rifabutin: The coadministration of rifabutin can safely be done with raltegravir or dolutegravir (without any dose adjustments) but should be avoided with regimens that contain bictegravir or elvitegravir boosted with cobicistat. With some antiretroviral regimens, dose adjustment of the antiretroviral medication or rifabutin may be needed.- - Health care providers should also be aware that rifabutin, or any rifamycin, should not be used concurrently with tenofovir alafenamide, since rifamycins significantly reduce tenofovir levels. 7 Common Class Interactions with ARVs Statins CYP3A4 metabolism Lovastatin Simvastatin Safe to use atorvastatin (<20mg), rosuvastatin (not a 3A4 substrate- start at lowest possible dose) Antipsychotics CYP3A4 metabolism Levels of antipsychotics increased with boosted-regimens NNRTIs- less significant interaction with rilpivirine or doravirine www.hiv-druginteractions.org; DHHS HIV Guidelines 2021 HMG-CoA Reductase Inhibitors (Statins) The key pharmacokinetic drug interactions between antiretroviral medications and statins occur with the statins that are metabolized through the CYP3A4 pathway (simvastatin, lovastatin, and atorvastatin) when taken concomitantly with the potent CYP3A inhibitors ritonavir or cobicistat. Clinically important interactions also occur through induction of the CYP3A4 pathway by certain NNRTI medications, which do not cause adverse effects but can decrease statin efficacy. Lovastatin and Simvastatin: The use of simvastatin or lovastatin is contraindicated in patients receiving PI-containing or cobicistat containing regimens due to significant increases in serum statin levels. Atorvastatin: Levels of atorvastatin can also be increased by ritonavir-boosted PIs and cobicistat-containing regimens, though the increases in drug levels are not as substantial as seen with simvastatin and lovastatin. If atorvastatin is to be used in conjunction with a ritonavir-boosted PI and cobicistat-containing regimen, a low dose (20 mg or less of atorvastatin) should be used as initial therapy, since this dose is likely to provide the lipid-lowering effect equivalent to a dose 3 to 5 times higher if administered without a ritonavir-boosted PI or cobicistat-containing regimen. Rosuvastatin is not a CYP3A4 substrate, but clinically relevant interactions with antiretroviral medications primarily occur through other transporters, specifically with OATP1B1 or BCRP.[73] When coadministering rosuvastatin with PIs or cobicistat-containing regimens, rosuvastatin should be initiated at the lowest possible dose, with close observation for evidence of statin toxicity. Mental Health Medications Antipsychotics: Many antipsychotic medications are metabolized by CYP450, in particular CYP3A4, and thus levels of antipsychotic medications may increase when used concurrently with cobicistat- or ritonavir-containing regimens. Several case reports have highlighted clinically significant adverse effects resulting from combining quetiapine and ritonavir-boosted PI regimens. Since most of the medications in NNRTI class decrease antipsychotic drug concentrations, primarily due to induction of CYP34A and CYP2D6 enzymes, caution is advised with coadministration of these agents; the use of rilpivirine or doravirine is less likely to lead to significant interactions with antipsychotic medications. 8 Common Class Interactions with ARVs Selective Serotonin Reuptake Inhibitors (SSRIs) Levels can be increased or decreased by ARVs BIC, DTG, and RAL do not appear to impact SSRI levels Benzodiazepines Least drug interactions: lorazepam, oxazepam, temazepam Do not use with boosted-regimens, PIs, NNRTIs (benzodiazepine concentration raised): Alprazolam Clonazepam (exception: appears to be safe with NNRTIs) Diazepam https://www.hiv-druginteractions.org; DHHS HIV Guidelines 2021 Mental Health Medications Selective Serotonin Reuptake Inhibitors (SSRIs): Similar to the interactions noted between antiretroviral medications and antipsychotics, SSRIs may also interact with pharmacologic boosters (cobicistat and ritonavir), PIs, and NNRTIs. In general, most SSRIs are safe with concurrent antiretroviral therapy; nonetheless, the effects of coadministration are variable, and treatment should be titrated to response. For example, lopinavir-ritonavir raises paroxetine levels, darunavir given with ritonavir lowers paroxetine levels, and efavirenz does not significantly impact paroxetine levels. Bictegravir, dolutegravir, and raltegravir do not appear to impact SSRI levels. Benzodiazepines: In patients taking a PI, ritonavir, cobicistat, or an NNRTI, the safest benzodiazepines to use are those that are not metabolized via CYP-450; these include lorazepam, oxazepam and temazepam. Drug concentrations of other benzodiazepines, such as alprazolam, clonazepam, and diazepam, are likely to be increased by PIs, boosting agents (ritonavir and cobicistat), and NNRTIs, so these benzodiazepines and antiretroviral medications should not be used concurrently, with the exception that clonazepam appears to be safe in combination with NNRTIs. 9 Drug-Induced Cushing's Syndrome Ritonavir and cobicistat (boosters) Intranasal, inhaled, intra-articular, intramuscular steroid in patients on a boosted regimen Budesonide Fluticasone (available over the counter) Triamcinolone Mometasone Beclomethasone is safe as it is not metabolized by CYP3A4 https://www.hiv-druginteractions.org; DHHS HIV Guidelines 2021 Corticosteroids The risk of significant pharmacokinetic drug interactions between antiretroviral therapy and corticosteroid treatment was first identified in patients taking the inhaled or nasal preparation of the corticosteroid fluticasone. Multiple subsequent reports have documented iatrogenic severe adrenal suppression and Cushing's syndrome in patients (children and adults) concomitantly receiving a corticosteroid and a ritonavir boosted antiretroviral regimen. A similar drug interaction between cobicistat and corticosteroids has been documented. To mitigate these drug interactions in patients taking ritonavir or cobicistat, clinicians should consider using a corticosteroid other than fluticasone or budesonide, such as inhaled or nasal beclomethasone (which is not metabolized by the CYP3A4 enzyme and, thus, does not produce the same interaction). 10 Common Drug Interactions with ARVs: Require Dosage Modification or Cautious Use Antifungals Narcotics & treatment for opioid dependence Ergot alkaloids Antihistamines (astemizole) Hepatitis C NS3/4A protease inhibitors Antiplatelets Oral hormonal contraceptives Erectile dysfunction agents Herbal products (St. John's wort) Acid-lowering medications Anticoagulants Cardiac medications https://www.hiv-druginteractions.org; DHHS HIV Guidelines 2021 11 Drug Interactions with INSTIs Cations all INSTIs Al+, Mg+, Ca+: take INSTI 2 hours before or 6 hours after cations Significant decrease in RAL concentrations if dosed once daily, recommended to do BID dosing if cations needed Multivitamins with minerals Calcium carbonate Raltegravir (RAL) UGT1A1 (primary) Rifampin if RAL must be used, consider RAL 800mg BID www.hiv-druginteractions.org; Clinical Pharmacology; https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv/drug... Calcium carbonate (Tums) 12 Drug Interactions with INSTIs Elvitegravir (EVG)- CYP3A4 (major) & UGT1A1/3 Boosted: Cobicistat CYP3A4 (major) & 2D6 (weak) Avoid use with lovastatin, simvastatin, simepravir, amiodarone, rivaroxaban, apixaban (EVG/c inhibits metabolism) Decrease in EVG/c nevirapine, carbamazepine, phenobarbital, phenytoin, rifampin/rifabutin, St. John's wort Dolutegravir (DTG) & Bictegravir (BIC) - UGT1A1 & some CYP3A4 Rifampin - inducer of UGT1A1 decrease DTG & BIC [DTG can be used BID] Rifabutin- DTG safe. Do not use with BIC Metformin DTG concentration, max metformin 1000mg daily [BIC not affected the same, can use full dose metformin if normal renal function] www.hiv-druginteractions.org; Clinical Pharmacology; https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv/drug... Bictegravir/TAF/FTC & Rifabutin (per hiv-druginteractions.org): Quality of evidence:Very Low Summary: Coadministration is not recommended. Coadministration with bictegravir/emtricitabine/tenofovir alafenamide has not been studied. Coadministration of rifabutin (300 mg once daily) and bictegravir alone (75 mg once daily) decreased bictegravir Cmax, AUC and Cmin by 20%, 38% and 56%, respectively. Furthermore, rifabutin is an inducer of P-gp and is expected to decrease the absorption of tenofovir alafenamide absorption and thereby plasma concentrations. Description: Co-administration is not recommended due to the expected decrease of tenofovir alafenamide. Coadministration of rifabutin (300 mg once daily) and bictegravir (75 mg once daily) decreased bictegravir AUC, Cmin and Cmax by 38%, 56% and 20%, respectively (due to induction of CYP3A and P-gp). The interaction has not been studied with tenofovir alafenamide. Co-administration of rifabutin may decrease tenofovir alafenamide plasma concentrations. Biktarvy Summary of Product Characteristics, Gilead Sciences Ltd, June 2019. Coadministration may decrease concentrations of bictegravir and tenofovir alafenamide. Coadministration with rifabutin is not recommended. Coadministration of rifabutin (300 mg once daily) and bictegravir (75 mg once daily) decreased bictegravir Cmax, AUC and Cmin by 20%, 38% and 56%, respectively. Biktarvy Prescribing Information, Gilead Sciences Inc, August 2019. Dolutegravir & rifabutin (per hiv-druginteractions.org): Quality of evidence:Moderate Summary: Rifabutin has no clinically significant effect on the pharmacokinetics of dolutegravir. Coadministration of rifabutin (300 mg once daily) and dolutegravir (50 mg once daily) increased dolutegravir Cmax by 16%, and decreased AUC and Ctrough by 5% and 30%. No dose adjustment is necessary. Description: Coadministration had no significant effect on dolutegravir exposure (AUC and Ctrough decreased by 5% and 30% due to induction of UGT1A1 and CYP3A, Cmax increased by 16%). No dose adjustment is necessary. Tivicay Summary of Product Characteristics, ViiV Healthcare, March 2019. Based on drug interaction trial results, rifabutin can be coadministered with dolutegravir without a dose adjustment. Coadministration of rifabutin (300 mg once daily) and dolutegravir (50 mg once daily) to 9 subjects increased dolutegravir Cmax by 16%, but decreased AUC and Ctrough by 5% and 30%. Tivicay US Prescribing Information, ViiV Healthcare, July 2019. Coadministration of dolutegravir alone (50 mg once daily) and with rifabutin (300 mg once daily) was evaluated in 9 HIV-negative subjects. Rifabutin decreased dolutegravir AUC by 5% and Ctrough by 30%, but increased Cmax by 15%. The decrease in dolutegravir Ctrough is unlikely to be clinically significant given the known PK/PD relationships and data from phase 2b dose ranging studies. Safety, tolerability, and pharmacokinetics of the HIV integrase inhibitor dolutegravir given twice daily with rifampin or once daily with rifabutin: results of a phase 1 study among healthy subjects. Dooley KE, Sayre P, Borland J, et al. J Acquir Immune Defic Syndr, 2013, 62(1): 21-27. 13 Drug Interactions with PIs All are CYP3A4 substrates Serum levels may be affected by CYP inducers or inhibitors Some PIs are also inducers or inhibitors of other CYP isoenzymes, P-glycoprotein (PGP), or other transporters Darunavir (DRV) CYP3A4 (major), PGP Toxicity- simepravir, simvastatin, lovastatin, red yeast rice, rivaroxaban, quetiapine, colchicine, ubrogepant Rifampin/rifabutin- DRV concentrations Can use rifabutin 150mg once daily www.hiv-druginteractions.org; Clinical Pharmacology; https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv/drug... 14 Drug Interactions with NRTIs NRTIs No hepatic metabolism, however, 3A enzymes play a minor role in tenofovir metabolism example: TAF & rifampin/rifabutin Some NRTIs may interact via other mechanisms Avoid with TAF: Carbamazepine St. John's Wort www.hiv-druginteractions.org; Clinical Pharmacology; https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv/drug... TAF/FTC & rifabutin (per hiv-druginteractions.org): Quality of evidence:Very Low Summary: Coadministration with rifabutin has not been studied.Rifabutin is an inducer and therefore is expected to decrease the exposure of tenofovir alafenamide. Based on a drug-drug interaction study with rifampicin, if coadministration is required the product label recommends using tenofovir 25 mg twice daily. Coadministration of emtricitabine/tenofovir alafenamide (200/25 mg twice daily with bictegravir) and rifampicin (600 mg once daily) in healthy volunteers decreased the AUC of tenofovir and tenofovir-DP by ~14% and 24%, respectively, when compared to once daily administration alone. Of interest, coadministration of emtricitabine/tenofovir alafenamide (200/25 mg once daily) and rifampicin (600 mg once daily) decreased plasma exposure of tenofovir alafenamide and tenofovir by ~55%. Intracellular tenofovir-DP AUC decreased by 36%, however, intracellular tenofovir-DP exposure was 4.2-fold higher than that achieved with standard dose tenofovir-DF alone (300 mg once daily). Thus, this study suggests that use of tenofovir alafenamide 25 mg once daily with rifabutin may be acceptable. Description: The co-administration of Descovy is not recommended with rifabutin. Interaction not studied with either of the components of Descovy. Co-administration of rifabutin, a P-gp inducer, may decrease tenofovir alafenamide plasma concentrations, which may result in loss of therapeutic effect and development of resistance. Descovy Summary of Product Characteristics, Gilead Sciences Ltd, April 2016. Coadministration is expected to decrease concentrations of tenofovir alafenamide and is not recommended. Descovy US Prescribing Information, Gilead Sciences Inc, April 2016. The pharmacokinetics of tenofovir alafenamide and tenofovir diphosphate were determined in healthy volunteers following administration of tenofovir alafenamide alone (25 mg once daily, with emtricitabine) and with rifampicin (600 mg once daily). Rifampicin decreased tenofovir alafenamide AUC and Cmax by 55% and 50%. Plasma tenofovir Cmax, C24 and AUC decreased by 65%, 55% and 54% respectively. Intracellular tenofovir diphosphate (i.e. active entity) concentrations Cmax, C24 and AUC decreased by 38%, 43% and 36%, respectively, but AUC was still 4.21-fold higher than that achieved with standard dose tenofovir-DF alone (300 mg once daily). Rifampicin did not alter emtricitabine pharmacokinetics. Rifampin effect on intracellular and plasma pharmacokinetics of tenofovir alafenamide. Cerrone M, Alfarisi O, Neary M, et al. J Antimicrob Chemother 2019; 74:1670-8. The pharmacokinetics of tenofovir alafenamide and tenofovir diphosphate (TDF-DP) were determined following administration of tenofovir alafenamide alone (25 mg once daily, with bictegravir and emtricitabine) or tenofovir alafenamide (25 mg twice daily, with bictegravir and emtricitabine) and rifampicin (600 mg once daily). Following twice daily administration with rifampicin, the plasma AUC of tenofovir alafenamide and its active intracellular metabolite (TFV-DP) were modestly decreased by ~14% and ~24% when compared to tenofovir alafenamide once daily alone. This modest change is not expected to alter the efficacy of tenofovir alafenamide. Twice daily administration of tenofovir alafenamide in combination with rifampin: potential for tenofovir alafenamide use in HIV-TB coinfection. Custodio JM, et al. 16th European AIDS Conference (EACS). October 2017, Milan, abstract PS13/4. TAF/FTC & rifampin (per hiv-druginteractions.org): Quality of evidence:Very Low Summary: Rifampicin induces the transporters P-gp, BCRP, OATP1B1 which results in lower exposure of tenofovir alafenamide. If coadministration is required, the product label recommends using tenofovir alafenamide 25 mg twice daily. Coadministration of emtricitabine/tenofovir alafenamide (200/25 mg twice daily with bictegravir) and rifampicin (600 mg once daily) in healthy volunteers decreased the AUC of tenofovir and tenofovir-DP by ~14% and 24%, respectively, when compared to once daily administration alone. Of interest, coadministration of emtricitabine/tenofovir alafenamide (200/25 mg once daily) and rifampicin (600 mg once daily) decreased plasma exposure of tenofovir alafenamide and tenofovir by ~55%. Intracellular tenofovir-DP AUC decreased by 36%, however, intracellular tenofovir-DP exposure was 4.2-fold higher than that achieved with standard dose tenofovir-DF alone (300 mg once daily).Thus, this study suggests that use of tenofovir alafenamide 25 mg once daily with rifampicin may be acceptable. Description: The co-administration of Descovy is not recommended with rifampicin. Interaction not studied with either of the components of Descovy. Co-administration of rifampicin, a P-gp inducer, may decrease tenofovir alafenamide plasma concentrations, which may result in loss of therapeutic effect and development of resistance. Descovy Summary of Product Characteristics, Gilead Sciences Ltd, April 2016. Coadministration is expected to decrease concentrations of tenofovir alafenamide and is not recommended. Descovy US Prescribing Information, Gilead Sciences Inc, April 2016. The pharmacokinetics of tenofovir alafenamide and tenofovir diphosphate were determined in healthy volunteers following administration of tenofovir alafenamide alone (25 mg once daily, with emtricitabine) and with rifampicin (600 mg once daily). Rifampicin decreased tenofovir alafenamide AUC and Cmax by 55% and 50%. Plasma tenofovir Cmax, C24 and AUC decreased by 65%, 55% and 54% respectively. Intracellular tenofovir diphosphate (i.e. active entity) concentrations Cmax, C24 and AUC decreased by 38%, 43% and 36%, respectively, but AUC was still 4.21-fold higher than that achieved with standard dose tenofovir-DF alone (300 mg once daily). Rifampicin did not alter emtricitabine pharmacokinetics. Rifampin effect on intracellular and plasma pharmacokinetics of tenofovir alafenamide. Cerrone M, Alfarisi O, Neary M, et al. J Antimicrob Chemother 2019; 74:1670-8. The pharmacokinetics of tenofovir alafenamide and tenofovir diphosphate (TDF-DP) were determined following administration of tenofovir alafenamide alone (25 mg once daily, with bictegravir and emtricitabine) or tenofovir alafenamide (25 mg twice daily, with bictegravir and emtricitabine) and rifampicin (600 mg once daily). Following twice daily administration with rifampicin, the plasma AUC of tenofovir alafenamide and its active intracellular metabolite (TFV-DP) were modestly decreased by ~14% and ~24% when compared to tenofovir alafenamide once daily alone. This modest change is not expected to alter the efficacy of tenofovir alafenamide. Twice daily administration of tenofovir alafenamide in combination with rifampin: potential for tenofovir alafenamide use in HIV-TB coinfection. Custodio JM, et al. 16th European AIDS Conference (EACS). October 2017, Milan, abstract PS13/4. 15 Drug Interactions with NNRTIs NNRTIs Substrates of CYP3A4 can act as inducers (nevirapine) or mixed inducer and inhibitor (efavirenz) Etravirine- 3A4 substrate/inducer, 2C9 & 2C19 substrate/inhibitor Rilpivirine & doravirine- primarily 3A4 metabolism, not inducers/inhibitors Rilpivirine- do not use with PPIs www.hiv-druginteractions.org; Clinical Pharmacology; https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv/drug... 16 www.hiv-druginteractions.org 17 References HIV Guidelines: Drug-Drug Interactions https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv/over... Liverpool HIV Interactions www.hiv-druginteractions.org Clinical Pharmacology (subscription required) www.clinicalkey.com/pharmacology/ 18 Resources National Clinician Consultation Center http://nccc.ucsf.edu/ HIV Management Perinatal HIV HIV PrEP HIV PEP line HCV Management Substance Use Management Present case on ECHO http://echo.unm.edu [email protected] AETC National HIV Curriculum https://aidsetc.org/nhc Hepatitis C Online https://www.hepatitisc.uw.edu/ AETC National Coordinating Resource Center https://targethiv.org/library/aetc-national-coordinating-resource-center-0 Additional trainings [email protected] www.scaetc.org Find additional TeleECHO sessions in your area: https://echo.unm.edu/locations-2/echo-hubs-superhubs-united-states/ https://hsc.unm.edu/echo/get-involved/join-an-echo/ IDEA Platform: Infectious Diseases Education & Assessment. https://idea.medicine.uw.edu/ AETC National HIV Curriculum: 6 core modules for self study; regularly updated; CME, CNE Hepatitis C Online Curriculum: https://www.hepatitisc.uw.edu/ Hepatitis B Online Curriculum: https://www.hepatitisb.uw.edu/ National STD Curriculum: https://www.std.uw.edu/ 19