Blood borne viruses

Question 1

how are BBVs spread

Answer 1

by blood/bodily fluids including semen, vaginal secretions and breast milk

Question 2

name the three main BBVs

Answer 2

hep B and C

HIV

Question 3

give examples of professions in which there is contact with bodily fluids and as such risk of BBV transmission

Answer 3

health care
emergency services
lab work
mortuary
prisons
hairdresser/beautician
plumbing
tattoing/piercing

Question 4

describe the common course of Hep B infection

Answer 4

acute infection for 1-3 months

then 1/20 of those people will be affected by a chronic infection defined as >6 months duration

Question 5

what are the complications of hep b

Answer 5

cirrhosis

liver cancer

Question 6

how is hep b treated

Answer 6

antiviral (tenofovir or entecavir)
or immunomodulator (interferon alpha)

Question 7

what is the most common reason for hepatitis C infection

Answer 7

drug use

Question 8

how long does the acute infection last for

Answer 8

up to 6 months

Question 9

what proportion of people infected with hep c remain chronically infected

Answer 9

75 percent

Question 10

how many genotypes of hep c are there and which are the most curable with antiviral medication

Answer 10

genotypes 1,2,3

genotypes 1 - 50 percent will be cured with medication

genotypes 2,3- 80 percent are cured with medications

Question 11

what are the long term complications of hep c

Answer 11

cirrhosis and liver cancer

Question 12

What proportion of people infected with HIV are unaware

Answer 12

1 in 4

Question 13

what is the commonest route of infection in the uk of HIV

Answer 13

sexual intercours

Question 14

what affects the chances of infection transmission

Answer 14

viral load is proportional to chance of infection

Question 15

how is HIV treated

Answer 15

HAART

Question 16

what is the typical course of HIV infection

Answer 16

seroconvesion illness two to six weeks following infection (avg 15 days) - flu like illness
asymptomatic for up to 10 years
Symptomatic is characterised by opportunistic infections and certain cancers = AIDS

Question 17

describe the current nice guidelines for referring/treating infertile couples

Answer 17

Offer couple further clinical assessment afte 1 yr of not conceiving
Offer earlier if:
female older than 36
known pathology e.g. vasectomy, tubal blockage
apparently no chance of pregnancy with expectant management

offer IVF treatment after 2 yrs for unexplained infertility

Question 18

Under which aspect of the nice guidelines of treatment of BBV patients fit under`

Answer 18

‘apparently no chance of pregnancy with expectant managment’ –>as such can be offered treatment straight away

Question 19

What investigations are typically done prior to IVF

Answer 19

day 21 progesterone
rubella immunity 
chalmydia
gonorhea
TV/BV/candida/syphillus
FSH/LH/E2
Testosterone, SHBG, FAI
prolactin
HSG/hycosy/laparoscopy and HTB to check tubal patency

Question 20

what abnormality is more common in HIV pts

Answer 20

hydrosalpinx (4o percent of HIV positive patients)

Question 21

what abnormalities in sperm are seen in HIV pts

Answer 21

lower sperm motility
semen parameters not significantly different where detectable/undetectable viral load
significant correlation between CD4 count and sperm count and progressive motility
no correlation between CD4 count and sperm morphology

Question 22

what affect does haart have on sperm parameters

Answer 22

lowers sperm count, lower motility and higher percentage abnormal forms

Question 23

how is the risks of BBV transmission minimised in the ACU

Answer 23

hep B immunisation to staff
USS probe decontaminated
theatre
gametes/embryos handles and stored separately to non BBV

Question 24

give the advantages of IUI in these patients

Answer 24

less invasive than ivf

cheaper

Question 25

what are the disadvantages of IUI

Answer 25

need good sperm parameters low success rate cycle will be cancelled if more than three follicles more than 14mm (risk of multiple pregnancy)

Question 26

what is the success rate of IUI

Answer 26

13 percent per transfer per treatment cycle

Question 27

how is sperm prep done for BBV patients

Answer 27

Integral part of IUI +/- superovulation / IVF / ICSI 1. Density gradient preparation by centrifugation through viscous media (usually 40% / 80%) Puresperm used clinically (Colloidal silica suspension in isotonic salt solution) 2. Pellet washed 3. Followed by swim-up 4. Test for VL

Question 28

what is the difference between HIV virus RNA present in semen vs blood

Answer 28

generally levels are lower in semen (10 times lower)

Question 29

what is done to the sperm to reduce risk of transmission of HIV

Answer 29

sperm washing

Question 30

what percentage of men with undetectable viral load using HAART had virus detected in their semen pre and/or post sperm wash

Answer 30

9.7 percent

Question 31

what is the best indicator for reducing (if not elimating0 risk of transmission of HOV

Answer 31

reducing or elimating viral load

Question 32

when is sperm washing primarily used

Answer 32

IUI

Question 33

what services are offered in ninewells

Answer 33

sperm washing + IUI IVF/ICSI don't do : TUPSI, PrEP

Question 34

how often is peginterferon alpha taken for hep b

Answer 34

weekly injection for 12 months

Question 35

what further steps must be taken in case of patients with hep b

Answer 35

immunise seronegative partner | consider deferring ART to see if acute infection clears

Question 36

what blood result indicated current hep b infection (acute or chonic)

Answer 36

HBsAg | Anti-HBc positive

Question 37

what blood results indicate a previous infection but the person is now immune

Answer 37

Anti HBc and Anti HBs positive

Question 38

what blood results indicate a vaccinated person

Answer 38

antiHBs positive

Question 39

how are patients with hep c treated

Answer 39

refer to hepatologist pegylated inferferon and ribavirin will take 24/48 weeks to erradicate depending on serotype no current immunisation but sexual transmission risk is low

Question 40

how long should a pregnancy be avoided after hep c treatment

Answer 40

6 mths

Question 41

what are the treatment options of a HIV positive male

Answer 41

``` if no HAART/detectable VL: sperm washing then IU/IVF/ICSI HIV test for female 4/52 post treatment DI adoption ``` if HAART/undetectable VL for more than 6mths: options as above TUPSI - monthly HIV test for female partner consider PrEP

Question 42

what is the risk of HIV transmission be receptive vaginal intercourse per exposure

Answer 42

0.1 percent recepive anal intercourse is 10x higher and insertive vaginal or anal intercourse is much lower

Question 43

So what would be the avg HIV transmission risk over a course of TUPSI

Answer 43

3 percent (taking into account 5 exposures per cycle and average of 6 cycles to conceive)

Question 44

what is the dangers of having seroconversion illness in pregnancy

Answer 44

high risk of in utero transmission to fetus

Question 45

what is PreP

Answer 45

post exposure prophylaxis

Question 46

when should prep be started

Answer 46

within 72 hours of risk

Question 47

how long is a course of prep

Answer 47

28 days

Question 48

what are the negatives of Prep and why is it not widely used

Answer 48

may create viral resistance toxicity cost

Question 49

when may prep be useful

Answer 49

in reducing HIV transmission in high risk people: MSM, sero discordant couples, high risk women/men however still only used experimentally or in the special circumstance of conception

Question 50

how is a HIV positive female treated

Answer 50

if not on treatment: self insemination if HAART: self insemination can consider TUPSI if VL undetectable for more than 6 months and normal fertility screen - monthly test for male partener if no conception at 6/12 refer to ACU for IVF/ICSI

Question 51

what is the problem with HIV positive male and female and why can they not have UPSI?

Answer 51

theoretical risk of HIV superinfection however not reported in cohort studies

Question 52

is TUPSI acceptable in HIV positive male and female

Answer 52

yes

Question 53

when can TUPSI not be used in cases where the male and female is HIV +

Answer 53

if either partner has a detectable drug resistant virus if female- recommend self insemination if male- offer sperm washing