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HIV Flashcards

1
Q

How many new cases of HIV are diagnosed annually?

A

650000 - 1.5 million

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2
Q

How many people in total have died due to HIV?

A

> 40 million

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3
Q

In high burden HIV settings who should be offered routine HIV testing?

A

HIV testing should be offered to all populations and in all services (for example, services for sexually transmitted infections, hepatitis, TB, children under five, immunization, malnutrition, antenatal care and all services for key populations) as an efficient and effective way to identify people with HIV.

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4
Q

What diagnostics should be used to diagnose children under the age of 18 months with suspected HIV?

A

Point of Care NATs

**Cannot use antigen/antibody or antibody tests at these age, because maternal antibodies can still be found in infant blood up to 18 months; would give you a false +ve result

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5
Q

What three infectious diseases should all pregnant woman be screened for as early as possible/

A

HIV
syphilis
hepatitis B (surface antigen (HBsAg)a)

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6
Q

What is the WHO three test-strategy?

A

all people in low prevelence areas (<5%) presenting for HIV testing services should have three consecutive reactive test results in order to receive an HIV-positive diagnosis.

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7
Q

What is the WHO two-test strategy?

A

all people in high prevalence areas (>5%) presenting for HIV testing services should have two consecutive reactive test results in order to receive an HIV-positive diagnosis.

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8
Q

How can you reduce risk of HIV spreading within populations?

A
  • encourage condom use
  • offer safe needle exchanges for injecting drugs users
  • Voluntary Male Medical Circumcision
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9
Q

Apart from regular oral PrEP, what simple device can be given to women who are at high risk of acquiring HIV (i.e. transactional sex)

A

dapivirine vaginal ring

(An insert which contains locally acting prep; contains an NNRTI)

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10
Q

What is the recommended regime for PEP?

A

TDF + 3TC/FTC + DTG

Tenofovir + Lamivudine / emtricitabine + Dolutegravir

OD for 28/7

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11
Q

What is TDF?

A

Tenofovir

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12
Q

What is 3TC?

A

Lamivudine

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13
Q

What is FTC?

A

Emtricitabine

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14
Q

What is DTG

A

Dolutegravir

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15
Q

What is the recommended PEP regime in children under 10?

A

AZT/ZDT + 3TC + DTG

AZT/ZDV: Zidovudine + Lamivudine + Dolutegravir

Tenofovir is used as a rescue drug rather than first line in kids

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16
Q

What is AZT/ZDV

A

Zidovudine

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17
Q

What is the most effective way to reduce maternal transmission of HIV?

A

Early ART –> reduce viral load as much as possible

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18
Q

What chemoprophylaxis should be given to infants of mothers with HIV?

A

Daily NVP for 6/52

Nevirapine

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19
Q

What is NVP?

A

Nevirapine

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20
Q

When should ART be commenced in the context of TB co-infection?

A

within two weeks of initiating TB treatment, regardless of CD4 cell count, among people living with HIV

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21
Q

When should ART be commenced in the context of Cryptococcal meningitis co-infection?

A

Immediate ART initiation is not recommended for adults, adolescents and children living with HIV who have cryptococcal meningitis because of the risk of increased mortality

Treatment should be deferred by 4–6 weeks from the initiation of antifungal treatment

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22
Q

What test should you use to monitor HIV progress?

A

Viral Load

If viral load not available then CD4 count and clinical monitoring is advised

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23
Q

How often should you check the viral load in a patient?

A

6 months –> 12 months
Can continue 12 monthly is established on a good ART regime

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24
Q

How should you diagnosis Cryptococcal meningitis in HIV +ve patients?

A

prompt lumbar puncture with measurement of CSF opening pressure
cryptococcal antigen assay (CrAG)

** if CrAG not available then use India Ink test

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25
Q

When should you Screen for cryptococcal infection in HIV +ve patients?

A

When CD4 count is <100

Consider starting prophylactic antifungal (fluconazole) prior to starting ART if CrAg is positive but NO EVIDENCE of meningitis

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26
Q

What are the side effects of L-AMB?

A

hypokalaemia,
nephrotoxicity and anaemia

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27
Q

How do you treat Cryptococcal meningitis?

A

INDUCTION: 1/52 of:
- Liposomal Amphotericin B (STAT) + Flucytosine (100mg/kg/day in 4 divided doses)
+ Fluconazole 1200mg

CONSOLIDATION: 8/52 of:
Fluconazole 800mg OD
±

MAINTENANCE longterm fluconazole 200mg OD if CD4 continues to be low (<200) and viral load is managed

**Taken from updated WHO guidelines 2022

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28
Q

Are steroid recommended in the acute management of cryptococcal meningitis?

A

No - not recommended

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29
Q

What is the gold standard diagnostic for Histoplasmosis?

A

Serum Histoplasma antigen test

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30
Q

How do you manage Histoplasmosis infection?

A

Liposomal Amphotericin B 3mg/kg for 2/52
+
Itraconazole 200mg BD for 12/12 (Less than 12 months of therapy can be considered when the person is clinically stable, receiving ART, has suppressed viral load and the immune status has improved)

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31
Q

When should HIV +ve patients be given co-trimoxazole?

A
  1. HIV +ve people (including pregnant women) in malaria endemic areas
  2. General population (including pregnant women) with WHO stage 3/4 disease or CD4 <350
  3. All infants, children and adolescents with HIV, irrespective of CD4 count/disease status
  4. HIV and concurrent active TB
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32
Q

When and how should you screen HIV patients for TB?

A

At every clinical encounter

Screen using the 4 symptoms screening tool:
? Fever
? Cough
? Weight loss
? Night sweats

±CRP (<5)
±CXR (can be reported by automated system)

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33
Q

What can be used to treat LTBI infection in HIV +ve patients

A

Treatment is the same as the general populations

6/12 or 9/12 Isoniazid
3/12 Rifampicin/isoniazid daily
3/12 Rifapentine/isoniazid weekly

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34
Q

What chemoprophylaxis should be offered to HIV patients who are at high risk of TB (i.e. endemic area)

A

36/12 Isoniazid (daily)

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35
Q

Which ART is recommended in HIV/HBV co-infection?

A

Tenofovir

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36
Q

Which anti-malarial ACT should be avoided in HIV +ve people on co-trimoxazole

A

Artesunate - sulfadoxine-pyrimethamine (SP)

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37
Q

Which treatment should be used in patients with HIV + Visceral Leishmaniasis?

A

Liposomal amphotericin B + miltefosine regimen

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38
Q

Should HIV+ve women breastfeed?

A

Mothers living with HIV should breastfeed for at least 12 months and may continue breastfeeding for up to 24 months or longer (similar to the general population) while being fully supported for ART adherence

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39
Q

How can you encourage adherence to ART?

A
  • peer counsellors
  • mobile phone text message reminders
  • reminder devices
  • cognitive behavioural therapy
  • behavioural skills training or medication adherence training
  • fixed-dose combinations and once-daily regimens
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40
Q

What kind of virus is HIV?

A

RNA Retrovirus

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41
Q

What two strains of HIV are there?

A

HIV-1 (common)
HIV-2 (uncommon; <5% of cases, West Africa only)

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42
Q

What are the main virological components of the HIV Virus?

A

Enveloped, conical nucleocapsid
Main enzymes: Reverse transcriptase, integrase, protease
Main glycoproteins: gp120, gp41

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43
Q

Why can you never completely eradicate HIV?

A

The virus replicates rapidly initially and develops reservoirs in latent immune cells and in anatomical sanctuary sites, meaning you can never completely get rid of it. As soon as you stop ART the virus will re-start to replicate

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44
Q

What is the 95-95-95 UNAIDS target?

A

95% of people know their HIV status
95% of people with confirmed HIV are on ART
95% of people on ART are virally supressed

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45
Q

Describe how the HIV virus replicates.

A
  1. HIV virus binds to a CD4 cell/ onto CCR5 or CXCR4 chemokine co-receptor
  2. When the HIV binds to the CCR5 or CXCR4 cell there is a conformational change which allows the HIV to fuse with the host cell, releasing the nucleocapsid of the Virus into the CD4 cell
  3. RNA of the virus is reverse transcribed into DNA by Reverse Transcriptase in the cytoplasm of the cell

NB: Replication is not able to occur until the T cell is activated in response to the HIV antigens

  1. The virus is then uncoated and the DNA of the virus is able to travel across the nucleus and integrate into the hosts DNA using integrase
  2. The virus is then able to mature and bud onto the cell membrane of the host cell. Protease breaks down the poyproteins within the virus and allows it to mature.

SO BASICALLY:
HIV –> binds on CXCR4/CCR5 –> opens up cell for HIV to invade –> Reverse transcriptase –> integrase –> protease

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46
Q

Which MHC class do CD4 cells belong to?
CD8?

A

CD4 = MHC2
CD8 = MHC1

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47
Q

What do CD4 cells do?

A

1- Help CD8 T cells (anti-viral responses)
2- Help B cells create an antibody response
3- Immune regulation
4- Macrophage activation

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48
Q

On which cells is CD4 espressed?

A

T cells (CXCR4 and CCR5)

Macrophages (CCR5)

Dendritic Cells (CCR5)

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49
Q

Which part of the body contains the most CD4 cells?

A

The gut lumen

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50
Q

Which binding sites on the CD4 cell does the HIV virus bind to via gp41/gp120?

A

CXCR4
CCR5

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51
Q

What is the incubation period of HIV?

A

variable
anywhere from 1-10 years

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52
Q

How does HIV seroconversion present?

A

Fever
Rash (variable appearance)
Pharyngitis
Lymphadenopathy

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53
Q

What two genetic mutations can confer some protection against HIV?

A

HLA-B57 allele
CCR5-delta-32 mutation

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54
Q

According to the WHO, what is Stage 1 disease of HIV?

A

Asymptomatic

May have lymphadenopathy

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55
Q

According to the WHO, what is Stage 2 disease of HIV?

A

Mild weight loss <10%
Fungal nail infections
Angular cheilitis
recurrent resp. infections
Herpes Zoster

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56
Q

According to the WHO, what is Stage 3 disease of HIV?

A

Severe weight loss >10%
Chronic diarrhoea
Chronic fever
Oral hairy leukoplakia
Oral candidiasis
pulmonary TB

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57
Q

According to the WHO what is stage 4 disease of HIV?

A

Presentation with OIs

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58
Q

What is the mechanism of action of Neucleoside Reverse Transcriptase Inhibitors? (NRTIs)

A

Competitively inhibit
reverse transciptase;
Incorporation into DNA
causes chain termination

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59
Q

What is the mechanism of Non-Nucleoside reverse transcriptase inhibitors?

A

Bind to and inactivate
reverse transcriptase

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60
Q

What is the mechanism of action of Integrase inhibitors?

A

Block the action of integrase, a viral enzyme that inserts the viral genome into the DNA of the host
cell

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61
Q

What is the mechanism of action of Protease inhibitors?

A

Interfere with post-
translational processing of HIV-1 precursor proteins

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62
Q

How does the 4th Generation HIV test work?

A

Tests for HIV Antibody and p24 antigen

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63
Q

What is the window period for the 4th generation HIV test?

A

14 days

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64
Q

What RDTs are available for diagnosing HIV??

A

RDT - INSTI (poor at picking up outlier groups

RDT-OraQuick (good to use in areas of high prevalence)

RDT - 4th generation Antigen/antibody test

65
Q

How do you calculate Sensitivity of a test?

A

Number of true positives / total with illness

TP / TP+FN

66
Q

How do you calculate Specificity of a test?

A

Number of true negatives / total without illness

TN/FP+TN

67
Q

How do you calculate the Positive Predictive Value?

A

the proportion of positive results which are true positive

(TP / TP + FP)

68
Q

How do you calculate the negative predictive value?

A

The proportion of negative results which are true negative

(TN / TN +FN)

69
Q
  • You are practicing Tropical Medicine in Swaziland
  • You have the results of an evaluation of a new RDT compared to gold standard laboratory diagnosis.
  • What is the diagnostic sensitivity of the RDT?
A

99%

70
Q
  • You are practicing Tropical Medicine in Swaziland
  • HIV prevalence is 27%.
  • Alice tests positive on your new RDT.
  • What is the probability she truly has HIV? (PPV)
A

95%

71
Q
  • You move to practice Tropical Medicine in Darwin, Northern territories, Australia.
  • HIV prevalence is 0.1%.
  • Mary tests positive on your RDT.
  • What is the probability she truly has HIV?
A

85%

72
Q

What are examples of NRTIs?

A

Tenofovir (TDF or TAF),
abacavir (ABC)
Zidovudine (ZDV or AZT)
Stavudine (d4T)
Lamivudine (3TC)
emtricitabine (FTC)

73
Q

What are examples of NNRTIs?

A

Efavirenz (EFV)
nevirapine (NVP)

74
Q

What are examples of Protease inhibitors?

A

Lopinavir (LPV)
darunavir (DRV),
atazanavir (ATZ) (Ritonavir as booster)

75
Q

What booster is required if you are using protease inhibitors?

A

Ritonavir

76
Q

What are examples of Integrase Inhibitors (INSTIs)

A

Raltegravir (RAL)
Dolutegravir (DTG)

77
Q

What HIV ART should you start?

A

E.g. TDF + FTC + DTG
ABC + 3TC + RAL

  • Current gold standard is a three drug combination of an NRTI “backbone” with a third agent from a different class
  • Main NRTI combinations:
    Tenofovir disoproxil fumarate + emtricitabine (TDF/FTC)
    Abacavir + lamivudine (ABC/3TC)
  • Third agent:
    Integrase inhibitors (preferred)
    NNRTIs
    Protease inhibitors with booster
  • Consider opportunistic infection prophylaxis
78
Q

Which NRTIs also have activity with Hep B?

A

TDF/TAF (Tenofovir)
3TC (Lamivudine)
FTC (Emtracitabine)

79
Q

Which classes of HIV drugs do not work against HIV-2?

A

NNRTIs

80
Q

Which HIV classes of drugs is most robust against mutation?

A

Protease Inhibitors
INSTIs

81
Q

What additional baseline investigations should you do in a newly diagnosed HIV patient?

A
  • HIV confirmatory test
  • CD4 count and viral load
  • HIV resistance test
  • Hepatitis A IgG
  • Hep B, C, syphilis screens
  • Measles/mumps/rubella, VZV IgG
  • FBC/U+E/LFT/bone profile
  • Lipids, HbA1c
  • STI screen
  • Cervical cytology
82
Q

How often should you check viral load and CD4 after newly starting a patient on ART?

A

Viral Load:
1, 3 and 6 months
- If no significant improvement at month 1 then repeat at month 2

CD4:
At 3 months
- repeat at 6m if <350

83
Q

What drug is used as PrEP?

A

Truvada (Tenofovir + Emtricitabine)
TDF +FTC

Dapivirine vaginal ring in low resource settings in women at high risk

84
Q

Which HIV drug must be taken with food?

A

Rilpiverine (NNRTI)

85
Q

Which HIV drugs cause low mood?

A

Efavirenz (NNRTI)

86
Q

Which HIV drug is assocaited with osteopenia?

A

Tenofovir (TDF) (but antacids reduce the bioavailability so make sure you space them out)

87
Q

Which diabetic medication does Dolutegravir interact with?

A

Metformin

88
Q

NOT A FLASH CARD JUST A FACT:

  • Ritonavir interacts with almost everything
  • Rifampicin interacts with almost everything
A
89
Q

Why is HIV so prone to developing drug resistance?

A
  • Untreated HIV replicates around 1 billion times/day/ host
  • Reverse transcription is error prone
  • Mutational evolutionary rate is very high
  • Inadequate suppressive drug= rapid emergence of resistance
90
Q

What is the preferred first line ART combination?

A

o Tenofovir (TDF) + Emtricitabine (FTC) + Integrase inhibitor (preferred) OR NNRTI OR Protease inhibitor with booster
o Abacavir (ABC) + Lamivudine (3TC) + Integrase Inhibior (preferred) OR NNRTI OR protease inhibitor with booster

o SOME EVIDENCE THAT DOUBLE THERAPY CAN WORK IN PATIENTS WITH A GOOD CD4 COUNT >200, VL <500 000, NO HISTORY OF RESISTANT MUTATIONS AND NO CONCURRENT HEPATITIS B INFECTION
 Lamivudine/dolutegravir
 Rilpiverine/dolutegravir

MAIN WHO RECOMMENDATION:
tenofovir disoproxil fumarate (TDF) + lamivudine (3TC) (or emtricitabine, FTC) + efavirenz (EFV) 600 mg

91
Q

What is the preferred second like ART combination if ?? resistance?

A
  1. Change NRTI: (TDF or ABC) <-> AZT
  2. Keep lamivudine (3TC) or emtricitabine (FTC)
  3. Change third drug: from dolutegravir to a protease inhibitor (ATV/r or LPV/r) or from NNRTI to dolutegravir
92
Q

What is the WHO definition of Case Failure?

A
  • Viral load >1000 copies/ml
  • Confirmed on second test after 3 months (unless NNRTI, switch immediately)
  • Adherence support at all visits
  • If >50 copies/ml, repeat within 3 months
93
Q

Which of the following are true?

A. CD4 T cells recognise peptides
bound to MHC class I and CD8 cells
recognise peptides bound to MHC
class II

B. CD4 T cells recognise peptides
bound to MHC class II and CD8
cells recognise peptides bound to
MHC class I

C. CD4 T cells can recognise peptides
bound to MHC I and MHC II

D. No idea

A

B

94
Q

What are 4 functions of the T - Cell?

A

Help B Cells
Help CD8 cells
Activate macrophages
Mediate the immune response

95
Q

What proportion of your T cells are in
peripheral blood?
A. 0.2-1%
B. 2-5%
C. 10-20%
D. 40-60%
E. >70%

A

B

96
Q

Which contains the greatest proportion of total body T cells?
A. Bone marrow
B. Blood
C. Vascular endothelium
D. Mucosal surfaces
E. Lymphatics
F. Lymph nodes

A

D

97
Q

What is IRIS?

A

Immune reconstitution inflammatory
syndrome (IRIS)

  1. Inflammatory signs or symptoms
  2. Recent initiation, re-initiation, or change to a more effective combination ARV therapy
  3. Increase in CD4 count and/or decrease in viral load

+

The following have been excluded:
– Worsening of known infections due to inadequate or inappropriate therapy
– New infections not known to be associated with IRIS (e.g., bacterial sepsis)
– Medication reaction

98
Q

What are the 5 most common fungal infections in HIV +ve patients with poor control of viral load?

A

Cryptococcus
Histoplasmosis
Candida
PCP
Aspergillus

99
Q

What is the CD4 count likely to be if this spreads to the oesophagus?

A

This is oral candidiasis

If it progresses to oesophageal candidiasis

WHO Stage IV
CD4 <100

100
Q

What is the most likely causative spp. in Oral Candidiasis?

A

Candida Albicans

Others: C glabrata, C krusei, C
dubliniensis, C parapsilosis, C tropicalis

101
Q

How do you manage candidias?

A

Oral: Nystatin, Fluconazole 100mg OD

Oesophageal: Fluconazole 100-400mg for 3/52

102
Q

When should you screen patients for CrAG?

A
  1. New diagnosis of HIV, prior to starting ART
  2. When CD4 <100
    ± can consider when CD4 <200
103
Q

What antifungal chemoprophylaxis is recommended in patients with a CD4 count <100, to help prevent Cryptococcal meningitis?

A

Fluconazole primary prophylaxis:

800-1200 mg/day for 2 weeks,
followed by 800 mg/day for 8 weeks

104
Q

What are side effects of IV amphoterecin?

A
  • Nephrotoxicity
  • Anaemia
  • Infusional reactions
  • Thrombophlebitis
  • Nosocomial sepsis
  • Electrolyte disturbances
105
Q

What are side effects of IV amphoterecin?

A
  • Nephrotoxicity
  • Anaemia
  • Infusional reactions
  • Thrombophlebitis
  • Nosocomial sepsis
  • Electrolyte disturbances
106
Q

There are three phases of Treatment in Cryptococcal Meningitis. What are they?

A

Initiation
Consolidation
Maintenance

107
Q

What is the management in the initiation phase of Cr. Meningitis?

A

INITIATION:
Amp B 10mg/kg + Flucytosine + Fluconazole for 2/52

108
Q

What is the management of the CONSOLIDATION phase of cryptococcal meningitis?

A

8 weeks fluconazole 800mg/day

109
Q

What is the management in the MAINTENANCE PHASE of cryptococcal meningitis?

A

Fluconazole 200mg OD for 12/12
+
CD4>100

110
Q

Should you use steroids in Cryptococal meningitis?

A

NO - no improvement in symptoms and increased adverse events

111
Q

What other things are important in managing Cryptococcal meningitis?

A
  1. Antifungals
  2. ART
    * If ART experienced: continue (but consider treatment failure)
    * If ART naïve: DELAY initiation of ART by 4-6 weeks
  3. Therapeutic LPs
112
Q

How does histoplasmosis present?

A

**Very very similar to TB

Already disseminated in >95% patients
* Usually subacute (1-2 months)
* Cough, dyspnea, fever, wt loss
* Miliary reticulonodular pattern on CXR
* Diarrhoea, abdo pain due to colonic ulceration
* Lymphadenopathy, hepatosplenomegaly
* Cytopenias due to BM infiltration

113
Q

How do you diagnose histoplasmosis?

A

Microscopy and culture of blood/tissue/sputum/bone marrow

RDT

**diagnosis is HARD so you need to have a high index of suspicion

114
Q

How do you manage histoplasmosis?

A

Liposomal Amphotericin B + Itrazconazole

ART ASAP (Avoid Efavirenz and Nevirapine as CYP3A4 induction is likely)

115
Q

What is Aspergillosis?

A

Fungal infection which can cause invasive disease in patients

Assocaited with haemoptysis from lung haemorrhages

116
Q

What are the symptms of Aspergillosis

A
  • Cough 92%
  • Fever 91%
  • Dyspnoea 65%
  • Chest pain 24%
  • Haemoptysis 9%

(Can be hard to differentiate from Histoplasmosis, PCP and from TB)

117
Q

What are imaging findings in Aspergillosis?

A

X-ray: Moon in Crescent finding (Aspergilloma)
CT: Tree in Bud
CT: Halo sign (from pulmonary. haemorrhages)

118
Q

How is aspergillosis diagnosed?

A

REALLY challenging to diagnose as aspergillus spp. can be commensal/ not causing the disease picture

Microscopy
Culture
Histopathology

119
Q

How do you manage aspergillosis?

A
  1. Prompt ART management
  2. Voriconazole 6-12 weeks

**Fluconazole and Ketoconazole do not work; aspergillus is inherently resistant

120
Q

How does PJP present?

A

Persistent non-productive cough, chest
tightness, night sweats, progressive SOB, small volume haemoptysis

121
Q

A NOTE:

An HIV +ve patient presenting with a cough??? First rule out TB, then think PCP, then think Histoplasmosis or Aspergillosis

A
122
Q

How do you diagnose PJP in HIV?

A

CXR
Sputum BAL –> microscopy
(Hard to culture)
PCR of respiratory fluid

123
Q

What does a CXR show in PJP?

A

Bilateral symmetrical infiltrates +/- peripheral sparing

124
Q

How do you manage PJP?

A

Co-trimoxazole
+ ART
±Prednisolone

125
Q

When should you offer prophylaxis for PCP?
What is the medication of choice?

A

CD4<200
Co-trimoxazole

126
Q

Give 7 differentials for the following case:

27M, HIV status unknown, who has a 10/7 hx of myalgia fatigue, sore throat, and a 1/7 history of headache, meningism.

A

Infectious
* Viral meningitis
* Viral encephalitis
* TBM
* Listeria meningitis
* Fungal meningitis – crypto
* Partially treated bacterial meningitis
* Parameningeal infections - (cerebral abscesses)
* Syphilis
* HIV (esp. seroconversion)
* Autoimmune encephalitis
* Drugs eg NSAIDs, antibiotics
* ADEM (acute demyelinating
encephalomyelitis)
* Multiple Sclerosis
* Neoplastic/ paraneoplastic
* Sarcoid
* Vasculitis
* Other autoimmune disorders eg SLE

127
Q

What are the main causes of Meningitis in HIV?

A

Aseptic (seroconversion)
Bacterial (Meningococcal, pneumococcal)
Cryptococcal
Tuberculosis

128
Q

Name three causes of a brain mass in the context of HIV?

A

Toxoplasmosis
Cryptococcus
Tuberculosis

129
Q

What is Toxoplasmosis?

A
  • Cerebral disease associated with
    immunosuppression
  • HIV
  • Transplant recipients
  • Haematological malignancies
  • Immunomodulatory drugs
  • AIDS defining illness
  • Usually CD4 <100 cells/mm3
  • It is very rare at CD4 >200
  • In HIV +ve with CD4 <100 cells/μl & T.gondii seropositive:
  • 30% probability of developing reactivated toxoplasmosis if
    effective prophylaxis is not taken
130
Q

How does toxoplasmosis present?

A

Subacute
Headache, confusion
Fever
focal neuro deifecits
Seizure

± Eye signs, cardiac or pulmonary involvement

131
Q

How do you diagnose toxoplasmosis?

A

MRI
CTB - peripherally enhancing lesion
CSF Serology (IgG - chronic - for Toxo)

90% probability of toxoplasma encephalitis if HIV+ve CD4<100 AND
1. Toxo IgG positive
2. No effective prophylaxis was being taken
3. Multiple ring enhancing lesions on the neuroimaging

132
Q

How do you manage toxoplasmosis?

A
  • Pyrimethamine 50-100mg od plus
  • Sulphadiazine 4-6g od

OR

  • Pyrimethamine 50-100mg plus
  • clindamycin 600mg qds
133
Q

What is the biggest risk factor for vertical transmission in HIV?

A

High Maternal Viral Load

** In resource poor settings at least 50% of vertical transmission occurs during breastfeeding

134
Q

What are the 4 prongs of the WHO PMTCT approach to reduce vertical transmission of HIV?

A
  1. Primary prevention of HIV infection among women of childbearing age.
  2. Preventing unintended pregnancies among women living with HIV.
  3. Preventing HIV transmission from pregnant women living with HIV to their infants.
  4. Providing appropriate treatment, care and support to mothers living with HIV and their children and families.
135
Q

What prophylaxis should HIV - exposed infants be given?

A

6/52 of NVP if mother is on ART
12/52 NVP if mother has high viral load/poor HIV control

+ Co-trimoxazole after 6 weeks in all infants who continue to be breastfed

136
Q

When should HIV +ve children receive isoniazid prophylaxis against TB?

A
    1. Contacts are given INH for 6m
    1. Infants < 12m: with TB contact who are investigated and are not infected should still receive 6m preventative therapy
    1. Children > 12m: should receive routine INH prophylaxis for 6m. There should be facilities for monitoring for TB and regular follow up.
    1. INH should be given for each exposure to TB
    1. Children who have completed TB therapy may recieve 6m additional INH
137
Q

What is the first line ART in paediatrics?

A

ABC + 3TC + DTG

138
Q

What is the first line ART in neonates?

A

AZT + 3TC + RAL

139
Q
  • 38M
  • MSM
  • HIV on TDF/FTC + DRV(r) for 12 months
  • Nadir CD4 150; latest CD4 325
  • VL < 30
  • 10 day history of diarrhoea and fever
  • Opening bowels 6x a day, small volumes of stools with blood
  • No laboratory support is available locally

Is this acute or chronic diarrhoea?
What region of the GI tract is implicated?

A

Acute (Chronic is >14 days)
Lower GI tract (dysentery)

140
Q

What is the differential diagnosis for diarrhoea in HIV +ve?

A

Shigella
Campylobacter
Giardia
E Coli
iNTS

141
Q

How do you treat presumed bacterial enteric infections in HIV?

A
  1. Start ART
  2. Ciprofloxacin 500mg BD for 5-7 days
142
Q

Name 5 causes of chronic diarrhoeal illness in HIV

A
143
Q

What classic eye sign is seen in disseminated CMV infection in HIV?

A

Margarita pizza retinopathy

144
Q

How does CMV present?

A

Chronic diarrhoea
Retinitis
Colitis
Oesophagitis
Pneumonitis
Encephaltis

(bascially

145
Q

How can you diagnose CMV?

A

Look for disseminated disease

  1. Histology (‘Owl Eye’ appearance from Inclusion bodies in cells)
  2. Serology
  3. PCR

You can get the samples from anywhere that you think the disease is present

146
Q

How do you manage CMV?

A

Ganciclovir

147
Q

What infectious cause is the leading cause of death in HIV?

A

Tb Co-infection

148
Q

How should you diagnose TB in HIV+ve patients?

A

Urinary LAM
Blood cultures (increased risk of TB Bacteraemia)

149
Q

Name 5 causes of breathlessness in HIV?

A
150
Q

What is the most common OI in HIV?

A

PJP

151
Q

How do you manage PJP?

A

Co-trimoxazole 120mg/kg/day for 3d;
then 90mg/kg/day for 18d.

152
Q

You have just diagnosed a patient with HIV. What other things must you screen for:

A
  1. CD4 / viral load
  2. TB symptom Screen
  3. CrAG if concerns re: neuro

±HBV
±HCV
±Hb if starting AZT
±Renal fxn if starting TDF

153
Q

How do you diagnose PCP?

A

**Hard to diagnose

  • Serum B Glucan (also raised in other fungal infections so non-specific)
  • BAL
    • immunoflouroscopy
    • Ganocott Staining
    • ZN staining (for AFB to rule out TB)
154
Q

How do you diagnose PCP?

A

**Hard to diagnose

  • Serum B Glucan (also raised in other fungal infections so non-specific)
  • BAL
    • immunoflouroscopy
    • Ganocott Staining
    • ZN staining (for AFB to rule out TB)
155
Q

How do you diagnose PCP?

A

**Hard to diagnose

  • Serum B Glucan (also raised in other fungal infections so non-specific)
  • BAL
    • immunoflouroscopy
    • Ganocott Staining
    • ZN staining (for AFB to rule out TB)
    • PCR (highly sensitive)

NB: PCR of sputum is not reliable, because could simply be indicationg of CARRIAGE rather than infection

156
Q

How do you manage PCP?

A

High Dose Co-trimoxazole for 21/7
±
O2
±
Prednisolone if O2 requirement
± ART if naive –> start within 2/52

157
Q

How does PCP present?

A

Classic symptoms are sub-acute onset of malaise, non-productive cough and progressive exertional dyspnoea; fever may also be present.

On examination, desaturation on exertion is the classic sign; this is a useful clinical test in resource- limited settings because it is easy to perform using a simple pulse oximeter.

158
Q

What are side effects of co-trimoxazole?

A

cytopaenias (40%)
rash (25%)
fever (20%)
abnormal liver profile (10%).

159
Q

What is the prophylaxis of PCP?

A

Recommended Co-trimoxazole until CD4 >200 for at least 3/12

Sometimes dapsone is given if patient will not tolerate co-trimoxazole

DTM&H (29 decks)

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