HIV Flashcards
4 types of HIV 1 (M - Major, N - New, O and P)
Which type of M is most common worldwide? Which M is most common US / Europe?
M- C worldwide
M - B Europe/ US
% HIV infection is sexual?
80% new infections
HIV vertical transmission if mother is on ART?
<2% if ART is used
HIV infection risk with blood transfusions
90% risk if donor is HIV-positive
WHO recommends PREP in those who are at high risk of infection. What are the 3 PREP options?
Tenofovir-based oral PREP
Dapivirine ring for women since 2021 (every 28 days)
Cabotegravir long-acting injection since 2022 (1 monthly x 2, then every 2 months)
[Take a long cab to lectures]
Most common sx in acute HIV
Fever >90%
How long til HIV ELISA is positive?
What can you test in the meantime?
usually by 4-6 weeks
Can test P24 antigen / HIV RNA load
[New 4th gen ELISA can do p24 antigen and will be positive]
Time from infection to HIV to late disease average
7 years
[can be from 1 - 25+ years]
3 ways of defining AIDS
AIDs defining illness
CD4 <200
CD4 <14% - important if someone has an abnormal number of lymphocytes Eg low post-chemo or high with Lymphoma
Most sensitive test cryptococcal meningitis?
How much pressure ti drain if raised pressure on LP?
Serum CrAg
Use LP + India inkif no access to crag
Drain until pressure is <20cmH2O or until half of opening pressure if its very high
Key factors that increase risk of HIV transmission through sex
- Anal
- STIs - especially ulcerating
- Uncircumcised
Baby risk of HIV when mum positive? Key predictor of this
25%
- About 10% in utero, 5% at delivery, 10% breastfeeding
Maternal HIV viral load
New HIV infection (probably due to high viral load)
Risk of HIV following needlestick from a positive patient
0.3%
Who gets ART in HIV
Rapid ART initiation (within 7 days) should be
offered to all PLWH
HIV rx of amoeba?
Metronidazole
HIV rx of giardia? If doesn’t respond
- Metronidazole
- Nitazoxanide
HIV rx of salmonella / shigella?
Cipro / co-trimox
What does karposis sarcoma look like? Caused by?
- Purple / violet plaques
- HHV8
HIV cryptococcal meningitis stain? Rx?
- India ink
- Amphotericin B and flucytosine followed by fluconazole
Flu-cytosine
HIV toxoplasmosis seen on CT? rx?
- Ring enhancing lesions
- Sulfadoxime and pyrimethamine OR Co-trimox
Reduce peripheral neuropathy with isoniazid prescription?
Give pyridoxine
Key bug in HIV reduced vision? Rx?
- CMV (cd4 often <50) - ‘forest fire / pizza pie’ on fundoscopy
- Ganclyclovir
Prophylaxis in HIV against cryptococcal disease?
Fluconazole
(Usually not until cd4<100)
Zidovudine key side effect (NRTI)
Anaemia
[A-Z of side effects]
Which NNRTI do you need to screen liver enzymes before using and during treatment
Nevirapine
[Nevir forget to check LFTs]
Which NRTI do you need to screen renal function for?
Tenofovir
[T = 2 kidneys leading to bladder….]
Hiv control strategies
Condom provision
Clean needles for IVDUs
Treatment of STIs
Targeting at risk groups
Male circumcision
Blood screening
Prevent vertical transmission of HIV in labour
C-section if resource-rich only
zidovudine and Nevirapine
[Nevir forget it in labour either]
General HIV control to prevent mother-to-child transmission?
Testing Testing Testing
Maternal ARV through preg/breastfeeding
Infants get ARV prophylaxis for 4-6weeks
In the first 3 months after infection HIV might not be detected giving false negative results. What can you test for?
Tests for HIV activity monitoring longer term?
HIV RNA [First thing to be positive]
+ p24 antigen
HIV RNA (viral load) and CD4 count for markers of disease
Returning traveller with maculopapular rash what things are we considering?
Urticarial rash?
Dengue
HIV seroconversion
Zika
Chikungunya
Rickettsia
Urticarial - shisto
HIV + pleural effusion usually
TB
PCP more just patchy bilat changes
PI
Indinavir - drug used in HIV. Key side effect
renal stones in 10% of people
2 most common causes of meninitis in HIV
Cryptococcal Cryptococcal Cryptococcal
Toxoplasmosis - 90% of focal CNS lesions (cat poo)
MR brain in HIV encephalitis
‘multiple ring enhancing lesions’?
‘Widespread small white matter lesions’?
Ring enhancing - toxoplasmosis
White matter - PML
HIV PML (Progressive multifocal leukoencephalopathy) diagnostic test
CSF for JC virus DNA
[Polyomavirus JC (often called JC virus)]
Key Ix in HIV opthalmic disease
CMV / Toxoplasmosis IgG
which proteins used by HIV to get into cells
Gp120 fuses to CD4 receptor
GP41 to penetrate cell
Raised triglycerides in HIV drugs caused by
Protease inhibitors
Ritonavir / lopinavir
[Navir (-navir) tease (pro-tease) them with sweets or fatty foods]
Hepatitis in HIV drugs which ones
Non/nucleoside reverse transcriptase inhibitors (NRTI / NNRTI)
Eg Lamivudine/Nevirapine
HIV drugs classes - how to tell which drug in class and side effects
Fusion inhibitors
Protease inhibitors
Integrase inhibitors
NNRTIs
NRTIs
Fusion inhibitors - [prevent Fusion of rock and tide on the beach]
- maraviroc and enfurvitide
Protease inhibitors
All end in -navir
-Cause hyperglycaemia/raised triglycerides + nausea / diarrhoea and hepatoxicity
[navir -tease them with sweets or fat foods]
InTERGRAse inhibitors - Prevent HIV cells integrating with host cells
- all have -TERGRA- in middle
-Get fat and raised CK
(not going to INTEGRate with CK model)
NNRTIs
All have -vir- in middle
Vivid dreams, hepatitis, rash
NRTIs
Everything else
-Mitochondrial toxicity
-Lactic acidosis
-Lipodystrophy
-GI disturbance
-neuropathy
Which primary cell receptor does HIV bind to on which cell? using?
CD4 on T-helper cells using protein gp120
HIV - White patches on tongue that cant be dislodged
EBV - Hairy leukoplakia
Usually on lateral aspect
renal stones in 10% of people on which HIV med
Indinavir
[stuck Indi nephron]
No access to expensive tests, what can you use for quick Dx HIV
RDTs
New HIV diagnosis what tests do you need to do as a minimum?
CD4
- If <200 check CrAg
TB symptom screening
Ideally HepB/C, LFTs, U&E (Tenofovir) , FBC (AZT)
What circumstances do you delay the commencement of ART?
[TB / cryptococcal] meningitis
Wait 4-6weeks
Example 1st line ARV combination? Which often unavailable in resource-poor settings? Chang to?
1 intergrase inhibitor
Dolutegravir - safe for all
2 NRTIs
Tenofovir
Lamivudine
Intergrase inhibitors are expensive and often not available
-Can use NNRTI
- Efavirenz
Dolu-tegra-vir
Teno-fovir
Lami-vudine
Efa-vir-enz
Painful swallowing in HIV - most likely? CD4? DDx?
What cause if immunocompetent and no HIV? rx?
CD4 likely <200 if HIV oral/oesophagal candida
-CMV and HSV differential
Occasionally due to inhaled steroids
Treatment: Fluconazole (w/oesophagal involvement = 14 days)
A 21 year old cisgender male presents with 3 day history of fever ( Tmax 38.8C, 102F), headache, sore throat and generalized fatigue.
On exam: +Cervical, axillary and inguinal lymphadenopathy, pharyngeal erythema and morbilliform rash?
Bloods?
HIV seroconversion (Acute HIV)
-Very high HIV viral load (>100,00copies/ml)
-transient drop in CD4.
-Lymphopenia
DDx
[Acute EBV or CMV infection
Syphilis
Disseminated gonococcal infection
Acute toxoplasmosis
Viral hepatitis
Other viral illness: Influenza, COVID
Streptococcal infection]
U=U refers to what
Undetectable means Untransmissible (U = U)
Oral candida and oral hairy leukoplakia excluded
Syphilis
32 year old with HIV and non-adherence to ART presents without complaints, but with the rash seen.
Rx?
Molluscum
TREATMENT: Liquid nitrogen, curettage,
imiquimod.
[DDx: cryptococcus, histoplasmosis, condylomata lata]
24 year old male presents with four day history of fever ( Tmax 38.3C/101F), malaise and painful lesions scattered on the body and anogenital region. Sexually active with men
only (oral, RAI. IAI). Last sexual activity 10 days ago. Dx?
Where is most of this disease?
MPox
90% in congo
Usually Between 10 150 lesions that are similar in size
Firm, rubbery, deep seated and often umbilicated
Start on face and spread to extremities
Prodrome»_space; Rash
22 year old with advanced HIV, not on ART presented with one week of fever, progressively worsening headache, visual changes and subsequent development of emesis and altered mental status, resulting in coma. Found to have following rash.
Dx?
Rx?
Screening?
prevention?
Cryptococcus neoformans
Amphotericin B, flucytosine, fluconazole
Screening for SCRAG+ in asymptomatic people with a
CD4 <100 (may be considered at < 200)
Fluconazole if positive
No CrAg screening available- when would you suggest fluconazole prophylaxis
All with CD4 <100
Umbilicated papules - What are the differentials
Molluscum contagiosum
Cryptococcus neoformans (cutaneous cryptococcosis)
Monkeypox virus
Talaromyces marneffei (“the crypto of SE
Histoplasmosis
North and central america
fever, fatigue, HSM, pancytopenia.
In HIV: Often presents with disseminated illness:
Rx if severe?
Histoplasmosis
Ampho B + flucytosine —-> itraconazole
HIV positive in SE Asia including China & India
Symptoms vary: skins lesions, fever, weight loss, HSM LAD
Dx?
Reservoir?
Rx if severe?
Talaromyces marneffei (dimorphic fungi)
Bamboo rats are only known host. Suspected airborne route of transmission
Amphotericin B -> Itraconazole
Which infections common in CD4 <50 <100 <200
HIV when rx of PCP? Choice?
CD4<200 - co-trimoxazole
In resource-poor CD4<350 Used
Co-trimox good for the prevention of toxoplasmosis too
[Dapsone, atovaquone, pentamidine alternatives]
HIV when prophylaxis of Mycobacterium avium complex?
drug of choice?
Cd4 <50
Azithromycin 1,200mg PO weekly
Or Clarithromycin 500mg PO BID
Do NOT need to use if immediately starting ARV
HIV prophylaxis of Toxoplasma gondii Drug?
co-trimoxazole
[Usually get when Cd4 <100 - so will already be on co-trimox for PCP]
HIV whn prophylaxis of Coccidiomycosis? drug of choice?
Positive test in patients who live in a disease endemic area
AND CD4 <250cells/mm3
Fluconazole
HIV prevention of Talaromycosis? drug?
CD4 <100cell/mm3 unable to have ART who reside in endemic areas
Itraconazole
35 year old MSM comes in with progressive shortness of breath for 1 week. He is non-adherent to ART and has a CD4=72 and VL of 56,000. Skin lesions below seen on initial exam. Lesions are raised and non-tender
dx?
Caused by?
Bar cutaneous where else?
rx?
Kaposi sarcoma
HHV8
GI and pulmonary lesions common
ARV is Rx [occationally surgical]
*note lesions variable in colour and appearance
HIV poor control. This is NOT kaposis sarcoma. What is it? Rx?
Bacillary Angiomatosis (Bartonella ssp)
Indistinguishable from kaposi
Doxycycline (or azithro)
+rifampin if disseminated eg CNS
32 year old HIV positive man fails AZT/3TC/EFV and starts TDF/FTC/ LPVr . Asymptomatic, and now with a suppressed VL, he comes to see you 3 months later with this rapidly emerging skin lesion over the past few weeks.
What is the likely diagnosis?
Usual presentation?
Who is it common in?
RX?
Pyogenic granuloma [Lobular capillary hemangioma]
[Misnomer as neither pyogenic, nor granulomatous}
Usual Presentation: solitary red papule/nodule (skin, face, gingiva), friable and ulcerates easily, grows
fast (weeks)
Pregnancy, Trauma…
Removal, recurrences common
-eliminate inciting factor; give birth!
17yoM with newly diagnosed HIV with CD4 <200
Noted to have several months of the following skin findings,
-Started on LE and then spread to include entire body.
-Some itching but otherwise clinically well.
=?
Rx?
Acquired Ichthyosis
ART
Emollients
Pregnant woman - HIV negative but high risk for HIV acquisition, plan?
Tenofovir-based oral PREP
ART regime for mum who is found to be HIV positive? When start? Target?
Dolutegravir (DTG) - intergrase inhibitor
2NRTIs
Tenofovir disoproxil fumerate (TDF)
Lamivudine (3TC) or emtricitabine (FTC)
[Dol Ten Lam]
Start as soon as possible
Aim for viral load <1000copies/ml
When is a baby high risk for HIV?
born to persons receiving <4 weeks of ART at delivery
maternal VL >1000c/ml in the 4 weeks before delivery,
New maternal HIV during pregnancy or breastfeeding
Zidovudine and Nevirapine x 6 weeks
- NVP alone x 6 weeks (12 weeks total)]
Low risk infant for transmission with HIV Rx? When extend?
Nevirapine for 6 weeks
Extend to 12 weeks if breastfeeding [+6weeks zidovudine]
[Nevir forget in babs]
What antimicrobial prophylaxis do HIV-exposed babies need?
Co-trimoxazole until HIV is completely ruled out
1st line ART for Adults/adolescents? Children 1-9? Infants?
Adults - TDF + 3TC or FTC + DTG
-tenofovir + lamivudine + Dolutegravir
[Lanky Dudes aged Ten (or older)]
Children - ABC + 3TC + DTG
-Abacavir + lamivudine + Dolutegravir
[Children learn ABC]
Infants - AZT + 3TC + RAL
-Zidovudine + lamivudine + Raltegravir
[Babies sleep ZZZ and have rattles]
Best way to monitor treatment response to ART
Viral load
CD4
Child with HIV but normal CD4 should continue co-trimox prophylaxis when?
Endemic malaria
Which childhood vaccine the only one definitely not to give to a child with HIV
RUBELLA: DO NOT give
A 21 year old presents to first prenatal appointment and is found to be HIV+ on routine screening. Asymptomatic and started on ART.
Two weeks prior to delivery, HIV VL is <50copies/ml. What is the risk of MTCT?
Vaginal delivery and infant will be breastfed. Mother plans to continue ART. What is the best infant prophylaxis?
Low risk
NVP once daily for six weeks
A 21 year old presents to first prenatal appointment and is found to be HIV+ on routine screening. Asymptomatic and started on ART.
Two weeks prior to delivery, HIV VL is 6,400copies/ml. What is the risk of MTCT?
Vaginal delivery and infant will be breastfed. Mother plans to continue ART. What is the best infant prophylaxis?
High risk
NVP + AZT (Zidovudine) for 12 weeks
A 21 year old with known HIV on ART with TDF/FTC/DTG and most recent labs: CD4 560, VL<50. She is found to be pregnant w/ LMP 8 weeks ago
What is the best next steps for her ART?
She experiences severe post-partum depression and self-discontinues ART. Plans to breastfeed for 12 months.
What is best infant prophylaxis?
Continue current ART
NVP + ZDV (AZT) until 1 week after stoppage of breastfeeding
If a mother cannot tolerate or declines ART how long should the baby continue prophylaxis?
Throughout breastfeeding and until 1 week after cessation
Key causes of chronic diarrhoea with blood in HIV? - key Sx?
Tenesmus + small volume diarrhoea
Salmonella
CMV
Shigella
campylobacter
C diff,
HSV
2 Investigations in CD4 <100 new diagnoses of HIV
Urine LAM - TB
Serum CRAG
Most common side effect of NNRTIs? How to limit
Vivid dreams
Take on an empty stomach
28M headache nausea vomiting 2 weeks
HIV RDT positive
LP - OP 50cm, WBC 3, protein 65mg, Glucose 50mg
Crypto
Normal WCC is common in HIV as you don’t mount an immune response
LP normal OP? WCC? Protein? glucose?
OP- 12-20CM
WCC <5
Protein -15-60mg/dL
Glucose - 50 to 80 mg/100 mL (or greater than two-thirds of blood
HIV first / alternate ART
Main issue with Efavirenz and nevirapine?
Resistance often develops quickly
40F CD4 85
2 days progressive right-sided hemiplegia/sensory deficit + CN VII palsy
DDx and how to exclude?
Toxoplasmosis - most common
Lymphoma - may present in this way but is less common
PML (JC virus) - usually would present over weeks/months
TB -
HIV - name the agent?
Why do you get a IgM/IgG
Rx?
Why not steroids?
Toxoplasma gondii
If negative rules out toxo
->Lymphoma/TB….
No steroids - as can’t tell if it was TB/lymphoma which improves with steroids
Pyrimethamine and sulfadiazine, plus folinic acid
OR - Co-trimoxazole
-Both for 7-10 days and assess response
3 most common causes of CNS mass lesion in HIV
Toxoplasmosis
Lymphoma
Tuberculoma
Where is toxo from
Usually raw meat
50-80% sero positive in Europe / Africa
42M 6/12 mild weight loss
1-month fever dyspnea, diarrhoea
HIV positive
DDx?
Pneumocystis jirovecii
TB
Bacterial
Fungal - Eg crypto / histo
Kaposi’s especially if mucocutaneous Eg under eyelids/lips
HIV with pneumothorax most likely
Pneumocystis jirovecii
- right pneumothorax (thin arrow)
- subcutaneous emphysema (solid arrow)
- pneumomediastinum (hollow arrow)
What infections can have a normal appearance of CXR in HIV
PCP - most common
TB
Fungal
name 3 DDx of nodultes / cavities in CXR HIV
Tumour
Endocarditis -> septic emboli to lungs - IVDU
Nocardia, rhodococcus, Staph aureus
TB
Fungal
Kaposis
HIV TB which HIV class should be avoided
Protease inhibitors - interactions with rifampin
any ending in -navir
Alternative to rifampin which has fewer interactions Eg in HIV-TB coinfection
rifabutin
33F throat and chest pain with swallowing, HIV serology positive - oral thrush - what do you need to do?
Treat the thrush - fluconazole
- No need to jump into endoscopy
Appearance of HSV vs CMV oesophageal ulcer? [Bonus marks for Pathology]?
Herpes - multiple small punched-out ulcers
[Small intranuclear inclusions in squamous cells]
CMV - few large ulcers
[large intranuclear inclusions in stromalcells]
13M HIV positive not on ART - 1/12 progressive watery diarrhoea and weight loss
Most likely? Rx? DDx?
Cryptosporidium
Nitazoxanide + ART
Microsporidium, cystoisospora, giardia
32 HIV from Sudan with 6 weeks of weight loss, hepatosplenomegaly and pancytopenia
Diagnosed with visceral leishmaniasis Rx ?
Liposomal amphotericin B + Miltefosine
44 from El Salvador admitted with seizures. HIV test positive
Toxo IgG negative. CT demonstrates likely abscess lesions
=? Key Ix? rx? systemic sx?
El Salvador = chagas - Trypanosoma cruzi
-Mimicks toxo
Ix - 2 serologies, CSF, peripheral blood microscope
[limited data for PCR]
Rx - Benznidazole or nifurtamox
May cause myocarditis, erythema nodosum
36F on AZT/3TC/NVP but lost to follow up
Diagnosed with TB and CD4 50 and then re-started on TDF/FTC/EFV
After 6m clinically better but VL 2500, CD4 65
Good adherence to meds.
Which is the most sensitive test for failure?
What VL cut-offs are used?
VL - changes quicker compared to CD4
<50 copies/ml = good
50-1000 - likely compliance issue
>1000 - change to an alternate regime
Rescue regimes for ART
Non DTG?
DTG?
Non DTG - DTG + NRTI backbone + extra
Already on DTG -> NRTI + boosted protease inhibitor + extra
HIV on TDF/FTC/RFV
Now has high Cr and reduced GFC
Urine - protein + glucose
What’s going
Fanconi syndrome - Due to tenofovir
[T 2 kidneys and 1 urethra]
HIV on ABC/3TC/EFV
-> MI with raised LDLs =?
Abacavir - risk of MIs
Zidovudine side effects? Which is specific
Anaemia
Then as with all NRTIs
-Mitochondrial toxicity
-Lactic acidosis
-Lipodystrophy
-GI disturbance
Abacavir side effects? What do you need to do before prescribing?
Risk of MIs
Hypersensitivity in 3% - need to test for HLA-B5701 first to predict
Fever rash GI
Lipodystrophy in which hiv drugs
NRTIs
Especially Zidovudine + stavudine
Lactic acidosis in which HIV drug expecially
stavudine (NRTIs)
Which ARVs don’t work against HIV-2
NNRTIs
What is a boosted PI?
PI combination eg lopinavir-ritonavir
-ritonavir prevents the metabolism of other PIs -> can use lower doses -> less toxicity
Atazanavir specific side effect
5% get Jaundice - but not hepatotoxicity
[Off to the sunbeds to get Atan]
2 key ART meds causing significant skin rash
Nevirapine, abacavir
[Nasty Acne]
TDF + 3TC (or FTC) + DTG is first line. Main alternative to this?
Low dose EFV (400) alternative to DTG
When starting ART in HIV/TB infection
start within 2 weeks
In ART what is preferred to diagnose and confirm treatment failure?
VL - Should be checked at 6 months , 1 year, and then every 12 months
Can stop checking CD4 when patient stable and VL suppressed
Alternative to CD4 in resource-poor
Lymphocyte count
HepB/HIV coinfection which drugs should you use?
TDF (or TAF) and 3TC (or FTC)
Tenofovir + lamivudine
3 ways to define ART treatment failure
New WHO stage 4 infection after 6 months
Fall of CD4 to below 100
VL of >1000copies/ml
HIV - how to screen for TB in resource poor (WHO)
Any symptom of - Weight loss, night sweats, fever, cough
CXR
CRP >5
If any positive - > treat for TB
Vaccines to avoid in immunocompromised? which of these can you actually give in HIV if the CD4 is preserved?
You Must Prescribe BCG Incase They RIP Stat
Yellow fever
MMR
Polio (oral)
BCG
Influenza - live
Typhoid
Rotarus
Shingles (varicella) [varicella vax is live but shingrix is not]
Can give varicella and MMR if CD4 preserved
43 yo man, comes with 1 year of progressive memory loss. No family history of Alzheimer. His exam is normal. HIV positive. MRI is shown.
Dx?
HIV associated dementia
[AKA HIV associated neurocognitive disorder (HAND)]
peripheral neuropathy worst with which ART
Stavudine, didanosine
[And all NRTIs]
AIDs defining cancers
Kaposi
CNS lymphoma
non-Hodgkins
Invasive cervical cancer
HIV - multiple vascular lesions seen in GI tract / bronchial tree on endoscopies =?
Disseminated kaposis
Extra screening for women with HIV
Cervical smear every 3 years between 25-50
Anaemia in HIV - simple blood test to differentiate Production vs haemolysis
Reticulocyte count
dyslipidaemia especially with which class of ART?
Boosted PIs
Weight gain especially with which combination of ART?
Dolutegravir + tenofovir alafenamide
MIs and HIV - more or less than in normal population
More in HIV
-Especially high in people who’ve had ART interruptions
2 locations lipoatrophy is most common in HIV
Cheeks
Legs - ‘i have new varicose veins’ -> they’re just newly visible
Rx with cheek fillers if needed
Osteopenia in HIV rx
Smoking cessation, exercise, limit alcohol, stop steroids
Calcium and vitamin D
Bisphosphonates if severe
26yo black man, 4 weeks of progressive swelling. He describes his urine as frothy. On exam he has diffuse oedema. Creatinine is 4.2 mg/dL, urinalysis shows 4+ protein, no WBC or RBC. HIV test is positive.
Dx? Seen on biopsy?
HIV associated nephropathy
-Especially high in African
Focal segmental glomerulosclerosis
Does any ART cause malignancies?
No
HIV what is the impact on malaria parasitaemia, clinical/severe malaria/ Hb levels, and drug efficacy?
2x rate of a detectable parasitaemia
2-3x higher parasitaemia in those infected
12x higher risk of severe malaria
more anaemia and slower recovery
**No difference in ACT rx
Malaria impact on HIV viral load? CD4? HIV RDTs? HIV transmission?
10x increased viral load
Transient reduced CD4 - reversible with Rx
Reduced specificity of RDTs for HIV -> false positive diagnosis
More transmission
Which drug often used in HIV prophylaxis of opportunistic infections works for malaria prevention
co-trimoxazole
Which ACT should you not give with efavirenz
artesunate /amodiaquine
- risk of hepatitis
HIV on zidovudine - need to avoid which ACT for malaria?
artesunate /amodiaquine
- High risk of severe neutropenia (75%) in HIV+ children under zidovudine containing regimen
artesunate /amodiaquine should be avoided with which 2 ART drugs
Efavirenz
Zidovudine
[EZ to remember]
Which ARTs affect artemisinin levels?
NNRTIs and PIs
- Artemesin levels decreased ***
- Partner drugs eg lumefantrine increased
How do these factors affect the choice of ART
Liver problems?
CD4 > 250 in women , > 400 in men?
Anemia?
Renal problems?
TB disease?
Chronic HBV?
Liver problems : nevirapine is not the first choice
CD4 > 250 in women , > 400 in men: avoid nevirapine hepatotoxicity
Anemia - zidovudine is not the 1st choice
Renal problems : caution with tenofovir
TB disease : prefer efavirenz less interactions with rifampicine than nevirapine
Chronic HBV : tenofovir + lamivudine or emtricitabine since these drugs have also activity against HBV
Pulm TB is what stage in WHO HIV staging
stage 3
WHO stage 1 - 4 based on CD4 count
Stage 1: The CD4+ 500 cells per microlitre.
Stage 2: The CD4+ is 350 to 499.
Stage 3: The CD4+ is 200 to 349.
Stage 4: The CD4+ <200 or <15% of all lymphocytes.
Papular eruptions in HIV WHO staging
stage 2
Define viral failure in HIV
- Persistently detectable viral load exceeding 1000 copies/ml with a 3-month interval
- with adherence support between measurements
- after at least 6 months of starting a new ART regimen.
Starts 1st line ART then Three weeks later
Fever, body ache Painful knee swelling and these lesions?
Rx?
IRIS - TB
Steroids + RIPE
Double dose dolutegravir
An HIV patient is given 3TC/AZT/NVP and cotrimoxazole
Develops this rash rx?
Stop NVP
HIV on FTC/3TC/NVP for 1 month
Development of cervical lymphadenopathy: aspiration
AFB+ on smear
rx?
Continue ART
start RIPE
Patient on AZT/3TC/NVP for 3 years
-Initial increase in body weight and no opportunistic infections
Now
-Last month: recurrence of prurigo, herpes zoster, and weight loss
rx?
Check Viral load
Ensure adherence
-> Change to dolutegravir containing regime
Child, CD4 50, few lesions of molluscum contagiosum in the face.
Starts FTC/TDF/EFV then molluscum worsens
rx?
IRIS reaction (of molluscum)
No specific Rx -> continue rx for now
A pregnant woman started D4T/3TC/NVP two months previously.
Now Current complaint: fatigue, nausea, vomiting, abdominal pain and dyspnoea.
dx?
rx?
Mitochondrial toxicity - stop D4T (Stavudine)
Treatment failure:
After first line with AZT or D4T?
After first line with TDF/3TC?
After first line with AZT or D4T -> TDF+3TC
After first line with TDF/3TC -> AZT+3TC
+ Dolutegravir or boosted PI (DGT or LPV/r) according to first line
Which PI seems to be associated with lower risk of metabolic side effects when compared to most of the other PIs
Atazanavir
