HIV Flashcards
What are the three classes of ARVs?
Nucleoside reverse transcriptase inhibitors (TDF, AZT, 3TC, FTC)
Non-nucleoside reverse transcriptase inhibitors (NVP, EFV)
Protease inhibitors (Aluvia, Kaletra)
What is first line ARVs?
Single tablet- EFV, TDF, 3TC
Trade names- odimune, atripla, atroiza
How often is viral load monitored?
Every 4/12
At what point is viral load concerning?
> 400
When can you not give AZT?
Anaemic patients, Hb
When can you not give EFV?
History of severe psychiatric illness
When can you not give TDF?
Severe/ chronic kidney disease
How do you manage a raised VL?
Check adherence. Re-check in 1/12. Move to SLR
What 5 parameters are integrated in PMTCT?
Antenatal care. Postnatal care. Child health. Reproductive health. TB screening.
What is done if TB screening is positive in an HIV positive mother?
Give INH prophylaxis
Why is a CD4 count done if option B is followed?
Informs decision to - Provide prophylaxis (bactrim) if CLAT serum screen positive
How do you treat an HIV positive mother on HAART who comes in in labour with a high viral load?
Additional 3 hourly AZT
How do you treat an unbooked HIV+ mother in labour?
Truvada at start of labour.
Stat dose NVP
AZT 3 hourly in labour
(Option A)
What is Option A antenatally?
Treatment dependent on CD4 count (cut off 350)
>350- PMTCT AZT/NVP . Aim to protect baby. AZT from 14/40 plus labour protocol
What were the problems with Option A?
Doesn’t priorities maternal health.
Increase risk of transmission compared to HAART.
Increased postnatal transmission during BF.
Mixed feeding more likely.
NVP discontinued when supply from delivery runs out.
What are the aims of Option B regarding the population?
Halt the epidemic to save the new generation
What are the aims for the infant of Option B?
Prevent vertical transmission by completely suppressing viral load
Aims to reduce infant mortality
What are the aims for the mother in Option B?
Keep mother well so she can care for infant
Reduce maternal mortality
What is Option B?
All pregnant women started on HAART irrespective of CD4.
CD4 and creatinine tested but no delay in rx.
Start rx on the day of booking (if concerned about C/I, then give AZT prophylaxis and refer to specialist)
Stop HAART 1/52 after BF stopped if mother well
Under what circumstances is HAART continued after breastfeeding stopped?
Maternal CD4
At what CD4 count is bactrim initiated?
What are the problems with Option B?
Does not priorities maternal health.
In Option B, why is stopping HAART a problem?
Rx interruptions increases morbidity and mortality Wrong message (can stop ART if well) All women will need to start HAART eventually
Is there an increased risk of resistance with Option B because of stopping HAART?
No. Not is stopped correctly with cover of the NVP tail
What is Option B+?
Much like option B but woman continues HAART for life instead of stopping after BF
Prioritizes maternal and infant health
What are the problems with B+?
Expensive (but in LT these women will all need HAART anyway)
? Adherence problem
What are the benefits of Option B+?
Prioritizes maternal and infant health
Will decrease transmission to HIV neg men
One clear message that ARVs are for life
What is the drug group composition for lifelong ARV regimens?.
NRTI + NRTI + NNRTI
What is the second line ARV composition?
NRTI + NRTI + PI
What are the dangers associated with NVP?
Hypersensitivity is common –> rash, SJS, TENS; liver toxicity
Very high mortality
More common at CD4>250
Pregnancy protocol is
Why is retesting so important in pregnancy?
If the mother seroconverts during pregnancy, labour or BF, the viral load is at its highest and the risk of transmission to the infant is higher than any other time
When would you test a patient’s VL if recently started on ARVs (
Do at month 4 unless:
Patient likely to deliver within 1/12 of starting ART- do first VL at month 4 (will be high because no chance to suppress it yet if done any time before then)
If patient likely to deliver between 1-4/12 on ART then do 1st VL at 36/40
How long do you provide infant PEP?
Until the mother is virologically suppressed
What do you do if a VL is > 400 on first reading?
If 28/40, add Aluvia. For baby, consider birth PCR and adding AZT to NVP
What do you do if the VL is >400 on second reading?
Switch to second line (change ALL drugs)
For baby, birth PCR and consider adding AZT to NVP
What are other PMTCT strategies employed antenatally?
Avoid amniocentesis unless suppressed
Avoid ECV
Present early is SROM (>4 hrs has increased transmission risk)
What other PMTCT strategies can be employed during labour?
Avoid scalp clips and scalp blood testing
No vacuum delivery
What are the national guidelines regarding infant feeding?
All women continue FDC until 1/52 after BF stopped.
NVP syrup to baby for 6/52
Start NVP as soon after birth as possible, latest 72 hours
When is HIV tested in pregnancy?
At booking Retest at 32/40 Retest in labour Retest at 6/52 postpartum Retest 3/12 thereafter while breastfeeding
