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MFSRH part 2 > HIV > Flashcards

HIV Flashcards

1
Q

factors influencing the efficacy of PEP?

A 
delayed initiation
transmission of resistant virus
variable genital tract drug penetration
poor / non-adherence
further high risk sexual exposures
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2
Q

factors increasing the risk of HIV transmission

A

high viral load of source
breaches in mucosal barrier - ulcers / trauma
menstruation / other bleeding - theoretical
ejaculation
non-circumcision
discordant VL in genital tract

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3
Q

HIV prevelence in sex workers

  • western european
  • central european
  • eastern european
  • Male CSW
A
  • western european <1%
  • central european 1-2%
  • eastern european 2.5 - 8%
  • Male CSW 14%
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4
Q

which medications are usually used for PEPSE

A

Truvada = tenofovir and emtricitabine OD
AND
Raltegravir BD 400mg

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5
Q

Timeframe from exposure for starting PEPSE

A

72 hours

ideally within 24 hours

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6
Q

At what risk of transmission is PEPSE indicated

A

> 1:1000 recommended

1:1000 - 1:10,000 consider

<1:10,000 not required

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7
Q

Is PEPSE required if the source is HIV +ve with an undetectable VL?

A

No - as long as on ART and taking reliably
<200 copies / ml
sustained for min 6m

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8
Q

risk of HIV transmission per exposure for receptive anal intercourse on average
with ejaculation
without ejaculation

A

receptive anal 1:90
with ejaculation = 1:65
without ejaculation = 1:170

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9
Q

risk of HIV transmission per exposure for insertive anal intercourse on average
not circumcised
Circumcised

A

insertive anal intercourse on average 1:666
not circumcised 1:909
Circumcised 1:161

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10
Q

Risk of HIV transmission per exposure for receptive vaginal sex
and insertive vaginal sex

A

Receptive vaginal sex = 1:1,000

Insertive vaginal sex 1:1219

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11
Q

If the source is known HIV +ve what is the risk of HIV transmission from:

  • human bite
  • semen splash to eye
  • oral sex - insertive or receptive
  • blood transfusion
  • needlestick injury
  • sharing injecting equipment
A
  • human bite <1;10,000
  • semen splash to eye <1;10,000
  • oral sex - insertive or receptive <1;10,000
  • blood transfusion 1:1
  • needlestick injury 1:333
  • sharing injecting equipment 1:149
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12
Q

If HIV transmission risk falls into the ‘consider PEPSE’ category - what factors would suggest it should be offered?

A

Source or patient has a diagnosed STI
breaches in the mucosal barrier - ulcers, trauma etc
Primary HIV infection in the source
Victim of sexual assault / trauma
more than one high risk exposure within 72 hours
menstruation or other bleeding

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13
Q

calculation for estimating HIV risk of transmission

A

risk the source is HIV positive x risk per exposure

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14
Q

management of a patient requiring PEPSE in ED

A

Sexual history
+
medical history

medication history incl OTC / alternative / recreational

smoking / alcohol

4th gen POCT

U+Es, LFTs

urine ACR

UPT if required + EC

1st dose hep B vaccine

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15
Q

management of a patient requiring PEPSE in GUM clinic

A 
Sexual history
medical history 
medication history incl OTC / alternative / recreational
smoking / alcohol
4th gen POCT
Send 4th gen serum sample
bloods for STS, Hep B, Hep C
STI screen
U+Es, LFTs
urine dip for proteinuria - if present send urine ACR
UPT if required + EC
hep B vaccine
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16
Q

What advice should you give a patient starting PEPSE?

A

rational for PEPSE
Drugs not licenced for PEPSE but commonly used
full course = 28 days
continue if baseline bloods return as +ve
usually minimal SE - sometimes GI upset or allergy
Baseline liver and renal function taken
Avoid further high risk sexual exposures - but if this occurs in the last 48 hours of course need to continue for another 48hr
safe sex, risk reduction advice
drug and alcohol advice
PEPSE not 100% effective
Return if develops rash or flu-like illness
take first dose immediately then remainder at same time daily
FU HIV test and PN

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17
Q

Initial FU after starting PEPSE

A 
review bloods at 48 hours
Check compliance and SE
any symptoms of STIs
2 weeks STI test
3m repeat bloods for STS and HIV
Plan for remaining Hep B vaccines - 3m and 12m
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18
Q

Management of <16yo requiring PEPSE

A

assess as per adult guidelines
if >13 and >35kg can use adult dose
and refer to HIV transition team or paeds HIV team for follow up

If <13yr or <35kg refer to CHIVA guideline and refer to paeds HIV team - medication and dose will be weight and age dependent

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19
Q

Management of a pregnant woman requiring PEPSE

A

Pregnancy does not alter the decision to start PEPSE

Calculate risk and offer if >1:10,000 and within 72 hours

POCT + 4th gen serum test
SHS incl HBV, HCV, STS

serum U+Es, LTFS
Urine dip
explain PEPSE medications unlicensed in pregnancy

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20
Q

recommendations for missed doses of PEPSE

A

always reinforce importance of adherence

<24 hours since last dose - take missed dose immediately and next at usual time

12-48 hours since last dose - continue PEPSE

> 48 hours since last dose - stop PEPSE

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21
Q

Management of a further high risk sexual exposure in the last 2 days of a patient taking PEPSE

A

Continue PEPSE for 48 hours after the last high risk sexual exposure

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22
Q

When should patients taking PEPSE be advised to return for an urgent review

A

if they develop a rash
or flu-like illness

may represent HIV seroconversion

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23
Q

Management of a patient who has a +ve baseline HIV test after PEPSE has already been started

A

continue PEPSE

review by HIV specialist

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24
Q

Alternative for raltegravir in PEPSE for patients who cannot take it

A

Dolutegravir (integrase inhibitor)

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25
Q

If a HIV +ve patient has a CD4 count <200/mm3 what should they recieve in addition to ARVs?

A

CD4 count < 200/mm3
should receive prophylaxis against Pneumocystis jiroveci pneumonia
= co-trimoxazole

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26
Q

Why is abacavir not recomended for PEPSE?

A

Hypersensitivity reaction in 8% of pateints

NRTI

27
Q

What class of drug is Abacavir?

A

NRTI = Nucloside reverse transcriptase inhibitor

28
Q 
what is in truvada
and what class of drug is it?
A

Tenofovir and Emtricitabine

Class = NRTI = Nucloside reverse transcriptase inhibitor

29
Q 
SE of Nevirapine
and what class of drug is it?
A

Hepatotoxicity in 10%
some require transplant, can cause death

NNRTI = Non-Nucloside reverse transcriptase inhibitor

30
Q 
SE of Efavirenz
and what class of drug is it
A

CNS side effects
drowsiness, dizziness, headache, insomnia, strange dreams, reduced concentration, seizures

NNRTI = Non - Nucloside reverse transcriptase inhibitor

31
Q 
What is in kaletra 
and what class of drug is it?
A

Lopinavir and Ritonavir

Protease inhibitor = PI

32
Q

SE of kaletra (Lopinavir and Ritonavir)

A

Nausea and vomiting
diarrhoea
hyperlimidaemia

therefore co-administered with antiemetic and anti-diarrhoeal in PEPSE - no longer first line for PEPSE

33
Q 
SE of Maraviroc
and what class of ARV is it?
A

few SE
well tolerated

CCR% receptor antagonist

34
Q

Signs of PCP infection

A

CXR: bilateral interstitial pulmonary infiltrates (can present with other x-ray findings e.g. lobar consolidation or may be normal)
Exercise-induced desaturation.
Sputum often fails to show PCP
Bronchoalveolar lavage (BAL) often needed to demonstrate PCP (silver stain shows characteristic cysts)

35
Q

Symptoms of PCP

A

dyspnoea
dry cough
fever
very few chest signs

HIV +ve patient - CD4 <200

36
Q

Treatment of PCP

A

co-trimoxazole
IV pentamidine if severe

steroids if hypoxic ( reduce risk of respiratory failure and death)

37
Q

What additional baseline

investigations do pregnant women who are newly diagnosed with HIV require (BHIVA)

A

No additional baseline investigations

Those routinely offered

38
Q

If a HIV positive pregnant woman is not on ART when should it be commenced?

A
  • As soon as able in 2nd T where baseline VL
    ≤30,000 copies/mL
  • Start of 2nd T or ASAP thereafter if baseline VL 30,000–100,000 copies/mL
  • Within 1st T if VL >100,000 copies/mL and/or CD4
    count < 200 cells/mm

All women should have commenced ART by week 24
A woman who presents after 28 weeks should start ART without delay

39
Q

If ART commenced in pregnancy what should be started?

A

Start Tenofovir DF or Abacavir
with Emtricitabine or Lamivudine

Third agent - efavirenz or atazanavir

40
Q

Management of an untreated HIV +ve woman presenting in labour at term

A

STAT dose - Nevirapine 200 mg
Commence oral zidovudine 300 mg and lamivudine 150 mg BD
And raltegravir 400 mg BD
And IV zidovudine for the duration of labour

41
Q

Management of a women presenting in labour or with spontaneous rupture of the membranes (SROM) without a documented HIV test result?

A

Advised to have an urgent HIV test.
4th gen POCT and send serum sample
Act immediately on a postitive result - initiate interventions to reduce vertical transmission

42
Q

recommended investigations on diagnosis of new HBV infection in a pregnant F with HIV co-infection?

A

Confirm viraemia
Quantitative HBV DNA, ‘e’ antigen status
AND hepatitis A, C and D tests
Test to assess hepatic inflammation/fibrosis and liver function

43
Q

Which ARVs are recommended for treatment of pregnant women with HIV and HBV co-infection?

A

Tenofovir DF and emtricitabine or lamivudine should form the backbone

44
Q

What is the recommendation regarding delivery route for a pregnant woman with HIV and HBV co-infection

A

Vaginal delivery can be recommended
IF the HIV VL is fully suppressed on ART,
Irrespective of HBV viral load

45
Q

Management of an infant born to a woman with HBV

A

Neonatal immunisation +/- hepatitis B immunoglobulin commenced within 24 hours of delivery

46
Q

BHIVA recommendations on invasive pre-natal diagnostic tests for women who are HIV +ve

A

Deferred until HIV viral load suppressed to <50 HIV RNA copies/mL

47
Q

Can ECV be offered to HIV +ve pregnant women

A

Yes - if on ART and plasma viral load <50 HIV RNA

copies/mL.

48
Q

HIV +ve pregnant women can be offered a vaginal delivery if the VL is less than……

A

plasma viral load of <50 copies/mL at 36 weeks

planned vaginal delivery should be supported

49
Q

Recommended delivery method for HIV +ve pregnant women with a plasma viral load of 50-399 copies/ml at 36 weeks?

A 
Consider pre-labour CS 
Take into account the actual viral load
VL trajectory 
Duration on treatment
Adherence issues
Obstetric factors
Patient preference and views
50
Q

Recommended delivery method for HIV +ve pregnant women with a plasma viral load of ≥400 copies/ml at 36 weeks?

A

VL ≥400 HIV copies/mL at 36 weeks,

pre-labour CS recommended

51
Q

For a HIV +ve patient with SROM in what timeframe should delivery be aimed for?

A

In all cases of term pre-labour SROM in HIV +ve women

Aim for delivery within 24 hours

52
Q

When is Intrapartum intravenous zidovudine infusion recommended?

A
  • women with a HIV VL >1000 copies/mL who present in labour or with SROM or are admitted for Pre-labour CS
  • untreated women presenting in labour /with SROM and current VL is not known
  • Consider in women on ART with a plasma HIV VL between 50 and 1000 copies/mL.
53
Q

BHIVA advice re PEP for infants of HIV +ve mothers

A

2/52 zidovudine monotherapy if infant = V Low risk
- mother on ART > 10 weeks
AND
- 2 documented HIV VL <50 during pregnancy at
least 4 wk apart
AND
- Maternal VL <50 HIV at /after 36/40

Extend to 4 weeks zidovudine monotherapy:
• If the criteria above not all fulfilled but maternal HVL <50 HIV or infant born <34 weeks but most recent maternal VL <50 H

If infant at HIGH RISK - Use combination PEP = zidovudine, lamivudine and nevirapine
- maternal VL is >50 on day of birth, uncertain or unknown VL

54
Q

when should neonatal PEP should be commenced?

A

As soon as possible after birth

At least within 4 hours

55
Q

Maximum duration of infant PEP advised by BHIVA

A

4 weeks

56
Q

Factors which reduce vertical transmission of HIV

A

Reduce risk from 25-30% to 1-2%

  • maternal antiretroviral therapy
  • mode of delivery (caesarean section)
  • neonatal antiretroviral therapy
  • infant feeding (bottle feeding)
57
Q

Toxoplasmosis accounts for what % of cerebral lesions in patients with HIV

A

50%

58
Q

Symptoms of toxoplasmosis in patients with HIV

A

constitutional symptoms
headache
confusion
drowsiness

59
Q

CT findings of toxoplasmosis in HIV +ve patient

A

CT: single or multiple ring enhancing lesions#mass effect may be seen

60
Q

management of toxoplasmosis

A

management: sulfadiazine and pyrimethamine

61
Q

What stains with India ink

A

Cryptococcus neoformans

62
Q

Most common cause of diarrhoea in HIV +ve patients

A

Cryptosporidium = most common cause of diarrhoea in patients with HIV infection.

Mycobacterium avium intracellulare and giardiasis are known causes of diarrhoea in HIV patients but are not as common

63
Q

in what % of patients is HIV seroconversion symptomatic

A

in 60-80%

64
Q

typical presentation of HIV seroconversion illness

A

Occurs 3-12 weeks after infection

sore throat
lymphadenopathy
malaise, myalgia, arthralgia
diarrhoea
maculopapular rash
mouth ulcers
rarely meningoencephalitis

MFSRH part 2 (24 decks)

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