HIV Flashcards
In women conceiving on ART, when should CD4 count be monitored?
Minimum one Cd4 at baseline and one at delivery
If a woman starts ART in pregnancy, when should CD4 count be monitored
As per routine initiation of ART and also at delivery even if starting CD4 is >350
If a newly diagnosed HIV+ woman starts ART in pregnancy, when does she need VL performing?
2-4 weeks after starting ARV.
At least 1x per trimester
At 36/40
At delivery
If a woman has started ART in pregnancy but not suppressed VL to <50, what interventions are recommended?
Review adherence Perform resistance tests if appropriate Consider TDM Optimise to best regime Consider intensification
When should pregnant woman (including elite controllers) start ART?
Immediately and continue life long
If a pregnant HIV pos woman is not on ART when should she commence it?
As soon as she can in 2nd trimester when VL >30,000 copies
As soon as she can in 2nd trimester if VL 30,0000-100,000 HIV copies
In the first trimester if VL >100,000 copies and or CD4 <200
All women should start ARV by 24/40
Which ART regime is recommended for newly diagnosed HIV pos in pregnancy?
TDF or abacavir with emtricitabline or lamivudine as nucleoside backbone (truvada or kivexa)
3rd agent- efavirenz or atazanavir (most safety data in pregnancy)
Dolutegravir can be considered after 8/40
Is zidovudine monotherapy recomended in pregnancy?
No- only if the woman declines cART and has VL <10,000 HIV RNA copies and is willing to have a caesarean section
Is PI mono therapy recommended in pregnancy?
Np
When might a Integrase inhibitor be recommended in as 3rd choice on ART agent in pregnancy?
If very high VL >100,000 HIV RNA copies
If CART is failing to suppress the virus
What to give a woman presenting >28/40 pregnant HIV positive with VL unknown or >100,000 RNA copies
3 or 4 drug regime that includes raltegravir 400mg bd or dolutegravir 50mg od
How would you manage an untreated woman HIV positive in labour at term?
Stat dose of nevi rapine 200mg
Start oral zidovudine 300mg and lamivudine 150mg bd
and Raltegravir 400mg bd
AND RECEIVE IV ZIDOVUDINE FOR DURATION OF LABOUR
What to do if a unbooked woman presents in labour/SROM without documented HIV result
Advise them to have an urgent HIV test
If reactive/positive, act upon it immediately
Initiation of interventions to prevent vertical transmission of HIV
Don’t wait for formal serology
What confirmatory tests are needed for hep B/HIV coinfection in pregnancy?
Confirm viraemia with HBV DNA, e antigen status, screen for HAV, HDV, HCV
Tests to assess liver inflammation/fibrosis and LFT
What treatment is recommended for HIV/Hep B coinfection in pregnancy
TDF and emtricitabine should form the backbone if no CI.
If TDF is not part of ART it should be added
If HIV/Hep B confection, pregnant and not immune to HAV, are vaccines recommended and if so what schedule?
Yes- but after first trimester
Normal schedule 0 and 6 m
Unless CD4 <300, give additional dose 0,1,6m
HIV/Hep B coinfection in pregnancy, what is recommended mode of delivery ?
NVD if fully suppressed HIV VL (irrespective of hep b VL)
HIV/Hep B or hep C coinfection in pregnancy, does baby need any intervention at birth?
Immunisation against hep b with/without immunoglobulin should commence within 24h
Then national infant HBV schedule should be followed
Can ribavirin based DAAs be used in pregnancy for management of HCV infection?
No- discontinue immediately.
Can invasive prenatal diagnosis be performed on women who are HIV pos?
It should not be done until VL known
Ideally this should be <50 RNA copies/ml
Combined screening test and non invasive prenatal testing- has better sensitivity and specificity and minimises the number needing invasive testing
If HIV pos and not on ART and needing a prenatal invasive diagnostic test what can be done to prevent transmission?
Start ART and give raltegravir and a single dose of nevirapine 2-4h prior to the procedure
Can ECV be done in HIV positive women?
Yes if VL <50 HIV RNA copies/ml
What mode of delivery is recommended in HIV pos women?
If VL <50 at 36/40 and no obstetric CI can have NVD
In what circumstances in an HIV woman might a pre labour c section be recommended?
If VL >400 at 36/40
What would be recommended with regards to mode of delivery if HIV positive and VL 50-399 at 36/40?
Prelabour c section should be considered
Taking into account length of time on ARV, adherence, obstetric factors and women views
IF HIV positive and SROM and VL <50 what is the time frame ideally required for delivery?
Within 24 hours should be the aim.
IF VL <50, immediate induction/augmentation of labour
If HIV positive and SROM and VL <50-399 (or >400) what is recommended with regards to delivery?
Immediate C section recommended
HIV positive and SROM <34/40, what intervention is required?
Same as per HIV neg
Im steroids
Optimise HIV VL
MDT re timing/mode of delivery
When is IV intrapartum zidovudine recommended in HIV pos women ?
If VL >1000 and they present in labour or with SROM or are admitted for PLCS
For untreated women in labour and VL unknown
Can consider if VL 50-1000
Can HIV pos women have a water birth?
Yes if VL <50
Does baby need PEPSE if Mum has had ARV in pregnancy and VL <50?
YES
2 weeks zidovudine mono therapy recommended if
Mum has been on ART for >10 weeks
2 viral loads >50 during pregnancy 4 weeks apart
Maternal VL <50 at or after 36/40
Does baby need PEPSE if Mum has had ARV in pregnancy and VL <50?
Extend to 4 weeks if
not all low risk criteria fulfilled but VL <50 at or after 36/40
If infant born <34/40 but most recent VL <50
Combination PEPSE needed:
If maternal VL >50 on day of birth ?adherence or unknown VL
If resistance to zidovudine
If high risk - Mum HIV and VL >50 at delivery, when does neonatal PEPSE need to be started?
Neonatal PEP should be started within 4 h of birth
When should infant PEPSE be stopped
By 4 weeks
Should BCG given to neonate at birth if risk of HIV?
Only if low/very low risk HIV transmission and BCG at birth is indicated as per UK guidelines
What is the safest way to feed babies born to HIV + mothers?
Formula milk
Free formula provided
When should HIV follow-up be done on baby born to HIV pos mother not breast feeding?
In first 48h and prior to discharge If HIGH risk at 2 weeks 1t 6 weeks At 12 weeks HIV ab for seroconversion should be checked at 18-24 m
When should HIV follow-up be done on baby born to HIV pos mother who is breast feeding?
In first 48h and prior to discharge At 2 weeks Monthly while b/f At 4 and 8 weeks once stopped b/f HIV ab for seroconversion should be checked at 18-24 m
What follow-up is required for HIV pos mother postpartum
All should be reviewed by member of MDT within 4-6 weeks
MH assessment
Contraceptive needs discussed
Cytology 3/12 postpartum
If newly diagnosed, testing of partner/other children
When should individuals with AIDS defining infection or serious bacterial infection and CD4 <200 start ARV?
Within 2 weeks of starting specific antimicrobial chemotherapy
Which ARV therapy is recommended for therapy naive PLWH
2 NRTI + 1 PI/r/NNRTI or II TDF (or TAF) + Emtricitabine + Atazanavit/r Darunavir/r Dolutegravir/r Elvitgeravir/c Raltegravir Rilpirivine
Alternative Abacavir and lamivudine
+ Efavirenz
When is Abacavir contraindicated?
HLA-B-5701 positive
What needs to be considered if using Abacavir and lamivudine as backbone?
Viral load
If VL >100,000 only use if in combination with dolutegravir
What do you need to consider if using TDF/emtricitabine/elviteravir
Do not use in individuals with Creatinine clearance <70 ml/min
TAF/emtricitabine/elviteravir should not be initiated if cdcl <30ml/min
When is use of RIlpivirine recommended?
When baseline VL is 100,000 copies/ml
If there is a risk of prolonged ART interruptions what alternative could be considered?
Protease inhibitor/ritonavir booster
- may be considered
May be associated with less frequent selection for drug resistance
What to do if VL 50-200 copies /ml, followed by a undetectable VL?
Nothing
Not a cause for clinical concern
What to do if VL >200 copies /ml?
Genotypic resistance test
This is indicative of virological failure
Example of NRTIs?
ZELAT Zidovudine Emtricitabine Ladivudine Abacavir Tenofovir
Examples of NNRTIS
NEER Nevirapine Efavirenz Etravirine Rilpivirine
Examples of integrate inhibitors
DR
Dolutegravir
Raltegravir
Examples of Protease inhibitors
Boosted with ritonavir (r) or cobisistat (c) FatLAD Fosamprenavir (r) Lopinavir (r) Atazanavir (r/c) Darunavir (c/r)
Example of CCR5I
Miraviroc
What to do if patient experiences virological failure on first line ART with wild type virus and without emergent resistant mutations
Switch to a PI/r or PI/c based cART
When should patients with HIV TB coinfection start ART if CD4 <50?
As soon as TB treatment is tolerated and where possible within 2 weeks
When should patients with HIV TB coinfection start ART if CD4 >50?
ART can be deferred until between 8 and 12 weeks of TB treatment
What ART regimen should be recommended in HIV/TB coinfection?
TDF+ emtricitabine + Efavirenz
Are there any interactions between ARV and Rifampicin to be aware of?
Raltegravir should be used with caution with rifampicin
Rifampicin should not be used with Nevirapine or any boosters (cobicistat or ritonavir)
HIV/Hep B coinfection requiring treatment: what to do about ART?
Start ARV promptly
Include TDF/TAF and emtricitabine
HIV/Hep B coinfection not requiring treatment: what to do about ART?
Start ARV
Include TDF/TAF and emtricitabine
HIV/Hep C coinfection requiring treatment for Hep C: what to do about ART?
Start ART before Hepatitis C treatment
If CD4 >500 however can defer ART
When to start ARV in Hepatitis B coinfection?
Should be treated with ART inclusive of anti HBV active drugs regardless of CD4
Hep B/HIV coinfection- if emtricitabine/lamivudine resistance- what to do?
Can just give TAF/TDF
When should ART be started if KS?
ART should be started promptly
When should women with CIN2 /3 start treatment?
Promptly
If having chemoradiotherapy for cervical cancer also need opportunistic infection prophylaxis
What needs to be considered in hiv associated malignancy?
ART should be started immediately
If starting chemotherapy they should be offered HSV prophylaxis
Which drugs should be avoided if worsening renal function?
TDF and atazanavir
Which HIV drugs are preferred if high CVD risk?
Avoid miraviroc and abacavir
Alternatives to fosamprevanir and lopinavir/r
Atazanavir is preferred PI
First line therapy is
TDF + emtricitabine +
Dolutegravir /raltegravir/rilpirivine
If VL <100,000
When should efavirenz be stopped promptly?
If current or past history of Depression Psychosis Suicidal ideation Attempted suicide Self harm
Which ART should be avoided if osteoporosis?
TDF should be avoided if
>40 with osteoporosis
History of fragility fracture
FRAX >20% - major osteoporotic fracture
What is the res of HIV transmission in anal sex?
Receptive 1 in 90
Insertive 1 in 666
What stain is used for diagnosis of PCP?
Silver stain
What stain is used for diagnosis of cryptococcal meningitis?
India ink stain
Why do G6PD levels need to be taken before administering Cotrimoxazole, dapsone or primaquine?
Can trigger haemolysis
When is prophylaxis for PCP required?
If CD4 is <200
Or they have oral candida/AIDS defining ilness
What is the appearance of cerebral toxoplasmosis on CT?
Cerebral abscesses
Ring enhancing lesions at grey/white interface and in deep grey matter of basal ganglia or thalmus
Associated with cerebral oedema/mass effect
When to test baby to HIV positive mum?
48 hours 6 weeks, 12 weeks and his ab at 18-24 months If breast feeding: 48 h Then monthly until stopped Then 4, 8 weeks post stopping b/f 18-24 m HIV ab
In 2008, what was the % of undiagnosed HIV in the UK?
25% heterosexuals and 47% MSM
What are the preferred treatments for HIV2?
Lopinavir/r
Tenfovir and emitricitabine
Which class of ART does HIV2 have innate resistance to?
NNRTIs
What follow-up is required for newly diagnosed HIV?
2-4 weeks
3m
6m
U&E, LFT, urinalysis
FBC (if on zidovudine or unwell)
CD4 - if <350- every 3m and ay 6m if still <350
If baseline >350, no need to repeat if undetectable VL
VL- measure at 1, 3, 6 months
What would you do if VL not fallen by 10 fold after 1 month in newly diagnosed HIV positive?
Repeat again at 2 months
If established on ART, how often does CD4 count need monitoring?
If CD4 >200- test 3-6 m
200-350- annual
>350 twice >1 year apart- no more
What to recommend if HIV positive patient is a contact of VZV?
Prophylaxis with VZV vaccine or varivax
within 3-5 days of exposure
If CD4 <400 - varicella immunoglobulin should be given within 7-10 days of exposure
Contraindications to live vaccines in HIV?
BCG and Typhoid are contraindicated
All replicating live vaccines are contraindicated in pregnancy
Can you give replicating live vaccines in HIV?
BCG and typhoid CI.
Only give live vaccines if CD4 >200
i.e. MMR, Varicella, herpes zoster and yellow fever
When does HIV seroconversion usually occur?
1-3 weeks after infection.
During this time up to 80% of people have symptoms. These symptoms can last for a few days or a few weeks.
What are the symptoms of HIV seroconversion?
Fatigue Fever Sore throat Rash Headache Loss of appetite Aching muscles and joints Swollen lymph glands
Cause of Kaposi’s sarcoma?
HHV8 Other risk factors: Immunosuppression Male Caucasian, mediterranean, middle East, Africa MSM ?non smoking, DM, oral steroids
Advice regarding exposure prone procedures in HCW with HIV?
HIV infected HCWs must meet the following criteria before they can perform EPPs:
a) be on effective combination antiretroviral therapy (cART), and
b) have a plasma viral load <200 copies/ml
Or
c) be an elite controller
And
d) be subject to plasma viral load monitoring every three months and
e) be under joint supervision of a consultant occupational physician and
their treating physician, and
f) be registered with the UKAP Occupational Health Monitoring Register
(UKAP-OHR)
what is a late diagnosis of hiv?
cd4 <350
why should women who are HIV pos and undetectable be advised not to breast feed even if undetectable?
as a immunoglobulins /cd4 in breast milk
why should women who are HIV positive and breast feeding not add in formula/solids?
increases risk of transmission because formula can cause gut inflammation?
someone who is newly diagnosed HIV with low cd4 (bbv screen neg) develops transaminitis? what are causes?
could be drug related - raletgravir
iris- most likely
if immunosuppressed and exposed to hep c, may not have developed hep c ab and then can reactivate as immune response improves
if reactive HIV POC test what would you advise patient?
risk of false positive
around 10% but depends on prevalence of population
need serum sample
When should ARV be started in HIV/Hep C coinfection?
Starts ARVS prior to Hepatitis C treatment
What is IRIS?
Inflammatory response induced by ARVs CMV retinitis HCV MAC VZV TB HSV PML
Which factors might increase risk of HIV transmission?
High VL in source Breaches to mucosa (ulcers/trauma) Mensutruating STIs Ejaculation Non circumcision
