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
What % of MSM with syphilis are HIV1 coinfected?
40%
HIV POCT- what advise patient?
Different tests
Use oral fluid, finger prick, plamsa, whole blood or urine
In low prevalence setting- false positive relatively higher with poor PPV (number of people with positive test who have disease)
All reactive tests need a confirmatory serum test
Zidovudine- side effect
Nail pigmentation with zidovudine occurs primarily in black patients.
Reversible and dose-dependent.
? Mechanism
The longitudinal streaks of discoloration seen with zidovudine must be distinguished from the brownish hyperpigmented stripes that are seen in HIV.
Another unusual side effect of zidovudine noted by some is a grayish-black discoloration of the tongue. This is not associated with any toxicity and is asymptomatic.
What are HIV clinical indicators for AIDS defining conditions?
Tuberculosis Pneumocystis Cerebral toxoplasmosis Primary cerebral lymphoma Cryptococcal meningitis Progressive multifocal leucoencephalopathy Kaposi’s sarcoma Persistent cryptosporidiosis Non-Hodgkin’s lymphoma Cervical cancer Cytomegalovirus retinitis
Other clinical indicators where HIV testing should be offered?
Bacterial pneumonia
Aspergillosis
Aseptic meningitis/encephalitis
Cerebral abscess
Space occupying lesion of unknown cause Guillain–Barré syndrome
Transverse myelitis
Peripheral neuropathy
Dementia
Leucoencephalopathy
Severe or recalcitrant seborrhoeic dermatitis Severe or recalcitrant psoriasis Multidermatomal or recurrent herpes zoster
Oral candidiasis
Oral hairy leukoplakia
Chronic diarrhoea of unknown cause
Weight loss of unknown cause
Salmonella, shigella or campylobacter Hepatitis B infection
Hepatitis C infection
Anal cancer or anal intraepithelial dysplasia Lung cancer
Seminoma
Head and neck cancer
Hodgkin’s lymphoma
Castleman’s disease
Vaginal intraepithelial neoplasia
Cervical intraepithelial neoplasia Grade 2 or above
Any unexplained blood dyscrasia including: • thrombocytopenia
• neutropenia
• lymphopenia
Infective retinal diseases including herpesviruses and toxoplasma
Any unexplained retinopathy
Lymphadenopathy of unknown cause Chronic parotitis
Lymphoepithelial parotid cysts
Mononucleosis-like syndrome (primary HIV infection)
Pyrexia of unknown origin
Any lymphadenopathy of unknown cause
Any sexually transmitted infection
What are symptoms of neurotoxicity with efavirenz?
Symptoms of CNS toxicity
Dizziness, irritability, headache, diminished concentration, euphoria, vertigo and depression, insomnia, nervousness, suicidal ideation, psychosis
Sleep disturbance (somnolence, insomnia and vivid or abnormal dreams) -nearly half of cases.
2% of subjects report more serious neurological effects, including delusion, paranoia, depersonalization, hallucinations, anxiety, aggressive behaviour, abnormal thinking, mania and severe depression.
Mechanisms - ?disturbances in brain mitochondrial function
Which ARV causes hyperbilirubinaemia and kidney stones?
Atazanavir
Which ARV causes CV problems eg MI and stroke?
Abacavir (and PIs)
Which ARV causes high cholesterol?
Efavirenz
Which ARV can cause SJS and TEN and liver problems?
Nevirapine
What are commonest causes of community acquired bacterial pneumonia in HIV positive?
Strep pneumonia and Haemophilus influenza (same as general population.)
S aureus and pseudomonas aerginosa are more common in HIV pos than HIV neg
Allergy to Darunavir?
Darunavir is a PI
Darunavir contains a sulfonamide moiety. She patients may have sulfonamide allergy.
Also can't have Amprenavir Darunavir Delavirdine Fosamprenavir Tipranavir
What is the BASHH guidance for follow up HIV testing post PEPSE?
Follow-up HIV testing at 8–12 weeks post-exposure
Why might you need to come off efavirenz safely?
It has a long half life so if stop all ARV at same time, risk of monotherapy and therefore resistance.
Advised to put patient on a PI for 1/12 (PI monotherapy is ok as there is a high barrier to resistance)
Level of evidence for PEPSE where risk >1 in 1000
Level 1C
We recommend the use of PEPSE where there is a significant risk of HIV transmission (risk >1/1000)
Level of evidence for PEPSE regimen where risk >1 in 1000
Level 1B
Truvada and raltegravir as the regimen of choice for PEPSE
Level of evidence for f/u testing post PEP
Level 1C
We recommend follow-up HIV testing at 8-12 weeks after exposure
How is chickenpox transmitted (VZV)
Chickenpox is highly infectious and can be transmitted by respiratory droplets and aerosols up to 48 hours prior to the onset of the rash.
Complications of VZV?
Complications may include severe cutaneous rashes, secondary bacterial infections, visceral involvement (e.g. pneumonia, hepatitis), and neurological disease (meningitis, encephalitis, myelitis).
All adults with chickenpox, and especially pregnant women, are at risk of VZV pneumonia.
Complications of VZV or HZV in pregnancy?
Occasionally, infection in pregnancy leads to fetal injury (congenital varicella syndrome).
Complications of shingles HZV
Shingles is usually self-limiting, although persistent debilitating pain is a frequent complication, particularly in the elderly (post-herpetic neuralgia, PHN); eye involvement may lead to permanent visual impairment.
Can varicella vaccines causes latent infection?
The vaccine strain can establish latent infection in some vaccine recipients, and can reactivate to cause shingles,
CI to varicella vaccine
Contraindications include pregnancy and significant immunocompromise.
HIV don’t give is cd4 <200 as live vaccine
Who should receive shingles vaccine?
In the UK, shingles vaccination is recommended for adults without a history of immunodeficiency aged 70 years,
‘catch- up’ programme currently targets those aged 70–79 years.
Contraindications include pregnancy and breast feeding and significant immunocompromise.
What are recommendations for HIV positive adults with ?hx of chickenpox or shingles
VZV IgG testing to determine susceptibility to primary infection and reactivation
What if HIV positive and bloods are VZV seronegative for IgG?
If CD4 cell count >200 cells/μL and preferably on ART
two doses of the chickenpox vaccine
3 months apart
Serological testing for evidence of VZV IgG seroconversion should be performed 4–6 weeks after the second vaccine dose
What if HIV positive and bloods are VZV seropositive for IgG?
We recommend VZV IgG seropositive patients who have a CD4 cell count >200/μL and preferably are established on ART be offered one dose of the shingles vaccine in line with national age- related indications- but may benefit from shingles vaccination from the age of 60 years
If HIV positive and given replicating VZV and develop rash/other sx, what is recommendation?
Report and seek medical evaluatio
May be offered appropriate antiviral therapy against VZV if required
HIV positive and contact of VZV?
We recommend that following a significant exposure to VZV, the VZV IgG status of the HIV- positive contact be ascertained regardless of vaccination history (although prophylaxis should not be delayed waiting for the results)
VZV IgG seronegative patients be considered for post- exposure prophylaxis and monitored closely for symptoms to facilitate prompt institution of antiviral therapy
HIV positive- CD 4 <200, exposed to VZV and seronegative what would recommend?
If CD4 <200 cells/μL give VZIG and antiviral prophylaxis
Aciclovir (800 mg qds / valaciclovir (1 g tds) starting from day 7 after exposure and continuing for 7 days
HIV positive- CD 4 <400, exposed to VZV and seronegative what would recommend?
If CD4 <400 cells/μL:
PEP with VZIG within 7 days and not later than 10 days after exposure
If no PEP, antiviral prophylaxis
Aciclovir (800 mg qds / valaciclovir (1 g tds) starting from day 7 after exposure and continuing for 7 days
HIV positive- CD 4 >400, exposed to VZV and seronegative what would recommend?
If CD4 cell counts >400 cells/μL:
Varivax vaccine within 3 and up to 5 days after exposure
2nd dose- >3 months
Can you give antivirals and VZV vaccine together?
No
VZV replicating vaccines are not given treatment doses of antiviral drugs with anti-herpetic activity (e.g. aciclovir) at the time of vaccination and for 4 weeks subsequently as it may reduce vaccine immunogenicity
How common are strokes/TIA in HIV?
0.5-8% of HIV positive
What are vascular risk factors that increase risk of stroke in HIV pos?
HIV is hypercoaguable state
RFs- smoking high BP Hyperlipidaemia Cocaine/alcohol- nacres risk of thrombotic stroke
Cerebral vasculitis from syphilis, VZV may cause cerebral thrombosis
Face-to-face provision of HIV test results is strongly encouraged for
ward-based patients
patients more likely to have an HIV-positive result
those with mental health issues or risk of suicide
English is a second language
young people under 16 years
those who may be highly anxious or vulnerable
Refusal of testing by a competent young person
Legal advice should be sought about whether to apply to the court if testing is thought to be in the best interests of a competent child who refuses.
What to tell children about having an HIV test
A developmentally and age-appropriate explanation of the test should be given to children
Does not necessarily mean using the term HIV.
1) Older children (> 11 yo) should be asked to give consent for an HIV test.
2) Younger children (5-10 yo) can be told they are being tested for a ‘bug’ in the blood.
3) Pre-school children and infants do not need any formal explanation of why they are having a blood test.
Refusal of testing by parents of a non-competent child or young person
If in the best interests –
consider involving other members of the multidisciplinary team
an independent advocate or named/designated doctor for child protection before seeking legal advice.
This also applies if both a young person with capacity and their parents refuse testing.
What to do if source patient in a needlestick injury is HIV pos or other HIV risk exposure
The source patient’s consent to testing must always be gained.
Consent from the patient should be obtained from a healthcare worker other than that who sustained the injury.
If the rationale for testing is explained, it is unusual for consent to be refused.
If the patient does not wish to know the result the option of testing without any documentation should be considered.
HIV testing and insurance?
Questions regarding whether an individual has ever had an HIV test or a negative result should not be asked.
Applicants should declare any positive results if asked as would be the case with any other medical condition
In which cases is HIV testing universally recommended?
- GUM or sexual health clinics
- antenatal services
- termination of pregnancy services
- drug dependency programmes
- healthcare services for those diagnosed with tuberculosis, hepatitis B, hepatitis C and
lymphoma.
HIV test should be considered in the following settings where diagnosed HIV prevalence in the local population?
Where diagnosed HIV prevalence in the local population (PCT/LA) exceeds 2 in 1000 population
- all men and women registering in general practice
- all general medical admissions.
HIV testing should be also routinely offered and recommended to the following patient?
- all patients presenting for healthcare where HIV, including primary HIV infection, enters the differential diagnosis (see table of indicator diseases and section on primary HIV infection)
- all patients diagnosed with a sexually transmitted infection
- all sexual partners of men and women known to be HIV positive
- all men who have disclosed sexual contact with other men
- all female sexual contacts of men who have sex with men
- all patients reporting a history of injecting drug use
- all men and women known to be from a country of high HIV prevalence (>1%*)
- all men and women who report sexual contact abroad or in the UK with individuals from countries of high HIV prevalence.*
HIV testing should also be routinely performed in the following groups in accordance with existing Department of Health guidance
- blood donors
- dialysis patients
- organ transplant donors and recipients.
How often to offer an HIV test?
- all individuals who have tested HIV negative but where a possible exposure has occurred within the window period
- men who have sex with men (MSM) – annually or more frequently if clinical symptoms are suggestive of seroconversion or ongoing high risk exposure
- injecting drug users – annually or more frequently if clinical symptoms are suggestive of seroconversion (see section on primary HIV infection)
- antenatal care – women who refuse an HIV test at booking should be re-offered a test, and should they decline again a third offer of a test should be made at 36 weeks. Women presenting to services for the first time in labour should be offered a point of care test (POCT).
Should pregnant women be offered a second HIV test in pregnancy?
In areas of higher seroprevalence, or where there are other risk factors, women who are HIV negative at booking may be offered a routine second test at 34–36 weeks’ gestation as recommended in the BHIVA pregnancy guidelines
How common is seborrhoeic dermatitis in HIV?
Occurs in 85%
May be first indicator
Severity/increased recurrences if CD4 count low
Related to infection with pittosporum app, increased sebum and genetic predisposition
Treatment of seborrhoeic dermatitis?
Topical antifungals/steroids eg miconazole/hydrocortisone
Scalp- tar shampoo, salicylic acid, ketoconazole
Severe disease- systemic triazoles eg itraconazole
What is hep B vaccine schedule if HIV positive and not on ARV?
Hep B vax pro 40 mcg or Engerix B (double dose) 40 mcg or fendrix 20 mcg 4 doses 0, 1 m, 2m, 6m
Can ultra rapid Hepatitis B vaccine course be given in HIV positive patients?
ultra-rapid vaccination course (0, 7, 21 standard dose) be considered only in selected patients with CD4 cell counts >500 cells/μL
If imperative need to ensure rapid completion of vaccination and/or where compliance with a full course is doubtful
We recommend against using high-dose vaccination in an ultra-rapid schedule due to the lack of safety data
If primary vaccine hep B course in HIV pos and HBsAb levels <10 IU/L at 6 weeks, what is recommended?
three further vaccine monthly intervals high dose (40 μg) with Engerix B or HBvaxPRO standard dose (20 μg) with Fendrix
We suggest that revaccination with Fendrix may be preferred in non-responders
revaccination of non-responders may be
delayed until the viral load is suppressed on ART and the CD4 cell count has increased >350
If after primary vaccine for hep B in HIV, HBsAb levels ≥10 but <100 IU/L, what is recommended?
one booster dose
How often should hepbsAb level be measured in HIV positive patients who are vaccinated?
guided by the initial HBsAb level (measured
after completion of the primary vaccine course
Usually yearly HBsAb screening
Longer intervals (i.e. 2–4 years) if initial HBsAb levels >100 IU/L, CD4 cell counts >350 cells/μL, and viral load suppression on ART
HIV pos, exposed to Hepatitis B
No prophylaxis required if evidence of current/ past HBV infection
Vaccinated patients with initial HBsAb >10 IU/L - 1 booster dose and if the CD4 cell count is <200 cells/μL also receive HBIg
Non-responders to previous HBV vaccination (initial HBsAb <10 IU/ L)–> booster vaccine and HBIg regardless of CD4 cell count
Patients who have not been vaccinated or ? vaccination history should be offered a rapid vaccine course (0, 1, 2 months; see above for dosing) and also receive HBIg regardless of CD4 cell count
When indicated, two doses of HBIg should be given 1 month apart
Post-exposure prophylaxis should be given within 7 days of exposure
We suggest that prophylaxis beyond 7 days (up to 6 weeks after exposure) may be considered
Which is the screening test antenatally for hepatitis B?
HepBsag- looking for active infection
Which is the screening test in SH for hepatitis B?
Hep B Core ab IgG
hepBcab
Which HBV genotype is highest risk for HCC?
Genotype C
PREP baseline tests required?
HIV testing with ag/ab Hep B Hep C Syphilis serology GC/CT Renal funciton- egFR PT Urinalysis
Risk of HIV transmission in IV drug use (Sharing equipment)
1 in 149 per exposure from a known HIV positive individual not on ART
Complications of PCP?
Systemically unwell- weight loss, cough
SOB (initially on ecxertion, then on rest)
PNEUMOTHORAX- may need chest drain
Respiratory failure
Prophylaxis for PCP- when offered in HIV?
Recommended if CD4 <200
1st line cotrimazole 480-960mg daily
Alternatives- dapsone +pyrimethamine + folinic acid
Continue until CD4 >200 for 3 months
Prophylaxis for Toxoplasma- when offered in HIV?
Recommended if CD4 <200 and positive serology
1st line cotrimazole 480-960mg daily
Alternatives- dapsone +pyrimethamine + folinic acid
Continue until CD4 >200
Prophylaxis for mycobacterium avium- when offered in HIV?
Recommended if CD4 <50
1st line: azithromycin 1250mg weekly
Discontinue if CD4v >50 for 3 months
PEP in HIV positive patients for
- diphtheria, h. influenzae, meningococcus, pertussis
Offer abx and vaccination if contacts
Prophylaxis if HIV pos and contact of HAV
Offer HAV if HAV IgG negative
If CD4 <200, offer HAV immunoglobulin within 14 days
Prophylaxis if HIV pos and contact of Hep B?
Determine Hep B immunity
If suboptimal - offer booster
Non immune- rapid vaccine
Hep B immunoglobulin regardless of CD4
Prophylaxis if HIV pos and contact of measles
Request measles igG
If IgG positive and CD4 >200 do nothing
If cd4 <200- give immunoglobulin (even if
measles immunity)
If IgG negative and Cd4 >200, give measles vaccine within 3 days or immunoglobulin within 6 days
If immunocompromised and given oral polio by mistake, what can you do?
Give polio HNIG
Contact of VZV and HIV positive?
Prophylaxis with VZV- chickenpox/varivax vaccine within 3-5 days
If CD4 <400- give varicella immunoglobulin within 7-10 days of exposure
Why do you need to give ART first in HIV/Hep C confection?
Immune recovery if CD4 <350 (or 350-500)
The start anti HCV rx
How long do you treat HCV with DAAs?
Total 48 weeks
When diagnosed with HIV, what hepatitis serology needs to be done?
HCV ab Screen HepA ing HepBsAg (annual) HepCab Hepsab
If HIV positive and HepBcab positive HepBsag negative HepBsAb negative AST and ALT raised
?occult
Need to check HepB RNA
Who do you need to check HDV ab on?
All who are HepBSag positive
If HDV ab positive check RNA
If someone has raised transaminases what do you need to consider?
Hep B, Hep C
If negative consider HEV
What is recommended ART regimen for Hep B, HIV coinfection?
TDF/ FTC
How common in oral candida in HIV?
seen in 90%
How does oral candida present?
White plaques/red patches
Angular chelitis
Treatment of oral candida?
Fluconazole 50-100mg 7-14 days
Itraconazole 100-200mg 7-14 days
Prophylaxis - fluconazole 50mg daily
Apthous ulcers- treatment
Vesicular Can be necrotic Lidocaine 5% Hydrocortisone tablets held on lesions If severe prednisolone 40-60mg
Complications of oral HSV in HIV?
Keratitis
Oesophagitis
Meningitis
Treatment of oral HSV in HIV?
400mg Aciclovir 5 x day for 10/7
or 1000mg bd Valaciclovir
Presentation of CMV oral ulcers in HIV
Deep necrotic red/white ulceration
Arise when CD4 <50 cells/ul
Prevalence of CMV oral ulcers in HIV?
90% in HIV MSM
Presentation of oral hairy leukoplakia?
White adherent corrugated lesion Found in the mouth EBV NOT PREMALIGNANT Associated with increase progression to AIDS
Presentation/rx of oesophageal candida?
CD4 <200
Oral candida association
Painful to swallow
Treat with fluconazole 100-200mg 10-14 days
How to treat salmonella in HIV?
Needs treating in PLWH- severity, high relapse, high risk of dissemination
Ciprofloxacin 750mg bd
Treatment of CMV retinitis?
CD4
Causes of bacterial pneumonia in HIV?
AS in general population
Strep pneumoniae
Haemophilus influenza
(staph aureus and pseudomonas aeriginosa -commoner than HIV neg)
Treatment of bacterial pneumonia in PLWH?
IV cefuoroxime 1.5 g tds
and macrolide eg clarithromycin 500mg bd
Investigation and treatment of PCP?
Night sweats, weight loss, cough/sob
CXR- bibasal perihilar interstitial infiltrates,
CT- ground glass
Rx- clotrimoxazole 120mg /kg or dapsone
Investigation and treatment of TB?
Pleuritic chest pain
Haemoptysis
Weight loss
AFB- 2 sputum
CXR- UL cavity changes
Rx- isoniazid, rifampicin, ethambutol, pyrazinamide
Which group of ARV can cause insulin resistance?
PIs
What derangement of lipids can be seen with HIV?
Raised triglycerides
Raised cholesterol
Low LDL
Side effects of azoles
Low cortisol and low testosterone
Electrolyte disturbances with drugs- raised K
cotrimoxazole
Trimethoprim
HIV nephropathy - investigations
Heavy proteinuria Low albumin Oedema Lipids raised BP normal
Electrolyte disturbances with drugs- low Ca
Tenofovir
Foscarnet
Ketoconazole
HIV nephropathy - treatment?
ARV
Avoid nephrotoxic trigs - eg TDF and PI
Immune mediated renal disease - HIV
What are associations?
Hep B and hep C
Light proteinuria
microhaematuria
Treat with ARV
HIV - CV complications
Infective endocarditis
Which valve is affected by infective endocarditis in HIV and which infections implicated?
Tricuspid valve
step viridians, staph A, candida
Which ARVs cause cardiac complications?
Zidovudine, foscarnet cause cardiomyopathy
Ganciclovir, interferon- dysrrythmia
Cotrimoxazole- conduction defect
Reactive arthritis - HIV
Lower limb and peripheral joints
Leucocytes and glucose in synovial fluid
Rx- NSAIDs
What is persistent generalised lymphadenopathy in HIV?
2 extra inguinal LN sites >3/12 symmetrical LN >1cm Non tender
Kaposi’s sarcoma- how does it present?
Pigmented macules/papules/plaques
YEllow halo
On face, nasal margin, end of nose, eyelid
33% have red purple lesion on hard palate
How much more common is KS in HIV?
500 x
Diagnosis of KS?
biopsy or HHV8 VL
Treatment of KS?
80% improve with ART
Cryotherapy
Radiotherapy
Chemotherapy if prognosis poor
Treatment of Castleman’s disease
rituximab
What is castlemans disease?
HIV associated malignancy
Recurrent increase in LN
HHV8
High VL
Cause of Non hodgkins lymphoma?
12 x more likely in HIV
Monoclonal B cells- large B cells
Burketts/non Burketts
Systemic lymphoma
Diagnosis of Non hodgkins lymphoma?
Biopsy
MRI/CT to stage
Toxoplasma serology
treatment of Non hodgkins lymphoma?
ART
CHOP
Radiotherapy
Which 3 types of cancer are AIDS defining?
High grade B-cell non-Hodgkin’s lymphoma (NHL) including primary cerebral lymphoma
Kaposi sarcoma (KS)
Invasive cervical cancer
How common is high grade B-cell NHL in PLWH?
60-100 times more frequently in people with HIV than in the matched general population
What is associated with primary effusion lymphoma in HIV?
KS herpesvirus, (a gamma-2 herpesvirus,) is the causative agent of
- KS
- Primary effusion lymphoma
- A plasma cell variant of multicentric Castleman’s disease.
Primary effusion lymphoma may present with effusions (pleural, pericardial or ascites) without any nodal mass of disease is associated with KS herpesvirus
Treatment of Non Hodgkin’s lymphoma?
Intravenous combination chemotherapy
Intrathecal chemotherapy (for those at risk of meningeal relapse)
ART
Opportunistic infection prophylaxis - PCP, MAC and antifungal.
This management approach will result in durable complete remission in about 60% of patients who will in effect be cured of their NHL.
Define Primary cerebral lymphoma?
Primary cerebral lymphoma is defined as lymphoma that is confined to the cranio-spinal axis without systemic involvement.
In the context of HIV infection, it occurs in patients with advanced immunosuppression and has a particularly poor prognosis. The incidence of PCL has declined since the introduction of ART
What are commonest causes of cerebral SOL in HIV?
Toxoplasmosis and PCL are the most common causes of cerebral space occupying lesions in HIV
At what CD4 count and toxoplasma and Primary cerebral lymphoma seen in HIV?
Both toxoplasmosis and PCL occur at low CD4 counts (<50 cells/ µ L) and present with headaches and focal neurological deficits.
What is the aetiology of primary cerebral lymphoma?
The detection of Epstein–Barr virus (EBV) DNA in the cerebrospinal fluid (CSF) by polymerase chain reaction (PCR) in patients with PCL has become established as a diagnostic test with a high sensitivity and specificity.
How common is primary cerebral lymphoma in PLWH?
1000x
How to differentiate between cerebral toxoplasma and PCL?
Clinical and radiological features may aid differential diagnosis but are not definitive.
Toxoplasma- fever (PCL and PML don’t)
Over 85% patients with cerebral toxoplasmosis will respond clinically and radiologically to 2 weeks of anti-toxoplasma therapy.
EBV DNA in the CSF by PCR in patients with PCL has become established as a diagnostic test with a high sensitivity and specificity.
F-fluorodeoxyglucose-positron emission tomography (FDG-PET) helps differentiate between PCL and cerebral toxoplasmosis.
Where in the brain does toxoplasma affect?
Basal ganglia and brainstem
Where in the brain does primary CNS lymphoma affect?
periventricular/anywhere
Where in the brain does PML (progressive multifocal leukoencephalopathy) affect?
parietal lobe/white matter
Which infection causes KS?
KS is caused by infection with a gammaherpesvirus
named either Kaposi sarcoma herpesvirus (KSHV)
or human herpesvirus 8 (HHV8).
This virus which resembles EBV is transmitted horizontally. Highest levels of KSHV are found in saliva.
What is the route of transmission for KS?
kissing
Major differential diagnosis for KS?
The major clinical differential diagnosis is bacillary angiomatosis caused by the rickettsia Bartonella henselae and this is best excluded by biopsy
What are the most common sites of visceral involvement by KS?
lungs and stomach.
What are GI associations with KS?
Gastrointestinal lesions are usually asymptomatic but may bleed or cause obstruction. The diagnosis is usually confirmed at endoscopy
How much more common is cancer in PLWH than general population?
2-3 x more common in HIV
Cancers associated with oncogenic viral infections
eg anal cancer HPV
Hodgkin’s disease- EBV
Hepatocellular cancers- hepatitis
However, some cancers with no known viral aetiology such as seminoma and non-small cell lung cancers also occur significantly more commonly in people living with HIV.
Can NHL be cured?
The treatment of systemic AIDS related NHL results in durable complete remission in about 60% of cases
Examination newly diagnosed HIV pos
Physical exam Weight Height BMI BP Waist circumference
Ix for newly diagnosed HIV pos
Confirmatory test HIV1/2 Test for primary HIV (avidity) VL Drug resistance CD4 HepA ing Hep B Hep B ab STI Measles/varicella ab FBC U+E LFT Bone profile Dip urine Ur pr/cr ratio if pos HLA B5701 Viral tropism if considering CCR5 inhibitor QRrisk if over 40 FRAX- ver 50/postmenopausal/high risk ?IGRA (TB)
Smear- women
Rubella
What additional considerations in first 3 months for newly diagnosed HIV?
MH Neurocognitive problems Social hx Employment Immigration status
ARV treatment failure?
Inadequate response to initial regimen with
-Less than a 1 log reduction in VL by week 4 on therapy
-OR failure to suppress VL to <50 copies/ml within 4-6 months of initiation of therapy
Or
-Persistent viral load rebound where previously <50 copies/ml and either low-level viraemia >50 and <400 copies/ml or sustained viral load rebound to >400 copies/ml
HIV transmitted drug resistance ARV
Global prevalence of HIV drug resistance (HIVDR) is rising, mainly due to resistance to NNRTI drugs
Which ARV are less prone to resistance?
Newer ARVs and drug classes, such as the integrase inhibitor, dolutegravir, have much higher genetic barriers to resistance.
And PIs?
Mutations that confer resistance to ARV?
For some drugs, such as the NRTI lamivudine and all NNRTIs, just one mutation – notably the M184V or K103N mutations – can result in high-level drug resistance.
K65R and M184V can confer resistance to 2 drugs in PREP
K103N is the most common resistant mutation to NNRTIs- can cause efavirenz or nevirapine failure
Types of resistance testing in HIV?
Genotypic resistance testing
Genotype tests look at the specific genetic sequence within the viral DNA to assess whether there has been any change in structure compared to a ‘wild type’ virus (a viral sample with no genetic mutations or drug resistance). This type of test will detect specific mutations within the genetic structure of the virus.
Phenotypic resistance testing
Phenotype tests look at the impact of mutations on resistance in practice. They test the dose of antiretroviral drugs needed in order for viral replication to stop (testing each drug separately).
What drives HIV drug resistance?
Patient factors- not taking their drugs as prescribed, increasing their risk of developing drug resistant mutations.
Programme factors- challenges arising from the delivery of HIV treatment programmes
Drug stock-outs, where people cannot get their drugs because the pharmacy doesn’t have their treatment,
Drug and treatment regime factors
Regime and drug-specific factors refer to the selection of ARV that may increase or decrease the likelihood of HIVDR, with different types of drugs and drug classes having varying genetic barriers to resistance
NNRTI-based treatment regimens are still commonly prescribed as first-line treatment , and while these drugs are effective, they are more susceptible to drug resistance over other treatment regimens – such as boosted PI-based or integrase-based regimes.
Providing treatment in one single-pill fixed-dose means people are more likely to adhere to their drug taking regime; it also makes it easier for drug procurement.
Sub-optimal prescribing of ARVs, such as single tablet nevirapine or zidovudine for pregnant women, as well as use of just one of two types of drug for HIV therapy also increase the risk of HIVDR as they allow for mutations to occur in the presence of drugs already in the body.
Viral factors
Virus-related factors refer to resistance that arises by nature of the HIV type or subtype that may affect a drug regime. For example, HIV-2 is intrinsically resistant to NNRTIs, so people with this strain of HIV should not have NNRTIs included in their regime.
Also, some evidence suggests that thymidine analog mutations – caused by the drugs zidovudine and stavudine – may develop more quickly in people with HIV subtype C. These cannot be helped on their own, but if the healthcare provider is aware, they can control the progressions of drug resistance by addressing other drivers.
Types of HIV drug resistance?
Transmitted HIVDR (TDR) – occurs when an uninfected, treatment-naïve person is infected with a drug-resistant strain of HIV from someone with HIVDR mutations.
Acquired HIVDR (ADR) – occurs when a treatment-experienced person living with HIV develops drug mutations in the presence of ART as a result of sub-optimal treatment adherence, treatment interruptions, inadequate drug concentrations in the body, or the use of suboptimal drugs and combinations.
Pre-treatment HIVDR (PDR) – HIVDR that is detected at the time of first-line ART initiation or re-initiation, that could be due to transmitted drug resistance, or HIVDR acquired as a result of previous ARV exposure, such as mothers and children in prevention of mother-to-child transmission programmes (PMTCT).
HIV dug resistance
PrEP is not directly linked to the emergence of HIVDR
But regular testing for HIV while on PrEP is important to ensure that people aren’t inadvertently taking suboptimal HIV treatment should they become HIV-positive while on PrEP.
HIV risk of transmission?
Risk that source is HIV positive x risk per exposure
eg. receptive UPAI with ?HIV source in london
Risk= 12.5/100 (prevalence in london) x 1/65 (risk HIV UPAI Rec)
= 12.5/6500= 1/520
Which ARV are enzyme inducers and can’t give with contraception?
NEAR
Nevirapine
Efavirenz
Atazanavir
Ritonavir
