HIV

Question 1

Which 2 agents should you be cautious with starting for viral loads>100000 copies/ml?

Answer 1

Abacavir and rilpivirine

Question 2

What are the creatinine clearance limits for tenofovir?

Answer 2

CrCl <70 for TDF, <30 for TAF

Question 3

If starting treatment, and cannot use TDF, TAF or ABC, what is recommended?

Answer 3

Darunavir/ritonavir and Raltegravir

Question 4

In which 2 populations and 3 clinical scenarios should therapeutic drug monitoring be considered?

Answer 4

Children, pregnancy

malabsorption, drug interactions, suspected non adherence

Question 5

If stopping treatment NRTI with NNRTI, what should it be switched to?

Answer 5

Darunavir/ritonavir for 4 weeks

Question 6

If previous NRTI resistance, what agent should be switched to?

Answer 6

Protease inhibitor

Question 7

What is a virological blip, low-level viraemia, incomplete virological response and virological failure?

Answer 7

1) blip- VL 50-200 followed by undetectable result
2) low-level viraemia- multiple blips
3) incomplete virological response VL>200 but never undetectable
4) failure- VL>200 after being undetectable

Question 8

Virological failure- what should the switch be for:

1) on 1st line ART and wild type?
2) on 1st line PI +2 NRTI with limited major PI mutation?
3) Extensive drug resistance?

Answer 8

1) switch to PI based combination
2) switch to active PI and 1-2 agents with novel mechanism
3) 2 or more fully active agents with at least 1 PI and 1 novel agent (INI, MVC or enfurvitide) with Etravirine an option

Question 9

HIV/TB co-infection, when should ART start if:

1) CD4 <50
2) CD4>50?

Answer 9

1) within 2 weeks

2) delay 8-12 weeks

Question 10

What is the 1st line ART for HIV/TB coinfection?

Answer 10

Tenofovir DF, emtricitabine and efavirenz

Question 11

HIV/TB- when should rifabutin be used instead of rifampicin?

Answer 11

If using ritonavir, cobicistat or nevirapine

Question 12

HIV/TB- what are the issues with rifampicin and:

1) efavirenz
2) raltegravir
3) dolutegravir?

Answer 12

1) use same dose regardless of weight
2) cautious due to reduced levels
3) can use but 50mg BD, frequent viral load monitoring

Question 13

Which are the AIDS defining cancers?

Answer 13

Kaposi’s sarcoma
Non hodgkin’s lymphoma (Burkitt’s, primary effusion lymphoma, DLBCL etc)
Cervical cancer

Question 14

What should be considered with chemotherapy and HIV?

Answer 14

1) drug interactions ,especially cytochrome P450 with ritonavir/cobicistat
2) prophylaxis if previous Hep B
3) prophylaxis if previous HSV

Question 15

In cardiovascular disease, which is the preferred PI?

Answer 15

Atazanavir/ritonavir

Question 16

In cardiovascular disease, what is 1st line ART?

Answer 16

tenofovir DF, lamivudine or emtricitabine and dolutegravir or raltegravir or rilpivirine (<100000)

Question 17

In cardiovascular disease, which agents should be avoided?

Answer 17

abacavir, maraviroc, lopinavir/ritonavir and fosamepravir

Question 18

What are the 4 issues with rilpivirine?

Answer 18

Can’t give initially if VL>100,000, need to take with food, prolongs QT interval, interacts with PPI

Question 19

In which 3 scenarios regarding bone health would you avoid TDF?

Answer 19

1) >40 yrs with osteoporosis
2) history of fragility fracture
3) FRAX score >20%

Question 20

In which 4 scenarios would you expedite treatment for primary HIV infection?

Answer 20

1) Neurological involvement
2) CD4< 350
3) AIDS defining illness
4) diagnosed within 12 weeks of previous negative HIV test

Question 21

In suspected TB meningitis in HIV patients, what is the WHO preferred test on CSF for diagnosis?

Answer 21

Xpert MTB/Rif

Question 22

In patients with TB pleuritis and HIV why should respiratory samples be obtained in the absence of lung parenchymal involvement?

Answer 22

Because sputum culture diagnosis approaches 55%

Question 23

What urinary test has a high sensitivity for TB and is best at what CD4 counts?

Answer 23

LF- liparabinomannan, CD4<100

Question 24

Why are corticosteroids not advised in HIV patients with TB pericarditis despite shorterning resolution of effusions/thickening?

Answer 24

Increased risk of Kaposi’s Sarcoma and CMV disease, no effect on mortality or respiratory function.

Question 25

What is the regime for HIV patients with isoniazid only resistance?

Answer 25

RZE and levofloxacin for 6 months

Question 26

in RR/MDR TB how many effective agents are recommended?

Answer 26

at least 4 during intensive phase, moving to orals where possible

Question 27

In RR or MDR TB, in which circumstance can isoniazid be used?

Answer 27

If InhA resistance, not KatG

Question 28

What is the definition of DILI for asymptomatic and symptomatic patients

Answer 28

> 5x ULN ALT asymptomatic, or >3x ULN ALT for symptomatic patients

Question 29

in Pre-existing liver disease, which standard TB meds are most likely to cause hepatotoxicity?

Answer 29

pyrazinamide>isoniazid>rifampicin

Question 30

in pre-existing liver disease, if ALT is 2-3 times higher than the baseline, what standard regimen should be employed?

Answer 30

stop pyrazinamide, give RH for 9 months with E for 8 weeks (or stop once known sensitive)

Question 31

In pregnant women starting ART for HIV, when should viral loads be checked

Answer 31

2-4 weeks after starting, at least once per trimester, at 36 weeks and delivery

Question 32

When should women seek advice about dolutegravir around pregnancy?

Answer 32

Around conceiving and risks of neural tube defects. Also to take folic acid 5mg daily during 1st trimester.

Question 33

When should pregnant women start ART?

Answer 33

If VL<30,000 during 2nd trimester
if VL 30-1000,000 start of 2nd trimester
if VL>100,000 during 1st trimester and/or CD4<200

Question 34

What are recommended 3rd ART agents in pregnancy?

Answer 34

efavirenz or atazanavir/ritonavir

rilpivirine, raltegravir and darunavir/ritonavir are alternatives

Question 35

Under what circumstance is zidovudine monotherapy acceptable in pregnancy?

Answer 35

Patient refuses cART, has VL<10000 and agrees to Caesarean section

Question 36

If VL is >100,000 during pregnancy at 28 weeks what should be done?

Answer 36

Use a 3-4 drug regimen including raltegravir 400mg bd or dolutegravir 50mg daily

Question 37

What ART regimen should be given to untreated HIV +ve pregnant women presenting at term?

Answer 37

stat nevirapine, plus zidovudine/lamivudine/raltegravir and IV zidovudine throughout labour +/- double dose tenofovir to load pre-term infant if unable to take oral

Question 38

when should pre-labour C section be considered or recommended in HIV?

Answer 38

At 36 weeks: VL 50-399, consider

VL 400 or more, recommend

Question 39

In which 3 situations would you give intrapartum IV infusion of zidovudine?

Answer 39

1) VL>1000 in labour or SROM or having pre-labour C section
2) Untreated women in labour whose viral load is unknown
3) VL 50-1000

Question 40

Infant PEP should be given within 4 hours of birth, but what regimes are advised for very low risk, low risk, high risk?

Answer 40

zidovudine monotherapy for 2 weeks (very low risk), 4 weeks (low risk), zidovudine, lamivudine and nevirapine for high risk

Question 41

What are the recommendations for infant feeding in HIV mothers?

Answer 41

Formula feed recommended, and cabergoline to suppress lactation.
However breastfeeding mothers (controlled on cART) can do so with monthly monitoring, and HIV RNA in infant tested up to 2 months after breastfeeding

Question 42

When should infants be tested for HIV RNA and antibody testing?

Answer 42

non breastfed: 48 hours after delivery and at discharge, 6 weeks and 12 weeks (at least 4 and 8 weeks post PEP), Antibody at 22-24 months, f/u till at least 18 months.

Breastfed: 2 weeks, monthly for duration of breastfeeding, 4 weeks and 8 weeks post breastfeeding. Antibody test minimum 8 weeks post breastfeeding if this is the latter or 22-24 months