HIV including (incl pregnancy guidelines) + HBV

Question 1

If not already on ART, what are the indications for starting ART in pregnancy? ie when and what CD4 counts and viral loads

Answer 1

All PLWHIV should be on ART by 24 weeks
- Generally avoid starting in first trimester BUT Start in first trimester if VL is over 1 million and/or CD4 count less than 200
-Start as soon as possible (i.e start of second trimester) if between 30,000 and 1 million
- if v/l is less than 30,000 start “as soon as they are able”

Question 2

1)When should you do CD4 counts and viral loads in pregnancy?
2) How often should you do V/Ls
3) any other tests indicated

Answer 2

1) CD4 and V/L

baseline, delivery
(even if CD 4 count above 350, note in a non-pregnant person If >350 cells/mm3 on two occasions >1 year
apart, no further CD4 cell counts required)
Viral load at 36 weeks

2) In women starting ART- 2-4 weeks after starting, once a trimester and at 36 weeks

3) Liver function tests and Resistance test- ideally wait for result before starting ART, unless late booker (considered to be late if after 28 weeks)

Question 3

At what gestation is the viral load a determinant of future planning for delivery?
If at this time the V/L is between 50 and 399 what is recommended (mum only)?

Answer 3

36 weeks
“Consider” C section at 38-39 weeks gestation (taking into account the actual V/L, the trajectory of the V/L, length of time on treatment, adherence issues, obstetric factors and the woman’s views)

NOTE:Cut off for definite C-section is viral load 400 or over at 36
weeks

“consider” IV zidovudine in women on cART
with a plasma HIV viral load between 50 and 1000 HIV RNA copies/mL

If <50- Vaginal birth

Note transmission occurs during contractions- aim is to avoid these

Remember to repeat CD4 and Vl at delivery

BABY: Would be low risk and get 4 weeks Zidovudine
Test baby at birth and two weeks after completion of ART ( During the first 48 hours and prior to hospital discharge;
* At 6 weeks (or at least 2 weeks after cessation of infant prophylaxis);
* At 12 weeks (or at least 8 weeks after cessation of infant prophylaxis), test monthly if breast fed

Low risk as at 36 weeks V/L is over 50

Other things needed to be very low as opposed to low risk are

• The woman has been on cART for longer than 10 weeks
• Needs two V/L <50 four weeks aoart
• If the infant is born prematurely (<34 weeks) but most recent maternal HIV viral load
  is <50 HIV RNA copies/mL.

Question 4

What are the indications for intravenous zidovudine at delivery?

Answer 4

1) When HIV V/L not known
2) When V/L is over 1000
(when they present in labour, when they come in for a pre labour C section or if they have SROM)

3) Consider if viral load is between 50-1000 at 36 week
- study has shown no benefit in this range if neonatal PEP is used)

Question 5

Which ART is contra-indicated in pregnancy (slight trick question)

Answer 5

1) PI monotherapy (just because it is a “non-stamdard regime)

2) TAF should not be given in first trimester

3) Was concern about dolutegravir causing neural tube defects in babies- if on this when concieveing, take high dose folic acid

If starting ART in pregnancy, avoid Dolutegravir for first 6 weeks

3) Cobicistat- poor PK in pregnancy

Question 6

Which ART used during pregnancy needs dose alteration

Answer 6

Raltegravir- should be 400mg BD

Question 7

See viral loads of pregnant a pregnant women, on ART for 5 years
at 16 weeks: <50
at 24 weeks 1000
at 26 weeks 200
at 36 week 0
What would you recommend for mum and baby at delivery

Answer 7

HIV RNA test on day of birth
PEP for baby- considered low risk
Zidovudine for 4 weeks for baby
PEP should be started within 4 hours

Send repeat viral load and CD4 count at delivery from mum

low risk criteria:
Not detectable at 36 weeks + all the below criteria have to be met
- ART for 10 weeks minimum
- 2 x V/L <50 4 weeks apart (in this case this was not met but the most recent V/L was undetectable)
- baby born after 34 weeks gestation

Question 8

If a baby is born to a HIV positive mother how oftern do you test them?

Answer 8

RNA 48 hours after birth (gives an idea of congeital vs early childhood aquisition)
2 weeks after sessation of pep on two occasions (this will be 4/6, 6/8 weeks)

Then do serology at around 2 years

Question 9

When should you start ART when someone has PCP?

Answer 9

WITHIN 2 weeks of PCP treatment

Question 10

According to BHIVA recommendations (2024 guidelines), what is the diagnostic method for confirming CMV pneumonitis

Answer 10

1) Biopsy + 2) compatible symptoms + 3) excluding other pathogens

• they specifically say that most people with CMV detected (on isolation from a sputum or biopsy) should not be treated, ie you need points 1 and 2)

If there are co-pathogens treat the other pathogen first and then consider CMV

Question 11

In suspected CMV pneumonitis what do BHIVA recommend for determing CMV shedding vs pneumonitis

Answer 11

Biopsy

Virus culture- has a high negative predictive value (although not done) 2024 guidelines

• We recommend that the majority ofindividualsinwhom microbiologicaltests on
  BAL fluid, or biopsy, demonstrate CMV should not receive treatment for CMV
  (Grade 1C).
• In cases with a compatible clinical syndrome and consistent microbiological or CMV
  PCR findings in the absence of any other pathogens, we recommend that anti-CMV
  treatment should be considered (Grade 1C).
• In individuals co-infected with other pathogens, it is reasonable to start by
  treating the co-pathogen first and to treat the CMV only ifthere is a failure of
  clinicalresponse (Grade 1C).
• We recommend ganciclovir as standard therapy for CMV pneumonitis (Grade 1C)

Question 12

What is the treatment for CMV pneumonitis (BHIVA 2024)

Answer 12

ganciclovir 5mg/kg BD for 14-21 days (duration not evidenced)
Alternatives: 900mg BD valgan oral- not studied
Foscarnt 90mg/kg BD
Cidofovir 90mg/kg weekly

Question 13

A pregnant women has a confirmed HTLV infection. What are the options to reduce transmission to baby?

Answer 13

Advise against breast feeding
Consider C section
INSTI

Question 14

If at 36 weeks gestation mums viral load is 200 what is recommended for the baby (ART and follow up)

Answer 14

Consider C section (unless SROM then go for C section)

Assess risk of having detectable viral load at delivery

Depending on mums V/L at delivery
Bloods within 48 hours of birth
2 weeks after stopping ART

PEP should be started within 4 hours of delivery

High risk baby prep: zidovudine + lamivudine + nevirapine (nevirpaine is only given for one dose if mum got it ifor more than three days in labour), otherwise given for two weeks when other agents are given for 4)

Question 15

What is considered “blip” in HIV care? What do you do about this

Answer 15

Single viral load of 50-200

Repeat test in 2-6 weeks
Check adherence, DDI’s

Consider resistance testing if there are repeated blips

Question 16

PLWHIV on treatment has a single viral load of >200. What do you do?

Answer 16

Retest ASAP (+/- resistance testing)
This is in the level for considering virologic failure

Question 17

What conditions need to be met for a patient to be a candidate injectables for HIV?

Answer 17

In trials virologic failure assocaited with : HIV subtype A6/A1, a body mass index (BMI) ≥30 kg/m2

Can’t have any resistance
have to be able to attend every two months

Question 18

Suitability for starting 2 drug regimine for HIV in a new starter TBC

Answer 18

Dolutegravir/Lamivudine is recommended as initial treatment for most people living with HIV with the following caveats:

It is not recommended for those with pre-treatment viral load of > 500,000 copies/mL

It is not recommended for those with a CD4 count < 200 cells/mm3

It is not recommended for those with hepatitis B co-infection

It is not recommended in the context of transmitted drug resistance

It is not recommended for those with documented/archived/suspected M184VI mutation

It is not recommended for those with HIV-related cognitive impairment

It should be considered with caution in specific populations such as those with primary HIV infection, opportunistic diseases or renal impairment

Question 19

Indications for rapid starting of art (4 answers)

Answer 19

Start ASAP when

Neurological involvement

Any AIDS-defining illness

CD4 count <350 cells/mm3

PHI diagnosed within 12 weeks of a previous negative test

Question 20

Key DDI for rilpivirine

Answer 20

omeprazole (PPI)

Question 21

Which women should be screened for HCV in pregnancy

Answer 21

Risk factors
Or risk factors in partner

Risk factors
Past or current history of illicit drug use, particularly if IV users.
* Partner (current or past) diagnosed with HCV
* Partner (current or past) who is a known drug user
* Other known blood borne virus (HIV, Hep B)
* Women who have undergone female genital mutilation (FGM)
* Tattoos or piercings where infection control measures may not have been
adequate
* Known sex workers
* Recipient of a blood transfusion pre September 1991 in the UK
* Recipient of blood transfusion in a country where Hepatitis C screening of blood
donors is not routinely undertaken

Question 22

Mother is HCV IgG positive, RNA negative. Points in management

Answer 22

Assess for ongoing risk of infection (PWID, sex worker and same for partner)
Make sure RNA has been done on more than one occasion
Baby should have IgG checked at 18 months of age.

Note: HCV antibody and RNA tests should be repeated at birth in all women with on-going risks for HCV infection

Question 23

Indications for starting TDF in pregnancy

Answer 23

Continue if on it already
Switch to it if they are on ETV

V/L of over 200,000
Hb surface antibody level 4 log10 IU/ml,

Question 24

If starting HBV in pregnancy

At what gestation and for how long

Answer 24

antiviral prophylaxis with TDF should start at week
24–28 of gestation and continue for up to 12 weeks after
delivery

Question 25

Duration of
1) Hep B core IgM

Answer 25

1) 3 months after icteric phase

Note anti-HBc IgM results at levels consistent with new acute HBV infection should
be reported urgently (by telephone)

Question 26

Comment for

HBs Ag: Detected
Anti HBc(total):Not detected
HBc IgM: Not detected
HBe Ag: Not detected
Anti HBe: Not detected
Anti HBs: Not detected
Hep B DNA: Detected

Answer 26

Consistant with early acute hepatitis B.
Please report to public health.
Screen for other blood born viruses

Note if DNA not tested:
“HBsAg detected.
Send further sample in one
week, or EDTA blood for HBV
DNA, if no history of vaccination”

Question 27

HBs Ag: Detected
Anti HBc(total):
HBc IgM:
HBe Ag:
Anti HBe:
Anti HBs:
Hep B DNA: Not Detected

Answer 27

HBsAg detected. No evidence of
viral replication.

The HBsAg in vaccine can be detectable
for about one week after vaccination

Question 28

Describe the WHOglobal health sector strategy report on viral hepatitis

Answer 28

Called for the elimination of HBV and HCV by 2030, defined as a 90% reduction in new cases and a 65% reduction in mortality.

Question 29

Risk of neonatal transmission of hbv if mother infected

Answer 29

The rate of HBV transmission from an HBsAg-positive mother to her neonate ranges from 5 to 90% in the absence of maternal antiviral treatment or neonatal immunoprophylaxis, with approximately 90% of perinatal HBV infections becoming chronic.

Question 30

When should babies born to HBV positive mothers get HBV vaccine (6 in total)

Answer 30

Birth
4 weeks
8 weeks
12 weeks
16 weeks
1 year

Note (needs editing)
Close Family Contacts of an individual with chronic Hepatitis B infection
Newborn infants born to a hepatitis B negative woman but known to be going home to a household with
another hepatitis B infected person may be at immediate risk of hepatitis B infection. In these situations, a
monovalent dose of hepatitis B vaccine should be offered before discharge from hospital. They should then
continue on the routine childhood schedule commencing at 8 weeks.

Infants born to Intravenous Drug users
A monovalent dose of Hepatitis B vaccine should be offered before discharge from hospital. They should
then continue on the routine childhood schedule commencing at 8 weeks.

Question 31

Describe follow up if neonate at high risk of HBV aquisition

Answer 31

Administration of Hepatitis B vaccine with dried blood spot taken prior to vaccination (only if high
risk) and HBIG if indicated.
Hepatitis B vaccination filled in (for red book) and documented on checklist and accompanying paperwork if HBIG given.
Letter to GP and Child health generated
GP/ Child health to organise subsequent vaccinations and testing with 4th dose i.e. at 12 months (dried blood spot sent to Public Health England laboratory).
GP to refer infants with chronic carrier status for assessment and further management

Question 32

Key changes to WHO HBV guidelines

Answer 32

• treat all HbsAg positive adults with markers of fibrosis (fibroscan of >7 or APRI >0.5). Previously had to be cirrhosis.
• treat all adults with co-infection (HCV/HIV/HDV), immunosupresion, extrahepatic manifestations, familt history of liver cancer
• In pregnancy: treat all adults with HBV DNA > 200,000 IU/ml and an ALT above ULN (2o in women 30 in men). If HBV DNA or e-antigen not available, treat all who are surface antigen positive

(Note: old guidelines from WHO recommended treatment of pregnant women who are e-antigen positive- note recommended by EASL, EASL it is just if HBV V/L over 200,000, start at week 24-28)

Question 33

Parvovirus infectious period

Answer 33

10 days before until onset of rash

(noteo opposite to rubella which is 7 days before and 10 DAYS AFTER)

Question 34

Pregnant patient. HIV fourth gen low positive, not confirmed on two assays.
Action points

Answer 34

Note: IDPS book states to never call out results unless they are complete
“Positive or equivocal screening results must not be reported until confirmatory tests are completed on the screening sample.”

To avoid unnecessary distress and anxiety referral to sexual health services is not recommended unless the repeat sample confirms an infection.

Report as HIV screening assay not confirmed by two other assays. Send repeat sample in 14 days.

(if high risk of HIV aquisition please send sample for HIV v/l testing)

Question 35

HIV bands for HIV 2

Answer 35

GP 36 and GP 140

Need both to confirm infections

Question 36

Infectious period of rubella

Answer 36

7 days before to 10 days after rash