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DipHIV > HIV Routine investigation and monitoring of adults > Flashcards

HIV Routine investigation and monitoring of adults Flashcards

1
Q

For all newly diagnosed HIV-positive patients, what THREE recommendations are made about the initial history?

A

1) FULL history
2) Identify patients GENDER
3) MENTAL health and SOCIAL history

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2
Q

What THREE aspects comprise a FULL history for all newly diagnosed HIV-positive patients?

A

1) MEDICAL
2) PSYCHOSOCIAL
3) SEXUAL & REPRODUCTIVE

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3
Q

What FIVE parts of a MEDICAL history for all newly diagnosed HIV-positive patients should there be particular emphasis on at INITIAL assessment?

A

1) PAST (&current) MEDICAL HISTORY
2) other MEDICATIONS
3) lifestyle HABITS
4) HIV status of PARTNERS or CHILDREN
5) CONCEPTION issues

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4
Q

What particular aspects of SEXUAL & REPRODUCTIVE health history should be taken for all newly diagnosed HIV-positive patients at INITIAL assessment?

A

Partner notification
HIV testing for children
Current or past gender based violence

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5
Q

What particular aspects of PSYCHOSOCIAL history should be taken for all newly diagnosed HIV-positive patients at INITIAL assessment?

A

KNOWLEDGE & BELIEFS of HIV

  • infection
  • transmission
  • treatment
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6
Q

What FIVE specific OBSERVATIONS should be taken for all newly diagnosed HIV-positive patients at INITIAL assessment?

A 
weight
height
BMI
blood pressure
waist circumference
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7
Q

Is an examination required of for all newly diagnosed HIV-positive patients at INITIAL assessment?

A

YES, regardless of symptoms

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8
Q

Why is HIV confirmatory serological testing required?

A

SAFEGUARD against

  • sample mix ups
  • specimen contamination
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9
Q

When is HIV confirmatory serological testing NOT required?

A

IN ADDITION:
HIV viral load
or
typing assay

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10
Q

What THREE results help confirm PRIMARY HIV INFECTION?

A

1) SEROCONVERTING HIV serology - antigen, no antibody or p24 antigen
2) HIV viral load, and negative serology
3) AVIDITY

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11
Q

If a viral load is UNDETECTABLE at initial HIV diagnosis what must be performed?

A

REPEAT sample
check for HIV-2
use a DIFFERENT ASSAY

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12
Q

When is viral load HIGHEST in HIV infection?

A

PRIMARY HIV INFECTION

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13
Q

After primary HIV infection when does viral load decline to a steady state?

A

FOUR (4) to SIX (6) months

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14
Q

What method is used for resistance testing in HIV?

A

GENOTYPIC resistance testing

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15
Q

What are the BENEFITS of NEXT GENERATION SEQUENCING?

A
  • detect MINORITY VARIANTS of transmitted drug resistance

- predict HIGHER risk of virological failure with LOW genetic BARRIER drugs

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16
Q

When is INSTI resistance testing recommended at baseline for HIV infection?

A
  • if OTHER baseline RESISTANCE
  • PARTNER evidence of INSTI resistance
  • if BACKGROUND resistance rate >3%
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17
Q

Why is CD4 count crucial in patients BEFORE starting ART?

A
  • correlates with level of IMMUNE DYSFUNCTION & SUPPRESSION

- dictates URGENCY of ART

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18
Q

What is the CD4 count used to guide?

A
  • risk of INFECTION & CANCER
  • CHEMOPROPHYLAXIS for OIs
  • when LIVE VACCINATION is safe
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19
Q

CD4 count can fluctuate widely especially in PHI and acute illnesses, what measurement is less variable?

A

CD4 PERCENTAGE

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20
Q

What is the negative predictive value of HLA-B5701 testing?

A

99-100%

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21
Q

When MUST HLA-B5701 be checked?

A

prior to ABACAVIR

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22
Q

Who is HLA-B5701 more prevalent in - Black African or White European?

A

White European

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23
Q

What is the prevalence of HLA-B5701 in Black Sub-Saharan Africans?

A

LESS THAN 1%

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24
Q

What is the prevalence of HLA-B5701 in White Europeans?

A

6.5%

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25
Q

If a person is HLA-B5701 negative, is there any risk fo Hypersensitivity Reaction?

A

Yes, but lower risk

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26
Q

What THREE hepatitis B tests should be checked in all people with a diagnosis of HIV?

A

Hepatitis B surface antigen (HBsAg)
Anti-core total antibody (anti-HBc)
Anti- surface antibody (anti-HBs)

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27
Q

If a person with new diagnosis of HIV has HCV antibody POSITIVE, what else needs checked?

A

HCV VIRAL LOAD

at least TWICE if initially negative

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28
Q

What TWO hepatitis viruses can be vaccinated against?

A

Hepatitis A
&
B

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29
Q

Why is it important to offer a full STI test to all patients newly diagnosed with HIV?

A
  • increased risk of HIV TRANSMISSION if DETECTABLE viral load, if simultaneous STI
  • increase risk of COMPLICATION from STI if HIV +ve
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30
Q

How often is cervical screening recommended for WLW HIV?

A

Annually

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31
Q

Other than hepatitis what other viruses should be screened for in people newly diagnosed with HIV?

A

Varicella zoster virus IgG
Measles IgG
Rubella IgG (women of childbearing age)

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32
Q

How should TB be screened for in people newly diagnosed with HIV?

A

interferon gamma release assay (IGRA)

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33
Q

When should people newly diagnosed with HIV be tested for parasitic infection?

A

If persistent eosinophilia
>500cells/mL (>0.5x10(9))
AND
relevant travel history

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34
Q

When should toxoplasma serology be checked in people newly diagnosed with HIV?

A

suspected CEREBRAL INFECTION
or
LOW CD4 and UNABLE to tolerate co-trimoxazole

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35
Q

What tests form the baseline METABOLIC screen in people newly diagnosed with HIV?

A

FBC
RENAL profile - U&E, eGFR, urinalysis, uPCR
LIVER profile - bilirubin, ALT (or AST), ALP (+GGT & albumin if other abnormal)
BONE profile - calcium, phosphate, (ALP)
LIPID (random) - total cholesterol, LDL, HDL, triglycerides
HbA1c

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36
Q

In newly diagnosed HIV, anaemia, neutropenia &/or thrombocytopenia may be signs of?

A

Advanced IMMUNOSUPPRESSION
Severe OPPORTUNISTIC infection
MALIGNANCY

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37
Q

What co-infections or opportunistic infection may result in deranged liver function in HIV?

A

viral HEPATITIS
TB
CMV
CRYPTOSPORIDIUM

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38
Q

What drugs used to treat or prevent OIs in HIV commonly cause deranged liver function?

A

ANTIMICROBIALS

  • rifamycins
  • isoniazid
  • pyrazinamide
  • co-trimoxazole
  • fluconazole
  • co-amoxiclav
  • cephalosporin
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39
Q

When should CARDIOVASCULAR risk assessment be made in people with HIV?

A

ANNUALLY if
>40
or
significant CVD risk factors

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40
Q

What TOOL is recommended to use for CARDIOVASCULAR risk assessment in HIV?

A

QRISK2

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41
Q

When should FRACTURE risk assessment be made in people with HIV?

A

THREE YEARLY if
>50
POST MENOPAUSAL women
other risk factors for OSTEOPOROSIS

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42
Q

What TWO tools is recommended to use for FRACTURE risk assessment in HIV?

A

1) FRAX

2) QFracture

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43
Q

Asymptomatic patients NOT on ART - how often should they be reviewed if CD4 count <350?

A

3-6 monthly

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44
Q

Asymptomatic patients NOT on ART - how often should they be reviewed if CD4 count 350-500?

A

6 monthly

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45
Q

Asymptomatic patients NOT on ART - how often should they be reviewed if CD4 count >500?

A

6-12 monthly

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46
Q

Asymptomatic patients NOT on ART - if they do not attend an appointment how quickly should they be contacted to re-engage?

A

TWO weeks

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47
Q

Asymptomatic patients NOT on ART - in addition to CD4 count what other factors might make frequent monitoring preference?

A

high RISK of STI or viral HEPATITIS

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48
Q

In patients with HIV who are HIGH risk of STI how often should they be offered STI tests?

A

3 monthly

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49
Q

In patients with HIV who are HIGH risk of hepatitis acquisition, how often should they be offered testing?

A

ANNUALLY
HBsAg
and
HCV Ab (or RNA if Ab +ve or ALT abnormal)

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50
Q

How often should random lipid profile be performed in PLW HIV?

A 
2 yearly (if previous baseline normal)
unless smoker, >40 yrs or >30 BMI
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51
Q

When should random LIPID profile be performed ANNUALLY in PLW HIV?

A

SMOKER
BMI >30
>40 years old

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52
Q

What bloods test at a minimum should be performed for PLW HIV ANNUALLY?

A 
VIRAL LOAD
CD4
FBC
RENAL profile
LIVER profile
Hepatitis B surface Ab (or sAg if non-immune)
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53
Q

STI testing including syphilis serology should be offered to PLW HIV a minimum of annually in which situation?

A

If CHANGE in PARTNER since last test

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54
Q

When should cardiovascular risk assessment be performed in PLW HIV who are under 40 years old?

A

SMOKER
DIABETIC
BMI>30

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55
Q

When is cardiovascular risk assessment not required for PLW HIV?

A

under 40 years and no other risk factory

known CARDIOVASCULAR DISEASE

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56
Q

What vaccine status should be checked annually?

A

Flu vaccine
Hepatitis B status/sAb level
HPV completion

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57
Q

By what process is HIV thought to increase risk of cardiovascular disease?

A

PRO-INFLAMMATORY state induced by HIV infection

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58
Q

What is the potential BENEFIT of DEXA in all PLW HIV?

A

20% more patients with early bone mineral density disorders identified than with scoring tools

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59
Q

Why is DEXA not recommended for all PLW HIV?

A

Further studies required to assess utility

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60
Q

If choosing to start efavirenz what assessment should be done?

A

Depression assessment

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61
Q

When assessing cholesterol levels, does this need to be fasting or non-fasting?

A

NON-FASTING is acceptable (as per NICE)

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62
Q

Who should Qrisk2 not be used to assess CVD risk in?

A

people with DYSLIPIDAEMIA
people with T2DM
people with CKD
(all have a significant risk anyway and should have specific management to reduce that)

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63
Q

What is the importance of a baseline viral load prior to starting ART?

A
  • REDUCED EFFICACY of some ART if VL >100 000

- RESPONSE to treatment is measured by the fall in viral load

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64
Q

What is the proportion of people with untreated HIV with transmitted drug resistance?

A

7-19%

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65
Q

What proportion of participants in the START trial had baseline resistance?

A

4.7%

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66
Q

In what rare circumstance would baseline resistance be repeated before starting ART?

A

if potential SUPERINFECTION with other strain of HIV

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67
Q

What proportion of people get SUPERINFECTION with a second HIV strain?

A

2%

large cohort 4425

68
Q

When should tropism testing be performed for PLW HIV?

A

If plan to treat with CCR5 INHIBITOR (ie maraviroc)

69
Q

CCR5 inhibitors are ineffective in what circumstances?

A

patient’s virus is
- CXCR4 tropic
or
- CCR5 + CXCR4 tropic (DUAL)

70
Q

What is the diagnostic merit of a urinalysis looking for proteinuria in PLW HIV?

A

Glomerular disease - majority urinary protein albumin

albumin identified on dipstick

71
Q

Which old ART commonly cause cytopenias?

A

Zidovudine

72
Q

What is the benefit of doing full blood count on people with new diagnosis HIV?

A
  • Haemoglobin is an independent prognostic factor

- FBC abnormalities may be a sign of OI eg disseminated mycobacterium avium complex infection

73
Q

How soon after starting ART should a patient be reviewed?

74
Q

When do the majority of adverse drug effects occur after starting ART?

A

within 2 weeks

75
Q

What should be assessed at each clinic visit, especially after recent ART start?

76
Q

When should a CD4 count be checked after starting ART?

77
Q

CD4 count >350cells/mm 3 months after starting ART + viral suppressed - when do you re-check CD4?

A

ONE (1) year

78
Q

CD4 count <350cells/mm 3 months after starting ART - when do you re-check CD4?

A

SIX (6) months

79
Q

A small proportion of PLW HIV have a drop in CD4 count on effective ART - what are they at increased risk of?

A

CARDIOVASCULAR disease
CANCER
DEATH

80
Q

When should a viral load be checked after starting ART?

A

ONE (1), THREE (3) and SIX (6) months

81
Q

What fold drop is appropriate after 1 month of ART?

82
Q

If there has not been a 10-fold drop in viral load 1 month after starting ART what additional monitoring should take place?

A

check viral load:

TWO (2) and FIVE (5) months

83
Q

By what point should most people with HIV recently started on ART have an undetectable viral load?

A

SIX (6) months

84
Q

When should RENAL and LIVER function be checked after starting ART?

A 
RENAL & LIVER:
2-4 weeks
then
RENAL
3 & 6 months
85
Q

What is the incidence of RENAL TOXICITY in clinical trials on TDF?

86
Q

What RENAL PATHOLOGYS has the use of TDF been implicated in?

A 
AKI
PROGRESSIVE renal decline
HYPOPHOSPHATAEMIA
RTA
FANCONI syndrome
NEPHROGENIC diabetes insipidus
HYPOKALAEMIA
OSTEOMALACIA
URINARY CONCENTRATION defects
87
Q

What additional ART in combination with TDF increases the risk of renal toxicity?

A

DIDANOSINE
or
RITONAVIR-boosted PIs

88
Q

What patient factors increase risk of renal toxicity with TDF?

A

ADVANCED HIV disease
OLD age
low BMI
Pre-existing renal disease

89
Q

In addition to eGFR and urinalysis, what other measurement related to renal function should be taken for people on TDF?

A

PHOSPHATE level

90
Q

What features may suggest TDF toxicity?

A 
Progressive eGFR DECLINE
severe HYPOPHOSPHATAEMIA
new onset HAEMATURIA
GLYCOSURIA (normal blood glucose)
PROTEINURIA
91
Q

What level is considered SEVERE hypophosphataemia?

A

< 0.64 mmol/L

92
Q

If hypophosphataemia is identified, what additional measurement should be made to ensure accuracy of reading?

A

FASTING phosphate sample

93
Q

If proteinuria is identified on urinalysis what additional measurement should be requested?

A

urinary protein:creatinine ratio

94
Q

What should the main focus of routine follow up appointments be for pLW HIV?

A 
RISK of STI/hepatitis
Hepatitis B IMMUNITY
LIFESTYLE
MENTAL HEALTH
Recreational DRUG use
ADHERENCE to ART and appointments
95
Q

BHIVA guidelines - which group of people can have VIRAL LOAD every 12 months?

A

stable on ART with a PROTEASE INHIBITOR

96
Q

When can a patient routine follow up be 6 monthly?

A

STABLE on ART

97
Q

If a person starts ART with a CD4 cell count over 350 do they need it repeated?

A

NO, unless treatment failure or HIV-related symptoms

98
Q

When can CD4 cell count monitoring be stopped?

A 
CD4 >350
VL UNDETECTABLE (2 occasions, 1 year apart)
99
Q

How often should CD4 be checked if VIRAL LOAD >200?

A

ANNUALLY

if VL undetectable for more than a year

100
Q

What should HbA1c performed for PLW HIV?

A

ANNUALLY

if >40 years old

101
Q

What proportion of HIV diagnoses present with advanced disease (CD4 <200)?

102
Q

If CD4 count <50 what additional investigation should be performed?

A

Fundoscopy or retinal photography

103
Q

Why should fundoscopy be performed for PLW HIV with CD4 <50?

A

CMV retinitis

104
Q

When should a PLW HIV be screened for TOXOPLASMA?

105
Q

When should a PLW HIV be screened for CRYPTOCOCCUS?

106
Q

When should a PLW HIV be screened for MYCOBACTERIAL DISEASE?

107
Q

Within what time period should a PLW HIV started on ART be assessed for IRIS?

A

within THREE (3) months

108
Q

What proportion of PLW HIV with an OI are at risk of IRIS on starting ART?

109
Q

Which group of PLW HIV are at highest risk of IRIS after starting ART?

A

CD4 nadir <50

110
Q

What additional examination should take place for PLW HIV who inject drugs?

A

Examine INJECTION sites for signs of INFECTION

111
Q

What common infective complications occur for PWIDs with HIV?

A 
BACTERAEMIA
- staphylococcal, streptococcal
CANDIDAEMIA and other yeasts
ENDOCARDITIS
OSTEOMYELITIS
112
Q

Why is a travel history important in PLW HIV?

A

to identify risk of
HELMINTHS
TROPICAL infections

113
Q

What cancer screening programmes should be recommended to PLW HIV?

A

all NATIONAL

  • CERVICAL
  • BREAST
  • COLORECTAL
114
Q

What proportion of PLW HIV are over 50 yrs?

A

25% (QUARTER)

115
Q

What proportion of NEW diagnoses of HIV are in over 50 yrs?

116
Q

What effect does older age at HIV diagnosis have on CD4 CELL COUNT recovery?

A

Less recovery

117
Q

What effect does older age at HIV diagnosis have on MORTALITY?

118
Q

What multiple factors are more common or complicate management in PLW HIV over 50 years?

A 
Altered drug ABSORPTION & METABOLISM
Risk of DRUG-DRUG interaction
bone mineral DENSITY & RESORPTION
NEUROCOGNITIVE impairment
CANCER screening
119
Q

What is the COLORECTAL cancer screening programme/recommendations for PLW HIV?

A

60-74 year olds
MEN & WOMEN
Faecal occult blood (FOB)
TWO (2) YEARLY

120
Q

What is the BREAST cancer screening programme/recommendations for PLW HIV?

A

50-70 year olds
WOMEN
MAMMOGRAM
THREE (3) YEARLY

121
Q

What is the CERVICAL cancer screening programme/recommendations for PLW HIV?

A

25-65 years old
WOMEN
Cervical SMEAR
ANNUALLY

122
Q

What is the indication for a women to be offered breast screening under 50 years?

A

FIRST DEGREE relative
with
Breast cancer YOUNG AGE

123
Q

How often should family planning and contraception needs be checked with WLW HIV?

A

Baseline
ANNUAL
POSTNATAL
when AGE appropriate (young person clinic)

124
Q

When should WLW HIV be asked about menopausal symptoms?

A

over 45 years

125
Q

What symptoms may be attributed to peri menopause?

A 
Hot FLUSHES
SWEATS
MENORRHAGIA
DEPRESSION
TIREDNESS
dry SKIN
Loss of LIBIDO
126
Q

What is the definition of chronic kidney disease (CKD)?

A

eGFR <60ml/min
or
proteinuria

127
Q

What proportion of PLW HIV have CKD?

128
Q

What are the modifiable risk factors for CKD in PLW HIV?

A

SMOKING
OBESITY
DYSLIPIDAEMIA
HYPERTENSION

129
Q

Albuminuria is a risk factor for cardiovascular disease, what is the target blood pressure?

130
Q

In PLW HIV + CKD but no albuminuria what is the target blood pressure?

131
Q

What is the criteria for albuminuria?

A

ACR >70mg/mmol

132
Q

When should people with CKD/albuminuria be offered an ACEi or ARB?

A 
CKD + ACR >70mg/mmol
or
Hypertension + ACR >30mg/mmol
or 
Diabetes + ACR >3mg/mmol
133
Q

If a PLW HIV has HYPERTENSION, at what level of albumin:creatinine ration should they be started on an ACEi or ARB if not already?

A

ACR >30mg/mmol

134
Q

If a PLW HIV has DIABETES, at what level of albumin:creatinine ration should they be started on an ACEi or ARB if not already?

A

ACR >3mg/mmol

135
Q

Which ARVs may inhibit creatinine secretion and therefore result in reduction in eGFR?

A

DOLUTEGRAVIR
RITONAVIR
COBICISTAT
RILPIVIRINE

136
Q

What ARVS can be dose adjusted in renal impairment?

A

LAMIVUDINE
EMTRICITIBINE
Tenofovir disoproxil

137
Q

What effect does HIV have on graft function in people with a renal transplant?

A

INCREASED risk graft rejection

138
Q

When should PLW HIV be referred for RENAL evaluation?

A

PROGRESSIVE eGFR decline
Unexplained or severe CKD
ACR >30 or PCR >50mg/mmol

139
Q

At what level of proteinuria should PLW HIV be referred for RENAL evaluation?

A

PCR >50mg/mmol

140
Q

What is the definition of SEVERE CKD?

A

eGFR <30ml/min

141
Q

What is the definition of PROGRESSIVE decline in eGFR?

A

> 5-10ml/min/YEAR

142
Q

In addition to TDF, what ARV CLASS is associated with LOW bone mineral density?

A

PROTEASE INHIBITORS

143
Q

What are the THREE RISK factors for VITAMIN D DEFICIENCY?

A

WINTER sampling
BLACK ethnicity
Exposure to EFAVIRENZ

144
Q

Is HIV an INDEPENDENT risk factor for low bone mineral density?

145
Q

What are the modifiable risk factors for CARDIOVASCULAR disease?

A

HYPERTENSION
DYSLIPIDAEMIA
DIABETES
SMOKING

146
Q

What ARVs have been associated with myocardial infarction or cardiovascular disease?

A

ABACAVIVR
DIDANOSINE
LOPINAVIR

147
Q

What dose of ATORVASTATIN is recommended for people at increased risk of cardiovascular events?

A

80 mg

HIGH DOSE

148
Q

In addition to atorvastatin what dietary and lifestyle RECOMMENDATIONS can be made to people with increased risk of cardiovascular events?

A 
RESTRICT:
- dietary salt
- saturated fat
- cholesterol
- alcohol
WEIGHT REDUCTION
physical ACTIVITY
SMOKING cessation
149
Q

What level of HIV VIRAEMIA is associated with viral REBOUND or FAILURE?

A

> 200 copies/ml

150
Q

What is the definition of LOW-LEVEL VIRAEMIA?

A

50-200 copies/ml (repeatedly)

151
Q

If PLW HIV has low level viraemia which ARV class should there be a low threshold for switching?

A

LOW genetic BARRIER NNRTI (switch sooner than later)

152
Q

If is important to exclude in low level viraemia?

A

CNS replication

CSF for viral load

153
Q

What is a recommended COMMUNICATION aid for helping to assess a patients physical and psychological needs?

A

WELLNESS THERMOMETER

154
Q

What is the most frequently cited SOCIAL care need of PLW HIV?

A

POVERTY and issues related to it

155
Q

What is the relationship of STIs in male prisoners vs the male STI clinic attendees?

A 
HIGHER rate:
- genital warts
- hepatitis B
- hepatitis C
but less often offered STI testing
156
Q

What elements of history are unique to a trans person living with HIV?

A

Gender IDENTITY
Time LIVING as trans
Social TRANSITION - binding/tucking, hormones, silicone
Plans for SURGERY
PSYCHOSOCIAL - mental health, PTSD, GBV, support network, sex work, substance use
LEGAL concerns - gender certificate, ID, NHS records

157
Q

What is the global prevalence of HIV in TRANSGENDER WOMEN?

158
Q

When should a resistance test be performed on a CSF sample?

A

If DETECTABLE viral load

159
Q

When should resistance testing be repeated in people who have recently initiated ART?

A

if < 1 log drop after 4 weeks ie 40000 to 4000

160
Q

At what viral load level is resistance testing most likely to be accurate or possible?

A

> 500 copies/ml

161
Q

What is the potential benefit of next generation sequencing in CCR5 tropism?

A

MORE SENSITIVE in predicting CCR5 inhibitor failure

162
Q

What online tools can be used to interpret HIV-1 resistance genotyping?

A

STANFORD database
ANRS (France)
REGA (Belgium)

163
Q

Why might a PLW HIV have virological failure on MARAVIROC (CCR5 inhibitor)?

A

If the TROPISM SWITCHES from CCR5 to X4
or
SPECIFIC maraviroc resistance

164
Q

In women of childbearing age, what additional past exposure to infections should be checked?

A

Measles IgG
Rubella IgG
Varicella IgG
(unless confident about past vaccination or exposure)

165
Q

When is FBC re-checked following ART start if asymptomatic?

166
Q

What are the indications for FBC monitoring after ART start?

A

ZIDOVUDINE
or
UNWELL

DipHIV (14 decks)

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