HIV testing Flashcards
RFs of HIV
MSM multiple partenrs history of STI hep B or C anal sex or sex clubs or chem sex female sexual contacts of MSM current or former partner with HIV IV drug use tattoos HIV positive mothers needlestick injury from HIV country prevalent prostiturtes rape.sexual assault
who are recommended to have a test for HIV
MSM female contacts IVDU Black african men and women born high risk countries DD partner with HIV
can someone with HIV treatment can have sex with someone who doesnt have
undetectable viral load for 6 months = untrasmissable
take meds properly
methods for HIV testing
1) venepuncture - highly sensitive and highly specific P24 Antigen HIV Antibody BEST TEST ELISA on blood or saliva
2) rapid point if care test and dried blood spot - comes back within 20 minutes
drawback - looks for ABs against HIV virus ABs take time to build up. delay in picking up the infection
not specific or sensitive
window period for HIV
high risk exposure
- 45 days days later for result
if initial test is negative for HIV
repeat test in a few weeks
what other tests would you offer in HIV patient
HEP B/C chlamydia gon syphillis HIVA HEP A viral load and CD4 count - offer hep B vaccination - HPV vaccination - upto age of 45 to - prevent warts adn cancer of genital skin - discuss PEPSE/PrEP (take one tablet daily to reduce risk of HIV acquisition) - discuss safe sec - Window Period testing - infectious period 45 days
where will you take swabs for HIV
oral
rectal
urine
window period for chlam or gonoe
takes 2 weeks
windown period for syphillis, hepB orC
12 weeks
hep C is 9 months
fequency of HIV testing
every 3 months - MSM
- USING pREp
Annual test for HIV is recommeded to who
commerucal sex workers
IVDU
hetero changin partner
Black african men
in which condition which will you recommend HIV testing
mononucleosis-like syndrome
recurrent bacterial pneumonia
recurrent or severe shingles
what is bacterial vaginosis
most common cause of abnormal vaginal discharge in women of reproductive age.
CAUSE
- imbalance of vaginal flora
- loss of lactobacilli that maintain acidic pH of vagina >4.5
Triggers
- sex
- menses
- receptive oral SI
- vaginal douching
- perfumed bath products
- change in sexual partners
- presence of STI
The most common organisms include Gardnerella vaginalis
presentation of bacterial vaginosis
Offensive, fishy-smelling vaginal discharge without soreness or irritation.
On examination, there is usually a thin layer of white discharge covering the vaginal wall.
Ix and diagnosis fro bacterial vaginosis
Hay-Ison criteria
Gram stain post fornix
0= no bacteria
1=normal
2= reduced lactobacilli plus mixed flora (intermediate)
3= few or absent lactobacilli and mixed flora, predom Gardnerella morphotypes
4=Gram positive Cocci dominate
Amsel’s criteria require at least three of the following for diagnosis:
- Homogeneous discharge as described above.
- Microscopy showing vaginal epithelial cells coated with a large number of bacilli (“clue cells”).
- Vaginal pH >4.5.
- Fishy odour on adding 10% potassium hydroxide to vaginal fluid. (WHIFF TEST)
Mx and complications of BV
General advice e.g. avoiding vaginal douching, use of shower gels.
Asymptomatic women usually do not need treatment, unless they are pregnant.
If symptomatic - oral metronidazole 400-500 mg bd for 5-7 days. Treatment of choice (and can be used in pregnancy).
complications
BV can increase the risk of acquiring and transmitting HIV and other STIs.
In pregnancy, BV is associated with various complications including preterm delivery, premature rupture of membranes and postpartum endometritis.
DDx
- chlamydia and gonorrhoea
- trichomonad vaginalis
- vaginal candidiasis
factors ass w vaginal candidiasis
diabetes mellitus recent antibiotics upto 3m before steroids - high oestrogen levels -> pregnancy, luteal phase, COCs immunosuppression: HIV
features of vaginal candidiasis
Mx
- ‘cottage cheese’, - non-offensive discharge
- vulvitis: superficial dyspareunia, dysuria
itch
Examination
vulval erythema, fissuring, satellite lesions may be seen, pH - 4
Ix
- swabs taken from high vaginal walls
- microscopy shows pores, pseudohyphae -> active then neutrophils too
Mx
1. fluconazole 150mg PO stat -> avoid in pregnancy/breastfeeding or clotrimazole pessary 500mg PV stat
PLUS clotrimazole 1% cream top BD for 2 weeks
recurrent vaginal candidiasis
4 or more episodes per year
compliance with previous treatment should be checked
confirm the diagnosis of candidiasis
high vaginal swab for microscopy and culture
consider a blood glucose test to exclude diabetes
exclude differential diagnoses such as lichen sclerosus
consider the use of an induction-maintenance regime
induction: oral fluconazole every 3 days for 3 doses
maintenance: oral fluconazole weekly for 6 months
CI - clotrimazole pessaries used
HIV Mx
antenatal care
- before pregnancy they have to take all their antiretroviral therapy
do blood test to check CD4 count
HIV obstetrics clinic
never been on therapy
- need to be started
- tenofovir
less than 50 CD4 before giving birth
during birth
>50 viral load C section -> give IV antiretrovirals zidovudine
<50 normal vaginal delivery
once u get baby wash the baby and cord clamp
postnatally
- really low viral load and compliant w therapy - baby has to be on one retroviral 2-4 weeks
high risk pregnancy 3-4 weeks
test HIV delivered, upon discharge,
Mum cant breastfeed
factors which reduce vertical transmission of HIV in pregnancy
- maternal antiretroviral therapy
- mode of delivery (caesarean section)
- vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended
a zidovudine infusion should be started four hours before beginning the caesarean section - neonatal antiretroviral therapy
- > zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml. Otherwise triple ART should be used. Therapy should be continued for 4-6 weeks.
- infant feeding (bottle feeding)
RFs of STI
aged under 25
>1 sexual partner in the last 12 months
new sexual partner
UPSI
Ix for STI
endocervical swab p wet mount - trichomonas
gram stain microscopy, culture -> BV/candida
vulvovaginal swab
- NAAT for N. gonorrhoeae
- C. Trachomatis
Other tests
- culture - endocervical culture
DDx for vaginal discharge
physiological
- sexual arousal
- menstrual cyclical variation
- pregnancy
pathological vaginal - candidiasis - trichomonas - BV - foreign body - PM vaginitis
Cervical
- gonorrhoea
- non-specific infection
- herpes
- cervical ectopy
- cervical neoplasm
what is trichomonas vaginalis
flagellated protozoan
STI -> vagina urethea in paraurethral glands
clinical features - frothy vaginal discharge - dysuria - vulval soreness/itching-> vulvitis/vaginitis strawberry cervix - 2%
infections in males present as non specific (urethritis)
complications
- pregnancy ->preterm, low birth weight
increase HIV transmission
Ix - swab from posterior fornix - wet mount - charcoal culture - NAATS -> 98-100% TV testing -> persistent urethritis w urethral culture or culture of first void urine
Mx
1st - metronidazole 400mg BD 5-7 days
2nd - metronidalzole stat
treat partners prophylatically
avoid sex til Mx complete
Ix for male urethral discharge
- urine NAAT for gonorrhoea/chlamydia
- gram-stained smear from urethra (having held urine)
+/- polymorphonuclear leucocytes (urethritis)
+/- gram negative intracellular diplococci
(Gonorrhoea) - Gonorrhoea culture - Mx or if suspecting
Non specific urethritis
make this diagnosis in the absence of chalmydia/gonorrhoea
urethral discharge, dysuria, penile irritation
Diagnosed thru gram stain and microscopy of urethral sample
>5 polymorphonuclear leucoyctes
Mx
Doxycycline for 7 days
chlamydia trachomatis
asymptomatic
- cervicitis, urethritis
- obligate intracellular bacterium
complications
- PID, epididymoorchitis, SARA, tubal factor infertility, increase risk of ectopics pregnancy
clinical features of chlamydia
asymptomatic
- conjuncitivits, pharyngitis, SARA, proctitis
men
- discharge
- dysuria
- testicular pain
women
- discahrge
- postcoital bleeding
- IMB
- lower abdominal pain/PID
- dysuria
Mx
1st line -> doxycycline 100mg BD for 7 days CI in PREGNANCY
2nd line Azithromycin
complicated infections
PID/epidiymoorchitis
retest at 3-6 months in under 25s
Neisseria Gonorrhoeae
Gram negative ontracellular diplococci
asymptomatic
proctitis
DI rash joint pain or erythema
men
- purulent urethral discharge
- epididymoorchitis
women
- purulent discahrge
- IMB/PCB
- PID
diagnosis
- > near patient testing microscopy
- > NAAT testing
- > cultures
Mx
- ceftriaxone 1g Stat IM single dose
- if sensitivities are back then we can gibe ciprofloxacin
Pregnant - azithromycin FAILS erythromycin
no sex until 1 week post treatment
they come back after one week
mycoplasma genitalum
same as normal in terms on Sx
doxycyline 1 weeks followed by 3 days of azithromycin
alternative moxifloxacin
what are genital warts
benign lesions cause by HPV - 6/11
STI
incubation period 2-8w
HPV affects the basal layer
warty growth - asymptomatic painless
itchy
urethral - urinary Sx
bleedings
signs
- soliatry/multiple
- broad/penduculated/pigmented
- non keratinised on warm moist skin
- keratinised on hairy skin firm
Ix
speculum - women
DDx
molluscum contagiosum
condylomata lata - secondary syphillis
features of cancerous warts
pigmentation depig pruritus immune defifcicny previous Hx of intraepithelial neoplasia
refer - internal lesions - do not respond to Mx - immunosuppressed pts pregnant women children elderly pts
Mx of genital warts
screen for other STs
encourage condom use
await sponataneous resolution
cryotherapy
surgery
anti-miotic agents
cervical smears in HIV positive women
every year
Women who are HIV positive are at an increased risk of cervical intra-epithelial neoplasia (CIN) and cervical cancer due to a decreased immune response and decreased clearance of the human papilloma virus. (1) HIV positive women who have low-grade lesions (CIN1) do not clear these lesions and these can progress to high-grade CIN or cervical cancer. Even those women who are effectively treated with antiretrovirals have a high risk of abnormal cytology and an increased risk of false-negative cytology. (1)
