HIV - Treatment and Care

Question 1

What to look for in a physical examination?

Answer 1

Kapusi’s sarcoma - purple-y vasculor tumours

Mucosal candidiasis - also check for painful swallowing which is associated with immunosupression

Pneumocystic pneumonitis

Syphilis

Question 2

Name the targets for antiretroviral drugs

Answer 2

Reverse transcriptase
Integrase
Protease
Entry 
  - Fusion 
  - CCR5 receptor 
Maturation

Question 3

Name the only drug that targets the host

Answer 3

CCR5 antagonist

Question 4

Effectiveness of mono and dual therapy

Answer 4

Monotherapy - reduced viral load but not survival

Dual therapy - slightly better but not much. Useful to prolong survival only if patient is started on dual therapy directly, rather than adding to monotherapy.

Question 5

Define highly active anti-retroviral therapy ***

Answer 5

a combination of 3 drugs from at least 2 drug classes to which the virus is susceptible

Question 6

What is the purpose of highly active antiretroviral therapy (HAART)

Answer 6

Reduce viral load to undetectable
Restore immunocompetence
Reduce morbidity and mortality

Question 7

Preventing drug resistance

Answer 7

ADHERENCE (95%) - take medicines every day

Lifestyle - night shifts? regular meals?  
Tolerability
Pharmacokinetics
Drug-drug interactions
Treatment interruptions

Question 8

How to manage treatment interruptions

Answer 8

Provide protease which is harder to get resistance to and allow some viral breakthrough as it is better than resistance

Question 9

Factors to consider when choosing an anti retroviral

Answer 9

Tolerability
Low toxicity
Low pill burden
Low dosing frequency
Minimal drug-interactions
High barrier to resistance

Question 10

List the effects of HAART toxicity in each system

Answer 10

GI side-effects (protease inhibitors)

Skin: rash, hypersensitivity, Stevens-Johnsons (abacavir, nevirapine)

CNS side-effects: mood, psychosis (efavirenz)

Renal toxicity: proximal renal tubulopathies (tenofovir, atazanavir)

Bone: osteomalacia (tenofovir)

CVS: increased MI risk (abacavir, lopinavir, maraviroc)

Haematology: anaemia (zidovudine)

GI: transaminitis, fulminant hepatitis (nevirapine, most others)

Question 11

What is the only HAART drug licensed to be used in pregnant women?

Answer 11

Zidovudine

Question 12

Drug-drug interactions in HAART therapy

Answer 12

Protease inhibitors are generally potent liver enzyme inhibitors
NNRTIs are generally potent liver enzyme inducers
Some drugs require pharmacological boosting (with potent liver enzyme inhibitors)

Question 13

Is partner disclosure and notification mandated by law?

Answer 13

No. Voluntary process.

Question 14

What are the different partner notification strategies

Answer 14

Partner referral
Provider referral
Conditional referral

Question 15

Barriers to PN and disclosure

Answer 15

Fear

• rejection
• isolation
• violence

Confidentiality

Stigma - leads to discrimination and/or ostracisation

Question 16

What does prevention medicine encompass?

Answer 16

CVS risk
Smoking cessation
STI screening 
Hep A/B 
Flu vaccine
HPV vaccine 
Harm reduction

Question 17

Prevention of onward HIV transmission

Answer 17

Sexual transmission

• Condom use
• HIV treatment
• STI screening and treatment
• Sero-adaptive sexual behaviours
• Disclosure
• Post-exposure prophylaxis
• Pre-exposure prophylaxis

Question 18

Sero - adaptive behaviour

Answer 18

If the HIV +ve partner is the inserting partner, the risk of transmission is greater rather than if he is the receiving partner

Question 19

STI and HIV transmission

Answer 19

HIV is more likely to take root in the presence of an STI rather than without it during intercourse with an HIV+ person

Question 20

Can HIV be transmitted through use of cutlery, kissing, bath towels or other casual/household contact?

Answer 20

No

Question 21

Conception options for HIV+ male and HIV - female

Answer 21

Treatment as prevention
(+/- timed condomless sex)
?HIV PrEP for female partner

Question 22

Conception options for HIV- male and HIV + female

Answer 22

Treatment as prevention
(+/- timed condomless sex)
? Self-insemination
?HIV PrEP for male partner

Question 23

Prevention of mother to child transmission

Answer 23

HAART during pregnancy
Vaginal delivery if undetected viral load
Caesarean section if detected viral load
4/52 PEP for neonate
Exclusive formula feeding

Question 24

List members of the MDT in HIV management

Answer 24

Physicians
Nurse specialists
Pharmacist
Patient co-ordinator
Secretaries
Virologists
Clinical psychologist
Social workers
Sexual health

Question 25

List the HIV prevention strategies that are effective on the individual level

Answer 25

Condom programmes
PEPSE
Behavioural change interventions (short term impact)
PrEP

Question 26

List the HIV prevention strategies that are effective on the community level

Answer 26

Needle exchange
Testing and treatment for STIs
Circumcision
Treatment as prevention

Question 27

PrEP eligibility criteria

Answer 27

Aged ≥ 16 and

HIV negative and

Can commit to 3/12’ly follow-up and

Willing to stop if eligibility criteria no longer apply and

Resident in Scotland

Question 28

Is the patient high risk for HIV?

Answer 28

HIV+ partner with detectable viral load or

MSM or transwoman
UPAI ≥ 2 partners in 12/12 and likely to do so again in next 3/12 or
Confirmed bacterial rectal STI in last 12/12 or

Other high risk factor agreed with another clinician