Infectious Disease- Newly diagnosed HIV patient

Question 1

History

Answer 1

Ask about TB symptoms
Cough
Weight loss
Fever
Night sweats
Headache, diarrhea and any other symptoms

Past medical history focused on WHO staging conditions
Medication
Sexual partners
Substance use
Mental health

Question 2

Examination

Answer 2

Wasting
Oral
Oral candida
Kaposi’s sarcoma
Oral hairy leukoplakia
Skin
Lymphadenopathy

Question 3

WHO Clinical Staging System of HIV/AIDS
for Adults and Adolescents with confirmed HIV Infection
Clinical stage 1

Answer 3

Asymptomatic
Persistent generalized lymphadenopathy

Question 4

WHO Clinical Staging System of HIV/AIDS
for Adults and Adolescents with confirmed HIV Infection
Clinical stage 2

Answer 4

Moderate unexplained weight loss (<10% of presumed or measured body weight)
Recurrent respiratory tract infections (sinusitis, tonsillitis, otitis media, and pharyngitis)
Herpes zoster
Angular cheilitis
Recurrent oral ulceration
Papular pruritic eruptions
Seborrhoeic dermatitis
Fungal nail infections

Question 5

WHO Clinical Staging System of HIV/AIDS
for Adults and Adolescents with confirmed HIV Infection
Clinical stage 3

Answer 5

Unexplained severe weight loss (>10% of presumed or measured body weight)
Unexplained chronic diarrhoea for longer than one month
Unexplained persistent fever (above 37.6°C, intermittent or constant, for longer than one month)
Persistent oral candidiasis
Oral hairy leukoplakia
Pulmonary tuberculosis (current)
Severe bacterial infections (such as pneumonia, empyema, pyomyositis, bone or joint infection, meningitis, or bacteraemia)
Acute necrotizing ulcerative stomatitis, gingivitis, or periodontitis
Unexplained anaemia (<8 g/dl), neutropaenia (<0.5 × 10⁹ per litre), or chronic thrombocytopaenia (<50 × 10⁹ per litre)

Question 6

WHO Clinical Staging System of HIV/AIDS
for Adults and Adolescents with confirmed HIV Infection
Clinical stage 4

Answer 6

• HIV wasting syndrome
• Pneumocystis pneumonia
• Recurrent severe bacterial pneumonia
• Chronic herpes simplex infection (orolabial, genital, or anorectal of more than one month’s duration or visceral at any site)
• Oesophageal candidiasis (or candidiasis of trachea, bronchi, or lungs)
• Extrapulmonary tuberculosis
• Kaposi’s sarcoma
• Cytomegalovirus infection (retinitis or infection of other organs)
• Central nervous system toxoplasmosis
• HIV encephalopathy
• Extrapulmonary cryptococcosis including meningitis
• Disseminated non-tuberculous mycobacterial infection
• Progressive multifocal leukoencephalopathy
• Chronic cryptosporidiosis (with diarrhoea)
• Chronic isosporiasis
• Disseminated mycosis (coccidiomycosis or histoplasmosis)
• Recurrent non-typhoidal Salmonella bacteraemia
• Lymphoma (cerebral or B-cell non-Hodgkin) or other solid HIV-associated tumours
• Invasive cervical carcinoma
• Atypical disseminated leishmaniasis
• Symptomatic HIV-associated nephropathy or symptomatic HIV-associated cardiomyopathy

Question 7

Investigations

Answer 7

Pregnancy test
CD4 count
Creatinine (and calculated eGFR)
If CD4 count < 100 (this will likely to change to < 200):
Plasma Cryptococcal Antigen Test (CrAg) done automatically by lab
If TB symptoms:
Sputum for Xpert MTB/RIF Ultra (+/- TB culture)
Consider urine LAM test and Chest X-ray

Question 8

Treatment of TB

Answer 8

If patient has TB symptoms but cannot produce sputum or sputum Xpert is negative
and there is no response to an antibiotic (eg. amoxicillin) then
TB treatment may be started empirically based on chest X-ray with close follow-up
and ART delayed 2-8 weeks depending on CD4 count

Question 9

Management

Answer 9

ANTIRETROVIRAL THERAPY (ART)
All patients eligible at time of HIV diagnosis now

Co-trimoxazole prophylaxis if CD4 < 200 or Stage (2), 3 or 4
Can stop when CD4 > 200

TB preventive therapy provided no TB symptoms or contra-indications
Isoniazid (INH) for 12 months with vitamin B6 (pyridoxine)

Fluconazole pre-emptive therapy if plasma CrAg positive

Question 10

When to start ART?

Answer 10

ART can be started on the day of diagnosis provided:

The patient is ready
There are no clinical reasons to defer

Question 11

What is the recommended action if a patient is diagnosed with cryptococcal meningitis (CM)?

Answer 11

Defer ART for 4–6 weeks after the start of antifungal treatment

Question 12

What is the action if a patient’s serum or plasma is positive for cryptococcal antigen?

Answer 12

Defer ART for 2 weeks after starting antifungal treatment (if meningitis is excluded on lumbar puncture, ART does not need to be deferred).

Question 13

How long should ART be deferred after a diagnosis of TB meningitis or tuberculoma?

Answer 13

Defer ART for 4–8 weeks after starting TB treatment

Question 14

What is the action for a patient diagnosed with TB at a non-neurological site?

Answer 14

Defer ART for up to 2 weeks after starting TB treatment if CD4+ ≤ 50 cells/µL, and up to 8 weeks if CD4+ > 50 cells/µL.

Question 15

What is the action for a patient diagnosed with TB at a non-neurological site?

Answer 15

Defer ART for up to 2 weeks after starting TB treatment if CD4+ ≤ 50 cells/µL, and up to 8 weeks if CD4+ > 50 cells/µL.

Question 16

What should be done if a patient has a headache before initiating ART?

Answer 16

Investigate for meningitis before starting ART.

Question 17

What should be done for a patient with TB symptoms (cough, night sweats, fever, or recent weight loss) before starting ART?

Answer 17

Investigate for TB before starting ART.

Question 18

What is the action if a patient has significantly abnormal liver function tests (ALT > 200 or jaundice)?

Answer 18

Investigate and address the cause before starting ART, including assessing for drug-induced liver injury (DILI).

Question 19

First line is TLD

Answer 19

Fixed dose combination taken in the morning

Tenofovir
Lamivudine (3TC)
Dolutegravir

Question 20

Dolutegravir: women of child bearing potential

Answer 20

Counsel about benefits and teratogenicity risk
Offer effective contraception (dual methods preferred)
Women’s autonomy in decision-making should be respected
Tenofovir/Lamivudine/Dolutegravir or Tenofovir/Emtricitabine/Efavirenz
Informed decision (document counselling and choice)
Do not start dolutegravir in first 6 weeks of pregnancy

Question 21

Benefits of using DTG

Answer 21

-Provides raid viral suppression
- High genetic barrier to resistance
- No interaction with hormonal contraceptives
- Side effects are mild and uncommon

Question 22

Risks of using DTG

Answer 22

• DTG may increase the risk of neural tube defects (NTDs) if used before or in the first four weeks after conception
• Drug interactions with rifampicin, metformin, anticonvulsants, and polyvalent cations (Mg, Fe, Ca)

Question 23

Benefits of using EFV

Answer 23

• Safe in pregnancy
• No significant interaction with TB treatment

Question 24

Risks of using EFV

Answer 24

• Low genetic barrier to resistance
• Drug interactions with contraceptives
• Neuropsychiatric side effects

Question 25

What is the effect of Rifampicin on Dolutegravir (DTG), and what is the recommendation?

Answer 25

Rifampicin decreases Dolutegravir levels. The recommendation is to double the DTG dose to 50 mg every 12 hours. If on TLD FDC, add DTG 50 mg 12 hours after the TLD dose.

Question 26

How do polyvalent cations (e.g., Mg²⁺, Fe²⁺, Ca²⁺, Al³⁺, Zn²⁺) affect Dolutegravir, and what is the recommendation?

Answer 26

Polyvalent cations decrease Dolutegravir concentrations. The recommendation is:

•	Calcium supplements: Can be taken with DTG at the same time if with food; if taken on an empty stomach, they should be taken at least 4 hours apart.
•	Iron supplements: Can be taken with DTG at the same time if with food; otherwise, should be taken at least 4 hours apart.
•	Magnesium/aluminum-containing antacids: Should be taken at least 2 hours after or 6 hours before DTG.

Question 27

How do anticonvulsants like carbamazepine, phenobarbital, and phenytoin affect Dolutegravir, and what is the recommendation?

Answer 27

Anticonvulsants decrease Dolutegravir concentrations. The recommendation is to avoid coadministration if possible. Use alternative agents such as valproate, lamotrigine, levetiracetam, or topiramate. If no alternatives, double the DTG dose to 50 mg every 12 hours when using carbamazepine.

Question 28

What effect does the co-administration of Metformin and Dolutegravir have, and what is the recommendation?

Answer 28

Dolutegravir increases Metformin levels. The recommendation is to limit the maximum Metformin dose to 500 mg every 12 hours.

Question 29

Patients with renal impairment

Answer 29

If eGFR < 50 then do not use tenofovir, but use abacavir

Regimen is then:
Abacavir 600mg daily
Lamivudine dose adjusted according to eGFR
Dolutegravir 50mg daily

Question 30

Key issues to cover in ART counselling

Answer 30

Understanding of HIV (the virus, clinical complications and transmission)
Benefits of ART
ART is life-long therapy
Importance of good adherence and concept of resistance
Side-effects and what to do and who to contact if serious side-effects occur
Safer-sex practices, reproductive health and family planning choices
Address mental health and substance use
Disclosure of HIV status
Encourage joining a support group and/or identifying a treatment ‘buddy’
Personal treatment plan: drug storage, strategies for missed doses and how to integrate taking medication into their daily routine with reminders and support

Question 31

Monitor on 1st line ART- key aspects

Answer 31

Medication refills and adherence
Weight and TB symptoms
CD4 count
At 12 months, then can stop if CD4 > 200 and viral load < 1000
HIV viral load
At 6 months, 12 months then 12-monthly if viral load suppressed
Creatinine and eGFR
At months 3, 6 and 12 then repeat every 12 months

Question 32

What is suppressed viral load

Answer 32

VL< 50 copies / ml

Question 33

What is suppressed viral load

Answer 33

VL< 50 copies / ml

Question 34

Ideal response to ART

Answer 34

Increasing CD4 count
Decrease in viral load