Newly Diagnosed HIV

Question 1

What are the important things to ask a newly diagnosed HIV patient on history?

Answer 1

TB symptoms - cough, weight loss, fever, night sweats
Headache (meningitis)
Chronic diarrhoea (advanced HIV)

Focus history on WHO staging conditions
Medication - drug interactions with ART
Sexual partners - need to bring partners in for testing
Substance use - adherence issues
Mental health

Question 2

What are some important things to note on examination in a newly diagnosed HIV patient?

Answer 2

Generalized wasting

Oral candida
Kaposi’s sarcoma
Oral hairy leukoplakia

Skin

Lymphadenopathy - generalized, symmetrical lymphadenopathy is likely caused by HIV itself
- assymeterical, >2 cm = opportunistic infections (TB)/ opportunistic cancer (lymphoma/KS)

Anaemia - opportunistic infection

Question 3

What are the signs of WHO stage 1 HIV?

Answer 3

Persistent generalized lymphadenopathy

Question 4

What are the signs of WHO stage 2 HIV?

Answer 4

Moderate, unexplained weight loss (<10%)

Recurrent RTIs, sinusitis, tonsillitis, otitis media, pharyngitis
Angular cheilitis
Recurrent oral ulceration

Herpes zoster

Papular pruritic eruptions (PPE)
Seborrhoeic dermatitis
Fungal nail infections

Question 5

What are the signs of WHO stage 3 HIV?

Answer 5

Unexplained severe weight loss (>10%)
Unexplained chronic diarrhoea (>1 month)
Unexplained persistent fever (>37.6°C for >1 month)

Persistent oral candidiasis
Oral hairy leukoplakia
Acute necrotising ulcerative stomatitis/ gingivitis/ periodontitis

Pulmonary TB
Severe bacterial infections (pneumonia, empyema, pyomyositis, bone/joint infection, meningitis, bacteraemia)

Unexplained anaemia (<8), neutropaenia (<0.5) or chronic thrombocytopenia (<50)

Question 6

What are the signs of WHO stage 4 HIV?

Answer 6

HIV wasting syndrome
Pneumocystis
Recurrent severe bacterial pneumonia
Extrapulmonary TB

Chronic HSV infection
Kaposi’s sarcoma
CMV

HIV encephalopathy
Progressive multifocal leukoencephalopathy

Extrapulmonary cryptococcis
Disseminated non-TB mycobacterial infection

Oesophageal candidiasis

Chronic crytosporidiosis
Chronic isosporiasis
Disseminated mycosis
Recurrent non-typhoidal salmonella bacteriamia

Lymphoma
Invasive cervical carcinoma

Atypical disseminated leishmaniasis
Symptomatic HIVAN/ HIV associated cardiomyopathy

Question 7

What is the work-up for a newly diagnosed HIV patient?

Answer 7

CD4 count
Creatinine ( and calculated eGFR)
CrAg if CD4<100

If TB symptoms:
- Sputum GeneXpert
- Urine lam
- CXR

Pregnancy test for women

Question 8

What is the management for a newly diagnosed HIV patient?

Answer 8

ARV - all patients eligible, can be started immediately (if no clinical reason to defer)

Co-trimoxazole prophylaxis if CD4 < 200 (stage 2/3/4)

TB preventive therapy (if no TB symptoms/contraindications) - INH for 12 months with vit B6 (pyridoxine)

Fluconazole - if plasma CrAg + (if no headache)

Question 9

In which patients should ART be delayed?

Answer 9

Cryptococcal meningitis - delay for 4-6 weeks - risk of IRIS

+ serum CrAg - delay for 2 weeks

TB meningitis - delay for 4-8 weeks

TB at non-neurological site - delay for 2 weeks (CD4 <50)/ <8 weeks (CD4 >50)

Headache - investigate for meningitis first

TB symptoms- investigate for TB first

Significantly abnormal LFTs - investigate cause - risk of DILI

Question 10

What is the first-line HIV treatment?

Answer 10

TLD
- Tenofovir
- Lamivudine (3TC)
- Dolutegravir (possible increased risk of NTD- don’t start in first 6 weeks of pregnancy)

Can give women with child-bearing potential Tenfovir/Emtricitabine/Efavirenz (old regimen)

Question 11

What are the benefits and risk of dolutegravir?

Answer 11

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

Increased risk of NTD <4 weeks conception
Drug interactions with rifampicin, metformin, anticonvulsant and polyvalent cations (Mg2+, Fe2+, Ca2+)

Question 12

What are the benefits and risks of efavirenz?

Answer 12

Safe in pregnancy
No significant interaction with TB treatment

Low genetic barrier to resistance
Drug interaction with contraceptives
Neuropsychiatric side effects

Question 13

What ART do you use in patients with renal impairment?

Answer 13

If eGFR <50, use abacavir instead of tenofovir

= Abacavir/Lamivudine/Dolutegravir

Adjust dose according to eGFR

Question 14

What should be monitored in a HIV + patient on 1st line ART?

Answer 14

Medication adherence
Weight
TB symptoms
CD4 count - at 12 months (no need to repeat if CD4 >200 and viral load <1000)
HIV viral load - at 6 months, 12 months and then 12 monthly if suppressed
Creatinine and eGFR - at 3,6 and 13 months, and then repeated every 12 months