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Dip GUM > ART/HIV questions > Flashcards

ART/HIV questions Flashcards

1
Q

how many drugs are usually used in ART to treat HIV?

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4

A

3 drugs are usually used combination to treat HIV

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2
Q

what class of drugs makes up the ‘backbone’ of ART Rx?

a) NNRTI (non nucleoside reverse transcriptase inhibitor)
b) NRTI (nucleoside reverse transcriptase inhibitor)
c) PI (protease inhibitor)
d) INI (intergrase inhibitor)

A

b - NRTI (commonly truvada - tenofovir DF + emtricitabine)

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3
Q

what is the first line ART backbone in treatment of HIV in therapy naive patients (assuming no co-morbidities, no drug interactions etc)

A

tenofovir DF + emtricitabine (truvada) plus a third agent e.g raltegravir

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4
Q

A patient is noted to have a HLA B 75:01 positive result. Which of the following ARTs are contra-indicated?

a) tenofovir
b) efavirenz
c) abacavir
d) rilpivirine

A

c - abacavir

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5
Q

When is rilpivirine generally only recommended at baseline rx for HIV?

A

when VL > 100,000 copies at baseline

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6
Q

if first line standard NRTI backbone (truvada) is contra-indicated what is an alternative first line option that could be used for therapy naive patients?

when is this option recommended in patients diagnosed with HIV and not already on ART?

A

Abacavir + Lamivudine (3TC = kivexa)
plus efavirenz

if VL>100,000 copies/mL then abacavir + lamivudine (3TC - kivexa) is recommended

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7
Q

at what CrCL level is Tenofovir DF contra-indicated?

A

CrCL <70

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8
Q

At what CrCL if tenofovir-AF contra-indicated?

A

CrCL < 30

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9
Q

what did the PARTNER study show?

A

no risk of HIV transmission between serodiscordant couples when VL < 200 (undetectable = untransmissable (u=u))

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10
Q

list 4 situations when you would consider changing the ART regime

A
  1. viral load becomes detectable i.e. vial rebound
  2. side effects
    drug interactions
    drug resistance
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11
Q

what is the definition of a viral blip

A

when the HIV viral load becomes detectable on ART for a short period of time (no need to change meds if VL subsequently goes back to being undetectable)

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12
Q

If the VL goes above 200 copies/ml what should you do?

A

investigate for drug resistance if pt states they are complying with treatment
if it is sustained VL rebound then you should consider the need to change ART

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13
Q

what is the ART first line for patients with HIV and TB co-infection?

A

tenofovir -DF + emtricitabine (truvada) + efavirenz

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14
Q

A patient is diagnosed with HIV and TB co-infection. They are not on ART for HIV. Their CD4 count comes back at 24. how would you manage their TB and HIV, how quickly should ART be started?

a) start ART immediately prior to TB treatment
b) start TB treatment first, aim to start ART within 2 weeks once established on TB treatment
c) just start ART once established on ART then worry about TB Rx
d) delay ART for up to 8-12 weeks, focus on TB treatment for now.

A

b- start TB treatment with the aim to start ART within 2 weeks

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15
Q

Ben is diagnosed with HIV and TB co-infection. these are both new diagnoses and he is not currently on any treatment. His CD4 count comes back at 87 and VL 500.

How would you manage the TB and HIV treatment?

a) simultaneously start TB and ART treatment
b) start TB treatment and delay initiation of ART for 8-12 weeks
c) start ART once established then start TB once Ben is ready
d) start TB treatment, only start ART once he has completed TB treatment

A

b) start TB treatment - delay starting ART for 8-12 weeks

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16
Q

Jodie is admitted unwell with severe confusion and pyrexia of unknown origin. LP demonstrates CNS TB and her HIV blood test comes back positive. She was previously known to have HIV but was lost to follow up and is not on any HIV medication. Her VL is 87,000 and CD4 count 43.

How would you manage the TB and HIV co-infection?

a) simultaneously start TB and ART treatment
b) start TB treatment and delay initiation ART after 8 weeks
c) start ART once established then start TB once Ben is ready
d) start TB treatment, only start ART once he has completed TB treatment

A

b - start TB treatment and delay ART initiation regardless of CD4 count for minimum of 8 weeks

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17
Q

Which ART should be avoided in patients with neurocognitive impairment or mental health illnesses including depression and anxiety?

a) Efavirenze
b) Tenofovir
c) Emtricitabine
d) Raltegravir

A

a- efavirenze

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18
Q

which of the following ART should be avoided in patients with known CKD?

a) Efavirenze
b) Tenofovir -DF
c) Emtricitabine
d) Raltegravir

A

b - tenofovir DF

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19
Q

a patient has a QRisk 3 score of 10 and is on treatment for unstable angina. Which of the following ART medications should be avoided in the treatment of his HIV?

a) Efavirenze
b) Tenofovir
c) Emtricitabine
d) Abacavir

A

Abacavir - should be avoided in patients who have risk factors for CVD.

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20
Q

John is 47 years old and has been diagnosed with HIV. Whilst taking a drug history he mentions he is on regular bisphosphonates for treatment of osteoporosis that was picked up following the diagnosis of a fragility fracture. Which ART treatment should be avoided in patients with reduced bone mineral denisity?

a) Efavirenze
b) Tenofovir
c) Emtricitabine
d) Raltegravir

A

b - tenofovir

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21
Q

list the three AIDS defining malignancies

A

a) KS (Kaposi Sarcoma)
b) NHL - typically diffuse large B cell lymphoma or Burkitt’s lymphoma
c) Cerivcal cancer

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22
Q

Is anal cancer an AIDs defining malignancy in men with HIV

A

no - but it is 2-3 times more common in men who are HIV +ve

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23
Q

In patients diagnosed with an AIDS defining malignancy, when should they start ART if not already established on Rx?

a) immediately
b) once established on chemotherapy or radiotherapy
c) never - treat the malignancy first

A

a - immediately. all patients with AIDS defining malignancies should be started on ART immediately

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24
Q

In a patient with an aids defining malignancy due to start cancer treatment when would you consider starting HSV prophylaxis and PCP prophylaxis?

A

start HSV prophylaxis if they have a history of HSV due to start cancer Rx (otherwise not indicated)
PCP prophylaxis if CD4 count < 200 then start PCP prophylaxis (co-trimoxazole 960mg OD three times a week)

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25
Q

what is the definition of primary HIV infection (PHI)?

A

HIV infection that is diagnosed within 6 months of possible HIV acquisition (can determine this by looking back at retrospective blood tests)

26
Q

what is the definition of a LATE HIV diagnosis?

A

new HIV positive diagnosis and CD4 count < 350 cells/uL

27
Q

What time frame should patients presenting with an AIDS defining infection or with a serious bacterial infection and CD4 count <200 start ART within?

A

within 2 weeks of starting anti-microbial chemotherapy

28
Q

what are the two types of HIV virus?

A

Type 1 and type 2 HIV

29
Q

which type of HIV Virus (type 1 or 2) is more prevalent in west africa

A

HIV type 2

30
Q

out of both types of HIV virus which type if more virulent and rapidly progressive?

A

HIV 1

31
Q

how is HIV transmitted?

A

through infected bodily fluids - sexually transmitted, sharing needles, vertical transmission, occupational exposure

32
Q

What is the definition of AIDs? At what CD4 count does it develop?

A

AIDs = acquired immunodeficiency virus is the final stage of HIV infection. It usually develops when the CD4 count drops very low < 200. At this stage the HIV has attacked the the immune system and makes it vulnerable to opportunistic infections or malignancies that people with healthy immune systems would not usually develop.

33
Q

Give an example of an AIDs defining infection

A

PCP

oral and oesophageal candidiasis

34
Q

what is the window period for HIV blood tests?

A

45 days

35
Q

when does seroconversion typically occur following acquisition of HIV?

A

seroconversion can occur 2-6 weeks following HIV infection. symptoms typically last 5-10 days and can vary

36
Q

What are some of the ‘classical’ symptoms of seroconversion

A

fever, rash, sore throat, lymphadenopathy

  • severe oral ulceration can be highly suggestive of acute seroconversion
37
Q

what vaccines should all HIV patients receive regardless of CD4 count/viral load

A
  • pneumococcal vaccine (PCV 13 - single dose)
  • influenza vaccine
  • engerix (double dose) if this fails to provide immunity then fenderix

avoid live vaccines in HIV positive patients

38
Q

what is the commonest opportunistic infection worldwide in PLWH

A

TB

39
Q

is HIV a notifiable disease

A

no

40
Q

is TB a notifiable disease

A

yes

41
Q

how does pulmonary TB typically present?

A

cough, night sweats, weight loss, fever +/- haemoptysis

42
Q

what is the most common type of extra-pulmonary TB?

CNS TB
renal TB
TB Lymphadenitis
abdominal TB

A

TB lymphadenitis

43
Q

what might the clinical signs of TB be on a CXR?

A

upper lobe changes, pleural effusion, patchy consolation, cavitations, milliary TB

44
Q

what is the standard treatment for TB?

A

RIPE - rifampicin, isoniazid, pyrazinamide, ethambutol

2 months of all 4 drugs and then 4 months of just rifampicin and isoniazid
n.b 12 months treatment in CNS TB

45
Q

what other medication might be needed in patients co-infected with HIV and TB to try and prevent IRIS (immune reconstitution inflammatory syndrome)

A

Steroids

46
Q

What countries are considered high prevalence countries for TB?

A 
Africa 
south America
China 
Russia 
South pacific - vietnam, cambodia, philippines 
South Asia
47
Q

For PLWH whom should we screen for latent TB ?

A

patients born in endemic countries for TB (Africa, Russia, south america, south asia, pacific, china)

  • pts with CD4 < 200
  • medical workers
  • IVDUs
  • stage 4/5 ckd
  • DM
  • about to have chemotherapy Rx for malignancy
  • Immune suppression following organ transplant
  • Biologics for inflammatory conditions
48
Q

what type of blood test should we use in PLWH to confirm the diagnosis of latent TB?

A

IGRA (interferon gamma release assay)

(latent TB is absence of clinical signs, normal CXR, asymptomatic but positive serology usually IGRA in PLWH or TST - tuberculin skin test)

49
Q

John is a medical worker on ART for HIV. His viral load is undetectable and has a good CD4 count. He wants to know if he can have the BCG vaccine as he has recently seen a patient on his ward that tested positive for TB and he is worried about his risk. Is he eligible to have the vaccine?

A

No - BCG vaccine is a live vaccine and so needs to be avoided

50
Q

what are the three groups of the herpes virus

A

herpes virus is a family of DNA viruses. There are three groups

  1. Alpha HSV - HSV 1 and 2 + VZV (varicella zoster virus)
  2. Beta HSV - HSV 6&7, CBV
  3. Gamma HSV - HHV-8 and EBV
51
Q

what is the cause of kaposi sarcoma>

A

Is an infection with the gamma herpes virus HHV 8 (human herpes virus 8)

52
Q

how is HHV 8 spread?

A

kissing - highest level of HHV 8 is found in the saliva

53
Q

what is seen on histology in kaposi sarcoma

A

spindle shaped cells

54
Q

how does Kaposi sarcoma present

A

multiple, pigmented, raised and painless lesions

55
Q

Can KS affect visceral organs?

A

Yes - lungs and stomach, pulmonary KS is life threatening

56
Q

what is the usual treatment of KS in PLWH?

A

ART will usually treat KS
if CD4> 150 and lesions confined to the skin - ART alone
if CD4< 150; extensive skin disease
/ oral involvement/ GI involvement - ART and IV chemotherapy

57
Q

how frequently should women living with HIV have cervical smears? and why?

A

annual smears as acquisition of HPV is much higher in women living with HIV

58
Q

how much more common is the prevalence of cancer in PLWH compared to the general population

A

2-3 times more common

59
Q

how is anal cancer Rx in PLWH

A

chemotherapy and radiotherapy

60
Q

what screening exists for PLWH and anal cancer

A

no screening currently exists

Dip GUM (23 decks)

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