HIV

Question 1

How does PCP present?

Answer 1

Exertional dyspnoea progressing over several weeks, malaise and dry cough

AIDS defining

CXR normal in 39% but perihilar haze and interstitial infiltrates

Question 2

Which services should offer opt out testing?

Answer 2

Antenatal, SH, TOP, substance misuse, hep b/c services, tb and lymphoma

Question 3

What do 4th gen tests test for?

Answer 3

Antibodies and p24 antigen

P24 antigen is a viral capsid protein detectable in blood earlier than antibodies in primary hiv infection

Window period 45 days (but most detectable prior)

Confirmatory testing indicated if positive

Question 4

Which MSM should have 3/12 hiv tests?

Answer 4

Chems
>10 partners in year
Multiple/anon partners since last test
Condomless AI with unknown or zero discordant not suppressed

Also consider prep

Question 5

What do PHE define as high prevalence?

Answer 5

2-5/1000 adults living with diagnosed HIV

> 5/1000 is extremely high

In high or extremely high prevalence area hiv test should be offered to anyone undergoing venepuncture

Question 6

When should you test in best interests?

Answer 6

If pt cannot consent and would change management now eg indicator condition and unwell

Question 7

Is CAP an indicator condition for HIV?

Answer 7

Yes

And indicator condition is any medical condition associated with an undiagnosed seroprevalence of 1 or more per 1000

Question 8

At what level of undiagnosed hiv prevalence does screening become cost effective?

Answer 8

0.1%

Allows earlier rx,
Reduces onward transmission

Question 9

When do BHIVA say start ART in pregnancy if not already on?

Answer 9

Beginning second trim with:

TDF + emtricitabine or lamivudine

Or abacavir + emtricitabine or lamivudine

Weigh up medication in first trimester vs achieving suppressed viral load by latest 36/40

Higher load will take longer to suppress so if VL >30,000 start at start 2nd trim ; if less just as soon as able 2nd trim

Question 10

Which ART are not recommended started in pregnancy?

Answer 10

Efavirenz-good evidence but not in guidelines art naive (note also linked with depression)

TAF
Elvitegravir
Cobicistat

Question 11

Can you treat hepatitis C in pregnancy?

Answer 11

No.
Do not use directly acting antivirals in pregnancy lack safety data
Ribavirin is a teratogen
Defer treatment until postnatal
Can recommend vaginal delivery regardless hepatitis c viral load

Question 12

What are criteria to support BF?

Answer 12

Good adherence ART
Undetectable viral load
Monthly mother and child VL measurement during and for 2/12 after BF

Advise
Shortest time possible
Exclusive feeding only not mixed for first 6/12
Stop if mastitis or gi sx baby
U=U does not apply

If BF with known viral load-social services

Question 13

How do you manage pre labour SROM viral load <50?

Answer 13

Immediate IOL aim delivery within 24hrs

If VL <50 vertical transmission risk is <0.5% regardless mode delivery

Question 14

What infant pep is indicated if suppressed by 36 weeks but don’t have 2 VL <50 4 weeks apart?

Answer 14

Four weeks zidovudine within 4 hours

Combination pep if not superseded by 36 weeks

2 weeks zidovudaine only if suppressed by 36 weeks and 2 <50 viral loads.

Question 15

When do you test routinely infant for HIV post natal ? (Not BF and not high risk)

Answer 15

Birth
(Not while on pep)
6 weeks
12 weeks
18-24 mths (ideally antibody only as just checking mat antibodies cleared)

Question 16

Does Hep b viral load affect mode of delivery if hiv suppressed?

Answer 16

No can have vaginal delivery plus vacinnation within 24hrs

If maternal hbv >10 to power of 6, or e antigen positive or anti-hbe negative or unknown give HBIG too

Question 17

If need an amino and VL not suppressed?

Answer 17

Do amnio but ensure on raltegravir regime and cover procedure with stat nevirapine 2-4hrs prior

Question 18

Do people on ART need extra antenatal scans?

Answer 18

No

Of note dolutegavir associated with neural tube defects (past 6 weeks do not switch as neural tube closed)

Question 19

When should people with HIV in pregnancy be assessed re mental health?

Answer 19

Booking
4/52 PN
3/12 PM

Minimum

Prevalence PND HIV high income is 30-53%

Question 20

How do you treat new diagnosis in labour?

Answer 20

Double dose TDF 490mg stat
Nevirapine 200mg stat

Start bd
Lamivudine
Zidovudine
Raltegravir

IV zidovudine for duration labour

Question 21

Can you give people with CD4 <200 live vaccines?

Answer 21

No

If > 200 consider VL (suppression will increase safety) and risk natural infection vs vaccination if been exposed…likely vaccination less risky

Live include VZV, MMR, yellow fever

You can give not live vaccines if <200 however may have reduced effect so consider delay if beneficial risk v benefit

Question 22

Réceptive AI risk?

Answer 22

1:90

1:65 ejaculation
1: 170 no ejaculation

Question 23

Risk insertive anal (not suppressed)

Answer 23

1:666

Not circumcised 1:161
Circumcised 1:909

Question 24

Réceptive vaginal

Answer 24

1:1000

Question 25

Insertive vaginal

Answer 25

1: 1219

Question 26

Semen to eye
Giving and receiving oral sex
Human bite

Answer 26

< 1:10,000

Question 27

Needle stick

Answer 27

1:333

Injecting sharing is 1:149

Question 28

Why is it important to consider concurrent sti risk with hiv transmission?

Answer 28

Syphilis HSV increase risk x 10-50 male to female x 50-300 female to male

Break in mucosal barrier, increased lymphocytes

Gc/C4 increase risk 2-5 fold…increased virus in genital fluids

Question 29

How effectively do condoms reduce hiv risk?

Answer 29

80-95%

Question 30

Topical microbicides effective?

Answer 30

Yes-ring and gel in rct