HIV Routine investigation and monitoring of adults Flashcards by Yvonne McFarlane

For all newly diagnosed HIV-positive patients, what THREE recommendations are made about the initial history?

1) FULL history
2) Identify patients GENDER
3) MENTAL health and SOCIAL history

How well did you know this?

Not at all

Perfectly

What THREE aspects comprise a FULL history for all newly diagnosed HIV-positive patients?

1) MEDICAL
2) PSYCHOSOCIAL
3) SEXUAL & REPRODUCTIVE

How well did you know this?

Not at all

Perfectly

What FIVE parts of a MEDICAL history for all newly diagnosed HIV-positive patients should there be particular emphasis on at INITIAL assessment?

1) PAST (&current) MEDICAL HISTORY
2) other MEDICATIONS
3) lifestyle HABITS
4) HIV status of PARTNERS or CHILDREN
5) CONCEPTION issues

How well did you know this?

Not at all

Perfectly

What particular aspects of SEXUAL & REPRODUCTIVE health history should be taken for all newly diagnosed HIV-positive patients at INITIAL assessment?

Partner notification
HIV testing for children
Current or past gender based violence

How well did you know this?

Not at all

Perfectly

What particular aspects of PSYCHOSOCIAL history should be taken for all newly diagnosed HIV-positive patients at INITIAL assessment?

KNOWLEDGE & BELIEFS of HIV

infection
transmission
treatment

How well did you know this?

Not at all

Perfectly

What FIVE specific OBSERVATIONS should be taken for all newly diagnosed HIV-positive patients at INITIAL assessment?

weight
height
BMI
blood pressure
waist circumference

How well did you know this?

Not at all

Perfectly

Is an examination required of for all newly diagnosed HIV-positive patients at INITIAL assessment?

YES, regardless of symptoms

How well did you know this?

Not at all

Perfectly

Why is HIV confirmatory serological testing required?

SAFEGUARD against

sample mix ups
specimen contamination

How well did you know this?

Not at all

Perfectly

When is HIV confirmatory serological testing NOT required?

IN ADDITION:
HIV viral load
or
typing assay

How well did you know this?

Not at all

Perfectly

What THREE results help confirm PRIMARY HIV INFECTION?

1) SEROCONVERTING HIV serology - antigen, no antibody or p24 antigen
2) HIV viral load, and negative serology
3) AVIDITY

How well did you know this?

Not at all

Perfectly

If a viral load is UNDETECTABLE at initial HIV diagnosis what must be performed?

REPEAT sample
check for HIV-2
use a DIFFERENT ASSAY

How well did you know this?

Not at all

Perfectly

When is viral load HIGHEST in HIV infection?

PRIMARY HIV INFECTION

How well did you know this?

Not at all

Perfectly

After primary HIV infection when does viral load decline to a steady state?

FOUR (4) to SIX (6) months

How well did you know this?

Not at all

Perfectly

What method is used for resistance testing in HIV?

GENOTYPIC resistance testing

How well did you know this?

Not at all

Perfectly

What are the BENEFITS of NEXT GENERATION SEQUENCING?

detect MINORITY VARIANTS of transmitted drug resistance

- predict HIGHER risk of virological failure with LOW genetic BARRIER drugs

How well did you know this?

Not at all

Perfectly

When is INSTI resistance testing recommended at baseline for HIV infection?

if OTHER baseline RESISTANCE
PARTNER evidence of INSTI resistance
if BACKGROUND resistance rate >3%

How well did you know this?

Not at all

Perfectly

Why is CD4 count crucial in patients BEFORE starting ART?

correlates with level of IMMUNE DYSFUNCTION & SUPPRESSION

- dictates URGENCY of ART

How well did you know this?

Not at all

Perfectly

What is the CD4 count used to guide?

risk of INFECTION & CANCER
CHEMOPROPHYLAXIS for OIs
when LIVE VACCINATION is safe

How well did you know this?

Not at all

Perfectly

CD4 count can fluctuate widely especially in PHI and acute illnesses, what measurement is less variable?

CD4 PERCENTAGE

How well did you know this?

Not at all

Perfectly

What is the negative predictive value of HLA-B5701 testing?

99-100%

How well did you know this?

Not at all

Perfectly

When MUST HLA-B5701 be checked?

prior to ABACAVIR

How well did you know this?

Not at all

Perfectly

Who is HLA-B5701 more prevalent in - Black African or White European?

White European

How well did you know this?

Not at all

Perfectly

What is the prevalence of HLA-B5701 in Black Sub-Saharan Africans?

LESS THAN 1%

How well did you know this?

Not at all

Perfectly

What is the prevalence of HLA-B5701 in White Europeans?

6.5%

How well did you know this?

Not at all

Perfectly

If a person is HLA-B5701 negative, is there any risk fo Hypersensitivity Reaction?

Yes, but lower risk

What THREE hepatitis B tests should be checked in all people with a diagnosis of HIV?

Hepatitis B surface antigen (HBsAg) Anti-core total antibody (anti-HBc) Anti- surface antibody (anti-HBs)

If a person with new diagnosis of HIV has HCV antibody POSITIVE, what else needs checked?

HCV VIRAL LOAD | at least TWICE if initially negative

What TWO hepatitis viruses can be vaccinated against?

Hepatitis A & B

Why is it important to offer a full STI test to all patients newly diagnosed with HIV?

- increased risk of HIV TRANSMISSION if DETECTABLE viral load, if simultaneous STI - increase risk of COMPLICATION from STI if HIV +ve

How often is cervical screening recommended for WLW HIV?

Annually

Other than hepatitis what other viruses should be screened for in people newly diagnosed with HIV?

Varicella zoster virus IgG Measles IgG Rubella IgG (women of childbearing age)

How should TB be screened for in people newly diagnosed with HIV?

interferon gamma release assay (IGRA)

When should people newly diagnosed with HIV be tested for parasitic infection?

If persistent eosinophilia >500cells/mL (>0.5x10(9)) AND relevant travel history

When should toxoplasma serology be checked in people newly diagnosed with HIV?

suspected CEREBRAL INFECTION or LOW CD4 and UNABLE to tolerate co-trimoxazole

What tests form the baseline METABOLIC screen in people newly diagnosed with HIV?

FBC RENAL profile - U&E, eGFR, urinalysis, uPCR LIVER profile - bilirubin, ALT (or AST), ALP (+GGT & albumin if other abnormal) BONE profile - calcium, phosphate, (ALP) LIPID (random) - total cholesterol, LDL, HDL, triglycerides HbA1c

In newly diagnosed HIV, anaemia, neutropenia &/or thrombocytopenia may be signs of?

Advanced IMMUNOSUPPRESSION Severe OPPORTUNISTIC infection MALIGNANCY

What co-infections or opportunistic infection may result in deranged liver function in HIV?

viral HEPATITIS TB CMV CRYPTOSPORIDIUM

What drugs used to treat or prevent OIs in HIV commonly cause deranged liver function?

ANTIMICROBIALS - rifamycins - isoniazid - pyrazinamide - co-trimoxazole - fluconazole - co-amoxiclav - cephalosporin

When should CARDIOVASCULAR risk assessment be made in people with HIV?

ANNUALLY if >40 or significant CVD risk factors

What TOOL is recommended to use for CARDIOVASCULAR risk assessment in HIV?

QRISK2

When should FRACTURE risk assessment be made in people with HIV?

THREE YEARLY if >50 POST MENOPAUSAL women other risk factors for OSTEOPOROSIS

What TWO tools is recommended to use for FRACTURE risk assessment in HIV?

1) FRAX | 2) QFracture

Asymptomatic patients NOT on ART - how often should they be reviewed if CD4 count <350?

3-6 monthly

Asymptomatic patients NOT on ART - how often should they be reviewed if CD4 count 350-500?

6 monthly

Asymptomatic patients NOT on ART - how often should they be reviewed if CD4 count >500?

6-12 monthly

Asymptomatic patients NOT on ART - if they do not attend an appointment how quickly should they be contacted to re-engage?

TWO weeks

Asymptomatic patients NOT on ART - in addition to CD4 count what other factors might make frequent monitoring preference?

high RISK of STI or viral HEPATITIS

In patients with HIV who are HIGH risk of STI how often should they be offered STI tests?

3 monthly

In patients with HIV who are HIGH risk of hepatitis acquisition, how often should they be offered testing?

ANNUALLY HBsAg and HCV Ab (or RNA if Ab +ve or ALT abnormal)

How often should random lipid profile be performed in PLW HIV?

``` 2 yearly (if previous baseline normal) unless smoker, >40 yrs or >30 BMI ```

When should random LIPID profile be performed ANNUALLY in PLW HIV?

SMOKER BMI >30 >40 years old

What bloods test at a minimum should be performed for PLW HIV ANNUALLY?

``` VIRAL LOAD CD4 FBC RENAL profile LIVER profile Hepatitis B surface Ab (or sAg if non-immune) ```

STI testing including syphilis serology should be offered to PLW HIV a minimum of annually in which situation?

If CHANGE in PARTNER since last test

When should cardiovascular risk assessment be performed in PLW HIV who are under 40 years old?

SMOKER DIABETIC BMI>30

When is cardiovascular risk assessment not required for PLW HIV?

under 40 years and no other risk factory | known CARDIOVASCULAR DISEASE

What vaccine status should be checked annually?

Flu vaccine Hepatitis B status/sAb level HPV completion

By what process is HIV thought to increase risk of cardiovascular disease?

PRO-INFLAMMATORY state induced by HIV infection

What is the potential BENEFIT of DEXA in all PLW HIV?

20% more patients with early bone mineral density disorders identified than with scoring tools

Why is DEXA not recommended for all PLW HIV?

Further studies required to assess utility

If choosing to start efavirenz what assessment should be done?

Depression assessment

When assessing cholesterol levels, does this need to be fasting or non-fasting?

NON-FASTING is acceptable (as per NICE)

Who should Qrisk2 not be used to assess CVD risk in?

people with DYSLIPIDAEMIA people with T2DM people with CKD (all have a significant risk anyway and should have specific management to reduce that)

What is the importance of a baseline viral load prior to starting ART?

- REDUCED EFFICACY of some ART if VL >100 000 | - RESPONSE to treatment is measured by the fall in viral load

What is the proportion of people with untreated HIV with transmitted drug resistance?

7-19%

What proportion of participants in the START trial had baseline resistance?

4.7%

In what rare circumstance would baseline resistance be repeated before starting ART?

if potential SUPERINFECTION with other strain of HIV

What proportion of people get SUPERINFECTION with a second HIV strain?

2% | large cohort 4425

When should tropism testing be performed for PLW HIV?

If plan to treat with CCR5 INHIBITOR (ie maraviroc)

CCR5 inhibitors are ineffective in what circumstances?

patient's virus is - CXCR4 tropic or - CCR5 + CXCR4 tropic (DUAL)

What is the diagnostic merit of a urinalysis looking for proteinuria in PLW HIV?

Glomerular disease - majority urinary protein albumin | albumin identified on dipstick

Which old ART commonly cause cytopenias?

Zidovudine

What is the benefit of doing full blood count on people with new diagnosis HIV?

- Haemoglobin is an independent prognostic factor | - FBC abnormalities may be a sign of OI eg disseminated mycobacterium avium complex infection

How soon after starting ART should a patient be reviewed?

2-4 weeks

When do the majority of adverse drug effects occur after starting ART?

within 2 weeks

What should be assessed at each clinic visit, especially after recent ART start?

ADHERENCE

When should a CD4 count be checked after starting ART?

3 months

CD4 count >350cells/mm 3 months after starting ART + viral suppressed - when do you re-check CD4?

ONE (1) year

CD4 count <350cells/mm 3 months after starting ART - when do you re-check CD4?

SIX (6) months

A small proportion of PLW HIV have a drop in CD4 count on effective ART - what are they at increased risk of?

CARDIOVASCULAR disease CANCER DEATH

When should a viral load be checked after starting ART?

ONE (1), THREE (3) and SIX (6) months

What fold drop is appropriate after 1 month of ART?

10-fold

If there has not been a 10-fold drop in viral load 1 month after starting ART what additional monitoring should take place?

check viral load: | TWO (2) and FIVE (5) months

By what point should most people with HIV recently started on ART have an undetectable viral load?

SIX (6) months

When should RENAL and LIVER function be checked after starting ART?

``` RENAL & LIVER: 2-4 weeks then RENAL 3 & 6 months ```

What is the incidence of RENAL TOXICITY in clinical trials on TDF?

<1%

What RENAL PATHOLOGYS has the use of TDF been implicated in?

``` AKI PROGRESSIVE renal decline HYPOPHOSPHATAEMIA RTA FANCONI syndrome NEPHROGENIC diabetes insipidus HYPOKALAEMIA OSTEOMALACIA URINARY CONCENTRATION defects ```

What additional ART in combination with TDF increases the risk of renal toxicity?

DIDANOSINE or RITONAVIR-boosted PIs

What patient factors increase risk of renal toxicity with TDF?

ADVANCED HIV disease OLD age low BMI Pre-existing renal disease

In addition to eGFR and urinalysis, what other measurement related to renal function should be taken for people on TDF?

PHOSPHATE level

What features may suggest TDF toxicity?

``` Progressive eGFR DECLINE severe HYPOPHOSPHATAEMIA new onset HAEMATURIA GLYCOSURIA (normal blood glucose) PROTEINURIA ```

What level is considered SEVERE hypophosphataemia?

< 0.64 mmol/L

If hypophosphataemia is identified, what additional measurement should be made to ensure accuracy of reading?

FASTING phosphate sample

If proteinuria is identified on urinalysis what additional measurement should be requested?

urinary protein:creatinine ratio

What should the main focus of routine follow up appointments be for pLW HIV?

``` RISK of STI/hepatitis Hepatitis B IMMUNITY LIFESTYLE MENTAL HEALTH Recreational DRUG use ADHERENCE to ART and appointments ```

BHIVA guidelines - which group of people can have VIRAL LOAD every 12 months?

stable on ART with a PROTEASE INHIBITOR

When can a patient routine follow up be 6 monthly?

STABLE on ART

If a person starts ART with a CD4 cell count over 350 do they need it repeated?

NO, unless treatment failure or HIV-related symptoms

When can CD4 cell count monitoring be stopped?

``` CD4 >350 VL UNDETECTABLE (2 occasions, 1 year apart) ```

How often should CD4 be checked if VIRAL LOAD >200?

ANNUALLY | if VL undetectable for more than a year

What should HbA1c performed for PLW HIV?

ANNUALLY | if >40 years old

What proportion of HIV diagnoses present with advanced disease (CD4 <200)?

24%

If CD4 count <50 what additional investigation should be performed?

Fundoscopy or retinal photography

Why should fundoscopy be performed for PLW HIV with CD4 <50?

CMV retinitis

When should a PLW HIV be screened for TOXOPLASMA?

SYMPTOMS

When should a PLW HIV be screened for CRYPTOCOCCUS?

SYMPTOMS

When should a PLW HIV be screened for MYCOBACTERIAL DISEASE?

SYMPTOMS

Within what time period should a PLW HIV started on ART be assessed for IRIS?

within THREE (3) months

What proportion of PLW HIV with an OI are at risk of IRIS on starting ART?

16%

Which group of PLW HIV are at highest risk of IRIS after starting ART?

CD4 nadir <50

What additional examination should take place for PLW HIV who inject drugs?

Examine INJECTION sites for signs of INFECTION

What common infective complications occur for PWIDs with HIV?

``` BACTERAEMIA - staphylococcal, streptococcal CANDIDAEMIA and other yeasts ENDOCARDITIS OSTEOMYELITIS ```

Why is a travel history important in PLW HIV?

to identify risk of HELMINTHS TROPICAL infections

What cancer screening programmes should be recommended to PLW HIV?

all NATIONAL - CERVICAL - BREAST - COLORECTAL

What proportion of PLW HIV are over 50 yrs?

25% (QUARTER)

What proportion of NEW diagnoses of HIV are in over 50 yrs?

16%

What effect does older age at HIV diagnosis have on CD4 CELL COUNT recovery?

Less recovery

What effect does older age at HIV diagnosis have on MORTALITY?

INCREASED

What multiple factors are more common or complicate management in PLW HIV over 50 years?

``` Altered drug ABSORPTION & METABOLISM Risk of DRUG-DRUG interaction bone mineral DENSITY & RESORPTION NEUROCOGNITIVE impairment CANCER screening ```

What is the COLORECTAL cancer screening programme/recommendations for PLW HIV?

60-74 year olds MEN & WOMEN Faecal occult blood (FOB) TWO (2) YEARLY

What is the BREAST cancer screening programme/recommendations for PLW HIV?

50-70 year olds WOMEN MAMMOGRAM THREE (3) YEARLY

What is the CERVICAL cancer screening programme/recommendations for PLW HIV?

25-65 years old WOMEN Cervical SMEAR ANNUALLY

What is the indication for a women to be offered breast screening under 50 years?

FIRST DEGREE relative with Breast cancer YOUNG AGE

How often should family planning and contraception needs be checked with WLW HIV?

Baseline ANNUAL POSTNATAL when AGE appropriate (young person clinic)

When should WLW HIV be asked about menopausal symptoms?

over 45 years

What symptoms may be attributed to peri menopause?

``` Hot FLUSHES SWEATS MENORRHAGIA DEPRESSION TIREDNESS dry SKIN Loss of LIBIDO ```

What is the definition of chronic kidney disease (CKD)?

eGFR <60ml/min or proteinuria

What proportion of PLW HIV have CKD?

15%

What are the modifiable risk factors for CKD in PLW HIV?

SMOKING OBESITY DYSLIPIDAEMIA HYPERTENSION

Albuminuria is a risk factor for cardiovascular disease, what is the target blood pressure?

<130/80

In PLW HIV + CKD but no albuminuria what is the target blood pressure?

<140/90

What is the criteria for albuminuria?

ACR >70mg/mmol

When should people with CKD/albuminuria be offered an ACEi or ARB?

``` CKD + ACR >70mg/mmol or Hypertension + ACR >30mg/mmol or Diabetes + ACR >3mg/mmol ```

If a PLW HIV has HYPERTENSION, at what level of albumin:creatinine ration should they be started on an ACEi or ARB if not already?

ACR >30mg/mmol

If a PLW HIV has DIABETES, at what level of albumin:creatinine ration should they be started on an ACEi or ARB if not already?

ACR >3mg/mmol

Which ARVs may inhibit creatinine secretion and therefore result in reduction in eGFR?

DOLUTEGRAVIR RITONAVIR COBICISTAT RILPIVIRINE

What ARVS can be dose adjusted in renal impairment?

LAMIVUDINE EMTRICITIBINE Tenofovir disoproxil

What effect does HIV have on graft function in people with a renal transplant?

INCREASED risk graft rejection

When should PLW HIV be referred for RENAL evaluation?

PROGRESSIVE eGFR decline Unexplained or severe CKD ACR >30 or PCR >50mg/mmol

At what level of proteinuria should PLW HIV be referred for RENAL evaluation?

PCR >50mg/mmol

What is the definition of SEVERE CKD?

eGFR <30ml/min

What is the definition of PROGRESSIVE decline in eGFR?

>5-10ml/min/YEAR

In addition to TDF, what ARV CLASS is associated with LOW bone mineral density?

PROTEASE INHIBITORS

What are the THREE RISK factors for VITAMIN D DEFICIENCY?

WINTER sampling BLACK ethnicity Exposure to EFAVIRENZ

Is HIV an INDEPENDENT risk factor for low bone mineral density?

YES

What are the modifiable risk factors for CARDIOVASCULAR disease?

HYPERTENSION DYSLIPIDAEMIA DIABETES SMOKING

What ARVs have been associated with myocardial infarction or cardiovascular disease?

ABACAVIVR DIDANOSINE LOPINAVIR

What dose of ATORVASTATIN is recommended for people at increased risk of cardiovascular events?

80 mg | HIGH DOSE

In addition to atorvastatin what dietary and lifestyle RECOMMENDATIONS can be made to people with increased risk of cardiovascular events?

``` RESTRICT: - dietary salt - saturated fat - cholesterol - alcohol WEIGHT REDUCTION physical ACTIVITY SMOKING cessation ```

What level of HIV VIRAEMIA is associated with viral REBOUND or FAILURE?

>200 copies/ml

What is the definition of LOW-LEVEL VIRAEMIA?

50-200 copies/ml (repeatedly)

If PLW HIV has low level viraemia which ARV class should there be a low threshold for switching?

LOW genetic BARRIER NNRTI (switch sooner than later)

If is important to exclude in low level viraemia?

CNS replication | CSF for viral load

What is a recommended COMMUNICATION aid for helping to assess a patients physical and psychological needs?

WELLNESS THERMOMETER

What is the most frequently cited SOCIAL care need of PLW HIV?

POVERTY and issues related to it

What is the relationship of STIs in male prisoners vs the male STI clinic attendees?

``` HIGHER rate: - genital warts - hepatitis B - hepatitis C but less often offered STI testing ```

What elements of history are unique to a trans person living with HIV?

Gender IDENTITY Time LIVING as trans Social TRANSITION - binding/tucking, hormones, silicone Plans for SURGERY PSYCHOSOCIAL - mental health, PTSD, GBV, support network, sex work, substance use LEGAL concerns - gender certificate, ID, NHS records

What is the global prevalence of HIV in TRANSGENDER WOMEN?

19%

When should a resistance test be performed on a CSF sample?

If DETECTABLE viral load

When should resistance testing be repeated in people who have recently initiated ART?

if < 1 log drop after 4 weeks ie 40000 to 4000

At what viral load level is resistance testing most likely to be accurate or possible?

>500 copies/ml

What is the potential benefit of next generation sequencing in CCR5 tropism?

MORE SENSITIVE in predicting CCR5 inhibitor failure

What online tools can be used to interpret HIV-1 resistance genotyping?

STANFORD database ANRS (France) REGA (Belgium)

Why might a PLW HIV have virological failure on MARAVIROC (CCR5 inhibitor)?

If the TROPISM SWITCHES from CCR5 to X4 or SPECIFIC maraviroc resistance

In women of childbearing age, what additional past exposure to infections should be checked?

Measles IgG Rubella IgG Varicella IgG (unless confident about past vaccination or exposure)

When is FBC re-checked following ART start if asymptomatic?

6 monthly

What are the indications for FBC monitoring after ART start?

ZIDOVUDINE or UNWELL