Dip HIV Man(SA)

THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain Reg No 1955/000003/08

Examination for the Diploma in HIV Management of the

College of Family Physicians of South Africa

31 August 2012 Paper 2 Short essay-type questions (3 hours) All questions to be answered. Each question to be answered in a separate book (or books if more than one is required for the one answer)

1 Glynnis is a 29-year-old woman who was diagnosed HIV positive 6 months ago. Her CD4 count then was 368, she is WHO stage II (previous shingles) and she is on co-trimoxazole prophylaxis, but not on ARVs. You have been seeing her every two months since her initial diagnosis and workup. She has adjusted well to her diagnosis and she has disclosed her status to her sister. During her routine follow up she reveals to you that she now has a boyfriend, who is in fact a patient (Johannes) you are treating for hypertension. They have been sexually active and are not using condoms. She has not yet disclosed her HIV status to him. Her plan is that she is going to suggest to him that they should both have an HIV test together seeing as they are starting a relationship, and her positive status can be disclosed in this way. She wants you to do the counselling and testing and pretend that you do not know that she is already HIV positive.

Johannes has recently refused your offer of a routine HIV test again.

Discuss how you would manage this situation. Clearly outline the patients agendas (remember that there are two of them) and the doctors agenda. Then discuss management options in terms of the disclosure issue / harm reduction that could in some way satisfy these agendas. Include both ethical and legal considerations in your answer. [15]

PTO/Page 2 Question 2

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2 Madelaine is a 5-month-old girl diagnosed with HIV at the age of 8 weeks in Lesotho, and initiated on lamivudin, zidovudine and nevirapine at a clinic at 10 weeks of age. She was not exposed to antiretroviral therapy in utero or in the postnatal period. She presented to a hospital in South Africa five days ago with severe pneumonia. Her current CD4 count is 113 cells/l (3.6%) and the HIV viral load is 6 884 480 RNA copies/ml. a) What aspects on clinical history would you explore to determine why this

child is failing her ART regimen? (2) b) How can one estimate adherence to therapy in infants receiving ART?

(2) c) Discuss the likelihood that resistance to antiretroviral therapy emerged if

the following had occurred and discuss what resistance patterns may have emerged under these circumstances. i) Her mother gave her ART intermittently for one week, but then

decided to stop therapy because she was afraid that her family would realise that the child is HIV positive. (2)

ii) Her mother has been dosing the child at irregular intervals, often missing doses, over the last 3 months. (2)

d) Assuming her mother has been dosing the child at irregular intervals often missing doses, how would you manage this child further given that she will remain with extended family in South Africa? (4)

e) Discuss the evidence as to whether protease inhibitor based regimes are more effective than non-nucleoside reverse transcriptase based regimens for the treatment of high-level viraemia in infants. (3)

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3 In your area, uptake of antenatal HIV testing at the first clinic visit is 93%. Your PMTCT programme follows the national guidelines, with AZT plus single dose nevirapine in labour (with tenofovir plus emtricitabine) for women not eligible for ART. Women eligible for ART are referred to ART clinics and fast tracked to start treatment. A research study looking at prevention of mother-to-child-transmission in your area has just been published, which showed a higher than expected transmission rate (7.4%). In the study 22% of cord blood samples were seropositive for HIV. The HIV seropositive samples were further tested for the presence of antiretroviral drugs: 27% showed the presence of a triple drug ART regimen, 29% contained both zidovudine and nevirapine, 12% zidovudine alone and 8% nevirapine alone, and 24% contained no antiretrovirals. a) Explain what the cord blood HIV antibody and antiretroviral assay data

means to the clinic staff. (4) b) Based on this study, what measures could be taken to reduce vertical

transmission in your area? (6) c) What additional factors may contribute to the high rate of vertical

transmission in your area, and what measures could you take to address them? (5)

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PTO/Page 3 Question 4

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4 A 35-year-old HIV-infected man presents to the local clinic with the 3 week history of cough, fever and weight loss. He had a previous episode of TB that was fully treated two years ago. A sputum is tested using a commercially available real-time PCR tuberculosis assay, Xpert MTB/RIF, and the result is negative. a) Discuss the advantages and disadvantages of the Xpert MTB/RIF test

on sputum when compared to sputum microscopy, TB culture and culture-based drug susceptibility testing. (8)

b) What is the next diagnostic step in this patient? (2) [10]

5 A patient on AZT/3TC/efavirenz loses 7kg in weight over 2 months after a year of virological suppression, with no other symptoms or clinical signs. Discuss a) The differential diagnosis, from most to least likely. (5) b) Relevant investigations and the rationale for each. (5) c) A step-wise management approach, if investigations fail to yield a diagnosis. (5)

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6 Write short notes on each of the following a) The mechanism by which HIV gains entry into the CD4 T- lymphocyte. (2) b) The functions of the HIV proteins that are encoded for by the gag, pol and env genes. (8)

[10] 7 A 35-year-old man started antiretroviral therapy (tenofovir, lamivudine and

efavirenz) two months ago after he had been on treatment for pulmonary tuberculosis for two weeks. The baseline CD4 count was 75 cells/microlitre. He presents with a 5 day history of altered mental status and left hemiplegia. a) What are the most likely causes for the neurological features? State what you consider to be the most likely diagnosis. (4) b) What key investigations would you do to determine the cause of the neurological presentation? (6)

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8 Peter is a 2-year-old boy who initiated antiretroviral therapy 2 weeks ago with abacavir, lamivudine and lopinavir/ritonavir. He is also receiving co-trimoxazole for the past year. At the time of ART initiation he was well. His mother calls you stating that she is worried that Peter is having a hypersensitivity reaction to abacavir as he has developed a rash. a) What is the most important risk factor for abacavir hypersensitivity reaction? (1) b) Discuss the expected rates of abacavir hypersensitivity in Africa. (1) c) Describe how you would make a clinical diagnosis of the abacavir hypersensitivity reaction. (8)

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