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)

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

-22

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)
[15]

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-childtransmission 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)
[15]

PTO/Page 3 Question 4

-34

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]

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)
[15]

Write short notes on each of the following

a)
The mechanism by which HIV gains entry into the CD4 Tlymphocyte.
(2)
b)
The functions of the HIV proteins that are encoded for by the gag, pol
and env genes.
(8)
[10]

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)
[10]

Peter is a 2-year-old boy who initiated antiretroviral therapy 2 weeks ago with
abacavir, lamivudine and lopinavir/ritonavir. He is also receiving cotrimoxazole 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)
[10]