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
27 March 2015
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)

A 30-year-old newly diagnosed HIV infected patient with a CD4+ lymphocyte count of 24
cells/L presents with weight loss and a cough of two weeks duration. His sputum GeneXpert
MTB/RIF assay result is positive for Mycobacterium tuberculosis, rifampicin resistant. He is
hepatitis B surface antigen negative. Renal function is normal (eGFR >60 mL/min). Hb 10
g/dL
a)
What other sputum investigations will you request?
(2)
b)
What TB treatment would you start?
(5)
c)
What antiretroviral regimen will you commence? Justify your choice.
(3)
[10]

A 32-year-old HIV infected woman started tenofovir, emtricitabine and efavirenz in 2012. She
now presents with a history of intermittent diarrhoea over a period of 4 months requiring
recurrent admissions for dehydration in the short stay ward attached to the emergency unit.
A single stool microscopy and culture was negative from a previous admission and her
current CD4 count is 32 cells/L with a viral load of 60,000 copies/mL. She claims to have
good adherence. Clinically she is afebrile, dehydrated and wasted with mild non-localised
abdominal tenderness, but otherwise her examination is unremarkable. CXR is normal. Hb
7.8 g/dL, urea 24 mmol/L, creatinine 125 mol/L, sodium 123 mmol/L, potassium 2.9 mmol/L,
and repeat stool microscopy and culture is negative. You admit her to the medical ward in
your large secondary level hospital and commence rehydration with normal saline and added
potassium chloride
a)
Discuss the differential diagnosis in this patient.
(5)
b)
What investigations would you do?
(5)
[10]

PTO/Page 2 Question 3

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3

You see Mr Fulani for the first time today. His notes show that he was diagnosed with HIV
infection 3 weeks ago. Two weeks ago when his CD4 result came back at 130 cells/ L he
was started on fast-track work-up for ART. He has been counselled around ART and his
baseline creatinine is normal. However, you note that he has lost 1kg since his first visit,
although he has no other TB symptoms. He also tells you that he is moving to another city
the day after tomorrow for work purposes. It is unclear how many months he will be there, so
he requests a transfer letter
a)
In point form, list the advantages and disadvantages of starting ART today or of
deferring his ART start to his new place of residence.
(8)
b)
Suggest actions that you as the clinician could take to ameliorate (lessen) the
disadvantages of starting ART today in this patient.
(2)
[10]

Write short notes on the following

a)
The functions of the HIV proteins that are encoded for by the gag, pol and env genes.
(5)
b)
Outline the steps involved in HIV viral entry into CD4+ cells.
(5)
[10]

A 22-year-old woman was diagnosed with HIV infection at the age of 19, when she started
first line ART (tenofovir, emtricitabine and efavirenz). She switched to second line ART
(zidovudine, lamivudine and lopinavir/ritonavir) 18 months ago for virologic failure. She is now
36 weeks pregnant. She booked at 16 weeks and has had regular antenatal care, including
visits 3 weeks ago and the previous week. The midwives concern at both visits was that her
baby was not growing well, and they had booked an appointment at your hospital obstetric
clinic. Her CD4 count was 160 cells/uL when she booked. You ask if she knows her viral load,
and she says she has never heard of this test. You establish that her viral load was 870,000
copies/mL on the day of booking. There is no record of this in her obstetric notes. You look
back through previous results, and find that she has never suppressed on second line ART
a)
What is your plan for her ART?
(3)
b)
How will you manage the baby after delivery?
(5)
c)
At a district maternal morbidity meeting several weeks later, her case is discussed.
What health systems problems are shown by this case, and how would you address
them?
(7)
[15]

The mother of a 5-day-old infant just tested positive for HIV. The mother is breast feeding
and the infant is well. No PMTCT was given during the pregnancy and delivery
a)
What is the appropriate prophylaxis regimen for this infant?
(3)
b)
What would the appropriate prophylaxis be if the infant was not breastfeeding?
(1)
HIV infection is diagnosed in a 7-day-old premature infant (gestation 35 weeks) with a positive
HIV PCR. Discuss initiation of ART for this infant under the following topics
c)
When would you start ART?
(1)
d)
What antiretroviral drugs would you choose? Give the reasons for your choice.
(5)
e)
Outline your follow up plan.
(5)
[15]

PTO/Page 3 Question 7

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7

The current ART guidelines for the USA recommend any one of the following first-line ART
regimens (all with two nucleoside reverse transcriptase inhibitors): efavirenz; the ritonavirboosted protease inhibitors atazanavir or darunavir; the integrase strand transfer inhibitors
dolutegravir or elvitegravir (boosted with cobicistat) or raltegravir. Discuss the pros and cons
of a policy switch to a new first-line ART regimen in southern Africa based on
a)
The protease inhibitors listed above plus tenofovir and emtricitabine.
(7)
b)
Integrase strand transfer inhibitors plus tenofovir and emtricitabine.
(8)
[15]

Write short notes on the following metabolic complications of ART

a)
Aetiology, diagnosis and management of decreased bone mineral density.
(6)
b)
Antiretroviral drugs associated with dyslipidaemia. Also include a discussion of therapy
for the dyslipidaemia.
(9)
[15]