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
28 March 2014
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)

Stavudine (d4T) use is being phased out in your district. Write a policy guideline for the
clinics in your district advising doctors and nurses how to safely switch people who are on
d4T-based first-line ART regimens to an alternative regimen and how to monitor patients
after such a switch. Provide a brief justification for each point in your guideline.
[15]

A 35-year-old man started first-line ART one year ago, with tenofovir, lamivudine (3TC) and
efavirenz. Baseline CD4 count was 50 cells/L, and baseline viral load was 750 000
copies/mL. He had treatment interruptions twice in the first 6 months due to service delivery
issues. His 6 month viral load was 765 copies/mL and his 12 month viral load was 25 000
copies/mL. A genotypic antiretroviral resistance test shows high level resistance to 3TC (the
M184V mutation) and efavirenz/nevirapine (the K103N mutation)
a) Explain what is meant by the term genetic barrier to resistance and how this might
explain his failure to achieve full virologic suppression.
(5)
b) Using your understanding of drug resistance mutations, provide a rational explanation
for using tenofovir in the first line treatment regimen followed by zidovudine in the
second line treatment regimen.
(5)
[10]

A 6-year-old boy on abacavir, lamivudine and efavirenz has been experiencing virological
and immunological failure with a CD4 of 150 cells/L and viral loads of more than 5000
copies per mL on 2 specimens over a 4 month period. While you are preparing to switch the
child to a second-line regimen you obtain a history of a close household contact with
tuberculosis and a chronic cough. The childs CXR shows extensive bilateral alveolar
opacification. His sputum is positive for M. tuberculosis on Xpert, susceptible to rifampicin.
You commence isoniazid, rifampicin and pyrazinamide for tuberculosis. Briefly discuss the
advantages and disadvantages of the following three antiretroviral options for this child
while he is on anti-tuberculosis therapy: Continue current ART; switch to triple NRTI
regimen (abacavir, lamivudine and zidovudine); switch to lamivudine, zidovudine and
adjusted doses of lopinavir-ritonavir.
(10)
PTO/ Page 2 Question 4

-24

A 25-year-old woman presents with a 2 week history of a dry non-productive cough and an
O2 saturation of 85% on room air at rest. Her chest x-ray shows a bilateral ground glass
interstitial infiltrate. She is not on ART and her rapid HIV test is positive. You suspect
Pneumocystis jirovecii pneumonia.
a) How could you confirm the microbiological diagnosis?
(2)
b) Discuss your management plan.
(5)
c) Give a treatment option if the patient has a history of severe sulphonamide allergy. (2)
d) List one complication directly due to the Pneumocystis pneumonia.
(1)
[10]

In South Africa non-pregnancy related infections, most of which are HIV-related, are still the
most common cause of maternal mortality (defined as the death of a woman while pregnant
or within 42 days of the end of pregnancy, from any cause related to or aggravated by the
pregnancy or its management but not from accidental or incidental causes). What can be
done to prevent women dying from HIV-related causes in pregnancy and the postpartum
period? In your answer discuss both programmatic and individual patient care aspects. [15]

You are working in the staff health clinic of a public sector hospital with a high TB
prevalence and see a nursing sister who works in the busy medical wards. She has recently
been diagnosed HIV positive with a CD4 count of 400 cells/L. She has no current TB
symptoms, but she is worried about her risk of contracting TB. She wants to know what TB
prevention options are available to her in light of her current working conditions. Outline the
strategies that are available to prevent TB in this lady and discuss what you would advise
her.
[15]

A 28-year-old intern, who is 9 weeks pregnant, pricks herself with a needle while placing a
drip for a patient with cryptococcal meningitis
a) What are the major factors associated with a higher risk of HIV transmission following
needlestick injuries?
(5)
b) What additional information do you need in order to decide what post-exposure
prophylaxis is appropriate?
(5)
c) What blood tests should you order from the source patient (on the day of the injury) and
the intern (on the day of the injury and during follow-up)? Justify the reasons for the
tests you request.
(5)
[15]

Maria is a 36-year-old woman who has been attending your clinic for the past 18 months
since being diagnosed with HIV. Her CD4 count done last week was 332 cells/L, so she is
starting work-up for ART as per your protocol. One of the criteria for starting ART at your
facility is that she bring a treatment buddy to one of her three counselling sessions. Discuss
the advantages and disadvantages of making a treatment buddy a compulsory requirement
for starting ART.
[10]