IM6.1-22 | HIV — Graded Quiz

Correct. NACO Treat All mandates ART for all PLHIV regardless of CD4 count or clinical findings. The bilateral hilar adenopathy does not constitute a contraindication to starting ART. The active TB screen (4-symptom screen + CXR + CBNAAT) has not revealed active TB. ART should be started promptly; concurrent investigation for the aetiology of hilar adenopathy (sarcoidosis, lymphoma, MAC, PCP early, histoplasmosis) can proceed alongside. Deferring ART while pursuing a histological diagnosis would expose the patient to preventable immune deterioration.

ART timing principle: Treat All = start immediately unless specific OI mandates sequencing (TB meningitis: defer 8 weeks; cryptococcal meningitis: defer 4-6 weeks). Bilateral hilar adenopathy requires workup but does not delay ART. CBNAAT negative + 4-symptom screen negative = active TB not confirmed; IPT can be added after TB excluded.

NACO Treat All: start ART for all PLHIV with no life-threatening active OI requiring specific sequencing. Hilar adenopathy in HIV has a differential (TB, lymphoma, sarcoidosis, MAC, fungal) but is not itself a contraindication to ART. Concurrent evaluation and ART initiation are correct. Only TB meningitis and cryptococcal meningitis mandate specific ART deferral.

Correct. WHO and NACO define virological failure as VL >1000 copies/mL on two consecutive readings after enhanced adherence support. A single VL of 1,800 copies/mL after previously undetectable levels may represent a blip or poor adherence; it does not by itself confirm treatment failure. The correct response is: (1) intensive adherence counselling to identify and address barriers; (2) repeat VL in 3 months. Only confirmed virological failure (VL >1000 on repeat after adherence support) triggers a switch to second-line. Premature switching wastes second-line options and may be unnecessary if the elevated VL was adherence-driven.

NACO virological failure criteria: VL >1000 copies/mL on two consecutive measurements (at least 3 months apart) after enhanced adherence counselling. First-line failure → second-line (AZT/TDF + 3TC + LPV/r or ATV/r). Adherence (>95%) is the single most important determinant of viral suppression.

Virological failure is defined as VL >1000 copies/mL on two consecutive tests after enhanced adherence counselling. A single elevated VL may reflect a 'blip' or temporary non-adherence. The correct sequence is: intensive adherence counselling → repeat VL in 3 months → switch if VL still >1000. Premature switch to second-line is incorrect.

Correct. Ring-enhancing lesion on CT brain in a PLHIV with CD4 <100 and positive Toxoplasma IgG is presumptive cerebral toxoplasmosis. Standard practice is empirical anti-toxoplasma therapy (pyrimethamine 200 mg loading then 75 mg/day + sulphadiazine 4-6 g/day in divided doses + leucovorin 10-25 mg/day to prevent pyrimethamine myelotoxicity). Clinical and radiological improvement at 2 weeks confirms toxoplasmosis. Brain biopsy is reserved for lesions that fail to respond to empirical therapy or atypical presentations (should rule out PCNSL). Starting anti-TB empirically without clinical or laboratory TB support is inappropriate first-line management here.

CNS lesion differential in AIDS: single enhancing lesion = often PCNSL (no Toxo IgG, EBV PCR positive in CSF); multiple ring-enhancing = toxoplasmosis (Toxo IgG positive, responds to empirical therapy). The 2-week therapeutic trial distinguishes them without biopsy in most cases. Co-trimoxazole prophylaxis prevents toxoplasmosis at CD4 <200.

Ring-enhancing brain lesion + CD4 <100 + Toxoplasma IgG positive = presumptive cerebral toxoplasmosis. Standard management is empirical pyrimethamine + sulphadiazine + leucovorin. Response at 2 weeks is diagnostic. Brain biopsy is reserved for failure to respond (may indicate PCNSL, tuberculoma, or fungal abscess). Leucovorin is essential to prevent pyrimethamine's myelosuppressive effect.

Correct. Under NACO PPTCT Option B+ guidelines, all HIV-positive pregnant women should start ART immediately regardless of CD4 count and continue it lifelong (for their own health and PPTCT). The recommended regimen includes TLD (Tenofovir + Lamivudine + Dolutegravir). Early concerns about dolutegravir and neural tube defects (periconceptional exposure) have been substantially revised — current WHO (2020) and NACO guidance supports TLD for pregnant women because the risk is very low and the benefit of viral suppression is substantial. The high viral load at 28 weeks needs to be addressed urgently for maternal health and to reduce vertical transmission risk.

PPTCT Option B+: ART for all pregnant PLHIV, lifelong, regardless of CD4. Regimen: TLD. Breastfeeding: exclusive breastfeeding for 6 months + infant prophylaxis (NVP for 6 weeks, extended in high-risk settings). Viral suppression is the goal to reduce vertical transmission to <1%. ART in pregnancy + infant prophylaxis reduces MTCT from 25-45% to <2%.

NACO PPTCT Option B+: all HIV-positive pregnant women start ART immediately and continue lifelong. TLD is the recommended regimen. The initial neural tube defect signal for dolutegravir (from Botswana 2018) was at periconceptional exposure; subsequent larger studies significantly revised the risk estimate downward. WHO 2020 supports TLD in pregnancy. Single-dose NVP at labour is an obsolete, suboptimal PPTCT strategy.

Correct. Small acid-fast oocysts (4-6 microns) on modified ZN stain = Cryptosporidium parvum, an important cause of profuse watery diarrhoea in AIDS at CD4 <100. Cryptosporidiosis in immunocompromised patients is very difficult to treat with antimicrobials alone — there is no reliably effective specific drug. ART to restore immune function (CD4 recovery) is the primary treatment; immune reconstitution often clears Cryptosporidium. Nitazoxanide can be used as adjunct in immunocompetent patients but has limited efficacy in severe immunosuppression. Aggressive fluid replacement is critical. Metronidazole is effective for Giardia and amoebiasis but not Cryptosporidium.

HIV-related diarrhoea differential: Cryptosporidium (small acid-fast oocysts 4-6 micron, no good drug — treat with ART + nitazoxanide); Isospora belli (large acid-fast oocysts 25x12 micron, responds to co-trimoxazole); CMV colitis (CD4 <50, haematochezia, biopsy shows owl-eye inclusions, treat with ganciclovir); Microsporidium (spores, trichrome stain).

4-6 micron acid-fast oocysts = Cryptosporidium parvum. Unlike Isospora (larger, responds to co-trimoxazole) or Giardia (responds to metronidazole), Cryptosporidium in AIDS has no reliably effective specific treatment. ART-driven immune recovery is the primary intervention. Nitazoxanide has some activity. Oral rehydration and nutritional support are essential.

Correct. The student's approach has two fundamental flaws: (1) it is judgmental and fear-inducing — threatening the patient with death is not therapeutic counselling; it damages the therapeutic relationship and is unlikely to improve adherence; (2) it fails to explore the actual barrier (nausea from medicines) in a non-judgmental, patient-centred manner. Correct adherence counselling explores barriers (side effects, forgetfulness, stigma, cost), provides practical solutions (antiemetics, administration with food, pill timing), and builds self-efficacy through motivational interviewing techniques. A non-judgmental attitude toward PLHIV (including their lifestyles) is explicitly required by IM6.22.

HIV adherence counselling principles: non-judgmental, patient-centred, barrier-exploration, motivational interviewing. Side effects (nausea, dizziness with EFV, rash) are a common modifiable barrier — address them rather than blame the patient. 95% adherence is the target for viral suppression. U=U (Undetectable = Untransmittable) is a positive adherence motivator that avoids stigma.

Fear-based counselling ('you will die') is an ineffective and ethically inappropriate approach to adherence. It may worsen adherence by creating shame and avoidance of healthcare. Correct technique: non-judgmental exploration of the specific barrier (nausea), patient-centred problem-solving (take with food, antiemetic, timing change), and motivational interviewing to build intrinsic motivation. The HIV Act 2017 and medical ethics require non-discriminatory, non-judgmental care.

Correct. HIV is not a contraindication to pregnancy. With ART-driven viral suppression, PPTCT Option B+ reduces mother-to-child transmission (MTCT) to below 1-2% (from a background rate of 25-45% without intervention). The serodiscordant couple should receive pre-conception counselling: partner should be offered PrEP, she should be on effective ART with confirmed viral suppression before conception, and partner-to-partner transmission risk during conception can be addressed via timed unprotected intercourse during ovulation when she is virally suppressed. Denying reproductive autonomy to PLHIV is ethically prohibited and contrary to the HIV Act 2017.

PPTCT: without intervention MTCT is 25-45%; with ART + infant prophylaxis it falls to <1-2%. Serodiscordant couples: virally suppressed partner + PrEP for negative partner reduces transmission to near zero (U=U). Reproductive counselling for PLHIV must be non-judgmental and rights-based.

Pregnancy is NOT contraindicated in HIV. With viral suppression on ART (PPTCT Option B+), MTCT can be reduced to <1-2%. Reproductive counselling for PLHIV includes: start/continue effective ART, achieve viral suppression before conception, partner PrEP for serodiscordant couples, avoid delaying ART until pregnancy. Denying reproductive rights to PLHIV is discriminatory and prohibited.

Correct. This presentation (CD4 <50, painless posterior retinal lesion with perivascular haemorrhages and exudates advancing centrifugally) is CMV retinitis. CMV DNA quantitative PCR in plasma detects CMV viraemia — a positive result confirms active systemic CMV disease, supports the retinal diagnosis without vitreous sampling, and guides systemic treatment (IV ganciclovir or oral valganciclovir). Serum CMV IgG/IgM cannot distinguish active disease from prior exposure (most adults are IgG positive). Vitreous biopsy is invasive and not standard for diagnosis. FFA characterises lesion extent but does not confirm the aetiology.

CMV retinitis investigation: clinical diagnosis on fundoscopy + CMV DNA PCR to confirm active viraemia and monitor treatment response. Treat with IV ganciclovir 5 mg/kg BD (induction 2 weeks) then oral valganciclovir maintenance until CD4 >100 for >3-6 months on ART. Risk of retinal detachment increases with large lesions; intravitreal ganciclovir for sight-threatening lesions.

CMV DNA PCR (viraemia) is the gold-standard investigation for active systemic CMV disease in immunocompromised patients. Serum IgG/IgM cannot confirm active disease (IgG shows past exposure, which is nearly universal). CMV retinitis diagnosis is primarily clinical (characteristic fundus appearance at CD4 <50); CMV PCR confirms systemic infection and guides treatment monitoring.

Correct. Violaceous spindle-cell vascular tumour on skin and mucosal surfaces (hard palate, lower limbs) is Kaposi sarcoma (KS). KS is caused by Human Herpesvirus 8 (HHV-8), also called Kaposi Sarcoma-associated Herpesvirus (KSHV). KS is an AIDS-defining malignancy (CDC category C). In the setting of HIV, KS is classified as epidemic/AIDS-related KS, caused by HHV-8 acting on an immunosuppressed background. ART-driven immune recovery causes regression of KS in many patients; systemic chemotherapy (pegylated liposomal doxorubicin) is used for extensive or visceral disease.

HIV-related malignancies: Kaposi sarcoma (HHV-8, violaceous vascular tumour, responds to ART); Primary CNS lymphoma (EBV, single enhancing ring lesion, no Toxo IgG response); Non-Hodgkin lymphoma (EBV/HIV immunosuppression, systemic B symptoms, CD4 variable); Cervical carcinoma (HPV 16/18, AIDS-defining in women). AIDS-defining malignancies = CDC category C.

Kaposi sarcoma = spindle cell vascular tumour, violaceous plaques on skin/mucosa = HHV-8 (KSHV). Not EBV (which causes primary CNS lymphoma and some Burkitt lymphoma) and not HPV (cervical/anogenital carcinoma). KS regresses with ART in many; systemic chemo for visceral/extensive disease. CDC category C = AIDS-defining.

Correct. The efficacy of PEP is strongly time-dependent; current guidelines state that PEP should be initiated as soon as possible and WITHIN 72 HOURS of exposure. Beyond 72 hours, PEP is not recommended because the virus has likely already established a systemic infection and antiviral therapy at this stage does not prevent infection — it would essentially be treating established HIV infection. At 80 hours (past the 72-hour cutoff), PEP should not be started. The worker should instead be counselled on regular HIV testing (baseline now, 6 weeks, 3 months, 6 months post-exposure), safe practices, and reporting future exposures immediately.

PEP: 72-hour window, ideally within 2 hours. After 72 hours: no PEP; advise HIV testing follow-up. PrEP (pre-exposure prophylaxis): TDF + FTC/3TC daily for ongoing HIV-negative individuals at high risk. PEP vs PrEP distinction is frequently tested: PEP = post-exposure, 28 days; PrEP = pre-exposure, ongoing.

PEP must be started within 72 hours of exposure to be effective. At 80 hours (past the window), PEP is NOT recommended. Extending duration or starting late does not compensate for the delay. The worker needs HIV testing (baseline, 6w, 3m, 6m) and counselling. Starting PrEP for post-exposure management is incorrect — PrEP is a pre-exposure strategy.

Correct. Bilateral ground-glass infiltrates + progressive hypoxia + markedly elevated LDH + HIV (CD4 <200 although here 110 — it can occur at higher CD4 on ART if inadequately suppressed) is the classic presentation of Pneumocystis jirovecii pneumonia (PCP). The gold-standard investigation is induced sputum or BAL examination using direct immunofluorescence (DIF) or PCR for P. jirovecii — the organism cannot be cultured on standard media. LDH elevation is a useful but non-specific marker of disease severity. CBNAAT is for TB, not PCP. Empirical bacterial antibiotics would miss PCP.

PCP diagnostic pearl: CXR may be normal in early/mild PCP despite significant hypoxia — ALWAYS do ABG/SpO2 in suspected PCP. Treat PCP: TMP-SMX high-dose × 21 days + corticosteroids for moderate-severe (PaO2 <70 mmHg). PCP prophylaxis: co-trimoxazole DS once daily at CD4 <200. P. jirovecii is not culturable — diagnosis requires DIF or PCR on BAL/induced sputum.

Bilateral GGO + dyspnoea + hypoxia + elevated LDH in HIV = PCP until proven otherwise. Diagnosis: induced sputum or BAL for P. jirovecii (DIF or PCR — not routine culture). Treatment: co-trimoxazole high-dose (TMP 15-20 mg/kg/day) for 21 days; add corticosteroids (prednisolone 40 mg BD → taper) if PaO2 <70 mmHg or A-a gradient >35 mmHg on room air. CXR may be normal early in PCP.

Correct. The HIV and AIDS (Prevention and Control) Act 2017 prohibits disclosure of a patient's HIV status or treatment details to any third party without the patient's written consent. The physician must: (1) acknowledge the wife's concern with empathy; (2) explain the confidentiality obligation; (3) offer to include the wife in the consultation with the patient's explicit consent. Asking the husband in front of his wife to consent could be coercive (he may feel pressured). Confirming to the wife without consent violates the Act. The ideal outcome is that the patient chooses to include his wife in the care discussion — this should be facilitated, not forced.

HIV confidentiality framework: HIV Act 2017 = written consent required for any disclosure; no mandatory disclosure to partners; no HIV testing without consent; discrimination is prohibited. Clinical approach: counsel toward voluntary partner disclosure; offer couples testing; never disclose without consent; the HIV Act protects both confidentiality AND requires non-discriminatory healthcare delivery.

HIV Act 2017: confidentiality of HIV status and treatment details is legally protected. Disclosure to the wife without written consent violates the Act. The correct approach respects confidentiality while facilitating family involvement through patient-led disclosure: acknowledge wife's concern, explain confidentiality, seek patient's consent before including her. Asking the patient publicly in front of his wife to consent is subtly coercive — a private moment is preferable.