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
4 September 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)

Answer the following questions about HIV prevention

a)
What is the scientific evidence that prescribing ART for people with HIV is effective at
reducing transmission?
(6)
b)
List three major barriers to expanding each of the following HIV prevention modalities
in our region
i)
HIV pre-exposure prophylaxis.
(3)
ii)
Female condoms.
(3)
iii)
Male medical circumcision.
(3)
[15]

A patient presents to your clinic for initiation of antiretroviral therapy. His CD4+ count is
35 cells/L and the routine cryptococcal antigen test is positive
a)
What would you do in response to the positive cryptococcal antigen test?
(5)
b)
He becomes impatient waiting for medication at the pharmacy and absconds without
receiving any of the medication you prescribed. Three months later he is brought back
to your hospital by his relatives. He is now confused with a severe headache and a
lumbar puncture confirms cryptococcal meningitis. Outline your management plan for
the cryptococcal meningitis.
(7)
c)
He responds well to therapy for cryptococcal meningitis. When would you plan to start
his antiretrovirals? Justify your answer.
(3)
[15]

You are reviewing a 4-year-old boy in your clinic. His mother received zidovudine, lamivudine
and efavirenz in pregnancy, and the infant boy received 6 weeks of nevirapine for PMTCT.
The boy tested positive at 6 weeks of age and started ART at the age of 6 months with
abacavir, lamivudine, and lopinavir/ritonavir. His viral load was suppressed until the age of 2
years since then his viral loads have been >1,000 copies/mL. The last viral load a month ago
was 5,000 copies/mL
a)
Is antiretroviral resistance testing indicated in this boy? Justify you answer.
(3)
b)
What is your approach to management of the virologic failure in this boy?
(7)
[10]

PTO/Page 2 Question 4

2
4

A 30-year-old woman with a CD4 count of 160 cells/L has failed her first line antiretroviral
therapy (ART). She requires second line ART and you have decided on the following regimen
of abacavir, lamivudine and atazanavir plus ritonavir all at standard doses
a)
Outline the adverse effects she might experience on atazanavir.
(4)
b)
List five clinical features of abacavir hypersensitivity reaction.
(5)
c)
How can abacavir hypersensitivity be prevented?
(1)
[10]

A 21-year-old woman in her first pregnancy booked for antenatal care at your clinic 2 weeks
ago. She is now 32 weeks pregnant. She has been on the fixed dose combination of tenofovir,
emtricitabine, and efavirenz for 18 months. The viral load result from her last visit is 32,794
copies/mL
a)
How will you manage her ART?
(5)
b)
How will you manage the infant?
(5)
[10]

a)
b)

A 29-year-old woman gives a history of having an increasing tingling pain on the right side of
her head and forehead for the last two days; today on waking there is a rash of small blisters
visible where the tingling was in the V1 distribution of the right 5th cranial nerve. You diagnose
shingles (herpes zoster)
a)
Discuss your assessment and management of the shingles.
(5)
b)
She gives a history of a negative HIV test 5 years ago when she was pregnant. A rapid
HIV test confirms that she is HIV positive now. List how you will manage her further
under the headings
i)
Social.
(5)
ii)
Medical.
(5)
[15]

A 25-year-old well educated woman is getting married to a HIV-negative partner. She is HIV
positive with a CD4 count of 600 cells/L with no other co-morbidities. Her partner knows her
HIV status. They plan to have a family. She is not convinced that she should initiate ART as
she is still healthy
a)
What advantages of starting ART now would you discuss with her as part of pretreatment counselling?
(7)
b)
Briefly discuss the evidence of clinical benefit to the individual starting ART with a CD4
count >500 cells/L.
(3)
[10]

Explain the genetic barrier to resistance.

(5)
Contrast how adherence patterns affect the development of resistance to nonnucleoside reverse transcriptase inhibitors versus ritonavir-boosted protease
inhibitors. Justify your answers.
(10)
[15]