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
15 April 2016
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 50-year-old male healthy smoker with high cholesterol was started on tenofovir,
emtricitabine and efavirenz. A baseline creatinine was over double the upper end of normal
for his age, estimated glomerular filtration rate 40mL/min. However, the attending doctor did
not note the renal dysfunction, and started the antiretrovirals listed above anyway. A year
later, he is healthy, his CD4 count is 500 cells/L, his viral load undetectable, and his
creatinine clearance and lipids unchanged
a)
What investigations should the doctor have done, prior to starting antiretrovirals, to
investigate the renal dysfunction?
(2)
b)
Discuss and justify 3 ART regimen options, which could be used in this case, as you
take over management.
(8)
[10]

A 7-year-old boy with a CD4 count of 75 cells/L presents with a hoarse soft voice for the
past week. He has never been on antiretroviral therapy. There is no history of choking
aspiration or dysphagia. On examination you note some candidiasis in the pharynx. There
are no masses in the neck. His neurological assessment is normal
a)
What is the differential diagnosis?
(5)
b)
After you treat the cause of the hoarseness you commence ART with abacavir,
lamivudine and efavirenz. Two weeks later the child presents with dizziness and
ataxia. Which drug is the likely cause?
(1)
c)
The caregiver is only able to administer medication once daily. Which substitution
would you make in light of this side effect?
(2)
d)
What is the most common laboratory abnormality you can expect on this new regimen
and what is the cause?
(2)
[10]

A 35-year-old man presents to your clinic with a three week history of coughing and night
sweats. He tells you that he tested HIV positive five years ago but did not go back for any
follow up investigations or treatment. He is wasted and has oral thrush. You send his sputum
off for a GeneXpert MTB/RIF assay, which is negative. His CD4 count is 78 cells/L
a)
Discuss the limitations of the sputum GeneXpert MTB/RIF assay, with particular
reference to this patient.
(3)
b)
What other investigations would be helpful to establish the cause of his symptoms?
(5)
c)
Outline your management plan for this patient. Justify your answers.
(7)
[15]
PTO/Page 2 Question 4

The renal transplant team have identified a potential donor in the emergency department.
The patients partner is HIV positive and not on ART. He says that the potential donor had a
negative HIV test 3 months ago. They do not regularly use barrier contraception so a recent
infection is possible. The transplant team ask for your advice in ruling out HIV infection prior
to transplant
a)
What are the principles of rapid HIV tests? Discuss the pros and cons of using a rapid
test in this scenario.
(5)
b)
What is the principle of an ELISA HIV test? Discuss the pros and cons of using the
(5)
current 4th generation ELISA test in this scenario.
[10]

A 26-year-old woman in her second pregnancy presents to the antenatal clinic at your district
hospital at 16 weeks gestation. She was diagnosed six months ago with acute hepatitis B
infection. She is currently asymptomatic. At her first antenatal visit she tests positive for HIV1 infection. At her follow up antenatal visit a week later the following results are obtained:
hepatitis B surface antigen positive, liver function tests are normal, CD4 cell count is 824
cells/uL, syphilis serology (TPHA) negative
a)
Which further investigations will you perform on her at this visit?
(4)
b)
Justify your selection of antiretroviral drug regimen for this woman.
(2)
c)
Briefly outline your counselling and monitoring plan with specific reference to her
hepatitis B infection during the antenatal period.
(4)
d)
She goes into preterm labour at 36 weeks gestation, and delivers a 2.4kg male infant
vaginally, with Apgar score of 9/10. Broadly outline your management of the newborn
infant, including prophylaxis for both HIV and hepatitis B.
(5)
[15]

A 37-year-old man presents with a 3 month history of large volume loose watery stools,
frequency about 6 per day, no blood or mucus. He has weight loss, but no fever. His BMI is
17, HIV rapid test positive, and his CD4 count is 50 cells/L
a)
What initial diagnostic tests would you request as part of your workup?
(3)
b)
What is your differential diagnosis (focus on the four most likely diagnoses) and
discuss the treatment for each?
(12)
[15]

Ann (18-years-old) requested an HIV test three months ago because she had heard that her
previous boyfriend had AIDS. She tested positive with a CD4 of 520 cells/L and was
clinically WHO stage one. She defaulted her follow-up appointment a month later. Today she
attends complaining of an ongoing discharge after her period finished a week ago. On
questioning she tells you that she has had no boyfriend for the last five months, but that she
did have sex about two weeks ago at a party with a casual partner without a condom. On
examination there is evidence of a scanty cervical discharge but no thrush; there is no cervical
or adnexal tenderness or masses on bimanual palpation
a)
Give your diagnosis and management of her current complaint.
(5)
b)
Discuss the complications her current complaint might have if left untreated.
(5)
[10]

PTO/Page 3 Question 3

Tenofovir/emtricitabine combination tablets have been approved for pre-exposure

prophylaxis (PrEP) of HIV internationally and in South Africa. In light of this, you have been
asked to develop guidelines for the implementation of provision of PrEP in your local district.
Discuss
a)
The role of PrEP within currently available HIV prevention strategies.
(5)
b)
Who will be targeted for the use of PrEP?
(3)
c)
What steps you will take to implement the use of PrEP on a programme and individual
client level?
(7)
[15]