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 July 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 patient is seen with virological failure on second line ART in July 2016. He had started ART
in February 2009. In September 2012 he was diagnosed with virological failure on first line
and switched to second line. Certain of the results from CD4 count and viral load
monitoring are shown below

CD4 count
Viral load
ARV1
ARV2
ARV3

Feb
2009 Sep 2012
(Initiation)
(Regimen
1)
195
290
Not done
5000
Pre-ART
3TC
Pre-ART
TDF
Pre-ART
Efavirenz

Mar
2013
(Regimen
2)
490
<40
3TC
AZT
Lop/r

Mar 2016
(Regimen
2)
250
50 000
3TC
AZT
Lop/r

Jul 2016
(Regimen
2)
225
60 000
3TC
AZT
Lop/r

An HIV genotypic resistance assay is done and the following mutations are found
-M184V.
-K103N.
-Minor PI mutations, but no major PI mutations.
a)
b)
c)
d)

Explain the nomenclature of M184V.

Write short notes on the M184V mutation.
Write short notes on the K103N mutation.
How will you manage this patient? Explain your decisions.

(2)
(4)
(3)
(6)
[15]

The Minister of Health of South Africa recently announced the removal of any CD4 threshold
for ART eligibility; a Test and Treat policy. One of the motivations for this is to reduce HIV
transmission. Discuss
a)
The evidence that ART prevents HIV transmission in sero-discordant couples.
(5)
b)
What Test and Treat means for transmission within communities?
(5)
c)
Chose ONE intervention other than Test and Treat which has been proven to reduce
HIV transmission and discuss how you would implement it in a low resource, high HIV
prevalence setting.
(5)
[15]
PTO/Page 2 Question 3

2
3

A 32-year-old woman comes to your clinic after having tested HIV seropositive at her
workplace. This was her first HIV test. You confirm the results and she claims to have no
other symptoms. Her CD4+ comes back three days later and is 78 cells/l and she is plasma
cryptococcal antigen positive. She is called back and returns after 5 days
a)
Describe your next management steps.
(6)
b)
If the patient has by now developed a mild headache, what would you then do?
Discuss management.
(6)
c)
Discuss your management with respect to ART in this patient.
(3)
[15]

Currently first line antiretroviral therapy in South Africa has efavirenz as the backbone drug.
Dolutegravir is now registered in the country and may be a first line option in the future
a)
Describe the mechanisms of action of efavirenz and dolutegravir.
(8)
Many patients starting first line antiretroviral therapy have TB
b)
Discuss the drug interactions between each of these drugs and TB treatment.
(7)
[15]

A 37-year-old HIV-infected patient with a CD4 of 136 cells/l and HIV viral load 939 673
copies/ml not yet on ART is referred to you by a psychiatrist with a 10 day history of confusion.
He was previously seen by 2 other doctors and prescribed antipsychotic treatment prior to
the psychiatric referral. When you see him his GCS is 12/15 and he has neck stiffness. His
LP results are as follows: Polymorphs 202, Lymphocytes 210, Red cells 12, Total protein
1.65g/l, Chloride 111, Glucose 1.2, ADA 6.5, Cryptococcal antigen negative. His U&E: Na
116, K 3.7, Cl 84, CO2 21, Urea 6.7, Creat 41. Serum glucose 4.5
a)
Based on the CSF findings what is the probable diagnosis?
(1)
b)
What treatment would you start?
(2)
c)
When would you commence ART and which regimen would you choose?
(4)
d)
Discuss potential complications that may occur with respect to his neurological
condition.
(3)
[10]

You receive feedback from the national 3rd line committee that a 12-year-old 35kg boy in
your care can receive tenofovir, lamivudine, raltegravir and darunavir/ritonavir as his new
third line regimen
a)
What should you remember when discussing the ordering of the raltegravir with the
pharmacist?
(3)
b)
If you are considering darunavir as a once daily dose what factors should you
consider?
(2)
c)
Which other medication/s should be given?
(3)
d)
How will you assess renal function prior to initiation of the tenofovir?
(2)
[10]

Abnormal liver function tests are common after initiation and sometimes after discontinuation
of ART. Discuss how the following ART drugs cause liver function derangement (both
common and uncommon mechanisms) with a focus on timing of the derangments after
initiation or discontinuation of ART. Do not discuss investigation or management
a)
Efavirenz.
(4)
b)
Tenofovir.
(2)
c)
Protease-inhibitors.
(4)
[10]
PTO/Page 3 Question 8...

3
8

A 24-year-old HIV positive woman attends your clinic. She would like to have a child
a)
What are the critical baseline issues you need to establish to assist in your further
management?
(5)
You screened for syphilis and the result is TPHA positive, and the RPR is positive with a titre
of 1:16. You treat her and her partner with three doses of Benzathine Penicillin 2.4mu. A
subsequent RPR test taken five months later has a titre 1:32
b)
Discuss your interpretation of this result and your further management.
(5)
[10]