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

9 February 2018

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)

1) A 33-year-old woman comes to see you. She has been on tenofovir, emtracitabine and
efavirenz for 2 years, her CD4 nadir was 440 cells/µl and it is currently 550 cells/ µl. She
complains of persistent vivid dreams since starting therapy, she finds these unpleasant and
wants to stop efavirenz. Her current HIV viral load is 980 copies/ml. She has heard about a
new fixed dose combination of tenofovir, emtracitabine and dolutegravir that has recently been
made available at your clinic and she wants to try it
a) List the pros and cons of changing her to the new tablet containing dolutegravir? (4)
b) List the pros and cons of changing her to zidovudine/lamivudine/lopinavir/ritonavir
second line therapy? (4)
c) What would you tell her about the possible side-effects of the new tablet containing
dolutegravir? (3)
d) She tells you that she wishes to fall pregnant; how would this influence your choice of
regimen? (4)
[15]

2) A 30-year-old HIV infected man is admitted to your hospital complaining of a cough for three
weeks, night sweats and he has a fever. On his referral note, he has a CD4 count of
32cells/µl and his reflex serum cryptococcal antigen test was negative. At the clinic, a
GeneXpert was done and the result reflects that mycobacterium tuberculosis was not
detected.
a) Discuss the role of the GeneXpert in the management of pulmonary and extrapulmonary
tuberculosis. Describe the advantages and disadvantages of the test. (5)
b) What other laboratory tests can be done to help diagnose TB? Give two advantages and
disadvantages for each one. (6)
c) A rifampicin based TB regimen is started. Describe the drug-drug interactions between
rifampicin and each of the following antiretroviral drugs
i) Efavirenz.
ii) Lopinavir/ritonavir.
iii) Dolutegravir. (4)
[15]

PTO/Page 2 Question 3…
 2

3) A medical intern has been referred to you by the gynaecologist consultant. The previous
night she had a splash of amniotic fluid into her eyes while assisting on a caesarian section.
The source patient presented late, and was diagnosed with HIV during labour. An urgent
hepatitis B surface antigen (HBsAg) test was done and was positive. After taking a history,
you find out that the intern is otherwise well, but is 12 weeks pregnant. She does not
remember her hepatitis B vaccination status
a) List the issues you would cover when counselling the intern. (3)
b) What are the indications for PEP? (2)
c) What ARV regimen would you advise if PEP was indicated? (2)
d) What common adverse event would you warn her about with this regimen, and how
would you manage it? (4)
e) What steps would you take to reduce the risk of hepatitis B transmission, including
doses of any therapy given? (4)
[15]

4) You are asked to see a newly diagnosed 3-year-old HIV-infected boy who is clinically well
(asymptomatic). His CD4% is 15. What prevention strategies would you advise and what is
your rationale for these strategies? [15]

5) Mr Mdluli, 25-years has been living with the HIV for the past three years. He was started on
tenofovir, emtricitabine and efavirenz, when his CD4 count was 150 cells/µl with a viral load
of 9600 copies/ml. He admits to defaulting treatment for the past eight weeks, during which
time he was taking a herbal potion from a trusted elderly family member. For the past week
he has had a non-productive cough, feeling hot and sweaty with difficulty in breathing. On
examination he is emaciated with mild pallor. BP: 87/55, pulse: 110, respiratory rate: 36
breaths per minute, temp 38.4°C. Chest auscultation reveals bilateral diffuse crackles. No
other physical examination abnormalities are found.
a) What would be you differential diagnosis of Mr Mdluli? (3)
b) Discuss the important clinical features and rapidly available laboratory tests that help
determine the appropriate level of care and empiric treatment regimen you would
provide for Mr Mdluli. (5)
c) Discuss the appropriate empiric antibiotic choice for Mr Mdluli. (4)
d) List the options available to Mr Mdluli to prevent lower respiratory tract infections. (3)
[15]

6) A 20-year-old HIV infected lady presents to your clinic. She has been told that HIV is
associated with cervical cancer and wants to know more about the condition and how to
prevent it.
a) List the risk factors for cancer of the cervix. (5)
b) List strategies to prevent cancer of the cervix. (5)
[10]

PTO/Page 3 Question 7…
 3

7) A 26-year-old HIV positive women with a CD4 count of 350 cells/µL presents to you
requesting to be put on antiretroviral therapy (ART). She has been investigated for TB and
has no evidence for tuberculosis. She is requesting first-line ART
a) Outline the pharmacokinetic/pharmacodynamic characteristics of efavirenz and how
they contribute to efavirenz adverse drug reactions and resistance. (10)
b) Discuss the late neurological manifestation of efavirenz toxicity. (5)
c) Discuss the features of tenofovir disoproxil fumarate (TDF) renal tubular dysfunction.
(5)
[20]