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IM6.1-22 | HIV — PBL Case

CLINICAL SETTING

Rajan, a 34-year-old male farmer from a small village in coastal Andhra Pradesh, presents to the general medicine outpatient department of the district hospital in August. He has been referred by the primary health centre (PHC) after 6 weeks of fever, chronic diarrhoea, and significant weight loss. He tells the intern, Dr Preethi, that he has lost approximately 8 kg over the past two months and has had loose stools 5-6 times a day for 6 weeks. He has been treated twice with ciprofloxacin and metronidazole by the local doctor without improvement. He is a married man with two young children. He works as a migrant seasonal labourer, spending 5-6 months each year in a port city. He is visibly embarrassed and speaks very little. His wife, who has accompanied him, is sitting outside the consultation room. On general examination: height 165 cm, weight 51 kg (BMI 18.7). Temperature 38.2 degrees Celsius. Pulse 96/min. BP 100/70. Oral examination reveals white plaques on the buccal mucosa and tongue. There are two 1.5 cm firm, non-tender lymph nodes in the right posterior cervical chain. Dr Preethi writes her initial notes: 'Chronic diarrhoea, weight loss, fever, oral white plaques, cervical lymphadenopathy — 6 weeks. Possible [?]'.

Trigger 1: The Differential Diagnosis — What Is the Most Likely Diagnosis?

Dr Preethi presents the case to her registrar, Dr Sandeep. He examines Rajan carefully and adds the following findings: the oral white plaques scrape off easily leaving a raw red base. There is mild splenomegaly. The right posterior cervical lymph nodes are firm but non-tender with no matting. Skin examination reveals multiple small, reddish-brown nodules on the right lower limb — non-tender, non-blanching. Dr Sandeep tells the students: 'Let us reason through this systematically. What is the CD4 count telling us indirectly through the clinical picture, even before we have the lab result?'

DISCUSSION POINTS

What is the differential diagnosis for a young man with 6 weeks of fever, chronic diarrhoea, weight loss, oral white plaques (scrapeable), and cervical lymphadenopathy? Prioritise your differential using the clinical context of a migrant worker.
The oral white plaques scrape off — what does this distinguish, and what is the likely causative organism? What does this finding tell you about approximate immune status?
What are the reddish-brown, non-blanching, non-tender nodules on the lower limb likely to represent in this clinical context, and what oncogenic virus is responsible?
What specific component of the HIV-focused history is MOST important to elicit from Rajan at this stage, and how would you approach it sensitively given his visible embarrassment?

Click to reveal Trigger 2: The Investigation Results — Confirming the Diagnosis and Staging (discuss previous trigger first!)

Trigger 2: The Investigation Results — Confirming the Diagnosis and Staging

Rajan's blood results return. Fourth-generation HIV Ag/Ab combination assay: REACTIVE. HIV-1/HIV-2 differentiation assay: HIV-1 positive. CD4 count: 104 cells/mm3. HIV viral load: 210,000 copies/mL. Chest X-ray: right hilar prominence, no parenchymal infiltrates, no pleural effusion. Stool microscopy: no ova or cysts on routine examination; modified ZN stain shows 4-6 micron acid-fast oocysts. Blood counts: Hb 9.8 g/dL, WBC 2,800 cells/mm3 (lymphocytes 18%), platelets 128,000. Serum LDH: 480 U/L (normal <250). CrAg (cryptococcal antigen) serum: negative. The registrar shows the students the full picture and asks: 'Now stage this patient using both classification systems. What does each CD4-threshold OI here tell us about his immune status, and what are the management priorities?'

DISCUSSION POINTS

Apply CDC HIV classification and WHO clinical staging to Rajan. What CDC category does he fall into? What WHO clinical stage? Justify your answer with specific findings from the history and investigations.
The stool microscopy shows 4-6 micron acid-fast oocysts. What organism is this? What is the most important treatment for this infection in an HIV-positive patient, and why does standard antibiotic therapy fail?
The CrAg is negative. What is the significance of performing CrAg screening at this CD4 count, and what would you have done differently if it were positive?
Rajan has a hilar prominence on CXR. How would you investigate this in the context of HIV and a CD4 of 104, and what is your differential for the hilar finding?

Click to reveal Trigger 3: Starting ART — Timing, Regimen, and Prophylaxis (discuss previous trigger first!)

Trigger 3: Starting ART — Timing, Regimen, and Prophylaxis

The team decides to investigate the hilar finding urgently. CBNAAT of induced sputum is negative for Mycobacterium tuberculosis. A CT chest shows bilateral hilar and mediastinal lymphadenopathy without parenchymal disease. The registrar notes: 'CBNAAT negative, active TB screen negative on the 4-symptom screen, CrAg negative. We are now ready to plan ART.' He turns to the students: 'What regimen do we start? When do we start? What prophylaxis does Rajan need right now, at CD4 104?' Later, while the team is discussing the plan, the house officer mentions she found a co-trimoxazole strip in Rajan's bag from the PHC. She does not know why the PHC prescribed it.

DISCUSSION POINTS

Under NACO Treat All policy, what is the first-line ART regimen for Rajan? State the full drug names, doses, and schedule. Why is dolutegravir preferred over efavirenz as the third agent?
What OI prophylaxis should Rajan receive right now? State the drug, dose, and the CD4 threshold that triggers this recommendation. What other prophylaxis should be considered given his CD4 of 104?
The co-trimoxazole strip suggests the PHC may have already started prophylaxis. What is the significance of finding co-trimoxazole in a patient not previously known to be HIV-positive, and how does this 'co-trimoxazole clue' aid HIV diagnosis in primary care?
Rajan's Cryptosporidium diarrhoea is active. Does this change the timing of ART initiation? How does starting ART alter the course of cryptosporidial diarrhoea in an HIV patient?

Click to reveal Trigger 4: Two Weeks After ART — IRIS and Counselling Challenge (discuss previous trigger first!)

Trigger 4: Two Weeks After ART — IRIS and Counselling Challenge

Rajan returns 14 days after starting TLD (and co-trimoxazole prophylaxis, and fluconazole for oral candidiasis). His diarrhoea is improving. However, he now presents with high fever (39.5 degrees Celsius), worsening cervical lymphadenopathy (right posterior cervical nodes now 2.5 cm with mild tenderness), and a new left axillary lymph node. His CD4 count repeated today: 168 cells/mm3 (was 104 two weeks ago). Chest X-ray is unchanged. His wife has come with him this time and asks the nurse: 'My husband has been very secretive about his medicines — can you tell me what he is being treated for? Is it contagious? Am I at risk?' Meanwhile, Rajan privately tells Dr Preethi: 'I have not told my wife about my HIV. Please do not tell her. But she should also get tested — I am worried for her.'

DISCUSSION POINTS

What is the most likely explanation for Rajan's worsening lymphadenopathy and fever two weeks after starting ART, despite improving CD4 count? Define the condition, explain the mechanism, and state the management — specifically, should ART be stopped?
Rajan's CD4 rose from 104 to 168 in two weeks. Is this expected? What does it tell you about the treatment response, and how does this CD4 recovery relate to the worsening clinical picture?
How do you respond to the wife's question at the nursing counter? Apply the HIV and AIDS (Prevention and Control) Act 2017 — what can and cannot be disclosed to her, and what approach should the nursing and medical team take?
Rajan has expressed concern for his wife's safety but refuses disclosure. Walk through the ethical reasoning: how do you balance his right to confidentiality under the HIV Act with the duty of care to his seronegative wife? What is the step-by-step counselling approach you would use?

Group Task Assignments

Construct a complete CD4-stratified OI risk table for Rajan: for each of the following CD4 ranges (<500, <200, <100, <50), list the OIs he is at risk for, the prophylaxis indicated, and the first-line treatment if the OI occurs. Use NACO and WHO guidelines.
Design a 15-minute structured counselling session for Rajan's first ART initiation visit. Cover: diagnosis disclosure, what HIV means for his health, what ART will do, adherence requirements (95%), common side effects of TLD, and the prevention message including U=U. Write the session as a script showing both patient and clinician dialogue — avoid fear-based language.
Rajan's wife is sitting outside the consultation room and is clearly anxious. She has not been tested for HIV. Draft the conversation the team would have with Rajan to encourage him to permit partner testing — using motivational interviewing principles (open questions, affirmations, reflective listening, summary). Do not violate confidentiality in this task.
Debate the proposition: 'HIV testing should be opt-out (routine) at all inpatient admissions and antenatal visits in Indian hospitals.' Divide into two groups — one arguing for opt-out, one arguing for opt-in with consent — and cite the HIV Act 2017 and public health evidence in your arguments.

Learning Issues

Research these questions and bring your findings to the discussion.

[IM6.2] What are the CDC classification criteria for HIV disease (categories A, B, C), and how does WHO clinical staging (stages 1-4) differ from the CDC system in clinical application?
[IM6.3] How does the CD4 count predict the risk of specific opportunistic infections, and at what thresholds are co-trimoxazole, CrAg screening, and MAC prophylaxis indicated?
[IM6.4] What are the pathogenesis, clinical features, and specific investigation findings for Cryptosporidium diarrhoea, oral candidiasis, and Kaposi sarcoma in the context of HIV-induced immunosuppression?
[IM6.14] What is the NACO Treat All policy, what is the first-line ART regimen (TLD — full drug names, doses, mechanism), and what are the ART timing rules for TB and cryptococcal meningitis co-infection?
[IM6.15] What is Immune Reconstitution Inflammatory Syndrome (IRIS) — definition, mechanism, common precipitants in India, and management (including why ART must not be stopped)?
[IM6.21] What does the HIV and AIDS (Prevention and Control) Act 2017 specify regarding confidentiality, partner disclosure, discrimination, and the physician's obligations when a patient refuses partner notification?