IM6.1-22 | HIV — Practice Quiz

Correct. This presentation is classic acute HIV seroconversion syndrome (primary HIV infection) — fever, pharyngitis, rash, and lymphadenopathy 2-4 weeks post-exposure. The fourth-generation Ag/Ab combination assay detects both p24 antigen (appears within 2 weeks of infection) and HIV antibodies, dramatically shortening the window period to 18-45 days. An antibody-only ELISA may be falsely negative this early in infection because antibodies have not yet formed.

Acute HIV seroconversion mimics infectious mononucleosis (hence 'HIV mononucleosis-like syndrome') but monospot is negative. The fourth-generation Ag/Ab assay reduces the window period because p24 antigen appears before antibodies — critical for early detection and prevention of onward transmission.

This presentation — fever, pharyngitis, maculopapular rash, and lymphadenopathy 3 weeks after high-risk exposure — is acute HIV seroconversion. The fourth-generation Ag/Ab combination assay is the correct first test: it detects p24 antigen (present within 2 weeks) as well as antibodies, so it captures acute infection that antibody-only tests would miss. Western blot is a confirmatory test, not a primary screen.

Correct. Oral candidiasis (thrush) presents as white plaques that can be scraped off — the key distinguishing feature from oral hairy leukoplakia (OHL), which cannot be scraped off. Oral candidiasis is an HIV-related oral condition that typically occurs at CD4 counts below 200 cells/mm3 and is an AIDS-defining illness when it extends to the oesophagus. The causative organism is usually Candida albicans.

The scrape test distinguishes oral candidiasis (scrapes off) from oral hairy leukoplakia (cannot be scraped off). Both are HIV-related oral lesions but have different aetiologies: Candida albicans vs EBV. Oesophageal extension of candidiasis (odynophagia, dysphagia) is an AIDS-defining condition.

White oral plaques that scrape off leaving a raw red base = oral candidiasis. Oral hairy leukoplakia (EBV-driven corrugated white plaques on the lateral tongue) cannot be scraped off — this is the key differentiator. Oral candidiasis occurs at CD4 <200 and is a marker of significant immunosuppression. Kaposi sarcoma presents as violaceous non-tender plaques or nodules.

Correct. This is cryptococcal meningitis (India ink positive, elevated opening pressure, lymphocytic pleocytosis at CD4 <100). Treatment is amphotericin B deoxycholate 0.7-1 mg/kg/day IV plus flucytosine 100 mg/kg/day for 2 weeks (induction), followed by fluconazole consolidation. ART must be DEFERRED for at least 4-6 weeks because early ART initiation in cryptococcal meningitis significantly increases mortality from IRIS. This is the one OI where ART deferral beyond the usual 2-8 weeks is mandated.

ART timing in OI co-infection: start ART within 2 weeks for most OIs (including TB if CD4 <50), EXCEPT cryptococcal meningitis where defer for 4-6 weeks. The COAT trial showed that starting ART early in cryptococcal meningitis doubles mortality — a critical distinction that is frequently tested.

India ink positive CSF with elevated opening pressure at CD4 <100 = cryptococcal meningitis. The standard treatment is amphotericin B + flucytosine (induction 2 weeks), then fluconazole. Critically, ART must be DEFERRED for 4-6 weeks in cryptococcal meningitis — unlike most OIs where ART is started early, early ART in cryptococcal meningitis paradoxically increases mortality (IRIS-related). Fluconazole monotherapy is inferior for induction.

Correct. NACO's Treat All policy (adopted in 2017, aligned with WHO 2015 guidelines) mandates ART for ALL PLHIV regardless of CD4 count, WHO clinical stage, or symptom status. The target is to start within 7 days of diagnosis (same-day start is encouraged). The first-line regimen in India is TLD (Tenofovir + Lamivudine + Dolutegravir). This policy was adopted because early ART reduces transmission, prevents immune damage, and improves long-term outcomes.

NACO Treat All: ART for all PLHIV, first-line = TLD (Tenofovir + Lamivudine + Dolutegravir). Dolutegravir is the preferred third agent due to high genetic barrier to resistance, minimal drug interactions, and once-daily dosing. Exception for start timing: concurrent TB meningitis or cryptococcal meningitis (defer ART to prevent IRIS).

NACO Treat All policy: ART for ALL PLHIV, regardless of CD4 count or clinical stage. There is no CD4 threshold below which to wait. The first-line regimen is TLD (Tenofovir/Lamivudine/Dolutegravir). Same-day start (or within 7 days) is the target. Previous CD4 thresholds (500, 350, 200) are obsolete under Treat All.

Correct. PEP is indicated after all significant HIV exposures (hollow-bore needlestick from HIV-positive source is high-risk) regardless of the source's viral load — undetectable viral load reduces but does not eliminate transmission risk. PEP must be started within 72 hours (ideally within 2 hours) and continued for 28 days. NACO PEP regimen: TDF + 3TC (or FTC) + DTG. A baseline HIV test must be done before starting PEP to confirm the nurse is currently HIV-negative. Follow-up testing at 6 weeks, 3 months, and 6 months.

PEP: start within 72 hours (2 hours is optimal); 3-drug regimen TDF + 3TC + DTG; duration 28 days. An undetectable viral load in the source does NOT eliminate risk — U=U applies to sexual transmission with consistent suppression, but occupational exposure still warrants PEP. Baseline HIV test in the exposed person is mandatory before starting PEP.

PEP is indicated for significant occupational exposures regardless of source viral load. Hollow-bore needlestick from an HIV-positive patient is a high-risk exposure. Start within 72 hours (earlier = better), use NACO regimen TDF + 3TC + DTG for 28 days. Baseline HIV test the exposed healthcare worker BEFORE starting PEP to confirm current HIV-negative status. Monotherapy PEP is obsolete.

Correct. Co-trimoxazole (TMP-SMX) prophylaxis is indicated for all PLHIV in India with CD4 <200 cells/mm3 (or WHO clinical stage 3/4 regardless of CD4). The dose is one double-strength tablet (960 mg = TMP 160 mg + SMX 800 mg) once daily. Co-trimoxazole protects against PCP, toxoplasmosis, and bacterial infections. In India, NACO recommends co-trimoxazole for ALL PLHIV regardless of CD4 count in resource-limited settings. MAC prophylaxis (azithromycin) is for CD4 <50, but is not the first priority here. CrAg screening (for cryptococcosis) is for CD4 <100.

OI prophylaxis CD4 thresholds: Co-trimoxazole <200 (universally in India); CrAg screening at CD4 <100, fluconazole 200 mg/day if CrAg positive (cryptococcal antigenaemia prevention); MAC prophylaxis (azithromycin) at CD4 <50 (less commonly used in India). Co-trimoxazole can be stopped once CD4 rises above 200 on ART for >3 months.

Co-trimoxazole prophylaxis is indicated at CD4 <200 (and universally in India per NACO). The dose is one DS tablet (960 mg) daily. It covers PCP, toxoplasmosis, and some bacterial OIs. MAC prophylaxis (azithromycin 1200 mg weekly) is for CD4 <50, not 85. Fluconazole weekly is not standard primary prophylaxis in India. Dapsone is a second-line substitute for co-trimoxazole in sulpha-allergic patients.

Correct. CMV retinitis is the most common serious ocular opportunistic infection in AIDS, occurring at CD4 <50 cells/mm3. The 'pizza fundus' appearance — retinal haemorrhages, exudates, and perivascular sheathing in a pattern resembling a pizza with tomato sauce — is pathognomonic for CMV retinitis. Treatment is with intravenous ganciclovir or oral valganciclovir. CMV retinitis is painless (unlike acute bacterial endophthalmitis) and can lead to retinal detachment and permanent blindness if untreated.

CMV retinitis occurs at CD4 <50, presents as painless progressive visual loss, fundus shows 'pizza retina' (haemorrhages + exudates). Treat with IV ganciclovir (induction) → oral valganciclovir (maintenance). Risk of retinal detachment increases with large lesions. Distinguish from toxoplasma retinochoroiditis (focal lesion, vitritis, responds to pyrimethamine + sulphadiazine).

The 'pizza fundus' — retinal haemorrhages, exudates, perivascular sheathing — at CD4 <50 is CMV retinitis. Toxoplasma chorioretinitis is typically focal with vitritis. Progressive outer retinal necrosis (VZV) is rapidly progressive peripheral retinal necrosis. CMV retinitis is the most common serious HIV ocular OI; treatment is IV ganciclovir/oral valganciclovir.

Correct. This is paradoxical IRIS (Immune Reconstitution Inflammatory Syndrome). IRIS occurs 2-8 weeks after ART initiation when the recovering immune system mounts an exaggerated inflammatory response against pre-existing pathogens (in this case, TB). Key features: patient was stable before ART, clinical deterioration temporally linked to ART initiation, no new infection. Management: NEVER stop ART or TB treatment (both must continue); treat symptoms with NSAIDs for mild-moderate IRIS; corticosteroids (prednisolone 1.5 mg/kg/day tapered over 4-6 weeks) for severe IRIS causing life-threatening complications (airway compromise, CNS involvement).

IRIS pearl: never stop ART for IRIS. The instinct to pause ART to 'let inflammation settle' is wrong. Two forms: paradoxical IRIS (worsening of treated infection) and unmasking IRIS (reveals previously unknown infection). TB is the most common precipitant in India. Corticosteroids for severe IRIS; ART continues throughout.

Paradoxical IRIS: clinical deterioration 2-8 weeks after ART start, in a patient stable on OI treatment, without a new infection. The immune system 'overshoots' against existing pathogens as CD4 count recovers. Treatment is NEVER to stop ART — this is a critical trap. Continue ART + TB treatment; add NSAIDs or corticosteroids depending on severity. Stopping ART is wrong and dangerous.

Correct. The presence of a hilar mass on CXR raises suspicion of active TB, which must be excluded before starting INH preventive therapy (IPT). IPT is contraindicated if active TB is present or suspected, because monotherapy with isoniazid will select resistant TB. The correct approach is thorough investigation for active TB: sputum CBNAAT/culture, bronchoscopy/BAL if sputum-negative but clinical suspicion is high. Once active TB is excluded, NTEP/NACO guidelines recommend IPT (isoniazid 300 mg/day for 6 months) for all PLHIV with no active TB.

IPT (Isoniazid Preventive Therapy) is recommended for all PLHIV in India after excluding active TB. The 4-symptom screen (current cough, fever, weight loss, night sweats) is the entry screen — any symptom positive → investigate for active TB before IPT. If all 4 negative → start IPT (isoniazid 300 mg + pyridoxine 25 mg daily × 6 months).

Before starting IPT, active TB must be actively excluded. An abnormal CXR with hilar mass in an HIV-positive patient necessitates full TB workup (CBNAAT, sputum culture, bronchoscopy if needed). Starting IPT with a possible active TB would lead to INH monotherapy — a recipe for resistance. Once active TB is excluded, IPT + ART can be initiated.

Correct. The HIV and AIDS (Prevention and Control) Act 2017 protects confidentiality of HIV status — disclosure without written consent is prohibited. However, the Act also recognises a public health obligation when a PLHIV engages in behaviour that puts a partner at serious risk. The correct approach is intensive counselling to encourage voluntary partner disclosure, offer couples testing, and support disclosure. The Act does not mandate direct physician-to-partner disclosure but provides a framework for involving a medical officer in extreme cases. The partner should be offered testing if disclosure occurs.

HIV Act 2017: confidentiality of HIV status is legally protected; disclosure without written consent is prohibited; discrimination in healthcare, employment, education is prohibited; designated courts for HIV-related discrimination. The ethical tension between patient confidentiality and partner protection is real and frequently tested. Counselling-first, patient-led disclosure is the approach; involuntary physician disclosure is legally and ethically fraught.

Under the HIV Act 2017, HIV status is confidential and protected by law. Disclosure to a third party without written consent is prohibited. However, the duty of care to the at-risk partner must be balanced through counselling the patient toward voluntary disclosure. The Act does not mandate direct physician disclosure to the partner — intensive counselling + support for voluntary disclosure is the correct initial and primary approach.