🟦 HIV BASICS & INITIAL MANAGEMENT
A 32-year-old male is newly diagnosed with HIV. CD4 count is 420/µL and viral load is 85,000 copies/mL. He feels well and has no opportunistic infections. What is the most appropriate next step?
What is initiation of antiretroviral therapy (ART)?
ART is recommended for all patients regardless of CD4 count. Early treatment improves survival and decreases transmission.
A 36-year-old woman with advanced HIV presents for follow-up after being off antiretroviral therapy for several years. Her CD4 count is 180/µL. She reports a history of anaphylaxis to sulfonamide antibiotics. This medication should be started for Pneumocystis jirovecii pneumonia (PJP) prophylaxis.
What is atovaquone?
Alternative PJP prophylaxis is indicated in patients with CD4 <200 cells/µL who cannot take TMP-SMX due to severe sulfa allergy.
A patient with PJP is started on antimicrobial therapy. When should ART generally be initiated?
What is within 2 weeks?
Early ART initiation improves outcomes in most opportunistic infections.
Which vaccine type is generally contraindicated in patients with CD4 count <200/µL?
What are live vaccines?
Severe immunosuppression increases risk of disseminated infection from live vaccines.
A 45-year-old man with HIV starts antiretroviral therapy and develops worsening fevers and enlarging lymph nodes two weeks later despite improving viral load. This immune-mediated complication is the most likely diagnosis
What is immune reconstitution inflammatory syndrome (IRIS)?
A patient with HIV presents with headache and multiple ring-enhancing brain lesions on MRI. What is the most likely diagnosis?
What is cerebral toxoplasmosis?
Multiple ring-enhancing lesions in advanced HIV strongly suggest toxoplasmosis.
A patient with cryptococcal meningitis improves after antifungal treatment. When should ART be started?
What is delayed for approximately 4–6 weeks?
Early ART increases risk of severe cryptococcal IRIS.
A patient with HIV asks how to prevent transmitting HIV to a sexual partner. What is the most effective strategy?
What is maintaining an undetectable viral load (U=U)?
Sustained viral suppression prevents sexual transmission of HIV.
A patient on ART + TMP-SMX has maintained a CD4 count above 200/µL for 4 months. What change in management is appropriate?
What is discontinue PJP prophylaxis?
PCP prophylaxis may be discontinued after CD4 >200 for ≥3 months.
A patient with HIV presents with fever, anemia, weight loss, and CD4 count of 30/µL. Blood cultures later grow acid-fast organisms. Diagnosis?
What is disseminated Mycobacterium avium complex (MAC)?
Disseminated MAC commonly causes systemic constitutional symptoms in severe immunosuppression.
A patient with active tuberculosis and CD4 count of 30/µL begins TB therapy. When should ART be initiated?
What is within 2 weeks?
Early ART reduces mortality in patients with CD4 <50.
A newly diagnosed patient with HIV should routinely be screened for which chronic viral co-infection?
What is hepatitis B virus infection?
HBV screening is essential because treatment choices affect both HIV and HBV.
A patient has CD4 count of 80/µL and positive Toxoplasma IgG serology. What prophylaxis is indicated?
What is TMP-SMX?
TMP-SMX prevents both PCP and toxoplasmosis.
A patient with HIV develops headache and elevated opening pressure on lumbar puncture. India ink stain is positive. What is the diagnosis?
What is cryptococcal meningitis?
Cryptococcus causes meningitis with markedly elevated intracranial pressure.
A patient with active TB and CD4 count of 180/µL starts RIPE therapy. When should ART be initiated?
What is within 8 weeks?
ART timing depends on immune status; less urgent when CD4 ≥50.
A patient with HIV and no prior vaccination history presents for care. Which vaccine series is especially important regardless of CD4 count?
What is pneumococcal vaccination?
HIV increases risk of invasive pneumococcal disease.
A 52-year-old man with HIV has been adherent to ART for 2 years and maintains an undetectable viral load, but his CD4 count remains 150 cells/µL. He feels well and has no new opportunistic infections. This is the best next step in management.
What is continue ART and maintain opportunistic infection prophylaxis until CD4 recovery?
Teaching Pearl:
Some patients experience incomplete immune reconstitution despite effective viral suppression.
A 42-year-old man with AIDS (CD4 38) presents with headaches and right-sided weakness. MRI shows a solitary ring-enhancing brain lesion. Toxoplasma IgG is negative, and he fails empiric toxoplasmosis therapy. What is the next best diagnostic step?
What is stereotactic brain biopsy?
In patients with AIDS, multiple ring-enhancing lesions favor toxoplasmosis, whereas a solitary lesion with negative toxoplasma serology and failure to improve on therapy raises concern for primary CNS lymphoma, warranting tissue diagnosis with stereotactic brain biopsy.
A patient develops worsening lymphadenopathy after starting ART for tuberculosis but remains hemodynamically stable. What is the best management?
What is continue ART and treat underlying infection?
Most IRIS cases are self-limited and do not require stopping ART.
Which malignancy requires routine screening in patients with HIV regardless of immune status?
What is cervical cancer?
HIV increases risk of persistent HPV infection and cervical dysplasia.