HIV

Symptoms

• Constitutional: Weight loss, fatigue, night sweats, lymphadenopathy

• Flu-like: Fever, myalgia, rash, arthralgia (particularly in acute HIV or seroconversion illness)

• Opportunistic Infections:

  • Candidiasis (oral thrush, oesophageal candidiasis)

  • Chronic diarrhoea (Cryptosporidium, Isospora)

  • Seborrhoeic dermatitis

• Advanced (AIDS):

  • PJP (Pneumocystis jirovecii pneumonia): Dyspnoea, dry cough, bilateral interstitial infiltrates

  • Kaposi’s Sarcoma: Violaceous lesions on skin or mucous membranes

  • CMV Retinitis: Visual floaters, flashes, field loss

Risk Factors

• Unprotected Anal/Vaginal Sex (especially with uncircumcised males, multiple partners)

• HIV-positive Partner or high-risk behaviour (e.g., sex workers, MSM)

• Shared Needles (IV drug use), chemsex, unsterile tattooing, overseas blood transfusions (historical risk in some regions)

• Hepatitis B/C or STI history; needle-stick injuries

Pre-Test Counselling

• Explain the testing process (screening, confirmatory tests) and window period (up to 3 months for antibody detection, though modern Ag/Ab combo tests shorten this)

• Discuss implications of potential results, prevention strategies (e.g. PEP within 72 hours, PrEP for high-risk)

• Screen for co-infections: Hepatitis B/C, syphilis, chlamydia, gonorrhoea

Diagnosis

• Screen: HIV Ag/Ab test (4th generation)

• Confirm: Western blot or NAT (nucleic acid testing) if initial positive or equivocal

• Baseline Investigations:

  • CD4 count (assesses immune status)

  • Viral load (monitors treatment response)

  • Genotyping (detects resistance mutations)

  • Additional labs: FBC, UEC, LFT, fasting lipids/glucose, co-infections (e.g. TB, hepatitis B/C)

Management

1. Contact Tracing: Identify sexual and needle-sharing partners dating back to risk onset

2. Education: Emphasise that modern ART prevents progression to AIDS and reduces transmission (U=U principle if sustained viral suppression)

3. Safe Sex: Regular condom use, status disclosure to partners, consider PrEP for at-risk partners

ART (Antiretroviral Therapy)

When to Start

• Initiate ASAP following diagnosis, regardless of CD4 count (improves outcomes, reduces transmission)

Pre-ART Tests

• CD4, viral load, and resistance genotype

• Co-infection checks: Hepatitis B/C, TB status

• Baseline FBC, UEC, LFT, fasting lipids/glucose

First-Line Regimens (Once Daily)

• Dolutegravir + abacavir + lamivudine (Triumeq) if HLA-B*57:01 negative (to avoid abacavir hypersensitivity)

• Tenofovir alafenamide + emtricitabine + bictegravir (Biktarvy) as an alternative integrase inhibitor–based regimen

HIV in Pregnancy

• Testing: All antenatal patients offered HIV testing, repeat for high-risk if indicated

• ART:

  • Initiate immediately and continue effective regimens unless contraindicated

  • Omeprazole has no direct role here; but note that standard antiretroviral therapy is essential to reduce vertical transmission

• Delivery:

  • Caesarean section if viral load >50 copies/mL at 36 weeks

  • IV zidovudine intrapartum if detectable viral load

• Neonatal Prophylaxis: Zidovudine within 6–12 hours post-birth

• Breastfeeding: Avoid in developed settings (formula feeding recommended to prevent transmission)

Follow-Up

• Viral load & CD4: Every 3–6 months, or more frequently if treatment changes

• Monitor ART adherence, side effects (hepatotoxicity, renal effects, metabolic changes)

• Screen for co-infections (Hep B/C, STIs) and comorbidities (diabetes, CVD)

Prevention

• PrEP (Pre-Exposure Prophylaxis): Daily or on-demand TDF/FTC for high-risk groups (MSM, serodiscordant couples, IV drug users)

• PEP (Post-Exposure Prophylaxis): Start within 72 hours of potential exposure (sexual, needle-stick)

• Safe Sex: Condoms, regular STI screening, risk reduction counselling

• Harm Reduction: Clean needle programmes, supervised injecting facilities