Deck 40: Post-Exposure Prophylaxis for Hiv Infection

Question 1

A woman and her 6-year-old son present to your urgent care clinic after the boy sustains a bite on his forearm from another child on the school playground. The boy's skin was broken and he reports that the wound bled slightly after the bite. The boy denies any trauma to the biter's mouth prior to the bite and says the biter's saliva and teeth were not bloody. To address the mother's concern about HIV transmission you:

A) Offer three-drug postexposure prophylaxis (PEP) for this exposure and reassure the patient and his mother that PEP is effective in preventing HIV transmission
B) Offer two-drug PEP for this exposure and reassure the patient and his mother that this is a low-risk exposure
C) Reassure the patient and his mother that this is a low-risk exposure but inform them that PEP is not recommended for persons under the age of 18
D) Reassure the patient and his mother that this was not a potential exposure to HIV and therefore PEP is not indicated

Answer 1

D

Question 2

A nurse sustains a deep stick from a bloody needle used to start intravenous fluids 2 hours ago on a patient admitted for sepsis. The source patient's HIV status is unknown. Rapid testing is not available and the results are expected back in 3 days. The source patient's past medical history is significant for hepatitis C and IV drug use in the past month. The most appropriate way to manage this exposure is:

A) Start the exposed nurse on three-drug PEP today. Continue the PEP regimen for 28 days regardless of the results of the source person's HIV test.
B) Start the exposed on two-drug PEP today. Add a third antiretroviral (ARV) if the source patient is determined HIV positive.
C) Start the exposed on three-drug PEP today. Discontinue PEP if the source patient's HIV RNA result is negative.
D) Start the exposed on three-drug PEP today. Discontinue PEP if the source patient's HIV antibody test result is negative.

Answer 2

C

Question 3

A hospital worker who sustains a high-risk needlestick is 5 weeks pregnant. The ARV options at the hospital and surrounding pharmacies are limited. What fixed-dosed combination ARV tablet is a safe alternative in pregnancy and one that the patient could start taking immediately as PEP?

A) Efavirenz/emtricitabine/tenofovir coformulated as Atripla
B) Dolutegravir/abacavir/lamivudine coformulated as Triumeq
C) Abacavir/zidovudine/lamivudine coformulated as Trizivir
D) Emtricitabine/rilpivirine/tenofovir coformulated as Complera

Answer 3

D

Question 4

A 43-year-old female presents to clinic requesting PEP following unprotected receptive vaginal intercourse with a man 48 hours prior. She does not know the HIV status of the man and cannot contact him. When you review the risks and benefits of initiating PEP for this potential exposure you include the following facts:

A) If the man was infected with HIV, her risk of acquiring the virus is 0.1%.
B) PEP should be initiated only if the source patient is known to be infected with HIV.
C) If any side effects to the medications occur, PEP must be stopped for toxicity concerns.
D) It is too far out from the exposure for this patient to initiate PEP.

Question 5

A physician receives a cut from a bloody scalpel while operating on an HIV-infected woman and initiates three-drug PEP immediately following the exposure. The soonest it can be documented that no transmission from the exposure occurred is:

A) 4 weeks following exposure, by a HIV RNA assay
B) 6 weeks following exposure, by a negative fourth-generation antigen-antibody test
C) 4 months following the exposure, with a negative fourth-generation antigen-antibody test
D) 6 months following the exposure, with a negative HIV antibody test

Question 6

You are the primary care provider for a 55-year-old male who is currently on preexposure prophylaxis (PrEP) and reports 100% daily adherence for the past 6 months. He comes into clinic stating that last night he had unprotected receptive anal intercourse with an HIV-infected male who is not adherent to his ARV therapy. Your priority is to:

A) Offer the patient three-drug PEP for this high-risk exposure
B) Obtain the resistance profile of the patient's partner
C) Reassure the patient that PrEP, when taken daily, provides a 92% to 99% reduction in HIV risk and continue with routine surveillance
D) Reassure the patient that transmission is likely but that he should stop PrEP today to reduce the chance of creating resistant virus

Question 7

A 32-year-old female patient with no chronic medical problems initiates PrEP. You notice that her serum creatinine increases from 0.80 to 1.00 in her 3-month surveillance labs. Her CrCl dropped slightly but remains above 60 ml/min. The next most appropriate step to address this is:

A) Reassure the patient that this increase can be transient and recheck kidney function in 1 to 3 months
B) Reassure the patient that this increase can be transient and check for proteinuria today
C) Have the patient stop taking PrEP and check for proteinuria today
D) Have the patent stop taking PrEP and refer to nephrology

Question 8

The baseline labs for a patient who is interested and eligible in PrEP contain the following results: hepatitis B surface antigen negative; hepatitis B surface antibody positive; hepatitis B core antibody positive. The patient reports never receiving the hepatitis B vaccine. Before initiating PrEP you should:

A) Caution the patient that a hepatitis flare may occur if PrEP is discontinued
B) Ensure that the patient completes the hepatitis B vaccination series
C) Order a quantitative hepatitis B surface antibody
D) Do nothing-the patient is immune to HBV

Question 9

You are the primary care provider for an HIV-uninfected female who is trying to conceive with her HIV-infected male partner who is virally suppressed on ARV therapy. When discussing Truvada for PrEP you make sure to explain to your patient that:

A) PrEP trials did not study the effects of PrEP on the developing fetus
B) Truvada is Pregnancy Category B
C) Truvada is recommended as a component of a HIV prevention strategy for serodiscordant couples trying to conceive
D) All of the above

Question 10

You are the primary care provider for a patient who has taken PEP twice in the past 12 months following sexual exposures to partners with HIV infection. The patient comes into clinic today request PEP for an exposure the previous day. You are sure to discuss the following with the patient:

A) The risk of toxicity from PEP increases with every 28-day course.
B) PEP must be held until the patient's current HIV status is determined.
C) PrEP is a good option for this patient and can initiated after a 28-day PEP course.
D) PrEP is a good option for this patient and can be initiated after surveillance testing for this exposure is completed.