We have a married patient who came to us and on testing he was diagnosed with hiv secondary syphilis and genital herpes…. On examination he had macular papular rash mostly on lower limbs papulosquamous lesion at bilateral palms and soles, herpes erosions over glans scrotum and anal area…. Write clinical description of this patient for my dermatology practical exam
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CDC STI treatment guidelines secondary syphilis HIV genital herpes clinical presentation
Clinical description
A married adult male presented with a generalized cutaneous eruption and genital and perianal erosive lesions. He was diagnosed on laboratory testing to have HIV infection, secondary syphilis, and genital herpes simplex infection.
On cutaneous examination, there was a bilateral, symmetrical maculopapular eruption, predominantly involving the lower limbs. Multiple well-defined papulosquamous lesions were present over both palms and soles. The palmar and plantar involvement with papulosquamous morphology is clinically suggestive of secondary syphilis.
Examination of the genital and perianal region revealed multiple grouped superficial erosions over the glans penis, scrotum, and perianal area, consistent with ruptured herpetic vesicles/erosions.
Provisional dermatological diagnosis:
- Secondary syphilis, presenting with generalized maculopapular and palmoplantar papulosquamous eruption.
- Genital herpes simplex infection, with genital and perianal erosions.
- HIV infection with multiple sexually transmitted infections.
For an exam, avoid adding findings that were not observed, such as lymphadenopathy, mucous patches, condylomata lata, fever, or hepatosplenomegaly. Secondary syphilis classically produces a diffuse rash that can involve the palms and soles.
Find recent guidelines for managing HIV with STIs
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site:clinicalinfo.hiv.gov guidelines HIV opportunistic infections sexually transmitted infections syphilis herpes 2025
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https://www.cdc.gov/std/treatment-guidelines/hiv.htm
Current guideline-based approach: HIV with concurrent STIs
For a patient with newly diagnosed HIV, secondary syphilis, and genital herpes, manage all infections promptly and in parallel, ideally through an HIV/STI clinic. The most relevant current sources are the NIH Adult and Adolescent OI guidelines, reviewed in 2025, CDC STI guidance, and WHO 2025 integrated STI-service guidance.
1. At the first visit
- Link to HIV care urgently and start ART as soon as possible, irrespective of CD4 count, unless another specific contraindication exists. CDC recommends prompt ART both for individual health and to prevent sexual transmission. CDC HIV-STI guidance
- Record baseline HIV viral load, CD4 count, HIV genotype resistance test, CBC, renal and liver function, urinalysis, hepatitis B and C serology, and TB screening as appropriate to local protocol.
- Screen for other STIs:
- Syphilis quantitative RPR/VDRL with treponemal confirmation
- NAAT for gonorrhea and chlamydia from all sites of exposure: urine/urethral, rectal, and pharyngeal where indicated
- Hepatitis B and C
- Consider trichomonas testing when relevant.
- Perform a careful examination for neurological, ocular, and otic symptoms/signs in every patient with HIV and syphilis. Lumbar puncture is not routine in asymptomatic disease. It is indicated when neurological, ocular, or otic involvement is suspected, or when treatment failure is being evaluated. NIH syphilis guideline
2. Secondary syphilis
- Recommended treatment: benzathine penicillin G 2.4 million units IM once for primary or secondary syphilis, including in people living with HIV.
- Do not give extra weekly doses merely because the patient has HIV. Available evidence has not shown added benefit from additional benzathine penicillin, amoxicillin, or other antibiotics for early syphilis in HIV. CDC primary and secondary syphilis guidance
- Warn about a possible Jarisch-Herxheimer reaction during the first 24 hours after treatment: fever, myalgia, headache, and transient worsening of lesions. Treat symptomatically and do not mistake it for penicillin allergy.
- Document the baseline quantitative RPR/VDRL titer and repeat clinical and serologic evaluation at 3, 6, 9, 12, and 24 months in people with HIV.
- Persistent/recurrent symptoms, a sustained fourfold rise in RPR/VDRL titre, or lack of a fourfold decline by 24 months should prompt assessment for reinfection versus treatment failure, including neurological examination and consideration of CSF examination. NIH guidance
3. Genital herpes simplex infection
Obtain lesion HSV PCR/NAAT where available, particularly if the presentation is atypical, extensive, severe, or nonhealing.
- Treat a first episode with oral acyclovir, valacyclovir, or famciclovir. In HIV, lesions may be larger, more painful, atypical, or prolonged, so treatment may need extension until lesions resolve.
- Consider suppressive antiviral therapy for severe/frequent recurrences, patient preference, or during ART initiation in patients with low CD4 count because genital herpes can transiently flare during early immune reconstitution.
- NIH lists suppressive options for people with HIV as:
- Valacyclovir 500 mg orally twice daily, preferred
- Acyclovir 400 mg orally twice daily, alternative
- Famciclovir 500 mg orally twice daily, alternative.
NIH HSV guideline
- Severe, extensive, disseminated, visceral, or suspected acyclovir-resistant HSV requires specialist assessment and usually IV therapy or resistance-directed treatment.
- HSV should not delay ART initiation. ART often reduces the frequency and severity of clinical genital herpes over time, though asymptomatic HSV shedding may persist. CDC herpes guidance
4. ART and prevention counselling
- Counsel that durable viral suppression on ART prevents sexual HIV transmission: U=U, meaning undetectable equals untransmittable.
- Until suppression is achieved, advise consistent condom use and avoidance of sex during active genital ulcers or erosions.
- Vaccinate or complete vaccination for hepatitis A and B when nonimmune, and give other indicated vaccines according to CD4 status and local HIV immunization recommendations.
- Review medication interactions, renal function, adherence barriers, mental health, alcohol/substance use, and possible TB risk before and after ART initiation.
5. Partner management and public-health measures
- Ensure confidential notification, testing, and treatment of sexual partners.
- Sexual contacts exposed to infectious syphilis should be clinically and serologically evaluated, with presumptive treatment when indicated under local STI protocols.
- Partners should be offered HIV testing. HIV-negative partners may need PEP if exposure was within 72 hours, or PrEP if there is ongoing risk. CDC partner-services guidance
- For symptomatic genital herpes, partners should be assessed and counselled; asymptomatic partners can be offered type-specific HSV-2 serology in appropriate settings. CDC HSV partner guidance
6. Ongoing STI screening
For sexually active people with HIV:
- Screen for syphilis, gonorrhea, and chlamydia at least annually.
- Screen every 3 to 6 months when risk is ongoing, including new/multiple partners, anonymous partners, prior STI, or high local STI prevalence.
- Test at each relevant anatomical site of exposure. The NIH specifically recommends annual syphilis screening for sexually active people with HIV, increasing to every 3 to 6 months when risk factors are present. NIH syphilis screening recommendation
WHO’s 2025 guidance also supports integrated, person-centred HIV/STI care with risk-based screening, partner services, decentralization, and linkage to prevention and treatment services. WHO STI service-delivery recommendations
Recent evidence supports the importance of close STI surveillance in people living with HIV. A 2025 systematic review/meta-analysis evaluated syphilis prevalence in this population [PMID: 39763073], and a 2024 systematic review found a substantial burden of syphilis among people with HIV in sub-Saharan Africa [PMID: 38180840].
Prepare me with questions answers of moderate to hard to very hard questions that examiner might ask me in this case
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CDC NIH guidelines HIV secondary syphilis genital herpes management persons with HIV
Dermatology practical viva: HIV with secondary syphilis and genital herpes
Use these as short viva answers. Start every answer by linking it to the actual findings: palmoplantar papulosquamous eruption suggests secondary syphilis; painful genital/perianal erosions suggest herpes simplex infection.
Moderate questions
1. What is your diagnosis?
Answer: This is a case of HIV infection with secondary syphilis and genital herpes simplex infection. The generalized maculopapular rash with bilateral palmoplantar papulosquamous lesions favors secondary syphilis, while the erosions over glans, scrotum, and perianal area are compatible with genital herpes.
2. What are the classical cutaneous features of secondary syphilis?
Answer: The rash is usually generalized, symmetrical, nonpruritic, and may be macular, papular, maculopapular, papulosquamous, or occasionally pustular. It characteristically involves the palms and soles. Other features include mucous patches, condylomata lata, patchy moth-eaten alopecia, and generalized lymphadenopathy.
3. Why are palm and sole lesions important in this patient?
Answer: Palmoplantar involvement narrows the differential. In a sexually active adult, a symmetrical papulosquamous rash involving palms and soles is highly suggestive of secondary syphilis.
4. What is the usual sequence of lesions in genital herpes?
Answer: Grouped vesicles arise on an erythematous base, rupture rapidly, and form painful superficial erosions or ulcers. In this patient, the erosions may represent ruptured vesicles.
5. What causes syphilis?
Answer: Treponema pallidum subspecies pallidum, a motile spirochete.
6. What causes genital herpes?
Answer: Usually herpes simplex virus type 2, but HSV-1 can also cause genital infection, especially in first episodes.
7. What are the stages of acquired syphilis?
Answer: Primary syphilis, secondary syphilis, latent syphilis, and tertiary syphilis. Neurosyphilis, ocular syphilis, and otosyphilis may occur at any stage.
8. When does secondary syphilis occur after primary syphilis?
Answer: Usually about 2 to 8 weeks after the primary chancre, though primary and secondary manifestations can overlap, particularly in people with HIV.
9. What are the differential diagnoses of a palmoplantar papulosquamous rash?
Answer: Pityriasis rosea, psoriasis, lichen planus, drug eruption, tinea, scabies, viral exanthem, erythema multiforme, and secondary syphilis. In this clinical context, secondary syphilis is most likely.
10. What are the differentials of genital erosions or ulcers?
Answer: Genital herpes, primary syphilis, chancroid, lymphogranuloma venereum, fixed drug eruption, Behçet disease, traumatic erosions, and aphthous ulcers.
11. How would you investigate suspected secondary syphilis?
Answer: I would perform:
- A quantitative non-treponemal test: RPR or VDRL
- A confirmatory treponemal test: TPPA/TPHA, EIA, CIA, or FTA-ABS depending on the laboratory algorithm
- HIV testing if status is unknown
- Screening for other STIs, including gonorrhea, chlamydia, hepatitis B, and hepatitis C.
12. What is the role of RPR/VDRL?
Answer: RPR and VDRL are non-treponemal tests. They are useful for baseline quantification and for monitoring response after treatment. The titre should decline after successful therapy.
13. What is the role of TPHA/TPPA?
Answer: These are treponemal tests used to confirm infection. They often remain positive for life and should not be used to assess treatment response.
14. How will you confirm genital herpes?
Answer: HSV PCR or nucleic acid amplification test from a fresh lesion is preferred. Viral culture is less sensitive, especially after lesions begin healing. Type-specific HSV serology has a limited role and does not diagnose the cause of a current lesion.
15. What additional history would you take?
Answer: Duration and progression of rash and ulcers, pain, fever, sore throat, genital discharge, prior painless genital ulcer, sexual exposure and condom use, previous STIs, partner symptoms, drug intake, allergy history, neurological, visual, or auditory symptoms, TB symptoms, hepatitis risk, and substance-use history.
Hard questions
16. How does HIV alter syphilis?
Answer: Most patients have typical syphilis, but HIV can be associated with atypical, severe, overlapping, ulceronodular, or relapsing manifestations. There may be a greater concern for neurological involvement and serologic treatment failure, especially with advanced immunosuppression. However, early syphilis is treated with the same recommended regimen as in people without HIV, with more careful follow-up.
17. How does HIV alter genital herpes?
Answer: HSV episodes may be more frequent, severe, prolonged, extensive, painful, atypical, and may involve genital, perianal, or oral sites. Viral shedding is increased. Lesions that are chronic, hypertrophic, or nonhealing should raise concern for acyclovir resistance.
18. State the treatment of secondary syphilis in this patient.
Answer: Benzathine penicillin G 2.4 million units intramuscularly as a single dose, provided there is no neurological, ocular, or otic involvement. HIV status alone is not an indication for additional doses in early syphilis.
19. Does an HIV-positive patient with early syphilis need three weekly injections of benzathine penicillin?
Answer: No. For primary, secondary, or early latent syphilis, one dose of benzathine penicillin G 2.4 million units IM is recommended. Extra doses have not shown improved efficacy merely because the patient has HIV.
20. What if the duration is unknown or the patient has late latent syphilis?
Answer: Benzathine penicillin G 2.4 million units IM weekly for three doses, making a total of 7.2 million units.
21. What if he has a true penicillin allergy?
Answer: In nonpregnant patients with early syphilis, doxycycline 100 mg orally twice daily for 14 days may be used where appropriate, but evidence in HIV is less robust and follow-up must be reliable. If follow-up is uncertain, or in pregnancy, penicillin desensitization followed by penicillin therapy is preferred.
22. What is a Jarisch-Herxheimer reaction?
Answer: It is an acute inflammatory reaction occurring within 24 hours, usually after treatment of early syphilis. It causes fever, chills, headache, myalgia, tachycardia, and transient worsening of rash or lesions. It is due to cytokine release following spirochetal destruction, not to penicillin allergy.
23. How will you differentiate Jarisch-Herxheimer reaction from penicillin anaphylaxis?
Answer: Jarisch-Herxheimer reaction presents mainly with fever, chills, myalgia, headache, and transient flare of lesions after treatment. Anaphylaxis presents with urticaria, angioedema, bronchospasm, hypotension, and possible cardiovascular collapse, often soon after drug administration.
24. What is the treatment for a first episode of genital herpes?
Answer: Treat all first episodes. Options include:
- Acyclovir 400 mg orally three times daily for 7 to 10 days
- Valacyclovir 1 g orally twice daily for 7 to 10 days
- Famciclovir 250 mg orally three times daily for 7 to 10 days.
In HIV, extend treatment if lesions have not completely healed.
25. When would you use suppressive anti-HSV therapy in this patient?
Answer: For severe or frequent recurrences, substantial distress, patient preference, and in those starting ART with low CD4 count because herpetic flares can occur during early immune restoration. A commonly used regimen is valacyclovir 500 mg twice daily or acyclovir 400 mg twice daily.
26. Should HSV infection delay ART initiation?
Answer: No. Genital HSV should not delay ART. ART should be started promptly in a newly diagnosed patient with HIV. Genital herpes may transiently worsen after starting ART, particularly with low CD4 count, but this can be managed with antiviral therapy.
27. Which baseline HIV investigations are essential?
Answer: Confirmatory HIV test according to the testing algorithm, CD4 count, HIV viral load, HIV resistance genotype, CBC, renal and liver function tests, hepatitis B and C serology, TB screening, STI screen, and assessment of vaccination status. Additional tests depend on symptoms and local HIV protocol.
28. What ART regimen would you expect to start?
Answer: Current first-line treatment generally uses an integrase inhibitor-based regimen, often dolutegravir plus two nucleoside reverse transcriptase inhibitors, such as tenofovir plus lamivudine or emtricitabine. The exact regimen should be selected after checking renal function, hepatitis B status, resistance results, drug interactions, and local/national protocol.
29. Why are genital ulcer diseases important in HIV?
Answer: Genital ulcers disrupt the mucosal epithelial barrier and cause local inflammation, facilitating HIV acquisition and transmission. HSV-2 also increases genital HIV RNA shedding in untreated HIV infection.
30. How frequently should this patient be screened for other STIs after treatment?
Answer: At least annually if sexually active. If there is ongoing high risk, recent STI, new or multiple partners, or relevant local epidemiology, screen for syphilis, gonorrhea, and chlamydia every 3 to 6 months, including all anatomical sites of exposure.
Very hard questions
31. When do you perform CSF examination in this patient?
Answer: Do CSF examination if there are neurological signs or symptoms, meningitis, stroke-like symptoms, cognitive change, cranial neuropathies, ocular disease with suspected neurosyphilis, or concern for treatment failure in a patient with low risk of reinfection. It is not routinely required solely due to HIV infection, low CD4 count, or high RPR/VDRL titre in an otherwise asymptomatic patient.
32. What ocular and otic symptoms should you specifically ask about?
Answer: Visual blurring, reduced visual acuity, eye pain, photophobia, floaters, red eye, headache, tinnitus, hearing loss, vertigo, and imbalance. Ocular or otosyphilis requires urgent specialist involvement.
33. How is neurosyphilis treated?
Answer: Aqueous crystalline penicillin G 18 to 24 million units per day intravenously, given as 3 to 4 million units every 4 hours or continuous infusion, for 10 to 14 days. The exact local protocol should be followed.
34. How do you follow the serological response to treatment of secondary syphilis in HIV?
Answer: Document the initial quantitative RPR/VDRL titre and repeat it at 3, 6, 9, 12, and 24 months. A fourfold decline in titre is expected over time. A sustained fourfold increase suggests reinfection or treatment failure.
35. The RPR is still reactive after treatment. Is that treatment failure?
Answer: Not necessarily. Treponemal tests often remain positive permanently, and non-treponemal titres can remain low-level reactive, called a serofast state. Treatment failure or reinfection is suggested by persistent symptoms or a sustained fourfold rise in RPR/VDRL titre. Clinical context and sexual re-exposure are essential.
36. The RPR has increased fourfold after treatment. What are the possibilities?
Answer: The leading possibilities are reinfection and treatment failure. I would take a detailed sexual history, repeat examination, assess neurological, ocular, and otic symptoms, repeat HIV-related parameters, and consider CSF evaluation if reinfection is unlikely or neurological findings exist.
37. How do you distinguish primary syphilis chancre from herpetic ulcer?
Answer: A classical syphilitic chancre is usually solitary, painless, clean-based, indurated, and accompanied by non-tender regional lymphadenopathy. Herpetic lesions are usually painful, multiple or grouped, begin as vesicles, and become shallow erosions or ulcers. However, atypical lesions and coinfection occur, particularly in HIV, so clinical appearance alone is insufficient.
38. What is condyloma lata, and how do you differentiate it from condyloma acuminata?
Answer: Condyloma lata are broad-based, moist, smooth, flat-topped, highly infectious papules or plaques of secondary syphilis, usually in intertriginous or anogenital areas. Condyloma acuminata are HPV-related genital warts, usually verrucous, papillomatous, and cauliflower-like.
39. Why may the primary chancre be absent in this case?
Answer: It may have been unnoticed, located in an inaccessible site such as the anal canal, cervix, or oral cavity, healed spontaneously, or overlapped with secondary-stage disease. Overlap of primary and secondary lesions is more commonly reported in HIV.
40. What is malignant syphilis?
Answer: Malignant syphilis, also called lues maligna, is an uncommon severe ulceronodular form of secondary syphilis. It presents with papulopustules that evolve into necrotic ulcerative lesions with thick crusts, often accompanied by systemic illness. It is more often associated with immunosuppression, including advanced HIV.
41. How would you suspect acyclovir-resistant HSV?
Answer: Suspect it if lesions persist, enlarge, or fail to improve despite adequate-dose antiviral therapy and confirmed adherence, particularly in advanced HIV. Obtain HSV PCR/culture and resistance testing where available, and seek specialist input. Foscarnet is generally used for proven or strongly suspected acyclovir-resistant HSV.
42. Does suppressive acyclovir or valacyclovir prevent HIV transmission?
Answer: No. It decreases symptomatic HSV recurrences but should not be relied upon to prevent HIV transmission. Effective ART with sustained viral suppression is the proven strategy for preventing sexual HIV transmission, alongside appropriate STI prevention measures.
43. What does U=U mean, and how would you explain it?
Answer: U=U means undetectable equals untransmittable. A person who takes ART consistently and maintains a suppressed HIV viral load does not sexually transmit HIV. This does not prevent acquisition or transmission of other STIs, so STI screening and prevention remain important.
44. How will you manage the spouse or sexual partner?
Answer: Maintain confidentiality and use nonjudgmental partner notification. The partner needs testing for HIV, syphilis, and other relevant STIs, plus clinical examination. Recent partners exposed to infectious syphilis require evaluation and may require presumptive treatment according to exposure timing and local protocol. If HIV-negative, assess eligibility for PEP if exposure was within 72 hours, or PrEP if future risk persists.
45. What counselling points are essential in this case?
Answer: Abstain from sex until herpetic lesions have healed and syphilis treatment has been completed as advised; use condoms consistently; disclose infection to partners with support from confidential partner services; adhere to ART and attend follow-up; understand that HSV can transmit even without visible lesions; avoid sharing needles; and ensure partner testing and treatment.
Examiner’s final challenge question
“Summarize management in one minute.”
Answer:
“This patient has HIV with secondary syphilis and genital herpes. I will assess for systemic symptoms and specifically for neurological, ocular, and otic involvement. I will document baseline quantitative RPR/VDRL and confirm syphilis with a treponemal test, obtain HSV PCR from a lesion if available, and screen for other STIs, hepatitis B/C, TB, CD4 count, viral load, renal and liver function, and HIV resistance. I will treat secondary syphilis with benzathine penicillin G 2.4 million units IM once, unless there is neurosyphilis or ocular/otic disease. I will treat the herpes episode with oral acyclovir or valacyclovir and extend therapy if healing is delayed. I will link him immediately to HIV care and initiate ART promptly. Finally, I will provide adherence and safer-sex counselling, ensure confidential partner notification, evaluate partners for HIV/STIs, and monitor RPR/VDRL at 3, 6, 9, 12, and 24 months.”
“This patient has HIV with secondary syphilis and genital herpes. I will assess for systemic symptoms and specifically for neurological, ocular, and otic involvement. I will document baseline quantitative RPR/VDRL and confirm syphilis with a treponemal test, obtain HSV PCR from a lesion if available, and screen for other STIs, hepatitis B/C, TB, CD4 count, viral load, renal and liver function, and HIV resistance. I will treat secondary syphilis with benzathine penicillin G 2.4 million units IM once, unless there is neurosyphilis or ocular/otic disease. I will treat the herpes episode with oral acyclovir or valacyclovir and extend therapy if healing is delayed. I will link him immediately to HIV care and initiate ART promptly. Finally, I will provide adherence and safer-sex counselling, ensure confidential partner notification, evaluate partners for HIV/STIs, and monitor RPR/VDRL at 3, 6, 9, 12, and 24 months.”
Current NIH guidance supports annual syphilis screening for sexually active people with HIV, increasing to every 3 to 6 months with ongoing risk, and recommends the same stage-specific syphilis therapy as for people without HIV, with careful follow-up. See the NIH syphilis guidance and NIH HSV guidance.
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site:clinicalinfo.hiv.gov adult adolescent antiretroviral guidelines initial evaluation initial regimen 2026 HIV
HIV viva questions and answers for dermatology practical
These are focused on the HIV component of your case. Keep answers structured and brief in viva. Do not volunteer a drug regimen or an AIDS diagnosis unless asked.
Moderate questions
1. What is HIV?
Answer:
HIV is a retrovirus of the family Retroviridae, genus Lentivirus. It infects and progressively depletes CD4 T lymphocytes, causing immunodeficiency and increased susceptibility to opportunistic infections and malignancies.
HIV is a retrovirus of the family Retroviridae, genus Lentivirus. It infects and progressively depletes CD4 T lymphocytes, causing immunodeficiency and increased susceptibility to opportunistic infections and malignancies.
2. Which types of HIV are known?
Answer:
There are two types: HIV-1 and HIV-2. HIV-1 is more common worldwide, more transmissible, and generally progresses faster. HIV-2 is mainly found in West Africa and usually has slower disease progression.
There are two types: HIV-1 and HIV-2. HIV-1 is more common worldwide, more transmissible, and generally progresses faster. HIV-2 is mainly found in West Africa and usually has slower disease progression.
3. What cells are primarily infected by HIV?
Answer:
The principal target is the CD4-positive T helper lymphocyte. HIV can also infect macrophages, dendritic cells, and microglial cells.
The principal target is the CD4-positive T helper lymphocyte. HIV can also infect macrophages, dendritic cells, and microglial cells.
4. Which receptors are required for HIV entry?
Answer:
HIV gp120 binds to the CD4 receptor and then to a chemokine co-receptor, either CCR5 or CXCR4. This permits fusion of the viral envelope with the host cell membrane via gp41.
HIV gp120 binds to the CD4 receptor and then to a chemokine co-receptor, either CCR5 or CXCR4. This permits fusion of the viral envelope with the host cell membrane via gp41.
5. Explain the HIV replication cycle.
Answer:
The virus attaches to CD4 and a co-receptor, enters the cell, and releases viral RNA. Reverse transcriptase converts RNA into DNA. Viral DNA is incorporated into host DNA by integrase. The host cell then produces viral proteins and RNA, which assemble at the cell surface. Protease cleaves polyproteins, producing mature infectious virions.
The virus attaches to CD4 and a co-receptor, enters the cell, and releases viral RNA. Reverse transcriptase converts RNA into DNA. Viral DNA is incorporated into host DNA by integrase. The host cell then produces viral proteins and RNA, which assemble at the cell surface. Protease cleaves polyproteins, producing mature infectious virions.
6. What are the major modes of HIV transmission?
Answer:
- Sexual transmission
- Blood and blood-product exposure
- Sharing contaminated needles or injection equipment
- Vertical transmission: during pregnancy, delivery, or breastfeeding
- Occupational exposure to infected blood, such as needle-stick injury.
It is not transmitted through casual touch, sharing food, mosquito bites, coughing, or social contact.
7. What is acute retroviral syndrome?
Answer:
It is a mononucleosis-like illness occurring usually 2 to 4 weeks after HIV acquisition. Features include fever, maculopapular rash, sore throat, lymphadenopathy, myalgia, headache, oral or genital ulcers, diarrhea, and aseptic meningitis.
It is a mononucleosis-like illness occurring usually 2 to 4 weeks after HIV acquisition. Features include fever, maculopapular rash, sore throat, lymphadenopathy, myalgia, headache, oral or genital ulcers, diarrhea, and aseptic meningitis.
8. How is HIV diagnosed?
Answer:
The usual laboratory approach is:
The usual laboratory approach is:
- A laboratory-based fourth-generation HIV-1/2 antigen-antibody immunoassay
- HIV-1/HIV-2 antibody differentiation assay if reactive
- HIV RNA nucleic acid testing if results are discordant or acute infection is suspected.
If acute HIV is suspected despite a negative screening test, HIV RNA testing should be done.
9. What does a fourth-generation HIV test detect?
Answer:
It detects HIV-1/2 antibodies and HIV-1 p24 antigen. It identifies infection earlier than antibody-only tests.
It detects HIV-1/2 antibodies and HIV-1 p24 antigen. It identifies infection earlier than antibody-only tests.
10. What is the window period?
Answer:
It is the period after infection during which a test may remain negative despite infection. The exact duration depends on the test and exposure timing. HIV RNA becomes detectable earliest, followed by p24 antigen, then antibodies.
It is the period after infection during which a test may remain negative despite infection. The exact duration depends on the test and exposure timing. HIV RNA becomes detectable earliest, followed by p24 antigen, then antibodies.
11. What is the role of CD4 count?
Answer:
CD4 count assesses immune status, helps identify risk of opportunistic infections, guides prophylaxis decisions, and is used to stage disease severity. It is not used alone to monitor ART efficacy.
CD4 count assesses immune status, helps identify risk of opportunistic infections, guides prophylaxis decisions, and is used to stage disease severity. It is not used alone to monitor ART efficacy.
12. What is the role of HIV viral load?
Answer:
HIV RNA viral load measures active viral replication. It is the key test for assessing response to ART and detecting virological failure.
HIV RNA viral load measures active viral replication. It is the key test for assessing response to ART and detecting virological failure.
13. What is AIDS?
Answer:
AIDS is advanced HIV disease, defined by either:
AIDS is advanced HIV disease, defined by either:
- A CD4 count below 200 cells/mm³, or
- A CD4 percentage below 14%, or
- An AIDS-defining illness, irrespective of CD4 count.
14. Does this patient automatically have AIDS because he has syphilis and herpes?
Answer:
No. Syphilis and ordinary genital herpes are STIs and do not themselves define AIDS. AIDS diagnosis depends on CD4 count or a recognized AIDS-defining condition.
No. Syphilis and ordinary genital herpes are STIs and do not themselves define AIDS. AIDS diagnosis depends on CD4 count or a recognized AIDS-defining condition.
15. Why are STIs common in people with HIV?
Answer:
They share sexual transmission risk factors. In addition, genital ulceration and inflammation caused by infections such as syphilis and herpes increase susceptibility to HIV acquisition and may increase HIV transmission when viral suppression is not achieved.
They share sexual transmission risk factors. In addition, genital ulceration and inflammation caused by infections such as syphilis and herpes increase susceptibility to HIV acquisition and may increase HIV transmission when viral suppression is not achieved.
Hard questions
16. What is the relationship between HIV and HSV-2?
Answer:
HSV-2 causes genital ulceration and inflammation, increasing the risk of HIV acquisition. In untreated HIV infection, HSV reactivation and genital shedding may be more frequent and severe. HIV-associated immunosuppression may produce chronic, extensive, atypical, or treatment-resistant herpetic lesions.
HSV-2 causes genital ulceration and inflammation, increasing the risk of HIV acquisition. In untreated HIV infection, HSV reactivation and genital shedding may be more frequent and severe. HIV-associated immunosuppression may produce chronic, extensive, atypical, or treatment-resistant herpetic lesions.
17. What are the common dermatological manifestations of HIV?
Answer:
They may be infective, inflammatory, neoplastic, or drug related.
They may be infective, inflammatory, neoplastic, or drug related.
- Infections: oral candidiasis, dermatophytosis, extensive molluscum contagiosum, recurrent herpes zoster, chronic HSV, scabies, bacterial skin infections, HPV warts
- Inflammatory disorders: seborrheic dermatitis, psoriasis, pruritic papular eruption, eosinophilic folliculitis, xerosis
- Neoplasms: Kaposi sarcoma, non-Hodgkin lymphoma, invasive cervical carcinoma
- Drug eruptions: due to antiretrovirals or drugs used for opportunistic infections.
18. Which skin conditions should prompt HIV testing?
Answer:
Examples include extensive or recurrent herpes zoster, chronic or extensive genital/oral herpes, oral candidiasis, recurrent bacterial infections, severe seborrheic dermatitis, extensive molluscum contagiosum in adults, multidermatomal zoster, pruritic papular eruption, and Kaposi sarcoma. Secondary syphilis is also a reason to test for HIV.
Examples include extensive or recurrent herpes zoster, chronic or extensive genital/oral herpes, oral candidiasis, recurrent bacterial infections, severe seborrheic dermatitis, extensive molluscum contagiosum in adults, multidermatomal zoster, pruritic papular eruption, and Kaposi sarcoma. Secondary syphilis is also a reason to test for HIV.
19. What is the significance of oral candidiasis in HIV?
Answer:
Oral candidiasis suggests significant immune suppression and should prompt HIV testing if status is unknown. Esophageal candidiasis is an AIDS-defining illness.
Oral candidiasis suggests significant immune suppression and should prompt HIV testing if status is unknown. Esophageal candidiasis is an AIDS-defining illness.
20. What is the significance of herpes zoster in HIV?
Answer:
Herpes zoster may occur at any CD4 count, but recurrent, severe, multidermatomal, disseminated, necrotic, or recurrent episodes should raise suspicion of HIV or advanced immunosuppression.
Herpes zoster may occur at any CD4 count, but recurrent, severe, multidermatomal, disseminated, necrotic, or recurrent episodes should raise suspicion of HIV or advanced immunosuppression.
21. What is the initial evaluation after an HIV diagnosis?
Answer:
I would:
I would:
- Confirm HIV diagnosis and establish linkage to HIV care
- Take history of symptoms, comorbidities, medications, sexual and exposure history
- Perform complete clinical examination, including skin, oral cavity, lymph nodes, and neurological examination
- Obtain CD4 count and HIV viral load
- Obtain HIV genotype resistance testing
- Check CBC, renal and liver function, urinalysis, fasting metabolic profile as per local protocol
- Screen for TB, hepatitis B, hepatitis C, and other STIs
- Review vaccine status
- Assess mental health, substance use, social support, and adherence barriers.
22. When should ART be started?
Answer:
ART is recommended for all people with HIV and should be started immediately or as soon as possible after diagnosis, including those with high CD4 counts. It improves survival and prevents transmission. NIH ART initiation guidance
ART is recommended for all people with HIV and should be started immediately or as soon as possible after diagnosis, including those with high CD4 counts. It improves survival and prevents transmission. NIH ART initiation guidance
23. What is the preferred principle for first-line ART?
Answer:
For most adults, the preferred approach is an integrase strand transfer inhibitor-based regimen with two nucleoside reverse transcriptase inhibitors. Choice depends on hepatitis B status, renal function, drug interactions, pregnancy potential, resistance data, availability, and national guidelines. NIH initial-regimen guidance
For most adults, the preferred approach is an integrase strand transfer inhibitor-based regimen with two nucleoside reverse transcriptase inhibitors. Choice depends on hepatitis B status, renal function, drug interactions, pregnancy potential, resistance data, availability, and national guidelines. NIH initial-regimen guidance
24. Give examples of first-line ART regimens.
Answer:
Common examples include:
Common examples include:
- Bictegravir/tenofovir alafenamide/emtricitabine
- Dolutegravir plus tenofovir with lamivudine or emtricitabine.
The final regimen must follow local and national HIV-programme guidance.
25. Name the classes of antiretroviral drugs.
Answer:
- Nucleoside/nucleotide reverse transcriptase inhibitors: NRTIs
- Non-nucleoside reverse transcriptase inhibitors: NNRTIs
- Protease inhibitors: PIs
- Integrase strand transfer inhibitors: INSTIs
- Entry/fusion inhibitors
- CCR5 antagonists
- Capsid inhibitors.
26. What is the aim of ART?
Answer:
To achieve durable undetectable HIV viral load, restore and preserve immunity, reduce HIV-related morbidity and mortality, prevent HIV transmission, and improve quality and duration of life.
To achieve durable undetectable HIV viral load, restore and preserve immunity, reduce HIV-related morbidity and mortality, prevent HIV transmission, and improve quality and duration of life.
27. What does U=U mean?
Answer:
U=U means undetectable equals untransmittable. A person who maintains an undetectable viral load on ART does not sexually transmit HIV. It does not prevent transmission of syphilis, herpes, gonorrhea, or other STIs.
U=U means undetectable equals untransmittable. A person who maintains an undetectable viral load on ART does not sexually transmit HIV. It does not prevent transmission of syphilis, herpes, gonorrhea, or other STIs.
28. Does genital herpes delay ART?
Answer:
No. Genital herpes should not delay ART. HSV lesions can occasionally flare in the first months after ART initiation, especially at low CD4 count, but HSV is treated concurrently.
No. Genital herpes should not delay ART. HSV lesions can occasionally flare in the first months after ART initiation, especially at low CD4 count, but HSV is treated concurrently.
29. Does secondary syphilis delay ART?
Answer:
No. Treat secondary syphilis and initiate ART promptly. There is no reason to delay ART solely due to uncomplicated secondary syphilis.
No. Treat secondary syphilis and initiate ART promptly. There is no reason to delay ART solely due to uncomplicated secondary syphilis.
30. What is IRIS?
Answer:
Immune reconstitution inflammatory syndrome is a paradoxical inflammatory worsening of a known infection, or unmasking of a previously subclinical infection, after starting ART due to recovering immune function.
Immune reconstitution inflammatory syndrome is a paradoxical inflammatory worsening of a known infection, or unmasking of a previously subclinical infection, after starting ART due to recovering immune function.
31. When is IRIS more likely?
Answer:
It is more likely with advanced immunosuppression, especially low baseline CD4 count, high pathogen burden, and a short interval between treatment of an opportunistic infection and ART initiation.
It is more likely with advanced immunosuppression, especially low baseline CD4 count, high pathogen burden, and a short interval between treatment of an opportunistic infection and ART initiation.
32. Does every clinical worsening after ART mean IRIS?
Answer:
No. Consider nonadherence, drug adverse effects, drug interactions, antimicrobial resistance, a newly acquired infection, disease progression, or an incorrect initial diagnosis.
No. Consider nonadherence, drug adverse effects, drug interactions, antimicrobial resistance, a newly acquired infection, disease progression, or an incorrect initial diagnosis.
Very hard questions
33. What are the criteria for virological failure?
Answer:
The exact threshold varies by guideline and programme. In practice, persistent detectable viral load on repeat testing after adherence assessment suggests virological failure. A single raised viral load must be interpreted cautiously and confirmed after checking adherence, interactions, and treatment interruption.
The exact threshold varies by guideline and programme. In practice, persistent detectable viral load on repeat testing after adherence assessment suggests virological failure. A single raised viral load must be interpreted cautiously and confirmed after checking adherence, interactions, and treatment interruption.
34. What is a viral blip?
Answer:
A viral blip is an isolated, low-level detectable HIV RNA result after prior suppression that returns to undetectable without changing therapy. It is different from persistent virological rebound.
A viral blip is an isolated, low-level detectable HIV RNA result after prior suppression that returns to undetectable without changing therapy. It is different from persistent virological rebound.
35. What should you do if viral load remains detectable on ART?
Answer:
First assess adherence, treatment interruptions, vomiting or malabsorption, drug interactions, dosing, and access barriers. Repeat viral load as per protocol. If persistent viraemia is confirmed, obtain resistance testing where possible and revise therapy with an HIV specialist.
First assess adherence, treatment interruptions, vomiting or malabsorption, drug interactions, dosing, and access barriers. Repeat viral load as per protocol. If persistent viraemia is confirmed, obtain resistance testing where possible and revise therapy with an HIV specialist.
36. What is the difference between HIV drug resistance testing and viral load testing?
Answer:
Viral load tells us whether HIV replication is controlled. Resistance testing identifies viral mutations that reduce susceptibility to antiretroviral drugs and helps select an effective regimen.
Viral load tells us whether HIV replication is controlled. Resistance testing identifies viral mutations that reduce susceptibility to antiretroviral drugs and helps select an effective regimen.
37. Why is hepatitis B testing essential before starting ART?
Answer:
Tenofovir, lamivudine, and emtricitabine have activity against hepatitis B. If a patient has chronic hepatitis B, stopping these drugs without an alternative HBV-active treatment can cause hepatitis B reactivation or hepatic flare. Therefore, ART selection must account for HBV status.
Tenofovir, lamivudine, and emtricitabine have activity against hepatitis B. If a patient has chronic hepatitis B, stopping these drugs without an alternative HBV-active treatment can cause hepatitis B reactivation or hepatic flare. Therefore, ART selection must account for HBV status.
38. Which opportunistic-infection prophylaxis is considered at CD4 count below 200 cells/mm³?
Answer:
Primary prophylaxis for Pneumocystis jirovecii pneumonia is generally indicated at CD4 below 200 cells/mm³, particularly below 100 cells/mm³, or with oral candidiasis. Trimethoprim-sulfamethoxazole is commonly used, subject to local guidance and contraindications.
Primary prophylaxis for Pneumocystis jirovecii pneumonia is generally indicated at CD4 below 200 cells/mm³, particularly below 100 cells/mm³, or with oral candidiasis. Trimethoprim-sulfamethoxazole is commonly used, subject to local guidance and contraindications.
39. What is the common prophylaxis for Pneumocystis jirovecii pneumonia?
Answer:
Trimethoprim-sulfamethoxazole, usually one double-strength tablet daily or an equivalent local regimen. The decision should follow CD4 count, clinical setting, allergy history, renal function, and national protocol.
Trimethoprim-sulfamethoxazole, usually one double-strength tablet daily or an equivalent local regimen. The decision should follow CD4 count, clinical setting, allergy history, renal function, and national protocol.
40. At what CD4 count is prophylaxis for disseminated MAC considered?
Answer:
In settings using prophylaxis, it may be considered at CD4 below 50 cells/mm³ when effective ART cannot be started immediately or viral suppression is not expected promptly. If effective ART is commenced immediately, routine MAC prophylaxis is often not required.
In settings using prophylaxis, it may be considered at CD4 below 50 cells/mm³ when effective ART cannot be started immediately or viral suppression is not expected promptly. If effective ART is commenced immediately, routine MAC prophylaxis is often not required.
41. Why are live vaccines approached cautiously in HIV?
Answer:
Because live attenuated vaccines can cause disease in people with severe immunosuppression. Their use depends on CD4 count, clinical status, and vaccine-specific recommendations. Inactivated vaccines are generally safe, though immune response may be reduced.
Because live attenuated vaccines can cause disease in people with severe immunosuppression. Their use depends on CD4 count, clinical status, and vaccine-specific recommendations. Inactivated vaccines are generally safe, though immune response may be reduced.
42. What are the AIDS-defining malignancies?
Answer:
Kaposi sarcoma, certain aggressive B-cell non-Hodgkin lymphomas, and invasive cervical carcinoma.
Kaposi sarcoma, certain aggressive B-cell non-Hodgkin lymphomas, and invasive cervical carcinoma.
43. How does Kaposi sarcoma present in the skin?
Answer:
It presents as painless, non-blanching violaceous, red-brown, or dark plaques, papules, or nodules. It may occur on skin, oral mucosa, lymph nodes, gastrointestinal tract, and lungs. It is associated with HHV-8.
It presents as painless, non-blanching violaceous, red-brown, or dark plaques, papules, or nodules. It may occur on skin, oral mucosa, lymph nodes, gastrointestinal tract, and lungs. It is associated with HHV-8.
44. How would you counsel this patient regarding disclosure to his spouse?
Answer:
I would counsel privately and nonjudgmentally, explain the benefits of partner testing and treatment, offer confidential partner-notification support, and follow applicable legal and public-health requirements. His spouse should be urgently offered HIV testing, syphilis testing, STI assessment, and appropriate prevention or treatment.
I would counsel privately and nonjudgmentally, explain the benefits of partner testing and treatment, offer confidential partner-notification support, and follow applicable legal and public-health requirements. His spouse should be urgently offered HIV testing, syphilis testing, STI assessment, and appropriate prevention or treatment.
45. What will you tell the spouse if she is HIV-negative?
Answer:
She needs HIV testing now and repeat testing according to the exposure timeline and local protocol. If a relevant exposure was within 72 hours, assess for HIV PEP urgently. If there is continuing risk, discuss PrEP. She should also receive full STI assessment and treatment as indicated.
She needs HIV testing now and repeat testing according to the exposure timeline and local protocol. If a relevant exposure was within 72 hours, assess for HIV PEP urgently. If there is continuing risk, discuss PrEP. She should also receive full STI assessment and treatment as indicated.
One-minute HIV summary for examiner
“HIV is a lentiviral infection that targets CD4 T cells and causes progressive immunodeficiency. In this patient, HIV is associated with multiple STIs, including secondary syphilis and genital herpes. I will assess immune status with CD4 count and viral load, screen for TB, hepatitis, and other STIs, and obtain baseline renal, liver, hematological, and resistance testing. ART should be started immediately or as soon as possible, typically with an integrase inhibitor plus two NRTIs, selected according to local guidelines and hepatitis B, renal, and resistance status. I will treat the concurrent STIs, counsel regarding adherence, condoms, partner notification, and U=U after sustained viral suppression, while continuing regular viral-load and STI follow-up.”
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