216.3 🩺 內科專科考前版

216.3.0.1 1⃣ Acute HIV Recognition

  • Mononucleosis-like + risk exposure + maculopapular rash → consider acute HIV
  • Distinguish from EBV/CMV mono: HIV RNA PCR
  • ALL acute mono-like illness in sexually active adults → HIV test
  • Test fertility-aged women planning pregnancy

216.3.0.2 2⃣ Functional Cure Cases

  • Berlin patient (Timothy Brown) 2008: CCR5Δ32/Δ32 stem cell transplant for leukemia → no detectable HIV off ART
  • London patient (Adam Castillejo) 2019: similar transplant context, ART discontinuation, no rebound
  • DÃŒsseldorf patient 2023: similar
  • NYC “Sister patient” 2023: cord blood + adult stem cell with CCR5Δ32 — first reported in woman
  • New York patient 2024: Esperanza patient — natural control without transplant
216.3.0.2.1 Common feature
  • CCR5Δ32/Δ32 homozygous mutation (HIV-resistant)
  • HSCT prerequisite
  • Not generalizable but proof of principle

216.3.0.3 3⃣ HIV Reservoir Research

  • Latent reservoir = barrier to cure
  • “Shock and kill” strategy (latency reversing agents + immune clearance)
  • “Block and lock” alternative (maintain latency permanently)
  • Broadly neutralizing antibodies (bNAbs) in trials
  • CRISPR + gene editing approaches

216.3.0.4 4⃣ HIV-2 Specifics

  • Naturally R to NNRTIs (efavirenz, nevirapine, rilpivirine don’t work)
  • Treatment: INSTI + NRTI backbone (TDF/FTC + dolutegravir works)
  • No commercially available HIV-2 RNA quantitative assay routine — use CD4 + clinical
  • Slower progression

216.3.0.5 5⃣ Window Period Counseling

  • Negative test < 3 mo post-exposure: not definitive
  • 4th-gen combo highly sensitive at 3-6 wk
  • Repeat at 3 mo for high-risk exposure
  • Post-exposure prophylaxis (PEP) within 72 hr if known exposure

216.3.0.6 6⃣ Self-Testing

  • HIV self-tests (OraQuick, Sure Check) — antibody-based
  • Window ~ 3 mo for definitive
  • Useful for hard-to-reach populations
  • Counseling + linkage to care critical

216.3.0.7 7⃣ HIV in Pregnancy

  • All pregnant women → HIV screen 1st prenatal + 3rd trimester
  • Prevention of mother-to-child transmission (PMTCT):
    • Maternal ART throughout pregnancy + labor
    • Infant ART prophylaxis for 4-6 wk post-delivery
    • Avoid breastfeeding in resource-rich (formula); breastfeed + maternal ART in resource-limited
    • Cesarean if VL > 1000 at delivery
  • Result: < 2% transmission with proper PMTCT

216.3.0.8 8⃣ 健保 / Taiwan

  • 公費 HIV testing free (公費 program)
  • 通報 mandatory
  • ART 健保 covered universally Taiwan
  • PrEP 自費 mostly (some 公費 for high-risk groups)
  • Public Health surveillance

216.3.0.9 9⃣ Counseling at Diagnosis

  • Acknowledge emotional impact
  • Confidentiality emphasized
  • Linkage to care immediately
  • Discuss U=U + ART benefits
  • Mental health screening
  • Partner notification (assisted)
  • Substance use + harm reduction (if applicable)
  • Long-term care plan

216.3.0.10 10. Stigma + Criminalization

  • HIV criminalization laws (sex without disclosure) — ongoing reform efforts
  • U=U messaging reduces stigma
  • Healthcare provider knowledge + advocacy