Case 2: 40-year-old Woman with Long-standing HIV Infection

1. Case 2: 40-year-old Woman with Long-standing HIV Infection Paul E. Sax, MD Clinical Director, Division of Infectious Diseases Brigham and Women’s Hospital Professor of Medicine Harvard Medical School Boston, MA

2. 40-year-old Woman with Long-standing HIV Infection • 40-year-old woman with long-standing HIV infection develops flank pain and hematuria • Seen in the ER and diagnosed with nephrolithiasis • After IV hydration and pain control, discharged in stable condition   • At follow-up 3 days later, has completely recovered   • Diagnosed as HIV-positive 10 years prior during pregnancy

3. 40-year-old Woman with Long-standing HIV Infection • Treated with AZT/3TC and LPV/r during pregnancy • After delivering child in 2005, she was changed to TDF/FTC, ATV/r once daily, which she has tolerated well thus far • Other medical problems include obesity, hypertension controlled with thiazide diuretic, and depression, for which she takes citalopram • She smokes 1/2 pack of cigarettes/day • Does not drink or use drugs

4. 40-year-old Woman with Long-standing HIV Infection Do you think the nephrolithiasis is due to atazanavir? • Yes • No

5. 40-year-old Woman with Long-standing HIV Infection Question to consider: • How would you prove this?

6. 40-year-old Woman with Long-standing HIV Infection She is quite happy taking the current regimen. Would you encourage her to switch? • Yes • No

7. 40-year-old Woman with Long-standing HIV Infection Question to consider: • Why / why not?

8. 40-year-old Woman with Long-standing HIV Infection If she switches treatment, what regimen would you choose? • FTC / RPV / TDF (Eviplera, Complera) • TDF / FTC / EFV (Atripla) • TDF / FTC / EVG / COBI (Stribild) • DTG-based regimen • RTV-boosted PI monotherapy • Maraviroc-containing regimen • Other

9. Case 3: 46-year-old Man with Untreated HIV Infection Paul E. Sax, MD Clinical Director, Division of Infectious Diseases Brigham and Women’s Hospital Professor of Medicine Harvard Medical School Boston, MA

10. 46-year-old Man with Untreated HIV Infection • 46-year-old man admitted with fever and shortness of breath  • Diagnosed as HIV positive 3 years before this admission when he was found to have leukopenia and anemia • At that time, CD4 cell count = 110; HIV RNA = 77,000; no baseline resistance • Antiretroviral therapy was recommended, but the patient did not believe the results of the blood tests since he felt completely well, and he never filled the prescriptions

11. 46-year-old Man with Untreated HIV Infection • During this current hospitalization, he is diagnosed with Pneumocystis pneumonia and treated with high-dose trimethoprim/sulfamethoxazoleand prednisone • CD4 cell count on admission = 10 • HIV RNA = 940,000 cop/mL • Hospital day 5, he is started on ART with TDF/FTC and raltegravir

12. 46-year-old Man with Untreated HIV Infection • After a 14-day hospitalization, he is discharged home with plans for close follow-up • Fails to show up for his first appointment • Arrives unannounced in clinic 1 month after discharge complaining of dysphagia • Reports intermittent compliance with his ART regimen • Examination demonstrates extensive oral candidiasis • CD4 cell count = 40 • HIV RNA = 80,000 • A resistance genotype demonstrates M184V (3TC and FTC resistance) and N155H (raltegravirresistance)

13. 46-year-old Man with Untreated HIV Infection Question to consider: • What are some strategies to manage patients whose belief systems are at odds with our medical recommendations?

14. 46-year-old Man with Untreated HIV Infection What regimen would you recommend for this patient? • FTC / RPV / TDF (Eviplera, Complera) • TDF / FTC / EFV (Atripla) • TDF / FTC / EVG / COBI (Stribild) • DTG + TDF / FTC • Protease inhibitor + TDF / FTC regimen • Other

15. 46-year-old Man with Untreated HIV Infection Question to consider: • What supports would you put in place to help maximize the chances of treatment success?