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

Paul E. Sax, MDClinical Director, Division of Infectious DiseasesBrigham and Women’s HospitalProfessor of MedicineHarvard Medical SchoolBoston, MA

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

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

40-year-old Woman with Long-standing HIV Infection

Do you think the nephrolithiasis is due to atazanavir? 1. Yes2. No

40-year-old Woman with Long-standing HIV Infection

Question to consider:• How would you prove this?

40-year-old Woman with Long-standing HIV Infection

She is quite happy taking the current regimen. Would you encourage her to switch? 1. Yes2. No

40-year-old Woman with Long-standing HIV Infection

Question to consider:• Why / why not?

40-year-old Woman with Long-standing HIV Infection

If she switches treatment, what regimen would you choose?1. FTC / RPV / TDF (Eviplera, Complera)2. TDF / FTC / EFV (Atripla)3. TDF / FTC / EVG / COBI (Stribild)4. DTG-based regimen 5. RTV-boosted PI monotherapy6. Maraviroc-containing regimen7. Other

Case 3: 46-year-old Man with Untreated HIV Infection

Paul E. Sax, MDClinical Director, Division of Infectious DiseasesBrigham and Women’s HospitalProfessor of MedicineHarvard Medical SchoolBoston, MA

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

46-year-old Man with Untreated HIV Infection

• During this current hospitalization, he is diagnosed with Pneumocystis pneumonia and treated with high-dose trimethoprim/sulfamethoxazole and 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  

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 (raltegravir resistance)

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?

46-year-old Man with Untreated HIV Infection

What regimen would you recommend for this patient?1. FTC / RPV / TDF (Eviplera, Complera)2. TDF / FTC / EFV (Atripla)3. TDF / FTC / EVG / COBI (Stribild)4. DTG + TDF / FTC 5. Protease inhibitor + TDF / FTC regimen6. Other

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?