A 28-year-old man was diagnosed with HIV infection 6 months ago
during an annual routine checkup. The patient believes he acquired the
infection during
... [Show More] college when he had episodes of binge drinking alcohol
and communal, unprotected heterosexual sex. For the last 3 years, the
patient has abstained from alcohol and he has become committed to 1
sexual partner. The patient is currently asymptomatic.
His partner was tested for HIV infection 6 months and 1 week ago and
she was negative in both instances. The couple only engages in
protected vaginal sex with condoms.
The patient brings copies of the results of his test performed at the office
of another health care professional (see Table).
Date CD4+ cell count, cells/µLHIV viral load, copies/mL
6 months ago742 24,200
1 week 750 25,600
Which of the following is the best recommendation regarding
antiretroviral therapy (ART) for this patient?
Start ART after checking HIV genotyping and coreceptor tropism test results.
Start ART now.
Start ART after checking HIV genotyping test results.
Delay ART until the CD4+ cell count is < 350 cells/µL.
Delay ART until the CD4+ cell count is < 200 cells/µL.
Remediation
Educational Objective:
Select the initial therapy for patients with previously untreated AIDS.
Key Point:
ART should be started in any patient infected with HIV regardless of CD4+ count.
Explanation:
Antiretroviral therapy (ART) is recommended for all individuals with HIV, regardless of CD4 T
lymphocyte cell count, to reduce the morbidity and mortality associated with HIV infection. In
this particular patient, ART is further indicated to prevent the transmission of HIV infection to
his sexual partner.
Because there is risk of acquiring a resistant strain of HIV, testing for HIV drug resistance is
recommended for all persons infected with HIV when they enter care, regardless of whether
ART will be immediately initiated or whether it is to be deferred. If therapy is deferred, then
repeat testing at the time of initiating ART should be considered. Genotyping testing is
preferred to phenotyping for checking resistance.
A coreceptor tropism test will determine whether the virus will bind the CCR5 or CXCR4 cell
receptors or both. This test is only indicated if there are plans to use a CCR5 inhibitor, which
is not part of the preferred initial ART combinations.
Reference:
Panel on Antiretroviral Guidelines for Adults and Adolescents; US Department of Health and
Human Services. Guidelines for the use of antiretroviral agents in adults and
adolescents living with HIV. Updated May 30, 2018. Accessed July 9, 2018.
Question 2
Edited: Jul 15, 2019
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Stem & Answers
A 35-year-old man is admitted to the hospital with hypoxia and bilateral
infiltrates on chest x-ray. He is diagnosed with Pneumocystis pneumonia
(PCP) and is successfully treated. His HIV test result is positive; his
CD4+ cell count is 154 cells/µL and his HIV viral load is 150,000
copies/mL.
At an outpatient visit 2 weeks later, the patient is started on abacavir,
lamivudine, and vicriviroc (a CCR5 inhibitor). Four weeks after beginning
antiretroviral therapy (ART), the patient returns and reports good
compliance and no symptoms.
During the next 2 weeks, the patient develops a fever of 102 °F (38.9
°C), diffuse maculopapular rash, diarrhea, malaise, fatigue, myalgia, and
mild shortness of breath.
Laboratory tests reveal the following:
White blood cells: 3500/µL
Hemoglobin: 10.8 g/dL
Hematocrit: 30% [Show Less]