A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

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A Guide to Primary Care of People with HIV/AIDS Chapter 5: Antiretroviral Therapy CASES 1. 5 A 36-year-old woman is asymptomatic and has a CD4 cell count of 210/mm 3 and a baseline viral load of >750,000 copies/mL. Other laboratory studies are unremarkable. She seeks your advice regarding management. Question: What can you recommend? a. zidovudine (AZT) plus stavudine (d4T) plus efavirenz (EFV) b. lamivudine (3TC) plus zidovudine plus nelfinavir (NFV) c. Trizivir (AZT + 3TC + ABC) plus lopinavir/ritonavir (LPV/r) d. Trizivir e. lamivudine plus stavudine plus indinavir (IDV) Answer: Virtually all of these are feasible except option a, which combines zidovudine and stavudine, a combination that shows pharmacologic antagonism. The worrisome part of her presentation is that the CD4 cell count is quite low and approaching the threshold of vulnerability to opportunistic infections, and the viral load is very high, which poses substantial challenge to virologic control. The best drugs for baseline high viral load according to currently available data are 2 nucleosides combined with efavirenz or lopinavir/ritonavir. Thus, option c would be the best choice. 2. A 42-year-old truck driver has HIV infection that was treated in 1999 with efavirenz (EFV), stavudine (d4T), and lamivudine (3TC). He subsequently did well and maintained a viral load of
A Guide to Primary Care of People with HIV/AIDS Chapter 5: Antiretroviral Therapy 3. A 36-year-old woman sees you for evaluation of HIV infection, which she has had since 1985. There have been multiple courses of treatment, including nucleosides in the period 1987 to 1996 and since then nucleosides combined with NNRTIs and PIs. The longest course of treatment was with zidovudine (AZT), lamivudine (3TC), and efavirenz (EFV), which produced a temporary period of virologic control but then failed. Currently she is receiving amprenavir (APV), lopinavir/ritonavir (LPV/r), and tenofovir (TDF). You perform a resistance test, which shows mutations on the reverse transcriptase gene at codons 41, 210, and 215 and mutations on the protease gene at 30 and 82. The conclusion is that HIV is resistant to most NRTIs and PIs. Her current numbers show a CD4 cell count of 87/mm 3 and a viral load of 210,000 c/mL. Question: What would you recommend? a. zidovudine plus lamivudine plus tenofovir plus efavirenz b. lopinavir/ritonavir plus efavirenz plus tenofovir c. AZT/3TC/ABC (Trizivir) plus lopinavir/ritonavir d. AZT/3TC/ABC plus tenofovir plus indinavir (IDV) plus ritonavir (RTV) e. enfurvirtide (T-20) plus atazanavir plus lamivudine plus tenofovir Answer: The tricky part of this question is the need to assume resistance to efavirenz and lamivudine despite the failure to demonstrate the associated mutations: 103 and 184 on the RT gene. This reflects the fact that these drugs were not being given at the time the test was done, but history suggests that resistance to these drugs occurred at the time of failure. The point is that interpretation of resistance tests must take into account both the current pattern and the history of drug exposure in terms of specific agent, duration, and virologic outcome. This patient is running low on options and low on CD4 cells. She does have some PI options, but the most predictable response would probably be a regimen with the fusion inhibitor enfurvirtide (option e). 5 4. A 50-year-old secretary has just learned that he has HIV infection with a CD4 cell count of 49/mm 3 and viral load of 280,000 c/mm 3 . He is quite shaken by this information, claims that he has never been able to take pills for anything and wants treatment, but wants it to be as simple as possible. Question: What would you recommend? a. Delay therapy until the patient is ready b. AZT/3TC/ABC (Trizivir) plus efavirenz (EFV) c. tenofovir (TDF), lamivudine (3TC), plus efavirenz d. zidovudine (AZT), lamivudine, amprenavir (APV), and ritonavir (RTV) e. AZT/3TC/ABC (Trizivir) f. zidovudine plus efavirenz plus indinavir (IDV) Answer: This patient needs to be treated rapidly because he is highly vulnerable to major opportunistic infections. We emphasize the need for patient readiness, but this patient does not have much time to get ready. Training will take substantial effort as described in Chapter 7: Adherence to HIV Therapies. We would like potency plus convenience to facilitate adherence. The combination of lamivudine plus tenofovir plus efavirenz (option c) means 4 pills once a day, which could be taken, for example, when he shaves. U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau 37
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