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

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).
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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
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