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

A Guide to Primary Care of People with HIV/AIDS
Chapter 6: Metabolic Complications of Antiretroviral Therapy
CASES
1.
A 36-year-old HIV-infected man has received stavudine (d4T) plus lamivudine (3TC) plus indinavir (IDV)
for approximately 4 years. This regimen was his first regimen and before starting therapy his HIV RNA
was 59,000 copies/mL and his CD4 count was 34 cells/mm 3 . His antiviral and immunologic response
has been excellent, with HIV RNA levels persistently less than 50 copies/mL and a CD4 count that
has increased to 526 cells/mm 3 . In the past 9 months, however, he has developed hyperlipidemia,
hyperglycemia, and body fat changes, most notably enlargement of his abdominal region and facial
thinning. He has been very hesitant to change his regimen but now comes into the clinic to discuss this
matter again.
Question: If he changes his antiretroviral regimen, will he likely continue to have excellent
control of HIV?
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Answer:
Since this patient has experienced excellent long-term viral suppression and this was his first regimen, it
is highly likely that a switch from a PI to a NNRTI (efavirenz [EFV] or nevirapine [NVP]) would maintain
continued viral suppression. Similarly, a change from one NRTI to another would likely have no adverse
affect on HIV suppression. In patients who have previously developed resistance and are currently on
a salvage regimen, changing a medication because of side effects can pose a much greater risk of not
maintaining excellent virologic control.
Question: What improvements would he likely expect if he makes a change?
Answer:
Among the problems this patient has developed as a complication of ART, insulin resistance and
hyperlipidemia are the most likely to improve with a regimen change. In particular, several studies have
shown switching from a PI to either nevirapine, efavirenz, or abacavir (ABC) typically leads to significant
improvement in hyperglycemia and insulin resistance. Improvements in lipids are most likely to occur if the
PI is switched to either nevirapine or abacavir. Switching from one PI to the new PI atazanavir (ATV) may
provide significant improvement in lipid abnormalities. Unfortunately, changing from a PI to an NNRTI
has not produced reliable improvements in lipodystrophy. Changing from stavudine to either abacavir or
tenofovir (TDF) may provide some improvement in lipodystrophy for some patients. Although tenofovir
causes less lipodystrophy than stavudine, studies that examine the effect of changing stavudine to
tenofovir have not been performed.
U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau
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