1. VIRTUAL MEDZONE Your Resource for HIV Related Innovative Medical Communication

2. HIV CASE PRESENTATIONS Mike Silverman MD FRCPC David Fletcher MD FRCPC

3. CASE 1 63 yo man HIV+ 1985 CD4 nadir 42 Previous PCP Anal Squamous Cell Cancer… in remission

4. CASE 1 2007 AZT/3TC/Abacavir/RTV/Lopinavir CD4 650 Viral load <50

5. CASE 1 DATEALTASTPLTSALBINR 01/055145---- 01/067346---- 10/0612973288411.0 01/07153100---- 03/07238130296421.0

6. CASE 1 No family history of liver disease No alcohol consumption/illicit drug use No new HIV medications Vaccinated for Hep A & B

7. CASE 1 Fenofibrate initiated in late 2006 for elevated triglycerides…this medication was discontinued in early 2007 with no improvement seen in liver enzymes over the next 2 months

8. CASE 1 DATEALTASTPLTSALBINR 01/055145---- 01/067346---- 10/0612973288411.0 01/07153100---- 03/07238130296421.0

9. CASE 1 MARCH 2007 HepA IgG (+) HepB sAb (+) HepC Ab (-) Iron studies/secondary liver disease workup negative

10. CASE 1 MARCH 2007 HCVRNA and HBVDNA negative U/S – Enlarged, fatty liver WHAT WOULD YOU DO?

11. CASE 1 Lipids optimized Antiretrovirals switched from AZT/3TC/ ABC/RTV/LPV to ABC/3TC/TDF/ATZ in June/07

12. CASE 1 DATEALTAST 03/07238130 07/0712264 08/075645 12/07334267 02/08228173 08/08362184 09/088454 09/107656 09/118853 ATZ → RTV/LPVr RTV/LPVr → ATZ

13. CASE 1 2008-2010 Serial Fibrotest + APRI suggest scarring stability around F 2/4 No changes on serial U/S

14. CASE 1 SEPTEMBER 2011 ABC/3TC/TDF/ATZ ALT 88 AST 53 Fibrotest F3/4 scarring → Progression!!!

15. CASE 1 DATECREATEGFRALB/CREATURINALYSIS 200882770.3(-) 20101235420.2+ protein 0.3 g/l 20111304719.4+ protein 1 g/l + GLUCOSE

16. CASE 1 WHAT WOULD YOU DO?

17. CASE 1 PREVIOUS ANTIRETROVIRAL HISTORY AZT monotherapy AZT/3TC/SQV with viral load 1500 AZT/3TC/ABC/RTV/LPVr or ABC/3TC/TDF/ATZ → 3 viral load blips >50 in 8 years No genotypes available

18. CASE 1 Which antiretroviral regimen would you choose given fatty liver disease and renal abnormalities?