1. Case 4: 65-year-old Man Newly Diagnosed, Has Other Health Issues Paul E. Sax, MD Clinical Director, Division of Infectious Diseases Brigham and Women’s Hospital Professor of Medicine Harvard Medical School Boston, MA

2. 65-year-old Man Newly Diagnosed, Has Other Health Issues 65-year-old man is newly diagnosed with HIV infection Celebrated retirement with prolonged trip to Brazil During the trip, he had multiple episodes of unprotected sex with both men and women After a lengthy "flu" (3 months ago) that in hindsight was likely acute HIV infection, he is found to be HIV-antibody positive

3. 65-year-old Man Newly Diagnosed, Has Other Health Issues Physical exam: BP = 160/110 Otherwise normal CD4 cell count = 310 HIV RNA = 144,000 Genotype shows no resistance Past medical history: Notable for difficult-to-control hypertension requiring amlodipine, lisinopril, and metoprolol Diabetes, treated with glipizide and metformin Other medications include simvastatin and sildenafil Renal function is normal, and he has no proteinuria

4. 65-year-old Man Newly Diagnosed, Has Other Health Issues Would you start ART now or wait another 2 to 3 months since HIV has been acquired recently and perhaps he has not reached his “set point”? 1. Start now 2. Wait 2-3 months 3. Wait longer

5. 65-year-old Man Newly Diagnosed, Has Other Health Issues Question to consider: What is the optimal initial regimen in a patient with several cardiovascular and renal risk factors?