Case 2: 40-year-old Woman with Long-standing HIV Infection Paul E. Sax, MD Clinical Director, Division of Infectious Diseases Brigham and Women’s Hospital Professor of Medicine Harvard Medical School Boston, MA

40-year-old Woman with Long-standing HIV Infection 40-year-old woman with long-standing HIV infection develops flank pain and hematuria Seen in the ER and diagnosed with nephrolithiasis After IV hydration and pain control, discharged in stable condition   At follow-up 3 days later, has completely recovered   Diagnosed as HIV-positive 10 years prior during pregnancy 2 2

40-year-old Woman with Long-standing HIV Infection Treated with AZT/3TC and LPV/r during pregnancy After delivering child in 2005, she was changed to TDF/FTC, ATV/r once daily, which she has tolerated well thus far Other medical problems include obesity, hypertension controlled with thiazide diuretic, and depression, for which she takes citalopram She smokes 1/2 pack of cigarettes/day Does not drink or use drugs 3 3

40-year-old Woman with Long-standing HIV Infection Do you think the nephrolithiasis is due to atazanavir? Yes No 4 4

40-year-old Woman with Long-standing HIV Infection Question to consider: How would you prove this? 5 5

40-year-old Woman with Long-standing HIV Infection She is quite happy taking the current regimen. Would you encourage her to switch? Yes No 6 6

40-year-old Woman with Long-standing HIV Infection Question to consider: Why / why not? 7 7

40-year-old Woman with Long-standing HIV Infection If she switches treatment, what regimen would you choose? FTC / RPV / TDF (Eviplera, Complera) TDF / FTC / EFV (Atripla) TDF / FTC / EVG / COBI (Stribild) DTG-based regimen RTV-boosted PI monotherapy Maraviroc-containing regimen Other 8 8

Case 3: 46-year-old Man with Untreated HIV Infection Paul E. Sax, MD Clinical Director, Division of Infectious Diseases Brigham and Women’s Hospital Professor of Medicine Harvard Medical School Boston, MA

46-year-old Man with Untreated HIV Infection 46-year-old man admitted with fever and shortness of breath  Diagnosed as HIV positive 3 years before this admission when he was found to have leukopenia and anemia At that time, CD4 cell count = 110; HIV RNA = 77,000; no baseline resistance Antiretroviral therapy was recommended, but the patient did not believe the results of the blood tests since he felt completely well, and he never filled the prescriptions 10 10

46-year-old Man with Untreated HIV Infection During this current hospitalization, he is diagnosed with Pneumocystis pneumonia and treated with high-dose trimethoprim/sulfamethoxazole and prednisone CD4 cell count on admission = 10 HIV RNA = 940,000 cop/mL Hospital day 5, he is started on ART with TDF/FTC and raltegravir   11 11

46-year-old Man with Untreated HIV Infection After a 14-day hospitalization, he is discharged home with plans for close follow-up Fails to show up for his first appointment Arrives unannounced in clinic 1 month after discharge complaining of dysphagia Reports intermittent compliance with his ART regimen Examination demonstrates extensive oral candidiasis CD4 cell count = 40 HIV RNA = 80,000 A resistance genotype demonstrates M184V (3TC and FTC resistance) and N155H (raltegravir resistance) 12 12

46-year-old Man with Untreated HIV Infection Question to consider: What are some strategies to manage patients whose belief systems are at odds with our medical recommendations? 13 13

46-year-old Man with Untreated HIV Infection What regimen would you recommend for this patient? FTC / RPV / TDF (Eviplera, Complera) TDF / FTC / EFV (Atripla) TDF / FTC / EVG / COBI (Stribild) DTG + TDF / FTC Protease inhibitor + TDF / FTC regimen Other 14 14

46-year-old Man with Untreated HIV Infection Question to consider: What supports would you put in place to help maximize the chances of treatment success? 15 15