1. 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

2. 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

3. 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

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

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

6. 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

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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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