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

2. HIV CASE PRESENTATIONS Roger Leblanc MD FRCPC Joss DeWet MBChB CCFP David Fletcher MD FRCPC

3. CASE 1 31 yo man HIV+ mid 2008 Clade B CD4 1130/38%, VL 100,000-200,000 Genotype clear

4. CASE 1 BASELINE GENOTYPE JUL/08

5. CASE 1 Late 2009…1 year later VL >500,000 CD4 down to 440/22% Feeling weak/tired

6. CASE 1 Late 2009 Initiated TDF/FTC/EFV/RTV/LPV as induction therapy given high viral load and precipitous decline in CD4 from over 1100 1 year previously

7. CASE 1 Late 2009 Diarrhea/vomiting/abdominal pain and anorexia Unable to tolerate therapy RTV/LPV discontinued from regime within first week continued TDF/FTC/EFV

8. CASE 1 Late 2009 Began to feel much improved from a GI standpoint so RTV/Darunavir added to TDF/FTC/ EFV Nausea/vomiting restarted so RTV/DRV discontinued within 1 wk

9. CASE 1 1 MONTH into therapy…TDF/FTC/EFV CD4 440/22% → 840/31% VL >500,000 → 1659 c/ml

10. CASE 1 2 Months into therapy…TDF/FTC/EFV CD4 730/28 % VL 1659 → 2085 WHAT WOULD YOU DO?

11. CASE 1 Persisted with TDF/FTC/EFV and was adherent by history DATEVIRAL LOADCD4 01/102085730/28% 02/10184970/33% 03/10104840/32% 04/10187870/40%

12. CASE 1 GENOTYPE JAN/10

13. CASE 1 GENOTYPE JAN/10

14. CASE 1 TROPISM JAN/10

15. CASE 1 MAY 2010 Raltegravir added to TDF/FTC/EFV Tolerated well/no problems

16. CASE 1 JUNE 2010 TDF/FTC/EFV/RGV CD4 1010/36% VL 918 WHAT WOULD YOU DO?

17. CASE 1 GENOTYPE JUN/10

18. CASE 1 GENOTYPE JUN/10

19. CASE 1 GENOTYPE JUN/10

20. CASE 1 JUNE 2010 TDF/FTC/EFV/RGV… tolerating well TDM…adequate levels of medication DATEVIRAL LOADCD4 06/109181010/36% 08/1056940/39% WHAT WOULD YOU DO?

21. CASE 1 AUGUST 2010 Regimen switched to TDF/FTC/RGV/RTV/fAPV/MVC DATEVIRAL LOADCD4 08/1056940/39% 09/10123950/42% 10/104501240/37%

22. CASE 1 OCTOBER 2010 Regimen switched to TDF/FTC/RGV/ETR/RTV/DRV DATEVIRAL LOADCD4 10/104501240/37% 11/10127960/38%

23. CASE 1 NOVEMBER 2010 Tolerating TDF/FTC/RGV/ETR/RTV/DRV Maraviroc added DATEVIRAL LOADCD4 11/10127960/38% 12/101181450/38% 01/115721010/40% 02/112131150/40% WHAT WOULD YOU DO?

24. CASE 1 FEBRUARY 2011 3 months of TDF/RGV/ETR/RTV/DRV/ MVC TDM of RGV + DRV shows no RGV level and low DRV levels Readjusted DRV dose and of course reinforced adherence

25. CASE 1 GENOTYPE JAN/11

26. CASE 1 MARCH 2011 Checked pharmacy log → all pills picked up at appropriate times Repeat TDM → therapeutic levels of all medications

27. CASE 1 MAY 2011 TDF/FTC/RGV/ETR/RTV/DRV/MVC DATEVIRAL LOADCD4 03/11129− 04/112691370/31% 05/11193− WHAT WOULD YOU DO?

28. CASE 1 MAY 2011 Regimen simplified to TDF/FTC//RTV/DRV DATEVIRAL LOADCD4 05/11193− 06/111231110/43% 07/111831120/44% Is this an issue related to patient, virus, or Inadequate immune control?