1. CASE 2 54 yo man…HIV + 1997 PCP Cryptospordiasis Chronic HepC Genotype 1a Biopsy… 2/4 activity, 3/4scarring CD4 40 No baseline genotype

2. CASE 2 1998-2002 D4T/3TC/Indinavir initiated CD4 30 → 400 Viral load undetectable

3. CASE 2 U/A - ++ WBC + IDV crystals Creatinine – 80 → 115 Indinavir crystal induced interstitial renal disease felt to be responsible

4. CASE 2 2002-2008 D4T/3TC/Nelfinavir Mild intermittent diarrhea Successfully treated for Hepatitis C with 48 wks of Peg Interferon/RBV CD4 450-700 VL <50

5. CASE 2 2008 D4T/3TC/Nelfinavir Ongoing diarrhea Increasing recognition of dorsocervical fat pad Switched to TDF/FTC/Efavirenz

6. CASE 2 TIMEASTALTOTHER 10/083331Etoh 6 beers/day x yrs 11/085586No increase in Etoh; HepA IgG (+); HepBsAb (+) 12/084159Workup for secondary liver disease (-); HCV RNA (-); U/S… fatty liver 04/0969143Repeat HCV RNA (-); Urinary Drug Screen (UDS) (-); 06/0997156UDS (-) WHAT WOULD YOU DO?

7. CASE 2 June 2009 TDF/FTC/Efavirenz switched to TDF/FTC/Etravirine to attempt to r/o Efavirenz as cause of hepatitis

8. CASE 2 TIMEASTALTOTHER 07/09641401 month post-switch 08/09581172 months post switch WHAT WOULD YOU DO?

9. CASE 2 TDF/FTC/Etravirine switched to D4T/3TC/Etravirine to attempt to r/o TDF/FTC as rare cause of hepatitis

10. CASE 2 Sept/09 D4T/3TC/Etravirine TIMEASTALTOTHER 08/0958117TDF/FTC/ETV 09/094768 10/094955 11/095491 WHAT WOULD YOU DO?

11. CASE 2 Switched back to TDF/FTC/Etravirine as patient concerned about lipodystrophy and unclear whether liver improving at all from Etravirine or TDF/FTC switch

12. CASE 2 TIMEASTALTOTHER 11/0954122D4T/3TC/Etravirine 03/1064143TDF/FTC/Etravirine… No increase in Etoh 06/1077224 WHAT IS HAPPENING? WHAT WOULD YOU DO?

13. CASE 2 Patient self-discontinues meds TIMEASTALT 06/1077224 07/104769

14. CASE 2 Restarted TDF/FTC/Efavirenz for simplicity/convenience TIMEASTALTOTHER 07/104769No Meds 07/10971452 wks 08/10971934 wks 09/10681898 wks NOW WHAT?

15. CASE 2 Late September 2010 Switched to D4T/3TC/Raltegravir as previously had normal liver enzymes for years on D4T/3TC/Nelfinavir and need to get rid of TDF/FTC and NNRTI class. Refused PI due to lipohypertrophy STAY TUNED!!!