Transcript HIV Rx Overview - Jacobi Medical Center

Management of the Treatment Naïve
Patient
Jason M. Leider, MD, PhD
NBHN Adult HIV Director
Associate Professor of Internal Medicine @ AECOM
August 5, 2009
ST, a 56-year-old white man, presents to your clinic for
initial management of HIV infection. He was diagnosed
4 months ago at the local health department where he
underwent testing after learning of exposure from a
previous sexual partner. He has no signs or symptoms
of an opportunistic infection. His past medical history
includes a myocardial infarction, hypertension, and
dyslipidemia. His CD4 count is 420 cells/µL and his
viral load is 83,000 copies/mL. Prior to his
appointment, you review the lab results and determine
that it may be prudent to recommend initiation of
antiretroviral therapy (ART).
This recommendation is based on which of the
following factors that mirrors the recommendations of
the US Department of Health and Human Services
Panel on Antiretroviral Guidelines for Adults and
Adolescents, issued November 3, 2008?
1)
2)
3)
4)
A plasma HIV-1 RNA level > 75,000 copies/mL
Emerging data showing no difference in all-cause mortality when
ART is initiated at CD4 counts between 351 cells/µL and 500
cells/µL compared with lower CD4 counts
Earlier initiation of ART may reduce cardiovascular or other nonAIDS-related disease risks
The risk for opportunistic infection decreases when treatment is
initiated at CD4 counts > 500 cells/µL compared with CD4 counts
between 351 cells/µL and 500 cells/µL
Which of these laboratory values or conditions
would not influence the choice of an initial
regimen for ST?
1)
2)
3)
4)
A plasma HIV-1 RNA level > 75,000 copies/mL
History of myocardial infarction
History of hypertension
History of dyslipidemia
After assessing his readiness to take medication and
addressing factors that might limit adherence, you
negotiate a treatment plan. He commits to beginning
an antiretroviral regimen.
Given his current medical problems and treatmentnaive HIV status, is there any class of drugs that
should be avoided as initial therapy?
1)
2)
3)
4)
5)
Nonnucleoside reverse transcriptase inhibitors
Nucleoside reverse transcriptase inhibitors
Protease inhibitors
CCR5 antagonists
None of these classes need to be excluded as
a group
A 35-year-old black woman who was screened
in your office tests positive for HIV on rapid
testing. A Western blot test confirms the initial
positive screening result. Her only risk factor is
3 male sexual partners in the past 6 years. She
reports that she is not currently sexually active.
She has no current medical problems and takes
no prescription medications. Her initial CD4
count is 387 cells/µL and her initial HIV-1 RNA
serum level is 46,000 copies/mL. She is very
nervous about having an infection in her body
and wants to start treatment as soon as
possible.
Which of the following would not be an
indication to start ART in this patient at
this time?
1)
2)
3)
4)
5)
Hepatitis B virus coinfection that needs treatment
Pregnancy
History of atypical squamous cells of undetermined
significance on a routine Pap smear
HIV-associated nephropathy
Opportunistic infection
RW, a 57-year-old Hispanic man, presents to your clinic
for initial management of HIV infection. He was
diagnosed 4 months ago at the local health department
where he underwent testing after learning of exposure
from a previous sexual partner. He has no signs or
symptoms of an opportunistic infection. His past
medical history includes a previous myocardial
infarction, hypertension, and dyslipidemia. His CD4
count is 410 cells/µL and his viral load is 78,000
copies/mL. Prior to his appointment, you review the lab
results and determine that it may be prudent to
recommend initiation of antiretroviral therapy (ART).
This recommendation is based on which of the
following factors that mirrors the recommendations of
the US Department of Health and Human Services
Panel on Antiretroviral Guidelines for Adults and
Adolescents, issued November 3, 2008?
1) A plasma HIV-1 RNA level > 75,000 copies/mL
2) Emerging data showing no difference in all-cause
mortality when ART is initiated at CD4 counts between
351 cells/µL and 500 cells/µL compared with lower CD4
counts
3) Earlier initiation of ART may reduce cardiovascular or
other non-AIDS-related disease risks
4) The risk for opportunistic infection decreases when
treatment is initiated at CD4 counts > 500 cells/µL
compared with CD4 counts between 351 cells/µL and
500 cells/µL
This recommendation is based on which of the
following factors that mirrors the recommendations of
the US Department of Health and Human Services
Panel on Antiretroviral Guidelines for Adults and
Adolescents, issued November 3, 2008?
Answer 3:
Earlier initiation of ART may reduce cardiovascular or other
non-AIDS-related disease risks
CD4 counts and clinical conditions, including
consideration of a possible benefit in terms of non-HIVrelated diseases, are generally considered to be more
important than the viral load. Although some experts
would start treatment when the viral load is > 100,000
copies/mL, a viral load > 75,000 copies/mL would not
generally be an indication for treatment.
Which of these laboratory values or
conditions would not influence the
choice of an initial regimen for RW?
1) A plasma HIV-1 RNA level > 75,000
copies/mL
2) History of myocardial infarction
3) History of hypertension
4) History of dyslipidemia
Which of these laboratory values or conditions
would not influence the choice of an initial
regimen for RW?
Answer 1: A plasma HIV-1 RNA level >
75,000 copies/mL:
A viral load > 100,000, but not 75,000
copies/mL, would argue against the use of
abacavir. The clinical conditions listed
would, appropriately, be used to select a
regimen, choosing one that is less likely to
cause dyslipidemia.
After assessing his readiness to take medication and
addressing factors that might limit adherence, you
negotiate a treatment plan. He commits to beginning an
antiretroviral regimen. Given his current medical
problems and treatment-naive HIV status, is there any
class of drugs that should be avoided as initial therapy?
1) Nonnucleoside reverse transcriptase
inhibitors
2) Nucleoside reverse transcriptase
inhibitors
3) Protease inhibitors
4) CCR5 antagonists
After assessing his readiness to take medication and
addressing factors that might limit adherence, you
negotiate a treatment plan. He commits to beginning an
antiretroviral regimen. Given his current medical
problems and treatment-naive HIV status, is there any
class of drugs that should be avoided as initial therapy?
Answer 4: CCR5 antagonists
The currently approved CCR5 antagonist is approved
for treatment-experienced -- not treatment-naive -patients, and the DHHS guidelines indicate that there
is insufficient evidence for it to be used as initial
therapy. It is also important to note that there is
substantial heterogeneity within the current classes of
antiretroviral agents and that an entire class need not
be avoided in a patient with cardiovascular risk factors.
A 27-year-old black woman who was screened
in your office tests positive for HIV on rapid
testing. A Western blot test confirms the initial
positive screening result. Her only risk factor
is 4 male sexual partners in the past 5 years.
She reports that she is not currently sexually
active. She has smoked a pack of cigarettes
per day since age 14 but otherwise has no
current medical problems and takes no
prescription medications. Her initial CD4 count
is 378 cells/µL and her initial HIV-1 RNA serum
level is 34,000 copies/mL. She wants to start
treatment as soon as possible.
Which of the following would not be an
indication to start ART in this patient at this
time?
1) Hepatitis B virus coinfection that needs
treatment
2) Pregnancy
3) History of atypical squamous cells of
undetermined significance on a routine Pap
smear
4) HIV-associated nephropathy
5) Opportunistic infection
Which of the following would not be an
indication to start ART in this patient at this
time?
Answer 3:
History of atypical squamous cells of undetermined
significance on a routine Pap smear
There are several instances in which an underlying
clinical condition takes precedence over the
recommendation to wait until the CD4 count has
dropped to 350 cells/µL. If the patient has a history of
an AIDS-defining illness, is pregnant, has hepatitis B
coinfection that is in need of treatment, or has HIVassociated nephropathy, treatment should be initiated
regardless of CD4 count. Note that the presence of
these conditions may affect the choice of treatment.