A 39-year-old man with a 12-year history of HIV infection comes for an initial evaluation after movi

Discussion in 'Step 3' started by Santosh Jadhav, Nov 25, 2013.

  1. Santosh Jadhav

    Santosh Jadhav Active Member

    A 39-year-old man with a 12-year history of HIV infection comes for an initial evaluation after moving to a new state. One month before moving, he was hospitalized for treatment of cryptococcal meningitis and is now receiving fluconazole as long-term maintenance therapy. The patient has taken numerous antiretroviral agents and has required several changes in medications in an attempt to suppress the HIV infection completely. His current regimen, which he has been on for 1 year, includes indinavir (800 mg), ritonavir (100 mg), stavudine (40 mg), and didanosine (200 mg), all taken twice daily.

    The patient generally feels well except for fatigue. Physical examination is normal. Results of a CD4 cell count, plasma HIV RNA viral load, and HIV genotype resistance assay are pending.

    In addition to the genotype resistance assay result, which of the following is most important for determining a revised antiretroviral regimen?
    A The current viral load
    B The CD4 cell count nadir
    C The presence of symptoms
    D The duration of HIV infection
    E The history of use of antiretroviral agents
  2. samuel

    samuel New Member

    ans e

    Even without knowing any of his HIV-related test results, this patient has been receiving an ineffective antiretroviral regimen, as evidenced by the development of a major AIDS-related complication. In order to select a more appropriate regimen, a careful and complete history of antiretroviral drug use is required.

    The HIV genotype resistance assay will only provide a profile of the patient's major circulating viral species. Because he has taken many antiretroviral agents, he is also likely to have various viral quasi-species that cannot be detected by genotype or phenotype assay. A detailed drug history is therefore needed. In practice, such a history is often difficult to obtain, particularly for patients who have had many health care providers or who have not adhered to their treatment regimen. However, it should be attempted for this patient.

    His CD4 cell count will predictably be less than 100/μL (0.1 × 109/L), and his HIV RNA viral load is unlikely to be below the level of detection. Neither result will likely influence the choice of medication, although the lower the viral load, the better the chance of controlling the HIV infection. The presence or absence of symptoms is irrelevant when selecting the next treatment regimen. In theory, the duration of HIV infection could be important because the longer the infection, especially infection that is uncontrolled or only partially controlled, the greater the chance that mutations have developed. However, there is no practical way to apply this information.

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