Patient Profile: Nico
Patient Case: Nico
Treatment Naïve, Rapid Initiation
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Nico’s Chief Complaint & History of Present Illness
Nico, a 25-year-old African American male,* reports that he developed an unexplained body rash shortly after learning that a friend was diagnosed with HIV. This prompted him to visit an STD clinic. At that visit, 2 weeks ago, he was diagnosed with HIV-1.
- Patient has been experiencing on and off flu-like symptoms for the past 2 weeks
- He is willing to start treatment immediately
- His current primary care provider referred him to you for HIV care
- HIV baseline labs (CD4+ cell count, viral load, resistance genotype tests, etc.) were ordered 3 days ago by primary care provider, but results are not yet available
- No renal or hepatic concerns
*This is a hypothetical patient
CD4+ = cluster of differentiation 4; STD = sexually transmitted disease
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Nico’s Personal & Social History
Sexual history: MSM
Occupation: Retail clothing store manager; recently asked to cover other stores out of state, which will require frequent overnight travel
Lifestyle:
- Multiple same-sex partners over the past year; one recently tested positive for HIV-1
- Shares small apartment with multiple roommates
- Parties on weekends
MSM = men who have sex with men
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Nico’s Physical Exam
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Positive findings:
- Swollen lymph nodes
- Low grade fever
- Mild body rash
Nico’s Assessment
25-year-old MSM with HIV-1 who is willing to start treatment but is at risk for suboptimal adherence:
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Busy lifestyle
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Social history
Baseline HIV laboratory results are pending
No renal or hepatic concerns
MSM = men who have sex with men
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In addition to recommending patient counseling and scheduling a follow-up visit in 2-4 weeks, which possible treatment strategies would you consider for Nico?
- Start ART today
- Wait for resistance test results before starting ART
- Start treatment once you get the CD4+ cell count and the count is <500 cells/mm3
- B and C
If you were to initiate ART today, during Nico’s first visit, what regimen would you consider prescribing?
- Atripla® (EFV/FTC/TDF)
- Biktarvy® (BIC/FTC/TAF)
- SYMTUZA® (DRV/c/FTC/TAF)
- Triumeq® (DTG/ABC/3TC)
DHHS guidelines recommend ART for all individuals with HIV, regardless of CD4 T lymphocyte cell count, to reduce the morbidity and mortality associated with HIV infection. The guidelines state that acute/early infection is one of the conditions that increase the urgency to initiate ART. Genotypic drug resistance testing should be performed before initiation of ART, but ART can be initiated before drug resistance test results are available.
ART=antiretroviral treatment; CD4=cluster of differentiation 4
Reference: Department of Health and Human Services Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in adults and adolescents living with HIV.
http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed November 8, 2018.
DHHS guidelines cite the following considerations for clinical scenarios in which ART should be started before HIV drug resistance results are available or in which rapid initiation of therapy is warranted:
- Avoid NNRTI-based regimens, because transmitted mutations conferring NNRTI resistance are more likely than mutations associated with PI or INSTI resistance
- Avoid ABC, because HLA-B*5701 results may not be available rapidly
- Recommend one of these DRV-based or DTG-based regimens: (DRV/r or DRV/c) plus tenofovir/FTC or DTG plus tenofovir/FTC. Both DRV and DTG have high barriers to resistance. While transmitted resistance to both drugs is uncommon, data regarding transmission of INSTI-resistant HIV and the efficacy of DTG regimens in early HIV infection are more limited. Within the recommended DRV- or DTG-based regimens, the tenofovir may be TAF- or TDF-based.
ABC=abacavir; ART=antiretroviral treatment; c=cobicistat; DRV=darunavir; DTG=dolutegravir; FTC= emtricitabine; HBV=hepatitis B virus; INSTI=integrase strand transfer inhibitor; NNRTI=non-nucleoside reverse transcriptase inhibitor; PI=protease inhibitor; r=ritonavir; TAF=tenofovir alafenamide; TDF=tenofovir disoproxil fumarate
Reference: Department of Health and Human Services Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in adults and adolescents living with HIV.
http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed November 8, 2018.