Justice
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A 35-year-old man was found to be HIV positive when he applied for life insurance. He is not certain when he became infected, but this could have occurred as long as 10 years ago. The patients only symptom is occasional night sweats two to three times each month. He otherwise feels well, works full time, and has never been hospitalized.
Physical examination discloses small white exudative patches on his soft palate that are consistent with thrush. His CD4 cell count is 260/μL, and his plasma HIV RNA viral load is 1550 copies/mL.
Which of the following is the most appropriate management for this patient?
A. Repeat the CD4 cell count; begin antiretroviral therapy only if the count is below 200/μL
B. Repeat the plasma HIV RNA determination; begin antiretroviral therapy only if the viral load is greater than 10,000 copies/mL
C. Antiretroviral therapy is not indicated at this time because the patient is asymptomatic
D. Begin treatment now with a three-drug antiretroviral regimen
E. Begin treatment now with a two-drug antiretroviral regimen
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Don't live in a town where there are no doctors
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| Markus2009
Forum Senior
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D
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| dr.wad
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D
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| peter90036
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D ...aww, and he was feeling so good. well, now he'll feel better (except for pancreatitis and peripheral neuropathy)
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| Justice
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The correct answer is D
There are many controversies concerning the proper time to initiate antiretroviral therapy. Experts agree that treatment is indicated for patients with an AIDS-defining condition, low CD4 cell count (< 200/ μL), or severe symptoms. The timing is more controversial for asymptomatic patients. Most experts suggest beginning therapy when the CD4 cell count is between 200 and 350/μL, irrespective of the HIV RNA viral load.
The key to decision making for this patient is the presence of thrush. Thrush indicates a poor prognosis for survival and an increased likelihood of opportunistic complications in AIDS patients. Therefore, even though this patients CD4 cell count is above 200/μL, he should be offered antiretroviral therapy at this time with one of several recommended three-drug regimens. Prophylaxis for Pneumocystis carinii pneumonia should also be started.
Repeating the CD4 cell count and plasma HIV RNA viral load is not needed. The fact that the patient has a low viral load at the beginning of treatment may influence the choice of agents but not the decision to use three versus two drugs.
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