1. Case Studies in the Management
of HIV-Positive Patients
Stephen Perez, RN, NP, AAHIV-S

2. Overview and Objectives
• Review case studies involving the
management of HIV-infected patient
• Apply knowledge to determine
appropriate ARV initiation and
management for case patients
• Engage in group discussion around the
complexities of initiating ARV’s
2

3. Case One: Juan
• 25 y.o. Salvadorian, bisexual male.
• Tested HIV-positive 4 weeks ago after
visiting a county clinic and being
treated for GC/CT
• He is presenting for his first visit with you
today
• Prior to his visit to the county clinic, he
has not had care since 1 year ago, he
has not had primary care since
childhood

4. Case One: Juan
• Juan brings a copy of
his records from the
county clinic
– RX with Rocephin and
Azithromycin
– Twinrix #1
– Positive HIV WB
– Positive GC NAAT
(urine), RPR non-
reactive, neg CT NAAT
(urine).
– Information flyer for
your clinic
4

5. Case One: Juan
• On initial history:
– UTI symptoms 6 weeks ago, now
resolved
– No other recent illnesses
– No history of chronic illness
– Family history relatively unknown
• Married with one child in El Salvador
– No Surgical Hx
– ED visit 1 year ago for
CAP, resolved with abx, prior ED
visit 3 years ago, for laceration
at work
– NKDA, no current meds 5

6. Case One: Juan
• What else do we want
to know about Juan?
6

7. Case One: Juan
• What other information do we want to know about Juan?
• Previous testing
– No previous HIV tests or STD history, no hx of ARV’s
• ETOH, Illicit Drugs
– Drinks alcohol 3-4 times a week, intoxicated 2 times a
week (approx. 8 beers)
• Sexual Activity
– Sexually active with 2 male partners last sexual activity last
week. Oral sex (no condoms), receptive anal sex (with
condoms)
• Work History
– Works as a cook at a local 24 hour restaurant. He works
alternate day and night shifts
• Immunizations
– Unknown, received a “shot” at the ED 3 years ago after
sutures
• Mental Health History
7
– None reported

8. Case One: Juan
• Physical Exam
– WNWD, NAD, BMI 26, VS wnl
– Mild palpable LN in anterior cervical chain
– 4cm well healed scar on left palm
– Otherwise unremarkable
8

9. Case One: Juan
• What Lab Tests Do We Want to Order?
– CD4 count
– Viral Load
– CMP/CBC
– Hepatitis Serologies (HAV, HBV, HCV)
– Urinalysis
– Genotype
– Fasting Plasma Glucose, Fasting Lipids
– Repeat Urine GC/CT, Throat GC/CT
– PPD
– Anti-Toxoplasma IgG
9

10. Case One: Juan
• Results
– CBC/CMP within normal
– CD4 644, VL is 56,346
– HBsAg neg, anti HBc Ab positive, anti HBs Ab
positive, Total anti-HAV Ab postive, anti HCV
Ab neg.
– UA wnl
– Genotype is pan-sensitive
– Lipids: TC-1, LDL-130, HDL-50, TG-200.
– FPG: 98
– Repeat GC/CT negative
– PPD 0mm, anti-toxo is <6.5
10

11. Case One: Juan
Should Juan Start Antiretroviral Therapy
(Audience Response)?
1. Yes
2. No
3. Maybe So
11

12. Case One: Juan
• What ARV’s Would You
Recommend for Juan?
– ARV Naïve
– Genotype is pan-sensitive
– Works odd hours
12

13. Case One: Juan
What ARV’s Would You
Recommend for Juan?
(Audience Response)
1. Atripla (EFV/TDF/FTC)
2. Prezista, Norvir and
Truvada (DAR/r +
TDF/FTC)
3. Reyataz, Norvir and
Truvada (ATV/r
+TDF/FTC)
4. Isentress and Truvada
(RAL + TDF/FTC)
5. Complera
13
(RPV/FTC/TDF)

14. Case One: Juan
• What are benefits
and risks of your
selected ARV
regimen?
• If starting Juan at his
next visit, when do
you want him to
return for follow-up?
• How would you
monitor his response
to therapy?
14

15. QUESTIONS?

16. Case Two: Janice
• 34 year-old A.A. female with HIV
infection
• She was diagnosed 4 years ago when
she presented to an OB clinic at 26
weeks, but has not been engaged in
care since her delivery.
• She recently moved to the area, and is
concerned because she has been
feeling tired. Also has some intermittent
throat pain
16

17. Case Two: Janice
• She does not have
her previous records
with her but tells you
the following
– She took HIV meds
during pregnancy but
can’t remember the
names
– Remembers “a lot of
pills” (yellow and white
)
– Her daughter is HIV
negative
– She stopped her meds
after delivering
17

18. Case Two: Janice
• On initial history:
– Has been feeling tired for about 3
months
– Intermittent night
sweats, intermittent pain with
swallowing ROS otherwise negative
– Family history
• Mother A&W with HTN, DM2, Father
Deceased from MI
• One daughter, 3 yrs old
– Surgical Hx includes C-Section 3 yrs
ago
– ED visit 6 months ago for GI
symptoms
– Allergic to Sulfa
– GYN: G2 P1, SAB X1, irregular
menses, LMP 2 months ago
18

19. Case Two: Janice
• What other information do we want to know about Janice?
• HIV History
– Viral Load was undetectable while on meds, thinks her
CD4 count was around 200, had a lot of GI side effects
with the meds, but never missed any doses.
• ETOH, Illicit Drugs
– Denies any alcohol or drug use. Does not smoke
• Sexual Activity
– Has a monogamous male partner, who is HIV negative.
They use condoms 100% of the time.
• Work History
– Full time work at small PR firm, does not have insurance
because she doesn’t want anyone at work to know about
her HIV.
• Immunizations
– Unknown, had a PPD from OB which was negative
• Mental Health History
– Was treated for depression 5 years ago after her father passed
away (x 1 year) 19

20. Case Two: Janice
• Physical Exam
– WNWD, NAD, BMI 24, VS: BP 144/90
otherwise wnl
– Well healed surgical scar from C-section
– White coating noted on posterior
oropharynx, scrapable with tongue
depressor
– Otherwise unremarkable
20

21. Case Two: Janice
• What Lab Tests Do We Want to Order?
– CD4 count
– Viral Load
– CMP/CBC
– Hepatitis Serologies (HAV, HBV, HCV)
– Urinalysis
– Genotype
– Fasting Plasma Glucose, Fasting Lipids
– RPR, GC/CT
– PPD
– Pregnancy Test
– Anti-Toxoplasma IgG
21

22. Case Two: Janice
• Results
– CBC Hgb: 8.7, Hct: 30, Plt 75,000, CMP: WNL
– CD4 75, VL is 132,675
– HBV sAg neg, anti HBc Ab negative, anti HBVs
Ab positive, HAV total Ab postive, anti HCV Ab
neg.
– Genotype is pan-sensitive
– Lipids: TC-175, LDL-98, HDL-40, TG-130. FPG: 98
– Urine Pregnancy test, negative, UA wnl
– PPD 0mm
– G6PD <3 U/g Hb
– Anti-toxoplasma IgG <6.5 IU/ml
22

23. Case Two: Janice
Does Janice needs PCP prophylaxis
(Audience Response)?
1. Yes
2. No
3. Maybe So
23

24. Case Two: Janice
What is the best option for PCP Prophylaxis for Janice
(Audience Response)?
1. Dapsone 100mg 1 tablet daily
1. Bactrim DS 1 tablet daily
1. Bactrim DS 1 tablet Q MWF
1. Mepron 1500 mg PO daily
1. Crossing your fingers
24

25. Case Two: Janice
Should Janice Start Antiretroviral Therapy
(Audience Response)?
1. Yes
2. No
3. Maybe So
25

26. Case Two: Janice
• What ARV’s Would You
Recommend for Janice?
– Her genotype is pan-
sensitive
– You show her a medication
chart in your office and she
identifies Combivir and
Kaletra as her previous
regimen
26

27. Case Two: Janice
What ARV’s Would You
Recommend for Janice?
(Audience Response)
1. Atripla (EFV/TDF/FTC)
2. Prezista, Norvir and
Truvada (DAR/r +
TDF/FTC)
3. Reyataz, Norvir and
Truvada (ATV/r
+TDF/FTC)
4. Isentress and Truvada
(RAL + TDF/FTC)
27

28. Case Two: Janice
• What are benefits and
risks of your selected ARV
regimen?
• If starting Janice at her
next visit, when do you
want her to return for
follow-up?
• How would you monitor
her response to therapy?
28

29. Case Two: Janice
QUESTIONS?
29

30. Case Three: Donna
• 53 year-old Caucasian female with HIV
infection
• She was diagnosed 2 years ago while
incarcerated.
• She was recently released from prison
and has not been treated for HIV in the
past. She is presenting today for
primary care/HIV Care
30

31. Case Three: Donna
• She has brought in her previous records from
prison
– CD4 count has been between 600 and 800 with a
nadir of 575 cells/mm3
– Viral Loads ~ 3,000 copies
– HBV sAg neg, anti HBc Ab negative, anti HBVs Ab
positive, HAV total Ab postive, anti HCV Ab neg.
– Genotype is pan-sensitive
– She also has hypertension and hypothyroid disease
for which she is taking:
• HCTZ 25 mg
• Lisinopril 20 mg
• Levothyroxine 100 mcg
– She has been taking prescriptions as above
31

32. Case Three: Donna
• On initial history:
– Has been feeling well in the past few months
– Is concerned about finding work and getting in touch
with family
– Family history
• Mother deceased from trauma, Father Deceased from
MI, Sister alive 49 with hypothyroid disease and high
cholesterol
• Two adult children whom she has little contact with, Alive and
Well as far as she knows
– Surgical Hx unremarkable
– NKDA
– GYN: G2 P2, LMP 5 years ago
32

33. Case Three: Donna
• What other information do we want to know about Donna?
• HIV History
– Previous HIV test 10 years ago which was negative. Risk factor is
heterosexual contact
• ETOH, Illicit Drugs
– Drinking 3-4 beers a day, no illicit drugs. Smokes ½ pack a
day
• Sexual Activity
– Has a monogamous female partner, who is HIV negative.
They use barrier protection 50% of the time
• Work History
– Previous work in retail. Is currently applying for jobs in the
area
• Immunizations
– UTD, had a PPD 9 mos ago which was negative
• Mental Health History
– Was treated for depression but has been off meds since she was
released
33

34. Case Three: Donna
• Physical Exam
– WNWD, NAD, BMI 28, VS: BP 128/84
otherwise wnl
– Unremarkable PE
34

35. Case Three: Donna
• What Lab Tests Do We Want to Order?
– CD4 count
– Viral Load
– CMP/CBC
– Urinalysis
– Fasting Plasma Glucose, Fasting Lipids
– RPR, GC/CT, PAP
– Anti-Toxoplasma IgG
35

36. Case Three: Donna
• Results
– CBC/CMP: WNL
– CD4: 672, CD4 %: 28
– Viral Load: 3,234 copies
– Lipids: TC-250, LDL-162, HDL-36, TG-224. FPG:
110
– UA wnl
– PAP negative
– GC/CT, RPR negative
– G6PD <3 U/g Hb
– Anti-toxoplasma IgG <6.5 IU/ml
36

37. Case Three: Donna
Should Donna Start Antiretroviral
Therapy? (Audience Response)
1. Yes
2. No
3. Maybe So
37

38. Case Three: Donna
• What ARV’s Would You Recommend for
Donna?
– Her genotype is pan-sensitive
– She is ARV Naïve
38

39. Case Three: Donna
What ARV’s Would You Recommend for
Donna? (Audience Response)
1. Atripla (EFV/TDF/FTC)
2. Prezista, Norvir and Truvada (DAR/r
+ TDF/FTC)
3. Reyataz, Norvir and Truvada (ATV/r
+TDF/FTC)
4. Isentress and Truvada (RAL +
TDF/FTC)
5. Complera (RPV/FTC/TDF)
39

40. Case Three: Donna
• What are benefits and risks of your selected
ARV regimen?
• If starting Donna at her next visit, when do
you want her to return for follow-up?
• How would you monitor her response to
therapy?
40

41. Case Three: Donna
QUESTIONS?
41

42. AETC NCHCMC Contacts
Clinical Team Contacts
Stephen Perez, RN, NP, AAHIVS, HIV Clinical Specialist
stephen@healthhiv.org
Mona Moore, PA-C, MA, AAHIVS, HIV Clinical Program Specialist
Kmona@healthhiv.org
42

43. HealthHIV
AETC NCHCMC
2000 S Street NW
Washington, DC 20009
www.NCHCMC.org
202-232-6749