Monday, September 25, 2023
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Consultant Physician, Sexual Health & HIV
HIV Lead
Central and North West London NHS Trust
London, United Kingdom
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This educational activity is intended for an international audience of non-US HIV/ID specialists and primary care professionals.
The goal of this activity is for learners to be better able to manage people living with HIV who have complex medical needs.
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Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.
Consultant Physician, Sexual Health & HIV
HIV Lead
Central and North West London NHS Trust
London, United Kingdom
This activity has been peer reviewed and the reviewer has no relevant financial relationships.
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CME / ABIM MOC Released: 3/29/2023
Valid for credit through: 3/29/2024, 11:59 PM EST
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Appointment: Nadia, a 17-year-old female adolescent, presents to her pediatric infectious disease specialist, Dr Osei, to discuss the transition from pediatric to adult care in late summer 2022. Nadia is accompanied by her grandmother, Esther, who keeps track of her medications and manages her appointment scheduling.
HIV history: Nadia acquired HIV perinatally and has been on treatment since the age of 6 months. Nadia emigrated from Kenya in 2013 at the age of 7 with her mother and maternal grandmother due to fears of political and religious violence. In 2018, Nadia's mother died from AIDS-related complications. Now in the sole care of her aging maternal grandmother, Nadia suffers from anxiety and depression related to her diagnosis and to the trauma of losing her mother at a young age.
Relationship with clinician: Dr Osei has developed a close relationship with Nadia since the death of her mother. To ensure a successful transition to adult services, Dr Osei starts preparing Nadia to manage her own care when she leaves to attend university next year. Dr Osei also advises Esther about the need to step back from managing Nadia's medications to give her time to adjust.
Nadia's medical history, physical examination findings and antiretroviral (ART) treatment history are summarized in Tables 1 and 2. Her ART treatment history and HIV laboratory data are listed in Tables 3 and 4. This case takes place over 24 months, from August 2022 to August 2024.
| History | Findings |
|---|---|
| Medical | Perinatally acquired HIV |
| Current medications | Tenofovir disoproxil/emtricitabine, darunavir/cobicistat |
| Allergies | None |
| Psychosocial | Recreational cannabis use, depression, anxiety Patient reports difficulty sleeping No alcohol consumption reported |
| Immunizations | Current on all recommended immunizations, HAV |
HAV, hepatitis A virus.
| Physical Examination | Findings |
|---|---|
| Vital signs | Height = 5'7" (175 cm) Weight = 135 lb (59 kg) BMI = 19.3 kg/m2 BP = 118/75 mm Hg Heart rate = 76 bpm Temp: 37.1 C |
| General | None |
| Skin | Mild acne |
BMI, body mass index; BP, blood pressure.
| ART Regimen Initiated | Age (y) | Year | Reason for Switch | RAM |
|---|---|---|---|---|
| Abacavir/lamivudine + nevirapine/efavirenz | 6 months | 2007 | Initiation treatment | Test not sent |
| Abacavir/lamivudine + efavirenz | 7 | 2013 | Started treatment with UK physician; nevirapine no longer recommended; resistance testing reveals thymidine analogue revertant, T215D, nothing of clinical relevance found | T215D |
| TDF/emtricitabine, lopinavir + ritonavir |
9 | 2015 | Ceased abacavir/lamivudine + efavirenz due to tolerability issues and development of resistance; testing revealed presence of T215D, K103N, and M184V | T215D K103N M184V |
| TDF/emtricitabine, darunavir/cobicistat |
12 | 2018 | Ceased lopinavir due to gastrointestinal side effects -- had low-level viremia but did not test for resistance. Co-formulated darunavir/cobicistat to reduce pill burden. RAMs known from previous testing | T215D K103N M184V |
RAM, resistance-associated mutations; TDF, tenofovir disoproxil fumarate; UK, United Kingdom.
| Metric | February 2021 (previous) | August 2022 (current) |
Δ |
|---|---|---|---|
| CD4 | 410 cell/mm3 | 460 cell/mm3 |
= |
| HIV-1 RNA, PCR | < 50 copies/mL | < 50 copies/mL |
= |
PCR, polymerase chain reaction.
