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Complex HIV Case Study Library Extension

  • Authors: Laura Waters, MD, FRCP
  • CME / ABIM MOC Released: 3/29/2023
  • Valid for credit through: 3/29/2024, 11:59 PM EST
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  • Credits Available

    Physicians - maximum of 1.00 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 1.00 ABIM MOC points

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

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.

Upon completion of this activity, participants will:

  • Have increased knowledge regarding the
    • Implications of suboptimal adherence in a patient with resistance to multiple antiretroviral therapies
    • Implications of drug-drug interaction in people with complex comorbidities
  • Have greater competence related to
    • Individualizing management of people living with HIV based on clinical metrics


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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.


  • Laura Waters, MD, FRCP

    Consultant Physician, Sexual Health & HIV
    HIV Lead
    Central and North West London NHS Trust
    London, United Kingdom


    Laura Waters, MD, FRCP, has the following relevant financial relationships:
    Consultant or advisor for: Cipla Ltd.; Gilead Sciences, Inc.; Merck Sharp & Dohme; ViiV Healthcare
    Speaker or member of speakers bureau for: Gilead Sciences, Inc.; Janssen Biotech, Inc.; Merck Sharp & Dohme; Mylan Laboratories Inc.; Theratech; ViiV Healthcare
    Research funding from: Gilead Sciences, Inc.; Janssen Biotech, Inc.; ViiV Healthcare


  • Alessia Piazza, PhD

    Medical Education Director, WebMD Global, LLC


    Alessia Piazza, PhD, has no relevant financial relationships.

Compliance Reviewer

  • Stephanie Corder, ND, RN, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC


    Stephanie Corder, ND, RN, CHCP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.

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Interprofessional Continuing Education

In support of improving patient care, Medscape, LLC is jointly accredited with commendation by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.0 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Aggregate participant data will be shared with commercial supporters of this activity.

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This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 70% on the post-test.

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Complex HIV Case Study Library Extension

Authors: Laura Waters, MD, FRCPFaculty and Disclosures

CME / ABIM MOC Released: 3/29/2023

Valid for credit through: 3/29/2024, 11:59 PM EST


The following cases are modeled on the interactive grand rounds approach. The questions within the activity are designed to test your current knowledge. After each question, you will be able to see whether you answered correctly and read evidence-based information that supports the most appropriate answer choice. The questions are designed to challenge you; you will not be penalized for answering the questions incorrectly. At the end of the activity, there will be a short post-test assessment based on the material presented.

CASE 1: Nadia (17-Year-Old Adolescent)

August 2022 -- Nadia visits her pediatric disease specialist

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.

Table 1. Patient History

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.

Table 2. Physical Examination

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.

Table 3. HIV Treatment History

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
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
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
RAM, resistance-associated mutations; TDF, tenofovir disoproxil fumarate; UK, United Kingdom.

Table 4. HIV Monitoring Labs

Metric February 2021 (previous) August 2022 (current)


CD4 410 cell/mm3 460 cell/mm3


HIV-1 RNA, PCR < 50 copies/mL < 50 copies/mL


PCR, polymerase chain reaction.
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