Case Studies in the Management    of HIV-Positive Patients     Stephen Perez, RN, NP, AAHIV-S
Overview and Objectives• Review case studies involving the  management of HIV-infected patient• Apply knowledge to determi...
Case One: Juan• 25 y.o. Salvadorian, bisexual male.• Tested HIV-positive 4 weeks ago after  visiting a county clinic and b...
Case One: Juan          • Juan brings a copy of            his records from the            county clinic            – RX w...
Case One: Juan• On initial history:   – UTI symptoms 6 weeks ago, now     resolved   – No other recent illnesses   – No hi...
Case One: Juan• What else do we want  to know about Juan?            6
Case One: Juan• What other information do we want to know about Juan?• Previous testing   – No previous HIV tests or STD h...
Case One: Juan• Physical Exam  – WNWD, NAD, BMI 26, VS wnl  – Mild palpable LN in anterior cervical chain  – 4cm well heal...
Case One: Juan• What Lab Tests Do We Want to Order?  –   CD4 count  –   Viral Load  –   CMP/CBC  –   Hepatitis Serologies ...
Case One: Juan• Results  – CBC/CMP within normal  – CD4 644, VL is 56,346  – HBsAg neg, anti HBc Ab positive, anti HBs Ab ...
Case One: JuanShould Juan Start Antiretroviral Therapy(Audience Response)?1. Yes2. No3. Maybe So                     11
Case One: Juan    • What ARV’s Would You      Recommend for Juan?      – ARV Naïve      – Genotype is pan-sensitive      –...
Case One: Juan    What ARV’s Would You    Recommend for Juan?    (Audience Response)      1. Atripla (EFV/TDF/FTC)      2....
Case One: Juan• What are benefits  and risks of your  selected ARV  regimen?• If starting Juan at his  next visit, when do...
QUESTIONS?
Case Two: Janice• 34 year-old A.A. female with HIV  infection• She was diagnosed 4 years ago when  she presented to an OB ...
Case Two: Janice            • She does not have              her previous records              with her but tells you     ...
Case Two: Janice• On initial history:   – Has been feeling tired for about 3     months   – Intermittent night     sweats,...
Case Two: Janice• What other information do we want to know about Janice?• HIV History   – Viral Load was undetectable whi...
Case Two: Janice• Physical Exam  – WNWD, NAD, BMI 24, VS: BP 144/90    otherwise wnl  – Well healed surgical scar from C-s...
Case Two: Janice• What Lab Tests Do We Want to Order?  –   CD4 count  –   Viral Load  –   CMP/CBC  –   Hepatitis Serologie...
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...
Case Two: JaniceDoes Janice needs PCP prophylaxis(Audience Response)?1. Yes2. No3. Maybe So                    23
Case Two: JaniceWhat is the best option for PCP Prophylaxis for Janice(Audience Response)?1. Dapsone 100mg 1 tablet daily1...
Case Two: JaniceShould Janice Start Antiretroviral Therapy(Audience Response)?1. Yes2. No3. Maybe So                      ...
Case Two: Janice     • What ARV’s Would You       Recommend for Janice?       – Her genotype is pan-         sensitive    ...
Case Two: Janice     What ARV’s Would You     Recommend for Janice?     (Audience Response)       1. Atripla (EFV/TDF/FTC)...
Case Two: Janice• What are benefits and  risks of your selected ARV  regimen?• If starting Janice at her  next visit, when...
Case Two: JaniceQUESTIONS?        29
Case Three: Donna• 53 year-old Caucasian female with HIV  infection• She was diagnosed 2 years ago while  incarcerated.• S...
Case Three: Donna• She has brought in her previous records from  prison  – CD4 count has been between 600 and 800 with a  ...
Case Three: Donna• On initial history:   – Has been feeling well in the past few months   – Is concerned about finding wor...
Case Three: Donna• What other information do we want to know about Donna?• HIV History   – Previous HIV test 10 years ago ...
Case Three: Donna• Physical Exam  – WNWD, NAD, BMI 28, VS: BP 128/84    otherwise wnl  – Unremarkable PE                  ...
Case Three: Donna• What Lab Tests Do We Want to Order?  – CD4 count  – Viral Load  – CMP/CBC  – Urinalysis  – Fasting Plas...
Case Three: Donna• Results  – CBC/CMP: WNL  – CD4: 672, CD4 %: 28  – Viral Load: 3,234 copies  – Lipids: TC-250, LDL-162, ...
Case Three: DonnaShould Donna Start AntiretroviralTherapy? (Audience Response)  1. Yes  2. No  3. Maybe So                ...
Case Three: Donna• What ARV’s Would You Recommend for  Donna?  – Her genotype is pan-sensitive  – She is ARV Naïve        ...
Case Three: DonnaWhat ARV’s Would You Recommend forDonna? (Audience Response)  1. Atripla (EFV/TDF/FTC)  2. Prezista, Norv...
Case Three: Donna• What are benefits and risks of your selected  ARV regimen?• If starting Donna at her next visit, when d...
Case Three: Donna QUESTIONS?        41
AETC NCHCMC ContactsClinical Team ContactsStephen Perez, RN, NP, AAHIVS, HIV Clinical Specialiststephen@healthhiv.orgMona ...
HealthHIV  AETC NCHCMC  2000 S Street NWWashington, DC 20009   www.NCHCMC.org     202-232-6749
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Treatment outcome case studies perez

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  • What about an HLA-B5701 what about a co-recptor tropism assay?
  • What is Janice’s STAGE ACCORDING TO CDC STAGING. B3, she techincally does not have any AIDS indicator conditions, oropharyngeal thrush is not an aids indicator, but esophageal is. Does she need any opportunistic prophylaxis? Yes, for what? Should we take into account the G6PD finding? Can she be on Mepron?
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  • Treatment outcome case studies perez

    1. 1. Case Studies in the Management of HIV-Positive Patients Stephen Perez, RN, NP, AAHIV-S
    2. 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. 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. 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. 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. 6. Case One: Juan• What else do we want to know about Juan? 6
    7. 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. 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. 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. 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. 11. Case One: JuanShould Juan Start Antiretroviral Therapy(Audience Response)?1. Yes2. No3. Maybe So 11
    12. 12. Case One: Juan • What ARV’s Would You Recommend for Juan? – ARV Naïve – Genotype is pan-sensitive – Works odd hours 12
    13. 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. 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. 15. QUESTIONS?
    16. 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. 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. 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. 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. 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. 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. 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. 23. Case Two: JaniceDoes Janice needs PCP prophylaxis(Audience Response)?1. Yes2. No3. Maybe So 23
    24. 24. Case Two: JaniceWhat is the best option for PCP Prophylaxis for Janice(Audience Response)?1. Dapsone 100mg 1 tablet daily1. Bactrim DS 1 tablet daily1. Bactrim DS 1 tablet Q MWF1. Mepron 1500 mg PO daily1. Crossing your fingers 24
    25. 25. Case Two: JaniceShould Janice Start Antiretroviral Therapy(Audience Response)?1. Yes2. No3. Maybe So 25
    26. 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. 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. 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. 29. Case Two: JaniceQUESTIONS? 29
    30. 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. 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. 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. 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. 34. Case Three: Donna• Physical Exam – WNWD, NAD, BMI 28, VS: BP 128/84 otherwise wnl – Unremarkable PE 34
    35. 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. 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. 37. Case Three: DonnaShould Donna Start AntiretroviralTherapy? (Audience Response) 1. Yes 2. No 3. Maybe So 37
    38. 38. Case Three: Donna• What ARV’s Would You Recommend for Donna? – Her genotype is pan-sensitive – She is ARV Naïve 38
    39. 39. Case Three: DonnaWhat ARV’s Would You Recommend forDonna? (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. 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. 41. Case Three: Donna QUESTIONS? 41
    42. 42. AETC NCHCMC ContactsClinical Team ContactsStephen Perez, RN, NP, AAHIVS, HIV Clinical Specialiststephen@healthhiv.orgMona Moore, PA-C, MA, AAHIVS, HIV Clinical Program SpecialistKmona@healthhiv.org 42
    43. 43. HealthHIV AETC NCHCMC 2000 S Street NWWashington, DC 20009 www.NCHCMC.org 202-232-6749

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