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Author: Laura Kogelman, M.D.

A 43-year-old man presents to his PCP with an all over body rash. He has been feeling well otherwise. He reports an episode of profound fatigue one year ago that was thought to be secondary to “stress.” He describes that he has sex with both men and women and does not use condoms consistently.

  • Describe some ways that an individual can be infected by HIV.

The patient is found to be HIV positive with a CD4 count 74 cells/mm3 and an HIV-1 viral at 195,257 copies/mL.

  • What baseline testing might need to be checked?
Negative skin test for tuberculosis, PPD, 3 years ago when he emigrated from Brazil
CMV IgG positive
Toxoplama IgG positive
HCV Ab negative
HBV SAb positive
HAV Ab positive
RPR negative
  • Should he start antiretoviral therapy?Does everyone with HIV go on ART right away?
  • Before you start therapy what else might you want to know about his HIV?

Resistance testing reveals resistance to some NRTIs. He starts AZT, 3TC, tenofovir and efavirenz.

  • What other medications, vaccinations should he receive?

Bactrim DS (double strength) tablet PO daily as prophylaxis for PCP and Toxoplasmosis.

When CD4 counts increase, repeat PPD, give tetanus and pneumovax, flu shot when appropriate.

  • So how did JR do?
1 month on therapy viral load 1,469 copies/mL CD4 200 cells/mm3
4 months on therapy viral load <75 copies/mL, CD4 278 cells/mm3
9 months on therapy

viral load <75 copies/mL, >CD4 278 cells/mm3

He feels terrific, has good energy levels, is gaining weight. His rash has resolved.

He has no side effects of the medications and he has never missed a dose.