Medicine: HIV Case Management

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Topic: Health & Medicine
Updated:

Introduction

The present paper presents a HIV case management framework for a 36-year old woman who has been diagnosed with asymptomatic HIV infection. Although most of the patient’s laboratory results (e.g., electrolytes, serum creatinine, and liver function tests) are within normal limits and no resistance mutations have been detected in the genotype test, she has a CD4+ T cells (mature T-helper cells) count of 210 cells/mm3 and a viral load of 10,000 copies/mL.

Specific Goals for Treatment

The specific treatment goals for this patient should entail “maximal and durable suppression of viral load, restoration and preservation of immunologic function, improvement of quality of life, and reduction of HIV-related morbidity and mortality” (Dybul, Fauci, Bartlett, Kaplan, & Pau, 2002, para. 3).

Drug Therapy and Justification

Owing to the fact that the patient is an adult and the CD4+ T cells count is below the recommended <350 CD4+ T cells/mm3 (Dybul et al., 2002), she should be introduced to a first-line therapy regimen involving two nucleoside reverse-transcriptase inhibitors (NRTIs, e.g. tenofovir and zidovudine) and a non-nucleoside reverse-transcriptase inhibitor (NNRTI) such as efavirenz, etravirine or nevarapine (Boettiger et al., 2014).

A combination of these drugs is effective in (1) decreasing the progression of HIV to Acquired Immune Deficiency Syndrome (AIDS) through inhibiting the enzyme that HIV uses to synthesize DNA, (2) keeping the viral load down by preventing HIV from multiplying, and (3) improving the patient’s quality of life due to absence of serious long-term effects and irreversible toxicities associated with other first-line ARTs such as stavudine (Boettiger et al., 2014).

Parameters for Monitoring Success of Therapy

Owing to the fact that one of the underlying objectives for treating the patient with the mentioned drugs is virologic suppression, the parameters for monitoring the success of therapy should include (1) measuring HIV viral load (RNA) at ART initiation and after one month after ART initiation, (2) measuring RNA every two months until the viral load becomes undetectable, (3) measuring CD4 count at ART initiation and repeating the exercise every three to six months if level is below 200, (4) repeating the CD4 count measurement after every year if the level is between 201 and 500, (5) stopping the CD4 count if the level goes beyond 500, and (6) measuring renal function and other safety procedures (e.g., complete blood count, electrolytes, glucose, liver functioning) at ART initiation and each time an underlying medical condition is noted (Boettiger et al., 2014).

Specific Patient Education

The specific patient education for the selected therapy should cover such areas as drug adherence, dosage to be taken, what to do if the patient misses a dose, and the side-effects (e.g., yellowing of skin, dark-colored urine, light-colored bowel movements, nausea and stomach pain) to look out for.

The patient should also be educated on the consequences of non-adherence (e.g., regimen failure, immune suppression and emergence of resistant viral strains), the importance of safely disposing unneeded or expired drugs, and the importance of storing the drugs in their original containers (Colvin et al., 2014).

Adverse Reactions

Tenofovir is closely associated with failure of normal renal functioning and should be discontinued if negative effects are noted. Zidovudine is associated with milder side effects, including fever, sore throat, pale skin, unusual tiredness or weakness, confusion, convulsions, loss of appetite and nausea (Boettiger et al., 2014).

Second-Line Therapy

If the selected treatment regimen causes pronounced side effects to the patient or if HIV becomes resistant to this combination, the patient should be put on a second-line therapy regimen involving two NRTIs (e.g., dindanosine and abacavir) and a ritonavir-boosted protease inhibitor (PI, e.g., ritonavir and atazanafir or ritonavir and tipranavir), which derails the HIV replication process by inhibiting the protease protein (Boettiger et al., 2014).

Recommended Diet and Lifestyle Changes

In terms of diet, the patient should be encouraged to take food that is rich in vitamin A, vitamin B12, vitamin C, vitamin D, carotenoids, selenium, zinc and iron, as these micronutrients and minerals are important for the normal functioning of the body though consecutive research studies show that they are present at extremely low levels in most HIV-infected persons (Boettiger et al., 2014).

Additionally, the patient should be encouraged to eat a balanced diet in order to maintain a healthy body weight and immunity. In terms of lifestyle changes, the patient should be encouraged to continue exercising and do away with lifestyle habits that could jeopardize her health, such as drinking, smoking, and working in areas with increased environmental pollution (Dybul et al., 2002).

Drug-Drug Interactions for Selected Agents

Protease inhibitors, including ritonavir, have a high drug-drug interactions as they increase the level of many drugs and hence should not be taken together with medications for certain heart conditions (e.g., amiodarone, astemizole), electile dynfunction (e.g., Viagra and Cialis), tuberculosis (e.g., rifampicin), and depression (e.g., St John’s wort).

Additionally, a commonly used NNRTI known as etravirine has been shown to lead to adverse drug-drug interactions when coadministered with tipranavir/ritonavir or unboosted HIV PIs (Kakuda, Scholler-Gyure, & Hoetelmans, 2010).

Conclusion

The present paper has succeeded in demonstrating how the patient should be managed for asymptomatic HIV infection, from the regimens that should be used for first-line and second-line therapies to recommended dietary and lifestyle changes, as well as possible drug-drug interactions that should be avoided.

References

Boettiger, D.C., Kerr, S., Ditangco, R., Merati, T.P., Pham, T.T.T., Chaiwarith, R…Law, M. (2014). Trends in first-line antiretroviral therapy in Asia: Results from the TREAT Asia HIV observational database. PLoS ONE, 9(9), 1-10.

Colvin, C.J., Konopka, S., Chalker, J.C., Jonas, E., Albertini, J., Amzel, A., & Fogg, K. (2014). A systematic review of health system barriers and enablers for antiretroviral therapy (ART) for HIV-infected pregnant and postpartum women. PLoS ONE, 9(10), 1-17.

Dybul, M., Fauci, A.S., Bartlett, J.G., Kaplan, J.E., & Pau, A.K. (2002). Guidelines for using antiretroviral agents among HIV-infected adults and adolescents: Recommendations of the panel on clinical practices for treatment of HIV.

Kakuda, T.N., Scholler-Gyure, M., & Hoetelmans, R.M.W. (2009). Clinical perspective on antiretroviral drug-drug interactions with the non-nucleoside reverse transcriptase inhibitor etravirine. Antiviral Therapy, 15(2), 817-829.