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Clinical Case Conference
Slide 1.
HIV CASE STUDIES: 2005
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CASE 1: 32 year old male presents with 3 week history of fever, cough, shortness of breath
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HOSPITAL COURSE
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1. When would you start antiretroviral therapy?
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Reasons to delay initiation of antiretroviral therapy in the setting of acute OI
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Reasons to start ART in the setting of opportunistic infection(OI)
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Evidence based medicine: Q: When is the optimal to time to start ARV?
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2. Should Drug Resistance Testing be obtained prior to starting therapy?
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Consider these three questions
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Drug Resistance: What is the frequency in newly diagnosed HIV infected persons?
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Key Findings
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Types of HIV Mutations
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Clusters and Trends in Primary Resistance in San Francisco
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Persistence of primary drug resistance
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Thus, in contrast to chronic HIV disease...
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Drug Resistance Landscape
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Q: What is the effect of baseline drug resistance on treatment outcome in the treatment naive patient?
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Q: What is the effect of baseline drug resistance on treatment outcome? A: With NNRTI resistance, treatment response is poor
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Reasons to do Drug Resistance Testing in Treatment naive Patients
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The missing patient
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Patient found!!
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2 weeks later, back to square 1
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What do you think this patient has?
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Immune Reconstitution Syndrome
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Immune Reconstitution Syndrome(IRS): Also known as...
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Immune Reconstitution Syndrome: Clinical Settings
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Immune Reconstitution Syndrome: Clinical Settings
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IRS and PCP: It does happen
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KS and IRS: It does happen
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Cryptococcal IRS: Usually CNS Disease
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M. avium and IRS: Usually lymphadenopathy
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Diagnostic Workup
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Back to the literature... What do we know?
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Patient is now mildly dyspneic at rest. What would you do?
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Hospital Course
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The Recap and final comments on IRS
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Many Pathogens and Syndromes
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Usually occurs at low CD4 count and is associated with rapid reduction in HIV RNA levels, but is can occur...
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Clinical Management of IRS
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Case 2
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Additional history and exam
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Clinical Decisions: Considerations
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Clinical consequences of Treatment Interruption
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Acute Retroviral Syndrome After Treatment Discontinuation
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Reservoirs are reseeded with treatment interruptions
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Treatment Interruptions in suppressed patients: Immune and virologic dynamics
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CD4 Decline after stopping and restarting ART
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Drug Resistance in STI
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EXAMPLES OF DRUG RESISTANCE WITH STI
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Five Days On, Two Days Off (FOTO) Results at 48 Wk: <50 c/mL
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7 DAYS On/ 7 DAYS off
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8 weeks on; 4 weeks off
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Planned Treatment Interruption: Strategies
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Clinical Framework for Patients who present with Treatment Interruption
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What would you do with this patient?
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Summary Teaching Points: Starting and Stopping ART
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