Clinical Case Conference

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Clinical Case Conference

Slide Presentation
October 12, 2005
Diane Havlir, MD

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Slide 1.

HIV CASE STUDIES: 2005

Slide 1.

CASE 1: 32 year old male presents with 3 week history of fever, cough, shortness of breath

Slide 2.

HOSPITAL COURSE

Slide 3.

1. When would you start antiretroviral therapy?

Slide 4.

Reasons to delay initiation of antiretroviral therapy in the setting of acute OI

Slide 5.

Reasons to start ART in the setting of opportunistic infection(OI)

Slide 6.

Evidence based medicine: Q: When is the optimal to time to start ARV?

Slide 7.

2. Should Drug Resistance Testing be obtained prior to starting therapy?

Slide 8.

Consider these three questions

Slide 9.

Drug Resistance: What is the frequency in newly diagnosed HIV infected persons?

Slide 10.

Key Findings

Slide 11.

Types of HIV Mutations

Slide 12.

Clusters and Trends in Primary Resistance in San Francisco

Slide 13.

Persistence of primary drug resistance

Slide 14.

Thus, in contrast to chronic HIV disease...

Slide 15.

Drug Resistance Landscape

Slide 16.

Q: What is the effect of baseline drug resistance on treatment outcome in the treatment naive patient?

Slide 17.

Q: What is the effect of baseline drug resistance on treatment outcome? A: With NNRTI resistance, treatment response is poor

Slide 18.

Reasons to do Drug Resistance Testing in Treatment naive Patients

Slide 19.

The missing patient

Slide 20.

Patient found!!

Slide 21.

2 weeks later, back to square 1

Slide 22.

What do you think this patient has?

Slide 23.

Immune Reconstitution Syndrome

Slide 24.

Immune Reconstitution Syndrome(IRS): Also known as...

Slide 25.

Immune Reconstitution Syndrome: Clinical Settings

Slide 26.

Immune Reconstitution Syndrome: Clinical Settings

Slide 27.

IRS and PCP: It does happen

Slide 28.

KS and IRS: It does happen

Slide 29.

Cryptococcal IRS: Usually CNS Disease

Slide 30.

M. avium and IRS: Usually lymphadenopathy

Slide 31.

Diagnostic Workup

Slide 32.

Back to the literature... What do we know?

Slide 33.

Patient is now mildly dyspneic at rest. What would you do?

Slide 34.

Hospital Course

Slide 35.

The Recap and final comments on IRS

Slide 36.

Many Pathogens and Syndromes

Slide 37.

Usually occurs at low CD4 count and is associated with rapid reduction in HIV RNA levels, but is can occur...

Slide 38.

Clinical Management of IRS

Slide 39.

Case 2

Slide 40.

Additional history and exam

Slide 41.

Clinical Decisions: Considerations

Slide 42.

Clinical consequences of Treatment Interruption

Slide 43.

Acute Retroviral Syndrome After Treatment Discontinuation

Slide 44.

Reservoirs are reseeded with treatment interruptions

Slide 45.

Treatment Interruptions in suppressed patients: Immune and virologic dynamics

Slide 46.

CD4 Decline after stopping and restarting ART

Slide 47.

Drug Resistance in STI

Slide 48.

EXAMPLES OF DRUG RESISTANCE WITH STI

Slide 49.

Five Days On, Two Days Off (FOTO) Results at 48 Wk: <50 c/mL

Slide 50.

7 DAYS On/ 7 DAYS off

Slide 51.

8 weeks on; 4 weeks off

Slide 52.

Planned Treatment Interruption: Strategies

Slide 53.

Clinical Framework for Patients who present with Treatment Interruption

Slide 54.

What would you do with this patient?

Slide 55.

Summary Teaching Points: Starting and Stopping ART

Slide 56.