HUMAN IMMUNODEFICIENCY VIRUS

(HIV)

A Case Presentation

Submitted to: Dr. Jan Karlo Ecalne

Submitted by: GROUP 1

Armillo, Claire Marie

Cabrera, Frances Elaine U.
Cerda, Allyzon G.
Consarba, Jennifer L.
Contreras, Allianna Irish M.
Corsiga, April Jomerlynn S.
Cruz, Moira Patrice C.
De Guia, Princess Pauline S.
Deldio, Veronica Lourds A.

BSP3A - BLOCK 3
*Access link to powerpoint presentation:
https://drive.google.com/drive/folders/1wVLO1jLNxNSpgAgBom3MDB2L0VTQXZhl

DISEASE PRESENTATION
Introduction - De Guia, Princess Pauline
● HIV is a virus that lives in human blood, sexual fluids, and breast milk. It weakens your
immune system, so your body has a hard time fighting off common germs, viruses, fungi,
and other invaders. It spreads mainly through unprotected sexual contact and sharing
needles. In January 2022, there were 875 confirmed HIV-positive individuals reported to
the HIV/AIDS & ART Registry of the Philippines (HARP) and accounted for the total
(95,212) reported cases since January 1984. Of the total reported cases (875) in
January 2022, 99% (863) were infected through sexual contact. Further, <1% (3) of the
reported cases each have acquired HIV through sharing of infected needles and through
mother-to-child transmission.
Pathogenesis/Etiology - De Guia, Princess Pauline
● HIV disease is caused by infection with HIV-1 or HIV-2, both of which cause very similar
conditions. They differ in transmission and progression risks.The steps occurring in
infection involve an interaction of HIV not only with the CD4 molecule on cells but also
with other cellular receptors recently identified. Virus-cell fusion and HIV entry
subsequently take place. Following virus infection, a variety of intracellular mechanisms
determine the relative expression of viral regulatory and accessory genes leading to
productive or latent infection. With CD4+ lymphocytes, HIV replication can cause
syncytium formation and cell death; with other cells, such as macrophages, persistent
infection can occur, creating reservoirs for the virus in many cells and tissues. HIV
strains are highly heterogeneous, and certain biologic and serologic properties
determined by specific genetic sequences can be linked to pathogenic pathways and
resistance to the immune response.
Staging/Classification - De Guia, Princess Pauline
● Clinical HIV infection undergoes 3 distinct phases: acute seroconversion,
asymptomatic infection, and AIDS:
○ Satge 1: Acute seroconversion - during this phase, the infection is
established and a proviral reservoir is created. This reservoir consists of
persistently infected cells, typically macrophages, and appears to steadily
release virus. Some of the viral release replenishes the reservoir, and
some goes on to produce more active infection.
○ Stage 2: Asymptomatic infection - at this stage in the infection, persons
infected with HIV exhibit few or no signs or symptoms for a few years to a
decade or more. Viral replication is clearly ongoing during this time, and
the immune response against the virus is effective and vigorous. In some
patients, persistent generalized lymphadenopathy is an outward sign of
infection. During this time, the viral load, if untreated, tends to persist at a
relatively steady state, but the CD4+ T-cell count steadily declines. This
rate of decline is related to, but not easily predicted by, the steady-state
viral load.
 ○ Stage 3: AIDS - when the immune system is damaged enough that
significant opportunistic infections begin to develop, the person is
considered to have AIDS. For surveillance purposes in the United States,
a CD4+ T-cell count less than 200/µL is also used as a measure to
diagnose AIDS, although some opportunistic infections develop when
CD4+ T-cell counts are higher than 200/µL, and some people with CD4
counts under 200/µL may remain relatively healthy.
● The CDC classifies HIV infection into 3 categories, according to the presence of
certain infections or diseases. Category A is asymptomatic HIV infection without
a history of symptoms or AIDS-defining conditions. Category B is HIV infection
with symptoms that are directly attributable to HIV infection (or a defect in
T-cell–mediated immunity) or that are complicated by HIV infection. Lastly,
Category C is HIV infection with AIDS-defining opportunistic infections, as
outlined in Pathophysiology.

Risk Factors - Contreras, Alianna Irish

● Primary infection (Acute HIV) - Some people infected by HIV develop a flu-like illness
within 2 to 4 weeks after the virus enters the body. This illness, known as primary (acute)
HIV infection, may last for a few weeks.
● Possible signs and symptoms include:
○ Fever
○ Headache
○ Muscle aches and joint pain
○ Rash
○ Sore throat and painful mouth sores
○ Swollen lymph glands, mainly on the neck
○ Diarrhea
○ Weight loss
○ Cough
○ Night sweats
● Symptomatic HIV infection -As the virus continues to multiply and destroy your
immune cells — the cells in your body that help fight off germs — you may develop mild
infections or chronic signs and symptoms such as:
○ Fever
○ Fatigue
○ Swollen lymph nodes — often one of the first signs of HIV infection
○ Diarrhea
○ Weight loss
○ Oral yeast infection (thrush)
 ○ Shingles (herpes zoster)
○ Pneumonia

Diagnosis & Detection - Contreras, Alianna Irish

The primary tests for diagnosing HIV and AIDs include:

● ELISA Test ELISA, which stands for enzyme-linked immunosorbent assay, is used to
detect HIV infection. If an ELISA test is positive, the Western blot test is usually
administered to confirm the diagnosis. If an ELISA test is negative, but you think you
may have HIV, you should be tested again in one to three months. ELISA is quite
sensitive in chronic HIV infection, but because antibodies aren't produced immediately
upon infection, you may test negative during a window of a few weeks to a few months
after being infected. Even though your test result may be negative during this window,
you may have a high level of the virus and be at risk of transmitting infection.
● Home Tests The only home test approved by the U.S. Food and Drug Administration is
called the Home Access Express Test, which is sold in pharmacies.
● Saliva Tests A cotton pad is used to obtain saliva from the inside of your cheek. The pad
is placed in a vial and submitted to a laboratory for testing. Results are available in three
days. Positive results should be confirmed with a blood test.
● Viral Load Test This test measures the amount of HIV in your blood. Generally, it's used
to monitor treatment progress or detect early HIV infection. Three technologies measure
HIV viral load in the blood: reverse transcription polymerase chain reaction (RT-PCR),
branched DNA (bDNA) and nucleic acid sequence-based amplification assay (NASBA).
The basic principles of these tests are similar. HIV is detected using DNA sequences
that bind specifically to those in the virus. It is important to note that results may vary
between tests.
● Western Blot This is a very sensitive blood test used to confirm a positive ELISA test
result.

Treatment - Armillo, Claire Marie

Pharmacologic Treatment
There is no effective cure for HIV infection as of today. However, Antiretroviral Therapy
(ART) is currently used to control the infection and prevent further complications.
Regardless of the stage of infection, patients who are HIV-positive should start with the
treatment. ART lowers HIV amount in the patient’s blood by combining two or more
drugs from different drug classes. The drug classes are as follows:
● Non-nucleoside reverse transcriptase inhibitors (NNRTIs)- binds and blocks
HIV revers transcriptase which converts RNA into DNA (reverse transciption). It
prevents replication of HIV.
○ Efavirenz
○ Rilpivirine
○ Doravirine
 ● Nucleoside or nucleotide reverse transcriptase inhibitors (NRTIs) - blocks
reverse transcriptase from converting its RNA into DNA to prevent the virus from
copying itself.
○ Abacavir
○ Tenofovir disoproxil fumarate
○ Emtricitabine
○ Lamivudine
○ Zidovudine
● Protease inhibitors (PIs)- binds to proteolytic enzymes (proteases) and blocks
them.
○ Atazanavir
○ Darunavir
○ Lopinavir/ritonavir
● Integrase inhibitors- inhibits integrases, thereby stopping HIV from entering CD4
cells.
○ Bictegravir sodium/emtricitabine/tenofovir alafenamide fumarate
○ Raltegravir
○ Dolutegravir
○ Cabotegravir
● Entry or fusion inhibitors prevents the fusion of HIV and CG4 or other cells.
○ Enfuvirtide
○ Maraviroc

Non-Pharmacologic Treatment:
The following lifestyle and home remedies might be helpful along with the drug therapy:
● Eating healthy foods such as fresh fruits and vegetables, whole grains, and
lean protein to keep the body strong, and to support the body’s immune system.
● Avoid eating raw meats and eggs to prevent foodborne illnesses. In addition, it
is best to avoid unpasteurized dairy products, raw eggs and raw seafood such as
oysters, sushi or sashimi.
● Get the right vaccinations such as vaccinations for pneumonia, influenza, and
others. Vaccines with inactivated viruses are preferred over vaccines with live
viruses because HIV-positive patients have weak immune system.
● Take care with companion animals since some animals may have
infection-causing parasites
○ Cat feces can cause toxoplasmosis
○ Reptiles can carry salmonella
 ○ Birds can carry cryptococcus or histoplasmosis.

To avoid this, patients must wash their hands thoroughly after handling their pets or
emptying the litter box.

PATIENT DETAILS - De Guia, Princess Pauline

● A 27-year-old woman who was diagnosed with HIV infection 2 years ago during a routine
exam.

SUBJECTIVE - De Guia, Princess Pauline

1. Chief Complaint
“I am here for routine care.”

2. Past Medical History

● HIV infection diagnosed 2 years ago; risk factor heterosexual contact
● Appendectomy at 15

3. Famly History
● Noncontributory

4. Social History
● History of crack cocaine use (last use 3 yrs ago)
● Tobacco use 1PPD (pack per day)
● ETOH 1-2 drinks every weekends
● Full time employed at Candy Factory - stable shift
● Sexually active
● Has stable partner
● 100% condom use
● The partner is HIV (-)
● The partner is aware of her HIV status

OBJECTIVE - De Guia, Princess Pauline

Physical Examination:
General
● Thin, well-developed black female, No Acute Distress (NAD), alert and oriented x 3
Vital Signs
● Blood Pressure - 107/54 (Normal)
● Pulse - 68 (Normal)
● Respiratory Rate - 18 (Normal)
● Temperature - 36.4°C (Normal)
● Weight - 55 kg, Height - 5’2” (BMI - 22.2 - Normal)
Skin
● Anicteric, has large tattoo on back of neck
● No other skin lesions noted
HEENT (Head, Ears, Eyes, Nose, Throat)
● No oral lesions, sinuses nontender
● Pupils, equal, round, reactive to light and accommodate (PERRLA)
● Ear and nose clean
Neck
● Supple, no thyromegaly - L neck lymph node 0.5 cm in diameter
Chest
● Lungs clear
Cardiovascular
● S1, S2 without S3, S4, or murmur
Abdominal
● (+) BS, soft, nontender, without hepatosplenomegaly
Genitourinary
● Pelvic exam - normal external genitalia
● Vaginal vault within normal limits
● Perineum & perianal regions - free of grossly visibe lesions
● Guiaic (-) stools
Extremities
● No wasting, no clubbing, cyanosis, and edema (CCE)
Neuro
● No focal deficits

Laboratory: - Contreras, Alianna Irish, De Guia Princess Pauline

Paremeter (units) 2 yrs ago This visit 6 wk Later 12 wk later NORMAL
RANGE

General

Weight (kg) 60 55 56 58

Hematology

Hgb (g/dL) 13.6 12.9 12.7 13.1 11.6 - 15

g/dL
(female)

HCt (%) 39.9 37.0 38.5 38.6 36% - 48%

(female)

Plt (x 103/mm3) 220 114 145 161 150 - 400 x

10^9/L

WBC (x1 03/mm3) 3.9 3.3 3.3 3.4 3.3 -8.7

(x103/mm3)
 ● Lymphs (%) 34.6 28.4 34.3 40.1 20% to
40%

● Monos (%) 5.0 4.7 5.8 5.5 2% to 8%

● Eos (%) 1.0 1.9 1.5 1.0 1% to 4%

● Basos (%) 0.7 0.5 0.7 0.8 0.5% to 1%

● Neutros(%) 55.0 60.2 53.6 58.4 40% to

60%

ANC (x 103/mm3) 2.1 1.9 1.7 1.9 2.5-6.0

Chemistry

BUN (mg/dL) 12 11 14 13 7-24 mg/dL

SCr (mg/dL) 0.4 0.5 0.6 0.5 0.6 to 1.1

mg/dL

T. bili (mg/dL) - 0.6 - 0.6 Up to 1.2

mg/dL

Alb (g/dL) - 4.4 - 4.4 3.4 to 5.4

g/dL

AST (IU/L) 21 22 - 25 8 to 48 IU/L

ALT (IU/L) 19 18 - 20 7 to 55 IU/L

Fasting glucose 78 88 80 99 mg/dL or

lower

Fasting lipid
profile

● T. chol - 153 - 163 less than

200 mg/dL

● Triglycerides - 81 - 98 Less than

150 mg/dL

● LDL - 125 - 128 Less than

100 mg/dL

Surrogate Markers

CD4 (%) 33 18 - 15 25% to

65%

CD4(cells/mm3) 568 269 - 450 500 to

 1,400
cells/mm3

CD8 (%) 40 54 - 51 10%-30%

HIV RNA (RT-PCR) a 25,000 350,000 1,000 <50 Not

(copies/mL) Detected
Linear
Range = 40
- 1,000,000
copies/ml

Antiviral resistance No antiviral - - -

test (genotypic resistant
resistance test) mutations
detected

Hepatitis virus
serologies

● HBV Ab Negative

● HBV Core Negative

Ab total

● HBV Ag Negative

● HCV Ab Negative

● HAV Ab Negative

ASSESSMENT - Cerda, Allyzon

● 27-year-old woman with HIV infection and no other comorbidities, shows steady decline
in CD4 cell count and rising levels of HIV viremia since her initial diagnosis 2 years ago.
● Rising levels of HIV viremia
The patient’s treatment is not working well and the virus is much more active in which he
might be at higher risk of developing AIDS.
● Steady decline in CD4 cell count
The patient was diagnosed with HIV infection two years ago, her CD4 cell count declined
from 33% two years ago to 15% 12 weeks later. The number of CD4 lymphocytes in the
blood is a surrogate marker of disease progression.
● Hypotension
The patient’s blood pressure was 107/54, which indicates an orthostatic hypotension
(OH) as a consequence of her infection.
COURSE IN THE WARDS - NOT APPLICABLE

PROBLEM LIST - Corsiga, April Jomerlynn

1. HIV RNA detected (the genetic material of the virus in the blood)
2. Rising levels of HIV Viremia (the presence of the virus in the bloodstream)
3. Steady decline and below normal CD4 count (an indicator of the immune function)
4. Elevated CD8 cell count (increased risk of treatment failure)
5. Low ANC or absolute neutrophil count (confirms disease progression)
6. Below normal serum creatinine levels (due to untreated HIV infection that leads to
loss of lean body mass)

PHARMACOTHERAPY GOALS - Cruz, Moira Patrice

- The pharmacotherapy goals for this case are to improve HIV replication control, restore
and preserve the immune system, improve survival and quality of life, and reduce HIV
transmission and prevent new infection.

GUIDELINES VS ACTUAL MANAGEMENT - Cabrera, Frances Elaine

Guidelines
● Antiretroviral therapy (ART) is treatment of people infected with human
immunodeficiency virus (HIV) using anti-HIV drugs. The standard treatment consists of a
combination of drugs (often called “highly active antiretroviral therapy”) that suppress
HIV replication.
● ART reduces mortality and morbidity rates among HIV-infected people, and improves
their quality of life. The benefits of ART also include the prevention of HIV transmission
by suppressing HIV replication in people living with the virus.
● WHO recommends initiating ART in all persons living with HIV, regardless of WHO
clinical stage and at any CD4 cell count (also called “treat all”).

Post-test information and counseling for people who test HIV positive should include the
following:
● Clear information on ART and its benefits for maintaining health and reducing the risk of
HIV transmission, as well as where and how to access ART
● Arranging a specific date and time for active referral and follow-up of clients who are
unable to enroll in HIV care on the day of diagnosis;
● Information on how to prevent transmission of HIV, including information on the reduced
transmission risks when virally suppressed on ART;
● Encouragement and offer of HIV testing for sexual partners, children and other family
members, which can be done individually, through couples testing, index case testing,
family testing or partner notification
Actual Management

● There's no cure for HIV, but treatment options are much better than they were a few
decades ago. Because of medical advancements, people can now live long, active lives
with HIV
● Research shows that a combination, or "cocktail," of drugs is the best way to control HIV
and lower the chances that the virus will become resistant to treatment. Your doctor will
probably recommend that you take three medicines from two of the groups.
● You’ll need to see your doctor regularly so they can be sure your HIV treatment is
working. Let them know if you’re having trouble sticking to your treatment plan, such as if
you have problems remembering to take pills or side effects from the medications.

PLAN - Consarba, Jennifer

● Multiple steps are required for HIV replication. Using a combination of medicines that
target distinct phases of the HIV life cycle results in either a synergistic or additive
antiviral action, hence boosting the effectiveness with which viral replication is
controlled.
● Combinations consist of a "backbone" of 2-NRTIs
● Nucleoside Reverse Transcriptase Inhibitors co administered with PI ( Protease
Inhibitor)
● Person’s initial treatment regimen generally includes three HIV medicines from at
least two different drug classes that must be taken every day
● Contemporary antiretroviral regimens, HDL cholesterol generally increases with
control of HIV replication.
● Changes in triglycerides are variable and dependent on the specific antiretrovirals
used
● In untreated, advanced HIV disease, patients typically have

- low total cholesterol,

- low low-density lipoprotein (LDL) cholesterol, ( Patient lab result)
- low high-density lipoprotein (HDL) cholesterol,
- hypertriglyceridemia.

Drug Therapy

DRUG INDICATION DOSE & DOSAGE SCHEDULE &

FORM DURATION

Pepcid AC Treat heartburn Film-coated tablet - Take 1 tab with glass

20 mg of water PRN
Multivitamins Adjunctive therapy to 20 mg Take 1 tab daily
(Centrum Advance) potentially enhance
quality of life

ANTIRETROVIRAL THERAPY

Tenofovir Disoproxil 2 nucleoside Reverse Film-coated tablet - Take once daily with
Fumerate / Transcriptase 200 mg/ 300 mg or without food
Emtricitabine Inhibitors in one
(Truvada) tablet

Lopinavir / Ritonavir Protease inhibitor Film-coated tablet - Two times a day with
200 mg/ 50 mg food. The doctor may
adjust the dose if
needed.

Non-Pharmacologic Treatment - Deldio, Veronica Lourds

● Condoms - to protect and prevent sexual transmission of HIV.

● Smoking Cessation - quitting smoking may be one of the most essential measures a
person with HIV can take toward improved health since it lowers the risk of lung cancer
and other cancers, as well as heart disease, stroke and COPD. It also helps with
HIV-related symptoms like tiredness, nausea, and bodily discomfort. As a result, it
enhances the quality of life and extends life expectancy.
● Stop Drinking Alcohol - it is recommended that the patient should stop drinking alcohol
since it lowers the patient’s immune system and destroys the liver. According to the
researcher, those with HIV who regularly use alcohol had a higher viral load and lower
overall CD4 count.
● Reduction of Consumption of Saturated and Trans Fats - to lower LDL level.
● Exercise - Muscles can only be strengthened and built up through exercise. Muscles are
used by the body to store energy and protein, which the immune system may use as
needed. Exercise is thus very crucial for HIV/AIDS patients' health maintenance.
● Nutrition - Eat more staple foods such as rice, maize, millet, sorghum, wheat, bread,
potatoes, sweet potatoes, yams and bananas, increase intake of beans, soy products.
Eat snacks regularly between meals such as nuts, seeds, fruit, yogurt, and carrots.

PATIENT COUNSELING - Deldio, Veronica Lourds

1. Once medication has been given, the patient should be taking medication immediately.
2. Patient's laboratory and diagnostic results, shows that she does not have any
comorbidities.
3. It is also important for the patient to take HIV medication on a consistent basis
 4. If the patient develops drug resistance, she will have fewer alternatives to achieve a
satisfactory HIV treatment outcome.
5. The patient should continue to use condoms.

Antiretroviral therapy will be applied to the patient’s condition. It is used to decrease the amount
of HIV that is present in a person’s body.
● Once the medication has been given, the patient should begin taking medication
immediately. HIV drugs should be prescribed for all HIV-positive individuals, regardless
of their age or overall health.
● The patient should inform her health-care practitioner of any medical conditions she may
be suffering from as well as any medication she is currently taking.
● According to the patient’s laboratory and diagnostic results, she does not have any
comorbidities and simply has HIV.
● It is important for the patient to take HIV medication on a consistent basis and according
to the prescription since this helps to avoid drug resistance.
● Furthermore, if the patient develops medication resistance, she will have fewer
alternatives for achieving a satisfactory HIV treatment outcome.
● Even while taking antiretroviral medications, the patient should continue to use condoms
since these medications do not cure HIV; rather, they just lower the quantity of HIV
present in the body.

QUESTIONS

Problem Identification

1.a. What information (signs, symptoms, laboratory, values) indicates the severity of HIV
disease? - Contreras, Alianna Irish
● The laboratory values such as the CD4 (%), CD4 (cells/mm3), CD8 (%) and HIV RNA
(RT-PCR)a (copies/mL) indicate the severity of HIV disease of the patient. The CD4 (%)
and CD4 (cells/mm3) have a result of below normal and this shows that HIV has
weakened the immune system of the patient. On the other hand, an elevated CD8 cell
count is associated with an increased risk of HIV treatment failure for patients who
initially achieve an undetectable viral load, investigators from the US military report in the
online edition of the Journal of Acquired Immune Deficiency Syndromes. The detection
of HIV RNA also shows that the patient is infected with HIV infection. Low ANC is also
one of the values that shows that the patient's body ability to fight infection is low.
1.b. Is prophylactic therapy for any associated opportunistic pathogen indicated in this
patient? Why or why not? - Armillo, Claire Marie
● Opportunistic infections in patients who are HIV-positive include Pneumocystis
pneumonia, Toxoplasmosis, and Mycobacterium avium Complex (MAC).
Pneumocystis is a respiratory infection common in patients with AIDS; Toxoplasmosis is
an infection of the Central Nervous System; and MAC is an infection caused by two
nontuberculous mycobacterial species (M. avium or M. intracellulare).
 Ms. Sally Smith does not have any prophylactic therapy associated with the infections
mentioned. Pneumocystis pneumonia occurs in patients with CD4 count of <200
cells/microL; Toxoplasmosis in patients with <100 cells/miroL; and MAC in patients with
<50 cells/miroL. Based on the patient’s laboratory results, her CD4 counts do not fall
within the indicators of the three infections. Hence, prophylactic therapy is not indicated
to the patient.
1.c. What is your recommendation regarding antiretroviral therapy for this patient? -
Contreras, Alianna Irish
● Antiretroviral therapy is the treatment for individuals that are infected with human
immunodeficiency virus (HIV) using anti-HIV drugs. But some antiretroviral drugs may
concentrate in the kidneys, or inhibit creatinine secretion in the kidneys, leading to
damage to the kidney tubules. And based on the laboratory result of the patient, her
serum creatinine is below normal. The use of antiretroviral therapy for this patient can be
pushed through but make sure to pick antiretroviral drugs that do not concentrate on the
kidney.

Desired Outcome

2. What are the goals of pharmacotherapy in this case? - Contreras, Alianna Irish
● HIV attacks and destroys the infection-fighting CD4 cells (CD4 T lymphocyte) of the
immune system. Loss of CD4 cells makes it hard for the body to fight off infections and
certain HIV-related cancers. HIV medicines prevent HIV from multiplying (making copies
of itself), which reduces the amount of HIV in the body (called the viral load). Having less
HIV in the body gives the immune system a chance to recover and produce more CD4
cells. Even though there is still some HIV in the body, the immune system is strong
enough to fight off infections and certain HIV-related cancers. By reducing the amount of
HIV in the body, HIV medicines also reduce the risk of HIV transmission. A main goal of
HIV treatment is to reduce a person’s viral load to an undetectable level. An
undetectable viral load means that the level of HIV in the blood is too low to be detected
by a viral load test. People with HIV who maintain an undetectable viral load have
effectively no risk of transmitting HIV to their HIV-negative partners through sex.

Therapeutic Alternatives

3.a. What therapeutic options are available for treating this antiretro-viral naive patient? -
Cerda, Allyzon
PHARMACOLOGIC INTERVENTIONS:
Antiretroviral (ARV) regimen
**CD4 percentage at initiation of the first ART regimen predicts disease progression and
mortality independent of absolute CD4 count. Hence, ART can be considered in patients
whose CD4 >350 cells/uL but CD4 % <14%. Patient’s CD4 values 12 weeks later is 450
cells/uL and 13%.
Preferred:
● An antiretroviral (ARV) regimen for a treatment-naive patient generally consists of
two nucleoside reverse transcriptase inhibitors (NRTIs) administered in
combination with a third active ARV drug from one of three drug classes: an
integrase strand transfer inhibitor (INSTI), a non-nucleoside reverse transcriptase
inhibitor (NNRTI), or a protease inhibitor (PI) with a pharmacokinetic (PK)
enhancer (also known as a booster; the two drugs used for this purpose are
cobicistat and ritonavir)
● NNRTI-based
○ Efavirenz + tenofovir + emtricitabine (AI)
● HIV PI-based
○ Darunavir + ritonavir + tenofovir + emtricitabine (AI)
○ Atazanavir + ritonavir + tenofovir + emtricitabine (AI)
● InSTI-based
○ Raltegravir + tenofovir + emtricitabine (AI)
● This technique for first therapy has resulted in suppression of HIV replication and
increases in CD4 counts in most people with HIV
● More evidence now supports the use of the two-drug combination
dolutegravir/lamivudine (DTG/3TC) as an initial treatment for some HIV
patients.

Dolutegravir (DTG)
a regimen with two nucleoside reverse-transcriptase inhibitors (NRTIs) paired with DTG
was more effective, with higher viral suppression and CD4 cell count recovery rates and
lower risk of treatment discontinuation compared with EFV-based regimens among
treatment-naive adults (WHO, 2018)

First-line regimens:
● Two NRTIs + DTG
● Two NRTIs + EFV
Second-line regimens:
● Two NRTIs + (ATV/r or lopinavir/ritonavir LPV/r)
● Two NRTIs +DTG

Vaccination
● consider HAV, HBV, pneumococcal vaccination (if CD4 > 200), seasonal
influenza vaccination
NON-PHARMACOLOGIC INTERVENTIONS
● Education and support - Include reproductive/contraceptive advice and counseling for
the patient including his partner to avoid further risks. Consider joining peers/support
groups, it can be particularly useful for the patient whenever she is feeling vulnerable or
anxious because of ill health and lack of confidence due to HIV.
● Health maintenance - A nutritional food and a balanced diet will help. Start regular
exercises and getting enough sleep as it helps on patient’s physical and mental health.
● Risk assessment and prevention - Proper education, counseling and interventions
regarding safer sexual practice since they are sexually active. Injections and needles
from medications should not be shared with other people. Getting regular dental
check-ups might help not to spread the infection with others.
● Public measure - The patient should be notified in case of new HIV diagnosis and other
notifiable infections such as Syphilis, HBV, HCV. Advice to patient regarding the legal
obligations around disclosure of HIV status to sexual partner.

3.b. What economic, psychosocial, racial and ethical considerations are applicable to this
patient? - Cruz, Moira Patrice
● Since the patient should be treated for HIV, she must disclose her condition to her
company because she might put a hazard on the candy products. However, being
HIVpositive often has a negative impact on socioeconomic status by constraining an
individual's ability to work and earn income. Moreover, black women are
disproportionately affected by HIV as compared to women of other races/ethnicities
where she may experience discrimination. For psychosocial considerations, she may
view HIV as a persecutor or threat, feel loss of control & vulnerability, and fear of death.
Support and interventions should be provided by promoting communication and
medication adherence and also to address her emotional-related distress. Furthermore,
ethical considerations include protecting autonomy through informed consent, avoiding
exploitation and fostering altruism; maintaining a favorable benefits/risks balance,
safeguarding against vulnerability through patient-participant centeredness, and
ensuring acceptance of next-of-kin/loved ones and community stakeholders.

3.c. How would you evaluate patient readiness for antiretroviral treatment initiation? -
Corsiga, April Jomerlynn
● There are several factors to consider in order to know if the patient needs to start
antiretroviral treatment (ART). Such as CD4 cell count, in which the patient in this case
already shows a steady decline in CD4 cell count; co-morbidities, in which the patient, in
this case, has also no other comorbidities; willingness and readiness of the patient to
start therapy; and the availability of the resources. Therefore, in this case, the patient
needs to be assessed for readiness to start the therapy.
● ART readiness is an assessment used as a key predictor of ART initiation
(Maughan-Brown et al., 2018). The demographic characteristics and psychosocial
factors are associated with the assessment. The key components of this concept are:
○ 1. Awareness of the patient that the treatment will be beneficial
○ 2. Motivation of the patient to initiate treatment
 ○ 3. Intention of the patient to start treatment soon

OPTIMAL PLAN - Consarba, Jennifer

4.a. Propose an antiretroviral regimen for this woman. Indicate the drug name, dosage
form, dose, schedule, and duration of therapy for the regimen you choose.

PLAN A
Medication ( Dose Schedule Contraindica Duration Rationale
Nucleoside tions
Reverse
Transcriptas
e Inhibitors)

Emtricitabin 200/ 300 mg Once daily Low amount Truvada

e / Tenofovir with or of phosphate contains two
disoproxil without food in the blood nucleoside
Fumarate transcriptas
(Truvada) 6 months or e inhibitor
Patient who less for viral that will serve
is producing load to reach as “
milk and the Backbone”
breastfeeding undetectable
level After using
Chronic Truvada, lipid
levels
hepatitis B
returned to
normal. Since
the patient's
LDL level is
Medication Dose Schedule low, Truvada
(Protease is
Inhibitor) recommend
ed.
300 mg / 150 One tablet
mg taken

Truvada
● Contains two nucleoside transcriptase inhibitor
● Truvada is safe to take and causes no clinically significant bone or kidney changes
● Truvada contains TDF
 ● Lipid lipids returned to normal after returning to treatment that included TDF
● Not recommended for use as a component of a triple nucleoside regimen
PLAN B
● Combination Drugs
● Integrase Strand Transfer Inhibitor (elvitegravir)
● Nucleoside Reverse Transcriptase Inhibitor (emtricitabine, tenofovir DF)
● Pharmacokinetic Enhancer (cobicistat)
● Stribild is a complete HIV treatment regimen and should not be used with other HIV
medicines
Medication Dose Schedule Contraindicatio Rationale
n

Stribild ● Stribild Once a day , ● Drugs

comes in take by mouth that are
tablet with food highly
depende
form.
nt on
Each CYP3A
tablet for Can be used
contains: clearanc without other
e antiretroviral
- 150 mg medicines to
elvitegra ● Elevated treat HIV a
plasma Complete HIV
vir
concentr treatment
- 150 mg ations regimen
cobicistat are
- 200 mg associate
emtricita d with
bine serious
- 300 mg and/or
life-threat
tenofovir
ening
disoproxil events.
fumarate

4.b. Design an antiretroviral regimen that would be appropriate if the patient informs you
that she would like to consider becoming pregnant once her HIV infection is under
control.

● Darunavir/ Ritonavir plus NRTI (TDF/FTC) combination

● For TDF/ FTC for pregnant women no dose adjustment
● During pregnancy and the postpartum period, darunavir + ritonavir was reported to be
well tolerated.
Medication Dose Schedule Contraindicatio Rationale
n

Darunavir/ 800 mg/ 100 mg Once a day prior ● Diabetes For TDF/ FTC
Ritonavir to pregnancy ● High for pregnant
cholester women no dose
ol
adjustment
● high
amount During
of pregnancy and
triglyceri the postpartum
de i the period, darunavir
blood + ritonavir was
● Hemophil reported to be
ia
well tolerated.
With NRTI ( 200 mg/ 25 mg One tablet taken ● Low
Nucleoside orally once daily amount (DTG+FTC/TAF)
Reverse of may comprise
Transcriptase phosphat the safest and
Inhibitors) - e most effective
Tenofovir HIV treatment
alafenamide ● increase regimen
Fumarate / d blood currently
Emtricitabine acidity available during
due to pregnancy
high
levels of
lactic
acid

● Fanconi
syndrom
e, a
condition
of the
kidneys
resulting
in
excessiv
e
urination,
thirst and
vomiting

● Acute
kidney
failure
 ● Chronic
kidney
disease
stage 5
(failure)

● chronic
hepatitis
B

● Decreas
ed
kidney
function

4.c. Recommend an antiretroviral regimen that would be appropriate if this patient has a
history of chronic kidney disease, not requiring hemodialysis.

Medication Dose Schedule Contraindicatio Rationale

n

Rilpivirine/ 200 mg/25 mg/ One tablet taken Allergic to An alternative to

Tenofovir 25 mg orally emtricitabine, tenofovir
Alafenamide/ rilpivirine, or disoproxil
Emtricitabine tenofovir. fumarate
(Odefsey)
Concomitant TAF is well
carbamazepine, tolerated in
oxcarbazepine, those with mild
phenobarbital, to moderate
phenytoin, renal impairment
rifampin,
rifapentine, Found to be
dexlansoprazole safer for the
, esomeprazole, kidneys than the
lansoprazole, older version.
omeprazole,
pantoprazole, The doctor may
rabeprazole, recommend this
systemic drug for your
dexamethasone treatment if you
(more than a have, or are at
single dose), St. risk of
John's wort. developing,
 kidney disease.

Ritonavir / 300 mg/100 mg Once daily Has been an

Atazanavir important
innovation in the
treatment of
adult HIV
infection owing
to its ease of
dosing, virologic
potency, minimal
toxicity, high
genetic barrier to
resistance,
favorable
resistance
profile and lower
effect on lipid
and glucose
metabolism.

Dolutegravir / Lamivudine
● Combination pill DTG/3TG
● U.S FDA approved combinations pill consists
- Integrase inhibitor dolutegravir (DTG)
- NRTI lamivudine (3TC)
- Marketed with the trade name Dovato

● Does not require dose adjustment in patients with chronic kidney disease
● Confirming the efficacy and safety of this regimen in patients with chronic kidney disease

4.d. Discuss the role of HIV resistance testing in designing a regimen for the
antiretroviral treatment-naive patient.
● Used to determine whether a patient with HIV has a virus strain that is resistant to
antiretroviral therapy (ART).
● HIV can grow more rapidly if an HIV-positive patient develops resistance to a medicine
and continues to take it.
● If the resistant virus multiplies well enough, it may eventually become the most prevalent
form of HIV in the body.
OUTCOME EVALUATION
5. What clinical and laboratory parameters are necessary to evaluate the clinical efficacy
and toxicity of the antiretroviral regimen selected? Specify frequency with which you will
monitor the parameters. Indicate therapeutic goal. - Corsiga, April Jomerlynn

LABORATORY TEST THERAPEUTIC GOAL FREQUENCY OF

MONITORING

1. Viral Load Test It measures how many HIV

particles are in a sample of
blood. The desirable result
of the viral load must be low.
During and/or If:
● Entry into care
● Art
Initiation/Modification
● 2 to 8 weeks after ART
initiation or Modification
● Every 3 to 6 months
● Every 6 months
● Treatment failure
● Clinically indicated
● ART initiation is delayed
(repeat testing is
optional)
2. CD4 Cell Count Good measure of how well
the immune system is
working and the risk of
opportunistic infections.
Treatment with ART is
recommended for everyone
with HIV, no matter how high
or low their CD4 count is.
3. Blood Chemistry Tests To help monitor the health of
the heart, liver, and kidneys.
Health care providers use
these tests to look for side
effects caused by HIV
medicines.
During and/or If:
● Entry into care
● Art
Initiation/Modification
● Every 3 to 6 months
(during first 2 years, or
if viremia develops, or if
CD4 count is <300
cells/mm3)
● Every 12 months (After
2 Years on ART with
Consistently
Suppressed Viral Load)
● Treatment failure
● Clinically indicated
● ART initiation is delayed
(every 3 to 6 months)
During:
● Entry into care
4. Complete Blood Count To keep tract of patient’s
(CBC) overall health and spot
infections or other potential
medical problems.
5. Drug Resistance Tests To know if any, HIV
medicines will not be
effective against the strain of
HIV the patient has.
6. Fasting Glucose To help guide the choice of
(Blood Sugar) Test HIV medications and to
monitor possible increases
in the blood glucose.
During and/or If:
● Entry into care
● Art
Initiation/Modification
● Every 3 to 6 months
● Every 12 months (when
no longer monitoring
CD4 cell count)
● Treatment failure
● Clinically indicated
● ART initiation is delayed
(every 3 to 6 months)
During and/or If:
● Entry into care
● Art
Initiation/Modification
● Treatment failure
● Clinically indicated
● ART initiation is delayed
During and/or If:
● Entry into care
● Art
Initiation/Modification
● Every 12 months
● Clinically indicated
● ART initiation is delayed
(If normal at baseline,
annually)
 7. Fasting Lipid Panel To help guide the choice of
(Cholesterol and medications and to treat
Triglycerides) high lipids to avoid other
serious health problems.
During and/or If:
● Entry into care
● Art
Initiation/Modification
● Every 12 months
● Clinically indicated
● ART initiation is delayed
(If normal at baseline,
annually)

PATIENT EDUCATION - Deldio, Veronica Lourds

6.a. What important information would you provide to this patient about her therapy?
● Antiretroviral medications are drugs that have the ability to inhibit the virus to replicate in
the body. This provides the immune system with the opportunity to restore itself and
prevent potential harm.
● Antiretroviral Therapy cannot cure HIV but it helps the patients to live longer.
● The patient should not postpone her therapy since HIV may continue to weaken her
immune system, increasing her chances of having AIDS (Acquired Immunodeficiency
Syndrome) in the future.

6.b. Explain in non-technical terms the surrogate markers and their use in monitoring HIV
disease.
● HIV RNA Levels in Plasma ​were measured approximately every 6 months and provide
a rapid method of assessing the efficacy of a new antiretroviral agent. The standard
blood tests used in UK clinics can measure viral load down to 20 or 50 copies per
milliliter of blood. Anything less than this is called 'undetectable'. If someone has an
undetectable viral load, it does not mean they are cured of HIV.
○ A normal result means no HIV was found in your blood, and you are not infected.
○ A low viral load means the virus is not very active and probably means your HIV
treatment is working.
○ A high viral load means the virus is more active and your treatment is not working
well.
● CD4 Lymphocyte Count is useful for determining prognosis and susceptibility to
opportunistic infections. CD4 lymphocyte counts of subjects within 6 months of the
initiation of therapy rather than on clinical evidence of benefit.

6.c. Identify potential barriers to medication adherence, and discuss potential strategies
to overcome these barriers and maximize treatment adherence.
● Patient Factors (drug use, alcohol use, age, sex, or ethnicity) - patient-related
variables such as drugs and/or alcohol use, lack of awarenes of harmful drug
interactions and excessive anxiety due to disease stigma.
 ● Medication Regimen (dosing complexity), Number of Pills, and Food Requirement
- medications factors such as dose frequency of more than twice a day, route of
administration, inability to take medications when away from home, side effects and
dietary needs.
● Patient-health-care Provider Relationship and System of Care - the physician is
largely responsible for educating & monitoring their patient, and doing follow-ups

Although, medication adherence to therapy is difficult to measure and assess. It is important to

recognize these factors to be able to implement better interventions for the patient and have a
better control progression of HIV.

CLINICAL COURSE
The provider and patient accepted your treatment recommendations. The patient returns
to the clinic for follow-up 6 weeks and 12 weeks after treatment initiation. Her treatment
flow sheet is as follows:

Parameter 6 weeks later 12 weeks later

HIV RNA (RT-PCR) 1,000 copies/mL < 50 copies/mL

CD4 lymphocyte count NA 450 cells/mm3

Symptoms of HIV infection Asymptomatic Asymptomatic

Adverse events reported Mild nausea, no vomiting None

Concomitant medications Oral contraceptives Oral contraceptives

MVI MVI

FOLLOW-UP QUESTIONS
1.Provide an assessment of the antiretroviral regimen efficacy at each follow-up visit. -
Armillo, Claire Marie
After six weeks of following the combination therapy of Tenofovir Disoproxil
Fumarate/Emtricitabine (Truvada) and Lopinavir/Ritonavir (protease inhibitor), the patient’s viral
load significantly decreased from 350,000 copies/mL to 1,000 copies/mL. This difference
indicates that the recommended antiretroviral combination therapy significantly decreases the
patient’s viral load. However, the viral load is still detected, so the patient can still pass HIV
during sexual intercourse. Moreover, CD4 lymphocyte counts are not available after six weeks
of the treatment since the patient only started her therapy. According to the guidelines, CD4
testing should be done 3-6 months after the antiretroviral therapy. The patient is also
asymptomatic, indicating that she has a chronic HIV infection (stage 2 of infection). Her mild
nausea is caused by the initial treatment of antiretroviral drugs.
After 12 weeks of following the recommended antiretroviral therapy, the patient’s viral
load decreased from 1,000 copies/mL to <50 copies/mL, indicating an undetected viral load. It
indicates that HIV is not infectious, so the virus is not enough to pass the body fluids during
sexual intercourse. CD4 lymphocyte counts are already available after 12 weeks and are near
3
the normal value of 500-1,400 𝑐𝑒𝑙𝑙𝑠/𝑚𝑚 . Furthermore, the patient is still asymptomatic,
indicating that she still has stage 2 HIV. Her mild nausea also subsided after 12 weeks of
Antiretroviral Therapy.

2. Identify potential problems with her concomitant medications and discuss alternatives.
- Cruz, Moira Patrice
● Even within the same antiretroviral medication class, pharmacological interactions
between ART and systemic hormonal contraception are often unpredictable, resulting in
an increase or reduction in each hormonal component of the contraceptive. When taken
with efavirenz, etonogestrel concentrations discharged from subdermal implants were
reduced by 63.4 percent. With that, use an alternative contraceptive method according
to Faragon (2015). Instead of oral contraceptives, use DMPA
(Depo-Medroxyprogesterone Acetate) Injection. The use of this injectable contraception
is unrestricted. ARVs had no effect on the efficacy of injectable depot
medroxyprogesterone acetate (DMPA).
REFERENCES (APA 6TH EDITION)

ABIM Foundation. (2018, October 9). Human Immunodeficiency Virus (HIV). Retrieved from
https://www.choosingwisely.org/patient-resources/human-immunodeficiency-virus-hiv/

Aidsmap. Diagnosed with HIV at a low CD4 count. (2021, January 29). Retrieved from
https://www.aidsmap.com/about-hiv/diagnosed-hiv-low-cd4-count

Berry, J. (2018, December 4). What are integrase inhibitors for HIV? Retrieved 17 May 2022,
from https://www.medicalnewstoday.com/articles/323882

Cafasso, J. (2018). Viremia. Geraadpleegd op 10 mei 2022, van

https://www.healthline.com/health/viremia

Centers for Disease Control and Prevention (CDC). (n.d.). Treatment | Living with HIV | HIV
Basics | HIV/AIDS | CDC. Retrieved from
https://www.cdc.gov/hiv/basics/livingwithhiv/treatment.html#:%7E:text=There%20is%20n
o%20effective%20cure,of%20other%20sexually%20transmitted%20diseases

Clinical Info HIV. (n.d.). Non-Nucleoside Reverse Transcriptase Inhibitor (NNRTI) | NIH.
Retrieved from
https://clinicalinfo.hiv.gov/en/glossary/non-nucleoside-reverse-transcriptase-inhibitor-nnrti

Faragon, J. (2015). Drug Interactions with Oral Contraceptives and HIV Medications.
https://aidsetc.org/sites/default/files/resources_files/OralContraceptiveandHIVDrugIntera
ctionsGuide2015.pdf
HIV.gov. (n.d.). Lab Tests and Why They Are Important. Retrieved from
https://www.hiv.gov/hiv-basics/staying-in-hiv-care/provider-visits-and-lab-test/lab-tests-an
d-results

i-Base How long will it take for my CD4 count to go back up? | Q and A | HIV i-Base. (2017,
August 7). Retrieved from https://i-base.info/qa/1947

Madzime, M., Rossouw, T. M., Theron, A. J., Anderson, R., & Steel, H. C. (2021). Interactions of
HIV and Antiretroviral Therapy With Neutrophils and Platelets. Geraadpleegd op 10 mei
2022, van https://www.frontiersin.org/articles/10.3389/fimmu.2021.634386/full

Maughan-Brown, B., Smith, P., Kuo, C., Harrison, A., Lurie, M. N., Bekker, L. G., & Galárraga,
O. (2018). Readiness for Antiretroviral Therapy: Implications for Linking HIV-Infected
Individuals to Care and Treatment. AIDS and Behavior, 22(3), 691–700.
https://doi.org/10.1007/s10461-017-1834-2
Mayo Clinic. (2022, March 26). HIV/AIDS - Diagnosis and treatment - Mayo Clinic. Retrieved
from
https://www.mayoclinic.org/diseases-conditions/hiv-aids/diagnosis-treatment/drc-203735
31

MedScape. (2020, March 22). What is the mechanism of action of fusion inhibitors (FIs) in
antiretroviral therapy of HIV infection? Retrieved from
https://www.medscape.com/answers/1533218-163111/what-is-the-mechanism-of-action-o
f-fusion-inhibitors-fis-in-antiretroviral-therapy-of-hiv-infection#:%7E:text=Answer,of%20gly
coprotein%2041%20(gp41)

Mugwanya, K. K., Baeten, J. M., Wyatt, C., Mugo, N. R., Celum, C. L., Ronald, A., . . . Heffron,
R. (2018). Brief Report: Frequency of Monitoring Kidney Function in HIV-Uninfected
Persons Using Daily Oral Tenofovir Disoproxil Fumarate Pre-exposure Prophylaxis.
JAIDS Journal of Acquired Immune Deficiency Syndromes, 77(2), 206–211.
https://doi.org/10.1097/qai.0000000000001575

Pandhi, D., & Ailawadi, P. (2014). Initiation of antiretroviral therapy. Indian J Sex Transm Dis
AIDS, 35(1), 1–11. Geraadpleegd van
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4066590/

Sax, P.E., Hirsch, M.S., Bogorodskaya, M. (2019, November 11). Overview of prevention of
opportunistic infections in patients with HIV. Retrieved from
https://www.uptodate.com/contents/overview-of-prevention-of-opportunistic-infections-in-
patients-with-hiv

U.S. Department of Veterans Affairs. (n.d.). CD4 count (or T-cell count). Retrieved from
https://www.hiv.va.gov/patient/diagnosis/labs-CD4-count.asp
Very Well Health. How Often Should You Get Your CD4 and Viral Load Tested? (2020,
September 24). Retrieved from
https://www.verywellhealth.com/how-often-should-i-get-my-cd4-and-viral-load-tested-486
26

Waiswa, M., Byarugaba, B., Ocama, P., Mayanja-Kizza, H., Seremba, E., Ganguli, S., . . .
Colebunders, R. (2012). Hyperlactatemia and concurrent use of antiretroviral therapy
among HIV infected patients in Uganda. African Health Sciences, 12(3), 268–275.
https://doi.org/10.4314/ahs.v12i3.4

WebMD. (2021, April 23). What Are Protease Inhibitors? Retrieved from
https://www.webmd.com/hiv-aids/what-are-protease-inhibitors#:%7E:text=%E2%80%8C
Protease%20inhibitors%2C%20which%20figure%20among,stop%20HIV%20from%20re
producing%20itself
World Health Organization. (2009). Guidelines for HIV Diagnosis and Monitoring of Antiretroviral
Therapy. Retrieved from
https://apps.who.int/iris/bitstream/handle/10665/205162/B4375.pdf%3Bjsessionid=F8A0
46C1A532084573625AB4F36D107B?sequence=1

Yilma, D., Abdissa, A., Kæstel, P., Tesfaye, M., Olsen, M. F., Girma, T., . . . Kirk, O. (2019).
Serum creatinine and estimated glomerular filtration rates in HIV positive and negative
adults in Ethiopia. PLOS ONE, 14(2). https://doi.org/10.1371/journal.pone.0211630

Yoder, K. (2020, April 25). About Nucleoside/Nucleotide Reverse Transcriptase Inhibitors

(NRTIs). Retrieved from
https://www.healthline.com/health/hiv-aids/nucleoside-nucleotide-reverse-transcriptase-i
nhibitors#how-they-work