Question of the Week # 112

112)

A 30-year-old HIV-infected man presents to your office for evaluation regarding starting of Anti-retroviral therapy. The patient’s most recent CD4 count was 460 cells/mm3 and HIV RNA level of 20,000 copies/ml. He has  a history of Intravenos drug abuse. The patient was also noted to have elevated liver enzymes twice the upper limit of normal.  During the work-up for his liver abnormalities, his Hepatitis C is negative but Hepatitis B surface antigen returns positive consistent with hepatitis B active infection.  He has no HIV-related symptoms and has not had any AIDS-defining illnesses. The patient requests that he be started on Highly Active Anti-Retrovial therapy (HAART). Which of the following is the most appropriate indication for starting HAART in a HIV infected patient?

A) CD4 count of less than 500

B) HIV viral load greater than 50,000

C) Initiation of treatment for Hepatitis B co-infection

D) Renal Insufficiency with out proteinuria

E) All Reproductive age group HIV + women

19 Responses

  1. B
    Dr Red what is the answer?

  2. B,>50,000-From Premier Review

    • SUMMARY: Answer is C –
      Current NIH guideline to start HAART: A1 list of recommendations (strongest evidence based on randomized controlled clinical trials)
      1. AIDS (CD4 < 200) – not 100,000 – not > 50,000, to prevent heterosexual transmission, excludes Option B – wide ball!
      3. Co-infection with Hepatitis B or C – correct answer
      4. Pregnancy – to prevent perinatal transmission, not all HIV + women, excludes Option E – wide ball!
      Also, one A2 recommendation – HIV related illness (HIVAN, opportunistic infections) – without proteinuria, this is not HIV- Associated Nephropathy, excludes D – out!

      CD4 50,000 (> 100,000 = A1 but > 50,000 is < A1) – detractor!
      Initiation of treatment for HBV co-infection (A1) – correct answer
      Renal insufficiency without proteinuria (HIVAN = A2) – out!
      All reproductive age group HIV + women (Pregnancy= A1, Reproductive age 100,000 regardless of other findings (A1) to prevent transmission.

      FORMULA: HAART AIDS 100000 PREGNANT WOMEN WITH HEPATITIS AND PROTEINURIA

      References (please solidify your knowledge by reviewing these)
      http://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf – read pages E-1, E-5, and I-20 & J-1 (J-1 is on HIV/Hepatits co-infection, please read the 2nd recommendation on the illustrated table)

      • Attention: A1 list recommendation No. 2 was chopped out. Sorry about that.
        No. 2 – High HIV viral Load (> 100,000) is A 1 recommendation to start HAART to prevent transmission. (> 50,000 is not exactly A 1 recommendation).

      • I’m so sorry about this, things are getting chopped out. I hate to present this in fragments. I am so sorry. Please bear with me.
        Above (line eleven) ‘CD4 …then missing info…then 50,000(>100,000 = A 1 but > 50,000 is < A1)
        Line eleven reads as followed:
        CD4 should be <200 (not 100,000 not > 50,000 (>100,000 = A1 recommendation but > 50,000 is < A1 recommendation) – detractor!

      • some uncivilized genie is messing with my post. One last try – Line eleven reads CD4 <200 not <500 to be called A1 recommendation

      • Please disregard everything I said about WHO recommendations. I don’t think they expect Step 3 USMLE test takers to memorize the strengths of recommendation.
        Just look at the options. Which option is most deadly if left alone? That should be the most appropriate indication to start HAART.

        Option C

        HIV with HBV co-infection causing rapid progression of liver failure.
        No other option is as severe.

  3. b

  4. bbb

  5. HAART started when CD4 50000 by kaplan so B

  6. cd4 less than 350 and viral load more than 50 thousand so B

  7. ans C
    cd4100k
    dual infection hcv or hbv etc
    ref CMDT -antiretroviral rx

  8. The decision to initiate antiretroviral therapy can be based either on symptoms or on CD4 count.

    In the US, HAART is recommended in the following: [31]

    History of an AIDS-defining illness

    CD4 count less than 500 cells/microlitre

    All pregnant women, regardless of clinical stage, viral load, or CD4 cell count [45]

    Hepatitis B infection requiring treatment

    HIV nephropathy.

  9. C. Check out US HIV/AIDS treatment guidelines :”The progression of chronic HBV to cirrhosis, end-stage liver disease, and/or hepatocellular carcinoma is more rapid in HIV-infected persons than in persons with chronic HBV alone.” Basically, if a pt has HIV and HBV and they need treatment for at least 1 of these diseases (recall HIV treatment indications), then HAART should be started.

  10. can you send the answer key? it is very confusing ?

  11. Early initiation of HAART has benefits and risks. The final decision rests in the hands of the patient and managing doctor. Is it justified to expose the patient to the risk of drug toxicity, drug resistance, adverse effects, compliance issues. HAART is a long term commitment. So the patient decides, especially when he/she is asymptomatic. Definitely, initiation of HAART early will lower the viral load and slow the progression of disease. It also lowers the infectivity of the patient and lowers the viral set point.
    HIV experts ( NIH AIDS Research 2013) issue recommendations, A – Strong, B – Moderate, C – Optional and divide strength of evidence of research into 3 (in descending order) I – Randomized clinical trials, II – Non randomized clinical trials, III – Expert opinion
    so A-I is the strongest recommendation, followed by A-II, then A-III and in this order until C-III(Optional, based on expert opinion)
    The question is not concerned about this patient. It says ‘an HIV patient’ not ‘this patient’. It is asking about general recommendation for management of asymptomatic early or recent HIV infection. What will be your recommendation in five different presented patient scenarios;
    Option A- CD count 50,000. (high viral load) – (III) http://hivmanagement.org/arvprinciples.html
    Option C- Initiation of treatment for Hepatitis B co-infection. (A-II)
    Option D- Renal insufficiency without proteinuria, (see below)
    Option E- All reproductive age group HIV + women, (see below)
    For the last two options,
    If pregnant (A-I)
    If AIDS defining illness is present (A-I)
    If HIV- Nephropathy, HIVAN (A-II) – nephrotic syndrome in HIV
    If Renal insufficiency without proteinuria or women of reproductive age group HIV +; like standard recommendation for HIV infected patients basically,
    CD4 count 500 cells/mm3 – (B-III)

    My answer – Option A, why?, this is like ‘poison pawn’ in Chess. Option A is actually A-I in NIH AIDS research recommendation.
    For (the most prevalent heterosexual) behavioral pattern and for other reasons, CD4 count (350-500 cells/mm3) is A-I recommendation to prevent transmission of HIV.
    Recommendation for initiating HAART with treatment for Hepatitis B co-infection is still A-II. Believe it or not, initiation of treatment for Hepatitis B co-infection & CD4 count 350-500 are both A-II recommendation.
    CD4 count between 350-500 cells/mm3 is A-I for preventing heterosexual transmission.Even in patient population without Hepatitis B co-infection, treating with HAART for CD4 count (between 350-500cells/mm3) decreases the risk for transmission of HIV. CD4 count-based initiation of therapy has more significant and broader impact than Hepatitis B co-infection-based initiation.
    In different words, will you start HAART in Hepatitis B co-infection, if CD4 count is normal? I think A-II but will you start it if CD4 count is low, even if Hepatitis screen is negative? CD4 count becomes A-I.
    This question is not about Hepatitis co-infection, it’s about HIV infected patient. What is the most appropriate consideration? Hepatitis co-infection or CD4 count? I think it is most appropriate to start HAART in low CD4 count in EARLY/RECENT HIV infection because this covers a larger population of HIV patients. Hepatitis B co-infection occurs in less than 10 % of all HIV infections.

    As a clinician I will be tempted to say that the most appropriate response is option C, HAART must be initiated in HBV co-infection to save the liver from rapid degeneration. But in the broader picture, CD4-based initiation of HAART will have a much more significant impact in HIV infected patients. And the most appropriate indication for HAART in HBV co-infection is not initiation of HBV treatment, it is confirmatory diagnosis of HBV by HBV DNA quantitative analysis (not positive HBsA).

    I may be wrong. Dr Archer please moderate and teach us. In ‘this’ patient by answer is C for the health of this patient. In ‘an HIV’ patient, my answer is A. In the general HIV population, CD4 count <500 is a more appropriate indication to start HAART than wait for patients to develop HBV co-infection and then start HAART.

    Reference:
    Panel on Antiretroviral Guidelines for Adults and Adolescents. 'Guidelines for the Use of Antiretroviral Agents in HIV-1-infected Adults and Adolescents'. Department of Health and Human Services.
    September 2013. Available at http://aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf
    http://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf (page E-9)

    • Please disregard everything I said about WHO recommendations. I don’t think they expect Step 3 USMLE test takers to memorize the strengths of recommendation.
      Just look at the options. Which option is most deadly if left alone? That should be the most appropriate indication to start HAART.
      Option C
      HIV with HBV co-infection causing rapid progression of liver failure.
      No other option is as severe.

  12. e

  13. Answer: A

    Current US DHHS guidelines (published May 1, 2014) state:

    Antiretroviral therapy (ART) is recommended for all HIV-infected individuals to reduce the risk of disease progression.
    ART also is recommended for HIV-infected individuals for the prevention of transmission of HIV.
    Patients starting ART should be willing and able to commit to treatment and understand the benefits and risks of therapy and the importance of adherence. Patients may choose to postpone therapy, and providers, on a case-by-case basis, may elect to defer therapy on the basis of clinical and/or psychosocial factors.

    Alternatively, current World Health Organization guidelines (dated June 30, 2013) state:

    Initiate ART if CD4 cell count ≤500 cells/ml
    • As a priority, initiate ART in all individuals with severe/advanced HIV disease (WHO clinical stage 3 or 4) or CD4 count ≤ 350 cells/mm

    Initiate ART regardless of WHO clinical stage or CD4 cell count in
    • Active TB disease

    • HBV coinfection with severe chronic liver disease
    ** Note this patient was only recently diagnosed; he is asymptomatic for HBV infection, ie not severe chronic liver disease

    • Pregnant and breastfeeding women with HIV

    • HIV-positive individual in a serodiscordant partnership (to reduce HIV transmission risk)

    I’m sorry to be quoting off Wikipedia: http://en.wikipedia.org/wiki/Management_of_HIV/AIDS#Initiation_of_antiretroviral_therapy

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