CASE PRESENTATIONSDavid Fletcher MD FRCPCBenny Chang MD CCFPFred Crouzat MD CCFP

CASE 2• 78 yo man

•HIV+ 1990

• CD4 on diagnosis 700

CASE 2• ABC+3TC/Nevirapine & TMP/SMX initiated in 02/03-05

• CD4 up to 425 from 200

• VL <50 x3 then 73, 424, 55

CASE 2• ABC+3TC/NVP…11/05• CD4 220• VL 14,026• Incomplete Adherence

CASE 2GENOTYPE NOV/05

CASE 2• Patient pleaded with physician to not switch his ARVS out of fear of new side effects• Told to improve adherence and F/U in 6 weeks, but 4 months passes

CASE 2• ABC/3TC/Nevirapine…4/06

• VL <50 CD4 260 WHAT?...WHY?...HOW?

CASE 2

• ABC+3TC/NVP 2006-2007

• VL <50, 435, 140, <50 • CD4 260 → 300

• Intermittent non-adherence

CASE 2

• ABC+3TC/Nevirapine..2007-2008

• VL 4564, 105, 6201

• CD4 200 → 250

•more non-adherence

CASE 2GENOTYPE MAR/07

CASE 2•Once again, a switch in therapy was discussed at length, but decided on a retry of ABC+3TC/Nevirapine

• 2008-10• VL <50x8, 142, 745

• CD4 240 → 320

CASE 2• June 2010 ABC+3TC/Nevirapine

• VL 412, 1745

• CD4 230, 180• Incomplete adherence•Genotype unchanged

What would you do?

CASE 2• ABC+3TC/Nevirapine…August 2010

• VL <50

• CD4 260

• Continue as is