Case 4: 65-year-old Man Newly Diagnosed, Has Other Health Issues

Paul E. Sax, MDClinical Director, Division of Infectious DiseasesBrigham and Women’s HospitalProfessor of MedicineHarvard Medical SchoolBoston, MA

65-year-old Man Newly Diagnosed, Has Other Health Issues

• 65-year-old man is newly diagnosed with HIV infection• Celebrated retirement with prolonged trip to Brazil• During the trip, he had multiple episodes of unprotected sex with

both men and women • After a lengthy "flu" (3 months ago) that in hindsight was likely

acute HIV infection, he is found to be HIV-antibody positive

65-year-old Man Newly Diagnosed, Has Other Health Issues

Physical exam:• BP = 160/110• Otherwise normal• CD4 cell count = 310• HIV RNA = 144,000• Genotype shows no resistancePast medical history:• Notable for difficult-to-control hypertension requiring amlodipine, lisinopril, and

metoprolol• Diabetes, treated with glipizide and metformin• Other medications include simvastatin and sildenafil• Renal function is normal, and he has no proteinuria

65-year-old Man Newly Diagnosed, Has Other Health Issues

Would you start ART now or wait another 2 to 3 months since HIV has been acquired recently and perhaps he has not reached his “set point”?1. Start now2. Wait 2-3 months3. Wait longer

65-year-old Man Newly Diagnosed, Has Other Health Issues

Question to consider:What is the optimal initial regimen in a patient with several cardiovascular and renal risk factors?