• CD4+ percentage of lymphocytes and total CD4+ cell counts. 
• In addition quantitative assessment of HIV RNA in plasma provides prognostic information at the time of presentation which adds to the information obtained with CD4+ cell count.
•  Independent of CD+ lymphocvte percentage or count, the greater the amount of HIV RNA the more rapidly the disease will progress.

2. What would you tell him about his future sexual experiences?

• He should avoid sexual activitv in which there is opportunity for exchange of body fluids. 
• That includes heterosexual intercourse, oral sex. and anal sex which is particularly risky. 
• If he is unable to abstain he should: 1. ALWAYS use a condom in situations in which body fluids might be exchanged and 2. 
• Strive to establish mutually monogamous relationship.

3. Would you offer to refer him for psychiatric counseling?

• In addition to recently receiving the diagnosis of HIV-positive, this doctor's wife left with his two children. 
• He is described as anorexic, lost 12 pounds and can't sleep-all symptoms of depression.
•  Either his depression must be dealt with by the primary physician with counseling and probably medication OR he should be referred to a qualified mental health professional.

He returns two weeks later. He admits to feeling depressed; he misses his children; and he still has insomnia. His appetite is improved; his weight is unchanged. He has an appointment with a psychiatrist on the following day. Both of you review the laboratory results.

HIV :  ELISA and WB positive

PPD : negative

Anti HBs : positive

Toxoplasmosis titer :  positive

CD4+ lymphocyte count : % 24, = 306/mm3

HIV RNA level : 8400 copies/ml

•  HIV status is confirmed positive.
• PPD now negative. He is probably anergic.
• He has antibody to Hepatitis B surface antigen. He is immune and does not have chronic hepatitis B. He will derive no benefit from Hepatitis B Vaccine.
• He is at risk for toxoplasmosis encephalitis in the future and may benefit from prophylaxis.
• The CD4+ count is low but not in the AIDS range.
• With a CD4 + count of 306 and viral load of 8400, he is in the second prognostic quartile with an 65% estimated likelihood of developing AIDS in 9 years. (See attached table at end of facilitator guide).

5. Would you recommend antiretroviral therapy" Would you use one antiretroviral drug or multidrug therapy?

• Most experts would start combination therapy at this stage even though he has never been treated. 
• Combinations include zidovudine (ZDV) or stavudine (D4T) plus lamivudine (3TC) plus a protease inhibitor (indinavir or nelfinavir) or a non nucleoside reverse transcriptase inhibitor (nevirapine). 
• Other nucleosides, (didanosine. zalcitibine), NNRTI's (delavridine) and protease inhibitors (saquinavir, ritonavir) can be used either to substitute for intolerance or as part of salvage regimens. 
• Patients must be active participants in treatment decisions. 
• Education of the patient about schedule, drug and food interactions and THE ABSOLU'TE NECESSITY FOR COMPLIANCE is a requirement and ample time should be alloted.

6. What are the side effects of zidovudine? List one major side effect of didanosine, lamivudine, zalcitabine, stavudine, saquinavir, riconavir, and indinavir.

Major toxicities only

• Zidovudine 
  • Bone marrow suppression neutropenia and anemia which is more severe in late stage HIV disease. Can monitor compliance with macrocytosis.
  • Myopathy - less common but seen in late stage disease and long term therapy.
  • Lactic acidosis associated with mitochondrial toxicity in the liver - RARE
  • Nuisance side effects: Nausea, vomiting and headache
• Didanosine - Pancreatitis - 5-9%
• Peripheral neuropathv (burning or numbness in distal extremities) - 5-12%
• Nuisance: Nausea, vomiting, diarrhea
• Lamivudine-Almost none! (nausea, diarrhea and abdominal pain)
• Zalcitibine - Neuropathy, pancreatitis, mouth or throat sores
• Stavudine - Neuropathy, nausea, headaches, diarrhea
• Saquinavir- Nausea. diarrhea, abdominal pain. headache
• Ritonavir - Nausea, vomiting, peripheral and circumoral neuropathy
• Indinavir - Diarrhea, Nephrolithiasis
• Nelfinavir- Diarrhea, rash

7. Should he receive prophylactic therapy to prevent Pneumocystis carinii pneumonia?

No.