A 34-year-old woman comes to the office to discuss a recent diagnosis of HIV infection. The patient recently donated blood and later received a letter indicating a positive HIV test. She has no symptoms besides feeling anxious about the diagnosis. The patient had an episode of chlamydia cervicitis 5 years ago, and HIV testing was negative at that time. She has had several sexual partners in her lifetime but has been in a monogamous relationship for the past year. She drinks 1-2 glasses of wine at social events and does not use tobacco or illicit drugs. Vital signs are within normal limits. Physical examination findings are normal. Laboratory results are as follows: Which of the following is the most appropriate next step in management of this patient?

Question

A 34-year-old woman comes to the office to discuss a recent diagnosis of HIV infection.  The patient recently donated blood and later received a letter indicating a positive HIV test.  She has no symptoms besides feeling anxious about the diagnosis.  The patient had an episode of chlamydia cervicitis 5 years ago, and HIV testing was negative at that time.  She has had several sexual partners in her lifetime but has been in a monogamous relationship for the past year.  She drinks 1-2 glasses of wine at social events and does not use tobacco or illicit drugs.  Vital signs are within normal limits.  Physical examination findings are normal.  Laboratory results are as follows:  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient with a new diagnosis of HIV should now have genotypic drug-resistance testing followed by the initiation of combination antiretroviral therapy (ART). ART is recommended for all patients with HIV regardless of CD4 count. Early initiation of ART results in the following: Improved probability of restoring normal CD4 counts and normal CD4/CD8 ratio Reduction in immune activation and system-wide inflammation Reduction in AIDS-defining (eg, opportunistic infections) and non-AIDS-defining (eg, cardiovascular disease, kidney disease, malignancy) complications Improved quality of life Patients on ART also have lower viral concentrations in genital secretions, reducing the risk of transmission to sexual partners by up to 96%. As such, the use of ART may eventually result in community-wide or population-wide reductions in HIV prevalence. (Choice B) Cytomegalovirus is a common opportunistic infection in those with advanced HIV (CD4 count <100/mm³) and may cause viremia or tissue-invasive disease (eg, retinitis, colitis). Cytomegalovirus testing is only required when an active infection is suspected; this patient has a high CD4 count and no symptoms. (Choice C) Risk of tuberculosis reactivation is much greater in patients with HIV. All newly diagnosed patients should receive latent tuberculosis screening with skin testing or interferon-gamma release assay. Sputum samples are only required if screening is positive and the patient is symptomatic (eg, night sweats, weight loss, cough) or chest x-ray is abnormal. (Choice D) All patients with HIV should be initiated on ART. Treatment should not be delayed due to increased risk of morbidity or mortality. (Choice E) Trimethoprim-sulfamethoxazole (TMP-SMX) is used as primary prophylaxis to prevent Pneumocystis pneumonia in patients with HIV with CD4 counts <200/mm³ and to prevent toxoplasmosis in those with positive serology and CD4 counts <100/mm³. This patient has a CD4 count of 550/mm³, so no prophylaxis with TMP-SMX is required at this time. Educational objective: All patients with HIV should be initiated on antiretroviral therapy regardless of CD4 count. This reduces immune activation, system-wide inflammation, AIDS-defining complications (eg, opportunistic infections), and non-AIDS-defining complications (eg, cardiovascular disease, kidney disease, malignancies). Antiretroviral therapy also reduces the risk of transmission to sexual partners.

A 34-Year-Old Woman Comes to the Office to Discuss a Recent