Case Study

A 48-year-old woman who has been with HIV infection for 16 years is currently taking an antiretroviral regimen of tenofovir disoproxil fumarate (TDF), emtricitibine, and efavirenz. She has a CD4+ cell count of 480/µL (26%) and an undetectable HIV RNA level. She is naive to chronic hepatitis C virus (HCV) treatment and has an HCV RNA level of 1.3 million IU/mL and HCV genotype 1a infection. She also has chronic low back pain and a prior history of injection drug use. She previously received 8 years of methadone maintenance treatment, of which she tapered off 2 years earlier. She had not used opioids until 13 months ago when her husband passed away from complications of end-stage liver disease related to untreated HCV infection. She relapsed to heroin use and is now using up to 5 bags to 10 bags intravenously per day. She has noted that her use of heroin is escalating and is interfering with her ability to interact with her children and grandchildren. Although she has tried to stop using heroin, she has been unable to stop for more than 16 hours because of withdrawal symptoms, including muscle aches, irritability, and diarrhea, and craving. She recently stopped taking her antiretroviral therapy.