Case: A 36-Year-Old Man Presenting for Primary Care

A 36-year-old man presents to initiate primary care. He has no physical complaints, states that he is in excellent health, and has no notable medical history. His only request is blood glucose and cholesterol level testing because there is a history of adult-onset diabetes mellitus in his mother and sister and coronary artery disease in his father.

The patient was recently divorced and is currently sexually active with 1 female partner. He was tested for HIV “many years ago,” and the result was reportedly negative. He has had about 10 lifetime female sexual partners and 2 during the past decade. He does not consistently use condoms. He has no history of sexually transmitted infections (STIs), has never used injection drugs, and has not received blood-product transfusions. He drinks alcohol socially and does not smoke cigarettes. His physical examination shows that he is moderately overweight. His body mass index (BMI) is 28 and his blood pressure is 136/90 mm Hg but his examination is otherwise normal. He will undergo fasting blood glucose and cholesterol tests, but he is reluctant to have an HIV antibody test performed.

Clinical Decision Point A

What should be done to address the patient’s reluctance to undergo HIV antibody testing?

Choose one

The patient is counseled about the rationale for HIV screening and, after some discussion, agrees to have an HIV antibody test, which is positive. He is initially quite upset by the result but calms down after being counseled about its meaning and implications. The practitioner confirms that the patient is able to cope with the news and has social supports in place. Baseline laboratory tests are obtained (Table 2), and the patient returns the following week to review them. (See the Cases on the Web activity “Initial Antiretroviral Therapy in the HIV-Infected Patient” for further discussion.)

Of note, the patient has a CD4+ cell count of 380/µL, an HIV RNA level of 60,000 copies/mL, a blood glucose level of 140 mg/dL, and a cholesterol level of 230 mg/dL. His HIV genotype test shows no evidence of resistance. The result of his Chlamydia trachomatis urinary assay is positive. His serologic test results are noteworthy for nonreactive rapid plasma reagin (RPR), positive hepatitis B virus surface antibody (HBsAb), negative hepatitis C antibody, and negative hepatitis A antibody. His purified protein derivative (PPD) test is negative. He asks, “What now?”

Clinical Decision Point B

How should the patient’s question about the next steps in his care be addressed?

The patient and his partner are treated with azithromycin 1 g orally. His hemoglobin A1c level is 5.9% (normal range, 4.5%-6.5%), and his fasting lipid profile shows a total cholesterol level of 242 mg/dL (high level total cholesterol, ≥200 mg/dL) with a low-density lipoprotein (LDL) component of 148 mg/dL (high level LDL is >130 mg/dL), and a triglyceride level of 324 mg/dL (high level is >200 mg/dL). He is advised to work on weight reduction through diet and exercise. Also discussed is the rationale for antiretroviral therapy and its potential benefits and risks.

The patient returns 1 month later for a scheduled visit. His weight has decreased 4 pounds through dietary modification and regular exercise, and his blood pressure is 128/86 mm Hg. He is congratulated on his efforts to date. After further discussion, antiretroviral therapy with tenofovir alafenamide/emtricitabine/elvitegravir/cobicistat (fixed-dose combination) is initiated. (See the Cases on the Web activity “Initial Antiretroviral Therapy in the HIV-Infected Patient” for further discussion.) Based on his CD4+ cell count of 380/µL, he is not started on OI prophylaxis (Table 5).

He then asks, “Given my medical condition, are there any special vaccines that I should be receiving?”

Clinical Decision Point C

How should his question be addressed?

Choose one

The patient is taking his antiretroviral therapy reliably. His repeat plasma HIV RNA level has decreased to below 20 copies/mL, and his CD4+ cell count has increased to 520/µL. Follow-up visits are scheduled every 3 months. One year after initiating antiretroviral therapy, on routine laboratory testing, it is noted that his HIV RNA level is now 79 copies/mL.

Clinical Decision Point D

How should the patient’s detectable viral load be addressed?

Choose one