(Disclaimer: This article is for scientific use only, and the information in the following content has been processed to protect patient privacy)
Abstract: A 37-year-old patient with no significant increase in CD4 count and plasma viral load of 1400 copies/ml after antiviral therapy, suggesting treatment failure, was tested for resistance and found to be resistant to both nucleoside reverse transcriptase inhibitors/nonnucleoside reverse transcriptase inhibitors. The patient’s compliance was poor. After changing the antiviral regimen based on the genotypic resistance test results, virological suppression was successfully achieved, plasma viral load was below the lower limit of detection, and CD4 count started to increase.
Basic information】Male, 37 years old
Disease Type】AIDS
Hospital】The 8th Hospital of Xi’an
Time of consultation】August 2018
Treatment regimen] Oral medication (tenofovir disoproxil fumarate tablets + lamivudine tablets + efavirenz capsules, later replaced with zidovudine capsules + lamivudine tablets + lopinavir ritonavir tablets)
[Treatment period] 3 months of outpatient follow-up review
Treatment effect] Virological suppression was achieved, and immune indexes began to recover.
I. Initial interview
The patient was 37 years old, diagnosed as HIV-positive. At the first visit, he was sad, tired and even reluctant to speak, and many words were replaced by nodding and shaking his head. The most frequently asked question was how long he would live. The patient’s lymphocyte immune subpopulation analysis showed a CD4 count of 147/μl and a positive HIV antibody report, which could determine that the patient was in a clinical AIDS stage, already in a highly immunosuppressed state, and prone to co-infection, including opportunistic infections, if not treated in a timely manner. According to the current situation, the patient was advised to use tenofovir disoproxil fumarate tablets, lamivudine tablets and efavirenz capsules orally for antiviral treatment.
II. Treatment history
After determining the antiviral treatment plan, one-on-one compliance education was conducted with the patient. Antiviral drugs cannot kill the virus, but can only inhibit viral replication and protect uninfected cells from infection, and the drug needs to be maintained at an effective concentration to effectively inhibit viral replication, while metabolism will reduce the drug concentration, which requires taking the drug on time and in the right amount to keep the drug concentration in a reasonable range, forgetting Forgetting to take the medication can seriously affect the concentration of the drug, which may not effectively inhibit the virus and lead to treatment failure or drug resistance. Patients are also advised to set an alarm clock and be instructed to take the drug on time and in the right amount every day. As the adverse effects of efavirenz capsules are obvious and may cause side effects such as dizziness, headache and rash, and these side effects may be aggravated when taken with food, so try to take the drug on an empty stomach or half an hour before bedtime to reduce the impact of side effects such as dizziness. Try not to eat food that is too fatty and difficult to digest for dinner. If a rash or other discomfort occurs while taking the medication, you should come to the hospital in time for follow-up.
At the follow-up visit, the patient’s mood improved slightly, but he continued to complain about the side effects of the medication, mainly dizziness, forgetfulness and sometimes uncontrollable temper tantrums. The test results showed no significant increase in the patient’s CD4 count, while the plasma viral load was 1400 copies/ml, suggesting treatment failure. After communication with the patient, genotypic resistance testing was performed, and K65R/Y15F, K103N/V06M mutations were present, and the results of resistance analysis using the HIVDB database were as follows.
After careful questioning of the patient’s medication and analysis that this treatment failure was mainly related to the patient’s poor compliance with medication, and after detailed communication with the patient again, informing him of the current situation and the importance of compliance, the antiviral regimen was changed to zidovudine capsules, lamivudine tablets, and lopinavir ritonavir tablets after discussion.
In the new regimen, zidovudine capsules and lopinavir ritonavir tablets had full antiviral activity, while lamivudine tablets were moderately resistant due to the K65R mutation, but K65R caused moderate resistance to lamivudine tablets while also making the virus replication rate lower and more sensitive to lopinavir ritonavir tablets, so lamivudine tablets were retained.
The good thing is that the patient’s psychological state has improved and after this failure, adherence is taken more seriously and he is committed to maintain it. Since both lopinavir ritonavir tablets and zidovudine capsules have adverse effects of elevated blood lipids and also tend to cause gastrointestinal discomfort, the patient was instructed to follow a Mediterranean diet and to maintain 150-300 minutes of moderate-to-high intensity aerobic exercise per week, running, basketball, badminton, etc. would be appropriate. If diarrhea is serious, a small amount of salty oatmeal can be consumed, which may relieve diarrhea.
Third, the effect of treatment
After the change of medication and the patient’s compliance with medication, the examination results showed that CD4 increased from 147/μl initially to 316/μl currently, and the viral load decreased to undetectable currently. Despite the ups and downs and treatment failure, complete virological suppression and immunological response were finally achieved after protocol adjustment and communication, but the patient was instructed to visit the doctor for review on time in 3 months.
IV. Notes
It was not easy for the patient to achieve virological suppression and immunological response, and we are sincerely happy for the patient. Weight gain is a good sign of good response to treatment, but if weight gain continues, it may lead to metabolic syndrome. At this stage, all indicators are good and blood lipids are not elevated, so live well and work well, and be sure to persevere! If there are uncomfortable symptoms, make sure to seek medical examination in time.
V. Personal insight
AIDS is still a disease for the public to talk about, and we are associated with many unfortunate patients because of this disease. During the treatment process, I really feel the joy and sorrow of the patients in this article.
For the treatment of AIDS, the first-line regimen commonly used in China, despite its efficacy, has a lower resistance barrier and relatively obvious side effects, which are not so friendly to patients and tend to reduce their medication compliance; while the second-line regimen, although with a higher genetic barrier, has a significant pill load and impact on life. We look forward to more drugs that are more potent, more convenient, and have fewer adverse effects entering the country and entering health insurance.
I also hope that the science about HIV infection can be more downward, understanding is the best means to eliminate discrimination, HIV infection is now preventable and treatable, life expectancy is close to that of the general population, infection is unfortunate, but the future is still worth the effort.