AIDS/HIV

Mr. A asks his new primary care physician whether he should get an HIV test. He states that he has “absolutely no risk factors for HIV.” He is a very healthy 21-year-old African American man who has been in a monogamous relationship with his current girlfriend for 2 years. The girlfriend was tested for HIV 6 months ago when a Board of Health nurse notified her that she might have been exposed to HIV, and retested 3 months ago. Both HIV tests were negative, effectively ruling out HIV infection.

Mr. A first became sexually active at age 15. Over the last 6 years, he has had only 4 female partners, although with a bit of overlap between the relationships (he had 2 simultaneous partners for about a year). He has never had sex with a male. He used condoms “pretty consistently.” He had Chlamydia trachomatis urethritis 3 years ago, but no other sexually transmitted infections (STIs). He has never used injection drugs although he smokes marijuana once or twice a week. He stopped drinking excessively when he met his current girlfriend. He does not recall an episode of mononucleosis-like illness with fever and lymph node enlargement. His past medical history, review of systems, and physical exam are otherwise unremarkable.

An HIV EIA is repeatedly positive and HIV-1 Western blot is also positive, with multiple bands present. Because of the excellent specificity of the 2-step HIV EIA and HIV-1 Western blot test, (99%, 99.8%) his posttest probability of HIV infection is > 99%. The CD4TL count is 150 cells/mcL (immunologic AIDS) and the HIV viral load is 80,000 copies/mcL (quite high). Toxoplasma antibody is negative. PPD is negative.

S: Mr A. a 21 y/o African American man who has been in a monogamous relationship with his current girlfriend for 2 years comes to the clinic wanting to get an HIV test. He states that his girlfriend was notified by the Board of Health that she might have been exposed to HIV, however, she tested negative both 6 and 3 months ago ruling her out of HIV infection. Mr A. reports he only had 4 female partners since he became sexually active at age 15, never MSM, but he had 2 simultaneous female partners for about a year. He uses condoms “pretty consistently”, tested positive for Chlamydia trachomatis urethritis 3 years ago, but no other STIs were found. Mr. A. reports marijuana use once or twice a week, stopped drinking excessively for 2 years ago, and denies ever using injection drugs. He denies mononucleosis-like illness with fever and lymph node enlargement.

O: His past medical history, review of systems, and physical exam are otherwise unremarkable.

Labs: HIV EIA – positive (repeatedly)

HIV-1 Western blot – positive (with multiple bands present)

CD4TL count – 150 cells/mcL (immunologic AIDS)

HIV viral load – 80,000 copies/mcL (quite high)

Toxoplasma antibody – negative

PPD – negative

A: 21 y/o African American man is diagnosed with AIDS confirmed with HIV EIA, HIV-1 Western blot, CD4TL count, and HIV viral load.

P: Immediate follow up with clinician X for

1. counseling on HIV, patient education, ways of transmission,
2. treatment choices,
3. notifying his sexual partners past and present,
4. option of pre-exposure prophylaxis (PrEP) for the unaffected partner
5. counseling on living with HIV,
6. offering support resources
7. psychological evaluation

SUMMARY:

When the patient is diagnosed with acute HIV infection, he or she should obtain counseling and education on ways to diminish the danger of transmission. The patient should get CD4 T lymphocytes cell count and HIV viral load tests within four to six weeks to screen the level of immune suppression and viremia. Patient should also screen for other STI such as chlamydia, gonorrhea, syphilis; as well as hepatitis B and C, and tuberculosis. The patient should meet with an HIV specialist to start with the antiretroviral therapy, no matter of CD4 T lymphocyte cell count. The great news for the patient is that the antiretroviral therapy (ART) has reduced HIV-related diseases and mortality at any stages of HIV infection as well as reduced HIV transmission (mother-child or partner to partner). There are more than 25 antiretroviral drugs with 6 different drug classes:

1. nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs),
2. non-nucleoside reverse transcriptase inhibitors (NNRTIs),
3. protease inhibitors (PIs),
4. fusion inhibitor (FI),
5. CCR5 antagonist,
6. integrase strand transfer inhibitors (INSTIs)

it is also important to remark that there are two drugs: Ritonavir and Cobicistat (PK-enhanced PI), use as boosters to improve the drugs performance.

The following strategy for initial therapy has succeeded in suppression of HIV replication and CD4TL cell increments in many patients with HIV. The initial treatment can start with two NRTIs that can be abacavir, lamivudine. or either tenofovir alafenamide, emtricitabine or tenofovir disoproxil fumarate with a drug from one of the three drug classes: an INSTI, an NNRTI, or a PK-enhanced PI.

 

Sources:

https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv/9/treatment-goals

https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv/10/initiation-of-antiretroviral-therapy

https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv/11/what-to-start

 

My Reflection

It was a great experience to practice on this first SOAP note, I enjoyed learning about the subject I wrote about (HIV/AIDS) and the process of creating the SOAP note. Looking for artifacts, such as tables and graphs, was a little difficult because I had a specific idea of what I would need to look for. The search took some time because I could not find what I was looking for but at the end, I found the artifacts I wanted and the incorporation to the E-portfolio appears complete. What I like about creating portfolios is that I can integrate my personal taste in terms of visual appearance. I think writing a SOAP note is a little easier than writing an H&P, especially since it is shorter, but it actually takes me almost the same time to write one (an entire day, or 6 hours – if I am lucky). This means that I really need to practice more on writing both H&P and SOAP notes to be able to complete them in less than 4 hours (which is acceptable for now, since I am a student). This is a learning process where I can learn from the mistakes and improve on them. It is important to have a solid understanding on concepts that the PA Program offers, during the Didactic phase, to be able to identify the diseases. This would further allow me to write comprehensive SOAP notes.