Problem 51 Management of a young man who is HIV positive

The patient reveals that previously he and his male partner used intravenous drugs and shared needles for about 5 months. He has not changed sexual partners, and has never had a blood transfusion or travelled overseas. On direct enquiry he recalls a severe flu-like illness about 4 months ago which involved headache, fever, weakness and muscle aches and pains and lasted about 10 days. The patient explains that he and his partner have definitely ceased intravenous drug use and limit their drug use to marijuana. His partner has not had an HIV antibody test as he is ‘too scared’.

Currently, the patient’s health is good. His weight is stable, he has no fevers or sweats and his systems review is unremarkable. The patient is examined. He does not have a fever or skin rash, he has good dentition and his mouth is unremarkable. There is no lymphadenopathy or any abnormalities that might be attributable to his recent diagnosis.

Blood screens show a complete blood picture within the normal range, CD4⁺ lymphocyte count of 800 cells/µL (RR 405–2205 cells/µL) and HIV viral load of 4000 copies/µL. He is hepatitis B surface antigen negative and hepatitis C antibody positive. The patient has asymptomatic HIV infection.

The partner is also found to be HIV antibody positive and has similar hepatitis serology. The partner describes a painless lesion on the tip of his penis which has been present for 10 days (Figure 51.1).

Figure 51.1

They are offered vaccination against hepatitis A and B viruses given their sexual orientation and recent history of injecting drug use. They both receive treatment for the penile lesion. The patient and his partner decline to identify any of their contacts. They are followed every 3 months with a full review of symptoms, examination findings and blood screens. After 12 months they stop attending appointments and are lost to follow-up.

Four and half years later the man presents with a 3–4-week history of feeling unwell. He is tired and lethargic and has lost 6 kg in weight. He has also had a sore mouth. He denies any other gastrointestinal symptoms including diarrhoea and there are no other significant symptoms on systems review.

On examination he appears thinner than previously and looks depressed. He is afebrile. His oral mucosa is coated with numerous thick white plaques (Figure 51.2). He has generalized lymphadenopathy, the nodes being 1–2 cm in size. You refer him to a hospital infectious diseases clinic. His blood screens reveal his haemoglobin has dropped to 112 g/L but his complete blood count is otherwise normal, his CD4⁺ lymphocyte count has dropped to 210 cells/µL and the HIV viral load is >200 000 copies/µL.

Figure 51.2

The patient is counselled and commences antiretroviral therapy with tenofovir/emtricitabine 300 mg/200 mg as a fixed-dose combination tablet and boosted atazanavir 300 mg/ritonavir 100 mg all taken once daily. His oral candidiasis is treated with fluconazole 100 mg daily. If his CD4⁺ count drops further (below 200 cells/µL) he will require Pneumocystis prophylaxis with co-trimoxazole 160 mg/800 mg daily. He is reviewed monthly.

Answers

A.1

• The patient’s understanding of the meaning of a positive HIV antibody test. The implications of the positive test must be explained to the patient in a sensitive manner.

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