If At First You Don't Succeed — The Experts Respond

Last week, we described the case of an HIV-infected patient who needs to restart treatment — but for whom the choice of regimen is complicated by a history of hyperlipidemia, severe adverse drug reactions, and antiviral resistance. Now, two experts describe what they would do.

A 48-year-old flight attendant needs a new HIV regimen. At the time of diagnosis (in 1997), he had a CD4 count of 90 cells/mm³ and a viral load of 120,000 copies/mL. He developed a rash after being placed on trimethoprim-sulfamethoxazole for Pneumocystis jirovecii pneumonia prophylaxis and also experienced anaphylaxis with fluconazole given for esophageal candidiasis. His first antiretroviral regimen — d4T + 3TC + nelfinavir — led to lipoatrophy and hyperlipidemia and …