Case of the Month: HIV Treatment in Sero-Discordant Couples

Case Summary
A family medicine clinician called about a 62-year-old man who was a new patient. As part of standard intake, the clinician sent off a routine HIV screen, which came back positive for HIV-1 antibodies. The patient told the clinician that he knew of his status already and that he had initially been diagnosed in 1988. The patient had been on and off medication for several years, and had been off all medications since 2001 after having been informed that his HIV medication was no longer necessary. The patient had a positive Western Blot, was negative for HIV-2 antibodies, had a viral load under 75 and a CD4 count of 346. The patient’s wife was currently under the same clinician’s care. The clinician believed that the couple was still sexually active, and that the husband had not disclosed his HIV status to his wife. The wife tested negative for HIV. How should this case be handled?

CCC Consultant Advice
In elite controllers with a declining CD4 count (as with this patient) or other evidence of disease progression, it would be indicated to resume antiretroviral (ARV) treatment to prevent further disease progression, suppress inflammation and immune activation, and to decrease transmission risk. The patient should be strongly encouraged to disclose his HIV status to his wife. Per HIPAA regulations, the clinician cannot disclose the husband’s status without his permission, but could be present in that discussion if the husband requested. Regarding how to choose an ARV regimen for this patient with undetectable viral load, resistance testing is not possible with an undetectable HIV viral load. Choice of regimen will thus be influenced by adverse effects, convenience, co-morbidities, and drug-drug interactions.

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