View source for WBR0306

 {{WBRQuestion
|QuestionAuthor= {{M.P}}
|ExamType=USMLE Step 3
|MainCategory=Primary Care Office
|SubCategory=Infectious Disease
|MainCategory=Primary Care Office
|SubCategory=Infectious Disease
|MainCategory=Primary Care Office
|SubCategory=Infectious Disease
|MainCategory=Primary Care Office
|MainCategory=Primary Care Office
|SubCategory=Infectious Disease
|MainCategory=Primary Care Office
|SubCategory=Infectious Disease
|MainCategory=Primary Care Office
|SubCategory=Infectious Disease
|MainCategory=Primary Care Office
|SubCategory=Infectious Disease
|MainCategory=Primary Care Office
|MainCategory=Primary Care Office
|SubCategory=Infectious Disease
|Prompt=A 40 year old male come to clinic following his recent exposure to HIV.  While he was on a business trip 4 weeks ago, he had unprotected anal intercourse with a man who confided he was HIV few days ago.  Immediately he purchased an over the counter HIV ELISA with the western blot test which turned out to be positive.  He has no symptoms at this time.  His vitals are pulse 80/min, BP: 120/80 mmHg, temperature 100 F, RR: 15/min.  Examination of other systems is normal.  You order another set of HIV testing kit including CD4 count, viral load, CXR, sputum testing, urine culture.  After 1 week, the HIV test turns out to be positive, CD4 count is 700 cells/µL, viral RNA 30,000 copies/ml but other routine tests are normal. On further inquiry, the patient says he already had an HIV test done a year back which was positive and CD4 count done 8 months back was 800 cells/µL.  What is the best next step in the management of this patient?
|Explanation=The [[CD4]] cell count is the main indicator of immune function in patients who are [[HIV]]-infected and is the strongest predictor of disease progression and survival.  It is also one of the key factors in deciding whether to initiate chemoprophylaxis for opportunistic infections and to evaluate clinical complications.   [[HAART]] is initiated when
•	Asymptomatic and CD4 count less than 350 cells/µL
•	Asymptomatic and viral load more than 55,000 copies/ml
•	AIDS defining illness
•	Severe symptoms of HIV
•	Pregnancy irrespective of CD4 count
•	Rapid decline in CD4 i.e. drop of 100 cells/µL /year.  

|AnswerA=Evaluate CD4 count and HIV load every  6-9months


|AnswerAExp='''Incorrect''' : Asymptomatic [[HIV]] positive individuals not on HAART should have CD4 count and viral load monitored every 3-4months.
|AnswerB=Initiate HAART

|AnswerBExp='''Correct''' : Patients has a rapid decline of CD4 counts, which meets the criteria to start him on [[HAART]].
|AnswerC=Evaluate CD4 count and HIV load every 12 months

|AnswerCExp='''Incorrect''' : Evaluating CD4 count and viral load less often may needlessly delay the initiation of HAART therapy in patients whose condition is worsening.
|AnswerD=Evaluate CD4 count and HIV load every month

|AnswerDExp='''Incorrect''' : Evaluating CD4 count and viral load more often is not required early in the course of disease as precipitous changes in the immune system is uncommon.
|AnswerE=Initiate HAART and trimethoprim-sulphamethoxazole
|AnswerEExp='''Incorrect''' : [[Pneumocystitis carnii]] prophylaxis is added when the CD 4 count is below 200.
|RightAnswer=B
|Approved=Yes
}}