1. CASE 1 54 yo man HIV+ 2005 Generalized Anxiety/OCD VL 15,185 CD4 ranges from 340 - 390 Baseline Genotype clear

2. CASE 1 Severe intermittent diarrhea – Giardiasis, new psychiatric meds Increasing anxiety/OCD 2005-07 CD4 300 - 390 VL 10,000 – 15,000

3. CASE 1 Mid-late 2007 CD4… 280, 230, 170 VL 35,000 – 50,000 Fatigue/intermittent diarrhea increasing anxiety/OCD Feels like he is going to die from AIDS

4. CASE 1 Late 2007 Initiates TDF+FTC/Nevirapine Week 1 Abdo pain with normal liver enzymes Day 14 Fever/maculopapular rash/weakness/flu-like illness ARV’s discontinued

5. CASE 1 2007-09 TDF+FTC/Delaviridine as patient concerned about PI related fat changes/potential Efavirenz related anxiety/depression CD4 200 →490 VL <50x5, 133, 117, 189

6. CASE 1 2007-09 TDF+FTC/Delaviridine Increasingly incapacitating fatigue Crestor, Zoloft, Clonazepam, Neurontin…discontinued with no improvement in fatigue

7. CASE 1 2009 TDF+FTC/Delaviridine CD4 250 VL 2521 Adherence was suspect and ARVS discontinued No dramatic improvement in fatigue for the record

8. CASE 1 GENOTYPE JUN/09

9. CASE 1 What would you do?

10. CASE 1 TDF+FTC/RTV/Darunavir/Etravirine CD4 250 →350 VL 98,636…486 (month 1), 232 (month 2), 94 (month 3), 73 (month4), 60 (month 5) 58 What would you do?

11. CASE 1 TDF+FTC/RTV/Darunavir/Etravirine continued CD4 380 VL <50x3 (last 8/10)

12. CASE 1…another issue January 2010 6 months post-initiation of TDF/FTC/RTV/Darunavir/Etravirine liver enzymes begin to rise Serology revealed HEP A & B immune

13. CASE 1 ALTTIMEHEPATITIS SEROLOGY 3623/11/09HepC Ab negative 17512/01/10Work up for secondary liver disease negative 46528/01/10Hep C Ab negative 56418/02/10Hep C Ab negative No New Meds/No illicit drugs

14. CASE 1 Cause? What would you do?

15. CASE 1 Urinary Drug Screen done Methamphetamine detected Patient was brought in and the above findings discussed including the concept of a methamphetamine induced hepatitis…importance of abstinence outlined

16. CASE 1 ALTTIMEHEPATITIS SEROLOGY 3623/11/09HepC Ab negative 17512/01/10 46528/01/10HepC Ab negative 56418/02/10HepC Ab negative 106701/03/10 Do you stop ARVs?

17. CASE 1 Surprise!...FEB/10…Hep C AB neg HCV RNA 3.35 x10 7 Genotype 3 ARVs continued with weekly monitoring

18. CASE 1 ALTTIMEHEPATITIS SEROLOGY 3623/11/09HepC Ab negative 17512/01/10 46528/01/10HepC Ab negative 56418/02/10HepC Ab negative 106701/03/10 111508/03/10 126816/03/10 Do you stop ARVs?

19. CASE 1 ALT began to decline after peaking at 1268 despite continuing ARVs It was felt that CD4 maintenance and HIV viral load suppression was important for hepatitis C self- cure…also no evidence of pre-existing liver disease

20. CASE 1 Probable Hepatitis C self-cure HCV RNADate 3.35 x10 7 18/02/10 3.65 x10 4 29/03/10 <1507/05/10 <1524/06/10