New HIV Diagnosis in a Patient on Hemodialysis
Clinical Vignette
A 38-year-old man with autosomal dominant polycystic kidney disease and end-stage kidney disease on chronic intermittent hemodialysis presents after a new diagnosis of HIV-1 infection. He receives dialysis three times weekly through a mature arteriovenous fistula and has no residual urine output.
Baseline labs show HIV RNA 186,000 copies/mL and CD4 count 228 cells/mm^3. Creatinine is 8.9 mg/dL (pre-dialysis), and liver enzymes are normal. He is treatment-naive and has no prior opportunistic infections. HIV genotype and integrase resistance testing are sent but not yet available.
Current medications include amlodipine, sevelamer carbonate, calcitriol, and epoetin alfa at dialysis. He is motivated to start antiretroviral therapy immediately and asks for the simplest effective regimen.
Question
What is the most appropriate initial antiretroviral regimen?
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Question 2
He starts dolutegravir plus TAF/FTC. Which counseling about phosphate binders is most appropriate?
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References
Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV. U.S. Department of Health and Human Services.
U.S. Food and Drug Administration. BIKTARVY (bictegravir/emtricitabine/tenofovir alafenamide) Prescribing Information.
U.S. Food and Drug Administration. TIVICAY (dolutegravir) Prescribing Information.