Volume 77, Number 8

Coronary heart disease in people infected with HIV

1. A 42-year-old black man diagnosed with human immunodeficiency virus (HIV) infection in the last month has a CD4 count of 220 x 109/L and a viral load of 96,000 copies/mL. A viral genotype test reveals a K103N mutation, which confers resistance to the nonnucleoside reverse transcriptase inhibitors efavirenz (Sustiva) and nevirapine (Viramune). He has poorly controlled diabetes on metformin (Glucophage). His fasting total cholesterol level is 200 mg/dL, low-density lipoprotein cholesterol (LDL-C) 122 mg/dL, high-density lipoprotein cholesterol (HDL-C) 24 mg/dL, and triglycerides 268 mg/dL. He smokes a pack of cigarettes daily. His father died of a myocardial infarction at age 50. His blood pressure is 134/84 mm Hg. You discuss with the patient his options for managing HIV at this time, and he decides that he wants to start antiretroviral treatment. Which of the following do you recommend?

1. Start antiretroviral therapy with Atripla (coformulated efavirenz, emtricitabine, and tenofovir) once daily
2. Start antiretroviral therapy with atazanavir (Reyataz), ritonavir (Norvir), and Epzicom (coformulated abacavir and lamivudine) once daily
3. Start antiretroviral therapy with atazanavir, ritonavir, and Truvada (coformulated emtricitabine and tenofovir) once daily
4. Do not start antiretroviral therapy yet; focus on diet control and smoking cessation to decrease cardiovascular risk before starting antiretroviral therapy