The Old Man and AZT

Helios comes into the clinic accompanied by his sister Selene for a post-hospitalization follow-up. He was recently admitted to the facility's MICU with community-acquired pneumonia; he was hypoxic, febrile, and dehydrated. He did well with fluids and antibiotics and was discharged home in less than a week.

Helios is 80 years old; he was given a diagnosis of HIV infection in 1994, has seen a CD4 cell count nadir of 156/µL and an HIV viral load (VL) as high as 2500 copies/mL. Some time before December 2000, therapy with Combivir (zidovudine [AZT]/lamivudine) and Viracept (nelfinavir) was started, and periodically he had an undetectable VL: <400 copies/mL in 2001; <50 copies/mL in 2011; and <20 copies/mL in October 2012. He has remained on this combination antiretroviral therapy (cART) to date.

When I picked up his care in 2005, he had a history of many missed visits, which continued for a time. He consistently drank more than one-fifth quart of vodka daily and his medication adherence was suspect. Despite all this, Helios’ VL remained suppressed, with his absolute CD4 cell count a fairly stable 200/µL and a CD4 % of 13. His MCV was slightly elevated, consistent with (among other things) adherence with AZT therapy. A low vitamin B12 level in 2006 was repleted to normal. Medications when we first met included a multivitamin with thiamine, B12, folate, aspirin (prn), hydrochlorothiazide, sotalol, cholecalciferol, calcium carbonate, and atovaquone. He states he is adherent with his medications as prepoured by his sister. His has a history of a left hip fracture, which was pinned several years ago, as well as a frozen right shoulder, cardiac arrhythmia, and hepatitis C.

On presentation for this follow-up appointment, he is a thin older man, who walks slowly into the examination room with antalgic gait. In good spirits, he sits down next to his sister who tells me that Helios had diarrhea this morning and that this happens occasionally. I ask him directly, "Helios, are you having diarrhea?" "No I ain't. I don' have no diarrhea, I don't know what she talking about . . ." She looks at me knowingly. I ask if he is benefitting from the home health aide (HHA) who has been helping at the house. He perks up and smiles mischievously, "She real good, she wash my butt . . ." "Thank you Lord,” responds Selene.  “Helios, are you still smoking and drinking?” He answers quickly, loud and angrily. "No I'm not, can you do something? It's not right-my sister takes my money; it's my money. She won't let me buy vodka or cigarettes." I try and defuse the situation by suggesting we talk about his medications.

I noticed that when he was an inpatient, his hematocrit value drifted down from the mid- to low 30's and his MCV drifted up from 112 to 118 fL. I asked the patient and his sister all the usual questions: any melena, BRBPR, bleeding, bruising, etc? Selene volunteered that although the patient’s AZT and Viracept have been prescribed twice-daily, at home he was only taking them once a day. While an inpatient, he was receiving it twice a day, as prescribed.

I had my epiphany: Helios’ macrocytic anemia is a result of the AZT and the Viracept is causing the diarrhea. I reorder labs, including CBC, B12, folate, iron studies, TSH, HLA-B 5701, and a follow-up chest x-ray film. We discuss several possible options for once-daily ART, including Atripla, the 3-drug fixed-dose combination of efavirenz/tenofovir/emtricitabine. But both Helios and Selene were concerned about possible CNS adverse events associated with efavirenz. We discussed trying to create a simple regimen. I pointed out that with 6 classes of medications and numerous combinations available this would be possible. Helios was not interested in a change, but his sister was curious. Then again, this patient’s VL has been suppressed for years on an ancient regimen.

The chest x-ray film showed a resolved pneumonia. The H/H and MCV were back to baseline levels; B12, folate, TSH, and iron studies-all normal. HLA-B 5701, negative.

So, the ultimate question was: in this older man who is possibly a long-term non-progressor who has had his HIV VL suppressed to <20 copies/mL on an ancient regimen despite questionable adherence-is now the time to change cART?

We decided to maintain his current cART, monitor him closely, maintain his HHA services, and encourage continued cessation of alcohol and tobacco.