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Case 5: Discordant CD4 Cell Count and Viral Load Responses to Antiretroviral Therapy

You answered:

D Continue the current antiretroviral regimen and Pneumocystis prophylaxis, but discontinue azithromycin.

This answer is correct. Although antiretroviral therapy has not generated the desired CD4 cell count response in this patient, she has achieved persistently undetectable HIV RNA levels and has tolerated the regimen well. Maintaining long-term virologic control provides clinical benefit, independent of CD4 cell count responses. Since her CD4 count has been greater than 100 cells/mm3 for longer than 3 months, the patient no longer needs the azithromycin for Mycobacterium avium complex prophylaxis. In this patient, it would be reasonable to switch the Pneumocystis pneumonia prophylaxis from trimethoprim-sulfamethoxazole to another agent less likely to cause marrow suppression.

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