2. HISTORICAL BACKGROUND
 HIV- Global Pandemic
 1981-1st case in USA
 1983-HIV isolated
 1984-HIV Confirmed as Causative
agent
 1985-ELISA developed

3. INDIAN SCENARIO
 First case – 1986.
 India now 3rd in World.
 Low rate of Infection
 Prevalence rate is 0.#%.More prevalent in
Southern/North-Eastern states.
 Highest adult prevalence is 1.4% (Manipur)
 U/R prevalence is 0.35/0.25 %.
 PLHA -1.4-1.6 million.
 UN 2011 AIDS – 50% decline in 10 yrs.

4. HIV

5. HIV
 Retrovirus
 Types:- HIV1,HIV2
 RNA Virus
 Icosahedral
 Has numerous spikes .
 Envelope has gp120 & gp41.
 Reverse transcriptase –hallmark.
 Affects CD4 T-lymphocytes.
 CD4 – 55 kDA protein
 CCR-5,CXCR4 – Co-receptors

6. PRE-ART Care
 HIV+ve not requiring ART
 Counseling to maintain healthy and positive living.
 Comprehensive medical history and exam.
 Baseline lab-Test.
 Follow-up visits – Pre ART care and CD4 screening
 Reporting to ARTC if unwell.
 Family screening and counseling.
 Registration.

7. Monitoring and Follow-up
CD4 Count Repeat at
<350 and not on ART 3 months
>350 and not on ART 6 months
On ART (any value) 6months
>500 Annual Screening

8. WHO Clinical staging of HIV/AIDS for
adults and adolescents, 2006
Clinical stage 1
 Asymptomatic
 Persistent generalized lymphadenopathy

9. Clinical stage 2
 Unexplained moderate weight loss
(< 10% of presumed or measured body
weight)
 Recurrent respiratory tract infections
(sinusitis, tonsillitis, otitis media,
pharyngitis)
 Herpes zoster
 Angular cheilitis
 Recurrent oral ulceration

10.  Papular pruritic eruptions
 Seborrhoeic dermatitis
 Fungal nail infections
Clinical stage 3
 Unexplained severe weight loss (>10%
of presumed or measured body weight)
 Unexplained chronic diarrhea for longer
than one month

11.  hairy leukoplakia
 Persistent oral candidiasis
 Unexplained persistent fever
 Severe bacterial infections.
 Acute necrotizing ulcerative
stomatitis, gingivitis or periodontitis
 Unexplained anaemia (<8g/dl),
neutropenia(<5x10/litre) and or
chronic thrombocytopenia (<50 X
10/litre

12. Clinical Stage 4
 HIV Wasting Syndrome
 Pneumocystis Syndrome
 Recurrent severe bacterial pneumonia
 Chronic herpes simplex infection
(Orolabial,genital or anorectal of more
than one monts duration or visceral at
any site)
 Oesophageal candidiasis (or
candidiasis of trachea,bronchi or lungs)

13.  Extrapulmonary tuberculosis
 Kaposi Sarcoma
 Cytomegalovirus infection (retinitis or
infection of other organs)
 Central Nervous system toxoplasmosis
 HIV encephalopathy
 Extra Pulmonary Cryptococcosis
including meningitis.
 Disseminated non-tuberculous
mycobacteria infection

14.  Progressive multifocal
leukoencephalopathy
 Chronic Cryptosporidiosis
 Chronic Isosporiasis
 Disseminated mycosis (Extrapulmonary
histoplasmosis,Coccidomycosis)
 Recurrent Septicaemia (including non-
typhoidal salmonella)

15.  Lymphoma (Cerebral or B Cell non-
Hodgkin
 Invasive Cervical; Carcinoma
 Atypical disseminated leishmaniasis
 Symptomatic HIV-associated
nephropathy or symptomatic HIV-
associated cardiomyopathy

16. CO-TRIMOXAZOLE
PROPHYLAXIS (CPT)
 Indications – WHO Clinical stage 3&4
- CD4 <200 Cell/cumm.
- CD4<350 Cell/Cumm(Symp.)
- PCP treated with CD4>200
Cells/cumm
- Dose double strength TMP-SMX
- Alternative Drug-Dapsone
- Dose 100mg OD

17. Protocol for Co-trimoxazole
desensitization
Protocol for Co-trimoxazole desensitization
Step Dosage
Dosage
80 mg SMX + 16 mg TMP (2ml oral suspension)
Day1 mg SMX + 32 80 mg SMX + 16 mg TMPsuspension)
160 mg TMP (4ml oral (2ml oral suspension)
Day2 mg SMX + 48 mg TMP SMX + 32(6ml oral suspension)
240
160 mg mg TMP (4ml oral suspension)
320 mg SMX + 64 mg TMP (8 ml oral suspension)
Day3 240 mg SMX + 48 mg TMP (6ml oral suspension)
One single-strength SMX-TMP tablet (400 mg SMX + 80 mg TMP)
Day4 320 mg SMX + 64 mg TMP (8 ml oral suspension)
Two single-strength SMX-TMP tablets (800 mg SMZ + 160 mg TMP)
Day5 double-strength tablet
or one One single-strength SMX-TMP tablet (400 mg SMX + 80 mg TMP)
Day6 Two single-strength SMX-TMP tablets (800 mg SMZ + 160 mg TMP)
or one double-strength tablet

18. HAART
 Mainstay of treatment
 Combination of 3 or more drugs.
 Interrupt Viral replication.
 Not a cure but prolongs life.
 Has changed HIV into a chronic
disease.
 To be taken lifelong
 Aim – low viral load
 Reduces drug resistance
 Important role in PMTCT.

19. Classes of ARV Drugs
Nucleoside reverse Non-Nucleoside Protease inhibitors
transcriptase reverse (PI)
inhibitors (NRTI) transcriptase
inhibitors (NNRTI)
Zidovudine Nevarapine (NVP) Saquinavir (SQV)
(AZT/ZDV)
Stavudine (d4T) Efavirenz (EFV) Ritonavir (RTV)
Lamivudine (3TC) Delavirdine (DLV) Nelfinavir (NFV)
Didanosine (ddl) Amprenavir (APV)

20. Zalcitabine (ddC) Fusion Inhibitors Indinavir (INV)
(FI)
Abacavir (ABC) Enfuvirtide (T-20) Lopinavir/Ritona
vir (LPV)
Emtricitabine Integrase Foseamprenavir
Inhibitors (New) (FPV)
(NtRTI) CCR5 Entry Atazanavir (ATV)
Inhibitor (new)
Tenofavir (TDF) Maturation Tipranavir (TPV)
Inhibitors(new)

21. Goals of ART
 Clinical Goals : Prolongation of life and
improvement in quality of life
 Virological Goals : Greatest possible reduction in
viral load .
 Immunological Goals : Immune reconstitution that is
both quantitative and qualitative
 Therapeutic Goals : Rational sequencing of drugs in
a fashion that achieves clinical,virological and
immunological goals while maintaining treatment
options,limiting drug toxicity and facilitating
adherence
 Reduction of HIV transmission in Individuals :
Reduction of HIV transmission by suppression of
Viral load

22. Initiation of ART based on CD4
Count and WHO clinical staging
Classification of HIV- WHO Clinical stage CD4 Test not CD4 test available
associated clinical available (or result
disease pending)
Asymptomatic 1 Do not Treat
Mild Symptoms 2 Do not Treat Treat if
CD4<350/cumm
Advanced 3 Treat
Symptoms
Severe/Advanced 4 Treat Treat
Symptoms irrespective of
CD4 Count

23. Managing OIs before starting
ART
Clinical Picture Action
 Any undiagnosed active Diagnose and treat first;start
infection with fever ART when stable
 TB Treat TB first;start ART as
recommended in TB section
 PCP Treat PCP first;start ART
when PCP treatment is
completed

24. ART Regimens
Zidovudine (AZT) -300mg + Lamivudine (3TC)-
150mg
Stavudine(d4T)-30mg+Lamivudine (3TC)-150mg
Zidovudine (AZT)-300mg+Lamivudine (3TC) –
150mg+Nevi-200mg
Stavudine(d4T)-30mg + Lamivudine (3TC)-150mg +

25. Principles of selecting the first-line
regimen
Choose 3TC (lamivudine) in all regimens
Choose one NRTI to combine with 3TC (AZT
or d4T)
Choose one NNRTI (NVP or EFV)

26. Monitoring of Patients on
ART
 Basic clinical assessment
-Hepatitis
-TB/STD
-Pregnancy
-IDU
-Psychiatric diseases
-Traditional medications
-Weight
-Readiness/Commitment of patients.

27. Mandatory Lab. Tests
 -Haemogram
 -Blood Sugar
 -LFT/RFT/Urine exm.
 -Lipid Profile
 -VDRL
 -CXR
 CD4 Count
 Viral Load

28. ART in pregnancy
 Risk of HIV 14-48%
 More than 2/3 transmission
during labour
 ART decreases vertical
transmission.
 Dual Goal-maternal
HIV/PMPCT

29. When to start ART in Pregnant
women
1 Do not treat
Treat if CD4<350cells/cumm
2 Do not treat
3 Treat
4 Treat Treat irrespective of CD4

30. HIV & TB

>60%PLHA develop TB.
 Commonest OI.
 Commonest cause of mortality.
 More drug interactions.
 More toxicity.

31. Initiation of first-line ART in relation to
anti-TB therapy
CD4 cell count Timing of ART in ART
(cells/) relation to initiation of Recommendations
TB treatment
Start ATT first Recommended
Start ATT as soon as TB ART
Any Count treatment is tolerated EFV-containing
(between 2 weeks and regimens
2 months)

32. HIV-HBV Co- Infection
 Hep.B is endemic in india
 Kills more patients than HIV
 HIV modifies natural history of HBV
 Higher progression to advance liver disease
 Impact of HBV on HIV less known
 Treatment
If chronic active hepatitis start
ART irrespective of CD4 Count , if no CAH
start ART,if CD4 < 350 cells/cumm

33. ART in HIV-HBV Co-infection
 1st Line
AZT + 3TC + EFV
AZT + 3TC + NVP
 Alternative
d4T + 3TC + (EFV or NVP)
TDF + 3TC + (EFV or NVP)
 Seroconversion at 1yr - 11-22%

34. HIV & HCV Co-infection
 Increased progression of liver disease
 Increased risk of toxicity with ART
 Effect of HCV on HIV Uncertain
 Treatment
If chronic active hepatitis start ART irrespective
of CD4 Count , if no CAH start ART,if CD4 <
350 cells/cumm
 ART Regimen same as HBV

35.  Timing of HCV therapy
- Before ART
- On ART - CD4 Count > 200
cells/cumm
 Outcome of HCV Therapy
 - genotype 1 : 15-28 %
 -genotype 2/3 :60-70%
 Combination not to be used

RBV & d4T

36. 1 st Six months of ART
 Critical period
 CD4 Recovery
 Early Toxicity
 Mortality
 IRIS

37. Treatment of IRIS
 No Std. guidelines
 Mostly self limiting
 Continue ART
 Stop only if life threatening.
 Drugs-NSAIDS,Steroids,Thalidomide

38. ARV Drug Toxicity
 Self limiting to life threatening
 Difficult to differentiate between disease
and drug toxicity.
 Intercurrent illnesses to be ruled out
 OI’s should be treated before ART.
 Management:- Reassurance
Substitution
Discontinuation

39. Side Effects and Common causes
Time Side-effects Drugs
Short term Nausea,Vomiting,Diarrhoea AZT,TDF,PIs
Rash NVP,EFV,Abacavir,Pis
Hepatotoxicity NPV,EFV,Pis
Drwsiness,Diziness,Confusion and EFV
Vivid dreams
Anaemia ,neutopenia BM AztT
Medium Term suppression,Hyperpigmentation
Lactic acidosis d4T,
Peripheral neuropathy d4T,ddI
Pancreatitis ddI
Long Term Lipodystrophy ,lypoatrophy D4t,ddI,AZT,PI

40. Determining ART Failure
Work with the patient to resolve
Does the patient issues causing non-adherence.
adhere properly to Continue the same first-line regimen,
ART? give of prophylaxis if necessary and
follow closely.Reassess and
determine need for second-line
therapy.Start second-line regimen
only after good adherence can be ensure
Signs or symptoms of IRIS
Patient has
or oi manage IRIS oi,
Been on ART for
especially TB.
Last 6 months

41. Diagnose treatment failure
C if oi present and on ART>6months
with good adherence,if
CD4 not available
Rule out the other causes
Cd4 indicating
such as IRIS and continue
failure of treatment
first-line ART.
Patient on ART- last
6 months
Prepare thepatient for second-line regimen.The
regimen is likely to be more complex.Make sure the
patient understands the new drugs,how to take
them and possible side-effects.Reinforce adherence

42. Treatment failure Parameters for First-line
regimen(WHO 2006 Guidelines)
Clinical New or recurrent WHO stage4
failure condition after at least 6 months
of ART.
Immunologic Fall of CD4 Count to pre-therapy
al failure baseline or below
50% fall from the on-treatment
peakvalue if known
Persistent CD4 levels below
100cells/cumm
Virological Plasma viral load>10,000 copies/ml
failure

43. Decide What to Give for second-line
regimen
 Second-line regimens should be prescribed by
experienced HIV physicians or in consultation
with them.The flow chart provides guidance
Step 1 Define treatment failure,see if
Define treatment failure adherence to treatment is
adequate,counsel and support

44. If AZT is used in first-line,NRTI
Step 2 Decide on choices in second-line could be TDF ,
ABC or ddL.If d4T is used in first-line,NRTI
NRTI component
choices could be TDF oR ABC.If neither TDF
of the second-line nor ABC is available,the last option is
ddL+3TC+-AZT).The combination of
regimen. TDF+ddL+ NNRTI is not recommended
due to early virological failure and safety
concerns.
Give only boosted PI in
Step 3 combination.The Choices are
Decide on the PI LPV/r,ATV/r,IND/r.NLF can be
Component of the used where no cold chain is
second-line regimen. available.It is less potent than
a boosted PI.
Step4 Include counseling for
Patient Education and adherence,linkages to care
agreement on treatment plan and support organizations,
including followup and outreach services and
monitoring follow-up monitoring plan.

45. List of regimens and Alternatives
First-line regimen Second-line regimen
NRTI PI Component
Component
AZT + 3TC + NVP Choices :
1 st LPV/r
(heat-stable)
AZT + 3TC + EFV Choices: 2 nd ATV/r
1 st TDF + 3 rd SQV/r
Standard D4T + 3TC + NVP ABC or 4 th IND/r
regimes 2 nd ddL + 5 th NLF
ABC or3rd Where no
D4T + 3TC + NVP TTF + AZT cold chain
( + - 3TC) available
TDF +3TC +NVP Choices1st
ddL/ABC
Special TDF + 3TC + EFV 2 nd ddL/AZT

46. Effect of Nutrition on HIV/AIDS
Optimal Benefits from treatment

47. Management of occupational
Exposure and PEP
 Avoid exposure to prevent HIV/AIDS
 Exposure
1)Occupational
2)Non-occupational
 PEP includes
Counseling
Risk assessment
Relevant Lab. Investigation.

48. First Aid
Short term ART
Follow-up & Support
 Principles of Providing PEP
Non-Discrimination
Confidentiality
Informed Consent

49. Potentially Infectious Body Fluids
Exposure to body fluids Exposure to body fluids considered ‘not at Risk’
considered ‘at Risk’
Blood
Semen Tears
Vaginal secretions Sweat
Cerebrospinal fluid
Synovial,pleural,perit Urine and faeces Unless these
oneal, pericardial secretions contain
fluid Visible blood
Amniotic fluid Saliva
Other body fluids
Contaminated with

50. Summaru of Do’s and Don’t
Do Do not
Remove gloves,if appropriate
Do not Panic
Wash the exposed site Do not put the pricked finger in
thoroughly with water mouth
Irrigate with water or saline- Do not squeeze the wound to
eyes and mouth bleed it
Wash the skin with soap and Do not use
water bleach,chlorine,alcohol,betadine,io
dine or other
antiseptics/detergents on the

51. Categories of Exposure
Mild Exposure Mucous Memberane/non-intact skin
with small volumes
Moderate Mucous memberane/non-intact skin with
Exposure small volumes or Exposure with solid needle
Severe Exposure Percutaneous with large volumes eg :
 an accident with high calibre needle
A deep wound
Transmission of a significant amount of
fluid
An accident with material that has been

52. HIV POST EXPOSURE
PROPHYLAXIS
Status of Source
Exposure HIV+ and Asymptomatic HIV+ and HIV Status
Clinically Unknown
Asymptomatic
Mild Consider 2-drug PEP Start 2-drug PEP Usually no PEP or
Consider 2-drug
PEP
Moderate Start 2-drug PEP Start 3-drug PEP Usually no PEP or
Consider 2-drug
PEP

53. Dosage of the drugs for PEP
Medication 2-drug regimen 3-drug regimen
Zidovudine (AZT) 300 mg twice a day 300 mg twice a day
Stavudine(d4T) 30 mg twice a day 30 mg twice a day
Lamivudine (3TC) 150 mg twice a day 150 mg twice a day
Protease Inhibitors 1st Choice
Lopinavir/ritonavir (LPV/r)
2nd Choice
Nelfnavir (NLF)

54. Regimens to be prescribed by
health centres
Prefered Alternative
2-drug regimen (basic PEP 1st Choice : 2nd Choice:
Regimen)
Zidovudine (AZT) + Stavudine (d4T) +
Lamivudine (3TC) Lamivudine (3TC)
3-drug regimen (Expanded PEP regimen)- Consult expert opinion
for starting 3rd drug eg LPV/r,NLF or IND
Not Recommended ddL+d4T Combination
NNRTI such as Nevirapine should not be
used in PEP

55. Follow-up lab. Tests
Timing In person taking In persons not taking
PEP(Standard regimen) PEP
Weeks 2& 4 Transaminases Clinical monitoring
Complete blood Counts for hepatitis
Week6 HIV-Ab HIV-Ab
Month 3 HIV-Ab,anti HCV,HBsAG HIV-Ab,anti
HCV,HBsAG
Month6 HIV-Ab,anti HIV-Ab,anti
-HCV,HBsAG,Transaminas HCV,HBsAG
es

56. Prevention
 Always better than cure
 Knowledge of disease
 Good habits
 Safe Sex-Barrier methods
 Loyal to Spouse
 Sterilized syringes
 Safe blood/blood products
 Treatment of STD’s
 Vaccination

58. NO
AIDS!!!!