9. WHO staging
Stage I- asymptomatic HIV infection
Stage II- minor mucocutaneous
manifestations & recurrent URTI
Stage III- unexplained weight loss/fever,
chronic diarrhea, severe bacterial infection,
pulmonary TB, low Hb/ANC/platelets
Stage IV- other OI or cancers
CDC- HIV +ve with CD4 T-cell <200
or <14% of all
lymphocytes
10. Diagnosis
HIV antibody
p24 antigen
PCR
Symptomatic person- sample reactive
with 2 different kits
Asymptomatic person- sample reactive
with 3 different kits
15. Goals of ART
Clinical- prolongation of life &
improvement in quality of life
Virological- greatest reduction in viral
load for as long as possible
Immunological- immune reconstitution
Therapeutic- rational drug use to
maximise benefit & avoid resistance
Reduction of transmission
16. Who gets HAART?
CD4 count <200
CD4 count <350 in Stage III
Stage IV, irrespective of CD4
17. HAART regime
At least 3 drugs, belonging to
2 classes of anti-retrovirals
2NRTI + 1NNRTI/PI
21. Immune Reconstitution
Inflammatory Syndrome (IRIS)
Occurrence/worsening of new/existing OI
within 6 weeks-6 months after initiating ART,
with an increase in CD4 count
Lower the CD4 count, more likely IRIS
Management-
Stabilise OI, before starting HAART
Life threatening OIstop ART
NSAIDssteroids
22. Monitoring
Regular counseling (adherence)
Weight
CD4- every 6 months
HIV-RNA- every 6 months
Hb- on Zidovudine
SGPT- on Nevirapine
RBS & lipid profile- on PI
23. Side-effects of ART
First few weeks
N/V/D-zido./PI, Rash-NNRTI, Hepatotoxicity-NNRTI/PI,
Drowsiness/confusion-efavirenz
First few months
Anemia/neutropenia-zido., Lactic acidosis-stavudine,
Peripheral neuropathy-stavu./didano., Pancreatitis-didanosine
After ~12 months
Lipodystrophy-NRTI/PI, Dyslipidemia-stavu./efavirenz/PI,
IGT/DM-indinavir
24. 1st
line HAART failure
At least after 6 months on ART
Confirm failure-
Clinical- new OI- stage 3 or 4, r/o IRIS
CD4 count- persistently below 100 or fall >50% from
peak or <pre-therapy baseline after 6 months of ART
Viral load- >1000 copies/ml
Question adherence
25. Switch to 2nd
line ART
CD4 &
virological failure
WHO stage-
1 & 2- consider switch
3 & 4- recommend
switch
CD4 failure
WHO stage-
1 & 2- don’t switch,
repeat CD4 in 3 months
3- consider switch
4- recommend switch
27. OI prophylaxis
PCP- CD4<200- TMP-SMX 1 DS OD
stop when CD4>200
Toxoplasmosis- CD4<100- TMP-SMX
stop when CD4>200
MAC- CD4<50- Azithromycin, 1 gm OD
stop when CD4>100
CMV retinitis- secondary only- oral Ganciclovir
stop when CD4>100
Cryptococcal meningitis- secondary only-
Fluconazole stop when CD4>100
Vaccination- HBV, HZV, HPV, S.pneumoniae
28. Special situations
TB- start ATT
CD4>350- defer ART
CD4 200-350- ART after intensive phase ATT
CD4<200- ART as soon as ATT is tolerated
CLD- efavirenz, not nevirapine
Pregnancy-
Zido+Lami+Efavirenz (Nevirapine in 1st
TM)
LSCS- if HIV-RNA>1000
No ante-partum Rx-
mother-Zido+NVP, baby-Zido x6 wks ± NVP
29. Post-exposure prophylaxis
Exposure- mild, moderate, severe
Source- HIV +ve- symptomatic or
asymptomatic or status unknown
Check baseline HIV, HCV, HBsAg
Start within 2-72 hours- ideally ASAP
PEP- Zido.+Lami.±PI (LPV/r,NLF,IND)
Source HIV status unknown- no PEP/2 drug PEP
Source HIV +ve- 2 or 3 drug PEP
Duration-4 weeks
Check HIV status- 1 & 6 months
30. Prevention
Protected sexual intercourse- condom
Precaution by healthcare workers to
prevent exposure to infected fluids
Proper disposal of sharps & waste
Needle exchange programmes for IVDU
Perinatal treatment of mother &
newborn
Avoid breast-feeding