ACQUIRED IMMUNE DEFICIENCY SYNDROME (HIV, AIDS)
Definition:Acquired immune deficiency syndrome or acquired immunodeficiency syndrome (AIDS) is a disease of the human immune system caused by the human immunodeficiency virus (HIV).
Indication of Treatment
AIDS
Treatment and prophylaxis indicated.
HIV
Treatment is indicated if:
CD4 < 350, viral burden > 5000 copies/ml or
CD4 350-500, viral burden > 30000 copies/ml
Treatment could help:
CD4 < 350, viral burden < 5000 copies/ml or CD4 350-500, viral burden 5000-30000 copies/ml or CD4 > 500, viral burden > 30000 copies/ml
No treatment (retest periodically) if:
CD4 350-500, viral burden < 5000 copies/ml or CD4 > 500, viral burden < 5000 copies/ml or CD4 > 500, viral burden 5000-30000 copies/ml
Drugs Used With Posology
NRTI (nucleoside reverse-transcriptase inhibitor)
Group A
zidovudine (AZT or ZDV): 200 mg PO TID or 300 mg PO bid
stavudine (d4T):
>60 kg: 40 mg PO bid
<60 kg: 30 mg PO bid didanosine (ddI):
>60 kg: 200 mg PO bid
<60 kg: 125 mg PO bid zalcibatine (ddC): 0.75 mg PO tid lamivudine (3TC):150 mg PO bid abacavir: 300 mg PO bid Combivir (ZDV/3TC): 1 tab POvbid Trizivirm (abacavir/ZDV/3TC): 1 tab PO bid NNRTI (non-nucleoside reverse-transcriptase inhibitor) nevirapine: 200 mg PO qd for 2 weeks, then 200 mg PO bid delavirdine: 400 mg PO tid efavirenz: 600 mg PO qd hs PI (protease inhibitor) saquinavir (2 generic): (Invirase): 600 mg PO tid (Fortovase): 1200 mg PO tid indinavir 800 mg PO q8h ritonavir 300 mg PO bid (increase to 600 mg PO bid over 2 weeks) nelfinavir 750 mg PO tid amprenavir 1200 mg PO bid (avoid high fat meals) lopinavir/ritonavir (Kaletra) 400 mg/100 mg PO bid with food Preferred drugs combinations take one from each group ritonavir frequently added to other PIs as it increases their serum level (P450 cytochrome inhibition) Group 1 efavirenz indinavir ± ritonavir saquinavir + ritonavir nelfinavir ± ritonavir nevirapine Group 2 d4T + 3TC d4T + ddI ZDV + 3TC ZDV + ddI Alternate drugs combinations take one from each group Group 1 amprenavir abacavir delavirdine Kaletra nelfinavir + saquinavir ritonavir saquinavir (1200 mg formualtion) Group 2 ddI + 3TC Combinations not recommended take one from each group hydroxyurea should never be used with any antiretroviral Group 1 saquinavir Group 2 d4T + ZDV 3TC + ddC d4T + ddC ddI + ddC Acute Retroviral Syndrome Usual microorganisms: HIV(HIV-1) Suggested therapy: Primary : (ZDV + 3TC + PI) for 2 years minimum Neddlestick injury & sexual exposure No treatment warranted Basic regiment Expanded regiment No Treatment Warranted Guidelines: Source is other than blood, bloody fluid, semen or vaginal fluid or any other normally sterile fluid or tissue or Intact skin or mucous membrane integrity or Source is HIV negative or Skin or mucous membrane integrity as been broken but no percutaneous exposure (e.g. dermatitis, open wound) and small volume (drops) of fluid was involved and source is asymptomatic with high CD4 count or Basic Regiment Guidelines Skin or mucous membrane integrity as been broken but no percutaneous exposure (e.g. dermatitis, open wound) and small volume (drops) of fluid involved and source has advanced AIDS/HIV high viral load/low CD4 count or Skin or mucous membrane integrity as been broken but no percutaneous exposure (e.g. dermatitis, open wound) and large volume (splash/long duration) of fluid involved and source is asymptomatic with high CD4 count or Percutaneous exposure but with solid needle or scratch and source is asymptomatic with high CD4 count or Any of the above situation where the exposure status or the source status is unknown Primary : zidovudine (AZT) 300 mg PO bid + lamivudine (3TC) 150 mg PO bid for 4 weeks or stavudine (d4T) 30/40 mg PO bid (according to weight) + didanosine (ddI) 200/125 mg PO bid (according to weight) or stavudine (d4T) 30/40 mg PO bid (according to weight) + lamivudine (3TC) 150 mg PO bid Expanded Regiment Guidelines Skin or mucous membrane integrity as been broken but no percutaneous exposure (e.g. dermatitis, open wound) and large volume (splash/long duration) of fluid involved and source has advanced AIDS/HIV high viral load/low CD4 count or Percutaneous exposure but with solid needle or scratch and source has advanced AIDS/HIV high viral load/low CD4 count or Percutaneous exposure with large bore hollow needle, deep puncture, visible blood, needle use in vein of source and source is HIV positive (any stage of disease) Primary : basic regimen and (indinavir 800 mg PO q8h or nelfinavir 750 mg PO q8h or abacavir 300 mg PO bid or efavirenz 600 mg PO qd hs) for 4 weeks Pregnancy Usual microorganisms: HIV(HIV-1) Suggested therapy: Mothers should not breastfeed if possible Primary : zidovudine300 mg PO bid for last half of pregnancy then zidovudine 2 mg/kg IV loading dose then 1 mg/kg/hr during labor then zidovudine 2 mg/kg PO q6h beginning 8-12 hours after delivery to infant for 6 weeks If mother received no anti-viral therapy: zidovudine 2 mg/kg PO q6h beginning 8-12 hours after delivery to infant for 6 weeks less developped countries nevirapine 200 mg PO to mother at onset of labour nevirapine 2 mg/kg PO to baby within 72 hours of birth Failure of Initial Therapy Defined as: Less than 1 log decrease in plasma HIV RNA after 4 weeks of adequate therapy. Detectable viral burden after 4-6 months of adequate therapy (debatable). Detectable plasma HIV RNA (>500 copies/ml) after a period of absence of detection.
Reproducible 3 fold increase from lowest plasma HIV RNA.
Persistent and significant decrease in CD4 and T cells.
Suggested therapy:
Primary:
same as preferred drugs combinations, but switch to different PI and a different combination of with NRTIs
(ritonavir + saquinavir 1200 mg formulation) ± NNRTI or
efavirenz + a different combination of NRTIs
Double PI + 2 different NRTIs
Alternative :
different PI + d4T + ddI + hydroxyurea 500 mg PO bid
use investigational drug (compassionate use)
NRTI: abacavir 300 mg PO bid
nucleotide RTI (as NRTI): adefovir 120 mg PO qd + L-carnitine 500 mg PO qd
amprenavir 1.2 g PO bid
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Last Revised on the 11th of July 2002
