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 PosologyNRTI (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 TherapyDefined 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
