Acquired immunodeficiency syndrome aids

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Transcript of Acquired immunodeficiency syndrome aids

  • A.I.D.S.A disease of human immune systemCaused by H.I.V 1 or 2

  • Burden- 2007 33.2 million people with AIDS2.5 million newly infected2.1 million deaths

  • Transmission Direct contact of mucous membrane or skin with infected body fluids- blood, semen, vaginal fluid, milk

  • HIVAIDSProgressive damage to CD4 +ve T-cells, macrophages, dendritic/glial cells

  • Progression Median time from HIV infection to AIDS- 9-10 yearsMedian survival after AIDS- 9-10 months, untreated

  • Effects Increased opportunistic infection & cancers

  • Common OITB, MAC infectionPCP- Pneumocystis jiroveciiEsophagitis- candida or viralChronic diarrhea- bacterial, fungal, viralToxoplasma encephalitisCryptococcal meningitisProgressive multifocal leucoencephalopathyCMV retinitis

  • Cancers Kaposi sarcoma- HHV-8High-grade B-cell lymphoma- EBVHodgkins lymphoma- EBVPrimary CNS lymphoma- EBVCervical/Anal cancer- HPVHCC- HBV/HCV

  • WHO stagingStage I- asymptomatic HIV infectionStage II- minor mucocutaneous manifestations & recurrent URTIStage III- unexplained weight loss/fever, chronic diarrhea, severe bacterial infection, pulmonary TB, low Hb/ANC/plateletsStage IV- other OI or cancers

    CDC- HIV +ve with CD4 T-cell

  • Diagnosis HIV antibodyp24 antigenPCR

    Symptomatic person- sample reactive with 2 different kitsAsymptomatic person- sample reactive with 3 different kits

  • Pretreatment considerationsCD4 cell countViral load (?)Patients readiness

  • Pre-treatment evaluationHIV testingRisk factors & exposureSystem review- H & PEh/o TB, STDh/o pregnancy & contraceptionh/o vaccinationTreatment history- ART & other

  • Pre-treatment lab. evaluationConfirm HIVCD4 countCBC, LFTUrine- R & MHBsAg & HCV AbPap smear

    Optional- Viral load, lipid profile, CxR, pregnancy test

  • Treatment No cure or vaccine, yet.HAART- highly active anti-retroviral therapy

  • Goals of ARTClinical- prolongation of life & improvement in quality of lifeVirological- greatest reduction in viral load for as long as possibleImmunological- immune reconstitutionTherapeutic- rational drug use to maximise benefit & avoid resistanceReduction of transmission

  • Who gets HAART?CD4 count
  • HAART regimeAt least 3 drugs, belonging to 2 classes of anti-retrovirals 2NRTI + 1NNRTI/PI

  • Drugs availableNRTI- Z,L,S,D,Z,E,A,TNNRTI- N,EPI- S,R,N,I,L/RFusion inhibitors- Enfuviritide, MaravirocIntegrase inhibitors- RaltregavirMaturation inhibitors- Bevirimat, ViveconCCR5 inhibitors

  • 1st line HAARTLamivudine-150 +Zidovudine-300/Stavudine-30 +Nevirapine-200/Efavirenz-600

  • NNRTI preferenceNevirapine- all & pregnantEfavirenz- deranged LFT & on Rifampicin containing ATT

  • Immune Reconstitution Inflammatory Syndrome (IRIS) Occurrence/worsening of new/existing OI within 6 weeks-6 months after initiating ART, with an increase in CD4 countLower the CD4 count, more likely IRISManagement-Stabilise OI, before starting HAARTLife threatening OIstop ARTNSAIDssteroids

  • Monitoring Regular counseling (adherence)WeightCD4- every 6 monthsHIV-RNA- every 6 monthsHb- on ZidovudineSGPT- on NevirapineRBS & lipid profile- on PI

  • Side-effects of ARTFirst few weeksN/V/D-zido./PI, Rash-NNRTI, Hepatotoxicity-NNRTI/PI, Drowsiness/confusion-efavirenzFirst few monthsAnemia/neutropenia-zido., Lactic acidosis-stavudine, Peripheral neuropathy-stavu./didano., Pancreatitis-didanosineAfter ~12 monthsLipodystrophy-NRTI/PI, Dyslipidemia-stavu./efavirenz/PI, IGT/DM-indinavir

  • 1st line HAART failureAt least after 6 months on ARTConfirm failure- Clinical- new OI- stage 3 or 4, r/o IRISCD4 count- persistently below 100 or fall >50% from peak or 1000 copies/mlQuestion adherence

  • Switch to 2nd line ARTCD4 & virological failureWHO stage-1 & 2- consider switch3 & 4- recommend switch

    CD4 failureWHO stage-1 & 2- dont switch, repeat CD4 in 3 months3- consider switch4- recommend switch

  • 2nd line ARTCore- ritonavir boosted PIWith 2 NRTI or 1NRTI+1NNRTINRTI- Tenofovir, Abacavir, Didanosine

  • OI prophylaxisPCP- CD4200Toxoplasmosis- CD4200MAC- CD4100CMV retinitis- secondary only- oral Ganciclovir stop when CD4>100Cryptococcal meningitis- secondary only- Fluconazole stop when CD4>100Vaccination- HBV, HZV, HPV, S.pneumoniae

  • Special situationsTB- start ATTCD4>350- defer ARTCD4 200-350- ART after intensive phase ATTCD41000No ante-partum Rx- mother-Zido+NVP, baby-Zido x6 wks NVP

  • Post-exposure prophylaxisExposure- mild, moderate, severeSource- HIV +ve- symptomatic or asymptomatic or status unknownCheck baseline HIV, HCV, HBsAgStart within 2-72 hours- ideally ASAPPEP- Zido.+Lami.PI (LPV/r,NLF,IND)Source HIV status unknown- no PEP/2 drug PEPSource HIV +ve- 2 or 3 drug PEP Duration-4 weeksCheck HIV status- 1 & 6 months

  • Prevention Protected sexual intercourse- condomPrecaution by healthcare workers to prevent exposure to infected fluidsProper disposal of sharps & wasteNeedle exchange programmes for IVDUPerinatal treatment of mother & newbornAvoid breast-feeding